PAGENO="0001" £~OL D REGIONAL MEDICAL PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERVICES FOR DOMESTIC AGRICUL- TURAL_MIGRATORY_WORKERS ___ HEARINGS BEFORE THE SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE OF THE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION ON H.R. 15758 A BILL TO AMEND THE PUBLIC HEALTH SERVICE ACT SO AS TO EXTEND AND IMPROVE THE PROVISIONS RELATING TO REGIONAL MEDICAL PROGRAMS, TO EXTEND THE AU- THORIZATION OF GRANTS FOR HEALTH OF MIGRATORY AGRICULTURAL WORKERS, TO PROVIDE FOR SPECIALIZED FACILITIES FOR ALCOHOLICS AND NARCOTIC ADDICTS, AND FOR OTHER PURPOSES MARCH 26, 27, AND 28, 1968 Serial No. 90-36 Printed for the use of the Committee on Interstate and Foreign Commerce ~ ) U S GOVFRNMENT PRINTING OFFICE 93-4530 WASHINGTON: 1968 PAGENO="0002" COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HARLEY 0. STAGGERS, West Virginia, Chairman SAMUEL N. FRIEDEL, Maryland TORBERT H. MACDONALD, Massachusetts JOHN JARMAN, Oklahoma JOHN E. MOSS, California JOHN D. IY[NGELL, Michigan PAUL C. ROGERS, Florida HORACE R. KORNEGAY, North Carolina LIONEL VAN DEERLIN, California J. J. PICKLE, Texas FRED B. ROONEY, Pennsylvania JOHN M. MURPHY, New York DAVID E. SATTERFIELD III, Virginia DANIEL J. RONAN, Illinois BROCK ADAMS, Washington RICHARD L. OTTINGER, New York RAY BLANTON, Tennessee W. S. (BILL) STUCKEY, Ja., Georgia PETER N. KYROS, Maine ANDREW STEVENSON JAMES M. MENGER, Jr. WILLIAM L. SPRINGER, Illinois SAMUEL L. DEVINE, Ohio ANCHER NELSEN, Minnesota HASTINGS KEITH, Massachusetts GLENN CUNNINGHAM, Nebraska JAMES T. BROYHILL, North Carolina JAMES HARVEY, Michigan ALBERT W. WATSON, South Carolina TIM LEE CARTER, Kentucky G. ROBERT WATKINS, Pennsylvania DONALD G. BROTZMAN, Colorado CLARENCE J. BROWN, Jx., Ohio DAN KUYKENDALL, Tennessee JOE SKUBITZ, Kansas WILLIAM J. DIXON ROBERT F. GUTERIE SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE JOHN JARMAN, Oklahoma, Chairman PAUL G. ROGERS, Florida DAVID E. SATTERFIELD III, Virginia PETER N. KYROS, Maine ANCHER NELSEN, Minnesota TIM LEE CARTER, Kentucky JOE SKUBITZ, Kansas W. E. WILLIAMSON, Clerk KENNETH J. PAINTER, Assistant Clerk Prof ession~tl Fit aff (II) PAGENO="0003" OONTENTS Hearings held on- Page March 26, 19~8~ March 27, 1968~ 131 March 28, 1968 231 Text of H.R. 15758 2 Report of- Agriculture Department 8 Health, Education, and Welfare Department 7 Treasury Department 8 Statement of- Becker, William N., Jr., assistant chief, Division of Alcoholism, Illinois Department of Mental Health 260 Boche, H. Leonard, director, Department of Social Welfare of the Board of Christian Social Concerns of the Methodist Church, and president, Association of Halfway House Alcoholism Programs of North America 291 Bratrude, Dr. Amos, Washington (State) Medical Association and Association of General Practitioners 197 Breslow, Dr. Lester, president-elect, American Public Health Asso- ciation 168 Brill, Dr. Henry, member, Committee on Alcoholism and Drug De- pendence, American Medical Association 147, 150 Brumback, Dr. Carl L., member, Executive Board, American Public Health Association 200 Cannon, Dr. Bland W., member, Council on Medical Education, American Medical Association 147, 148 Carpenter, Thomas P., president, National Council on Alcoholism, Inc 211 Chambers, Dr. J. W., representing the Medical Association of Georgia 208 Chapman, Dr. Carleton B., Association of American Medical Colleges.. 123 Cook, Dr. Richard S., chief, Division of Alcoholism, Illinois Depart- ment of Mental Health 260 Daley, Hon. Richard J., mayor, Chicago, Ill., presented by Phyllis K. Snyder, executive director, Chicago Alcoholic Treatment Center 131 Dc Bakey, Dr. Michael, chairman, Department of Surgery, Baylor University College of Medicine, Houston, Tex 133 Dimas, George C., president, North American Association of Alco- holismPrograms 185 Elam, Dr. Lloyd, Association of American Medical Colleges 123 Fair, Clinton M., legislative representative, American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) 231 Farber, Dr. Sidney, director of research, Children's Cancer Research Foundation, Boston, Mass 139 Fishman, Dr. Jacob, professor of psychiatry, Howard University College of Medicine (Washington, D.C.), and director, Howard University Community Mental Health Center.. 277 Harrison, Bernard, director, Legislative Department, American Med- ical Association 147 Hechier, Hon. Ken, a Representative in Congress from the State of West Virginia 207 Hewlett, Gus, executive secretary, North American Association of Alcoholism Programs 185 Huitt, Ralph K., Assistant Secretary for Legislation, Department of Health, Education, and Welfare 9 Johnston, Helen, Chief, Migrant Health Branch, Bureau of Health Services, Department of Health, Education, and Welfare 9 Kierman, Dr. Gerald L., associate professor of psychiatry, Yale Uni- versity School of Medicine, and director, Connecticut Mental Health Center 282 (III) PAGENO="0004" Iv Statement of-Continued Kuykendall, Hon. Dan, a Representative in Congress from the State Page of Tennessee 147 Larsen, Bernard, former member, board of directors, North American Association of Alcoholism Programs 185 Lee, Dr. Philip R., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare 9 Likoff, Dr. William, immediate past president, American College of Cardiology 161 Lookout, F. Morris, industrial representative, Tulsa (Okla.) Council on Alcoholism 258 Marston, Dr. Ralph Q., Director, Division of Regional Medical Pro- grams, Department of Health, Education, and Welfare 9 Millikan, Dr. Clark, chairman, Council on Cerebrovascular Disease, American Heart Association 163 Moore, William, executive director, National Council on Alcoholism, Inc 211 Nelligan, William D., executive director, American College of Cardi- ology 161 Pittman, David J., director, Social Science Institute, and professor of sociology, Washington University, St. Louis, Mo 238 Price, Rev. Thomas E., director, Department of Alcohol Problems and Drug Abuse, General Board of Social Concerns of the Methodist Church 174, 181 Ruhe, Dr. William, director, Division of Medical Education, American Medical Association 147 Schnibbee, Harry C., executive director, National Association of State Mental Health Program Directors 271 Shoemaker, Richard, assistant director, Social Security Department, American Federation of Labor and Congress of Industrial Organiza- tions (AFL-CIO) 231 Sibery, D. Eugene, executive director, Greater Detroit Area Hospital Council 218 Smith, Hon. Hulett C., Governor of the State of West Virginia, pre- sented by Louis S. Southworth, assistant supervisor, Division of Alcoholism, West Virginia Department of Mental Health 205 Snyder, Phyllis K., executive director, Chicago Alcoholic Treatment Center 131 Southworth, Louis S., assistant supervisor, Division of Alcoholism, West Virginia Department of Mental Health 205 Stark, Nathan J., chairman, Missouri regional medical program 193 Tuerk, Dr. Isador, commissioner, Maryland State Department of Mental Hygiene, representing the National Association of State Mental Health Program Directors 271 Works, Rev. David A., executive vice president, North Conway Institute, Boston, Mass 174 Yolles, Dr. Stanley F., Director, National Institute of Mental Health, Department of Health, Education, and Welfare 9 Additional information submitted for the record by- Alcoholic Recovery Homes Association, San Francisco, Calif., tele- gramfromAllenSkinner,chairman 298 Alcoholism Council of Palm Beach County (Fla.), letter from Richard A.Conlin,chairman 304 American Dental Association, letter from John B. Wilson, chairman, council on legislation 303 American Hospital Association, letter from Kenneth Williamson, associate director 299 American Medical Association, letter dated April 3, 1968, re need for halfway houses, under title III ofll.R. 15758 158 American Nurses' Association, Inc., statement of Judith G. Whitaker, executivedirector 296 American Psychiatric Association, statement of Dr. Walter Barton, medical director 289 California Committee on Regional Medical Programs, statement of Dr. Lester Breslow 171 Gateway Council on Alcoholism, letter from Steve Clark, chairman - - 304 Geis, Dr. Gilbert, professor of sociology, California State College, statement 290 PAGENO="0005" V Additional information submitted for the record by-Continued Greater Detroit (Mich.) Area Hospital Council, article from the Journal of the American Hospital Association, December 1967, entitled "Hospitals and Regional Medical Programs: A Plea for Page CoordinatedAction" 222 Hampton, Dr. H. Phillip, Tampa, Fla., letter 304 Hawaii, University of, School of Medicine, letter from Dr. Windsor C. Cutting, dean 303 Health, Education, and Welfare, Department of: Criteria for the evaluation of regional medical programs, state- ment on 86 Effectiveness of regional medical programs, statement on 84 Estimated new obligation authority required under H.R. 15758 for fiscal years 1969-77 (table) 119 Extent of "homeless alcoholic" problem, statement on 121 Hospital administrators participating in regional medical pro- grams,statementon 62 Involvement of the Kansas City General Hospital in the Missouri regional medical program, statement on 85 Migrant health program status, March 1968, statement on 87 Migrant health projects assisted by Public Health Service grants, adirectoryof 88 Migrant hospitalization, statement on 115 Operational projects affecting rural areas, statement on 76 Patient care costs supported with regional medical program grant funds 65 Professional involvement in regional medical programs, statement on 64 Public Health Service report on 12 operating regional medical programs 46 Television, radio, and telephone networks for continuing education 61 Regional medical programs, progress report, for heart disease, cancer, stroke, and related diseases 13 Regional medical program efforts directed against the health problems of the inner city, statement on 73 Status of regional medical programs, statement on 66-72 Table I.-Participation in regional medical programs by in- dividuals and organizations 33 Table II.-Regional medical programs, total obligation of funds, fiscal years 1966-69 34 Howard University Community Mental Health Center: Career development and related training and education for per- sonnel in the mental health program 279 Participation of subprofessional aides in rehabilitation treatment programs 281 Illinois Department of Mental Health, letter dated April 1, 1968, with attachments, replying to Congressman Rogers' request for additional information re Illinois general hospital detoxification program - - 264 Matsunaga, Hon. Spark M., a Representative in Congress from the State of Hawaii, letter 298 Missouri regional medical program, organization and goals - 195 National Consumers League, statement 297 National Council on Alcoholism, Inc., supplemental statement reply- ing to questions posed by Congressman Rogers 213 Appendix A-Estimates of alcoholics with and without compli- cations, 1960, by States, and rates per 100,000 adult population (table) 216 Appendix B-"Model" halfway house 216 National Council on Alcoholism, Monterey Peninsula area, Monterey County, Calif., telegram from George E. Ridgway, president 298 National Tuberculosis and Respiratory Disease Association, letter from James B. Perkins, managing director 30 1 Seattle (Wash.) Mental Health Institute, statement of Myron Kowals, assistant director 297 Smithers Foundation, The Christopher Ii, letter from R. Brinkley Smithers, president 303 PAGENO="0006" VI Additional information submitted for the record by-Continued Washington University (St. Louis, Mo.) Social Science Institute: St. Louis detoxification diagnostic and evaluation center- Page Budget and personnel, Dec. 1, 1967-Nov. 30, 1968 243 Preliminary evaluation report 250 West Virginia Department of Mental Health: Statement of- Dr. M. Mitchell-Bateman, director 206 Donald R. Dancy, supervisor, division of alcoholism 206 PAGENO="0007" REGIONAL MEDICAL PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS TUESDA~S~, MARCH 26, 1968 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE, COMMITrEE ON INTERSTATE, AND FOREIGN COMMERCE, Waehin~gton, D.C. The subcommittee met `at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). Mr. KYROS (presiding). The subcommittee will please be in order. The hearings today are on H.R. 15758, introduced by Chairman Staggers at the request of the administration. This bill would extend and expand the existing authorizations for regional medical programs, would extend the program of health serv- ices for domestic agricultural migratory workers, and would provide matching grants for construction and staffing of facilities for preven- tion of alcoholism `addiction and for treatment of alcoholics and nar- cotic addicts. REGIONAL MEDICAL PROGRAMS In 1965, the Congress considered legislation proposing the establish- ment of regional medical programs designed to improve the health care of the American people in the fields of heart disease, cancer, stroke and related diseases. The Congress made substantial revisions in the proposed program, providing in general for a maximum of decen- tralization of the decisionmaking process and encouraging the maxi- mum feasible cooperation between public and private groups interested in the health of the American people. It is impossible to give a simple description of a regional medical program since every program established is different, with each pro- gram tailored specifically to the needs of the region served. Over 90 percent of the population of the United States is or will be covered by regional medical programs established on the local level either on an operational basis today or through programs currently in the planning stage. Eventually, 100 percent of our population will be covered by these programs. Many fears and reservations were expressed at the time the Con- gress was considering the initial legislation. It is my understanding, however, that many of the groups which had reservations about the initial proposals have since modified their positions, in large measure (1) PAGENO="0008" 2 because of the modifications that were made in the program by the Congress and the manner in which the program has been administered to date. As I understand the bill presented to us, no major changes are pro- posed. The principal purpose of the legislation is to extend the pro- gram beyond its scheduled expiration date of June 30 this year, with minor improvements that experience has shown to be necessary or de- sirable. In regard to the section on domestic agricultural migratory workers, the bill also proposes to extend for two additional years the existing program of Federal grants for health services to domestic agricultural migratory workers. - The existing program is also scheduled to expire June 30 this year, so extension is essential at this time if these workers, who are among the neediest today, are to continue to receive the services they need. ALCOHOLIC AND NARCOTICS ADDICTS Title II of this bill would establish a program designed to provide assistance in the treatment and rehabilitation of alcoholic and narcotic addicts. The program proposed is an extension of the principles al- ready embodied in the community mental health centers and mental retardation facilities acts approved by this committee in 1963. The bill provides matching grants for construction and operation of facilities which are part of a complex providing essential elements of compre- hensive mental health services in order to provide services for the pre- vention and treatment of alcoholism. Grants are also authorized for construction and operation of special residential and other facilities for treatment of homeless alcoholics; grants for construction and operation of facilities for prevention and treatment of narcotic addiction; and grants for training and evalua- tion relating to the prevention and treatment of narcotic addiction, There are a substantial number of witnesses who have requested the opportunity to be heard on this legislation, which is indicative of the broad public response to the needs which will be served by the enact- ment of this bill. We hope to be able to expedite these hearings in order that the legis- lation may reach the President's desk at the earliest possible date in view of the relatively brief time remaining before two of the programs contained in the bill are scheduled to expire. The bill under consideration, and agency reports on the bill, will be included in the record at this point. (The bill, H.R. 15758, and departmental reports thereon, follow:) [HR. 15758, 90th Cong., second sess.] A BILL To amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the authorization of grants for health of migratory agricultural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, TITLE I-REGIONAL MEDICAL PROGRAMS EXTENSION OT REGIONAL MEDICAL PROGRAMS SEC. 101. Section 901(a) of the Public Health Service Act (42 U.S.C. 299a) is amended by striking out "and" before "$200,000,000" and by inserting after PAGENO="0009" 3 "June 30, 1968," the following: "$65,000,000 for the fiscal year ending June 30, 1969, and such sums as may be necessary for the next four fiscal years,". EVALUATION OF REGIONAL MEDICAL PROGRAMS SEC. 102. Section 901(a) of the Public Health Service Act is further amended by inserting at the end thereof the following new sentence: "For any fiscal year ending after June 30, 1969, such portion of the appropriations pursuant to this section as the Secretary may determine, but not exceeding 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the program authorized by this title." INCLUSION OF TERRITORIES SEC. 103. Section 902 (a) (1) of the Public Health Service Act (42 U.S.C. 299b) is amended by inserting after "States" the following: "(which for pur- poses of this title includes the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Trust Ter- ritory of the Pacific Islands)". COMBINATIONS OF REGIONAL MEDICAL PROGRAM AGENCIES SEC. 104. Section 903(a) and section 904(a) of the Public Health Service Act (42 U.S.C. 299c, 299d) are each amended by inserting after "other public or nonprofit private agencies and institutions" the following: ", and combina- tions thereof,". ADVISORY COUNCIL MEMBERS SEc. 105. (a) Section 905(a) of the Public Health Service Act (42 U.S.C. 299e) is amended by striking out "twelve" and inserting in lieu thereof "sixteen". (b) Section 905(b) of such Act is amended by striking out "and four at the end of `the third year" and inserting in lieu thereof "four at the end of the third year, and four at the end of the fourth year". MULTIPROGRAM SERVICES SEC. 106. Title IX of the Public Health Service Act is further amended by adding at the end thereof the following new section: "PROJECT GRANTS FOR MULTIPROGRAM SERVICES "SEC. 910. Funds appropriated i~nder this title shall also be available for grants to any public or nonprofit private agency or institution for services needed by or which will be of substantial use to, any two or more regional medi- cal programs." CLARIFYING OR TECHNICAL AMENDMENTS SEC. 107. (a) Section 901(c) of the Public Health Service Act is' amended by inserting before the period at the end thereof "or, where appropriate, a prac- ticing dentist". (b) Section 901 of such Act is further amended by adding at the end thereof the following new subsection: "(d) Grants' under this title to' any agency or institution for a regional medical program may be used by it to assist in meeting the cost of participa- tion in such progrum `by any Federal hospital." TITLE Il-MIGRATORY WORKERS EXTENSION OF SPECIAL GRANTS FOR HEALTH OF MIGRATORY WORKERS SEC. 201. Section 310 of `the Public Health Service Act (42 U.S.C. 242h) is amended by striking out "and, $9,000,000 for the fiscal year ending June 30, 1968" and inserting in lieu thereof "$9,000,000 each for the fiscal year ending June 30, 1968, and the next fiscal year, and such sums `as may be necessary fo'r the fiscal year ending June 30, 1970". PAGENO="0010" 4 TITLE III-ALOOHOLIO AND NARCOTIC ADDICT REHABILITATION Sno. 300.This title may be cited as the "Alc'holic and Narcotic A~dict Reha- bilitation Amendments of 1968". PART A-ALCOHOLIC REHABILITATION SEC. 301. The CoInrnun1~y Mental Health Centers Act (42 U.S.C. 2681, et seq.) is amended by adding after part B the following new part: "PART C-ALCOHOLISM "CONSTRUCTION GRANTS "SEC. 241. (a) Grants from appropriations under section 261 for construction of any facifities may be made only to a public or nonprofit private agency or or- ganization and only upon an: application (1) which meets the requirements for approval under clauses (1) through (5) and clause (A) of section 205(a), (2) which is for construction of a facility for the prevention and treatment of alcoholism, and (3) which contains- "(A) a showing of the need, in the area to be served by the applicant, for special facilities for the inpatient or outpatient treatment, or both, of alcoholism; "(B) satisfactory assurance that the services for prevention and control of alcoholism to be provided through the facility to be constructed, alone or in conjunction ~$th other facilities owned or operated by the applicant or affiliated or associated or having an arrangement with the applicant, will include, or 1e part of a program providing, principally for persons residing in or near the particular community or communities in which such facility is situated, at least those essential elements of comprehensive mental health services and services for the prevention and treatment of alcoholism, includ- ing postinstitutional aftercare and rehabilitation, that are prescribed by the Secretary; "(C) satisfactory assurance that the application has `been approved and recommended by the single State agency designated by the State as being the agency primarily responsible for care and treatment of alcoholics in the State, and, in case this agency is different from the agency designated pursuant to section 204(a) (1), a showing that the application has also been approved and recommended by the agency designated pursuant to section 204(a) (1); "(D) a showing that the project is entitled to priority over other projects for treatment of alcoholism, if army, within the State in accordance with regulations of `the Secretary as to general manner of determining priority, and is in accordance with such criteria, including the willingness and ability to provide satisfactory alternatives to custodial care, as the Secre- tary may determine to be appropriate for purposes of this section; and "(E) `a showing that adequate provision has been made for furnishing needed services for persons unable to pay therefor in accordance with regu- lations of the Secretary under section 203(4) and for compliance with State standards for operation and maintenance. "(b) The amount of any such grant with respect to any project shall be such percentage of the cost thereof, but not in excess of 06% per centum, as the Se'cre~ tary may determine. "STAFFING, OPERATION, AND MAINTENANCE GRANTS "SEC. 242. (a) Grants from appropriations under section 261 may be made to any public or nonprofit private agencies and organizations to assist them in projects for the operation, staffing, and maintenance of new facilities for preven- tion and treatment of alcoholism or of new services in facilities for prevention and treatment thereof. "(b) Grants under this section may be made only upon an application which meets the requirements for approval under part B. In making such grants, the Secretary shall take into account the relative needs of the several States for alcoholism programs and the relative financial need of the applicants and the relative population of area to be served by the applicants. In the case of any project the application for which is approved under this section, the maximum PAGENO="0011" 5 percentage of the cost of the project with respect to which a grant is made here- under shall be 90 per centum thereof for the first year following the first day of the first month for which a grant is made, 80 per centum thereof for the second year thereafter; 70 per centum for the third year thereafter; 60 per centum for the fourth year thereafter; and 50 per centum for each of the next six years thereafter. "SPECIALIZED FACILrrIE5 "SEC. 243. (a) Grants from appropriations under section 261 may also be made for projects for construction, operation, staffing, and maintenance of specialized residential and other facilities, such as halfway houses, day-care centers, and hostels, for treatment of homeless alcoholics requiring care in such facilities. "(b) Such grants may be made only with respect to facilities which (1) are affiliated with a community mental health center providing at least those essential elements of comprehensive community mental health services which are prescribed by the Secretary, or (2) are not so affiliated but with respect to which satis- factory provision (as determined by the Secretary) has been made for appropri- ate utilization of existing community resources needed for an adequate program of prevention and treatment of alcoholism. "PROJECTS ELIGIBLE UNDER REGULAR PROGRAM "SEC. 244. Nothing in this part shall be construed to preclude approval under parts A and B of a grant for a project for a facility or initial staffing thereof for the treatment of alcoholics but in determining the amount of any such grant under such part there shall be excluded from the cost of the project an amount equal to the sum of (1) the amount of any other Federal grant which the appli- cant has obtained, or is assured of obtaining, with respect to the project which is to be financed in part by a grant or grants under this part, and (2) the amount of any non-Federal funds required to be expended as a condition of such other Federal grant. "PAYMENTS "SEC. 245. Payments of grants under this part may be made in advance or by way of reimbursement, and on such terms and conditions and in such installments, as the Secretary may determine. "SHORT TITLE "SEC. 246. This part may be cited as the `Alcohol Rehabilitation Act of 1968'." PART B-NARCOTIC ADDICTION SEC. 302. The Community Mental Health Centers Act (42 U.S.C. 2681, et seq.) is further amended by inserting after part C (added by section 101 of this Act) the following new part: "PART D-NARCOTIC ADDICT REhABILITATION "PROGRAM OF TREATMENT "SEC. 251 (a) Sums appropriated pursuant to section 261 `shall be available for grants to any public or nonprofit private agencies and organizations. to assist them in projects for constructing, operating, staffing, and maintaining treatment centers and facilities (including po'stbospitalization treatment centers and facili- ties) for na'r~oatie `addidt~s within the `States. `(b) The grant program authorized by subsection (a) shall, insofar as it deals with the kind of `activities authorized by parts A and B `of this title, be carried out consistently with the grant programs under such parts A and B except to the extent, in the judgment of the Secretary, special consideration make differences appropriate. "TRAINING AND EVALUATION "Szc. 252. The Secretary is authorized, during the period beginning July 1, 1968, and ending with `the ~lose `of June 30, 1970, to make grants to any public or nonprofit private `agencies and `organizations to cover par't or all `of the cost of (A) developing specialized `training programs or materials relating to the pro- vision of public health services for `the prevention and treatment of n'are'ofic addiction, or developing imservice `training or short4erm `or refresher courses PAGENO="0012" 6 with respect to `the provision of such services; (B) training personnel to oper- ate, supervise, and administer such services; and (C) conduohing surveys and field trials to evaluate the adequacy of the programs for `the prevention and treatment of narcotic addiction within the `several States with `a view to deter- mining ways and means of improving, extending, and expanding such programs. "PROJECTS ELIGIBLE UNDER REGULAR PROGRAM "SEC. 253. Nothing in `this part shall be construed to preclude approval under parts A and B of a grant for a project for a facility or initial `sta~ng thereof for the treatment of narcotic addicts, but in determining the amount of any such grant under such part there shall be excluded from the cost of the project an amount equal to the sum of (1) the amount of any other Federal grant which the applicant has obtained, or is assured of obtaining, With respect to the project which is to be financed in part by a grant or grants under this part, and (2) the amount of any non-Federal funds required to be expended as a condition of such other Federal grant. PAYMENTS "SEC. 254. Payments under this part may be made in advance or by way of reimbursement, and on Suc!h terms and conditions and in such installments, as the Secretary may determine." PART C-GENERAL AUTHORIZATION OF APPROPRIATIONS FOR REHABILITATION OF ALCOHOLICS AND NARCOTIC ADDICTS SEC. 303. The Oommunity Mental Health Centers Act (42 U.S.C. 2681, et `seq.) is further amended by inserting `after part D (`added `by `section 201 of this Act) the following new part: "PART E-GENRRAL PROVISIONS "AUTHORIZATION OF APPROPRIATIONS FOR REHABILITATION OF ALCOHOLICS AND NARCOTIC ADDICTS "SEC. 261. (a) There are authorized to be appropriated for the fiscal year end- ing June 30, 1969, and the next fiscal year `such sums as may be necessary for project grants for construction, operation, staffing, and maintenance of facilities for the prevention and treatment of alcoholism (including specialized residential adn other facilities) under part C or `the prevention and treatment of narcotic addiction under part P. Sums so appropriated for any fiscal year shall remain available for obligation until the close of the next fiscal year. "(b) There are also authorized to be appropriated for the fiscal year ending June 30, 1971, and each of the next seven fiscal years such sums as may be neces- sary to continue to make grants with respect to any project under part C or P for operation, staffing, or maintenance of any facilities if such a grant was made thereunder with respect to such project from appropriations under th'is section for the fiscal year ending June 30, 1970, or any prior year, except that grants under such part may not be made with respect to any project after such grants have been made with respect to it from such appropriations for eight fiscal years. "PROGRAM EVALUATION `SEC. 262. Such portion of any appropriation under this title for any fiscal year ending after June 30, 1968, as the Secretary may determine, but not exceeding 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the programs authorized by this title." OPERATION AND MAINTENANCE GRANTS UNDER COMMUNITY MENTAL HEALTH CENTERS PROGRAM SEC. 304. Part B of the Community Mental Health Centers Act is amendeu by adding after section 224 (42 U.S.C. 2688d) the following new section: "FACILITIES RELATING TO REHABILITATION OF ALCOHOLICS OR NARCOTIC ADDICTS "SEC. 225. In the case of any community mental health center which includes (to such extent as may be determined in accordance with regulations) facilities PAGENO="0013" 7 for the prevention and treatment of alcoholism or narcotic addiction, the pur- poses for which the portion of the grant under this part which relates to such facilities may be made, the percentage of the cost to be met by such portion of the grant, and the duration of such portion of the grant shall, subject to limita- tions in such regulations, be determined as though the grant is being made for operation, staffing, and maintenance of facilities under part C, in the case of facilities for prevention and treatment of alcoholism, or part B, in the case of facilities for the prevention and treatment of narcotic addiction." USE OF ALLOTMENTS FOR COST OF ADMINISTRATION SEC. 305. Section 403 of the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 (42 U.S.C. 2693) is amended by adding at the end thereof the following new subsection: `(c) (1) At the request of any State, a portion of any allotment or allotments of such State under part A of title II shall be available to pay one-half (or such smaller share as the State may request) of the expenditures found necessary by the Secretary for the proper and efficient administration during such year of the State pain approved under such part; except that not more than 2 per centum of the total of the allotmens of such Sate for a year, or $50,000, whichever is less, shall be available for such purpose for such year. Payments of amounts due under this paragraph may be made in advance or by way of reimbursement, and in such installments, as the Secretary may determine. "(2) Any amount paid under paragraph (1) to any State for any fiscal year shall be paid on condition that there shall be expended from State sources for such year for administration of the State plan approved under such part A not less than the total amount expended for such purposes from such sources during the fiscal year ending June 30, 1968." DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Washinē/tee, D.C., Mavoh 18, 1968. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR MR. CHAIRMAN: This letter is in response to your request of March 6, 1968, for a report on HR. 15158, a bill "To amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the authorization of grants for health of migratory agri- cultural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes." This bill embodies the legislative proposal contained in a draft bill submitted by this Department to the Congress on March 4, 1968, to implement the recom- mendations on extension and improvement of regional medical programs con- tained in the President's March 4, 1968 Message on Health. The bill also includes the legislative proposal contained in that draft bill relating to temporary exten- sion of the program of grants for health services for migratory agricultural workers. In addition, HR. 15758 embodies the legislative proposal contained in the draft bill submitted by this Department to the Congress on February 8, 1968, to implement the recommendations on prevention and treatment of alco- holism and narcotic addiction contained in the President's February 7, 19438 Message on insuring the public safety and meeting the challenge of crime in our society. (This last mentioned proposal was also included in HR. 15281, on which we reported to your Committee on February 26, 19438.) We urge early enactment of this proposed legislation. The Bureau of the Budget advises that enactment of this proposed legislation would be in accord with the program of the President. Sincerely, WILnUR J. COHEN, Acting ~eoretary. PAGENO="0014" 8 DEPARTMENT OF AGRIOULTVRE, Washington, D.C., March 25, 1968. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DnAi~ MR. CHAIRMAN: This is in reply to your letter of March 6, requesting our views on HR 15758 a bill `To amend the Public Health Service Act This Department favors enactment of that portion of the bill which would provide grants for the health of migratory agricultural workers. We are not commenting on remaining sections of the bill which are more appropriately the interest of other departments. The bill would extend authorization to continue programs of the Public Health Service Act relating to the health of migratory agricultural workers for an additional two years, through June 30, 1970. The Act provides grants for medical diagnosis and treatment, immunization, and family health, nursing, and sanita- tion services. We believe that these programs are in the public interest, and we are par- ticularly concerned that steps already taken to improve the much needed health services for migratory agricultural workers and their families should be included. The Bureau of the Budget advises that the enactment of this proposed legisla- tion would be in accord with the President's program. Sincerely yours, ORVILLE L. FREEMAN, Secretary. THE GENERAL OOUN5EL OF THE TREASURY, Washington, D.C., March 26, 1.968. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR MR. CHAIRMAN: Reference is made to your request for the views of this Department on H.R. 15758, "To amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the authorization of grants for health of migratory agricultural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes." Only Title III of the bill is of concern to the Treasury Department. Title III would amend the Community Mental Health Centers Act to authorize grants to public or nonprofit private agencies or organizations for (1) the construction operation, staffing and maintenance of facilities for the prevention and treatment of alcoholism and of specialized residential and other facilities for the treatment of homeless alcoholics requiring care in such facilities; and (2) the construction, operation, staffing and maintenance of treatment centers and facilities for nar- cotic addicts within the States, and for the development of specialized training programs or materials relating to the provision of public health services for the prevention and treatment of narcotic addiction, and for the evaluation of such programs. The President, in his message on the Challenge of Crime to our. Society, urged enactment of legislation which would provide federal leadership and assistance to States and localities in developing non-jail atlernatives for the handling of alcoholics and asked the Secretary of Health, Education, and Welfare to increase the activities of his Department in the area of rehabilitation of drug addicts, and in alerting young people to the threat addiction poses to their lives. Title Ill of HR. 15758 would carry out these recommendations of the President. The Department rečommends enactment of Ttitle III of H.R. 15758. The Department has been advised by the Bureau of the Budget that there is no objeetioi~ to the submission of this report to your Committee and that enact- ment of the proposed legislation would be in accord with the program of the President. Sincerely yours, FRED B. SMITH, General Counsel. PAGENO="0015" 9 Mr. Kmos. I understand our first witness this morning will be Dr. Philip R. Lee, Assistant Secretary for Health and Scientific Affairs in the Department of Health, Education, and Welfare. Dr. Lee. STATEMENT OP DR. PHILIP R. LEE, ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, DEPARTMENT OP HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED' BY RALPH K. EUIT'T, ASSISTANT SECRETARY FOR LEGISLATION; D'R. RALPH Q. MAR~ STON, DIRECTOR, DIVISION OP REGIONAL MEDICAL PROGRAMS; DR. STANLEY P. YOLLES, DIRECTOR, NATIONAL INSTITUTE OP MENTAL HEALTH; AND' HELEN JOHNSTON, CHIEF, MIGRANT HEALTH BRANCH, BUREAU OP HEALTH SERVICES Dr. LEE. Thank you, Mr. Chairman. Mr. ROOERS (presiding). I might say that the committee is pleased to have you with us, and particularly since your new duties have been stated by the Secretary to be coordinator for health, and "Mr. Health" for the Government. We are delighted to have you with us in this capacity today, and we are pleased to have your associates. We will be glad to hear your statement. Dr. LEE. Thank you, sir. Accompanying me are Miss Johnston, Dr. Marston, and Dr. Yolks Mr. Ralph Huitt is with us this morning also. Mr. ROGERs. We are glad to see Mr. Huitt here. Dr. LEE. Mr. Chairman and members of the Subcommittee on Health and Welfare, it gives me great pleasure to appear before you today in support of the Health Services Act of 1968, which contains an extension and improvements to the Heart, Cancer, and Stroke Amendments of 1965, an extension of the Migrant Health Act of 1962, as amended in 1965, the transfer of authorities now in section 402 of the Narcotic Addict Rehabilitation Act of 1966 to the Community Mental Health Centers Act, and the establishment of a program to assist communities to improve treatment services to alcoholics, the latter two programs to be known as the Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968. These programs are all designed to carry forward our commitment to make the best health services available to all Americans. In his special message to Congress on health in 1965, President Johnson stated: Our first concern must be to assure that the advance of medical knowledge leaves none behind. We can-and must-strive now to assure the availability and accessibility of the best health care for all Americans, regardless of age or geography or economic status. Although much has been accomplished in the last 3 years, much remains to be done. We must remove the barriers of discrimination that have so long barred the alcoholic and the narcotic addict from receiving truly comprehensive care-a discrimination based on diag- nosis, which is just as intolerable as discrimination based on race. The migrant worker suffers from not only the disadvantages of language, poverty, and geography, but often the even more difficult PAGENO="0016" 10 problems of ignorance and inexperience in the use of modern medi- cal services. The removal of a different kind of barrier-the time lag between discovery and effective application of new knowledge-is a goal of the regional medical program. In his health message this year, President Johnson stated: Its purpose is to translate research Into action, so that all of the people of our nation can benefit as rapidly as possible from the achievement of modern medicine. Title I of H.R. 15758 extends the regional medical program through fiscal year 1973 and clarifies and improves certain aspects of the program. You will recall from your consideration of this legislation in the summer of 1965 that it was introduced as a result of the findings of the President's Commission on Heart Disease, Cancer, and Stroke. The Commission found that medical science has created the poten- tial to reduce the heavy tolls of these diseases but that this potential was not being realized for many of our citizens. The Interstate and Foreign Commerce Committee played a major role in clarifying both the nature of the program and the direc- tion in which it was to go. The basic objective of this program is to assure that the people of this Nation, wherever they may be, will benefit from the advances of medical science against the threats of heart disease, cancer, stroke, and related diseases. As an additional dividend, this program will have an impact extend- ing far beyond the control of specific diseases. The physicians and other health workers involved in the regional medical programs will be applying their new knowledge and new techniques to patients being treated under the medicaid, medicare, and other `health programs. The lessons learned in the regional medical programs cannot help but enhance the quality and efficiency of these other activities. The progress already made has justified our expectation that this program would significantly improve the effectiveness and quality of medical care for those who suffer from the major killer diseases. The program is already bringing together diverse groups in the health field in an unprecedented fashion `and in a manner that re- sults in a consideration of the unfilled health needs of the region, rather than those of the individual institutions. Despite the present shortage of manpower, the program has been successful in recruiting throughout the Nation talented persons willing to make firm career commitments to achieving the goals of the program. The programs have earned the support of the major health re- sources, professional and voluntary, at the national and regional levels. They have helped overcome hostilities and divisions which have existed in some cases for generations. Indeed, there has been a positive response to this committee's man- date in the original legislation that this program would be community based-that the responsibility for planning and organizing the opera- tion of the program would belong to the region, not to the Federal Government. As evidence of this response almost 1,000 medical institutions are participating in the regional medical programs, including every med- PAGENO="0017" 1:1 ical school and hundreds of hospitals. This involvement of medical schools and other teaching and research institutions helps develop close and continuous contact between medical advances and their ap- plication in the community. Almost 800 health organizations are participating, including every State medical society, State health department, State heart associa- tion, and State cancer society. Over 7,000 non-Federal-connected individuals are now actively engaged in the programs, including 1,800 employed either full- or part-time by the regional programs, over 1,900 members of the regional advisory groups required by the law who must advise on the development of the programs and approve all operational activities before they can be funded, and members of various subcommittees, task forces, and local action groups, who are contributing their time. This represents an involvement not only of the experts in the region but also the health personnel at the grassroots level, and this is illus- trated in table I (p. 33) which is submitted with the testimony. These people, institutions, and organizations are the forces which, with your support, will carry to fulfillment the high expectations for this program. The scope of the program is enabling the regional groups to assess thoroughly the needs and opportunities within their region and to implement the steps that can be realistically undertaken to improve the diagnosis and treatment of the major diseases. By coping with these problems on a regional scale, the groups are able to plan for the most efficient use of specialized resources for service or training from the largest medical center to the isolated rural physician. The regions have found that many different types of activities can contribute to objectives such as demonstrations of advanced diagnos- tic and patient-care techniques, training and continuing education of health personnel, development of communication and patient data networks, application of computer and other modern technology to health care, and research into better means for organizing and deliver- ing improvements iii health care. The first planning grant was awarded less than 2 years ago. Today there are 53 regions `which have received planning grants and include the entire populatioii, except Puerto Rico, and an application from that `Commonwealth is now being reviewed. Eleven regions have received grants to support initial operational activities, and 13 other regions have submitted applications to begin the operational phase of their programs. To finance these activities there has been a rapid increase in the obligation of funds, and `this is illustrated `on table II, `which is attached. The involvement in the regional medical programs by local insti- tutions and individuals has `been enthusiastic. Within the next year all of the programs e~peot to enter the operational phase of their program. They are eager to continue the work they have begun. In addition to extending the `basic authorities of the regional med- ical `program, the bill before yo'u contains amendments to those au- thorities `that would help the regions accomplish their go'als more effectively. It contains a provision that `would assure proper evalua- tion of the accomplishments ~f the program by providing that up to 93-453 O-68---2 PAGENO="0018" 12 1 percent of the appropriation for any fiscal year beginning with 1970 may be used by the Secr~tary for the evaluation. The bill makes clear that regional medical grants can be awarded to a combination of regional medical program agencies for carrying on a regional medical program. Also, a n~w authority is added which would permit the awarding of grants to any public `or private nonprofit agency or institution for services which `will be of substantial value and use to any two or more regional medical programs. Such services might include producing education materials, developing evaluation techniques, creating uni- form data-gathering systems, and other types of activities which cannot always be developed `most effi:oiently on the basis of the needs of a single region. The act is also amended to authorize the use of regional medical program grant funds to permit the full participation of Federal hospitals in regional medical programs as the important community resources which they in `fact are. Another amendment clarifies that a practicing dentist as well as a physician may refer a patient to a facility carrying out research, training, or demonstration activities which are supported by regional medical program `funds. Dentists can play an important role in such areas as the early identification of oral cancer, and the amendment corrects an unforeseen limitation in the original act which does not permit such referrals. An increase in the Advisory Council membership, from 12 mean- bers to 16, is provided in the bill, an expansion made necessary by the increasing workload of the Council in reviewing applications and the desirability of having members who reflect a broad diversity of interests. The bill also extends the provisions of the programs to Guam, American Samoa, and the Trust Territory of the Pacific Islands. The Hawaii regional medical program has indicated that it would be inter- ested in including these areas in its program. These provisions will strengthen regional medical programs and will provide the flexibility that will aid in making the most efficient use of all the health elements of the community in the program. The committee has received copies of the Surgeon General's report on regional medical programs, which describes in detail the initial progress. I would like to submit for the record material which adds to that report and which will bring you up to date on the accomplish- ments of the regional medical programs. May I submit that for the record, Mr. Chairman? Mr. ROGERS. Without objection, it will be received. (The document referred to follows:) PAGENO="0019" 13 PROGRESS REPORT 1 regional medical programs For Heart Disease, Cancer, Stroke, And Related Diseases Division of Regional Medical Programs National institutes of Health Bethesda, Maryland 20014 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service PAGENO="0020" 14 Regional Medical Programs have been awarded planning grants*. * to develop operational proposals through . * surveys of needs and resources * feasibility studies * organization and staffing Regional Medical Program is currently under development * PAGENO="0021" 15 *4*. Regional Medical Programs have received opera- ~ tional grafltS* V * to improve patient care through research, con- tinuing education, training, and demonstration projects * to develop better methods for the exchange of information among medical schools, medical centers, community hospitals, practicing phy- sicians, and other health institutions, organi- zations, and personnel * to continue to develop new and expanded plans for further improvement of patient care *As of February 29, 1968 PAGENO="0022" 16 REGIONS AND PROGRAM COORDINATORS OR DIRECTORS 1 ALABAMA B. B. Wells, M.D. U. of Ala. Med. Ctr. 1919 7th Ave. S. Birmingham, Ala. 35233 2 ALBANY, N.Y. F. M. Woolsey, Jr., M.D. Assoc. Dean Albany Med. Coil. 47 New Scotland Ave. Albany, N.Y. 12208 3 ARIZONA M. K. DuVal, M.D. Dean, Coil. of Med. U of Arizona Tucson, Ariz. 85721 4 ARKANSAS W. K. Shorey, M.D. Dean, Sch. of Med. U. of Arkansas 4301 W. Markham St. Little Rock, Ark. 72201 5 BI.STATE W. H. Danfoeth, M.D.. V. Chan. for Med. Affairs Washington U. 660 S. Euclid Ave. St. Louis, Mo. 63110 6 CALIFORNIA Paul D. Ward 655 Sutter St. #302 San Francisco, Calif. 94102 7 CENTRAL NEW YORK R. H. Lyons, M.D. State U. of N.Y. 750 E. Adams St. Syracuse, N.Y. 13210 8 COLORADO. WYOMING P. R. Hildebrand, M.D. U. of Coi. Med. Ctr. 4200 E. 9th Ave. Denver, Col. 80220 9 CONNECTICUT H. T. Clark, Jr., M.D. 272 George St. New Haven, Conn. 06510 10 FLORIDA S. P. Martin, M.D. Provost, J. Hillis Miller Med. Ctr. U. of Florida Gainesville, Fla. 32601 11 GEORGIA J. G. Barrow, M.D. Med. Assoc. of Ga. 938 Peachtree St. N.E. Atlanta, Ga. 30309 12 GREATER DELAWARE VALLEY W. C. Spring, Jr., M.D. Wynnewood House 300 E. Lancaster Ave. Wynnewood, Pa. 19096 13 HAWAII W. C. Cutting, M.D. Dean, Sch. of Med. U. of Hawaii 2538 The Mali Honolulu, Ha. 96822 14 ILLINOIS Wright Adams, M.D. 112 5. Michigan Ave. Chicago, 111. 60603 15 INDIANA G. T. Lukemeyer, M.D. Assoc. Dean Indiana U. Sch. of Med. 1100 W. Michigan St. Indianapolis, md. 46207 16 INTERMOUNTAIN C. H. Castle, M.D. Assoc. Dean U. of Utah Salt Lake City, Ut. 84112 17 IOWA W. A. Krehl, M.D., Ph.D. 308 Melrose Ave. U. of Iowa Iowa City, Ia. 52240 18 KANSAS C. E. Lewis, M.D. Chairman Dept. of Preventive Med. U. of Kansas Kansas City, Kan. 66103 19 LOUISIANA J. A. Sabatier, M.D. Claiborne Towers Roof 119 S. Claiborne Ave. New Orleans, La. 70112 20 MAINE M. Chatterjee, M.D. 295 Water St. Augusta, Me. 04332 21 MARYLAND W. S. Spicer, Jr., M.D. 550 N. Broadway Baltimore, Md. 21205 22 MEMPHIS MEDICAL REGION J. W. Culbertson, M.D. Coil, of Med. U. of Tennessee 858 Madison Ave. Memphis, Tenn. 38103 23 METROPOLITAN WASHINGTON, D.C. T. W. Mattingly, M.D. D.C. Medical Society 2007 Eye St. N.W. Washington, D.C. 20006 24 MICHIGAN A. E. Heustis, M.D. 1111 Michigan Ave. East Lansing, Mich. 48823 25 MISSISSIPPI G. D. Campbell, M.D. U. of Miss. Med. Ctr. 2500 N. State Ct. Jackson, Miss. 39216 26 MISSOURI V. E. Wilson, M.D. Executive Director for Health Affairs U. of Missouri Columbia, Mo. 65201 27 MOUNTAIN STATES K. P. Bunnell, Ed.D. Assoc. Director Western Interstate Comm. for Higher Ed. Univ. E. Campus Boulder, Col. 80302 PAGENO="0023" 28 NEBRASKA- SOUTH DAKOTA H. Morgan, M.D. 1408 Sharp Bldg. Lincoln, Neb. 68508 29 NEW JERSEY A. A. Fiorin, M.D. N. J. State Dept. of Hith. 88 Ross St. B. Orange, N.J. 07018 30 NEW MEXICO Reginald Fitz, M.D. Dean, Sch. of Med. U. of New Mexico Albuquerque, N.M. 87106 31 NEW YORK METR. AREA V. deP. Larkin, M.D. N.Y. Academy of Med. 2 E. 103d St. New York, N.Y. 10029 32 NORTH CAROLINA M. J. Musser, M.D. Teer House 4019 N. Roxboro Rd. Durham, N. C. 27704 33 NORTH DAKOTA T. H. Harwood, M.D. Dean, Scb. of Med. U. of North Dakota Grand Forks, N.D. 58202 34 NORTHEASTERN OHIO F. C. Robbins, M.D. Dean, Sch. of Med. Western Reserve U. 2107 Adeibert Rd. Cleveland, Ohio 44106 35 NORTHERN NEW ENGLAND J. E. Wennberg, M.D. U. of Vt. Coil, of Med. 25 Colchester Ave. Burlington, Vt. 05401 36 NORTHLANDS J. M. Stickney, M.D. Minn. State Med. Assoc. 200 1st St. S.W. Rochester, Minn. 55901 37 NORTHWESTERN OHIO C. R. Tittle, Jr., M.D. Medical College of Ohio at Toledo 38 OHIO STATE R. L. Meiling, M.D. Dean, Coil, of Med. Ohio State U. 410 W. 10th Ave. Columbus, Ohio 43210 39 OHIO VALLEY W. H. McBeath, M.D. 1718 Alexandria Dr. Lexington, Ky. 40504 40 OKLAHOMA K. M. West, M.D. U. of Ok. Med. Ctr. 800 N.E. 13th St. Oklahoma City, Ok. 73104 41 OREGON M. R. Grover, M.D. Director, Cont. Med. Ed. Sch. of Med. U. of Oregon 3181 S.W. Sam Jackson Portland, Ore. 97201 42 PUERTO RICO A. Nigaglioni, M.D. Chancellor, Sch. of Med. U. of Puerto Rico San Juan, P.R. 00905 43 ROCHESTER, N.Y. R. C. Parker, Jr., M.D. Sch. of Med. and Dent. U. of Rochester Rochester, N.Y. 14620 44 SOUTH CAROLINA C. P. Summerail, Ill, MD Dept. of Med. Med. Coil. Hospital 55 Doughty St. Charleston, S.C. 29403 45 SUSQUEHANNA VALLEY R. B. McKenzie 3608 Market St. P.O. Box 451 Camp Hill, Pa.17011 46 TENNESSEE MID-SOUTH S. W. Olson, M.D. 110 Baker Bldg. 110 21st Ave. S. Nashville, Tenn. 37203 47 TEXAS ~S. G. Thompson, M.D. Suite 724 Sealy.Smith Prof. Bldg. Galveston, Tex. 77550 48 TRI-STATE N. Stearns, M.D. 22 The Fenway Boston, Mass. 02115 49 VIRGINIA E. R. Perez, M.D. Richmond Acad. of Med. 1200 E. Clay St. Richmond, Va. 23219 50 WASHINGTON- ALASKA D. R. Sparkman, M.D. Sch. of Med. U. of Washington Seattle, Wash. 98105 51 WEST VIRGINIA C. L. Wilbar, Jr., M.D. W. Va. Univ. Med. Ctr. Morgantown, W. Va. 26506 52 WESTERN NEW YORK J. R. F. Ingall, M.D. Sch. of Med. State U. of N.Y. at Buffalo Buffalo, N.Y. 14214 53 WESTERN PENNSYLVANIA F. S. Cheever, M.D. Dean, Sch. of Med. U. of Pittsburgh 3530 Forbes Ave. Pittsburgh, Pa. 15213 54 WISCONSIN J. S. Hirsehboeck, M.D. Wisconsin RMP, Inc. 110 E. Wisconsin Ave. Milwaukee, Wisc. 53202 17 *Associate Coordinator PAGENO="0024" 18 NATIONAL ADVISORY COUNCIL E. L CROSBY, M.D. Director American Hosp. Assoc. Chicago, Ill. M. E. DEBAKEY, M.D. Prof. and Chairman Dept. of Surgery Baylor U. Houston, Tex. H. G. EDMONDS, Ph.D Dean, Graduate Sch. No. Carolina College Durham, N.C. B. W. EVERIST, JR., M.D. Chief of Pediatrics Green Clinic Ruston, La. J. R. HOGNESS, M.D. Dean, School of Med. U. of Washington Seattle, Wash. J. T. HOWELL, M.D. Executive Director Henry Ford Hosp. Detroit, Mich. C. H. MILLIKAN, M.D. Consultant in Neurology Mayo Clinic Rochester, Minn. G. E. MOORE, M.D. Director, Roswell Park Memorial Institute Buffalo, N.Y. E. D. PELLEGRINO, M.D. Director of the Med. Ctr. State U. of New York Stony Brook, N.Y. A. M. POPMA, M.D. Regional Director Mountain States Regional, Medical Program Boise, Idaho M. I. SHANHOLTZ, M.D. State Hith. Comm. State Dept. of Hith. Richmond, Va. W. H. STEWART, M.D. (Chairman) Surgeon General Public Health Service HISTORY AND PURPOSES OF REGIONAL MEDICAL PROGRAMS On October 6, 1965, the President signed Public Law 89-239. It authorizes the establishment and maintenance of Regional Medical Programs to assist the Nation's health resources in making available the best possible patient care for heart disease, cancer, streke and related diseases. This legislation, which will be referred to in this publication as The Act, was shaped by the interaction of at least four antecedents: the historical thrust toward regionalization of health resources; the development of a national biomedical research community of unprecedented size and productivity; the changing needs of society; and finally, the particular legislative process leading to The Act itself. The concept of regionalization as a means to meet health needs effectively and economically is not new. During the 1930's, Assistant Surgeon General Joseph W. Mountin was one of the earliest pioneers urging this approach for the delivery of health services. The na- tional Committee on the Costs of Medical Care also focused attention in 1932 on the potential benefits of regionalization. In that same year, the Bingham Associates Fund initiated the first comprehensive regional effort to improve patient care in the United States. This program linked the hospitals and programs for continuing education of physicians in the State of Maine with the university centers of Boston. Advocates of regionalization next gained national attention more than a decade later in the report of the Commission on Hospital Care and in the Hospital Survey and Construction (Hill-Burton) Act of 1946. Other proposals and attempts to introduce regionaliza- tion of health resources can be chronicled, but a strong national movement toward regionalization had to await the convergence of PAGENO="0025" 19 other factors which occurred in 1964 and 1965. One of these factors was the creation of a national biomedical research effort unprecedented in history and unequalled anywhere else in the world. The effect of this activity was and continues to be intensified by the swiftness of its creation and expansion: at the beginning of World War lithe national expenditure for medical re- search totaled $45 million; by 1947 it was $87 million; and in 1967 the total was $2.257 billion-a 5,000 percent increase in 27 years. The most significant characteristic of this research effort is the tre- mendous rate at which it is producing new knowledge in the medical sciences, an outpouring which only recently began and which shows no signs of decline. As a result, changes in health care have been dramatic. Today, there are cures where none existed before, a number of diseases have all but disappeared with the application of new vaccines, and patient care generally is far more effective than even a decade ago. It has become apparent in the last few years, however, (despite substantial achievements), that new and better means must also be found to convey the ever-increasing volume of research results to the practicing physician and to meet growing complexities in medical and hospital care, including specialization, increasingly intricate and expensive types of diagnosis and treat- ment, and the distribution of scarce manpower, facilities, and other resources. The degree of urgency attached to the need to cope with these issues is heightened by an increasing public demand that the latest and best health care be made available to everyone. This public demand, in turn, is largely an expression of expectations aroused by awareness of the results and promise of biomedical research. In a sense, the national commitment to biomedical investigation is one manifestation of the third factor which contributed to the creation of Regional Medical Programs: the changing needs of society-in this case, health needs. The decisions by various private and public institutions to support biomedical research were responses to this societal need perceived and interpreted by these institutions. In addition to the support of research, the same interpretive process led the Federal Government to develop a broad range of other pro- grams to improve the quality and availability of health care in the Nation. The Hill-Burton Program which began with the passage of the previously mentioned Hospital Survey and Construction Act of 1946, together with the National Mental Health Act of 1946, was the first in a series of post-World War II legislative actions having major impact on health affairs. When the 89th Congress adjourned in 1966, 25 health-related bills had been enacted into law. Among these were Medicare and Medicaid to pay for hospital and physician services for the Nation's aged and poor; the Comprehensive Health Planning Act to provide funds to each state for non-categorical health planning and to support services rendered through state and other health activities; and Public Law 89-239 authorizing Regional Medi- cal Programs. PAGENO="0026" 20 The report of the President's Commission on Heart Disease, Cancer, and Stroke, issued in December 1964, focused attention on societal needs and led directly to introduction of the legislation au- thorizing Regional Medical Programs. Many of the Commission's recommendations were significantly altered by the Congress in the legislative process but The Act was clearly passed to meet needs and problems identified and given national recognition in the Com- mission's report and in the Congressional hearings preceding pas- sage in The Act. Some of these needs and problems were expressed as follows: * A program is needed to focus the Nation's health resources for research, teaching and patient care on heart disease, cancer, stroke and related diseases, because together they cause 70 per- cent of the deaths in the United States. * A significant number of Americans with these diseases die or are disabled because the benefits of present knowledge in the medical sciences are not uniformly available throughout the country. * There is not enough trained manpower to meet the health needs of the American people within the present system for the delivery of health services. * Pressures threatening the Nation's health resources are building because demands for health services are rapidly increasing at a time when increasing costs are posing obstacles for many who require these preventive, diagnostic, therapeutic and rehabilitative services. * A creative partnership must be forged among the Nation's medi- cal scientists, practicing physicians, and all of the Nation's other health resources so that new knowledge can be translated more rapidly into better patient care. This partnership should make it possible for every community's practicing physicians to share in the diagnostic, therapeutic and consultative resources of major medical institutions. They should similarly be provided the op- portunity to participate in the academic environment of research, teaching and patient care which stimulates and supports medical practice of the highest quality. * Institutions with high quality research programs in heart disease, cancer, stroke, and related diseases are too few, given the magni- tude of the problems, and are not uniformly distributed through- out the country. * There is a need to educate the public regarding health affairs. Education in many cases will permit people to extend their own lives by changing personal habits to prevent heart disease, cancer, stroke and related diseases. Such education will enable indi- viduals to recognize the need for diagnostic, therapeutic or re- habilitative services, and to know where to find these services, and it will motivate them to seek such services when needed. PAGENO="0027" 21 During the Congressional hearings on this bill, representatives of major groups and institutions with an interest in the American health system were heard, particularly spokesmen for practicing physicians and community hospitals of the Nation. The Act which emerged turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of "regional centers" recommended earlier by the President's Commission was replaced by a concept of "regional cooperative arrangements" among existing health resources. The Act establishes a system of grants to enable representatives of health resources to exercise initiative to identify and meet local needs within the area of the categorical diseases through a broadly defined process. Recognition of geographical and societal diversities within the United States was the main reason for this approach, and spokes- men for the Nation's health resources who testified during the hearings strengthened the case for local initiative. Thus the degree to which the various Regional Medical Programs meet the objectives of The Act will provide a measure of how well local health resources can take the initiative and work together to improve patient care for heart disease, cancer, stroke and related diseases at the local level. The Act is intended to provide the means for conveying to the medical institutions and professions of the Nation the latest advances in medical science for diagnosis, treatment, and rehabilitation of patients afflicted wwith heart disease, cancer, stroke, or related di- seases-and to prevent these diseases. The grants authorized by The Act are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institu- tions, hospitals, and other medical institutions and agencies to achieve these ends by research, education, and demonstrations of patient care. Through these means, the programs authorized by The Act are also intended to improve generally the health manpower and facilities of the Nation. In the two years since the President signed The Act, broadly representative groups have organized themselves to conduct Regional Medical Programs in more than 50 Regions which they themselves have defined. These Regions encompass the Nation's population. They have been formed by the organizing groups using functional as well as geographic criteria. These Regions include combinations of entire states (e.g. the Washington-Alaska Region), portions of sev- eral states (e.g. the Intermountain Region includes Utah and sec- tions of Colorado, Idaho, Montana, Nevada and Wyoming), single states (e.g. Georgia), and portions of states around a metropolitan center (e.g. the Rochester Region which includes the city and 11 surrounding counties). Within these Regional Programs, a wide variety of organization structures have been developed, including executive and planning committees, categorical disease task forces, and community and other types of sub-regional advisory committees. Regions first may receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to fund activities planned with initial and subsequent planning PAGENO="0028" 22 grants. These operational programs are the direct means for Re. gional Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational activities, however, which will produce results by which Regional. Medical Programs will be judged. On November 9, 1967, the President sent the Congress the Report on Regional Medical Programs prepared by the Surgeon General of the Public Health Service, and submitted to the President through the Secretary of Health, Education, and Welfare, in compliance with The Act. The Report details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968, limit set forth in The Act. The President's letter transmitting the Report to the Congress was at once encouraging and exhortative when it said, in part: "Because the law and the idea behind it are new, and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progress-and it promises great advances in speeding research knowledge to the patient's bedside." Thus in the final seven words of the President's message, the objective of Regional Medical Pro. grams is clearly emphasized. THE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRAMS GOAL-IMPROVED PATIENT CARE The Goal is described in the Surgeon General's Report as ".. . clear and unequivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all." MEANS-THE PROCESS OF REGIONALIZATION Note: Regionalization can connote more than a regional cooperative arrange. ment, but for the purpose of this publication, the two terms will be used interchangeably. The Act uses "regional cooperative arrangement," but "regionalization" has become a more convenient synonym. A regional cooperative arrangement among the full array of available health resources is a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which ac~ company the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organizations in which they work. This requires PAGENO="0029" 23 a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than some more narrow basis. Itegionalization, or a regional cooperative arrangement, within the context of Regional Medical Programs has several other impor- tant facets: * It is both functional and geographic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. This interaction should occur within the operational activities as well as in the total program. The geographic boundaries of a region serve to define the popula- tion for which each Regional Program will be concerned and responsible. This concern and responsibility should be matched by responsiveness, which is effected by providing the population with a significant voice in the Regional Program's decision. making process. * It provides a means for sharing limited health manpower and facilities to maximize the quality and quantity of care and service available to the Region's population, and to do this as eco- nomically as possible. In some instances, this may require inter- regional cooperation between two or among several Regional Programs. * Finally, it also constitutes a mechanism for coordinating its categorical program with other health programs in the Region so that their combined effect may be increased and so that they contribute to the creation and maintenance of a system of comprehensive health care within the entire Region. Because the advance of knowledge changes the nature of medical care, regionalization can best be viewed as a continuous process rather than a plan which it totally developed and then implemented. This process of regionalization, or cooperative arrangements, con- sists of at least the following elements: involvement, identification of needs and opportunities, assessment of resources, definition of ob- jectives, setting of priorities, implementation, and evaluation. While these seven elements in the process will be described and discussed separately, in practice they are interrelated, continuous and often occur simultaneously. Involvement-The involvement and commitment of individuals, organizations and institutions which will engage in the activity of a Regional Medical Program, as well as those which will be affected by this activity, underlie a Regional Program. By involving in the steps of study and decision all those in a region who are essential to implementation and ultimate success, better solutions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other PAGENO="0030" 24 attempts to organize health resources on a regional basis have ex- perienced difficulty or have been diverted from their objectives because there was not this voluntary involvement and commitment by the necessary individuals, institutions and organizations. The Act is quite specific to assure this necessary involvement in Regional Medical Programs: it defines, for example, the minimum composi- tion of Regional Advisory Groups. The Act states these Regional Advisory Groups must include "practicing physicians, medical center officials, hospital administra- tors, representatives from appropriate medical societies, voluntary health agencies, and representatives of other organizations, institu- tions and agencies concerned with activities of the kind to be carried on under the program and members of the public familiar with the need for the services provided under the program." To ensure a maximum opportunity for success, the composition of the Regional Advisory Group also should be reflective of the total spectrum of health interests and resources of the entire Region. And it should be broadly representative of the geographic areas and all of the socioeconomic groups which will be served by the Regional Program. The Regional Advisory Group does not have direct administrative responsibility for the Regional Program, but the clear intent of the Congress was that the Advisory Group would ensure that the Regional Medical Program is planned and developed with the continuing advice and assistance of a group which is broadly representative of the health interests of the Region. The Advisory Group must approve all proposals for operational activities within the Regional Program, and it prepares an annual statement giving its evaluation of the effectiveness of the regional cooperative arrangements established under the Regional Medical Program. identification of Needs and Opportunities-A Regional Medical Program identifies the needs as regards heart disease, cancer, stroke and related diseases within the entire Region. These needs are stated in terms which offer opportunities for solution. This process of identification of needs and opportunities for solu- tion requires a continuing analysis of the problems in delivering the best medical care for the target diseases on a regional basis, and it goes beyond a generalized statement to definitions which can be translated into operational activity. Particular opportunities may be defined by: ideas and approaches generated within the Region, ex- tension of activities already present within the Region, and ap- proaches and activities developed elsewhere which might be applied within the Region. Among various identified needs there also are often relationships which, when perceived, offer even greater opportunities for solutions. In examining the problem of coronary care units throughout its Region, for example, a Regional Program may recognize that the more effective approach would be to consider the total problem of the treatment of myocardial infarction patients within the Region. This broadened approach on a regional basis enables the Regional PAGENO="0031" 25 Program to consider the total array of resources within its Region in relationship to a comprehensive program for the care of the myo- cardial infarction patient. Thus, what was a concern of individual hospitals about how to introduce coronary care units has been trans- formed into a project or group of related projects with much greater potential for effective and efficient utilization of the Region's re- sources to improve patient care. Assessment of Resources-As part of the process of regionalization, a Region continuously updates its inventory of existing resources and capabilities in terms of function, size, number and quality. Every effort is made to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creating an entirely new inventory. Information sources include state Hill-Burton agencies, hospital and medical associations, and voluntary agencies. The inventory provides a basis for informed judgments and priority setting on activities proposed for develop- ment under the Regional Program. It can also be used to identify missing resources-voids requiring new investment-and to develop new configurations of resources to meet needs. Definition of Objectives-A Regional Program is continuously involved in the process of setting operational objectives to meet identified needs and opportunities. Objectives are interim steps toward the Goal defined at the beginning of this section, and achieve- ment of these objectives should have an effect in the Region felt far beyond the focal points of the individual activities. This can be one of the greatest contributions of Regional Medical Programs. The completion of a new project to train nurses to care for cancer patients undergoing new combinations of drug and radiation therapy, for example, should benefit cancer patients and should provide additional trained manpower for many hospitals in the Region. But the project also should have challenged the Region's nursing and hospital communities to improve generally the continuing and in- service education opportunities for nurses within the Region. Setting of Priorities-Because of limited manpower, facilities, financing and other resources, a Region assigns some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors include: 1) balance between what should be done first to meet the Region's needs, in absolute terms, and what can be done using existing resources and compe- tence; 2) the potentials for rapid and/or substantial progress toward the Goal of Regional Medical Programs and progress toward re- gionalization of health resources and services; and 3) Program balance in terms of disease categories and in terms of emphasis on patient care, education and research. Implementation-The purpose of the preceding steps is to provide a base and imperative for action. In the creation of an initial op- erational program, no Region can attempt to determine all of ihe program objectives possible, design appropriate projects to meet all the objectives and then assign priorities before seeking a grant to PAGENO="0032" 26 implement an operational program which encompasses all or even most of the projects. Implementation can occur with an initial operational program encompassing even a small number of well- designed projects which will move the Region toward the attainment of valid program objectives. Because regionalization is a continuous process, a Region is expected to continue to submit supplemental and additional operational proposals as they are developed. Evaluation-Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quan- titative and qualitative evaluation wherever possible. Evaluation is in terms of attainment of interim objectives, the process of regionali. zation, and the Goal of Regional Medical Programs. Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ultimately, whether it achieved its purposes. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness. Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can range in complexity from simply counting num- bers of people at meetings to the most involved determination of behavioral changes in patient management. As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are implemented and finally con- cluded, some data will result which will be useful in determining the degree of success attained by the activity. REVIEW COMMITTEE K. P. BUNNELL, Ed.D. C. E. MILLER, MD. D. E. ROGERS, M.D. Assoc. Director Director, Off. of Research Prof. and Chairman Western Interstate Comm. in Med. Educ. Dept. of Med. for Higher Ed. Coil, of Med., U. of Ill. School of Med. Boulder, Cob. Chicago, Ill. Vanderbilt U. G. JAMES, M.D. P. M. MORSE, Ph.D. Nashville, Tenn. (Chairman) Director, Operations C H. W. RUHE, M.D. Dean, Mount Sinai Research Ctr. Assistant Secretary School of Med. Mass. Inst. of Tech. Council on Med. Ed. New York, N.Y. Cambridge, Mass. American Med. Assoc. H. W. KENNEY, M.D. A. PASCASIO, Ph.D. Chicago, Ill. Medical Director Assoc. Research Prof. R. J. SLATER, M.D. John A. Andrew Memorial Nursing School, U. of Executive Director Hosp. Pittsburgh The Assoc. for the Aid of Tuskegee Institute Pittsburgh, Pa. Crippled Children Tuskegee, Ala. S. H. PROGER, M.D. New York, N.Y. E. J.-KOWALEWSKI, M.D. Prof. and Chairman J. D. THOMPSON Chairman, Dept. of Med. and Prof. of Public Hlth. Committee of Environ. Med. Physician-in-Chief School of Public Hlth. Acad. of Gen. Practice Tufts N.E. Med. Ctr, Yale U. Akron, Pa. Pres., Bingham Assoc. Fund New Haven, Conn. Boston, Mass. PAGENO="0033" 27 OCTOBER DECEMBER Enactment of P.L. 89.239 National Advisory Council meeting Initial policies and pre- liminary Guidelines reviewed 1966 FEBRUARY APRIL JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER Establishment of Division Publication of preliminary Guidelines National Advisory Council meeting Review Committee meeting National Advisory Council meeting Review Committee meeting National Advisory Council meeting Publication of Guidelines Review Committee meeting National Advisory Council meeting First of 5 meetings of Ad Hoc Committee for Report to the President and Congress Review Committee meeting National Advisory Council meeting Policy for review proc- ess and Division activities set 7 planning grants awarded 3 planning grants awarded 8 planning grants awarded Report material discussed 16 planning grants awarded 1967 JANUARY FEBRUARY APRIL MAY JUNE JULY AUGUST OCTOBER NOVEMBER 1968 JANUARY Revigw Committee meeting National Conference National Advisory Council meeting Review Committee meeting National Advisory Council meeting Report to the President & Congress Review Committee meeting National Advisory Council meeting Review Committee meeting National Advisory Council meeting Conference-Workshop National views on Programs & information for Report provided 10 planning and 4 opera- tional grants awarded 5 planning and 1 opera- tional grant awarded 2 planning grants awarded 2 planning and 3 opera- tional grants awarded Regional activities and ideas presented 93-453 O-68----3 PAGENO="0034" 28 PUBLIC LAW 89-239 Through grants, to afford to the medical profession and the medical institu- tions of the Nation the opportunity of planning and implementing programs to make available to the American people the latest advances in the diagnosis and treatment of heart disease, cancer, stroke, and related diseases by estab- lishing voluntary regional cooperative arrangements among * Physicians * Hospitals * Medical Schools * Research Institutions * Voluntary Health Agencies * Federal, State, and Local Health Agencies * Civic Organizations REGIONAL ADVISORY COUNCILS The activities of Regional Medical Programs are directed by fulltime Co- ordinators working together with Regional Advisory Groups which are broadly representative of the medical and health resources of the Regions. Membership on these groups nationally is: Medical Center- School Officials Hospital Administrators Practicing Physicians Members of the Public PAGENO="0035" 29 Dr. LEE. The leadership you and members of the subcommittee and full committee have provided in the field of migrant health has brought medical care to great numbers of Americans who might not otherwise have known any of the benefits of modern medicine. Until passage of the Migrant Health Act in 1962, health care for migrants was virtually nonexistent. Today, thanks to extension of the act in 1965 and your continued support, major gains have been made in bringing health services to this group, who, in spite of their vital role in the agricultural industry, remain the last to receive health bene- fits most Americans take for granted. The core provision of the act is the family health service clinic. At present, family health service clinics are operating seasonally or year round at more than 200 locations. The typical project places major emphasis on general medical care offered by private medical practi- tioners in family health service clinics, in out-patient departments of hospitals, or in their own offices. Some projects provide dental services. All provide nurses who wel- come incoming migrants, informing them of the services available to them. All provide sanitation workers and health education programs. Hospitalization was added to the scope of service under the provi- sions of the 1965 extension of the Migrant Health Act. Funds became available for the first time for this purpose during 1967. In the latest 12-month period for which summarized project data are available, migrants made 215,000 visits to physicians and 24,000 visits to dentists. In addition, nurses made 125,000 visits to migrant households and sanitarians made almost the same number of visits to living or work sites. Many communities and individuals have invested their own time, facilities, equipment, funds, and other items essential to the provision of project services. The improvements which have been made in migrant health care since the passage of the act are quite dramatic, but there is still much to be done. Grant-assisted projects are reaching only about one-third of the Nation's migrants, and these for only part of the year. Nearly 40 percent of the counties with seasonal migratory workers still have no grant-assisted project services. Medical visits and dental visits made by migrants are only about one-fifth and one twenty-fifth of the national per capita average. Deaths from influenza and pneu- monia, tuberculosis and other infectious diseases, diseases of early in- fancy, and accidents are from 150 to 300 percent of the rates for the Nation as a whole. Without continued and expanded financial and technical assistance, much of the current effort would be lost. The President's National Advisory Commission on Rural Poverty has recommended extension of the Migrant Health Act with sufficient funds to expand the pro- gram in terms of geographic coverage and services offered. The advantages of a separate health program to migrant families have been great. But the time will come-and very shortly-when migrant families will be far better served by a recognition on the part of the States and communities that for all their unique problems and needs, migrant families are much like the rest of the population. They must have access to medical services at a price they can afford to pay. PAGENO="0036" 30 We recommend extension of the act for 2 years. By. the end of fiscal year 1970, we expect the States to be dealing with migrant health problems as part of a larger program of continuing operations authorized and supported by the partnership for health. In short, we believe that this separate program of assistance to migrant families is helping to overcome the inequalities in health care between them and the rest of the population, but that in the long run, true equality in health care will be realized only when their needs are not treated separately by the States. THE ALCOHOLIC AND NARCOTIC ADDICT REHABILITATION AMENDMENTS OF 1968 As introduced by the distinguished chairman of this committee, this bill will encourage the development of prevention and treatment programs for alcoholics and narcotic addicts in communities across the Natioti. This committee is well aware that the Community Mental Health Centers Act has already been beneficial to many of those suffering from mental illness and to their families, bringing treatment out of the remote custodial institutions into the community and making effective care available close to home. To date more than 260 mental health center grants have been awarded throughout the country. Eighty-five centers are now open. We propose an amendment to this vital legislation in order to bring these same benefits of readily accessible care to those suffering from alcoholism and narcotic addiction, by providing special incen- tive grants for that purpose. Mr. Chairman, it is estimated that some 5 to 6 million Americans can be classified as alcoholics-about 4.5 percent of the population aged 20 and over. Alcoholism, an enormous economic liability to the Nation, costs perhaps $2 billion a year in job absenteeism, lowered productivity, medical insurance expenses, and other losses. The damage in human terms is beyond measure-affecting not only the alcoholic but all those whose lives are touched by his illness. Further, it appears likely that virtually all American communities shortly will be facing `a major crisis in attempting to develop adequate medical, social, `and psychiatric service's for those alcoholics who formerly were handled almost exclusively by jails, prisons, and other penal institutions. Two recent Federal circuit court decisions have stated that if a man~s drunkenness is part of hi's illness-and this is `a nonvolunt'ary act-he should be treated as a sick person and not as a criminal. The U.S. Supreme Court will render i'ts decision on a similar case later this spring. Generally, neither the `alcoholic, his family, nor the friend or coun- selor who wishes to help has any single place in t'he community to turn for the full range `of services he needs. There `are few integrated networks to provide the treatment and other services needed to restore him to a productive and satisfying life. Therefore, Mr. Chairman, government at all levels has an obligation to accelerate the process that will make care and treatment accessible for these people. It is time that we provide t'he States and communities PAGENO="0037" 31 with the incentives to enable them to meet this critical public health challenge. This bill, building on the highly successful Community Health Centers Act, will amend that act to authorize special funds for the construction, staffing, and operation of facilities providing treatment for alcoholics. The community mental health center approach is well suited for ex- tension into this area of critical need, since it mobilizes the resources of the community in a program meeting the total mental health needs of its people. It helps to provide inpatient care, outpatient care, partial hospitalization, emergency service and communitywide serv- ices of consultation and education. It serves the full range of mental health needs-from the seriously ill patient to the person who can lead `a normal, successful life with the aid of certain supporting services. Clearly this is a highly appropriate model in which to integrate treatment `and rehabilitation services for alcoholics. The centers are tuned to the community__the setting in which the alcoholic lives. They are involved in essential relationships with general hospitals, with public health departments, with social welfare agencies, with the courts, the schools, the vocational rehabilitation agencies, and also with other community sources of help `such as d'octors, lawyers, and clergymen. It is now generally recogn'ized that alcoholics `and addicts `are in urgent need of social, psychological, and medical assistance. Such as- sistance in treatment and rehabilitation should take its place in the main'stream of community mental health effort. The proposed legislation authorizes grants for the construction of facilities for the prevention and treatment of alcoholism, and for their staffing, operation, and maintenance. These facilities are to be co- ordinated or associated with facilities providing comprehensive com- munity mental health services. For several reasons, we feel that a specific category of incentive grants for alcoholism should be authorized within the Community Mental Health Centers Act. First, alcoholism is a tragically long- neglected major public health problem. It has received only limited attention for State and community helping agencies in the past, and the problem must now be highlighted. Second, although community mental health centers have expressed interest in providing services for alcoholics, most of them have not yet taken substantial steps in this direction. They have had difficulty in developing services for these patients because community support for alcoholism programs has been lacking, because services for these patients are expensive, and because the patients frequently lack the means to pay for their own care. Third, professional interest in providing treatment for alcoholics. has been limited thus far. These persons are difficult to treat, and special incentives are urgently needed for an interim period until alcoholics are accorded medical, psychiatric, and other types of treat- ment on an equal basis with other patients in need of help. Two types of grant programs would be authorized by this legis-. lation: Grants for construction, staffing, operating, and maintenance of general alcoholism treatment programs, and similar grants for specialized residential facilities for homeless alcoholics. PAGENO="0038" 32 While those arrested for public drunkenness account for only a small proportion of any community's alcoholics, they do present a very substantial and highly visible problem. The proposed grants for residential and other special facilities for homeless alcoholics will go a long way toward providing help and hope for these persons who have in the past been handled primarily by the courts and police. NARCOTIC ADDICTION The problem of narcotic addicts likewise calls for special atten- tion. The number of such addicts is relatively small in comparison with the 5 million or more alcoholics. The Bureau of Narcotics records some 62,000 who are addicted to narcotics, and there are unquestion- ably countless thousands who exist anonymously. As in the case of alcoholics, there is today a grievous lack of ade- quate community services to provide care and treatment. The local com- munity presently offers only minimal help. There is a pressing need for special funds for the construction, staffing, and operation provid- ing treatment facilities, as well as for training of personnel, field trials, and demonstration projects related to improved treatment techniques. As in the case of alcoholism., there is a need for integrated treatment and rehabilitation services. Here, too, we believe the needs can be best met by building on the Community Mental Health Centers Act. The proposed legislation would amend the Community Mental Health Centers Act by transferring to it the authorities now contained in section 402 of the Narcotic Addict Rehabilitation Act of 1966. This section provides for project grants to States, communities, and nonprofit agencies for construction, staffing, and operation, and train- ing of personnel for facilities for the treatment of narcotic addicts as well as related surveys and demonstrations. The proposed transfer will not affect the relationship between this program and other activities authorized under the Narcotic Addict Rehabilitation Act. Professionals have long believed that narcotic addiction is, to a great extent, a symptom of underlying mental illness, and therefore that re- cent advances in treatment and rehabilitation of the mentally ill should be extended to the addict. The Narcotic Addict Rehabilitation Act of 1966 was an important step in advancing this concept. Let me describe briefly the program envisioned in such a narcotic addiction treatment center. A model comprehensive treatment program would provide care for approximately 400 narcotic addicts per year. Such a program would include a 10- to 12-bed inpatient unit to be used for withdrawal. Resi- dential treatment or partial hospitalization services, such as day care, would be another element of the program. Outpatient treatment and followup services, including rehabilita- tive, vocational, or educational programs, would also be provided. Preventive and diagnostic services should also be provided either di- rectly or through cooperation with other community agencies. A halfway house or residential treatment center located in the com- munity would house 30 to 40 patients. One or two outpatient facili- ties connected with each center would serve addicts and their families and would be staffed by two or three mental health professionals, a PAGENO="0039" vocational rehabilitation counselor, a community organizer, two trained ex-addicts, and five other persons, such as nurses or social workers. An evaluation and epidemiologic unit to study the extent and characteristics of that community's addiction problem might be another component. Mr. Chairman, the proposed amendments to the Community Mental Health Centers Act are intended to strike at the roots of an intensely tragic situation. In most American communities, alco- `holics and narcotic addicts-and their families who suffer with them- have few places to turn for professional help. Yet many of these people could `be restored to productive living if such help were within reach. Community mental health centers will be operating in cities with a high incidence of alcoholism and narcotic addiction. However, the Community Mental Health `Centers Act now offers no special induce- men:t to centers wishing to attack these critical and difficult problems. The proposed grant program is intended to provide the necessary stimulus and the capability to do the job. In addition, the amendments before this committee today will serve as a model for the States in developing and modifying their own community mental health, alcoholism, and addiction legislation. This committee, by recognizing the importance of incorporating facilities for the prevention and treatment of alcoholism and narcotic addiction into the community mental `health center complex, will make a vital contributi'on toward achieving prevention and control of these major public health problems. I would like to insert in the record two tables, showing participation in the regional medical program, and total obligation of funds. (The. documents referred to follow:) TABLE I.-Partic~patioa `ia regional medical programs by individuals and organizations individuals 7,200 Staffs of 54 programs 1, 80G Members of regional advisory groups 1,900 Subcommittee members 2,500 Local action group members 1,000 Institutions 934 Hospitals 800 Medical schools 1103 Dental schools 18 Schools of public health - 13 Organiza'tions 779 State medical societies 152 County medical societies 90 State health departments 152 State cancer societies 151 State heart association 152 State hospital association 40 Areawide health facility planning agencies 30 State dental association 29 Other professional societies, local voluntary agencies, etc 383 1 100 percent participation. PAGENO="0040" 34 TABLE 11.-Regional medical pro grams, total obligation of funds Fiscal year: 1966 $2, 500, ~ 1967 28, 900, 000 1968 1 53~ 800, 000 )69 299, 800,000 1 Projected. 2 President's budget. Dr. LEE. Thank you, Mr. Chairman, for this opportunity to explain to this subcommittee our views on H.R. 15758. Mr. Huitt, Dr. Marston, Dr. Yolles, and Miss Johnston will be happy to answer any questions you may have. Mr. ROGERS. Thank you very much, Dr. Lee, for your statement covering the proposed legislation. I think we will start our questions by Mr. Kyros. Mr. KYROS. Thank you, Mr. Chairman. I want to commend you, Dr. Lee, on a very excellent statement and to welcome you here. I would like to start with the last thing you said on page 18 of your statement. How will community mental health center completions, where you will have facilities for treatment of alcoholism and narcotic addic- tion, make a vital contribution toward preservation of such problems? Dr. LEE. I would like to ask Dr. Yolles to comment on that, and then I will comment also. Dr. YOLLES. The prevention referred to in terms of these programs, which are primarily pointed to treatment of alcoholics and addicts, re- fers to secondary prevention. The secondary prevention approach is, in effect, early intervention to prevent further pathology from occur- ring. We would hope that the preventive aspects-education, consulta- tion with other agencies, would be handled under other legislation, Public Law 89-749, the Partnership for Health Act, which also will deal with these problems. Mr. KYROS. Will these centers be similar to some of the mental health centers in Massachusetts? Will they treat people as outpatients? Dr. YOLLES. Depending on the type of case, you may have a varia- tion in types of treatment. If someone came in in an acute state, he would be hospitalized, generally in a general hospital, and then go on to perhaps transitional day care or night care and then outpatient care, and followup thereafter. Mr. K~nos. Let me ask a question generally about the regional medi- cal program. As I understand it, it has been in operation nearly ~ years, is that right? Dr. LEE. That is correct. Mr. Kviios. Have you been able to make qualitative analysis on whether this program has made knowledge of medical science avail- able to practitioners in rural areas? Dr. LEE. Yes; I think we can cite examples. I would like to emphasize that the efforts until now, of course, have been primarily bringing the various groups together, building the foundation on which the opera- tional programs will be moving forward rapidly. PAGENO="0041" 35 Dr. Marston? Dr. MARSTON. This is not an easy question to answer at this early stage in the program. We do have operational grants awarded which include more than 100 projects that are underway in the regions. Perhaps the best way I could answer this might be to take the ex- ample of one region and how it has moved in the area of heart disease, cancer and stroke. I would like to use, from time to time, some of the words of the ap- plicant, because this is a program that is occurring in the region. The l~orth Carolina regional medical program decided in the late summer of 1967, about a year after it received its planning grant, that it had attained readiness for operational status. Conceptual strategy to achieve the goals of the regional medical program had been de- veloped. A unified, representative leadership of the region, the prin- cipal health interests in the region, had been organized for the stimu- lation of productive, cooperative effort for guidance and coordination of program development, and an organization structured for effective decisionmaking based on needs in the region had been developed and adequately tested. During 1966 and 1967, North Carolina had had a small project in the area of heart disease. This development was described in the re- gion's progress report as follows: Since cooperative arrangements in- volving such a wide assortment of people and institutions in one proj- ect was a novel departure for us, the experience has been invaluable. We quickly learned that the original project contained seriously inade- quate provisions for manpower. Thus, in our operational grant appli- cation submitted in October 1967, an expansion of the project was i)roposed, and as time passes, further modification is anticipated. Con- ferences with staffs of small community hospitals and observations of patients with acute myocardial infarcts being treated therein convinced us that an effort had to be made to determine the feasibility of an ap- propriately designed coronary care unit for these small hospitals. The region's report goes on later to describe the availability of cor- onary care units, and particularly the ability in these units to do some- thing as far as the rhythm or the electrical disturbances in the heart is concerned, which is not possible without the specialized equipment and trained people in these units. The growing interest and availability of coronary care units in this region also has generated the need to provide a cardiopulmonary and resuscitation training program to expand on an earlier, limited prorn gram of the North Carolina Heart Association. Additional projects in the heart area, which are in var~ous stages of implementation or planning, include the diagnosis and treatment of hypertension, the use of specially equipped ambulances, pediatric cardiological screening, and so forth. In the cancer area, the North Carolina program worked with exist~ ing groups who have worked in the cancer field before, and they state an increasing number of community hospitals and their staffs are at- tempting to meet `the standard of the American College of Surgeons for the approval of their cancer programs. In this region there are only seven hospital programs that currently are approved, and they would `hope to increase this through the regional medical programs. PAGENO="0042" The North Carolina regional medical program now enjoys, accord- ing to a report of progress, an unusually active cooperative arrange- ment with all of the major groups concerned with planning and implementing cancer activities. The cancer subcommittee of the regional advisory group provides a mechanism whereby efforts can be better coordinated and tasks more rapidly and effectively accomplished. They are about to initiate a central cancer registry and a central cancer information service. Their goal is to establish a well-coordinated, comprehensive cancer program with full participation *of State agencies, academic agencies, com- munity hospitals, and professional and voluntary organizations. This group of cooperating groups also includes a special cancer commission established by the Governor some years ago, before the advent of the regional medical program. The North Carolina program reports that much less has been ac- complished in the area of stroke than in the other disease categories, but there is an emphasis in this statement that there is an intent to bring the program into balance. Knowledge sufficient to launch and maintain a meaningful stroke program in both urban and rural North Carolina communities is avail- able, and they have an application before us for development of a community stroke program. I would like to just mention one other thing, not in a categorical area, about a particular problem that this region has identified through its associate director for hospitals. In the western part of the State there are seven hospitals in as many communities that are facing manpower problems-that are facing the problem of keeping up. Dr. Amos ,Johnson, who is a past president of the American Acad- emy of General Practice, told the 1968 Washington conference work- shop on regional medical programs that these seven hospitals will be brought together in a coordinated program by the people in the region. These hospitals are prepared to go so far as to apply as a group for a single accreditation under the Joint Commission on Accredita- tion of Hospitals. Thus, North Carolina is in the midst of testing the concept of a unique regional hospital organization where no one hospital is able to provide the full range of necessary capabilities. Mr. KYROS. Thank you. Dr. LEE There has been in the last 3 years-and we want to make it clear we do not take credit for this with respect to the regional medical programs-a significant decline in deaths from high blood pressure. It is about a 20-percent decline over the past 3 years. I think there is no question that as the regional health programs develop activity and the knowledge of early detection of hypertension, and early treatment becomes more available, we will see an acceleration of this very signifi- cant decline, which, of course, will affect particularly the stroke prob- lem and, to a lesser extent, the deaths from coronary disease. Mr. KYROS. Dr Lee, pursuing the question of the effectiveness of the program, let's think for a moment about costs. As I understand it from your table II, "Regional Medical Programs," a total obligation of funds for the fiscal years 1966 through 1968, you show approximately $85 million, either in planning or operational grant obligations. PAGENO="0043" 37 Now, as measured against that $85 million, have you made any kind of an analysis or evaluation which shows that, for that kind of money, we have achieved some significant advance through the regional medical program? Dr. LEE. The program to date primarily has been one of planning and developing the mechanisms which then can be evaluated. For example, we were developing the data base which in many areas is seriously lacking. After we develop such a data base in the regions, we will carry forward the evaluations for which we are asking specific earmarked funds. I think it is really too early to be able to state with any degree of certainty a cost-to-benefit effect. I think that we should also recognize what I think is going to be one of the most significant contributions of the program. That is the spin off of benefits, well beyond the program itself, not only in terms of people whose care is paid for through medicare or medicaid. For example, as improvement takes place in community hospitals the way Dr. Marston described it, as physicians are able to participate in these programs in community hospitals, the program is bound to have a significant impact on improving quality. I think the best buy in medical eare is good care, high-quality, and this, to me, is going to be one of fhe most important long-term con- tributions of the program. And I think this is one of the reasons that we see the kind of enthusiastic support among practicing physicians in many parts of the country who were at first really very suspicious of the program. As they have seen it `develop, as they have participated, they have become increasingly enthusiastic. We will be developing for `this spin- off some techniques for measurement so that we can determine the additional conditions of the program. Mr. Kraos. Dr. Lee, in this bill as it is proposed, I understand that $65 million is sought for `the fiscal year ending June 30, 1969. Dr. LEE. That is correct. Mr. Kraos. What carryover of funds will we have for this program? Dr. LEE. The carryover is $30 million. Mr. Krnos. So of the approximately $95 million we are talking about, you have $30 million unobligated as yet. Dr. LEE. Yes. That is held in reserve, actually, by the Bureau of the Budget. Mr. KYROS. My next question is a general one abou't your program. Has the American Medical Association now endorsed this program as it is being carried out? Dr. MARSTON. I think the best answer to that is a paper that Dr. Dwight Wilbur gave at a conference workshop-which has been pub- lished in the current issue of JAMA. It is very supportive of the program. Mr. Kyaos. What does this program `do for a general practitioner, say, in a rural area like in my own State of Maine? Dr. LEE. I might add one thing. If the AMA has endorsed it, these are actions that would have to be taken by `the house of delegates. They would have to vote on a resolution saying they endorse it, and I am not sure that action has been taken. PAGENO="0044" 38 Mr. KYROS. But the President has put in a statement that he supports it. Can you tell us specifically how a general practitioner in a rural area gets involved in a program? Say there is a regional program in the area in which he practices, but he is in a small town that doesn't have a hospital. Dr. MARSTON. A number of examples come to mind. There was a problem-again in North Carolina, to take up where I left off- of a community that was about to be without a physician, and the peo- ple in the community turned to the regional medical program for assistance. The regional program was able to examine what the problems were in attracting physicians to that community and growing out of that, there has developed a rather major study for that region in the prob- lems of the rural area. The principal example, I think, is an easy tone: The tradition of the Birmingham Associates which, as you will recall from testimony lead- ing to passage of this legislation, was held up as a model of how various health institutions and resources can have a relationship through an organization such as the associates. The activities of the Birmingham Associates are being expanded and carried further by the regional medical programs. There are a variety of other things being done to assist the physician in rural areas where no hospital exists. There are opportunities for physicians from one part of Washington State to come into and actually spend time in larger hospitals. This includes an exchange so that someone arranges to take over their practice for a period of time. There are the usual continuing education programs, but I think with a different emphasis-with the emphasis on doing those things that meet the needs of the physician rather than offering a course that is pre- selected for him. The difference has been that the physician is involved in decisions and in planning in terms of his needs rather than coming in at a later stage. There are also other facilities or services in a number of the regions that are planned and will be implemented for the physician. Dr. LEE. I would just add another comment on that, and this relates to a personal experience I had visiting Vinel Haven Island, where there is one physician in general practice. He has been able to attract occa- sionally third- and fourth-year medical students to come and spend part of the summer with him, and this has been a tremendous stimulus to him. It has provided him the best possible opportunity to keep up. It has also been a unique educational experience for the students, be- cause people have lived there for many, many generations, and certain disease patterns there are somewhat unique. He has developed relation- ships with, for example, diabetic experts at Harvard, who have been interested in diabetes in this particular population group. He has been able to keep up far more effectively than the average practitioner, and one of the things that is being explored in the pro- gram is the participation of third- and fourth-year medical students in these community hospital teaching programs. The development of teaching programs in community hospitals, the extension of teaching programs, will attract young physicians to areas PAGENO="0045" 39 that would otherwise not have been attractive to them. They have been used to active teaching programs in the university centers, and they have tended not to want to go too far from these. But I think the opportunity to keep up professionally, to interact with other people and with students on a continuing basis, will be an added benefit. Maine is a very good example of the needs of the country to attract physicians to areas other than these urban areas where most of them have settled, or the suburban areas. I think that the regional medical programs are making and can con- tinue to make a significant contribution to this. Mr. K~nos. I have one last question, Mr. Chairman. That is this: You have seen the program in operation for a couple of years now. What can you say about the fact that this is Federal money, that there is a possibility, always, when using Federal funds, that the Fed- eral Government gets some kind of control over the medicine and medi- cal practice. You know, we hear this all the time, and we are concerned about it, and I wouldn't want to see Federal `control over medicine. How can you `say, sir, as administrator of this program, that Federal control is not an encroachment on medical practice through this program? Dr. MARSTON. I think this committee took a very important step when it gave essentially veto power to the regional advisory groups. This means that we cannot establish on the national level any regional operational activity that has not had prior approval of the appropriate Regional Advisory Group. And this is perhaps the strongest point. The other point is that, again, the Surgeon General is limited by the fact that every application must be recommended for approval by the non-Federal, National Advisory Council on regional medical pro- grams. I think basically these are the two sharpest assurances that the control will remain at the regional level. A third assurance is that the programs are working with the control remaining at the regional level. This is recognized, I think, alt the Federal level as well as throughout the country. Mr. KYROS. You have had no feedback of any problems concerning compla'int'n of Federal control like we have had in programs, such as OEO and others? Dr. LEE. I think there was a great deal of speculation that this would bo the case. The fact that it has not been the `case, the `fact that there han been increasing participation by practicing physicians in the planning of the programs and as the operational programs develop, the extent of participation, the fact that `there are 800 hospitals with their staffs participating are indications `that this, in the planning and early operation stage, really has grassroots support. I would add one other thing to what Dr. Marston said. I think the actions of this committee and the periodic oversight of the program by the Congress is another assurance to physician's, with the law as it is written, that there will not be Federal control. Certainly, the way in which the program has been administered has been just in the opposite direction, to stimulate to the maximum extent possible, local initiative. Those who participate have to solve their local differences, which have been considerable in some of the regions. PAGENO="0046" 40 Some people have felt that the program wa's moving too slowly, but it takes time to work out differences which have long existed. But as we view it, the way we are proceeding gives the best possible foundation for the program, because it is stimulating local initiative all over the country. Mr. Kyi~os. I am delighted to hear you say that, Dr. Lee. I know from my experience from talking with doctors in the State of Maine, that they think the program is an outstanding one, that it doesn't encroach on them, and I think this is a credit to your administration. You are the people who have to do a hard job, and I want to com- mend you highly on administering a program like this, which is com- plicated-and particularly because of the important relationship be- tween doctors and patients. You have done an outstanding job, and I am proud of you. Mr. ROGERS. Mr. Carter? Mr. CARTER. I notice that the new bill will include an authorization for funds for treatment of alcoholics, and it will also include funds for treatment of addicts, too. Dr. Liz. Yes, sir. Mr. CARTER. How much will that be this year and next year, your additional authorization? Dr. LEE. The amount that we have requested is, for the alcoholics, $7 million, and for the narcotic addict rehabilitation, $8 million, and in fiscal 1970, $15 million for the alcoholics and $10 million for the addicts. Most of that money will be for the development of services rather than construction. It is about 30 percent for construction or renova- tion of facilities. Mr. CARTER. Will these treatment centers for alcoholics and narcotic addicts be an integral part of the mental health centers, or will they be separate? Dr. LEE. I would like to ask Dr. Yolles to further elaborate on that. Dr. YOLLES. These treatment facilities, Dr. Carter, would be built into the community health center and would be an integral part of it. We would even relate the special facilities for homeless alcoholics to this continuum of services. This is the key point in the legislation to relate these services for treatment of alcoholics and narcotic addicts to the total panoply of services in the community health center. They may be physically separated, but there would be adequate transfer of patients and records between the services, just as in the basic program. Mr. CARTER. I think that it is good that it is so. It will be less dif- ficult, as I see it. I notice that in your regional health development, 11 regions have been funded. Is that right? Dr. LEE. Yes, 11 operational grants have been funded, and 53 plan- ning grants. Mr. CARTER. This is in its infancy at the present time? Dr. LEE. That is correct, sir. Mr. CARTER. Of course, there has been a decrease in the number of strokes in the past 3 years, but you really wouldn't attri~bute all that decrease to the establishment of these 11 regions? Dr. LEE. No, not at all, Dr. Carter. PAGENO="0047" 41 I think we would not want to imply that either these programs or some of the other programs that have been initiated in the last 8 years that have been making good progress would in any way have `done so. They may have contributed, but certainly, as far as the national figure i's concerned, it would he `a slight contribution to `date. Mr. CARTER. Actually, there are improved methods of treatment, really, different medicines used in treatment of strokes that have been mainly responsible for this. Dr. LEE. Yes, sir. I think the improved drugs and the earlier diagnosis of `the hypertensive association that they get under treatment at an earlier stage of the disea'se have contributed to this. Mr. CARTER. I `would like `to know how the specific organization of a region is. Could you give us a plan, who is head of it, and how it branches down? Dr. MARSTON. I think what one needs, Dr. Carter, is the organization of more than one region to achieve what you want. The one thing that h'as to be established in each region is a broadly representative regional `advisory group. it is a requirement of the law that `this be established. In every region, so far as I can remember, there are task forces in the areas of heart disease, cancer, and stroke, which include people with special knowledge in these `areas. In each region there `is also a core administrative unit, a staff that varies in `size. But on the average in the regions funded for planning only, it is about 20 to 26 `people, and in the operational regions, the staff that is actually paid on `an average number about 90. Operation of the program is set up differently in different regions. In `Connecticut there are 10 subregions. In Kansas there are 10 sub- regions. In Georgia, `there is really a subregion for each county, with representatives from every hospital in the `State, and with representa- tives from every county medical society. These local-level grou'ps `are active in de'termining their local needs. In some instances these units are called local advisory groups. Now, to come to a specific region, in Kansas these local action groups may either respond t'o information that has come from `studies c'arried out `by the regional staff or, indeed, other groups in the State. Or the local action groups may propose projects that they themselves identify a's being `particularly needed in that area. In `designing these projects, the local action groups can work with the staff of the regional medical program, calling on experts from outside of the region, if necessary. Kansas has a substantive review committee, that is, a committee that reviews, on the basis of scientific and professional merit, the proposals. Finally, with the results of this review available, the application, which may have been stimulated either at the local level or m'ay have' been stimulated as the result of data that has been gathered elsewhere, comes before the regional advisory group, which must approve all operational project proposals. A recent example of this process in Kansas resulted in about half of the proposals that came to the regional advisory group being returned to the originators for one reason or ano'ther for additional work before final approval at the regional level. After regional ad- PAGENO="0048" 42 visory group approval is gained, a grant proposal for funding pro- gr~tm activities comes to the Division of Regional Medical Programs. At this point, we have the opportunity to have special site visits as ~e did in the case of the Washington-Alaska Region's operational application. In this case we actually visited the locations where proj- ects were proposed, and made a~ report to our review committee and, finally, to our National Advisory Council. Does this help? Mr. CARTER. Yes, sir; that is helpful. What procedures do you have for continuing education to get to the general practitioner and communities your advances in research? Dr. MARSTON. Again, this has varied. There have been some in- stances in which a community took the lead. Great Bend, Kans., for example, has established an educational subcenter, if you want, for the area immediately surrounding Great Bend. The purpose here is to try to focus education and to focus care as close to the patient's home as possible. And in the instance of Kansas, *~rOu'~ find this focus has been moved out away from the university to spjcenters. In other areas, preexisting programs and facilities have been uti- i~zed-Albany, N.Y., for example, has a two-way radio system which provides in-hospital education throughout much of the New England area. This has been augmented by the Albany regional medical program. I would say continuing education related to the physician and the patient's needs, as opposed to continuing education that somehow has drifted away from the care of patients, is a very major focus of the program. Mr. CARTER. Do you have regional seminars on newer concepts in medicine attended by practitioners from the subregions? Dr. MARSTON. There was a major one in Oregon that a member of my staff attended not long ago. Mr. CARTER. The purpose of this bill is to diminish deaths from heart disease, cancer, and stroke. Do you have available to the practitioners in the subregions close liaison with specialists in the regional areas so that they can get in- formation quickly, or advice, or help in treatment? Dr. MARSTON. There is an example in Wisconsin of a 24-hour-a-day telephone service to physicians in the area. There is a specialty team in Iowa that has been activated to actually go out to the scene and provide consultation to the local physician and his stroke patients. Mr. CARTER. That is part of your regional system at the present time? Dr. MARSTON. Yes. Mr. CARTER. I want to congratulate you on that. I think that is very good. I certainly feel that these ideas, or these questions which I have asked you should be further implemented, if possible. Thank you, Mr. Chairman. Mr. ROGERS. Mr. Skubitz? Mr. SKUBITZ. Thank you, Mr. Chairman. Doctor, I am a new member on this committee, and I am from the great State of Kansas that you have been praising so highly. Doctor, I am interested in a number of things. PAGENO="0049" 43 First, I want to say I appreciate the fact that you are interested in Kansas. I hope we can get some money to keep this show on the road. How much money was authorized, Doctor, for these regional medical programs in 1966? Dr. MARSTON. The authorization was $50 million. Mr. SKUBITZ. How much was appropriated? Dr. MARSTON. $25 million, including $24 million for grants-$25 million total. Mr. SKUmTz. In 1967, how much was authorized? Dr. MARSTON. The authorization was $90 million. The appropria- tion was $43 million for grants and $2 million for direct operations. Mr. SKtTBITZ. You have a total of how much? Dr. MARSTON. $45 million was appropriated for 1967, $25 million appropriated for 1966, so that would be a total of $70 million. Mr. SKUBITz. In 1968, how much was authorized? Dr. MARSTON. $200 million. We have received $53.9 million in ap- propriations for grants and $4,900,000 for direct operations, for a total of $58.8 million. Mr. SRUBITZ. Out of this total amount of appropriations, how much do you have available to you now? Dr. MARSTON. $53.8 million-including $4.9 million for direct opera- tions. This total is comprised of $27.9 million of our 1968 appropria- tion-$30.9 million was put in reserve-plus $25.9 million in carry- over funds. Mr. SKUBITZ. T'he thing that bothers me, Doctor, is that you come here with an excellent program. It looks fine on paper. But, unless this Congress gives you money we accomplish nothing. So far as I am concerned, I want to be as helpful as I can to assist you in this impor- tant work. Thank you, Mr. Chairman. Dr. LEE. I would like to make an additional comment on that, Mr. Chairman. As the program has developed, of course, with the evolution of the planning, the authorizations were well aibove those required, and as we move into the operational phase, we feel that, of course, sig- nificantly more funds will be required with the operating programs. Planning is one thing, but operating programs is quite another. Mr. CARTER. Mr. Chairman, would the gentleman yield? Just how has this money been spent, Doctor, most of it? Dr. LEE. The money, primarily, goes, of course, for the hiring o~f staff and for the activities of the staff, in some cases for the purchase of equipment, the development of coronary care unit, or for long- distance transmission of cardiogram's, which is being tested on an experimental basis. This kind of thing, staff and equipment, which would be related to the educational efforts- Mr. CARTER. Do you have a central place in each region, to which place cardiograms may be transmitted by phone? Dr. LEE. Not in each region. I think that the experimental pro- gram is going on in Misisouri. 93-453 0-68-4 PAGENO="0050" 44 Dr. MARSTON. That is a major one, which has been supported by the National Center for Chronic Disease Control over the last 5 years. It is being field tested in Missouri a.t the present. Mr. CAR1~R. In one region you have such- Dr. MARSTON. Yes. Mr. CARTER. Do you envision in the future the use of such cen- tralized diagnostic aids? Dr. Li~. If we find the experiment in Missouri is successful, and it is demonstrated that you can improve patient care, and that it is feasible from a cost standpoint, that other regions will then want to develop similar programs. It may be that a computer would serve perhaps more than one region. These are expensive, dependmg on the kinds of programs that are developed, such as automated multi- phasic screening. Mr. SKUmTz. For example, to detect some of the diseases early, cancer and cardiovascular diseases particularly, the development of the automated long-distance cardiograms-as other advances take place, say, in the area of radiology, it may be that those would also be applied on a regional basis. I think it is wise to test them out first in a single area, as is now being done in Missouri, to find out how feasible it is at the level of the community hospital, and in the communities where the patients are and the physicians are in practice, to see if it is practical. Mr. CARTER. Many of our community hospitals have lines to these places to interpret their cardiograms in that way. Dr. MARSTON. Dr. Carter, this goes a bit beyond that. The reason they wanted to try this advanced system is that, in addition to the usual telephone lines for the transmission of EKG, this new system doesn't take the place of interpretation by the physician, but does save time in supplying the attending physician with an analysis of the electrocardiogram done by a centrally situated computer. What this project is facing is the fact that we are not going to have enough trained manpower over time to do EKG analyses, and we have to develop some system to augment the highly skilled manpower required in this area. So this system is more than a telephone line. Mr. SKtrBITz. Mr. Chairman, may I ask one more question? Mr. ROGERS. Yes. Mr. SIUBITz. Did you say $200 million was authorized in 1968? Dr. MARSTON. Yes, sir. Mr. SKUBITz. How much did Congress appropriate? Dr. MARSTON. $53,900,000 for grants, and $4,914,000 for direct operations. Mr. SKUBITz. Thank you. Mr. ROGERS. What do you think of combining the comprehensive health planning program and the regional program? What would you think of combining these two programs? Dr. LEE. The two programs have a different purpose. As we move down the path and as these programs develop, they will be obviously closely coordrnated and integrated. But I don't believe they should be combined into a single program. Mr. ROGERS. You don't feel that a comprehensive health plan for a State should include what we are doing in this regional program? PAGENO="0051" 45 Dr. LEE. Yes, I think as we develop our capabilities at the State level for planning and a capability in the areawide planning, it will encompass concerns with migrants, with other kinds of disadvantaged groups, and it will also include considerations of regional medical programs. Mr. ROGERS. In the comprehensive plan, don't we give money for treatment of heart disease to a city? Dr. LEE. In the partnership for health, a formula grant goes to the State, and project grants for the development of comprehensive health services, and these may include services for people who have heart disease or other diseases. The focus of the regional medical programs, and I think this is fundamental to an understanding of the program, is that they have developed a foundation for cooperative arrangements that simply didn't exist before. We did not have this-in some areas, there were programs of continuation of education, such as in Kansas, or we had the Bingham Associates in New England, but we had not seen the kind of grassroots participation focusing on improving patient care. The comprehensive health plan has to encompass manpower, en- vironmental health problems-the full spectrum-and the project grants can relate to a variety of these things. Mr. ROGERS. I realize we are getting this program started now, and it is in a beginning stage, but I would think your planners should be giving thought to combining these programs where there will not be an overlap, because I would think that there would be some areas where there would be rather considerable overlap within a State plan, partic- ularly for heart, cancer, and stroke. Dr. LEE. We are concerned not only about the relationship of the regional programs with the partnership for health, but also the better and more efficient use of all of the programs, such as OEO programs, and we have seen in the Watts area an excellent example of close cooperation between a regional medical program, the develop- ment of a community hospital, and the neighborhood health center program funded by OEO. We are concerned at the national level with stimulating at the State and local level the close integration of these programs so that we can make most efficient use of manpower, which is our scarcest resource, but also the funds available. Mr. ROGERS. Yes. I hope to see some of these OEO programs under your department. I feel strongly on this. I realize this was an innova- tive approach, but I think it should be tied in more closely. Let me ask a few questions that you may want to give answers for the record, that you may not have with you. How many regions are actually operating as of January 19~8? Dr. MARSTON. There are now 12 with funded operational programs. Mr. ROGERS. I know funds. I am talking about operating. Are they really operating now? Dr. MARSTON. Yes, sir; they are beginning. This will vary from one I signed yesterday, which is obviously not doing much, to ones that have been operating a year. Mr. ROGERS. Would you just give us for the record a rundown of each of these 12, the personnel, how they are involved, how much money they are getting, and I would like to know where that money is being PAGENO="0052" 46 spent, how much on television tie-ins, and how many hospitals are tied in, what improvements are made in hospitals. In other words, when we passed this bill, the idea of the thrust of this program was to make sure the new methods of treatment were going to get to the people. Now, I realize it is very early and too soon for us to make a critica' judgment, probably, but I get the feeling that this may be stopping in the dean's office at the medical colleges. Well, I just want to find this out. [Laughter.] Dr. LEE. It had better not be. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE (PUBLIC HEALTH SERVICE) REPORT ON 12 OPERATING REGIONAL MEDICAL PROGRAMS ALBANY REGIONAL MEDICAL PROGRAM The Albany Regional Medical Program was one of the first regions to receive an operational award on April 1, l9~7. Currently funded with $755,605, the region has approximately 43 operational staff members, including approximately 14 physicians, 17 nurses, 5 other allied health personnel, and 6 general support personnel. Over two-thirds oct the staff are from the community hospitals, and they are working closely with the local medical center and RMP staff to increase the capabilities for quality care at the local hospitals. Approximately 60 hospitals from the Albany Region are participating in the program. Approximately 30 of these hospitals are directly participating in the operational projects outlined below. Two hospitals are represented on the Ad- visory Committee, and the remaining are involved in on-going planning activities. Operational Projects 1. Two~way radio coinmunScation system, direct cost-$144,100 This project will expand an existing two-way radio network to include 57 hospitals and 24 high schools. It will provide continuing education for physicians and allied medical personnel. It will also provide information and education pro- grams for administrators, members of boards of trustees, voluntary health agen- cies, adult education classes, and selected civic groups. 2. Co'mmunity information coordinators, direct cost-$73,800 Former pharmaceutical representatives will be used to contact local phyni- cians to tell them about Regional Medical Programs and to evaluate their atti- tudes towards RMP. 3. Postgraduate Instruction Development Panel, direct cost-$102,600 This program proposes to have experimental and control groups of doctors to determine their educational needs. These doctors will then participate in in- structional programs. Afterwards they will be tested to determine the effective- ness of the instruction. 4. Community hospital learning centers, direct cost-$75,800 This project will establish learning centers at community hospitals using "Self Instruction Units" and audio-visual equipment for rapid dissemination of new medical knowledge. Eventually, the directors of this project hope to evaluate physician progress. Initially, 8 hoispitals will be involved. 5. Albany Medical Center coronary care training and demoastration programs, direct cost-$125,200 A coronary care unit will be established at Albany Medical College to serve as a model and training unit for training physicians and nurses who will then be able to establish similar units at community hospitals. This project will aug- ment the existing Coronary Intensive Oare Unit at the Albany Medical Center. PAGENO="0053" 4,7 6A and CB. Community hospital coronary care training and demonstration pro- gram, direct cost-$55,400 This will complement project #5 by establishing coronary care units of three beds each at three community hospitals: Pittsfield General, St. Lukes, and Vassar Brothers. These will serve as demonstration and educational projects for other hospitals in the region. A continuing educational program will serve the perma- nent Unit Staff and staffs from smaller hospitals. 7. Training and demonstration project, intensive cardiac care unit Herk'imer Memorial Hospital, direct cost-$3,500 The initial phase of this project is to train 6 or 8 nurses from small community hospitals in cardiac anatomy and physiology, coronary disease, the principals and staffing of a cardiac intensive care unit, and in handling the complex equipment. These nurses will also be sent to Albany Medical Center for active training with specialized equipment. INTERMOIYNTAIN REGIONAL MEDICAL PROGRAM The Intermountain Regional Medical Program received its first operational grant award on April 1, 1967 and its current operational award totals $1,832,800. Approximately 80 staff members are serving in the operational projects, about one-third of whom are from community hospitals working together with the Re- gional Medical Program staff from the medical center, they are bringing to local health practitioners and hospitals throughout the region modern techniques for treating patients with the categorical diseases. Approximately thirty hospitals are currently participating in the Program. Three hospitals are represented on the Regional Advisory Group, and almost every major hospital in the region has established a local planning group to study local n~eds and to serve as liaison with the Central IRMP staff. Seventeen hospitals are participating in the operational projects outlined below, and as the program continues to grow, it is anticipated that additional hospitals will become involved. Operational Projects 1. Regional faculty and core-staff seminar, direct cost-$12,60O The University of Utah Medical School will hold a series of quarterly seminars on comprehensive health care, continuing education, contemporary learning the- ory, behavioral science principles, and measurement technology. The faculty, ex- perts from across the country, will address an audience of health professionals in- volved in IRMP. 2. Network for continuing education in heart disease, cancer, stroke, and related diseases, direct cost-$243,OOO The objectives of this program are to develop a communications network be- tween patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing 2-way radio system, including 11 hospitals in 7 communities in or near Salt Lake City, will be extended to re- mote hospitals to serve as one link. Closed circuit TV and use of KVED (Uni- versity of Utah education TV) is also planned. This may establish the community hospital as the locus of continuing education. 3. Information and communications ecochange service, direct cost-$40,000 The CIE~S is a region-wide clearing house for information about IRMP. Staff will be put in local communities to act as public relations representatives and also to distribute information to medical personnel and the public. The community staff will also gather information on community needs and resources and re- sources and serve as a station for collecting economic, social, and medical data. 4. Cardiopulmonary resuscitation training program, direct cost-$63,400 The University of Utah will give a 3-day course in resuscitative techniques to selected physicians from small communities. Each physician will then be responsi- ble for teaching the techniques to health personnel in his community. This `resuscitation consultant" ~vill also collect data about the number of times resuscitation is employed and the results. PAGENO="0054" 48 5. A training program in intensive cardiac care, direct cost-$1l8,600 A core faculty of experts in using Cardiac Care Units and diagnosing and treat- ing heart disease will teach short courses in their subjects. The students will be interested physicians and nurses from community hospitals building coronary care units. 6. Training for nurses in cardiac care and cardiopulm'onarl/ resuscitation, direct cost -$34,000 This is an integral part of both the cardiac care and cardiopulmonary resus- citation programs for physicians (#4. #5). Nurses trained in Salt Lake City will return to their communities to serve as a core faculty for reaching the techniques at the local level. The nurses will work closely with the similarly trained physicians. 7. Clinical trainee program in cardiology, direct cost-$65,700 This program has two emphases- (1) To provide general practitioners, internists and cardiologists with training programs in heart disease techniques tailor made to their individ- ual situations. (2) To increase the number of formally trained clinical cardiologists through a training period (3 months to one year) at the existing cardiology school at the university of Utah. 8. Visiting consultants and teacher program for small community hospitals, direct cost -$14,800 Small communities will be given the option of requesting one or two-day clinics. A minimum number of four cardiac patients will be required. These clinics will upgrade the level of care to victims of heart disease living in remote areas. Visiting physicians will assist the local physician in a precise diagnosis in a precise diagnosis of his patients. 9. A regional computer-based system for monitoring physiologic data on-line from remote hospitals in the regional medical program, direct cost-$637,100 This project's purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- pitals, feeding the results of calculations from these signals back to stations within the hospitals, and using the information for diagnosis. 10. Cancer teaching project, direct cost-$94,300 This project attempts to upgrade the level of care available to local communi- ties. The coordinator will direct a program of physician education to create trained cancer specialists who in turn, will become centers of cancer information in their local communities. The physicians will receive a small stipend for teaching and obtaining information. A region-wide tumor registry will be started, as will a training program in new techniques for pathologists. 11. Stroke and related neurological diseases, direct cost-$.98,700 This project will establish clinics to bring expert consultation service in stroke and telated neurological diseases to local communities; will provide continuing education to local physicians and Nurses; will collect data about stroke patients seen and the problems they present to the practitioner. A 24-hour telephone con- sultation service and information library service will be maintained at the Utah Medical Center to provide community physicians with immediate advice. In addi- tion, practicing physicians will be trained at the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. 12. Educational program in respiratory therapy for physicians and nurses, direct cost-$25,300 To train physicians and nurses to utilize the special techniques and equip- ment in respiratory therapy. Five day seminars and foll~w~up 2 day refresher courses will train participants to administer therapy and to teach others. 13. Regional endocrine met a.bolic laboratory, direct cost-$ 237,900 To provide service facilities where practicing physicians can obtain laboratory data essential to the diagnosis and treatment; to create awareness among physi- cians of the possible presence of metabolic and endocrine abnormalities to PAGENO="0055" 49 derive statistical information. Three laboratories will be established: an immuno- assay laboratory, a chemical laboratory to measure steroid hormones, and a developmental laboratory to refine techniques. Seminars will be held both inside and outside of the laboratories. Abnormal findings will be reported to the refer- ring physician by telephone by a physician who is competent to offer consultation. KANSAS REGIONAL MEDICAL PBOGRAM The operational activities of the Kansas Regional Medical Program began on June 1, 1967, and are currently funded at the level of $099,852. Approximately 80 individuals with varied b~1ckgrounds, comprise the current staff, of which about one-sixth are physicians, one-fifth are nurses, and an additional one-fifth are other types of allied health personnel. The remaining staff includes related health personnel, such as communications specialists and social scientists, and general support personnel. About half the staff are from the medical center and the other half are from community hospitals. Together they are working on programs to improve community capabilities for treating the categorical diseases. Approximately 20 community hospitals are currently involved in the Kansas Program, and it is anticipated that additional hospitals will become involved as expansion takes place during the next few years. Ten of these hospitals are directly involved in operational projects, two are represented on the Advisory Committee, and eight are involved in on-going planning activities. Operational Projects 1. Educational programs-Great Bend, Kans.-$261,000 (direct cost) To develop a model educational program in this small community a full~time faculty, which will be affiliated with the Kansas Medical Center, will be In residence. Included in this comprehensive program are plans for continuing phy- sician and nurse education and clinical traineeships for heath-related personnel. Studies will be made of community needs, resources, etc. 2. Health Sciences Communication and Information Center-$77,900 (direct cost) This project is engaged in conducting studies to determine the feasibility of establishing communication linkages vital to education, service, and research programs. Specific studies to be undertaken are a physician communication sys- tem, TV teaching, electronic linkages, and Medlars search capacity. 3. Study of the quality and availability of medical care-$149,000 (direct cost) To determine unmet needs of patients, locations, professional education, and -~working arrangements of physicians and those in the health related disciplines. 4. Hospital information system and data facilities-$67,500 (direct cost) To conduct studies within the region concerning various aspects of community resources and needs, epidemiologic data and participation of health care per- sonnel in continuing educational programs. A computer system will be used. 5. Cardiovascuiar nurse training-$98,.50() (direct cost) To develop an in-service training program to prepare nurses, who are the main- stay of coronary care units in `community hospitals, with basic physiological knowledge of coronary care, ability to use instruments and equipment in coronary care units, experience in home care, and familiarity with social agencies that can aid in the rehabilitation of patients. 6. Cancer detection program~Providenc~ Hospital-$25,000 (direct cost) To evaluate the strengths and weaknesses of the Cancer Detection Center now operating as an area referral center in Providence Hospital in Kansas City, Kansas. The records of patients will be studied to show effectiveness and yield of test results, type of personnel who have used the clinic and their source of referral, and effectiveness of follow-up. 7. Cardiovasc tr work evaluatiou-$21,100 (direct cost) This project will demonstrate the Cardiac Work Evaluation Unit and show its usefulness for the evaluation and rehabilitation of the patient. it is developing an effective technique for showing physicians and the community at large the ability of patients to return to work after receiving the appropriate rehahilita. tion. PAGENO="0056" 50 METROPOLITAN DISTRICT OF COLUMBIA REGIONAL MEDICAL PROGRAM This region began its operational activities on March 1, 1968, with an award o~ $418,318. A staff of 47, including about 11 physicians, two nurses, seven other allied health personnel, and 27 other types of supportive personnel such as computer programmers, coding clerks and secretaries will work together to improve local medical capablities and resources. About half of the staff is from the medical center and the other half is from community hospitals and other local health agencies. This combination of medical center-community personnel helps assure a quality, community oriented program. Seven hospitals are currently participating, and this number will increase as the program expands over the next few years to reach out to the entire region. Three of these hospitals are directly participating in the projects outlined below, two additional hospitals are on the Regional Advisory Group, and two are serving on planning subcommittees. However, several additional hospitals will benefit from these programs as they send their personnel to be trained in the programs outlined below. Operational Projects 1. Freedman's Hospital Stroke Station for the Diagnosis, Treatment, and in- vestigation of Cerebral Vascular Disease, direct cost-$181,889 This project is a comprehensive approach to stroke, from diagnosis and treat- ment to home care and rehabilitation in an urban Negro area. Based in the Freedman's Hospital, a community hospital in the region, the stroke station will serve as a teaching component for physicians and medical students. Related epidemiological and soclo-economic studies will be undertaken. 2. The Washington, D.C. Regional Cerebrovascular Disease Followup and Sur- veillance System, direct cost-$94,~2OO Under the sponsorship of Georgetown University, this project is attempting to establish a uniform system for measuring and evaluating medical care given to stroke patients in the area, in order to facilitate nursing and follow-up services. It will provide information helpful in determining community medical facilities recluirements, and in carrying out epidemiological or demographic studies. Patients entering the system through the various community hospitals in the region will receive follow-up attention and therefore greater continuity of care. 3. A tra4ning progra~n for cardiovascular technicians, direct cost-$74,707 Qualified students *are being trained at the Washington Hospital Center in Washington, D.C. in specific areas of medical observation and procedures to com- plement nurses' activities. In addition to training personnel for work in hos- pitals throughout the region, this project hopes to produce a manual for training these technicians in the other regional hospitals. MISSOURI REGIONAL MEDICAL PROGRAM Operational activities began in Missouri on April 1, 1967, and current operaS tional funds amount to $2,619,000. An estimated 160 operational staff people, with diverse backgrounds, are serving on the Program, including approximately 15 physicians, four nurses, 16 allied health personnel, three social scientists, and approximately 60 computer specialists and their supporting personnel. The remaining staff provide overall support, such as research and staff assistants and administrative and clerical personnel. The developmental approach being employed by this region and outlined In project descriptions below suggests that hospital involvement will increase rapidly over the next two ~years. Currently, nine hospitals are involved in the program, including two hospitals which are represented on the Regional Ad- visory Committee. Operational Projects 1. Smithville community health service program-direct cost $200,957 The purpose of this project is to establish a model community health service program including continuing education and training programs and health education for the public; emergency intensive and restorative care facilities; home care programs; public health, preventive medicine, and school health; co- ordinated with voluntary health agencies~ Program centered around Smithville PAGENO="0057" 51 and to include about 50,000 persons in county (Clay). Activities are centered around Smithville Community Hospital and the group practice clinic as a nucleus. 2. Multipitasic testing of an ambulant population-direct cost $421,471 This project is designed to establish centers for performing series of diagnostic laboratory tests to identify the most useful tests feasible for screening large rural population groups; determine the different patterns for ill and healthy populations as an aid in detection of heart disease, cancer and stroke in pre- clinical stages. Model test centers `will be established at the University Medical Center, Columbia, Missouri, and the State Mental Hospital in Missouri. A third is planned for the Smithvffle complex. 3. Computer fact bank-direct cost $279,365 This project is designed to develop and apply techniques for delivering latest information on diagnosis and care of patients with stroke and allied diseases to the local physicians. Electronic data information storage and retrieval system will be developed at the University Medical Center (Columbia, Missouri) and later extend to include Smithvllle and other communities in the region. 4. Mass scrcening-radiologydi~e~t cost $54,814 This project will help improve the accuracy of radiologic diagnosis of heart disease, cancer and stroke through electronic communications media. Three small rural hospitals will be hooked into the University of Missouri computer and Department of Radiology to evaluate diagnostic efficiency and determine applic- ability of ultra-sound and thermography in diagnosis and therapy. 5. Comprehensive cardiovascular care units-S~pringfjeld, Mo., direct cost $69,341 A comprehensive care unit for grouping patients with heart disease or other circulatory system illness or who have been admitted for other purposes but require close cardiac `observation is being developed. The project is to be under- taken at hospitals without a house staff, where it is hoped that grouping of patients will relieve the workload for nurses on general medical and surgical wards. St. John's Hospital medical Staff and Greene County Medical Society are coordinating activities with 3 local hospitals in Springfield. 6. Communication research unit-direct cost $61,743 Supporting research unit for program to identify public attitudes and knowl- edge about heart disease, cancer, and stroke; tO understand motivations for seek- ing health care and to determine and develop effective methods for communicat- ing with public and lead them to seek medical care. 7. Data evaluation, computer simulation and systems design-direct cost $329,712 This program will help to determine data needed from the public and physicians for early detection of heart disease, cancer and stroke through studies on the form of data, mechanisms for classifying, storing and retrieving data most effectively. 8. Bioen~gineering project-$229,129 The aim of this activity is wider distribution in rural areas of sensor trans- ducers, for early detection of heart disease, cancer and stroke and to generate more information on physiological patterns of these diseases. 9. Program evaluation center-direct cost $103,899 Through a multidisciplinary research approitch accumniate data in `two sep- arate communities about health care, needs and attitudes as a base for developing instruments for measuring quality of care and levels of health in terms of an indiviclual',s function in his community. 10. Automated patient history-direct cost $77,561 This project is testing the feasibility of an automated system for obtaining patient history and analyze complaints prior to examination by physicians, as an aid in early disease detection. 11. Automated electrocardiography in a rural area-direct cost $369,000 To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analyses of ECG's; to demonsti~ate the feasibility of such systems where `this service is limited or non-existent, and to develop, test and implement `the use of bioengi- neering signals as aid in diagnosis. PAGENO="0058" 52 12. Operations research and systems design-direct cost $39,055 This activity will help develop systems concerned with testing "early detec- tion" hypothesis-develoP operational methods of early detection tests for a large rural population. 13. Population study group survey-direct cost $65,200 Using National H~alth Survey questionnaire study factors contributing to use of health services in small towns, with emphasis on the influence of availability of care. 14. Automated hospital record system-direct cost $52,100 This activity is testing the automation of hospital record data through use of computer systems to organize a ready reference service and ~asy access to hos- pital data as a base for measuring effectiveness of changes. 15. Computer Assembled On-Going Manual of Medical and Paramedical Serv- ices-direct cost $26,842 16. Central core administration, planning and coordination-direct cost $238,805 (University of Missouri Medical Center, Columbia, Missouri) Missouri Re- gional Medical Program. MOUNTAIN-STATES REOIONAL MEDICAL PROGRAM This four-state region (Idaho, Montana, Wyoming and Nevada) began its operational activities on March 1, 1968 with an operationhl award of $206,913 to include one activity in coronary care. An operational staff of approximately eleven will serve in the project, and includes five physicians and six nurses. The hospitals involved will include the community hospital in which the activity is taking place as well as those hospitals who will send their staff to `the unit for training. The Regional Advisory Group also includes two hospital representatives. Operational Projects 1. Intensive coronary care in small hospitals in the region-~direct cost $206,913 Hospitals in the Region will send Registered Nurses into St. Patrick's Hospital, Missoula, Montana for coronary care ti~aining. This 3 week course will be offered three times a year for 21 nurses, and there will be follow-ups at the home' hospi- tals four times a year. In addition, a 4-day training program especially designed for small town physicians will be held at the University of Montana four times a year. NORTH CAROLINA REGIONAL MEDICAL PROGRAM On March 1, 1968, the North Carolina Regional Medical Program received a combined planning and operational award totalling $1,485,341. The operational component of this award totalled $753,759 in direct costs' only. The operational staff includes approximately forty individuals, including twenty-eight physicians. one nurse, six other allied health personnel, and five general support personnel. North Carolina has already involved twenty-seven of its hospitals in the Pro- gram. The Advisory Group includes four hospital representatives and planning subcommittees include an additional ten hospitals. Approximately twenty-one hospitals are participating in the operational projects outlined below: Operational Projects 1. Education and research in co~nmunity medical care, direct cost-$209,200 To develop resources for training more medical and allied medical students; to provide new types of educational experiences which will make family practice more attractive; `to have a post-graduate education program at the medical school; to strengthen ties between the medical school faculty and practicing phy- sicians; and to have the medical school become involved in community planning for improving the quality and availability of medical care. Affected by this proj- ect are the following groups: the University Community; the Caiswell County Rural Health Services Project; the Regional Health Council of Eastern Appa- lachia, Inc.; the State of Franklin Health Council, Inc.; the Charlotte Memorial Hospital; the Moses Cone Memorial Hospital, Greensboro; and the Dorothea Dtx Neuromedical Service. PAGENO="0059" ~. Coronary care tra'ining and development, direct cost-$56,938 To use the project as a medium for developing cooperative arrangements among the various elements in the health care community. Initial and continuing education will be provided to nurses and physicians in community hospitals, con- sultation will be available to hospitals in establishing CCU's, and a computer- based system of medical record keeping will be developed. This project has led tO new working arrangements: (1) between the university medical centers; (2) be- tween medical and nurse educators; (3) between doctors and nurses iii comniu- nity hospitals; (4) between university medical centers and community hospitals. 3. Diabetic consultation and educational services, direct cost-$182,081 To establish three medical teams to deliver services throughout the state; to assist in expansion of diabetic consultations and teaching clinics; to provide seminars for physicians and teaching sessions for nurses and patients to assist in organization of a State Diabetes Association and local chapters; to test techniques of data collection. Many people of different disciplines in many coin- munities are involved in this project. 4. Development of a central cancer registry, direct cost-$66,615 To devise a uniform region-wide cancer reporting system, integrated with the PAS, the computer-stored data from which can be retrieved to serve a broad range of educational, research, statistical, and other purposes. The following hospitals are participating in the first year of the project: Duke University Med- ical Center, North Carolina Memorial Hospital, North Carolina Baptist Hospital, Charlotte Memorial Hospital. Veterans Administration Hospital, Watts Hospital, Hanover Memorial Hospital, Southeastern General Hospital, Craven County Hospital. In subsequent years the registry will be expanded to include all hos- pitals and physicians in the region. 5. Medical library e~rtension service, direct cost-~$25,839 To bring medical library facilities of the three medical schools into the daily work of those engaged in medical practice. Local hospital personnel will be trained to assist medical staff; libraries will be organized into a functional unit for responding to requests for services. Bibliographic request service will be established. 6. Cancer Information Center, direct cost-$41,7f6 To provide practicing physicians with immediate consultation by telephone and follow-up literature. Each of the three medical schools will be responsible for providing service in its geographic locale. The aims of this project are two-fold: (1) to assist physicians in providing optimum care of patients with cancer; and (2) to continue the education of the physicians by giving new information in a patient-centered experience. 7. Continuing education in internal medicine, direct cost-$33,313 To bring practicing internists from all over the state to the Medical Center for a month of up-to-date training in their subspecialities. They will share responsi- bilities with attending physicians and make ward rounds with students, staff, and together. This experience should `enhance the appreciation in the University, both at faculty and student levels, for the expanding role of the medical center for the quality of care in the community. 8. Continuing education in dentistry, direct cost-~$67,5OO To provide physicians and dentists with the knowledge of mutual concern which will enable them to be more effective members of the health team. Courses will be given at the University of North Carolina and in communities. Studies will be made of facilities needed to provide dental care in hospitals. The purpose of this project is to insure that as many patients as possible who suffer from heart disease, cancer, stroke, or a related disease receive appropriate dental care as a part of their comprehensive treatment. 9. Continuation education for physical therapists, direct cost-$27,888 To develop and establish regional continuing `education programs for physical therapists in order to strengthen physical therapy services for patients in all parts of the state. Subregions will be delineated where needs and interests will be identified and committees will be organized to arrange local activities~ PAGENO="0060" 54 10. The establishment of a network of coronary care units in small community hospitals in Appalachia, North Carolina This is a proposal to develop coronary care units in seven hospitals in this rural, mountainous area. RMP will supply the monitoring equipment (the hospital pro- vides suitable space) when adequately trained physicians and nurses are avail- able. An intensive training course for physicians will be conducted in the geo- graphic region, and continuing education programs will be conducted when necessary. ROCHESTER REGIONAL MEDICAL PROGRAM On March 1, 1968 the Rochester Program began its operational activities with a modest operational grant award of $255,487. ApproximatelY 15 people are cur- rently serving on the staff which will expand with additional recruitment. The current staff includes 13 physicians, and two allied health personnel. A majority of the staff are from community hospitals, and are working closely with medical center and RMP staff to improve the quality of local patient care. Approximately eleven hospitals from the region are now participating in the program, and this will expand as the program moves forward over the next few, years. Four hospitals are initially participating in the operational projects. Three of these four are represented on the Regional Advisory Committee. Seven addi- tional hospitals are serving on the Advisory Committee and planning subcom- mittees. Operational Projects 1. Renovation and equipping of facilities for a learning center for projected training programs related to heart disease, cancer, and stroke, direct cost- $26,400 The awarded funds are for the purpose of altering and renovating space in Helen Wood Hall, which houses the Departments of Nursing at the University of Rochester. It is planned to convert five rooms into two rooms for self-instructional learning. These facilities initially will be used for four 4-week coronary care training courses for nurses and physicians in the region. New techniques that are disseminated by means of these courses will then be caned to the various com- munity hospitals and rural areas in the region by the training course participants. 2. Postgraduate training program for the physicians in the Rochester 10-county region, direct cost-$83,900 The objectives of this project are centered around the further development of a postgraduate program in cardiology. Learning opportunities will be made avail- able for general practitioners and internists, as well as cardiologists practicing in the region. Several different programs are planned and vary in length from one-half day to two weeks. It is anticipated that a number of the participating physicians will represent community hospitals in rural areas. 3. Registry of patients with acute myocardial infarction in the Rochester re- gional hospitals, direct cost-$21,200 One objective of this registry is to provide a uniform data collection system from which both periodic information as well as longitudinal analyses may be extracted. Appropriate information as to prognosis and treatment will be dissemi- nated to participating hospitals and cooperating physicians in the region. Strong Memorial Hospital in Elmira, New York is already participlating in this project, and it is anticipated that several other community hospitals, especially those in rural areas, will soon also be participating. 4. Proposal for establishment and support of a regional laboratory for the educa- cation and training in the care of patients with thrombotie and hemor- rhagic disorders, direct cost-$69,400 At the present time no single, central facility concerned with the diagnosis and therapy of patients with thrombotic or hemorrhagic disease exists in the Ro- chester region. Laboratory technicians from the regional hospitals will be invited to spend three or four days in the new facility. In addition, the physicians direct- ing this project will visit the participating communities so that a continuing edu- cational program for practicing physicians in the care of patients with thrombotic diseases will be maintained. TENNESSEE MID-SOUTH REGIONAL MEDIOAL PROGRAM On February 1, 1968, the Tennessee Mid-South Regional Medical Program began its operational activities with a diverse array of programs designed to PAGENO="0061" 55 provide local health practitioners and hospitals with advanced techniques and facilities necessary for quality health care. Over fifty people are currently serv- ing on the staff of the operational program, including approximately thirty-five physicians, five nurses, five other allied health personnel, and nine general support personnel. About one-fourth of the staff are from community hospitals and the remaining are medical center staff who are working on the community oriented projects discussed below. Seventeen hospitals are currently participating in the operational projects, representing broad geographic spread throughout the region. Ten of these hos- pitals are also represented on the Regional Advisory Group. Operational Projects 1. Continuing medical education-Meharry, direct eost-$44,800 Meharry Medical College is informing Negro physicians in the region about more effective techniques for treating heart disease, cancer, and stroke. Teams of physicians will teach two-week courses in the three areas at the Medical Cen- ter, using various audio-visual aids and, where feasible, prograjnmed instruction. One of this plan's interesting provisions is sending a senior resident from Meharry to care for the physician's practice while he is attending the course. 2. Continuing education-Vanderbilt, direct cost-$141,600 Vanderbilt proposes to establish continuing education centers at community hospitals linked to a proposed Department of Continuing Education at Vander- bilt. Libraries and information centers at the local hospitals will bring Vander- bilt's information, resources to the local physician. The program, though planned and coordinated by Vanderbilt, will function through the local centers and em- phasize bringing information to the physician at the times he needs it. 3. and 4. Hopkinsville Education Center and Chattanooga Education Center, direct cost-$73,700 These are the first of the local continuing education centers specified in the Vanderbilt plan. At each hospital, a full-time Director with an appointment at Vanderbilt and an assistant director will supervise resident and physician edu- cation in their area. Their services will be available to physicians at smaller community hospitals in each area, as will the enlarged hospital library facilities. The Chattanooga and Hopkinsville locations provide the basis for looking at problems in continuing education in urban and rural settings. 5. Special training for practicing radiologists-Vanderbilt, direct cost-$50,400 This plan focuses on developing practicing radiologists' skills in vascular radiology, but might later be broadened to include all aspects of diagnosis and therapeutic radiology. Two post-graduate educational methods will be used. One to three month courses for technologists will be offered. In addition, emi- nent radiologists will preside at two-hour monthly seminars to which all radiologists in the region will be invited. 6. Cardiac nurse training program-Mid-State Baptist Hospital-N as hviUe, direct cost-$49,600 The key factor in reducing mortality from cardiac arrest is the immediate availability of a knowledgeable person to initiate resusCitation. Mid-South Baptist proposes to instruct cardiac nurses. in new resuscitation techniques by holding three four-week courses. These nurses will then be available to hospitals throughout the region. 7. School of X-ray and technology-Meharry, direct cost-$19,500 Meharry plans to establish a two-year program for training at least ten X~ra~s~ technologists per year. The faculty will be Meharry's Radiology staff. Feasibility studies for establishing nuclear medicine and radiotherapy programs will be conducted. 8. Radiology technologist training program-Vanderbilt, direct costs-$3O,30'O Vanderbilt proposes to increase the number of X-ray technologists, improve the `quality of their training, and increase their opportunities for continuing educa- tion. Three small hospital training programs in the area will be discontinued as separate entities and subsumed by a new school of X-ray technology at Vanderbilt. Practical clinical experience will be both at Vanderbilt and the smaller hospitals. PAGENO="0062" 9. Nuclear medicine training program-Vanderbilt, direct cost-$25,300 A new series of courses taught by paramedical and medical personnel will be made available to physicians and technologists to increase their skill in nuclear medical techniques. When poesible the physician and his technologist will spend some training time together to work out procedures suited to their situation. Trainees will be accepted from smaller community hospitals planning to establish or improve nuclear medicine services. 10. Ecepansion of ~Jchool of Medical Technology-Baroness Erlanger Hospital- Chattanooga, direct cost-$S5,400 To augment medical technology capabilities in the area, this plan makes two proposals: (1) Expand the Baroness Erlanger program for medical technologists; and (2) establish a school for certified lab assistants who could free technologists from more routine work for more complex procedures. 11. Vanderbilt Coronary Care Unit, direct cost-$51,600 This project's purpose is to establish a network of coronary care units with adequate equipment, staffed by well trained personnel. Vanderbilt will be the training and information center for the region; a demonstration unit there will provide a focal point for continuing education. In addition, communication systems will be set up to facilitate the flow of information from Vanderbilt to the community hospitals. Studies are being made to see if the small hospitals connected with Vanderbilt can become, in turn, centers for local networks of coronary care facilities in still smaller hospitals. 12. Franklin Coronary Care Unit-Williamson County Hospital-Franklin, direct cost-$31,400 This is one of the subsidiary units mentioned in the Vanderbilt proposal. This is primarily a pilot project to study the feasibility and usefulness of establishing a center in a small community hospital. 13. Hopkinsville Coronary Care Unit-Jennic Eitnart Memorial Hospital-Hop- kinsvifle, Ky., direct cost-$4.9,500 This plan is similar to the Franklin plan, except that it mentions establishing links to smaller community hospitals by helping set up smaller care units in them, thus providing for the grouping of rural community hospitals for `more efficient use of existing reskurces. 14. Clarksville Coronary Care Unit-ClarksvUle Memorial Hospital, direct cost- $19,000 As the Franklin program, this project `is a subsidiary `of the Vanderbilt pro- po~al. Since this hospital has been operating a unit, the plan calls for i:ts expan- sion, continuing education and a phone hook-up to Vanderbilt. 15. Nashville General Coronary Care Unit-Nashville Metropolitan General Hos- pital, direct cost-$42,100 Again, this is like the Franklin plan. Nurses here will be included `in the in- service training programs initiated throughout the participlating hospitals. 16. Meharry Medical College Coronary Care Unit, direct cost-$35,800 Meharry intends to establish a demonstration unit `of coronary care facilities which will serve as a continuing education center for smaller hospitals in its region. 17. Murray Coronary Care Unit-Mnrray-Calloway (Ky.) County Hospital, direct cont-$38,800 Murray-Oalloway Oounty Hospital, the training center for Murray State Uni- versity School of Nursing, will serve as `a demonstration center for the sub- region. Direct phone communication will be established with Vanderbilt, which will send consultants from its school of continuing education. This project has the dual objective of relating the Murray State Nursing program to an established medical center and providing regional training resource to a remote `area. 18. Chattanooya Coronary Care Unit-Baroness Erlanger Hospital, direct cost- $14,400 Bai~oness Erlanger plans `to establish a coronary care unit in a program `of co- operation `with Vanderbilt. Both telephone communications and electronic main- tenance systems connected with Vanderbilt will be installed. This unit will serve as a center for the smaller hospitals in Chattanooga. PAGENO="0063" .57 19. Baptist Hospital Coronary Care Unit-Mid-State Baptist Hospital, Nanh- vile, direct eost-$51,000 This plan is similar to the others included in the Vanderbilt plan. Baptist Hospital will expand its present facilities and `aid establishment `of smaller cen- ters at Tullahoma and Crossville, Tennessee. Direct `telephone lines will be estab- lished for `consultations. The unit director will have a clinical faculty `appoint- ment at Vanderbilt. He will devote approximately 25% of his time to the unit. 20. Crossville Coronary Care Unit-Uplands Cumberland Medical Center, Cross- vile, direct cost-$28,300 This project has two purposes: (1) to establish a two-bed coronary care unit in the hospital; and (2) to determine the feasibility of operating acute coronary care units in rural areas. The hospital will cooperate with Mid-State Baptist Hospital and Vanderbilt. 21. Tullahoma Coronary Care Unit-Horton Memorial Hospital, Tullahoma, Tenu., direct cost-$28,800 See Baptist Hospital Program. 22. Meharry supervoltage therapy program, direct cost-$58,300 This project `is aimed specifically at improving cancer therapy for a large in- digent population. Meharry will use its funds to obtain a cobalt 60 High Energy Source for therapy and a computer hook-up with Vanderbilt. These facilities will also be used to improve undergraduate and graduate radiology training programs at Meharry. 23. Project to improve patient core in a remote mountain community by recruit- ing and training health aides for a new eatended care facility-Scott County Hospital-Oneida, Tenn., direct cost-$10,300 Manpower shortage in this isolated mountain hospital is critical. Personnel to man an extended care facility now under construction will be obtained by two methods: (1) In-service training for hospital personnel; (2) an educational director (an RN) to serve as a liaison to the high schools to' encourage young people to enter the medical field and come back home to practice. In addition a training program leading to the LPN would be initiated. Clinical training will be supervised by the Educational Director while local high schools provide basic training. 24. Health evaluation studies on a defined population group-multiphasic screen- ing-Meharry Medical College, direct cost-$436,000 Meharry will determine the effectiveness of a comprehensive health program and multiphasic screening examinations in early diagnosis of heart disease, can- cer, stroke and their precursors. To run this experiment, a neighborhood medical center supported by OEO will serve a selected population of 18,000. The test population and a control population will be evaluated with reference to morbid- ity, changes in health attitudes and utilization patterns, effectiveness of the screening procedure and the cost per patient diagnosed or treated. 25. Ecperiment to test and implement a model of patient care-Vanderbilt Uni- versity Hospital, direct cost-$110,400 This is an attempt to define a new structure for pa'tient care. New personnel called stewardesses will be trained to take over the nurses' non-clinical duties. Nurses would then be free to spend more time with the patient and to keep up their specialized skills. After the model is refined at Vanderbilt, it will be tested in community hospitals-specifically Baptist and St. Thomas. 26. A medical surgical nurse specialist graduate program to improve nursing care of patients with heart disease, cancer, and stroke-Vanderbilt University School of Medicine, direct cost-$23,'600 Vanderbilt is developing a program to train medical surgical nurse specialists to improve nursing care of heart, cancer, and stroke patients. It will be a master's degree program staffed by physicians and clinical nurses (1 calendar year) plus one year of clinical experience half at Vanderbilt and half at the community hospital. Stipends will be provided during the first year only. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAM With an operational grant award of $1,032,003 on February 1, 1968, this two- state region began its efforts to bring quality care to the dispersed populations PAGENO="0064" 58 of this area. About forty operational staff members are currently serving on the program, including about seventeen physicians, three nurses, six other allied health personnel, and fourteen related health and general support personnel. About one-third of the staff is from the medical center, another third is from com- munity hospitals and the last third is from other health and medical organiza- tions. The entire staff is working in concert to bring up-to-date medical tech- niques to communities throughout the region. Strong hospital involvement in the Washington-Alaska program is evident in the project descriptions below. Approximately 36 hospitals are currently partici- pating in the program, almost 20 of which are directly involved in operational activities. Six of these hospitals are represented on the Regional Advisory Groups, and an additional four of these are on planning subcommittees. The re- maining participating hospitals are involved in current planning activities. It is likely that these, and the many other hospitals in the region, will become in- creasingly involved in operational activities. Operational Projects 1. Central Washington~-Communication system for continuing education for physicians-$18,181 (direct cost) This project is designed to bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to surrounding smaller communities through seminars and conferences, educational TV, other audio-visual instruction; and exchange of teachers and practitioners. It will also connect internists in Central Washing- ton to Yakima cardiologists via EKG telephone hot-line, to permit quick analysis (starting with 5 community hospitals). Three general hospitals in Yakima in- volved are: St. Elizabeth's, Yakima Valley Memorial, and New Valley Osteo- pathic. Nine other communit~y hospitals to be reached initially are located in Ellensburgh, Moses Lake, Othello, Toppenish, Prosser and Cynnyside. 2. S~outheastern Alaska-Postgraduate education-$27,062 (direct cost) This program will help improve communication between Seattle Medical Com- munity and University to alleviate problems of the isolated physicians in south- east Alaska cities and communities: Juneau, Sitka, Ketchikan (3 largest). As in Central Washington several methods will be used such as telelectures, consul- tant services, seminars and the EKG hot line to hospitals in Juneau, Sitka, and PHS Native Hospital at Mt. Edgecumbe and Ketchikan community hospital. 3. Postgraduate preceptorship for physicians-Coronary care-$17,610 (direct cost) A pilot project to provid~. opportunity for practitioners from isolated com- munities to spend a week or taore under a preceptor at major medical centers to study advances in care of coronary heart disease. The 4 major medical centers in Seattle are Providence Hospital, Swedish Hospital, Virginia Mason Hospitals and Medical Center, and University Hospital and Medical Center; two in Spokane are Deaconess Hospital and Sacred Heart Hospital. 4. Coronary care wait coordination-$70,255 (direct cost) This activity will serve as coordinating unit for CCU related projects-their development, improvement of operations, and training activities. A mock-up coronary care unit will be used in the educational programs for nurses and physi- cians; audio-visual self-instruction materials will be produced and evaluated. 5. Cardiac pulmonary technician training-$41,554 (direct cost) This program will help develop a formal program for training cardlo-pulino- nary technicians to perform non-critical functions in coronary care units and free physicians for other duties. Four larger general hospitals in Spokane will parti- cipate with Spokane Community College. The 4 hospitals are Deaconess, Holy Family, Sacred Heart and St. Luke's Hospital. 6. Information and education resource support unit-$522,304 (direct cost) This program will help provide medical communities with the skilled assist- ance which will help identify their educational needs and serve as a support unit in developing programs to meet them; to establish a central production unit, to coordinate audio-visual projects and the distribution of materials, to penetrate the entire region. PAGENO="0065" 59 7. Two-way radio conference and slide presentation-$8,4I~5 (direct cost) Six pilot programs on. heart, cancer and stroke topics to be transmitted via ti~ro.way radio-telephone slide conferences, to physicians and hospital staffs on topics selected by a panel of physicians, starting with 20 hospitals in Washington are underway. It will explore potential for continuing network series with local and remote regions. 8. Continuing education and on-the-job training of laboratory personnel-$53,446 (direct cost) Primary purpose of this activity is to train technical personnel in newer clinical laboratory procedures, and shorten gap between availability of advance in techniques and actual use. First phase is to be directed at 5 local designated training centers in Washington (cities of Seattle, Tacoma, Spokane, Yakima and Vancouver) and Anchorage, Alaska. University of Washington will select from a list of available lab procedures, arrange training courses for technicians in specific ones at designated facilities and establish quality control criteria; they will follow through with education of physicians in newer and practical tests for better diagnosis and treatment. 9. Alaska medical library facilities-$21,754 (direct cost) This activity will help develop a community medical library located at the PITS Alaska Native Medical Center, Anchorage, for Alaska physicians and health related staffs and agencies. It will have close ties with community col- leges, Arctic Health Research, University at Fairbanks and to supplement con- tinuing education projects for Southeast Alaska and the Anchorage cancer project. 10. Anchorage cancer program-$51,450 (direct cost) Tb~s project will aid in pro~riding a supervoltage therapy unit for cancer patients to be located in an addition to Providence Hospital in Anchorage. It involves training of radiologist and technical staffs, consultant clinical confer~ ence~ and accumulation and analysis of dianogstic data. Presbyterian Com- munity Hospital in Anchorage will be participating. 11. Care of children wiTh canc~' (study)-$28,030 (direct cost) This is an epidčmiological study to determine the impact of different metbod~ of care for children with cancer, focusing on differences among children treated in local communities and at thajor centers; to be conducted by the staff of Children's Orthopedic Hospital and Medical Center, Seattle. 12. Radiation physicist consultation program for radiologists in Washington and Alaska-$56,393 (direct cost) This project will provide consultation services of a radiologist-physicist for smaller hospitals, in dosimetry and other problems of radiotherapy. To enbtuice postgraduate education for radiology residents and paramedical trainees outside of the University system. 13. Computer-aided instruction in heart disease, cancer, and stroke and related diseases-$53,390 (direct cost) To develop and evaluate the effectiveness of computer-aided instruction for teaching medical techniques. Participants will be instructed in the use of com- puter terminals. WESTERN NEW YORK REGIONAL MEDICAL PROGRAM With an award of $357,761, the Western New York Regional Medical Pro- gram began its operational program on March 1, 1968. The current operational staff of seven physicians, one nurse, and two secretaries will be expanded to over 20 during the next several months. Over forty hospitals are currently in- volved in this program, almost all of which are slated to be part of the devel- oping regional two-way TV network for continuing education. Eleven hospitals are represented on the Regional Advisory Group, and an additional two hos- pitals are serving on planning subcommittees. Operational Projects 1. Two-way communications network, direct cost-$170,519 A two-way communication network will link hospitals of Western New York and Erie County, Pennsylvania to the Continuing Education Departments 93-453-68-5 PAGENO="0066" 60 of the State University of New York at Buffalo and the Roswell Park Memorial Institute. The network will serve several purposes, Such as continuing educa- tion for physicians and the health-related professions, public education, ad- ministrative communication, consultation, with experts, and contacts among blood banks. It will assist both the physician and community hospital in either the rural or urban environment in having at their fingertips the latest advances in the diagnosis and treatment of heart disease, stroke, and cancer. Particular emphasis will be placed upon involving rural hospitals in this program there- by improving both their didactic and restorative function. 2. Coronary care information coordinators, direct cost-$127,544 This project will test a training technique for providing qualified nurses who will be required to staff developing coronary care units in the Region. Approxi- mately 80 nurses will be selected from all parts of the Region for a combined academic and clinical course. It is planned that the nurses x~eceiving this train- ing will return to both rural and urban hospitals for the purpose of provid- ing a diagnostic and didactic function. While the program will be housed at the medical center, the community hospitals of this region will be the bene- factors of the project. Since there are few nurses trained to work in coronary care units, particularly in the rural environment, special attention will be paid to attracting nurses who will return to the community hospital. WI500N5IN REGIONAL MEDICAL PROGRAM The Wisconsin Program began its operational activities on September 1, 1967 when it became the first Regional Medical Program to be awarded a combined planning and operational grant. Currently funded with $630,147,. about one third of which is for operational activities, the operational staff num- bers 20. About one-third of the staff are physicians, another third are allied health personnel, and the last one third are supportive and other type of per- sonnel. Approximately 20 hospitals are involved in the current phase of the Pro- gram~ Eleven of these hospitals are directly involved in the operational projects. Five are represented in the Regional Advisory Group and the remaining are represented in planning subcommittees. As the program develops additional activities during the next few years, it is anticipated that many additional hospitals will be involved. 1. ,8t~tdy program~ for uterine cancer therapy and evaluation, direct cost-$40,10~.t This pilot project is designed to review and evaluate current radiotherapy for patients with uterine cancer. In its first phase it will involve information ex- change and dosimetry atandardization. Hospitals at Marquette and the Uni- versity of Wisconsin will be connected to a central, computerized data bank in Milwaukee which will compute radiation classes. When the necessary computer techniques are developed, it is projected that the central facility will be linked to other hospitals outside the Milwaukee and Madison areas with similar treatment programs, and the long-term result will be to improve local medical capabilities for the treatment of all uterine cancer patients in the Region. 2. A pilot demonstration program for pulmonary thromboembolism, direct cost- $84,600 In this project a center is being established at Marsbfield Hospital in Marsh- field, Wisconsin, for demonstrating diagnostic techniques and the available therapy for pulmonary thromboembolism. The project has a continuing educa- tion component which will reach physicia.ns from many hospitals in the Region. This will involve a 24-hour consultation service, the preparation of a movie on the topic, and special training sessions for groups of physicians. The project will demonstrate a comprehensive program which will encompass diagnostic, preventive, therapeutic, and rehabilitation procedures for patients,. postgraduate education, a rapid transportation system for patients from Northern sections of the state, and cooperation between the clinic and other hospitals and medical schools in the State. 3. Telephone dial access tape recording library in the areas of heart disease, can- cer, stroke, and related diseases, direct cost-$18,950 This feasibility study will he carried out by the University of Wisconsin which will record and store short, 4-6 minute, tapes on various aspects of treating iatients with the three diseases. Any physician anywhere in the PAGENO="0067" 61 Regioli t~an dial the library at any time and request a tape relevant to a problem in which he is interested. 4. Nursing telephone dial access tape recording library in the areas of heart disease, cancer, stroke, and related diseases, direct cost-$18,800 This feasibility study, similar to the one above, will establish a central tape library with information recorded on nursing care in emergencies, new pro- cedures and equipment, and recent developments in nursing. Nurses from any hospital in the region will be able to call at any time to have a tape played to them. 5. Development of medical and health related single concept film program in community hospitals, direct cost-$33,250 This education feasibility project involves ten community hospitals in its first phase. Fifteen films on procedures and techniques used in treating heart, cancer, and stroke, will be developed. Projectors and the filmis will 1e installed in the hospitals for use by physicians and other health personnel at their con- venience as a continuing education device. After four to six months the ma- terials will be relocated in ten additional hospitals. TELEVISION, RADIO AND TELEPHONE NETWORKS FOR CONTINUING EDUCATION OPERATIONAL PROJECTS I. Albany Regional Medical Program Two-way radio communication system-Direct cost, $144,100 This project will expand an existing two-way radio network to include 57 hospitals and 24 high schools. It will provide continuing education for physicians and allied medical personnel. It will also provide information and education programs for administrators, members of bohrds of trustees, voluntary health agencies, adult education classes, and selected civic groups. II. Intermountain Regional Medical Program Network for continuing education in heart disease, caincer, stroke, and re- lated diseases-Direct cost, $243,000 The objectives of this program are to develop a communications network between patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing two-way radio system, including 11 hospitals in 7 communities in or near Salt Lake City has been expanded to 10 additional remote hospitals to serve as one link: This system will be expanded to additional hospitals iiii response to physician requests. Closed circuit TV and use of KVED (University of Utah education TV) is also planned. This may establish the community hospital as the focus of continuing education. III. Kansas Regional Medical Program Health sciences communication and information center-Direct cost, $77,900 This project is engaged in conducting studies to determine the feasibility of establishing communication linkages vital to education, service and research programs. Specific studies to be undertaken are a physician communication sys- tem, TV teaching, electronic linkages, and Medlars search capacity. Linkages will be established at hospitals in Great Bend, Pittsburg and Kansas City. IV. Washington-Alaska Regional Medical Program Central Washington-Communication system for continuing education for physi- cians-Direct cost, $18,181 This project is designed to bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to surrounding smaller communities through seminars and conferences, educational TV, other audio-visual instruction; and exchange of teachers and practitioners. It will also connect internists in Central Washington to Yakima cardiologists via EKG telephone hot-line, to permit quick analysis (starting with 5 community hospitals). Three general hospitals in Yakima in- volved are: St. Elizabeth's, Yakima Valley Memorial, and New Valley Osteo- PAGENO="0068" pathic. Nine other community hospitals to be reached initially are located in Ellensburgh, Moses Lake, Othello, Toppenish, Prosser and Sunnyside. Southeastern Alaska-Postgraduate education-Direct cost, $27?062 This program will help improve communication between Seattle Medical Corn- inunity and University to alleviate problems of the isolated physicians in south- east Alaska cities and communities: Juneau, Sitka, Ketchikan (3 largest). As In Central Washington several methods will be used such as telelectures, con- sultant services, seminars and the EKG hot line to hospitals in Juneau, Sitka, ~tnd P115 Native Hospital at Mt. Edgecumbe and Ketchikan community hospital. Two-way radio con/'erence and slide presentation-Direct cost, $8,~45 Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio-telephone slide conferepces, to physicians and hospital staffs on topics selected by a panel `of physicians, `starting with 20 hospitals in Washing- ton are underway. It will explore potential for continuing network series with local and remote regions. V. Western New York Regional Medical Program Two-way communications network-Direct cost, $170,519 A two-way telephone ~communication network will link over 40 hospitals of Western New York and Erie County, Pennsylvania to the Continuing Education Departments of the State University of New York `at Buffalo and the Roswell Park Memorial Insii'tute. The network will serve several purposes, such `as con- tinning education for physicians `and the health~related professions, public ed- ucation, `administrative communication, consultation with experts, and contacts among blood bank's. Mr. Rooi~iRs. I notice you said in the North Carolina program there were some coronary care units. How many coronary care units? I want to know what is happening to the hospitals. Now, how many hospital administrators or people involved in the actual administration of hospitals where services are delivered? How many are on your national council? Dr. MARSTON. One, Dr. ~J. T. Howell, of the Henry Ford Hospital. The executive director of the American Hospital Association, Dr. Edwin Crosby, is also a member, so this is 2 out of 12 directly repre- senting the viewpoint of hospital administration. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON HosPITAL ADMINISTRATORS PARTICII?ATING IN REGIONA1~ MEDICAL PROGRAMS * Number of hospItal administrators Percent of total membership Total Regional advisory groups Subcommittees 338 10 222 83 12 7 Boards of directors 1 33 19 1 Boards of directors of the 14 new organizations formed as the coordinating agencies for their programs. HOSPITAL ADMINISTRATORS ON REGIONAL MEDICAL PROGRAM STAFFS Approximately 40% of the regions have established a Division of Hospital and Facilities Planning. These are, as a rule under the direction of a hospital administrator. EXAMPLES OF HOSPITAL ADMINISTRATOR PARTICIPATION IN RMP Georgia In Georgia, each hospital in the region was encouraged by the Georgia RMP to appoint a local advisory group to work with the Program to advise on local needs PAGENO="0069" 63 an~ problems and to serve as the liaison gro~ip between the Georgia Central Regional Medical Program office and the local community. To date, 121 hospitals have appointed local advisory groups out of the total 178 hospitals in the region. These represent 90% of the general and limited services hospital beds in the region. These groups consist of ~ physician, a hospital administrator, a nurse, and at least one interested member of the public. Uonneoticut In Connecticut, four Advisory Conferences have been established to aid the Advisory Board in its work. These four conferences consist of: (a) the Presidents of the Boards of Trustees of the hospitals of Connecticut; (b) the Chiefs of Staff of these hospitals; (c) the Administrators of these hospitals; and (d) rep- resentatives of over 50 "health" agencies of Connecticut. T~ire~tors of Medical Education from Connecticut hospitals~ have also been invited to meetings of the Advisory Conferences. Albany Part of the Albany operational program is~ concerned with the equipping of hospitals with two-way radio equipment. The Regional Medical Program person- nel have visited the non-participating hospitals and discussed wIth the adminis- trators and members of the staffs the advantages of joining the radio network, The number of hospitals involved in this network increased by 50~ in the first year, bringing to 36 the number of participating hospitals. Maryland In Maryland, the RMP staff has devoted considerable effort to developing con- tacts with the community hospitals. At least 21 of the 38 hospitals in the region have been visited by the Regional Medical Program staff. In November 1967 a three-day planning workshop was held by the Maryland RMP. Invitations were extended to all the hospitals in the region and over half of the short-term, non-federal hospitals sent one or more representatives. Those who attended expressed a genuine ~desire to cooperate in the planning process. OTHER DEVELOPMENTS Community planning committees have been organized In several other regions including South Carolina, Intermountain, and Greater Delaware Valley. These local planning committees all include hospital administrators in their mčni~ bership. HOSPITAL ADMINISTRATORS ON THE NATIONAL ADVISORY COUNCIL AND ON TillS REVIEW COMMITTEE Council: (1) Edwin L. Crosby, M.D., Director, American Hospital Association, Chicago, Ill. (2) James T. Howell, M.D., Executive Director, Henry Ford Hospital, Detroit, Mich. Committee: (1) Mr. John D. Thompson, Director, Program in Hospital Admin- istration, School of Public Health, Yale University, 1~ew Haven, Conn. Fo~mźrs Members: (1) Mark Berke, Director, Mount Zion Hospital and Medical Center, San Francisco, Calif. (2) Howard W. Kenney, M.D., Medical Director, John A. Andrew Memo- rial Hospital, Tuskegee, Ala. Mr. ROGERS. It seems to me the thrust of this program has got to get down to that. How about in your regional medical councils, the local ones? Dr. MARSTON. Ten percent of those represent hospitals. Mr. ROGERS. Should there be more? Dr. MARSTON. I don't know the answer to that, Mr. Chairman. Mr. ROGERS. Give US your thinking on that. I am concerned that we are not getting enough of the people involved who are meeting the patient and getting care to him. PAGENO="0070" 64 Dr. MAESTON. The American Hospital Association is ha~ing a con- ference at our request in June to focus on just the problem you are bringing up. Mr. ROGERS. I would be interested in following the results of that conference and your actions on it. Now, what other professions are involved in these regional medical programs, and in the field? Could you give me a rundown on that? If you will let us have this it would be helpful. Are you really tying them in-nurses, dentists, and so forth-as well as educators? (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON PROFESSIONAL INVOLVEMENT IN REGIONAL MEDICAL PROGRAMS The scope of professional involvement in Regional Medical Programs is both broad and balanced, and is evident in all facets of the programs across the country. Broad professional involvement is seen in the composition of Regional Advisory Groups, planning committees, program staffs and operational activities. Such involvement reflects the essential cooperative nature of Regional Medical Programs as they work toward harnessing the multiple health and medical resources in local areas in order to help provide high quality care in heart, cancer, stroke and related diseases. The membership of the Regional Advisory Groups, which currently totals ap- proximately 1900 individuals, includes 21.9% practicing phyicians 15.6% medi~ cal center officials; 13.1% hospital administrators; 11.7% voluntary health agencies; 7% public health officials; 8.1% allied health workers; 15.3% mem- her of the public and 7% others. Planning committees, which currently include about 2500 Individuals, also demonstrate broad involvement. The membership includes: 18% practicing physicians; 41% medical center officials; 13% hospital administrators; 6% voluntary health agencies; 6.5% public health officials; 10% allied health workers; 5% members of the public, and 5% others. In terms of participating organizations, it is estimated that over 1700 orga- nizations are now involved in Regional Medical Programs. These include all of the medical schools, state medical societies, state heart and cancer societies, and state health departments. Almost 60% of the state nursing and dental associations are involved; about 80% of the schools of public health and state hospital associations are involved; and about 35% of the schools of denistry. In addition, many schools of nursing and other allied health professions are involved as well as a broad array of other professional organizations and institutions. CORE PLANNING AND ADMINISTRATIVE STAFF Reports from the Regions indicate that approximately 47% of the professional and technical planning staff are physicians. Allied health professionals including nurses, hospitals administrators, dentists, and others account for approximately 12% of the core staff. Related health profesisionals, including health economists, medical sociologists, statisticians, and others account for approximately 19%; general supportive staff accounts for about 16%; and "other" groups account for 6%. OPERATIONAL STAFF The operational staff personnel are concerned with the implementation of specific operational projects. The manpower involved in these projects comes from a broad range of specialities, including physicians (25%); nurses (8%); other allied health (10%); education and communicationS (5%); computer and other electronics specialists and their supporting personnel (16%) ; other techni- cians (14%); administrative and clerical (20%); and other 2%. Dr. MARSTON. I spoke to 80 nurses in Wisconsin last night, via a telephone lecture system- Mr. CARTER. Will you yield on that? Mr. RoGERS. Yes. PAGENO="0071" 65 Mr. CARTER. I notice this bill provides that dentists may refer patients to some of the regional centers, and I want to say that I think that is very good. I am happy that dentists and oral surgeons are included. Mr. ROGERS. Thank you. Do you provide for patient care in hospitals under this program? Dr. MARSTON. Patient care costs must be limited to those which are incidental to research, training, education, or demonstration activities funded by the regional programs. We consulted various hospital groups to get advice of how we would administer this, and their advice was that we should be very cautious about the actual payment of patient cost, so we have not spent much. Mr. ROGERS. Let me have a breakdown on what you have done and where it has gone. (The following information was received by the committee:) The Department of Health, Education, and Welfare has determined that the ~following patient care costs, hospitalization costs, have been supported with regional medical program grant funds: (1) Missouri Regional Medical Program-$90,050. Mr. ROGERS. Do you use consultants, and where are these used mainly as far as the regional medical program is concerned? Dr. MARSTON. We have used consultants at the national program from just about every area of health-hospital planning grOups in~ cluded. We receive a grant request and we use consultants with ex~ pertise in the area covered by the request, on the site visit. Mr. ROGERS. Who determines what the region shall be? Do you de termine it? Dr. MARSTON. Essentially, the Surgeon General must determine this. Mr. ROGERS. Are they too large now? Dr. MARSTON. Some are quite large, but I think it will change. Mr. ROGERS. Are there any plans for changing these? Dr. MARSTON. There is discussion during the planning period in every region regarding the extent to which the regional approximation has worked, and this is commented on in the grant applications that come in to us. I think there will be changes over time, but I think many areas are finding they want the advantages of the larger regions and yet the opportunity of breaking down into subregional groups, and we have not discouraged this. Mr. ROGERS. What has happened in Florida? I don't think they have gotten off the ground there; have they? Dr. MARSTON. They have a planning grant that was made this year. Mr. ROGERS. So you would anticipate a year- Dr. MARSTON. Yes. I take that back, partially. We have had an ap~ plication from Florida since that planning grant asking for funds for a feasibility study, which the National Advisory Council allows under a planning grant. This application arrived on my desk yesterday. Mr. Roonns. I would like the status, if you could give it to us, of all the regions, the 53, what States they are in, when we can expect to see something get down to the local hospitals and into the medical pro- fession there. PAGENO="0072" 66 (The following information was received by the committee :) DEPARTMENT OF HEALTH, EDUCATION, 4ND W~I~FARE STATEMENT ON THE STATUS OF REGIONAL MEDICAL PROGRAMS As indicated in the table below, all Regions except Puerto Rico have embarked upon planning; and 41 of the 54 Regional Medical Programs liave been engaged in planning activities for a year or longer. These planning activities have in- volved a large number of diverse health and health related professionals (e.g., physicians, medical sociologists, hospital administrators, epidemiologists, allied health personnel) representative of a wide spectrum of health institutions and organizations, including community hospitals, local and state medical societies, official and voluntary health agencies, and state hospital associations. These indi- viduals are serving on planning task forces and local advisory committees as well as Regional Advisory Groups. In addition, a number of such individuals are also serving on the central core staffs of many Regional Programs. Experience to date clearly demonstrates that the involvement of community hospitals and other local health resources, private practitioners, and other health professionals becomes more extensive and intensive as Regional Programs enter the operational phase. At that stage, for example, community hospitals become the sites for coronary care unit demonstration and training programs; local physicians and hospitals undertake the training of cardiopulmonary technicians needed in the community; private practitioners and their patients in rural areas ~benefit from automated EKG readings utilizing telephone lines; and programs to recruit and train sub-professional health aides required to staff extended care facilities, are initiated. Initial operational grants have been awarded to 12 Regional Programs to date. Another 12 Regions have submitted initial operational grant requests which are now under review. Based upon the best information currently available, it is an- ticipated that the other 30 Regions will enter the operational phase before the end of fiscal year 1069. Thus, involvement and participation by community hospitals and private practitioners in Regional Medical Programs should become more widespread and increasingly evident over the next 12-15 months. PAGENO="0073" STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968 Alabama--State of Alabama Jan. 1, 1967 Albany-Northeastern New York, portions of southern July 1, 1966 Apr. 1, 1967 Vermont and western Massachusetts. Arizona-State of Arizona Apr. 1, 1967 Arkansas-State of Arkansas do Bi-State-Eastern Missouri, centered around St. Louis do and southern Illinois. California-State of California Nov. 1, 1966 Central New York-Syracuse, New York and 15 sur- Jan. 1, 1967 roundingcounties. Colorado-Wyoming-States of Colorado and Wyoming do Connecticut-State of Connecticut July 1, 1966 Florida-State of Florida Nov. 1, 1967 Georgia-State of Georgia Jan. 1, 1967 Greater Delaware Valley-Philadelphia-Camden (NJ.) Apr. 1, 1967 metropolitan area and adjacent areas of eastern Pennsylvania, southern New Jersey, and State of Delaware. Hawaii-State of Hawaii July 1, 1966 Illinois-State of Illinois do Indiana-State of Indiana June 1, 1967 lntermountain-Utah and portions of Colorado, Idaho, July 1, 1966 Apr. 1, 1967 Montana, Nevada, and Wyoming. Iowa-State of Iowa Dec. 1, 1966 Kansas-State of Kansas July 1, 1966 June 1, 1967 Louisiana-State of Louisiana Jan. 1, 1967 Maine-State of Maine May 1, 1967 Maryland-State of Maryland Jan. 1, 1967 See footnotes at end of table. $661, 756 Initial operational grant request anticipated in fiscal year 1969. 707,033 $921,510 119,045 Do. 360, 174 Do. 603,965 Do. 4, 079,593 Initial operational grant request under review. 434,156 Do. 488,359 Initial operational grant request anticipated in fiscal year 1969. 416;932 Initial operational grant request under review. 240,000 Initial operational grant request anticipated in fiscal year 1969. 694, 427 Initial operational grant request under review. 1, 534,494 Initial operational grant request anticipated in fiscal year 1969. - 194,771 212,781 Do. 336,366 336, 366 Do. 496, 013 - 706; 889 Do. 363, 524 2,038, 123 608, 615 2,038, 123 290, 591 552, 939 Initial operational grant request under review. 281,627 699,852 371,240 699,852 454,445 710,290 Initial operational grant request anticipated in fiscal year 1969. 193,909 193,909 Initial operational grant request under review. 770,230 967,459 Initial operational grant request anticipated in fiscal year 1969. Beginning Regional medical program Planning date Funding Currently available Cumulative awards Operational status Planning Operational Planning Operational Operational $393, 788 384,244 $921,510 119,045 360, 174 603,965 3, 226, 225 268, 634 339, 605 ~38, 513 240, 000 341, 824 1,534~494 PAGENO="0074" Memphis-Western Tennessee, northern Mississippi Apr. 1, 1967 and portions of Arkansas, Kentucky, and Missouri. Metropolitan Washington, D.C-District of Columbia Jan. 1, 1967 Apr. 1,1968 and surrounding suburban counties in Maryland and Virginia. Michigan-State of Michigan June 1,1967 Mississippi-State of Mississippi July 1,1967 Missouri-State of Missouri excluding metropolitan _do Apr. 1, 1967 St. Louis. Mountain States-States of Idaho, Montana, Nevada, Nov. 1, 1966 Mar. 1, 1968 and Wyoming. Nebraska-South Dakota-States of Nebraska and Jan. 1, 1967 South Dakota. New Jersey-State of New Jersey July 1,1967 New Mexico-State of New Mexico Oct. 1,1966 New York metropolitan area-New York City, Nassau, June 1, 1967 Suffolk, and Westchester Counties. North Carolina-State of North Carolma July 1,1966 Mar. 1,1968 North Dakota-State of North Dakota July 1,1967 Northeastern Ohio-Cleveland and surrounding 12 Jan. 1,1968 counties. Northern New England-State of Vermont and 3 July 1, 1966 counties in northeastern New York. Northlands-State of Minnesota ian. 1, 1967 STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968)-Continued ... Beginning date Funding Regional medical program Currently available Cumulative awards Operational status Planning Operational -~ Planning Operational Planning Operational $173, 119 $173, 119 Initial operational grant request under review. 527,089 $418,318 651,171 $418,318 1,294,449 322,845 324,254 2,887,903 1,082, 107 206, 913 349,367 297, 466 553, 270 967, 010 773,674 1,652,164 188,010 285, 783 723, 920 629, 887 1,294,449 Do. 322,845 Do. 635,967 2,887,903 1,747,370 206,913 597,609 Do. 297,466 Do. 803, 866 Initial operational grant request under review. 967,010 Initial opertional grant request anticipated in fiscal year 1969. 1, 000, 374 1,652,164 188,010 Do. 385,783 - Do. 883,695 Do. 1,000,791 DQ~ PAGENO="0075" Northwestern Ohio-20 counties in northwestern Ohio, Jan. 1, 1968 309, 180 309, 180 Do. centered around Toledo. Ohio State-Central and southern 3~ of Ohio (61 Apr. 1, 1967 136, 771 136,771 Do. counties) centered around Columbus, excluding Cincinnati metropolitan area. Ohio Valley-Greater Dayton-Cincinnati, Ohio, areas Jan. 1, 1967 346,797 472, 096 Do. and contiguous counties and part of Kentucky. Oklahoma-State of Oklahoma Sept. 1, 1966 282, 100 330, 318 Do. Oregon-State of Oregon Apr. 1, 1967 231, 125 353, 760 Award of initial operational grant pending. Puerto Rico-Commonwealth of Puerto Rico (1) Initial operational grant request anticipated in fiscal year 1969. Rochester-Rochester, N.Y., and 11 surrounding Oct. 1, 1966 Mar. 1, 1968 318, 286 255, 487 500, 425 255, 487 counties. South Carolina-State of South Carolina Jan. 1, 1967 379,246 502, 773 Initial operational grant request under review. Susquehanna Valley-24 counties, centered around June 1, 1967 263, 5~0 Initial operational grant request anticipated in fiscal Harrisburg-Hershey in central Pennsylvania. year 1969. Tennessee-Mid-South-Eastern and central Tennessee and contiguous counties of southern Kentucky and northern Alabama July 1,1966 Feb. 1,1968 523,738 1,630,304 673,421 1,630,304 Texas-State of Texas do 1,260, 181 1,667, 194 Initial operational grant request under review. Tn-State-States of Massachusetts, New Hampshire, and Rhode Island Dec. 1, 1967 439,037 439,037 Initial operational grant request anticipated in fiscal year 1969. Virginia-State of Virginia Jan. 1, 1967 254, 000 545,454 Do. Washington-Alaska-States of Washington and Alaska Sept. 1, 1966 Feb. 1, 1968 655, 148 1,032,003 837~, 948 1,032,003 West Virginia-State of West Virginia Jan. 1, 1967 208,910 282, 663 Do. Western New York-Buffalo and 7 surrounding New Dec. 1, 1966 Mar. 1, 1968 283, 717 357, 761 313, 033 357, 761 York counties and Erie, Pa. Western Pennsylvania-Pittsburgh, Pa., and 28 sur- Jan. 1, 1967 340, 556 340, 556 Do. rounding counties. Wisconsin-State of Wisconsin Sept. 1, 1966 Sept. 1, 1967 2 630, 149 344,418 630, 149 Initial planning grant application has been received and is under review. 2 Combined planning and operational grant; includes some $340,000 for planning. PAGENO="0076" 70 ILLUSTRATIVE EXAMPLES OF CURRENT STATUS In addition to this listing of grant awards and the projected initiation of operational activities `by the 54 regions, some specific examples of activities can serve to illustrate the status of activities in the Regional Medical Program and how these activities relate to achieving some of the major objectives of the program. P.L. 89-239 makes clear that activities under it are to be considered part of, and contributors to the evolution of a system which establishes and strengthens, on a regional basis, functional relationships among the elements of the health system. The law assumes that only through such regional arrangements can the health status of the patient benefit fully from the accomplishments of medical science. The following examples show how these mechanisms have been effective or give promise of being effective in influencing the quality of health care under the following headings: 1) Cooperative Arrangements; 2) The Relationship of Science to Service; 3) Education and Training; 4) Demonstrations of Patient Care; `and 5) Experimental Projects. 1. Cooperative Arrangements Regional Medical Programs are based upon voluntary cooperative arrange- ments among all the health resources in each Region. These cooperative ar- rangements characterize the type of regionalization with which this program is concerned. The word "regionalization" in the context of Regional Medical Pro- grams does not refer to the development of a rigid plan which has been imposed from above. Rather, it stresses the process whereby local resources are joined together to identify needs and opportunities, to assess resources, to define objec- tives, to set priorities, and then finally to implement a program and to establish methods of self-evaluation. Here are some specific examples of how such arrang& ments can be expected to affect patient services directly. Four hospitals in Lafayette, Louisiana, are pooling resources in cooperation with the State Heart Association and one of the medical schools, to improve the care of patients with myocardial infarction in that area of the Region through the establishment of a coronary care demonstration and training unit. The local decision was made to concentrate on developing a high quality coronary care unit in a single hospitaL These varied institutions joined with the public to raise private funds, recruit and train staff, and equip the unit. Although the Invest- ment of Regional Medical Program funds was limited, `the cooperation engendered by the program not only accomplished much, but also has served as a model of cooperative action to the Region. The community of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska Regional Medical Program for a high energy radiation source closer than Seattle, Washington, is now conducting h fund raising cam- paign. Solicited private funds will be used to construct housing for the equip- ment, which will be purchased by the Regional Medical Program. The treatment center will be operated as a regional resource by the Providence Hospital, as planned and `approved by local and regional advisory groups. The decision to support this activity involves cooperative arrangements at another level also, for the National Cancer Institute conducted the on-site visit which gave assur- ance of the sound scientific and professional basis of this project. The Anchorage Building and Construction Trades Council, comprising some 14 unions have taken on the construction of the building as a project, thus contributing more than one half the total cost from this one source. One of the most meaningful associations sponsored by Regional Medical Pro- grams is between Vanderbilt University Medical School and Meharry Medical College on the one hand, and the Neighborhood Health Center supported by the Office of Economic Opportunity, located near Meharry on `the other. Consultants from Vanderbilt are working with the faculty of Meharry and the staff o'f the Health Center to provide comprehensive health care for impoverished commu- nities formerly without adequate care. In many other Regions similar collabo- rations between institutions of varying maturity and strength have resulted in achievements heretofore difficult, if not impossible. 2. The Relationship of Science to Service The complex problem of relating the more sophisticated and advanced ac- tivities available in only a few institutions within a Region to the broader r~eeds of people of the Region is a significant mandate for the programs. This task is being carried out in a variety of ways. PAGENO="0077" 71 The computer expertise and facilities of the University of Missouri and the previous work of the Public Health Services' National Center for Chronic Dis- ease Control, aide being used by local physicians to test the effect of the avail- ability of computer-assisted and semlautomated interpretation of electrocardio- grams on the care of patients. The Intermountain Region has an outstanc~ing multi~iscip1ipary research group investigating computer application to clinical problems. Automated phy- siological monitoring has been extended from the Latter-day Saints JTospital in Salt Lake City to four other hospitals in the Region, through t~be use of remote computer consoles, allowing a more sop'bistjcated level of treatment in these hospitals. In this case, as in many others, the developmental work was sup- ported by the National Heart In~titute, which now is. jointly funding with Re- gional Medical Pi~ograms the application of the tecbi~ologic advances. The latest and best in medical science exists also in institutions other tl3an universities and research institutes. Wisconsin has a death rate from pulmonary embolism higher than the nation's average, and in Wisconsin, the Marshfield Clinic has a group especially knowledgeable about tbromboemJolic disease. The Wisconsin Regional Medical Program is supporting a unit at the Marshfield Clinic for the demonstration of the best techniques for diagnosis and non-surgical management of patients with pulmonary embolism. The Marchfleld Clinic has established referral routes from five hospitals in the Region for emergency care of patients suspected of having pulmonary embolism. The effect of this unit has already been made apparent by the increased demand from physicians through- out the Region for educational services there. The unit already has treated more than 30 patients, with results better than the national average-a distinct improvement in patient care. Research institutions are anxious that medical practice benefit from research efforts. For several years, the Memorial Sloan-Kettering Cancer Center has ex-~ tened its consultation and teaching programs out to the practicing community in six hospitals. Now, through the New York Metropolitan Regional Medical Program it is able to expand its coverage to surrounding areas, and is planning to include 28 additional hospitals so that the knowledge and talent of the Memo- rial Sloan-Ketering Oaricer Center can be made available to practitioners through- out the area. In many similar projects, Regional Mbdical Programs serves as a vehicle for transmission of the latest scientific advances to the bedside. 3. Edscation and Training J~ducation and Training have been traditional methods of improving quality in all fields. The emphasis in Regional Medical Programs has been to support education and training, not as separate isolated activities, but rather in terms of recognized needs for the improvement of patient care services and as an in- tegral part of other activities. An example of the development of this type of training and educational pro- gram arose in the Rochester Region, where 29 hospitals were faced with the problem of establishing coronar~r care units. Through their Regional Medical Program, they have been able to focus instead on the problems of giving the best diagnosis and treatment to all patients with myoc~rdial Infarction in the Region. A recently awarded operational grant wilt support training and eon- tinning educational programs for physicians and nurses to staff the units, the development of evaluation techniques, and the establishment of a coagulation resource in a community hospital. The California Region plans to anticipate the needs for education and training in a new etommunity hospital to be completed within the next three years in the Watts area of Los Angeles. A Post-Graduate faculty will be recruited now and sponsored jointly by the Charles Drew Medical Society, the University of Cali- fornia in Los Angeles, and the University of Southern C'aliforr~ia, Once built. the hospital itself will support the faculty, but Regional Medical Program funds are being sought for interim assistance. Numerous programs are seeking to provide e~pe~rt consultation on request. These include making consultation available by telephone or two-way radio on a 24-hou~r basis, a dial access telephone-audio tape systeup iii Wisconsin, and a medical jukebox in Albany which will show a variety of single concept films on demand. PAGENO="0078" 72 4. Demonstrations of Patient Care Demonstrations of patient care are proving to be effective in `serving the goals of the program, and have been a major expression of cooperative arrangements for the betterment df a partleularsiltutation. Resources in Mississippi for the management of stroke patients are limited. Four intensive care beds for the demonstration of latest advances and modern potential of stroke care have been established under Regional Medical Programs. The usual hospital costs are being supported from other sources but with this newly funded demonstration unit, physicians, nurses, and all allied health pro- fessionals have access to excellent training. The result of such training and "on line" experience is already leading to improved care for stroke patients. In Iowa, a different demonstration pattern is being used. Through the Iowa Itegional Medical Program, a stroke team with `physicians and allied health competence is available for on~si'te consultation. This unit, taken to the patient, provide's specific consultation and comprehensive education for those responsible for continuing care. In Smitbvilie, Missouri, an entire community has enthusiastically become a "demonstration project." With the funding of a much needed rehabilitation unit in that town of 2,500, which serves a population of 50,000, the imagination of the community was captured. Impressed by the potential of Regional Medical Programs, the town leaders sought and became a "demonstration sub-region" for the Missouri program. Thus, over a dozen regional projects are now being tested in S'mithville. There are many examples of uflits demonstrating care of pa'tients with acute myocardial infarction. The units are varied. Some are in small and some in large `hospital's. Some represent joint efforts between "Medical `Centers" and outlying hospitals. So'm'e are administered by physician's while others are administered by nurses. These models recognize the realities of manpower shortages, and of `the significant differences in the locales where patient's `are trea±ed. 5. Eaperimenta~ Projects Regional Medical Programs `are offering an excellent opportunity for the use of information coming out of research into better methods for making available the advances of medical science. North Carolina is paying considerable attention to the special problems of an area in the western part of the state known as the "State of Franklin." For example, seven hospitals in as many different communities are testing the fea- sibility of a common Board of Trustees and a coordinated program to the extent that they will request accreditation as one hospital by the Joint gommission on Accreditation of Hospitals. Separately these hospitals, plagued with manpower and facility shortages, face not only an uncertain future, but the knowledge that they will have increasing difficulty in maintaining quality patient care. As a result of the Regional Medical Program, these hospitals are now testing the concept of a unique regional hospital organization which will make possible the implementation of improved care in heart disease, cancer, and stroke. The University of Michigan School of Engineering is cooperating wIth the Intermountain Regional Medical Program in a systems and operations study of coronary care. Here we see recognition of the need for the health system to in- crease the effectiveness and efficiency of care modalities. In this era when na- tional attention is dircted to rising medical care costs, many resources and types of expertise will be needed to minimize needless expense. Vermont is in- volved in a modified cost benefit analysis of several health activities being ini- tiated. The data collected should provide not only the Vermont Regional Medical Program, but the health industry in general with information upon which deci- sions can be made on substantive rather than intuitive bases. Mr. ROGERS. Is there any particular emphasis given in the regional programs to the core city problem? Dr. MARSTON. Yes, sir. The program has tended to go more slowly in the very large, complex urban areas, I think, probably for the same reason some other programs there have gone more slowly. But there are some key examples of our activities in urban areas. In the California region, the Watts group is working on a program with UCLA, the local chapter of the National Medical Association, and USC. PAGENO="0079" 73 The Ten s~-Mid~outh region, in Nashville, is supporting a pro~ gram in combination with OEO-I could give you a list of these. Mr. ROOERs. Let us have a list of these, and what hospitals in these areas are involved and the personnel involved. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON REGIONAL MEDICAL PROGRAM EFFORTS DIRECTED AGAINST THE HEALTH PROBLEMS OF THE INNER CITY In August 1967, the National Advisory Council on Regional Medical Programs issued a statement which gave consideration to the health problems of metro- politan areas and their inner cities. While recognizing the complexities of the urban environment, the Council stressed the responsibility of Regional Medical Programs to contribute to the solution of health problems there. In addition, it recommended that an appropriate group of national leaders be named and called together to consider how the attention of Regional Medical Programs could best be focused on the issue. In response to the statement and to the Surgeon General's memorandum of October 9, 1967 "Improving the Health status of the Urban Poor," a meeting was held on November 16, 1967 to consider the problem. Among those persons invited to attend were hospital representatives, RMP coordinators from urban areas, health planners, representatives from OEO, medical school officials and physicians with responsibility for the provision of care to the urban poor. The discussion concerned the need for immediate action to reduce the health status differential which now exists, the need for experimentation in the methods of delivering health care, and the need for coordinating the activities of diverse groups which provide health care services in the inner city as well as specific approaches and projects which might be undertaken. At the local level, Regional Medical Programs which include major metro- politan areas have developed varied approaches to solving these problems. These efforts include cooperative arrangements between hospitals, health departments, medical schools, voluntary agencies and practicing physicians to meet the health needs of the poor. Examples of these approaches now under development or in operation can be summarized as follows: California Regional Medical Program has established a subregion covering the Watts-Willowbrook area of Los Angeles which will facilitate the develop- ment of activities aimed at meeting the specific needs of the people there. Through the Regional Medical Program, the University of Southern California School of Medicine and the UCLA School of Medicine are cooperating with the local Charles R. Drew Medical Society (an affiliate of the National Medical Associa- tion) in establishing a post-graduate medical school at the Southeast General Hospital now under construction in Watts. This school will provide back-up services to the OEO neighborhood health center in the area, develop training programs for allied health personnel, provide stimulus for additional physicians to enter the practice within the community and will develop training programs for physicians already there. California Regional Medical Program has requested funds for partial support of the school in the early stages of development. In addition, work is now underway at the University of Southern California School of Medicine on the application of cancer case finding methodology to poverty groups. New Jersey Regional Medical Program has organized an urban health unit within their office and has established a Task Forée on Urban Health Services under the chairmanship of Mrs. Anne Somers, a member of their Regional Advisory Group. Membership on the Task Force includes representatives of the New Jersey Hospital Association, the New Jersey State Department of Com- munity Affairs, county medical societies, local OEO CAP programs and other groups, The function of the group will be to stimulate and review projects for improving the av~ilabi1ity of health services to persons living in urban areas of the state, particularly low income groups. The group currently is working on the development of hospital based group practices at Middlesex General Hospital in New Brunswick and at West Jersey Hospital in Camden, as demonstrations of improved systems for patient care for heart disease, cancer and stroke. The New Jersey Regional Medical Program will assign a coordinator/planner to the Model Cities offices in Trenton, Newark, and Hoboken. The function of PAGENO="0080" 74 these persons will be to gather data on services and the facilities available for people shiferillg from heart disease, cancer and stroke; to provide liaison be- tween Regional Medical Programs and the Model Cities programs; and to assist the Model Cities offices in developing a program of bealtl~ services for the com- munity which will be consistent with the overall goals and objectives of the Regional Medical Program. Tennessee-midsouth Regional Medical Program has developed a number of projects which affect the health care of the pOor in Nashville. Coronary care units will be established at Nashville Metropolitan General Hospital and Hub- bard Hospital, which serve patients largely drawn from an indigent population. Mebarry Medical College will conduct continuing education programs for Negro physicians and will establish a supervoltage radiation unit to improve cancer therapy in the community and improve graduate and under-graduate radiology training. In addition, there is a project to test the effectiveness of multiphasic screening examinations in the early diagnosis of heart disease, cancer and stroke. Meharry will establish a screening center which will operate in support of a comprehensive neighborhood health center funded by OEO and will serve a pop- ulation of 18,000 people. The test population and a control grOup will be evaluated and compared with reference to changes in morbidity, patterns of utilization of health services, health attitudes and cost per patient diagnosed. Tn-State Regional Medical Program received a planning grant in late 1967 aąd is only now becoming completely organized. Since that time Dr. Norman Stearnes, Program Coordinator, has been involved in a number of meetings where be has made known Regional Medical Program's interest in working to improve the availability of health services to the urban poor. He also is serving on an ad hoc committee formed in Boston by Blue Shield to discuss the planning of home services and will sit on the Health Services Advisory Committee to the Boston City Department of Health and Hospitals. At this time, there are two projects for earmarked funds under development in the I~oston area, a stroke project at the New England Medical Center which will have a tie-in with the Columbia Point Neighborhood Health Center and a hypertension project being developed by Dr. Edward Kass of the Channing Laboratory, Boston Department of Health and Hospitals. Illinois Regional Medical Program has established a number of formal and informal contacts with persons in the Chicago area responsible for providing health services to the inner city including Dr. David Greeley, Associate Direc- tor, Chicago Board of Health and Dr. Mark Lepper, Vice President, Presbyterian- St. Luke's Hospital which operates an OEO financed neighborhood health cen- ter. Now in the planning stage at Presbyterian-st. Luke's Hospital is a com- munity hypertension detection program which will be focused on the Mile Square area of Chicago. Included would be evaluation of case finding methodology, ef- fectiveness of treatment, nurse interviews i~vith patients and an analysis of the interaction of the program to the community. Michigan Regional Medical Program: At its recent February meeting the Re- gional Advisory Group of this program formally adopted a statement for prior- ities for Regional Medical Program action which reads in part "the first priority for Regional Medical Program support will be given to those projects whtch are concerned with the improvement of the delivery system of health care including such aspects as (a) improvement of tile delivery system of health care to low income groups; and (b) innovations and improvements in the utilization of manpower . . ." Underway is a planning project supported jointly by' Regional Medical Programs and the State Health Department (Project ECHO) for gather- ing data on the health needs in depressed areas of Wayne County, Michigan. Wayne County General Hospital has submitted a project to study the use of subprofessional workers to assist the physician in patient care and, will design and establish training for Such persons recruited from the local community. Wayne County General Hospital serves the indigent population of Wayne County and is located adjacent to a large indigent group in western and southern Wayne County, Michigan. In addition, Regional Medical Program staff at Wayne State University School of Medicine is working to establish liaison with urban' health programs in Detroit including OEO and Model Cities. The Executive Director of the Detroit Urban League has been named to the Wayne State Advisory Group. Indiana Regional Medical Program is working with Planner Hotise, a volun- tary community agency in Indianapolis to develop a multiphasic health screening program for low income population groups. With State and local support the PAGENO="0081" 75 Regional Medical Program is conducting planning ~nd fea~ibility st~id!es to determine the types of screening procedures which will most effectively reach target population groups and which can in part be, adipinistered by previously untrained persons from the community who have received on-the-job training. New York Metropolitan Regional Medical Program has made specific assign- ments to niembers of their core staff for maintaining, liaison with community mental health programs, OEO~andModel Cities. Particular effort has been made to develop, a working relationship with the Provident Clinical Society~ the mov- ing force behind an OEO health center in Brooklyn and as a result the president of this organization has recently been appointed to the Regional Advisory Gr.oup. In upper Manhattan, the Regional Medical Program is practicing with representatives of the National Medical Association, Columbia University Col- lege of Physicians and Surgeons, Mount Sinai SchoOl of 1~fedicine and St. Luke's Hospital. in the development of continuing education programs for unaffihiated physicians. The Regional Medical Program is also taking leadership in co-spon- soring a conference on health careers for the underprivileged to bring together all interested forces in the area to develop a coordinated program. Also in the developmental stage, are several projects for earmarked funds including a pediatric pulmonary disease center at Babies Hospital, a feasibility study for the development of screening and treatment of stroke patients at Harlem Hospital, and a mobile coronary care unit to operate out ~f St. Vincent's Hospital in Greenwich Village. Metropolitan Washington, D.C., Regional Medical Program will establish a stroke station at Freedman's Hospital, the teaching hospital of Howard Uni- versity Medical School. The project will improve the care of patients from a predominantly Negro population group by setting up an intensive care stroka unit in the hospital and by developing extensive follow-up services for stroke patients. The unit will be used for training medical students, area physicians, nurses and paramedical personnel in the latest technIques of stroke management. There will be research studies undertaken on diagnostic methods, epidemiology and the cultural, behavioral and socio-economic consequences of stroke. Also submitted for review are stroke projects to be operated at George Washington University Hospital, D.C. General Hospital and Glenn Dale Hospital which would combine university and D.C. Department of Public Health efforts. Missouri Regional Medical. Program will establish at Kansas City General Hospital a special diagnostic and treatment unit for patients with cerebrovas- cular disease. Approximately 500 patients a year will be referred from the emergenCy room, outpatient department, clinical services of the hospital and from physicians in the surrounding communities. Kansas City General Hospital serves the majority of indigent patients in the Kansas City, Missouri area and will provide the back-up to an O~lO neighborhood health center now under develop- ment in the community. Missouri Regional Medical Program and Kansas Re- gional Medical Program have also established a greater Kansas City liaison com- mittee to review and coordinate the activities of both prograihs In the metropoli- tan area. Georgia Regional Medical Program `has submitted for review a project for the development of a community hypertensive control program, to determine the most effective methods, to identify symptomatic hypertension in an urban racially mixed community in Atlanta. The project which would `be conducted bj~~ the Georgia state Health Department would assess the most effective methods to achieve good blood pressure control in these hypertensives, train lay blood pres- sure aids, and determine whether a community program in `hypertension control is economic~1ly feasible using public health methods. Mr. ROGERS. What about the rural areas? Dr. MARSTON. I think things have tended to move more rapidly in the rural ~re~s. Mr. ROGERS. Let us have a breakdown there, too, please. (The following information was received by the committee:) 93-453-68---6 PAGENO="0082" 76 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON OPEIIATIc~NAL PROaECT5 AFFECTING RURAL AREAS ALBANY REGIONAL MEDICAL PROGRAM Many of the Albany operational activities will serve to enhance the capabili- ties of health professionals in the rural areas. By bringing professionals from small communities into the medical center for continuing education and by im- proving communications between the medical center and the communities they hope to raise the level of patient care in those communities. The following proj- ects involve rural areas: Operational Projects 1. Two-way Radio Communication Bystem: Direct Cost, $144,100 This project will expand an existing two-way radio network to include 57 hospitals and 24 high schools. It will provide continuing education for physicians and allied medical personnel. It will also provide information and education pro- grams for administrators, members of boards of trustees, voluntary health agen- cies, adult education classes, and selected civic groups. 2. Community Information Coordinators: Direct Cost, $78,800 Former pharmaceutical representatives will be used to contact local physicians to tell them about Regional Medical Programs and .to evaluate their attitudes towards RMP. 3. Community Hospital Learning Centers: Direct Cost, $75,800 This project will establish learning centers at community hospitals using "Self Instruction Units" and audio-visual equipment for rapid dissemination of new medical knowledge. Eventually, the directors of this project hope to evaluate physician progress. Initially, 8 hospitals will be involved. 4. Community Hospital Coronary Care Training and Demonstration Program: Direct Cost, $55,400 This project will establish coronary care units of three beds each at three community hospitals: Pittsfield General, St. Lukes, and Vassar Brothers. These will serve as demonstration and educational projects for other hospitals in the region. A continuing educational program will serve the permanent Unit Staff and staffs from smaller hospitals. 5. Training and Demonstration Project, Intensive Cardiac Care Unit Herkimer Memorial Hospital: Direct Cost, $3,500 The initial phase of this project is to train 6 or 8 nurses from small community hospitals in cardiac anatomy and physiology, coronary disease, the principals and staffing of a cardiac intensive care unit, and in handling the complex equipment. These nurses will also be sent to Albany Medical Center for active training with specialized equipment. INTERMOUNTAIN REGIONAL MEDICAL PROGRAM The Intermountain Regional Medical Program has essentially three types of projects for remote communities. Several projects are educational involving the training of health professionals who are brought into the medical center. Other projects send specialists from the medical center to the small communities to aid local physicians with specjfic areas of patient care. A third type involves the use of electronic monitoring equipment which transmits phyalologinal signals fyom patients in remote areas to the medical center for interpretation. A listing of these projects follows. Operational Projects 1. Network for Continuing Education in Heart Disease, Cancer, $troke and Re- lated Diseases: Direct Cost, $243,000 The objectives of this program are to develop a communications network be- tween patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing 2-way radio systems, including 11 hospitals in 7 communities in or near Salt Lake City, will be extended to remote hospitals to serve as one link. Closed circuit TV and use of EVED (Uni- versity of Utah education TV) is also planned. This may establish the community hospital as the locus of continuing education. PAGENO="0083" 77 2. Information and Communications Ecechange Service: Direct Cost, $40,300 The CIES is a region-wide clearing house for information about IRMP. Staff will be put in local communities to act as public relations representatives and also to distribute information to medical personnel and the public. The community staff will also gather information on community needs and resources and serve as a station for collecting economic, social, and medical data. & Cardiopulmonary Resuscitation Training Program: Direct Cost, $63,400 The University of Utah will give a 3-day course in resuscitative techniques to selected physicians from small communities. Each physician will then be responsi- ble for teaching the techniques to health personnel in his community. This re- suscitation consultant will also collect data about the number of times resuscita- tion is employed and the results. 4. A Training Program in Intensive Cardiac Care: Direct Cost, $118,600 A core faculty of experts in using Cardiac Care Units and diagnosing and treat- ing heart disease will teach short courses in their subjecta The students will be interested physicians and nurses from community hospitals building coronary care units. 5. Training for Nurses in Cardiac Care and Cardiopulmonary Resusoitatioiv:Direct Cost, $34,000 This is an integral part of both the cardiac care and cardiopulmonary resuscita- tion programs for physicians (#3, #4). Nurses trained in Salt Lake City will re- turn to their communities to serve as a core faculty for teaching the techniques at the local level. The nurses will work closely with the similarly trained physicians. 6. Visiting Consultants and Teacher Program for Small Community Hospitals: Direct Cost, $14,800 Small communities will be given the option of requesting one or two-day clinics. A minimum number of four cardiac patients will be required. These clinics will upgrade the level of care of victims of heart disease living in a remote area. Visit- ing physicians will assist the local physician in a precise diagnosis of his patients. 7. A Regional Computer-Based System for Monitoring Physiologic Data on-line from Remote Hospitals in the Regional Medical Program: Direct Cost, $637,100 This project's purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- pitals, feeding the results of calculations from these signals back to stations with- in the hospitals, and using the information for diagnosis. 8. Cancer Teaching Project: Direct Cost, $94,300 This project attempts to upgrade the level of care available to local communi- ties. The co-ordinator will direct a program of physician education to create trained cancer specialists who, in turn, will become centers of cancer informa- tion in their local communities. The physicians will receive a small stipend for teaching and obtaining information. A region-wide tumor registry will be started as will a training program in new techniques for pathologists. 9. Stroke and Related Neurological J3iseases: Direct Cost, $98,700 This project will establish clinics to ~rjng expert consultation service in stroke and related neurological diseases to local communities; will provide continuing education to local phy~icians and nurses; will collect data about stroke patients seen and the problems they present to the practitioner. A 24-hour telephone consultation service and information library service will be maintained at the Utah Medical Center to provide community physicians with immediate advice. In addition, practicing physicians will be trained at the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. KANSAS REGIONAL MEDICAL PROGRAM The Kansas Region is emphasizing cardiovascular care in its rural programs. In addition it is setting up a comprehensive model training program in a small community. The project descriptions follow: PAGENO="0084" 78 Operational Projects 1. Education Programs~---Great Bend, Kansas: Direct Cost, $261,000 To develop a model educational prOgram in this small community a full-time faculty, which Will be affiliated with the Kansas Medical Center, will be in residence. Included in this comprehensive program are plans for continuing physician and. nurse education and clinical traineeships for health-related per- sonnel. Studies will be made of community needs, resources, etc. 2. Ca'rdovctscular Nurse Training: Direct Cost, $98,500 To develop an in-service training program to prepare nurses, who are the mainStay of coronary care units in community hospitals, with basic physiological knowledge of coronary care, ability to use instruments and equipment in coro- nary care units, experience in home care, and familiarity with social agencies that can aid in the rehabilitation of patients. 3. Cardiovascular Work Evaluation: Direct Cost, $21,100 This project will demonstrate the Cardiac Work Evaluation Unit and show its usefulness for the evaluation and rehabilitation of the patient. It is developing an effective technique for showing physicians and the community at large the ability of patients to return to work after receiving the appropriate rehabilitation. MISSOURI REGIONAL MEDICAL PROGRAM The Missouri Regional Medical Program operational activities involve projects directed toward improved screening techniques, early disease detection and rapid diagnosis, and more effective delivery of services. These are coordinated with automated system's for transmission of information and health data to hid physicians and community hospitals in the treatment of patients with heart disease, cancer, stroke and related diseases. Six projects focus on the health needs, the care of patients, and training of staff for rural communities. Operational Projects 1. Smithville Community Health Service Program: Direct Cost, $200,957 To establish a model community health service program including continuing education and training programs and health education for the public; emergency intensive and restorative care facilities; home care programs; public health, preventive medicine, and school health; coordinated with voluntary health agen- cies. Program centered around Smithville (population of 3,500) and to include about 50,000 persons in Clay County. Activities are centered around Smithville Community Hospital (75 beds), and the group practice clinic as a nucleus. 2. Multiphasic Testing of an Ambulant Population: Direct Cost, $421,471 To establish centers for performing series of diagnostic laboratory tests to identify the most useful tests feasible for screening large rural population groups; determine the different patterns for ill and healthy populations as an aid in detection of heart disease, cancer, and stroke in, preclinical stages Model test centers will be establishedat the University Medical Center, Columbia, the State Mental Hospital and a third is planned for the Smithville complex. 3. Mass Screening-Radiology: Direct Cost, $54~8i4 To improve the accuracy of radiologic diagnosis of heart disease, cancer and stroke through electronic communications media. Three small rural ho~pitals will be hooked into the University of Missouri computer and Department of Radi- ology; to evaluate diagnostic efficiency and detqrmine applicability of ultra- sound and thermography in diagnosis and therapy. 4. Comprehensive Cardiovascular Care Units-Springfield, Missouri: Direct Cost, $69,347 To develop a comprehensive care unit for grouping patients with heart dis- ease or other circulatory system illness or wh6 have been admitted for other purposes but require close cardiacobservation. The project is to be undertaken at hospitals without a house staff, where it is hoped that grouping of patients will relieve the workload for nurses on general medical and surgical wards., Springfield (a community of over 100,000) has 4 general community hospitals PAGENO="0085" 79 ranging in size from 34 to 511 (a total of about 1,200 beds)., St. John's Hospital medical staff and Greene County Medical Society are čoordinating activities with 3 local hospitals in Springfield. 5. Automated Electrocardiography in a Rural Area: Direct Cost, $3t~i9,00O To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analyses of EGG's; to demonstrate the feasibility of such systems where this service is limited or non-existent, and to develop, test and implement the use of bioengi~ neerjng signals as an aid in diagnosis. 6. Operations Research and systems Design: Direct Cost, $39,055 To develop systems concerned with testing "early detection" hypothesis- develop operational methods of early detedtion tests for a large rural population MOUNTAIN STATES REGIONAL MEDICAL PROGRAM Operational activity in the Mountain States Region is specifically ~esIgned to benefit small hospitals in rural areas and to train health professionals from rural areas. Operational Projects 1. Intensive Coronary Care in small Hospitals in the Region: Direct Cost, $206,913 Hospitals in the region will send registered nurses into St. Patrick's Hospital, Missoula, Montana, for coronary care training. This three-week course will be offered three times a year for 21 nurses, and there will be follow-ups at the borne hospitals four times a year. In addition, a 4-day training program especially designed for small town physicinns will be held at the University čf Montana four times a year. NORTH CAROLINA REGIONAL MEDICAL PROGRAM ~ln North Carolina there are 10 funded Operati&nal projects all of which have a direct effect upon hospitals, health professionals, ~nd patients in rural areas. Some are concerned with education and training of physicians and allied health personnel, and others with patf~nt care. All of them are designed to bring the latest scientific advances down to the community level. The projects are listed as follows: Operational Projects 1. Education and research in com~nunity medicai care-direct cost, $209,200 To develop resources for training more medical and allied medical students; to provide new types of educational experiences which Will make family practice more attractive; to have a postgraduate education program at the medical school; to strengthen ties between the medical school faculty and practicing physicians; and to have the medical school become involved in community plan- ning for improving the quality and availability of medical care. Affected by this project are the following groups: the University Cor~munity; the Ca~well County Rural Health Services Project; the Regional Health Council of Eastern Appa- lachia, Inc.; the State of Franklin HealthCouncil, Inc.; the Charlotte Memorial Hospital; the Moses Cone Memorial Hospital, Greensboro; and the Dorothea Dix Neuromedical Service. 2. Coronary care traIning ctnd develo~pment-direct cost, $55,938 To use the project as a medium for developing cooperative arrangements among the various elements in the health care community. Initial and continuing educa- tion will be provided to nurses and physicians in community hospitals, consulta- tion will be available to hospitals in establishing CCU's, and a computer-based system of medical record keeping will be developed. This project has led to new working arrangements: (1) between the university medical centers; (2) be- tween medical and nurse educators; (3) between doctors and nurses in commu- nity hospitals; (4) between university medical centers and community hospitals. 3. Diabetic consultation and educational services-direct cost, $132,081 To establish three medical teams to deliver services throughout the state; to assist in expansion of diabetic consultations and teaching clinics; to provide PAGENO="0086" 80 seminars for physicians and teaching sessions for nurses and patients; to assist in organization of a State Diabetes Association and local chapters; to test tech- niques of data collection. Many people of different disciplines in many communi- ties are involved in this project. 4. Development of a central cancer registry-direct cost, $66,615 To devise a uniform region-wide cancer reporting system, integrated with the PAS, the computer-stored data from which can be retrieved to serve a broad range of educational, research, statistical, and other purposes. The following hospitals are participating in the first year of the project: Duke University Medi- cal Center, North Carolina Memorial Hospital, North Carolina Baptist Hospital, Charlotte Memorial Hospital, Veterans' Administration Hospital, Watts Hospi- tal, Hanover Memorial Hospital, Southeastern General Hospital, Craven County Hospital. In subsequent years the registry will be expanded to include all hos- pitals and physicians in the region. 5. Medical library ecetension service-direct cost, $25,839 To bring medical library facilities of the three medical schools into the daily work of those engaged in medical practice. Local hospital personnel will be trained to assist medical staff; libraries will be organized into a functional unit for responding to requests for services. Bibliographic request service will be established. 6. Cancer `Luformation center-direct cost, $41,716 To provide practicing physicians with imni~ediate consultation by telephone and follOw-up literature. Each of the three medical schools will be responsible for providing service in its geographic locale. The aims of this project are two- fold: (1) to assist physicians in providing optimum care of patients with cancer; and (2) to continue the education of the physicians by giving new information in a patient-centered experience. 7. Continuing education in iflternal medicine-direct cost, $33,313 To bring practicing internists from all over the state to the Medical Center for a month of up-to-date training in their subspecialties. They will share respon- sibilities with attending physicians and make ward rounds with students, staff, and together. This experience should enhance the appreciation in the University, both at faculty and student levels, for the expanding role of the medical center for the quality of care in the community. & Continuing education in dentistry-direct cost, $67,508 To provide physicians and dentists with the knowledge of mutual concern which will enable them to be more effective members of the health team. Courses will be given at the University of North Carolina and in communities. Studies will be made of facilities needed to provide dental care in hospitals. The purpose of this project is to insure that as many patients as possible who suffer from heart disease, cancer, stroke, or a related disease receive appropriate dental care as a part of their comprehensive treatment. 9. Continuing education for physical therapists-direct cost, $27,838 To develop and establish regional continuing education programs for physical therapists in order to strengthen physical therapy services for patients In all parts of the state. Subregions will be delineated where needs and interests will be identified and committees will be organized to arrange local activities. 10. The establishment of a network of coronary care units in small community hospitals in Appalachia, North Carolina-direct cost, $93,019 This is a proposal to develop coronary care units in seven hospitals in this rural, mountainous area. RMP will supply the monitoring equipment (the hospi- tal provides suitable space) when adequately trained physicians and nurses are available. An intensive training course for physicians will be conducted in the geographic region, and continuing education programs will be conducted when necessary. TENNESSEE MID-SOUTH REGIONAL MEDICAL PROGRAM Due to the geographical diversity of the region, the Tennessee Mid-South Regional Medical Program has been concerned with both the health problems of the urban poor as well as the health problems of remote rural areas. The Tennessee program has sought solutions to these and other regional programs PAGENO="0087" 81 through a system of linkages between the medical centers and the rural areas. In addition to providing programs to allow medical personnel and practicing physi- cians from rural community hospitals to come to the medical center for training courses, the Tennessee program has endeavored, through the use of modern com- munication techniques, to create medical education resources in the rural areas. The Hopkinsville Education Center and the deployment of coronary care units are two examples of such projects. Operational Projects 1 and 2. Hopkinsville Education Center and Chattanooga Education Center- direct cost, $73,700 These are the first of the iocal continuing education centers specified in the Vanderbilt plan. At each hospital, a full-time Director with an appointment at Vanderbilt and an assistant director will supervise resident and physician educa- tion in their area. Their services will be available to physicians at smaller com- munity hospitals in each area, as will the enlarged hospital library facilities. The Chattanooga and Hopkinsville locations provide the basis for looking at problems in continuing education in urban and rural settings. 3. Fran1th~n Coronary Care Unit-Williamson County Hospital-Franklin- direct cost, $31,400 Thi~is one of the subsidiary units mentioned in the Vanderbilt proposal. This is i~imarilya pilot project to study the fe~sibiIfty and usefulness of establishing a center in a nmall community hospital. 4. Clarksville Coronary Care Unit-Clarksville Memorial Hospital-direct cost, $19,000 As the Franklin program, this project is a subsidiary of the Vanderbilt pro- posal. Since this hospital has been operating a unit, the plan calls for its expan- sion, continuing education and a phone hook-up to Vanderbilt. 5. Murray Coronary Care Unit-Murray-Calloway (Ky.) County Hospital: Direct Cost, $38,800 Murray-Calloway County Hospital, the training center for Murray State IJni- versity school of nursing, will serve as a demonstration center for the sub-region~ Direct phone communication will be established with Vanderbilt, which will send consultants from its school of continuing education. This project has the dual objective of relating the Murray State Nursing program to an established mccli- cal center and providing regional training resources to a remote area. ~l. Crossviile Coronary Care Unit-Uplands Cumberland Medical Center Cross- vilie: Direct Cost, $28,300 This project has two purposes: (1) to establish a two-bed coronary care unit in the hospital; and (2) to determine the feasibility of operating acute coronary care units in rural a~reas. The hospital will coOperate with Mid-State Baptist Hospital and Vanderbilt. 7. Tullahoma Coronary Care Unit-Harton Memorial Hospital, Tullahoma, Tenn.: Direct Cost, $28,800 See Baptist Hospital Program. 8. Project to Improve Patient Care in a Remot~e Mountain Community by Recruit- ing and Training Health Aides for a New Ewtended Care Facility-Scott County Hospital-Oneida, Tenn.: Direct Cost, $10,300 Manpower shortage in this isolated mountain hospital is critical. Personnel to man an extended care facility now under construction will be obtained by two methods: (1) In-service training for hospital personnel; (2) an educational di- rector (an RN) to serve as a liaison tO the high schools to encourage young peo- pie to enter the medical field and come back home to practice. In addition a training program leading to the LPN would be initiated. Clinical training will be supervised by the Educational Director while local high schools provide basic training. 9. Hopkinsville Coronary Care Unit-Jennie Stuart Memorial Hospital-HopS kinsville, Ky.: Direct Co$t, $49,500 This plan is similar to the Franklin plan, except that it mentions establishing links to smaller community hospitals by helping set up smaller care units in them, PAGENO="0088" 82 thus providing for the grouping of rural community hospitals for more efficient use of existing reSources. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAM The Washington-Alaska Regional Medical Program Operational projects con- cern themselves largely with continuing education and training activities to en- hance the medical and paramedical capability. They focus on communications techniques and instruction materials and methodologies which are adaptable to the far flung and remote communities in' the vast State of Alaska and the many scattered rural communities in Washington State. Several projects are being con- ducted to improve the health manpower resources in communities with limited or no specialty health services, which are distant from a major medical center. Operational Projects 1, Central Washington-Communication system for Continuing Education for Physicians: Direct Cost, $18,181 To bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to sur- rounding smaller communities through seminars and conferences, educational TV, other audio-visual instruction; and exchange of teachers and practitioners. To connect internists in Central Washington to Yakima cardiologists via EKG tele- phone hot-line, to permit quick analysis (starting with' ~ community hospitals). Yakima is a community of about 45,000. The total population in 6 Central Wash- ington counties exceeds 300,000. In addition to"threė general hospitals in Yak- ima-St. Elizabeth, Yakima Valley Memorial, and New Valley Osteojē~athic-nine other community hospitals to be reached initially are located in small rural com- munities of Ellensburg, Moses. Lake, Othello, Toppunish, Prosser. and Sunny/side, (population ranges from 500 in Moses City to some 8,600 in Ellensburg.) 2. Southeast Alaska-Postgraduate Education: Direct Cost, $27,062 To improve communication between Seattle Medical Community and the uni- versity to alleviate problems of the isolated physicians in southeast Alaska cities and communities: Juneau, Sitka, Ketchikan (3 largest), As in Central Washing- ton several methods will be used such as telelectures, consultant services, semi- nars and the EKG hot line to `hospitals in Juneau, Si'tka and Ketchikan. The popu- lation in, these 3 cities totals about 17,000.. 3. Post~jraduate Preceptorship for Physicians-Coronary Care: Direct Cost, $17,610 A pilot project to provide opportunity for practitioners from' remote and 1so~ lated communities to spend a week or more under a preceptor at major medical centers to study advances in care of coronary heart disease and carry out these practices in their communities. The 4 major medical centers in Seattle are Provi- dence Hospital, Swedish Hospital, Virginia Mason Hospital and Medical Center, and University Hospital and Medical Center and two in Spokane are.Deaconess Hospital and Sacred Heart Hospital. 4. Cardiac Pulmonary Technician Training: Direct Cost, $41,554 Develop a formal program for training carcilo-pulmonary technicians to per- form non-critical function in coronary care units and free physicians for other duties. Four larger general hospitals in Spokan&-Deaconess, Holy Family, Sacred Heart, and St. Luke's-will participate in this training program with Spokane Community College. 5. Two-way Radio Conference and Slide Presentation: Direct Cost, $8,445 Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio~telephone slide conferences, to physicians and hospital staffs op topics selected by panel of physicians, starting with 20 hospitals in Washington~ To explore potential for continuing network series with local and remote regions. 6. Alaska'Medical Library Facilities: Direct Cost, $21,754 To develop a community medical library for Alaska at the PHS Alaska NatIve Medical Center, Anchorage for Alaska physicians and health related staffs and agencies; to have close ties with community agencies, Arctic Health Research, University at Fairbanks and to supplement continuing education project for Southeast Alaska and the Anchorage cancer project. PAGENO="0089" 83 WE5TE1tT~ ~S~W YOflK REGIONAL MEDICAL PROGEAM Both of the programs in the Western New York region have a direct effect upon hospitals, health professionals, and patients in the rural areis. Particular empha* ~ls will be placed upon involving community hospitals and on training nurses from community hospitals in rural areas. The projects are listed as follows: Operational Projects 1. Two-Way Communications Network: Direct Cost, $170,519 A two-way communication network will link hospitals of Western New York and Erie County, Pennsylvania to the Contilitting Education Departments of the State University of New York at Buffalo and the Roswell Park Memorial Insti- tute. The network will serve several purposes, such as continuing education for physicians and the health-related professions, public education, administrative communication, consultation with experts, and contacts among banks. It will assist both the physician and community hospital in either the rural or urban environment in having at their fingertips the latest advances in the. diagnosis and treatment of heart disease, stroke~ and cancer. Particular emphasis will be placed upon involving rural hospitals in this program thereby improving both their didactic and restorativefunction. 2. Coronary Care Program: Direct Cost, $127,544 This project will test a training technique for providing qualified nurses who will be required to staff developing coronary care units in the Region. Approxi- mately 80 nurses will be selected from all parts of the Region for a combined academic and clinical course. It is planned that the nurses receiving this train- ing will return to both rural and urban hospitals for the purpose of providing a diagnostic and didactic function. While the program will be housed at the medi- cal center, the community hospitals of this region will be the benefactors of the project. Since there are few nurses trained to work in coronary care uhits, par- ticularly in the rural environment, special attention will be paid to attracting nurses who will return to the community hospital. WISCONSIN REGIONAL MEDICAL PROGRAM Four of the Wisconsin projects have relevance to the improvement of health care in a rural setting, through the provision of education and infor- mation. Physicians and allied health personnel in commttnity hospitals will benefit from the following projects: Operational Projects J. A pilot denonstrqtion program for pulmonary thromboembolism: direct cost, $84,600 In this project a center is being established at Marsbfield Hospital in Marsh- field, Wisconsin, for demonstration diagnostic techniques and the available therapy for pulmonary thromboembolism. The project has a continuing edu- cation component which, will reach physicians from many hospitals in the Re- gion. This will involve a 24-hour consultation service, the preparation of a movie on the topic, and special training sessions for groups of physicians. The project will demonstrate a comprehensive program which will enconn~ pass diagnostic, preventive, therapeutic, and rehabilitation procedures for pa- tients, postgraduation education, a rapid transportation system for patients from Northern sections of the state, and cooperation between the clinic and other hospitals and medical schools in the State. 2. Telephone dial access tape recording library in the areas of heart disease, cancer, stroke, and related diseases: direct cost, $18,950 This feasibility study will be carried out by the University of Wisconsin which will record and store short, 4-6 minute, tapes on various aspects of treating patients with the three diseases. Any physician anywhere in the Region can dial the library at any time and request a tape relevant to a problem in which he is interested. 3. Nursing telephone dial access tape recording library in the areas of heart disease, cancer, stroke and related diseases: direct cost, $l8~~S00 This feasibility study, similar to the one above, will establish a central tape library with information recorded on nursing care in emergencies, new pro. PAGENO="0090" 84 cedures and equipment, and recent developments In nursing. Nurses from any hospital in the region will be able to call at any time to have a tape played to them. 4. Development of medical and health related single concept film program in community hospitals: direct cost, $33,250 This education feasibility project involves ten community hospitals in its first phase. Fifteen films on procedures and techniques used in treating heart, cancer, and stroke, will be developed. Projectors and the films will be installed in the hospitals for use by physicians and other health personnel at their con- venience as a continuing education device. After four to six months the ma- terials will be relocated in ten additional hospitals. Mr. R0GI~RS. When do you expect to have your first evaluation of a regional medical program? Dr. MARSTON. We have evaluations each time a region applies for a supplement, and we require an annual progress report. In one of the regions, as the funding was beginning to get up to a sizable level, we decided that in addition to these normal reviews that we should mount a special site visit and evaluate the region's status from the standpoint of the program. We now are doing this all of the time, picking out times of program movement, particularly the shift from planning to an operational grant and upon receipt of a supplemental request for an enlarged activity. We go back and re- view the entire history of the grant. Mr. RoGERS. What is the oldest region ~ Dr. MARSTON. The first four operational programs were funded at approximately the same time, Intermountain, Kansas, Missouri, and Albany, N.Y. Mr. Rociaiis. Could you let us have your evaluation of how effective these have been, for the record. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON EFFECTIVENESS OF REGIoNAL MEDICAI~ PnoGnAMs The effectiveness of Regional Medical Programs is determined in the following ways: Evaluation of the effectiveness of each Regional Medical Program is a con- tinuous process which involves review by the Federal Government, Its non- Federal advisors, and the grantee itself. These review activities are specifically intended, to determine the extent to which the region has implemented `the proc- ess of regionalization which includes seven essential elements: involvement, identification of needs and opportunities, assessment of resources, definition of objectives,, setting of priorities, implementation of program activities, and self- evaluation. This process of regionalization is the means by which the region moves toward its ultimate objective-the assurance of easily accessible improved patient care for heart disease, cancer, stroke, and related diseases. A systematic and comprehensive review of the scientific and administrative aspects of each Regional Medical Program has been designed in order to deter- mine the extent `to which each Regional Medical Program implements this proc- ess of regionalization for the purpose of achieving its goal of improved patient care. This review process includes surveillance at the regional and Federal level, and is conducted by both non-Federal and Federal experts. By law each opera- tional activity must be approved by the Regional Advisory Group prior to its submission to the Federal Government for review and approval. Frequently the regions themselves have elaborated on this requirement by establishing local, in addition to regional, advisory bodies and/or scientific review bodies which also carefully examine proposed activities. PAGENO="0091" 85 A site visit by members of the Review Committee and the National Advisory Council on Regional Medical Programs to the region is included as an integral part of approving an operational program for a region. As the operational pro- gram develops and is expanded additional site visits are made. Finally each Regional Medical Program is required to submit an annual progress report which describes in detail the region's program. Any proposed modification in program direction by the grantee must be justified in writing and subjected to these review procedures. Within the context of this comprehensive review process it is possible to deter- mine whether or not a regional program is in fact evolving a regional system intended to improve patient care. The Missouri, Kansas, Albany, New York, and Intermountain Regional Medical Programs were the first to enter the operational phase of development. The determination of their readiness to begin operations was a result of the review process described above, including a site visit by members of the National Ad- visory Council and members of he staff of the Division of Regional Medical Programs. The progress of these regions has been further evaluated during the review of supplemental grant requests which have been received from all four regional programs. Further site visits by Council and/or staff to review the first year's progress have either just been carried out or are scheduled for the immediate future. The results of these reviews carried out to date indicate that these Regional Medical Programs are making substantial progress toward the goals set forth a year ago as the basis for the operational grant award. The major problems encountered have been difficulties in recruiting personnel and slowness in the delivery of important equipment. These factors have caused some delays in implementing particular projects. In addition to this evaluation at the national level, the regional programs are developing their own capabilities for self-evaluation. Special staff has been added to the central staff of the regional programs with specific competence in evaluation techniques. These techniques are being further developed and ap- plied to the operational activities. Mr. ROGERS. In Kansas, is Kansas City General Hospital involved in that? Dr. MARSTON. In Kansas City, there is a joint committee from Kansas and Missouri to work together in the Kansas City area, and the Kansas City General Hospital has been involved; yes. Mr. ROGERS. Could you let us know to what extent? Dr. MARSTON. Yes, sir. (The following information was received by the committee:) DEPARTMENT or HEALTH, EDUCATION, AND WELFARE STATEMENT ON THE INvOLVE- MENT OF THE KANSAS CITY GENERAL HOSPITAL IN THE MISSOURI REGIONAL MEDICAL PROGRAM The Kansas City General Hospital is directly involved in the planning for and development of the Missouri Regional Medical Program. The Missouri Regional Medical Program has allocated $82,92~l for planning in Kansas City with head- quarters located at the Kansas City General Hospital. Several staff share respon- sibilities for Kansas City General Hospital operations and Missouri Regional Medical Program planning, including the Executive Director of the Kansas City General Hospital. Several proposals related to the Kansas City General Hospital have been submitted by the Missouri Regional Medical Program to the Federal Government for review. A project to develop programmed comprehensive cardio- vascular care at Kansas City General Hospital is pending final review by the Review Committee and the National Advisory Council on Regional Medical Programs. Planning studies are underway on manpower training and post- graduate medical education in heart disease, cancer, and stroke. Mr. ROGERS. How do you evaluate your regional medical program? Could you let us know the criteria used for evaluation? I think the committee would be interested in that. Dr. MARSTON. Yes, sir. (The following information wtts received by the committee:) PAGENO="0092" 8~ PnPAETMENP or HEALTH, EDUcATION, AND WELFAnE STArRMEN'I' ON T~E ORITERIA FOR TH~ EVALUATION OF REOIONAL MEDIOAL PnoouAMs Each planning and operatiQnal activity of ~ Region, as, well as the overall Regional Program, receives continuous, quantitative and quaiitativ~ evalution wherever possible. Evaluation is in terms Qf attainment of interim objectives, the process of regionalization, and the Goal of Regional Medical Programs, easily accessible improved patient care for heart disease, cancer, stroke, and related diseases. The criterion, for judging the success of a region in implementing the process of regio~alization is the degree to which it can be demonstrated that the Regional Program has implemented the seven essential elements of that process: involvement, identification of needs and opportunities, assessment of resources, definition of objectives, setting of priorities, implementation, and evaluation Ultimately, the success of any Regional Medical Program must be judged by the extent to which it can be demonstrated that the Regi~na~ Program has assisted the providers of health services in developing, a system whicb makes available to everyone in the Region improved care for heart disease, cancer, stroke, and related diseases. It is also important to note that each Regional Medical Program is encouraged to build self-evaluation methodologies into its ongoing program. These evalua- tion methodologies then form an integral part of the total evaluation of the Region's program. A fuller description* of the process of regionalization is contained in the Progress Report on Regional Medical Programs (see. p. 13) which was submitted for the Record during the hearings on H.R. 15758 and is the process upon which interim evaluations of each program nra based. Mr. Roonns. I know on page 2, section 103, it is simply a `correction to allow the District of Columbia, Commonwealth of Puerto Rico, and so forth, in. This amends the public health law itself. Doesn't this go to the entire act? Dr. LEE. Yes. Mr. ROGERS. So that this would affect every program of the Public Health Service, would it? Well, perhaps you can giv~ us the informatiot~. Mr. KARL YORDY (Deputy Director, Regional Medical Programs, HEW). Actually, there is a general definition in `the Public. Health Act which does not include these additions. These additions have been made to certait~ other programs in the act. This is bringing the regional medical programs into line on that. Mr. ROGERS. Thank you. I am `delighte~d to see the D~partment sup- port this program for migrant health, which I have been intereSted in and helped to write the original law. And I took a very active part since then in following this program. I have been very pleased with it, Miss Johnston. I think you have done a good job, and I think it is very essential that we recognize this a program that should be continued rather than letting it get into the partnership as yet, because I don't think this has been well planned for in many of the States. Dr. LEE. We would agree with that, Mr. Rogers, and also at the time the partnership for health comes up for review again, this would come up for review at the same time. And we would be able to then recommend, and you would be able to decide whether it should con- tinue as a separate special program or whether it could, in fact, be incorporated within the fabric of the partnership-for-health program. Mr. ROGERS. When you look over a partnership plan from a State, will the Department see that this plan has in it the necessary guide- lines to carry out this type of health program? PAGENO="0093" 87 Dr. L~E. A~ we develop, and as thfe States develop the capability for planning, the purpose, of course, of the pt~rtnership for health will continue to be to create a mechanism in the States and permit the States to set their own priorities. We then review that in relation to the priorities that have been sOt within the States; and certainly in terms of national needs and national priorities, those are also looked at as they relate to these State plans. But we want to have the States make these determinations. And this, of course, presents unique problems with the migrants, because they do move from State to State, and it is difficult to encompass that within any single State plan. Mr. ROGI~RS. Our' time is running out. I would like to have a rum down on the migrant health programs, what is being done, how many people are being affected; and how man~t people are involved, and in what are~as of. the country. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON MIGRANT HEALTIL PROGRAM STATUS, MAROTI 1968 Goal.-To improve the health status of migrants through improving their op- portunities for health services and a healthful environment. Guidelines.- Help the migrant help himself. Help communities recognize and assume responsibility for including migrants in total community health planning. Promote adaptations of commUnity services to migrants' needs and situation. Establish continuity of care as people move. Utilize fully all available resources. Get migrants Included in-not further isolated from-community life. I~tatus (see also attached directory (p. 88) and report (the PHS report, en- titled "Migrant Health Prograp~s-Curren~ Operations and Additional Needs" has been placed in committee ftles) ) ~- 115 single or multi-county projects are operating with migrant health grant assistance in 36 States £tnd Puerto Rico, 285 project counties offer migrants personal health and sanitation services. 155 additional project counties provide sa~4tatiou services only. More than 200 family health service clinics operate seasonally or year round. 1,000 physicians provide migrants medical care in the clinics, in their own offices and in hospitals. 300,000 migrant workers and famly dependents were in counties served by projects for at least part of 1967. They made- 215,000 medical visits; and 24,000 dental visits. 125,000 visits were made by nurses to migrant camps, other farm labor housing, and migrant schools and day care centers. 125,000 visits were made b~ project sanitārians and aides to home and work sites for inspection and follow-up. $7.2 million-the total funds appropriated for grants-was obligated in 1967 and tentative commitments for continued grant support were made at the same level. Most projects have submitted expanded requests for continued grant support. These requests could not be met since the 1968 appropriation was the same as that in 1967. In each year since the program started the total amount available for grants has been obligated and approved projects have had to be carried Co the next year. Hospital Compoijent (As of January 1968).- 55 of the 115 grant-assisted projects have hospital service components. These projects are located in 25 States. 162 hospitals have signed agreements with projects to provide migrants hospital care. PAGENO="0094" 88 190,000 migrant workers and dependents are included in project areas covered by hospital service. 3,000 migrant workers and dependents have had bills paid under `the pro- gram. (This is an underestimate due to the time-lag in getting paid bills in for processing.) $1,307,836 has been obliated thus far (1967 and 1968 funds) for in-hospital services, including hospitalization ($946,576) and physician's services ($361,260). Program Needs.- 441 more counties need `to be covered with personal health care and 286 more counties with sanitation services in order to meet the needs in all 726 counties with an annual influx of migrants. Approximately 700,000 additional migrant people need to be brought into contact with services. Medical and dental services need to be expanded. At present migrants in project areas are using medical services at about one-fifth and dental services at about one-twenty-fifth the rate for the general population. Undiagnosed and untreated conditions among migrants as the result of inadequate access to care need to be brought under treatment. Present es- timates indicate that among `migrants outside project areas there are- 5,600 with diabetes; 5,000 with tuberculosis; 9,800 children with iron deficiency anemia; 3,000 children under 18 with cardiac damage as a result of rheumatic fever; and many thousands of children and adults with visual, hearing, dental, and other uncorrected defects. A DIRECTORY OF MIGRANT HEALTH PROJECTS ASSISTED BY PUBLIC HEALTH SERvICE GRANTS INTRODUCTION The Migrant Health Act of' 1962, as amended in 1965, authorizes the Public Health Service to make grants to assist communities in e~1tending local health services to migrants. After local plans are approved, grants are made to public or private nonprofit organizations to pay part of the cost of health services for migrant farmworkers and family members. The 115 projects listed here were receiving grant assistance from the Public Health Service in August 1967. Located in 36 States and Puerto Rico; these projects provide both sanitation services and personal health care in some 330 / counties and sanitation services alone in 150 additional counties. The information for each project is from the project's application and report. PURPOSE The directory can assist project staff members and others concerned with migrants in identifying places where projects offer services to migrants along the major migratory streams. It can also facilitate intrastate and interstate pa- tient referrals, as well as interproject communication for the exchange of infor- mation and ideas. Each pro'ject description includes a reference to the duration of the migrant season. Projects in the northern work area are operational only during the months shown. However, many have one or two key staff members `available throughout the year to answer questions between seasons, and to do the necessary postseason followup and preseason planning and negotiation. ARRANGEMENT The States are arranged alphabetically, and the projects are listed numerically by project gran't number within the State. The location of family health service centers is included in the description of projects which operate one or more such centers. Typically the centers are tem- porary facilities, open periodically `at times and places conveniently accessible to migrants. At `the centers, physicians provide medical treatment, immunizations, and other health services with the assistance of project staff members, PAGENO="0095" 89 DEFINITION5 The estimated number of migrants includes workers and family dependents present in the project area. The estimate shown for each project is that made by the project itself. It includes both persons moving within the State and those moving out of the State. Health services provided are listed by type. The various types are defined as follows: Medical care.-Care of the type usually provided by a family physician, iriclud- ing both remedial and preventive services. It may be provided in a family health service center set up for the purpose in or near a large concentration of farm migrants, or it may be provided upon referral to a cooperating physician's private office, to a hospital outpatient department, or to a preexisting clinic or health service center. Mobile units are occasionally used. Hospita~zation.-Hospital and related professional care for up to 30 days for any one admission in a general, short-stay hospital. Dental care.-Care to remove infection and relieve pain. Some projects also pro- vide limited restorative care, especially for children. Nursing care.-Home visiting for caseflnding, family counseling about health problems, and related purposes. Nurses and aides working under their super- vision also refer migrants to sources of needed care and make followup visits to determine the outcome of referrals. In addition, nurses work in family health service centers. Sanitation services.-Inspecting living and work sites of migrant workers and families to determine health and safety deficiencies and obtaining their correction. Health education.-Formal or informal teaching of good personal or family health practices. Health education is shown as a service component only for projects which have a planned program of health education with part- or full- time assistance from a professional health educator. However, informal health counseling is considered as part of the job of every project staff member. The educational work of the health educator and other professional staff also extends into the community to help develop understanding of migrants, and of their needs for health care and a safe, healthful environment. Nutrition counseling, and social work.-Only a few projects with sufficient funds and professional manpower are able to provide these important services. PREPAEATION This directory was prepared by the Migrant Health Branch, Public Health Service. All Regional Migrant Health Representatives and project directors co- operated in providing the basic information. ARIZoNA Project Title: Maricopa County Migrant Family Health Clinic Project (MG 29). Sponsor: Maricopa County Health Department, 1825 East Roosevelt, Phoenix, Ariz. 85001; Telephone 602-258-6381. Director: Raymond Kaufman, M.D. Duration of migrant season: Year round. Estimated number of migrants: 16,671. County served by project: Maricopa. Health services provided: Medical care, dental care, nursing care, sanitation services, nutrition counseling, and health education. Location of family health service centers: Avondale*, Buckeye*, El Mirage, Glendale*, Guadalupe, Harquahala, Queen Creek, Tanitas Farm, and Tolleson*. Project Title: Assistance to Pima County Migrants (MG 49). Sponsor: Pima County Health Department, 161 West Alameda Street, Tucson, Ariz. 85701; Telephone 602-623-5071. Director: Frederick .1. Brady, M.D. Duration of migrant season: Year round. Estimated number of migrants: 1,200. County served by project: Pima. *Mobjle clinic. PAGENO="0096" 90 Health services provided: Medical care, dental care, nursing care, sanitation services, nutrition counseling, and health education. Location of family health service centers: Continental, Marana, and Sahuarita. Project Title: Yuma County Migrant llealth'Projeet (MG 66). Sponsor: Yuma Oounty Health Department, 145 Third Avenue, Ynma, `Ariz. 85364; Telephone 602-782-9221. Director: J. 0. Pinto, M.D. Duration of migrant season: Year round. Estimated number of migrants: 14,400. County served by project: Yuma. Health services provided: Medical care, hospitalization, nursing care, and sani- tation services. Location of family health service ceuters Roil, Somerton, and Ymna. Project Title: Pinal County Migrant Family Health Service Project (MG 94). Sponsor: Pinal County Health Department, Post Office Box 807, FlorencO, Aris. 85232; TeleŲhone 602-868-5844. Director: William C. Carpenter, `M.D. Duration of migrant season: Year round. Estimated number of migrants: 5,230. County served by project: FinaL Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Project Title: Arizona State Migrant Health Program (MG 111)., Sponsor: Arizona State Department of Health, Arizona State Office Building, 1624 West Adams Street, Phoenix, Ariz. 85007; Telephone 602-291-4549. Director: Robert C. Martens. Duration of migrant season: Year round. Estimated number of migrants: 39,700. Counties served by project: All counties with migrant~. Health servic1~s provided: Nursing `services in Cochise County; consultation services to local migrant health projects `in nursing, ~anitation, health education, and nutrition. ARKANSAS Project Title: Northwest Arkansas Area Migrant Committee Project to Estab- lish 5pringda1~ Family Health' Serstiee'Clinic (MG 50). Sponsor: Northwest Arkansas Area Migrant Committee,' 1401 Vista Drive, Fayetteville, Ark. ; Telephone 501-442-9481. Director: Mr. Bill E. Parette. Duration of migrant season: April-October. Estimated number of migrants: 1,459. Counties served by project: Benton and Washington. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, health education, and nutrition ~oun'seiing, Location of family health service centers: Springdale' School and labor camp. CALIFORNIA Project Title: Health Program for Farmworkers' Fainiliea in California (MG 06). Sponsor: California State Department of Health, 2151 Berkeley Wa3r, Ber- keley, Calif. 94704; Telephone 415-843-7900x201. Director: Robert W. Day, M.D. Duration of migrant season: Year round. Estimated number of migrants: 80,000.' Counties served by project: Butte, Colusa, Fresno, Kern, Merced, Monterey, Riverside, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Sutter, Yolo, and Yuba. Health services provided: Medical care, hospitalization (Riverside County), nursing care, sanitation services, and health education through county projects; consultation serviceO to county projects in nursing, sanitation, health education, medical care, and social work. Norz.-See following table for county detail. PAGENO="0097" Co cc County Os Butte Butte Couity-Gridley Camp Clinic Migrant Health Project. Colusa Seasonal Agricultural Workers Program- Colusa County. Contra Costa 1 Field Public Health Program for Seasonal Farmworkers. Fresco Migrant Health Project Kerri2 Seasonal Farmworker Health Edu- cation Project (Community Aides). Merced MercedCountyAgricultural Workers Project (Seasonal Farmworkers). Monterey Monterey County Health Project for Agricultural Laborers. Riverside Family Health Services for Migrant Farmworkers in Riverside County. San Benito San Bonito County Migrant Health Project. San Bernardino 1~ Migrant Farmworkers Project lrena Heindl, M.D Butte County Health Department, 2430 Bird Street, Oroville, Celif. 95965; Telephone 916-533-1230. J. Raymond Beeson, M.D_ Colusa County Health Departmelt. 85 East Webster Street, Colusa, Calif. 95932; Telephone 916-458-2919. Glen W. Kent, M.D Health Department, Contra Costa County, Martinez, Calif. 94553; Telephone 415- 228-3000. W. A. DeFries, M.D Fresno County Health Department, 515 South Cedar Avenue, Fresco, Calif. 93702; lelephone 209-485-8000x371. Carl Miller.. Kern County Health Department, Post Office Box 997, Bakersfield, Calif. 93302, Tele- phone 805-325-5051x218. A. Frank Brewer, M.D..__ Merced County Health Department, Post Office Box 1350, 240 East 15th Street, Mercecf, Calif. 95340; Telephone 209- 723-2861x531. R. S. Fraser, M.D Monterey County Health Department, 1270 Natividad Road, Post Office Box 2137, Salinas, Calif. 93901; Telephone 408-424- 7627. Everett M. Stone, M.D___ Riverside County Department of Public Health, 3575 11th Street, Riverside, Calif. 92501; Telephone 714-683-4O00.~ R. L. Huh, M.D San Benito County Health Department, 439 Fourth Street, Holhister, Calif. 95023; Telephone 408-637-5367. M. E. Cosand, M.D San Bernardino County Health Department, San Bernardino, Calif. 94201; Telephone 714-889-01 11x482. Services Family health service centers Medical care, nursing care Gridley Camp. Medical care, nursing caie, sani~ None. tation services. Medical care, dental care, nursing Do. care, sanitation services. Medical care, sanitation services, Firebaugh, Five Points, health education. Huron, Parlier Housing Project. Nursing care, sanitation services, None. niriTrition counsetiAg, health education. Medical care, nursing care, sanita- Planado, South Dos Palos tion aeryices, nutrition coon-- sehing. Medical care, nursing care, sanita- Pajaro. tine services. lttedical care, hospitalization, nursing ōare, sanitation services. 7 Medical care, nursing care, sani- tation services. Project title COUNTY COMPONENTS OF CALIFORNIA HEALTH PROGRAM FOR FARMWORKERs, FAMILIES (MG 06) Director Sponsor Number of migrants 1, 500 1,000 750 27, 000 9, 500 7,000 6,000 4,000 4,000 260 Blythe, Indio. None. Do. See footnotes at end of table, p. 92. Dental care, nursing care, health qducation. - - PAGENO="0098" COUNTY COMPONENTS OF CALIFORNIA HEALTH PROGRAM FOR FARMWORKERS, FAMILIES (MG 06)-Continued ~ ~ ~ ~ ~ ~ County Project title Director Sponsor Number of Services Family health migrants service centers San Joaquin 1 3_ ___Environmental Health Services for J. Don Layson San Joaquin Local Health Districl~, San 13, 000 Sanitation services None. Migrant Agricultural Workers. Joaquin, Calif. 93660; Telephone 209- 466-6781. Santa Barbara. -- - Migrant Health Project Frank Cline, Jr., M.D Santa Barbara County Health Department, 3,844 Nursing care, sanitation services.. Nipomo. 117 East Carrillo Street, Santa Barbara, Calif. 93102; Telephone 805-966--1611x- 385. Santa Cruz Farm Labor Health Services G. L. Dunnahoo, M.D Santa Cruz County Health Department, 2,800 Medical care, nursing care Watsonville. Project. 1060 Emeline Avenue, Post Office Box 962, Santa Cruz, Calif. 95060; Telephone 408-423-6020. San Luis Obispo~ Farm Labor Family Health Project. George L. Harper, M.D_ Department of Public Health, County of San 5, 000 Medical care, nursing care sani- Nipomo. Luis Obispo, Post Office Box 1489, San tation services. Luis Obiapo, Calif. 93401; Telephone 805-543-1200. Sutter Health Services to Migrant Farm- Thomas E. Leavenworth, Setter County Hospital, 1965 Live Oak Medical care, nursing care . Yuba City. workers and Their Families. M.D. 28000 Boulevard, Yuba City, Calif. 95991; Telephone 916-743-4609. Sutter-Yuba Migrant Health Project Leon M. Swift, M.D Sutter-Yuba Health Department, 370 Del 3,600 Medical care, nursing care, sani- Do. I4orte Aventre, Yuba City, Calif. 95991; tation services. Telephone 916-742-6407. Yolo Nursing Care and Health Super- Herbert Bauer, M.D Yolo County Health Department, Post Office 7, 500 Medical care, nursing care, sani- None. vision for Families of Migrant Box 1157, Woodland, Calif. 95695; Tele- tation services. Workers phone 016-662-3241x 250. 1 Supported by State funds only. ° See also Provision of Mobile Health Services for Migrant Agricultural Workers and Families in 2 See also Kern County Seasonal Medical Care Clinic Project-MG 158. San Joaquin County (MG 157). PAGENO="0099" 93 Project Title: Provision of Mobile Health Services for Migrant Agricultural Workers in San Joaquin County (MG 157). Sponsor: San Joaquin County Medical Society, 445 West Acacia Street, Post Office Box 230, Stockton, Calif. 95201; Telephone 200-460-6781. Director: Virgil Gianelli, M.D. Duration of migrant season: Year round. Estimated number of migrants: 6,000. County served by project: San Joaquin. Health services provided: Medical care, dental care, and nursing care. Location of family health service cent ers:* Acampo, Linden, Terminous, Thornton, and Vernalis. Project Title: Kern County Seasonal 1~4edical Care Clinic for Migrant Workers (MG 158). Sponsor: Kern County Medical Society, 2603 G Street, Bakersfield, Calif.; Telephone 325-5051x218. Director: Carroll Goss, M.D. Duration of migrant season: Year round. Estimated number of migrants: 2,000 (in Sunset Camp and nearby Weedpatch and Lamont). County served by project: Kern. Health services provided: Medical care and nursing care. Location of family health service centers: Sunset Labor Camp. Project Title: South County Migrant Medical Treatment Clinic (MG 159). Sponsor: Santa Clara County Medical Society, 700 Empey Way, San Jose, Calif. 95128; Telephone 408-286-5050. Director: Stanley A. Skillicorn, M.D. Duration of migrant season: Year round. Estimated number of migrants: 7,300. County served by project: Santa Clara. Health services provided: Medical care, nursing care, and social services. Location of family health service centers: San Martin. COLORADO Project Title: State Migrant Plan for Public Health Services (MG 09). Sponsor: Colorado State Department of Health, 4210 East 11th Avenue, Dcii- ver, Cob. 802220; Telephone 303-388-6111. Director: R. A. Downs, D.D.S. Duration of migrant season: April-November; year round in San Luis Valley. Estimated unmber of migrants: 20,400. Counties served by project: Adams, Alamosa, Baca, Bent, Conejos, Costilla, Delta, Kit Carson, Larminer, Mesa, Montrose, Morgan, Otero, Prowers, Pueblo, Rio Grande, Saguache, and Weld. Health services provided: Medical care, dental care, nursing care, health eclu- cation, nutrition counseling. Sanitation services only in 4 counties: Baca, Bent, Prowers, and Pueblo. Location of family heaith service centers: Fort Lupton. CONNECTICUT Project Title: Improved Migrant Farm Labor Sanitation Program (MG 82). Sponsor: Connecticut State Department of Health, 79 Elm Street, Hartford, Conn. 06115; Telephone 527-6351x816. Director: Marvin L. Smith. Duration of migrant season: March-November. Estimated number of migrants: 7,000. Counties served by project: Fairfield, Hartford, Litchfield, Middlesex, New Haven, New London, Tolland, and Windham. Health services provided: Sanitation services. *Mobfle clinic. PAGENO="0100" 94 DELAWARE Project Title: Delaware Migrant Health Project (MG 83). Sponsor: Delaware State Council of Churches, 217 North Bradford Street, Dover, Del.; Telephone 302-730~-6919. Director: Rev. Samuel A. Snyder, Jr. Duration of migrant season: June-August, Estimated number of migrants: 4,800. Counties served by project: Kent, New Ca~tie, and Sussex. Health services jrovided: Medical care, hospitali~atiOn, dental care, nursing care, and sanitation services. - FLORIDA Project Title: A. Project to Develop a Statewide Program of Health Services for Migrant Farmworkers and Their Dependents in Fiorlda (MG 18). Sponsor: Florida State Board of Health, Post Office Box 210, Jacksonville, Fla. 32201; Telephone 004-354-39G1. Director: B. Henry King, M.D. Duration of migrant season: Year round. Estimated number of migrants: 130,000. Counties served by project: Alachua, Broward, O~llier, Iflagler, Glades, Hendry, Highlands, Lee, Manatee; Martin, Orange, Polk, Putnam, Saint Lucie, Sarasota, and Seminole. Health services provided: Medical care, hospitalization, dental care, nursing rare, sanitation services, health education, and nutrition counseling through county migrant health projects; consultation at State level to local projects on general administration. NoTE.-~See following table for county detaiL PAGENO="0101" COUNTY COMPONENTS OF FLORIDA STATE PROJECT (MG 18)-A PROJECT TO DEVELOP A STATEWIDE PROGRAM OF HEALTH SERVICES FOR MlGRANT WORKERS AND THEIR FAMILIES IN FLORlDA County Director Organization Number of migrants Services Family health service centers Alachua Edward D. Byrne, M.D Alachua County Health Department, 816 South- west 4th Ave., Gainesville, Fla. Broward Paul W. Hughes, M.D Bruward County Health Department, 2421 South- west 6th Ave., Fort Lauderdale, Fla. Collier Clyde L. Brothers, M.D Collier County Health Department, Post Office Box 477, Naples, Fla. Highlands____ J. Dillard Workman, M.D Highlands County Health Department, Sebring, Fla. 1,500 14,000 19,000 Nursing care, sanitation services Alachua. Medical care, hospitalization, dental care, nursing Pompano Beach. care, sanitation services. Medical care, hospitalization, nursing care, sani- Immokalee. tation services. Glades do Glades County Health Department, Post Office Box 274, Moore Haven, Fla. Hendry do Hendry County Health Department, Post Office Box 278, LāBelle, Fla. ) Lee Joseph W. Lawrence, M.D -- - Lee County Health Department, Post Office Box 1226, 2115 2d St., Court House Annex, Fort Myers, Fla. Manatee George M. Dame, M.D Manatee County Health Department, 202 6th Ave. West, Post Office Box 2029, Bradenton, Fla. Martin Niel D. Miller, M.D Martin County Health Department, Post Office Box 1846, 442 Flagler Ave., Stuart, Fla. Orange Wilfred N. Sisk, M.D Orange County Health Department, 832 West Central Ave., Post Office Box 3187, Orlando, Fta. Polk William F. Hill, M.D Polk County Health Department, 229 Avenue D NW., Post Office Box 1480, Winter Haven, Fla. Potnum. - - Julius C. Brooks, Jr., M.D... Putnam County Health Department, Post Office Box Drawer 1070; PalatIne, Fla. Flagler do Flagler County Health Department, Post Office, Box 57, Burnieft, Fla. St. Locie iliel D. Miller St. tucie County Health Department, Post Office Box 580, Fort Pierce, Fla. Sorasota David L. Crane, M.D Sarasota County Health Department, Post Office Box 2658, Sarasota, Fla. Seminole.. Frank Leone, M.D.. Seminole County Health Department, Frenclu Ave. and 9th St., Post Office Box 1856, Stanford, Fla. 11, 500 10,625 5, 000 1, 100 10, 000 20, 000 ~ 10,000 2.000 12, 500 Medical care, hospitalization, nursing care, sanita- Moore Haven, LaBelle. tion services, health education. Medical care, hospitalization, nursing care, sani- Harlem Heights, Teter Rd., Charleston tation services. Park. Medical care, nursing care, sanitation services, None. health education. Medical care, dental care, nursing care, sanita- Indiantown. tion services. Medical care, nursing care, sanitation services, Apopka, Winter Garden, Winter Park, health education. Zellwood. Nursing care, sanitation servic~, health educa- None. tion. . ursing care 0. Medical care, dental care, nursing care, sanitation Fort Pierce. services. Medical care, nursing care, senitation services. -- Fame. do Midway, Oviedo. . PAGENO="0102" 96 Project Title: Comprehensive Health Services for Domestic Agricultural Mi- grants in Palm Beach County (MG 11). Sponsor: Florida State Board of Health, Palm Beach County Health Depart- ment, 826 Evernia Street, Post Office Box 29, West Palm Beach, Fla. 33402; Telephone 305-832-2441. Director: D. N. Logsdon, M.D. Duration of migrant season: Year round. Estimated number of migrants: 22,100. County served by project: Palm Beach. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Delray,* Belle Glade, and Pahokee. Project Title: Comprehensive Health Care for Migrant Farrnworkers in Dade County (MG 34) Sponsor: Dade County Department of Public Health, 1350 Northwest 14th Street, Miami, Fla. 33125; Pelephone 305-377-0341. Director: W. R. Stinger, M.D., Acting DireCtor. Duration of migrant seaso~t: October-May. Estimated number of migrants: 12,580. County served by project: Dade. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Krome Ave. Center, Perrine, South Dade, and Tally. IDAHO Pro ject Title: Idaho's Migrant Health Services (MG 124). Sponsor: Idaho Department of Health, Statehouse, Boise, Idaho 83701; Tele- phone 208-344-5811x370. Director: Terrell Carver, M.D. Duration of migrant season~: May-October. Estimated number of migrants: 19,000. Counties served by project: Ada, Bannock, Bingham, Bonneville, Butte, Can- yon, Caribou, Cassia, Elmore, Franklin, Gem, Gooding, Jefferson, Jerome, Madi- son, Minidoka, Nez Perce, Owyhee, Payette, Power, Teton, Twin Falls, and Washington. Health services provided: Sanitation services. ILLINOIS Project Title: An Action Prtgram for Agricultural Migrant Workers and Families (MG 105). Sponsor: Illinois Department of Public Health, Division of Preventive Medi- cine, State Office Building, Springfield, 111. 62706; Telephone 217-525-7577. Director: Donaldson F. Rawlings, M.D. Duration of migrant season: June-September. Estimated number of migrants: 7,800. Counties served by project: Lee, Ogle, and Vetmilion.** Health servioe~ pro4~ided: Medical care, dental care, nursing care, health edu- cation (Lee, Ogle, and Vermilion Counties, primarily) ; Statewide coordination and limited nursing, health education, vision and hearing, and school health consultation to all counties with migrants. Project Title: Princeville Migrant Health Services (MG 150). Sponsor: Princeville Migrant Council, Princeville, Iii. 61559; Telephone 309- 385-4370 or 309-385-4994. Director: Rev. William Smith. Duration of migrant season: April-October. Estimated number of migrants: 635. County served by project: Peoria. Health services provided: Medical care and nursing care. Project Title: Jones Memorial Community Center, Migrant Health Clinic (MG 151). *Mobile clinic. **At least limited health services through volunteers or supported from State and local sources are provided in the following counties: Bureau, De Kalb, Grundy, Henderson, Iroquois, Jackson, Kane, Marion, Union, Will, and Winnebago. PAGENO="0103" 97 Sponsor: Jones Memorial Community Center, 220 East 15th Street, Chicago Heights, Iii. 60411; Telephone 312-756-7000. Director: Dr. E. G. Wygant. Duration of migrant season: June-October. Estimated number of migrants: 700. County served by project: Oook. Health services provided: Medical care, dental care, and nursing care. Location of family health service centers: Jones Memorial Community Center and St. James Hospital. Project Title: Northwest Church Council Migrant Aid Services (MG 152) Sponsor: Northwest Church Council `for Migrant Aid, Inc., 3109 Swallow Lane, Rolling Meadows, Ill. 60008; Telephone 312-255-3667. Director: Virgil J. Bass. Duration of `migrant season: April-November. Number of migrants: 685. Counties served by project: Cook. Du Page, Kane, Lake, and Mdllenry. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, health education, and nutrition counselling. Location of family health service centers: Evanston and Elk Grove Village. Project Title: Rock Island-Mercer Migrant Family Health Service (MG 153). Sponsor: Migrant Ministry Committee of the Council of Churches of Scott and Rock Island Counties, 639 38th Street, Rock Island Ill. 61201; Telephone 309-786- 4451x327. Director: Rev. Donald F. Bautz. Duration of migrant season: July-September. Estimated number of migrants: 958. Counties served by project: Mercer and Rock Island. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Rock Island. INDIANA Project Title: Health Services for Migrant Workers (MG 20). Sponsor: Indiana State Board of Health, 1330 West Michigan Street, Indianap- olis, md. 46207; Telephone 317-633-6671. Director: Verne K. Harvey, Jr., M.D. Duration of migrant season: April-September.. Estimated number of migrants: 10,000. Counties served by project: Adams, Delaware, Grant, Huntington, Jay, Lake, Marshall, Miami, and Wells. Health services provided: Medical care, nursing care, and sanitation services in above listed counties; sanitation services only in 19 other counties. Location of family health service centers: Huntington County. IOWA Project Title: Muscatine Area Migrant Families Health Services (MG 23). Sponsor: Muscatine Neighborhood Center for Migrants, 421 East Second Street, Muscatine, Iowa 52761; Telephone 319-264-1155 or 319-263-5040. Director: Mrs. Thomas Manton. Duration~ of migrant season: May-October. Estimated number of migrants: 1,200. Counties served by project: Cedar, Louisa, Muscatine, and Scott. Health services provided: Medical care, hospitalization, nursing care, sanita- tion services, and health education. Location of family health service centers: Muscatine. Project Title: Health Services for Migrant Families in the North Iowa Area (MG 116). Sponsor: Migrant Action Program, Box 717, Mason City, Iowa 50401; Tele- phone 515-423-3984 or 515-423-7572. Director: Mrs. Richard E. Sandage. Duration of migrant season: May-August. Estimated number of migrants: 600. Counties served by project: Black Hawk, Cerro Gordo, Floyd, Franklin, Grundy, Hancock, Kossuth, Marshall, Mitchell, Winnebago, and Worth. PAGENO="0104" 98 Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Buffalo Center, Clear Lake, Latiiner, Manley, Northwood, and Reinbeck. KANSAS Project Title: Plan to Provide Health Services to Kansas Migrants (MG 64). Sponsor: Headquarters: Kansas State Department of Health, State Office Building, Topeka, Kans. 66612, Telephone 913-321-0011x729; Local: Migrant Health Services, 317 North Seventh Street, Garden City, Kans. 67846; Telephone 316-276-2131. Director: Patricia Scbloesser, M.D. Duration of migrant season: March-November. Estimated number of migrants: 6,000. Counties served by project: Finney, Grant, Greeley, Haskell, Kearney, Meade, Scott, Seward, Sherman, Stanton, Stevens, Wallace, and Witchita. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation, and health education services in 7 counties; nursing care pro- vided in 3 additional counties; health education and sanitation services in 3 additional counties. Location of family health service centers: Garden City, Goodland, Johnson, Lakin, Scott City, Sublette, Tribune, and Ulysses. Project Title: Plan to Provide Public Health Services for Migrants in Wyan- dotte County, Kansas (MG 74). Sponsor: Kansas City-Wyandotte County Health Department, 619 Ann Avenue, Kansas City, Kans. 66101; Telephone 913-321-4803. Director: N. G. Walker, M.D. Duration of migrant season: April-November. Estimated number of migrants: 2,120. County served by project: Wyandotte. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Edwardville and Wolcott. KENTUCKY Pro ject Title: Migrant Worker Health Project (MG77). Sponsor: Kentucky State Department of Health, 275 East Main Street, Frank- fort, Ky. 40601; Telephone 502-564-3970. Director: Jorge DeJu, M.D. Duration of migrant season: May-June. Estimated number of migrants: 1,000. Counties served by project: Carlisle and Hickman. Health services provided: Medical care, hospitalization, nursing care, dental care, sanitation services, health education, and nutrition eoiinseling. Location of family health service centers: Bardwell and Clinton. LOUISIANA Project Title: New and Improved Medical, Dental, and Nursing Services to Migratory Workers and Their Families (MG 54). Sponsor: Health Subcommittee, Tangipahoa Migrant Committee, Route 2, Box 257, Ponchatoula, La. 70454; Telephone 504-386-6749. Director: Milburn R. Fletcher. Daration of migrant season: March-June. Esfimated number of migrants: 3,400. County served by project: Tangipahoa. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. MARYLAND Project Title: Frederick County Migrant Health Project (MG 80). Sponsor: Frederick County Migrant Health Council, Inc., 1415 West Seventh Street, Frederick, Md. 21701; Telephone 301-663-3344. Director: Rev. Carrol L. Boyer. Duration of migrant seasort: June-Septeniber. Estimated number of migrants: 170. PAGENO="0105" 99 County served by project: Frederick. Health .s~ervices provided: Medical care, dental care, nnd nursing care. N0TE.-This project is now supported entirely by local funds. Project Title: Field Oriented Migrant Health Services (MG 155). $ponsor: Worcester County Community Action Committee, Inc., Post Office Box 67, Snow Hill, Md. 21863; Telephone 301-632-2160. Director: David M. McAllister. Duration of migrant season: June-October. Estimated number of migrants: 800 (300 home-based). County served by project: Worcester. Health services provided: Medical care, hospitalization, nursing care, and health education. MASSACHUSnTTS Project Title: Massachusetts Migrant Health Project (MG 68). $ponsor: Massachusetts Health Research Institute9 Inc., Somerset Street. Bos- ton, Mass. 0210R; Telephone 617-727-2662. Director: Leon Sternfield, M.D. Duration of migrant season: May-October. Estimated number of migrants: 5,000. Counties served by project: Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, and W~rceste.r. Health services provided: Medical care, sanitation services, and health edu- cation. MIcWGAN Project Title: Improvement and Expansion of Health Services to Migrant Agricultural Workers and Their Families (MG3O). $ponsor: Michigan Department of Health, 3500 North Logan, Lansing, Mich. 48914; Telephone 517-373-1406. Director: Douglas H. Fryer, M.D. Duration of migrant season: April-November. Estimated number of migrants: 79,400. Counties served by project: All counties having migrants (40 counties). Health services provided: Coordination of all migrant health activities within the Michigan Department of Health; provision of consultation and direct assist- ance in the development, administration, and evaluation of migrant health proj- ects in Michigan. Project Title: Oooperative Migrant Project (MG 31). $ponsor: Ottawa County Health Department, Grand Haven, Mich. 49417; Telephone 616-842-0100. Director: Ralph Ten Have, M.D. Duration of migrant season: July-September. Estimated number of migrants: 2,500. County served by project: Ottawa. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Holland. Project Title: Migrant Family Health Clinic-Nursing, Sanitation, and Dental Services (MC 79). t~ponsor Monroe County Health Department, Courthouse, Monroe, Mich. 481(31; Telephone 313-241-9434. Director: Paul W. Sundin, M.D. Duration of migrant season: April-September. Estimated number of migrants: 1,630. County served by project: Monroe. Health services provided: Medical care, hospitalization, dental care, nursing care, and sanitation services. Location of family health service centers: Erie and Ida. Project Title: Environmental Health Camp Sanitation Project for Migrant Agricultural Workers and Their Families (MG 91). $ponsor: Michigan Department of Health, 3500 North Logan, Lansing, Mich. 48914; Telephone 517-373-3720. Director: John E. Vogt. PAGENO="0106" 100 Duration of migrant season: April-December. Estimated number of migrants: 79,400. Counties served by project: All counties having migrants (40 counties). Health services provided: Sanitation services through inspections of labor camps, providing technical assistance to growers in construction of camp hous- ing and sanitation facilities, and providing consultation with local health de- partment sanitarians. Project Title: Tn-County Associated Health Departments Migrant Health Program (MG 107). $povsor: T~ni-Oounty Associated Health Departments, 505 Pleasant Street, St. Joseph, Mich. 49085; Telephone 616-983-6396. Director: Robert P. Locey, M.D. Duration of migrant season: April-October. Estimated number of migrants: 23,400. Counties served by project: Berrien, Oass, and Van Buren. Health services provided: Medical care, hospitalization, nursing care, sanita- tion services, and health education. Location of family health service centers: Baroda*, Berrien Springs*, Grand Junction*, Keeler, and Sodus*. Project Title: Comprehensive Care for Migrant Population of Grand Traverse, Leelanau, and Benzie Counties (MG 112). Sponsor: Grand Traverse-Leelanau-Benzie County Health Department-In cooperation with the Grand Traverse Migrant Labor Council, care of Grand Traverse Medical Care Facility, Traverse City, Mich. 49684; Telephone 616- 947-560G. Director: Loren Bensley, Acting. Duration of nvigrant season: July-September. Estimated number of migrants: 23,820. Counties served by project: Antnim, Benzie, Grand Traverse, and Leelanau. Health services provided: Medical care, hospitalization, dental care, and nurs- ing care. Location of famifly health service centers~ Cherry Farms-Grand Traverse; Munson Medical Center-Traverse City; and Leelanau County. Project Title: Migrant Family Medical Care, Nursing; and Hospital Program (MG 131). Sponsor: Manistee-Mason District Health Department, 401 East Ludington Avenue, Ludington, Mich. 49431; Telephone 616-843-3994. Director: Gladys J. Kleinsehmidt, M.D. Duration Of migrant season: April-September. Estimated number of migrants: 11,000. Counties served by project: Manistee and Mason. Health services provided: Medical care, hospitalization, nursing care, sanita- tion services (through MG 91), and health ~dueatlon. Location of fa4n.ily health service centers: Ludington. Project Title: District Health Department No. 4 Migrant Family Health Clinic and Hosptial Program (MG 138). Sponsor: District Health Department No. 4, 318 South Third Street, Rogers City', Mich. 49779; Telephone 517-734-2642. Director: William F. Jackson, M.D. Duration of migrant season: Jutie-November. Estimated number of migrants: 1,500. Counties served by project: Alpena, Oheboygan, Montmorency, and Presque Isle. Health services provided: Medical cane, hospitalization, nursing care, sanita- tion services (through MG 91), health education, and nutrition counseling. Location of family health service centers: Wilson Township School-Alpena. Project Title: Benzie Migrant Family Health Services Project (MG 149). Sponsor: l3enzie Migrant Ministry Committee, Frankfort, Mich. 49635.; Tele- phone O16-352~-9286. Director: Mrs. Grant Papinean. *Mobfle PAGENO="0107" 101 Dura~tion of migrant season: June-November. Estimated number of migrants: 4,000, County served by project: Benzie. Health services provided: Medical care, hospitalizat!on (through MG 112), dental care, nursing care, and sanitation services (through MG 91). Location of family health service centers: Beulah. MINNESOTA Project Title: Migrant Labor Environmental Health and Nursing Service, and Health Education Project (MG 67). ~8ponsor: Minnesota Department of Health, University Campus, Minneapolis, Minn. 55440; Telephone: 61Z-339-7751. Director: D. S. Fleming, M.D. Duration of migrant season: March-September. Estimated number of migrants: 10,000 Counties served by project: Anoka, Big Stone, Chippewa, Clay, Faribault, Freeborn, Hennepin, Kandiyohi, Kittson, Lac Qui Pane, Marshall, Martin, Mower, McLeod, Norman, Polk, Redwood, Renville, Sibley, Steele, Swift, Wilkin, Yellow Medicine, and Waseca. Health services provided: Nursing service where it is lacking locally; health aides to work with project nurses; medical care, hospitalization and dental care in two locations; sanitation services in all migrant areas; coordination of migrant health activities of State Health Department with those of state and local official and volnntary agencies, grt~wers' associations, and OEO-sponsored projects. Missouax Project Title: Family Health Education Services for Home-Based Migrants (MG 104). fiponsor: Delmo Housing Corp., Box 354, Lilbourn, Mo. 63862; Telephone 314-688-2565. Director: Mi-a Charlotte Ragan.. Duration of migrant season: June-September; December-May. Estimated number of migrants: 10,000. Counties ser~eed by project: Dunl~lin, Mississippi, New Madrid, Pemiscot, Scott, and Stodchird. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Lilbourn. NEERASKA Project Title: Nebraska Plan To Provide Health Eduottion and Other Public Health Services for Migrant Families (MG 88). $ponsor: Headquarters: Nebraska Department o~ Healthy Capitol Building, Lincoln, Nebr. 68500, Pelephone 402-477-5211; Local: Migrant Health Project Office, 1422½ Tenth Street, Gening, .Nebr. 69341; Telephone 308-434i--2095, Director: P. R. Dappen. Duration of migrant season: April-August; Septeniber-May. Estimated number of migrants: 5,485. Counties sot-ned by project: Box Butte, Chase, Garden, Morrill, Perkins, Scotts Bluff, and `Sioux. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Alliance, Bayard, Bridgeport, and ~ering. NEVADA Project Title: Moapa Valley Migrant Health Program (MG 133). $ponsor: Clark County District Health Department, 625 Shadow Lane, Las Vegas, Nev. 89106; Telephone 702-385-1291x201. Director: Otto Ravenholt, M.D. Duration of migrant season: December-September. Estimated number of migrants: 700. County served by project: Clark. Health services provided: Medical care, hospitalization, dental care, and nurs- ing care. Location of family health service ccn ters: Logandale and Overton. PAGENO="0108" .102 NEW JERSEY Project Title: Health Services for Migrant Agricultural Workers (MG 08). Sponsor: New Jersey State Department of Health, Health and Agriculture Building, John Fitch Plaza, Trenton, N.J. 08625; Telephone 609-292--5470. Director: Thomas Gilbert. Duration of migrant season: March-November. Estimated number of migrants: 26,300. Counties served by project: Atlantic, Burlington, Camden, Gloucester, Mercer, Middlesex, Monmouth, Ocean, and Salem. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Freehold, Mt. Holly, Salem, and Woodbury. Project Title: Migrant Health Service~, Cumberland County (MG 118). Sponsor: Board of Chosen Freeholders of Cumberland County, Cumberland County Courthouse, Bridgeton, N.J. 08302; Telephone 609-451-8000. Director: William P. Doherty, V.M.I). D uration of migrant season: April-September. Estimated number of migrants: 1,300. County served by project: Cumberland. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, social services, and health education. Location of family health service centers: Bridgeton. NEW Mnxrco Project Title: Las Oruces Migrant Health Project (MG 15). Sponsor: Las Cruces Committee on Migrant Ministry, 2930 Huntington Drive, Las Cruces, N. Mex. 88001; Telephone 505-526-8637. Director: George H. Ross. Duration of migrant season: May-September. Estimated wurnber of migrants: ~,000. County served by project: Dona Ana. Health services provided: Medical care, hospitalization, dental care, and nurs- ing care. . Location of fdmily service centers: Las Cruces. Project Title: Migrant Health Projeet-~Health Districts 1 and 5 (MG 134). Sponsor: New Mexico Department of Public Health, 408 Galisteo Street, Santa Fe, N. Mex. 87501; Telephone 505-983-6345. Co-Directors: Marion Hotopp, M.D., and Edith F. Millican, 1\LD. Duration of migrant season: May-October. Estimated number of migrants: p23,000. Counties served by project: Guadalupe, Mora, Rio Arriba, San Miguel, awl Taos. Health service provided: Medical care, dental care, and nursing care. Location of family health service centers: Anton ChIcO, Cleveland, El Rito, Espanola, Las Vegas, Lindrith, and Parkview. Project Title: New Mexico Migrant Health Project, . Health District 10 (MG 154). Spons~or: New Mexico Department of Public Health, 408 Gailsteo Street, Santa Fe, N. Mex. 87501; Telephone 505-983-6345. Director: George W. Prothro, M.D. Duration of migrant season: June-December. Estimated number of migrants: 2400. Counties served by project: Curry, DeBaca, Quay, and floosevelt. Health services provided: Medical care, nursing care, sanitation seryices, and health education. Location of family health service centers: Ranchos de Laos, Questa, and Penasco. PAGENO="0109" 103 N~w Yoiu~ Project Title: Family Service Clinics, Emergency Dental Care, Eye Examina. tions, and Provision of Glasses (MG 38). Sponsor: New York State Department of Health, Utica District Office, 1512 Genesee Street, Utica, N.Y. 13502; Telephone 315-732~-5137. Director: Evelyn F. H. Rogers, M.D. Duration of migrant season: September-October. Estimated number of migrants: 2~600. Counties served by project: Chenango, Herkimer, Madison, and Oneida. Health services provided: Medical care, dental care, nursing care, eye examina- tions and glasses if needed, sanitation services, and health education. Location of family health service centers: Bridgewater and Clinton. Project Title: Suffolk County, N.Y., Migrant Health Project (MG 60). Sponsor: Suffolk County Department of Health, Suffolk County Center, River- head, Long Island, N.Y. 11901; Telephone 516-727-4700 x 355. Director: Robert Specht, R.N. Duration of migrant season: July-November. Estimated number of migrants: 4,750. County served by project: Suffolk Health service provided: Medical care, nursing care, sanitation services, and health education. Location of family health service centers: Riverhead. Project Title: Monroe County Migrant Project (MG 103) Sponsor: University of Rochester, River Campus Station, Rochester, N.'~. 14627; Telephone 716-473-440x3271. Director: John F. Radebaugh, M.D. Duration of migrant season: June-November. Estimated number of migrants: 1,250. County served by project: Monroe. Health services provided: Medical care, dental care, nursing care, and health education. Location of family health service centers: Hilton, Martin's Camp, and Scottsville. Project Title: Cayuga County Migrant Health Services rrogram (MG 104~). Sponsor: Cayuga County Health Department, Box 219, 5 James Street, Auburn, N.Y. 13021; Telephone 315-253-9731. Director: C. Harold Warnock, M.D. Duration of migrant season: June-November. Estimated number of migrants: 828. County served by project: Cayuga. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health service centers: King Ferry and Moravia. Project Title: New Pal'tz Migrant Health Project' (MG 125). Sponsor: Ulster County Department of Health, 244 Fair Street, Kingston, N.Y. 12401; Telephone 914-331-9300x330. Director: Vernon B. Link, M.D. Duration of migrant season: July-November. Estimated number of migrants: 1,000. County served by project: Ulster. Health services provided: Medical care, deiital care, nursing care, and sanita- tion services. Location of family health service cent ers: New Paltz. Project Title: Orange County Migrant Health Project (MG 135). Sponsor: Migrant Committee of the Warwick Valley Council of Churches, South Street and Second, Warwick, N.Y. 10990; `Telephone 914-986-1725. Director; Mrs. Valerie Maize. PAGENO="0110" 104 Duration of migrant season: July-November. Estimated number of migrants: 1,500. County served by project: Orange. Health services provided: Medical care, dental care, nursing care, and health education. Location of family health service centers: Pine Island. Project Title: Migrant Health Services Coordination Project (MG 148). Sponsor: New York State Health Department, 84 Holland Avenue, Albany, N.Y. 12208; Telephone 518-472-2030. Director: Arthur G. Baker, M.D. Duration of iwigrain4 season: May-August. Estimated number of migrants: 25,000. Counties served by project: Broome, Cayuga, Chautauqua, Columbia, Dela- ware, Dutchess, Erie, Genesee, Herkimer, Livingston, Monroe, Niagara, Oneida, Ontario, Orange, Orleans, Oswego, Rockland, Steuben, Suffolk, Ulster, Wayne, Wyoming, and Yates. health services provided: Consultation and coordination of county projects, dental care in Wayne County, and sanitation services in all counties. NORm CAROL~NA Project Title: iarteret Area Mobile Migrant Clinic (MG 27) Sponsor: Oarteret County Migrant Committee, care of First Presbyterian Church, Morehead City, NC. 28557; Telephone 919-726-4449. Director: Rev. Charles L. Kirby. Duration of migrant season: April-August. Estimated number of migrants:500. County served ~y project: Carter~t. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Beaufort*. Project Title: Henderson County Migrant Family Health Service (MG 28). Sponsor: Henderson County Migrant Council, Inc., Post Office Box 65, Render- sonville, NC. 28739; Telephone 704-692-2815. Director: Mrs. Frank B. Burson, P.H.N. Duration of migrant season: July-September. Estimated number of migrants: 1,500. County served by project: Henderson. health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Hendersonville. Project Title: Migrant Health Project (MG 56). Sponsor: North Carolina State Board of Health, 225 North McDowall Street, Post Office Box 2091, Raleigh, NC. 27602; Telephone 919-829-3446. Director: W. Burns-Jones, Jr., M.D. Duration of migrant seasoa: April-November; November-April (home-base). Estimated number of migrants: 6,500. Counties~ served by project: All cOunties having migrants (35 counties). Health services provided: State level consultation, demonstration, and educa- tion are provided to existing migrant health programs; assistance in given in initiation of migrant health services in other areas of need; coordination between projects is developed. Project Title: Albemarle Migrant Health Service Project (MG 57). Sponsor: District Health Department, Elizabeth City, N.C. 27909; Telephone 91~-335-5429. Director: Isa C. Grant, M.D. Duration of migrant season: June-November. Estimated number of migrants: 1,200. Counties served by project: Camden, Currituck, and Pasquotank. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Elizabeth City. *Mobjle PAGENO="0111" 105 Project Title: Sampson Migrant Health Service Project (MG 122). ~pon,sor: Community Action Council, Inc., Sampson County Health Department, Clinton, N.C. 28328; Telephone 919-592-6177. Director: Caroline H. Callison, M.D. Duration of migrant season: June-August. Estimated number of migrants: 685. County served by project: Sampson, Health services provided: Medical care, dental care, nursing care, and health education. Location of family health service centers: Clinton, OHio Project Title: Migrant Health Clinics, Nursing and Sanitation Services Pro- gram (MG 21). $ponsor: Sandusky County-Fremont City, General Health District, Fremont, Ohio 43420; Telephone 419-332-6411. Director: William J. Eoswell, M.D. Duration of migrant season: April-November. Estimated number of migrants: 3,000. County served by project: Sanclusky. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, health education, and nutrition counseling. Location of fami~y health service centers: Freinout. Project Title: Environmental Health Project (Migrants) (MG.24)~. sponsor: Ohio Department of Health, 450 East Town Street, Post Office Box 118, Columbus, Ohio 43216; Telephone 614-469-3543. Director: Ray B. Watts. Duration of migrant season: April-November. `Estimated number of migrants: 14,780. Counties served by project: Darke, Fulton, Henry, Mercer, Putnam, Seneca, Stark, and Wood. Health services provided: Sanitation services. Project Title: Family Health Education Project for Migrants (MG 35). sponsor: Lucas County Health Department,. 416 North Erie Street, Toledo, Ohio 43624; Telephone 419-248-5911. ` ` Director: Dorothy M. Van Ausdal, M.D. Duration of migrant season: February-November. Estimated number of migrants: 1,200. County served by project: Lucas. ` Health services provided: Medical care, hospitalization, nursing care, sanita- tion services, health education, and nutrition counseling. Location of family health service centers: East side of. county,. West side of county, and Toledo. Project Title: Health Aide, Nursing, and Nutrition Consultation Project (MG 36). $ponsor: Ohio Department of Health, 450 East Town Street, Post Office Box 118, Columbus, Ohio43216; Telephone 614-469-3543. Director: Miss Helen Massengale. Duration of migrant season: June-October. Counties served by project: Darke, Fulton, Hancock, Henry, Lucas, Mercer, Ottawa, Putnam, Sandusky, Seneca, and Wood. Health services provided: Consultation in health education, nursing, and nutri- tion; coordination of training and work of health aides in various local migrant health projects. Project Title: Migrant Labor Family Care Program (MG 61). sponsor: Putnam County General Health District, Court House, Ottawa, Ohio 45875; Telephone: 419-527-1616. Director: Milo B. Rice, M.D. Duration of migrant season: April-October. Estimated number of migrants: 3,260. County served by project: Putnam. PAGENO="0112" 106 Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, health education, and nutrition counseling. Location of family health service centers: Ottawa. Project Title: Migrant Health Clinic and Nursing Services Project (MG 78). Sponsor: Darke County General Health District, Courthouse, Greenville, Ohio 45331; Telephone: 513-548-4196. Director: Giles Wolverton, M.D. Duration of migrant season: June-October. Estimated number of migrants: 1,400. County served by project: Darke. Health services provided: Medical care, dental care, nursing care, health edu- cation, and sanitation services. Location of family health service centers: Union City. Project Title: Ottawa County Migrant Family Health Service Clinic (MG 126). Sponsor: Ottawa County Ministry to Migrants, 159 North Church Street, Oak Harbor, Ohio 43449; Telephone 419-898-8486. Director: Rev. Robert Lamantia. Duration of migrant season: June-October. Estimated number of migrants: 1,400. County served by project: Ottawa. Health services provided: Medical care, hospitalization, dental care, nursing care, health education, sanitation services, and nutrition counseling. Location of family health service centers: Oak Harbor. Project Title: Migrant Health Study Project and Dental Care Program (MG 136). Sponsor: Hartville Migrant Council, Inc., Box 682, Hartville, Ohio 44632; Telephone 216-454-4719. Director: Mrs. Ralph McFadden. Duration of migrant season: April-October. Estimated number of migrants: 680. County served by projects: Stark. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, health education, and nutrition counseling. Location of family health service centers: Hartville. OKLAHOMA Project Title: Project To Furnish and Supplement Existing Public Health and Medical Care Service to Migrant Labor Families (MG 59). Sponsor: State Department of Health, 3400 North Eastern, Oklahoma City, Okia.; Telephone 405-427-6561. Project Office: Jackson County Health Depart- ment, 201 South Lee, Altus, O'kla.; Telephone 405-482-7308. Director: J. K. Leavitt, M.D. Duration of migrant season: May-December. Estimated number of migrants: 6,100. Counties served by project: Greer, Harmon, and Jackson. Health services provided: Nursing care, dental care, sanitation services, and health education. OREGON Project Title: Clinic Care, Public Health Nursing, and Sanitation Services to Migrant Farm Labor (MG 05). Sponsor: Orgeon State Board of Health, 1400 Southwest Fifth Avenue, Port- land, Oreg. 97201; Telephone 503-226-2161. Director: Ralph R. Sullivan, M.D. Duration of migrant season: March-September. Estimated number of migrants: 28,900. Counties served by project: Clackamas, Hood River, Jackson, Kiamath, Linri, Malheur, Marion, Polk, and Washington. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education through county migrant health projects; consultation to projects from State level includes nursing, sanitation, and health education. Norz.-See following table for county detail. PAGENO="0113" 107 COUNTY COMPONENTS OF OREGON MIGRANT HEALTH PROJECT (MG 05) Number of migrants Services Project Title: Yamhill County Migrant Health Project (MG 63). Oreg. 97128; Telephone 503-472-5161. sponsor: Yamhill County Health Department, Courthouse, McMinnville, Oreg. 97128; Telephone 503-472-5161. Director: H. Grant Skinner, M.D. Duration of migrant season: May-October. EsUmated number of migrants: 6,000. County served by project: Yamhill. Health services provided: Medical care, nursing care, sanitation services, men- tal health services, and health education. Locaiion of family health services centers: Eola Village. PENNSYLVANIA Project Title: Health and Medical Services for Migrants (MG 3/3). sponsor: Pennsylvania Department of Health, Post Office Box 90, Harrisburg, Pa. 17120; Telephone 717-787-69117. Director: A. L. Chapman, M.D. Duration of migrant season: June -November. Estimated number of migrants: 6,300. Counties served by project: Adams, Berks, Chester, Columbia, Franklin, Lacka- wanna, Lancaster, Lehigh, Luzerne, Montour, Northumberland, Potter, Schuylkill, Snyder, Union, Wyoming, and York. Health services provided: Medical care, dental care, nursing care, and sanita- tion services. Sanitation services only are provided ifl four additional counties. Location of family health service centers: Coatesville, Danville, Gettysburg, Lancaster, and Scranton. PUERTO Rico Project Title: Health Needs for Migrant Workers Project (MG 58). $ponsor: University of Puerto Rico, School of Medicine, Snn Juan, P.R. 00905 Telephone 723-0410. Office: Migrant Health Regional Office, Puerto Rican Medical Center, Barrio Monacillo, Rio Piedras, P.R.; Telephone 765-0038. Director: Ruben Nazario, M.D. Duration of migrant season: October-December. Estimated number of migrants: 2,178. County served by project: Northeast Health Region. Health services provided: Medical care nursing care, sanitation services, health education, and social services. Location of family health service centers: Puerto Rican Medical Center. SoUTH CAROLINA Project Title: Health Services for Migratory Agricultural Workers and Their Families--Charleston County (MG 26). sponsor: South Carolina State Board of Health, 2600 Bull Street, Columbia, S.C. 29201; Telephone 803-723-9251. 93*-453--68-----S County Director Clackamas Hollister M. Stolte, M.D., 1425 South Kaen Rd., Oregon City, Dreg. 3, 000 Medical care, hospitalization, dental care, nursing care, and sanitation services. Hood River Leonard L. Hoffman, M.D., County Courthouse, Room 104, Hood River, Dreg. Jackson A. Erin Merkel, M.D., 1313 Maple Grove Dr., Medford, Dreg. Klamath Seth M. Kerron, M.D., Klamath County Health Department, Post Office Box 1886, 3300 Vandenberg Rd., Kiamath Falls, Dreg Linn John W. Guepe, M.D., Courthouse, Albany, Dreg Malheur Kenneth Pfaff, M.D., Courthouse, Vale, Dreg Marion Peter). Batten, M.D., Post Office Box 2028, 2455 Franzen St., Salem, Dreg. Polk E. G. Bossatti, M.D., Post Office Box 34, 102 Courthousa, Dallas, Dreg. Washington JamesStewart,M.D., l5ONorth3dSt.,Hillsboro,Oreg 2, 500 1,645 500 1, 838 2,705 10, 700 2,850 2,500 Do. Do. DO. Do. Do. Do. ~ Do. Do. PAGENO="0114" 108 Director: L. P. Varn, M.D. Duration of migrant season: April-October. Estimated number of migrants: 2,130. County served by project: Charleston. Health services provided: Medical care, hospitalization, nursing care, and health education. Location of family health service centers: IMisto, Johns Island, Medical Col- lege Clinic, and Mount Pleasant. Project Title: Comprehensive Health Program for Agricultural Migrants-~ Beaufort County, S.C. (MG 121). Sponsor: South Oarolina State Beard of Health, 2600 Bull Street, Columbia, S.C. 29201; Telephone 803-524-3446. Director: H. Parker Jones, M.D. Duration of migrant season: May-September. Estimated number of migrants: 2,2~I5, County served by project: Beaufort. Health services provided: Medical ca're~ dental care, ntirslng čare, and sanita~ tion services. Location of family health service centers: Beaufort, Frogmore, and Sheldon. TEXAS. Project Title: TechnIcal Assistance in Approaches to Health Problems Asso- elated with Migratory Labor (MG 03). Sponsor: Texas State Department of Health, 1100 West 49th Street, Austin, Tex. 78756; Telephone 512-453-6631. S Director: Robert L. Cherry, M.D., Medical Directo~. S S Duration of migrant season: Year ropnd. S Estimated number of migrants: 129,000. S Health services provided: State level consultation to counties with local migrant health projects in nursing, sanitation, health education; assistance to conimu- nities without local projects in arranging fo~ provision of health services to migrants, including nursing, sanitation, health education, and other technical and consultation services; also iimtted direct services in communities without local projects. S S S S S Project Title: Hale County Migrant Health Service (MSG 37). Sponsor: Plaiuview.-Hale County Health Department, 10th and Ash StrO~t, Post Office Box 1776, Plainview, Tex. 79072; Telephone 806-224-435P. 5 ~ Carl P. Weidenbach,.M.D. S Duration of migrant season: July~-November. S S 5 Estimated number of migrants: 9,300. 5 S County served by project: Hale. S 5 5 Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. S S Location of family health service centers: Mobile unit. Project Title: Laredo-Webb County Family Health Service Clinic (MG 42). Sponsor: Laredo-Webb County Health Department, 400 Arkansas Avenue, Laredo, Tex. 78040; Telephone 512-722-2481. Director: Jose L. Gonzales. Duration of migrant season: November-March. Estimated number of migrants: 13,000. County served by project: Webb. S Health services provided: Medical care, nursing care, sanitation services, and health education. Location of family health service center: Laredo-Webb County Health Depart- ment. Project Title: Southwestern Texas Health Department Migrant Project (MG 44). Sponsor: Southwestern Texas Health Department, Post Office Box K, Eagle Pass, Tex. 78852; Telephone 512-773-2718. Director: B. Oliver Lewis, M.D. Duration of migrant season: September-May. Estimated number of migrants: 10,000. PAGENO="0115" 109 Counties served by project: Dimmitt, Kinney, Maverick, and Zavala. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health centers: One each in counties listed above. Project Title: Technical Assistance in Developing. Techniques and Approaches to Health Problems Associated w.ith Seasonal Farm Labor in Public Health Education, Sanitation, and Public Health Nursing-Countywide (MG 46). lT~ponsor: Lubbock City-County Health Department, 1202 Jarvis, Lubbock, Ten. 79408; Telephone 806-762-6411. Director: David M. C'owgill, M.D. Duration of migrant season: April-January. Estimated number of migrants: 9,500. County served by project: Lubbock. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. . Location of family health service centers: Services provided `at or coordinated by City-~C'ounty Health Department, . - Pro ject Title: Calhoun County Migrant Health Services Program-Port La: vaca-Caihoun County Health Unit (MG 96). Sponsor: Port Lavaca-Oalhoun County Health Department, 111 West Ash Street, Port Lavaca, Tex. 77979; Telepbone.512-524-4341. Director: L. E. Silverthorn, M.D. Duration of migrant season-: January-September. Estimated number of migrants: 4,000. County served by project: Calhoun. Health services provided: . Medical care, hospitalization, dental care, nursing care, and sanitation -services. Location of family health service centers: County Hospital. Project Title: Cameron County Migrant Health. Project (MG 97).- Sponsor: Cameron County Health Department; 186 North Sam Houston Boulevard, San Benito, Tex. 78586; Telephone 512-399-2781. Director: John R. Copenhaver, M.D. . -. Duration of migrant season: November-May. Estimated number of migrants: 25,000. - . County served by project: Cameron. . - Health services provided: Medical care, hospitalization, nursing.. care, `sani- tation services, and health education. . ., . Location of family health service centers: Brownsville. Project Title: Jim Wells C'onnty Migrant Health Project (MG 99;). Sponsor: Jim Wells Commissioners' Court, Jim Wells County. Cou-rth'onse,~ 200 North Almond Street, Alice, Tex. 78332; Telephone 512-664-5582. Director: Gonzal'o V. Trevino. Duration of migrant season: October-April. Estimated number of migrants: 10,500. County served by projects: Jim Wells. Health services provided: Medical care, nursing care, sanitation: ser trices, and health education. Location of family health service centers: Alice. Project Title: Zapata County Migrant Health Project (MG 100). - Sponsor: Zapata County Commissioners' Court, Post Office Box 272, Zapata, Tex. 78076; Telephone 512-765-4342. Director: Pedro Ramnirez, Jr. Duration of migrant season: April-November. Estimated number of migrants: 2,000. County served by project: Zapata. Health services provided: Medical care, nursiag care, sanitation services, and health education. Location of family health service centers: Zapata. Project Title: Crosby County Mi-grant Health Service Project (MG 108). Sponsor: Crosby County Commissioners' Court, Crosbyton, Tex.; Telephone 806-675-2924. PAGENO="0116" 110 Director: P. J. Taylor. Dnration of migrant season: March-December. Estimated number of migrants: 6,300. County nerved by project: Crosby. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Crosbyton, Rails, and Lorenzo. Project Title: Greenbelt Medical Society Migrant Health. Project; (MG 109). Sponsor: Greenjjelt Medical Society, 306 Third NE., Childress, Tex. 79201 Telephone 817-987-3636--Fox; 817-259-3510-Stevenson. Director: Jack F. Fox, M.D., Harold H. Stevenson, M.D. (co-directors), Duration of migrant season: June-December. Estin~ated number of migrants: 5,000. Counties served by project: Cbildress and Hall. Health services provided: Medical care, nursing care, sanitation services, and health edm~ation. Location of family health service centers: (Services c(~ordinated at Childress and Mernphi~). Project Title: Spur-Dickens County Health Service Project (MG 110). Sponsor: Spur City Alderman (Oity Commissioners), City Ha1l~ Post Office Box 356, Spur, Tex. 79370; Telephone 915-272-4535. Director: Robert Alexander, M.D. Duration of migrant season: November-January. Estimated nnmber of migrants: 4,000. County served by project: Dickens. Health services provided: Medical care, nursing care, and sanitation services. Location of family health service centers: Spur. Project Title: Yoakum County Migrant Health Service Project (MG 113). Sponsor: Yoakum County Commissioners' Court, Yoakum County Court- house, Box 516, Plains, Tex. 79355; Telephone 806-592-2121. Director: Mrs. Helen V. McMahan. Duration of migrant season: March-December. Esti'm~ated number of migrants: 4,Ll00. County served by project: Yoakum. Health services provided: Medical care, hospitalization, nursing care, and sanitation services. Location of family health service centers: Denver City. Project Title: Goliad County Migrant Health Project (MG 114). Sponsor: Gollad Project for Handicapped Children, BOx 53, Goliad, T~x. 77963; Telephone 512-645-3291. Director: Dr. L. W. Chilton. Duration of migrant sason: June-August, October-May. Estimated number of migrants: 1,250. County served by project: Goliad. Health services provided: Medical care, nursing care, sanitation services, and health education. Location of family health service centers: Goliad. Project Title: Gonzales County Migrant Project (MG 115). Sponsor: Gonzales County Medical Society, Gonzales, Tex. 78629; Telephone 512-672-2824. Director: Louis J. Stahl, M.D. D ovation of migrant season: June-February; September-June. Estimated number of migrants: 3,000. County served by project: Gonzales. Health services provided: Medical care, hospitalization, dental care, nurs- ing care, sanitation services, and health education. Location of family health service centers: Gonzales and Waelder. Project Title: Hidalgo County Migrant Health Grant (MG 117). Sponsor: Hidalgo County Health Department, Room 427, Courthouse, Edin- burg, Tex. 78539; Telephone 512-383-2751. Director: John R. Copenhaver, M.D. Duration of migrant season: Year round. PAGENO="0117" 111 Estimated number of migrants: 4,500. County served by project' Hidalgo. health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Project Title: Hudspeth County-Dell City Migrant Health Project (MG 119). Sponsor: Hudspeth County Commissioners' Court, Hudspeth County Court- house, Sierra Blanca, Tex. 79851; Telephone 915-309-2321, Director: Hon. Tom H. Neely. Duration of migrant season: April-June; Octo;ber-December. Est i/mated number of migrants: 4,000. County served by project: Hudspeth. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Dell City, Fort Hancock, and Sierra Blanca. Project Title: LaSafle County Migrant Health Project (MG 120), Sponsor: LaSalle County Commissioners' Couvt, LaSalle Courthouse, Center at Stewart Street, Cotulla, Tex. 78014; `Telephone 512-879-2342. Director: J. M. Barton, M.D. Duration of migrant season: Year round. Estimated number of migrants: 3,000, County served by project: LaSalle. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Cotulla. Project Title: Del Rio-Val Verde County Health Department-Migrant Health Project (MG 128). Sponsor: 1)el Ri'o-Val Verde County Health Department, Dodson Building, Del Rio, Tex. 78840; Telephone 512-775--5985. Director: B. Oliver Lewis, M.D. Duration of migrant season: Septemfber-~May. Estimated number of migrants: 4,000. County served by project: Val Verde. Health services provided: Medical care, dental care, nursing care, and sanita- tion services. Location of family health service centers: De'l.Rio. Project Title: Littlefield-Lamb County Migrant Health Project (MG 139). Sponsor: City Council, City of Littlefleld, Post 0111cc Box 1267, Littlefield, Tex 79339; Telephone 806-385-4411. lTRreotor: D. W. Still, M.D. Duration of migrant season: July-~N'ovember. Estimated number of migrants: 9,000. County served by project: Lamb. Health services provided: Medical care, hospitalization, dental care, nursing care, and sanitation services. Project Title: Leon Valley Migrant Health Projeet (MG 140). Sponsor: DeLeon Municipal Hospital, 407 Texas Avenue, DeLeon, Tex. 76444; Telephone 817-2944, 817-7111. Director: F. A. Eisenricb, M.D. Dnration of migrant season: October-May. Estimated number of migrants: 1,675. Coinity served by project: ~mancbe. Health services provided: Medical care, hospitalization, nursing care, sanitation services, and health education. Location of family health service centers: DeLeon. Project Title: Floyd Gounty Migrant Health Project (MG 141). Sponsor: Floyd County Commissioners, Floyd County Courthouse, Floydada, Tex. 78076; Telephone 80G-983-~3534. Director: Hon. J. K. Holmes. Duration of migrant season: Year round. Estimated number of migrants: 3,000. County served by project: Floyd. ~?ealth services provided: Medical care, dental care, nursing care, and sanita. tion services. PAGENO="0118" 112 Project Title: Jim Hogg County Migrant Health Project (MG 142). Sponsor: Jim Hogg County Commissioners' Court, County Courthouse, Heb bronville, Tex. 78361; Telephone 512-527-3015. Director: Hon. H. T. Martinez. Duration of migrant season: June-July; September-April. Estimated number of migrants: 1,120. County served by project: Jim Hogg. Health services provided: 1~{cdk,al care, nursing care; sanitation services, and health education. Location of family health service center: Hebbronville. Project Title: Castro County Migratory Health Project (MG 143). Sponsor: Castro County Conimissioners' Court, Courthouse, Dimmitt, Tex.; Telephone 806-647-5552, 806-647-2191--Hospital. Director: R. D. Newman Duration of migrant season: March-December. Estimated number of migrants: 6,000. County served by project: Castro. Health services provided: Medical care, hospitalization, nursing care, and san! tation services. Location of fa4nitly health service centers: Community Hospital, Dimmit. Project Title: Live Oak County Migrant Health Project (MG 146). Sponsor: Live Oak County Health Department, Courthouse, George West, Tex. 78022; Telephone 512-449--2201. Director: G. W. Sansom, M.D. Duration of migrant season: April-December. Estimated number of migrants: 2,200. County served by project: Live: Oak. Health services provided: Medical care, hospitalization, dental care, nursing care, sanitation services, and health education. Project Title: San Marcos-Hays County Migrant Project (MG 147). Sponsor: San Marcos-Hays County Health Department, Courthouse, San Mar cos, Tex. 78066; Telephone 512-392-5831. Director: B. M. Primer, M.D. Duration of mi9rant season: August-November. Estimated number of migrants: 2,700. County served by project: Hays. Health services provided: Medical care, sanitation services, and health cdii cation. Project Title: Starr County, Texas, Migrant Health (MG 160). Sponsor: Hidalgo County Health Department, Room 427, Courthouse, Edin burg, Tex.; Telephone 512-383-2751-Station 234. Director: John R. Copenhaver, M.D. Duration of migrant season: November-May. Estimated number of migrants: 45,000. County served by project: Starr. Health services provided: Medical care, hospitalization, nursing care, and sanitation services. * Location of family health service centers: Gr~illa, RIO G~ande City, and `Rorna. UTAH Pro ject Title: Utah Migrant Health Service. (MG 98). Sponsor: Utah State Department of Health, 44 Medical Drive, Salt Lake City, Utah 84113; Telephone 801-322-2431. Director: Robert W. Sherwood, M.D. Duration of migrant season: May-October. Estimated number of migrants: 5,000. Counties served by project: Box Elder, Cache, Carbon, Davis, Garfield, Grand, Piute, Salt Lake, Sanpete, Sevier, Utah, Washington, Wayne, and Weber. Health services provided: Medical care, dental care, nursing care, sanitation services, and health education. Location of family health service centers: Mobile clinic in Weber County. PAGENO="0119" 113 VIRGINIA Project Title: Migrant Health Project-Virginia (MG 41). Sponsor: Division of Local Health Services, State Department of Health, Rich- ~nond, Va. 23219; Telephone: 703-644-4111. Director: R. W. Moseley, M.D. Duration of migrant season: June-September. Estimated number of migrants: 8,180. Counties served by project: Accomack, Amherst, Albeinarle, Augusta, Bote- tourt, Clarke, Fauquier, Frederick, Loudoun, Madison, Nelson, Northampton, Rappahannock, Roanoke, Shenandoah, and Warren. Health services provided: Medical care, hospitalization, nursing care, dental care, sanitation services, and health education in Accomack and Northampton Counties; nursing care and sanitation services in other counties. Location of family health service centers: Mobile unit is used at points in Northampton and Accomack Counties during crop season. WASTIINGTON Project Title: Health Services for Migrant Workers in Puyallup-Stuck Valley; Medical Nursing, Environmentaj, and Study of Health Needs (MG 19). Sponsor: Tacoma-Pierce County Health Department, 649 County-City Build- ing, Tacoma, Wash. 98402; Telephone 206-383-331x347. Director: Ernst K. W. Kredel, M.D. Duration of migrant season: June--October. Estimated number of migrants: 2,000. County served by project: Pierce. Health services provided: Medical care, nursing care, sanitation services, and health education. Location of family health service centers: Puyallup. Project Title: Whatcom County Migrant Health Program (MG 132). Sponsor: Bellingham-wha~om County District Health Department, 509 Girard Street, Bellingham, Wash. 98225; Telephone 206-733-9520. Director: Philip Jones, M.D. Duration of migrant season: April-October. Estimated number of migrants: 1,100. County served by project: Whatcom. Health services provided: Medical care, dental care, nursing care, a.nd sanita- tion services. . . Project Title: Skagit County. Migrant Health Project (MG 144). Sponsor: Skagit County Health Department, Courthouse,. Mt. Vernon, Wash. 98273; Telephone 206-336-2106. Director: J. K. Neils, M.D. Duration of migrant season: March-October. Estimated number of migrants: 6,100. . . County served by project: Skagit. Health services provided: Medical care, hospitalizatiop, dental care, nursing care, sanitation services, health education, and social services.. Project Title: Washington State Department of Health-Migrant Health Proj- ect (MG 145). Sponsor: Washington State Department of Health, Public Health Building, Olympia, Wash. 98501; Telephone 206-352-1667. Director: Rhes~ Penn, M.D. Duration of migrant sea~on: April-November. Estimated number of migrants: 25,000. Counties served by project: Statewide. Health services provided: Consultant services in medical and dental care, nursing, sanitation, health education, nutrition, and social work to local proj- ects; coordination of needs and services for migrants within State; stimulation of services in areas of heavy migrant concentration. Wnsr VIRGINIA Project Title: Berkeley-Morgan Counties Migrant Workers Project (MG 123). Sponsor: District No. 6 Health Department, 209 East King Street, Martins- burg, W. Va. 25401; Telephone 304-263-5131. Director: 11. 0. Hood, M.D. PAGENO="0120" 114 Duration of migrant season: June-September. Estimated number of migrants: 885. Counties served by project: Berkeley and Morgan. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Berkeley Springs and Martinsburg. WISCONSIN Project Title: Migrant Medical Aid Program (MG75). ~8ponsor: Catholic Diocese of Madison, Elm Acre, Guadalupe House, Endeavor, Wis. 53939; Telephone 608-587-2033. Director: Mrs. Clayton S. Mills. Duration of migrant season: April-October. Estimated number of migrants: 900. County served by project: Marquette (with some influx from Columbia). Health services provided: Medical care, hospitalization, dental care, nursing care, health education, and nutrition counseling. Location of family health service centers: Endeavor. Project Title: St. Joseph Migrant family Health Clinic (MG 129). sponsor: St. Joseph Hospital, 707 South University Avenue, Beaver Dam, W is. 53916; Telephone 414-885-4975. Director: Sister M. Virginia. Estimated number of migrants: 650. Counties served by project: Columbia and Dodge. Health services provided: Medical care, hospitalization, dental care, nursing care, and health education. Location of family health service centers: Beaver Dam. Project Title: Waushara County Migrant Health Clinic (MG 130). Sponsor: Waushara County Committee for Economic Opportunity, Box 310, Wautoma, Wis. 54982; Telephone 414-787-2648. Director: Mr. Walter Brudnowski. Duration of migrant season: May-November. Estimated number of migrants: 8,000. County served by project: Waushara. Health services provided: Medical care, hospitalization, dental care, nursing care, health education, and nutrition čounseling. Location of family health service centers: Wautoma. Project Title: Migrant Labor Camp Sanitation Services (MG 137). Sponsor: The Industrial Labor and Human Relations Commission of Wiscon- sin, Hill Farms State Office Building, Post Office Box 2209, Madison, Wis. 53791; Telephone 608-266-1704. Director: Roger Oftrem. Duration of migrant season: May-September. Estimated number of migrants: 19,687. Counties served by project: Columbia, Dodge, Door, Fond du Lac, Jefferson, Kenosha, La Crosse, Marquette, Qcouto, Outagamie, Racine, Waukesha, Wan- shara, and Winnebago. Health services provided: Sanitation services. Mr. Rooi~s. Do you coordinate programs for migrants that are carried on by other branches of the Federal Government, such as OEO? Dr. LEE. I think there has been excellent coordination, and the mi- grant health program has served as a mechanism to make other serv- ices available to the migrants, such as crippled children's~ programs and infant care. There has been good cooperation with OEO, for ex- ample. OEO has developed a neighborhood health center program in King City, through the county medical society. That program is also serving migrants in the southern part of that country. There are other areas where they have been working on the educa- tion side and helping in housing construction, where we have been involved in sanitation and health services. I think there has been good cooperation. PAGENO="0121" 115 Mr. ROGERS. I have been interested in the program carried out in my area by Dr. Carl Brumback, in the county of Palm Beach. He has made excellent headway. Let me ask you about the hospital funds that the committee authorized, I believe, in 1965. Dr. LEE. First available in 1966. Miss JOHNsTON. The first funds for hospital care became available in January of last year. Up to the present time, 55 projects have made application for hospital funds. They are scattered over 25 different States. They have agreements with about 170 hospitals at the present time. Mr. ROGERS. Would you let us have a rundown on the ones that were approved, and what amounts, and the people involved? (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDuCATION, AND WELFARE STATEMENT ON MIGRANT HOSPITALIZATION As Of January 1968, 55 migrant health projects in 25 States had added inpatient hospital care to their existing services in an attempt to provide as broad a scope of comprehensive health care as possible. The hospitalization component in- cludes an intensified program of early casefinding, a referral system for medical care outside the hospital, and a system for predischarge planning. Amount currently State Project sponsor and location awarded for hospitalilatjon component, Fiscal Year 1967-68 Arizona Pinal County Health Department Florence, Ariz $29, 500 Yuma County Health Department, Yuma, Ariz 107, 445 Arkansas Northwest Area Migrant Committee Fayetteville, Ark -- - 2, 400 California California State Department of Public Health, Berkeley, Calif 114, 158 Delaware Delaware State Council of Churches, Dover, Del 7, 200 Florida Flotid~ State Board of Health, Jacksonville, Fla 125, 319 Dade County Department of Public Health, Miami, Fla - 25, 000 Palm Beach County Health Department, West Palm Beach, Fla 33, 176 Illinois Jones Memorial Community Center, Chicago Heights, III 1,900 Illinois Department of Public Health, Springfield, Ill 7, 359 Northwest Church Council for Migrant Aid, Inc., Rolling Meadows, 4, 500 III. Migrant Ministry Committee, Rock Island, Ill 3, 800 Iowa Neighborhood Health Center for Migrants, Muscatine, Iowa 3, 300 Migrant Action Program, Inc., Mason City Iowa 2,835 Kansas Kansas State Department of Health, Topei~a, Kans 13, 200 Kentucky Kentucky State Department of Health, Frankfort, Ky 1, 262 Maryland Worcester county Community Action Committee Inc., Snow Hill, 500 Md. Michigan Ottawa County Health Department, Grand Haven, Mich 2,330 Manistee-Mason District Health Department, Ludington, Mich 6. 0d6 Monroe County Health Department, Monroe, Mich 5. 404 Tn-county Associated Health Departments, St Josejh, Mich 92, 359 Health Department-Grand Traverse Migrant Labor Council, 43, 520 Traverse City, Mich Minnesota Minnesota Department of Health, Minneapolis, Minn - - - - - 5 100 Missouri Delmo Housing Corporation, Lilbourn, Mo 19, 500 Nevada Clark County District Health Department, Las Vegas, Nev 2,200 New Jersey New Jersey State Department of Health, Trenton, N.J 16, 348 Board of Chosen Freeholders of Cumberland County, Bridgeton, 8, 720 New Mexico Las Cruces Committee on Migrant Ministry, Las Cruces, N.M 17, 025 North Carolina District Health Department, Albemarle, N.C 2, 230 Henderson County Migrant Council, Inc., Hendersonville, N.C 4,993 Ohio Hartville Migrant Council, Inc., Hartville, Ohio 3,700 Sandusky County-Fremont City General Health District, Fremont, 9, 100 Ohio. Ohio Department of Health, Columbus, Ohio 2, 600 Darke CountyGeneral Health District, Greenville, Ohio 2, 000 Ottawa County Ministry to Migrants, Oak Harbour, Ohio 4, 700 Putnam County General Health District, Ottawa, Ohio 8, 000 Lucas County Health Department, Toledo, Ohio 4, 540 Oregon Oregon State Board of Health, Portland, Oreg 111, 159 South Carolina South Carolina State Board of Health (Charleston County), Comm. 20, 341 bia, S.C. 1 Riverside County only. PAGENO="0122" 116 Amount currently awarded for State Project sponsor and location ~ . hospitalization component, Fiscal Year . 1967-68 Texas Jim Wells County Commissioners Court, Alice, Tex Crosby County Commissioners Court, Crosbyton, Tex Castfro County Commissioners Court Dimmitt, Tex DeLeon Municipal Hospital, DeLeon, lox Hidalgo County Health Department (Starr and Hidalgo Counties, Edinburg, Tex. Gonzales County Medical Society, Gonzales, Tex Plainview-Hale County Health `Department, Plainview, Tax Yoakum County Commissioners' Court, Plains, Tex Cameron County Health Department, San Benito lox Hudspeth County Commissioners' Court, Sierra įianca, lox Virginia Virginia State Department of Health, Richmond, Va Washington Skagit County Health Department, Mount Vernon, Wash West Virginia District No. 6 Health Department (Berkeley-Morgan Counties), Martinsburg, W. Va. Wisconsin Catholic Diocese of Madison, Wis., Endeavor, Wis St. Joseph Hospital, Beaver Dam, Win Waushara County Committee fo~ Economic Opportunity, Wautoma, - Wis. Total amount currently awarded for hospitalization $19, 000 17, 100 89, 372 7,200 101, 340 16,250 18984 6,700 175, 612 13, 700 35, 558 13,691 5, 400 4, 400 2, 000 6, 800 1, 307, 836 Mr. ROGERS. What are the needs now of the migrant program, any need that you have? Miss JOHNSTON. Well, you ask for a rundown of the migrant health program. I could give it to you briefly i4ight now. At the present time we have 115 single or multicounty projects, They are providing personal health care in nearly 300 counties, per- sonal health care plus sanitation services. There are about 155 counties in which sanitation services only are being provided. , , YOu have to realize that "about `700 `counties have a migrant influx during the year, so, roughly, we are providing personal health care in300ofthe700counties. The personal health care is accessible to about 300,000 of the 1 mu-' lion migrants. The leitel of care that we are able to support with the funds that we now have available is considerably less than that for the general population. The number of medical visits in the project areas for migrants is about one-fifth of the number for the general popula- tion. The number of dental visits is about one twenty-fifth of the: gen- eral population. The funds have been obligated to the last cent in every fiscal year since the program started. We started out this year with every cent obligated from last year, and as you `will recall, our appropriation this year is exactly the same as last year's. Mr. ROGERS. Thank you very much. If there are any additions you may want to make, the committee would like to have that. I think you have done a great job with the program. Miss JOHNSTON. Thank you. Mr. ROGERS. Is alcoholism a mental problem? Dr. YOLLES. I think the experts in the field would say there is a large element of emotional problem in the alcoholic. I don't think all the experts agree as to the percentage of emotional problems in PAGENO="0123" 117 each alcoholic, but for a long time it has been handled by the field of mental health. Mr. ROGERS. For the confirmed alcoholic, would you say there is basically a mental problem involved, generally? Dr. YoLLES. Certainly there is a basic mental and behavioral prob- lem involved in the chronic alcoholic. Pr, LEE. Mr. Chairma; I would like to add a personal comment on that because I had, when I was in practice, a particular concern with the problems of the chronic alcoholic, and I would agree with what I think is the general professional judgment. These patients often have serious emotional problems, and their families are also involved. It is a complex problem that doesn't just affect the alcoholic, but also affects his family and the interaction between the husband and wife and also the children, and they are all involved. So it is a social behavioral problem, and there are many people who have sought for many, many years evidences of some physical cause, and we know t'here are certain biochemical derangements that occur with chronic alcoholism; `but we have never been able to demonstrate any cause and effect relationship. You cannot treat the chronic alco- holic without assisting his family and mental health services are an important component in the treatment. Mr. ROGERS. I assume that would apply to the narcotic addict as well. Dr. YOLLES. That is quite true. Mr. ROGERS. Why aren't they now covered under the Comprehensive Mental Health Act? Dr. YOLLES. They are covered, Mr. Rogers. Mr. ROGERS. It was our intent to cover them when we wrote that law. Dr. YOLLES. Yes. The communities have been less than interested in providing treatment for alcoholics, and particularly for narcotic ad- dicts. Their treatment has a `lower priority than `treatment for other patients. The cost of treating such patients runs high, `and very often the patients cannot pay for it. Dr. LEE. They are often discriminated against. An alcoholic often cannot be treated in a hospital because he is an alcoholic, so he is denied `access `to community `health care institutions, and this just compounds the problem. Mr. ROGERS. I would be concerned about increasing the percentage for staffing. Ninety percent, I notice you have changed it to in the proposal, 80 percent, 60 and 50, for each `of the 6 years, which is a considerable change from the formula we had for the community health hospital, and also for the mentally retarded facilities. Dr. YOLLES. Mr. Rogers, by raising the Federal matching in this level, and extending the length of the program from 4 years and 3 months to a period of 8 years, we are offering incentives to `communi- ties to pick up treatment programs that are vitally necessary. These communities at the present time are involved in supporting and financ- ing general mental health services which have the first priority. To add another treatment program which, in their eyes, and which we have seen from evidence over `the years `has a lesser priority, at the same matching ratio, without any special incentive, does not encourage them to pick up those programs. Mr. ROGERS. I think there is a growing concern `on the problems of alcoholism and narcotics addiction, and the communities are becoming PAGENO="0124" 118 more aware of that and the needs for treatment. I think the Su~prenie Court will probably make a decision soon that will affect this situation, as far as alcoholism is concerned. If we are building community health centers now, I would like to see us get into this before we start building alcoholic centers and nar- cotic centers. I would think maybe simple additions-if it is necessary, and it may not be necessary in many areas-I would hope this could be tied in more rather than just setting up two new programs to start out with almost. Dr. YOLL1~S. Mr. Rogers, this is exactly what we are trying to achieve in this legislation through the project approach. You see, only those communities which are ready to fund and ready to go with a new pro- gram such as this will be coming in for such project grant funds. These will be added to the community mental health center as an in- tegral part of it, but it will allow those who are ready to do it now to come in and be supported at a higher rate, now. Mr. ROGERS. I would like you to furnish us what your projection will be, your cost over the next 6 years, so let's give a projection of 6 years, if you can, if this is possible. And what it would require in per- sonnel, money, and possible projected results. (The following information was subsequently received by the com- mittee:) PAGENO="0125" DEPARTMENT OF HEALTH, EDUCATION AND WEt.FARE ESTIMATED-NEW OBLIGATION AUTHORITY REQUIRED UNDER FIR; 15758 FOR FISCAL YEARS 1969-77 New obligation authority Fiscal year Fiscal year Fiscal year Fiscal year Fiscal yeai Fiscal year Fiscal year Fiscal year Fiscal year 1969 1970 1971 1972 1973 1974 1975- 1976 1977 I. Regional medical programs $65,000,000 $140,000,000 $200,000,000 $275,000,000 $350,000,000 II. Special grants for health of migratory workers 9,000,000 15,000,000 Ill. Alcoholic and narcotic addict rehabilitation A. Construction grants and staffing, operation, and maintenance grants 15,000,000 25,000,000 1. Alcoholic rehabilitation (7,000,000) (15,000,000) 2. Narcotic addict rehabilitation (8, 000, 000) (10, 000, 000) B. Continuation costs for staffing, operation, and maintenance grants 15,309,000 13,276,000 11,242,000 $10,176,000 $10~176,000 ~10,176,O0O $5,330,000 1. Alcoholic rehabilitation (10, 424, 000) (9, 050, 000) (7, 675, 000) (6, 877,000) (6, 877,000) (6, 877, 000) (3,988, 000) 2. Narcotic addict rehabilitation (4, 885, 000) (4,226, 000) (3, 567,000) (3, 299, 000) (3,299, 000) (3,299, 000) (1, 342, 000) Total NOA required 89,000,000 180,000, 000 215, 309,000 288,276, 000 361, 242, 000 10, 176,000 10, 176, 000 10,176, 000 5,330, 000 Note: The projections contained in this table represent departmental predictions and do not represent the administration position on the future program or budget requirements. Personnel requirements will be dependent on program developments and budget factors which at this time cannot be fully predicted. PAGENO="0126" 120 Dr. YOLLES. In terms of community health center staffing, the States are beginning to comment about the shortness of the time with the very rapidly decreasing, rate of Federal support, and there has been some talk of the need for a longer period, hence the approach in this legisla- tion for an incentive that continues for a longer period before tailing off after 8 years. Mr. RoGERs. I thought this might lay a basis for the comprehen- sive mental health and mental retardation. That is why I wanted to make the record clear that we need it. Specialized facilities: Do you mean we are going to start building homes or housing for homeless alcoholics? Dr. YoLn~s. These are treatment facilities for the homeless alco- holics so that he can be kept in the treatment atmosphere, so that we can reach him. As you know, these homeless alcoholics are a transient group, and the biggest difficulty in maintaining them in treatment is that they move on to some other place as they feel like it. Most com- munities do not have the facilities to maintain them in a treatment environment. These funds would provide basic residential areas for them to live, such as "Halfway Houses." Mr. ROGERS. Hostels? Dr. YoI~Es. Hostels, yes. Mr. ROGERS. I would like to know more about that. Dr. LEE. We feel this would be related to purchase of some existing facilities and remodeling, rather than building new facilities, except where this was essential. Mr. RoGERs. How long are `you going to give him a home? Dr. LEE. We would hope for some it might not be too long. Some could be returned to the community and in some cases to their own families. Mr. ROGERS. Suppose he doesn't want to stay there, except over- night? Dr. LEE. You can't require them to stay, but by providing this en- vironment, and the support of services, we would hope they would stay and that this would be a `much more productive approach than periodically sending them to jail. Mr. RoGERs. Has this been tried in any of the other cities where you have any considerable number of homeless alcoholics? Dr. YOLLES. It' has been tried on an experimental basis. As you know, the District of Columbia is trying it at the present time. These programs are experimental. They offer hope of success, especially in working with the skid row alcoholic, as he is called. When a commu- nity treatment program becomes involved with the individual and works with him, it is remarkable how ~many of these individuals can be brought into treatment. Mr. ROGERS. HOw many do you estimate there are? Dr. YOLLES. Nobody knows for sure, but somewhere between 250,000 and 500,000, primarily in the large cities. Mr. ROGERS. If you would, let us have a rundown of what research has been done in this area. (The following material was received by the committee:) PAGENO="0127" 121 DEPARTMENT OF HEALTH, EDuCATIoN, AND WELFARE STATEMENT ON TEE EXTENT OF "HOMELESS ALCOHOLIC" PROBLEM 1. The national total for the estimated number of homeless alcoholics is be- tween 250,000 and 500,000.. 2. The vast majority of homeless alcoholics are located in the larger American cities. 3. Estimates for the number of homeless alcobolics in some major cities are given below: (a) New York City-25,000-30,000 (b) Chlcago-15,000 (c) Los Angeles-10,000 (d) Phlladelphia~-7,000 (e) Washington-6,000. (1) Detroit-5,000 (g) Houston-5,000 (h) Clevelancl-4,500 (i) Baltimore-4,000 (j) Atlanta-4,000 (k) St. Louis-3~000 (1) Pittsburgh-3,000 (m) Seattle-3,000 EFFECTIVENESS OF VOLUNTARY TREATMENT WITH HOMELESS ALCOHOLICS 1. There now Is increasing evidence that many homeless chronic alcoholics can be helped through voluntary treatment efforts. The development of new treatment approaches-and programs particularly attuned to the needs of these patients-are rapidly overcoming the past belief that homeless alcoholics could not be helped. Treatment programs for homeless alcoholics must deal with the interrelated medical, psychiatric, social and vocational problems of these men. For example, Dr. William T. Hart, Director of the Monroe County Psychiatric Hospital Center (Rochester, New York), has recently written, "I had formerly believed that only a system involving physical restraint or threat of it would control the confirmed alcoholic., If, however, the reduction of admissions `to the Penitentiary is due to increased use of treatment facilities, it is obvious that vol- untary agencies have made significant inroads into the involuntary care provided by judicial commitment to the Penitentiary." In Quarterly Journal of Studies on Alcohol-March 1968, Vol. 29, p. 100. 2. Below are listed five communities that have recently been pioneering in de- veloping various treatment services for homeless alcoholics. (a) St. Louis.-Alcoholics, formerly arrested for being drunk in public, are now brought to a special detoxification service in an abandoned general hospi- tal. Without exception these men have been willing to come to this facility'and the vast majority have remained in this hospital on a voluntary basis until such time as the staff felt they were ready to be discharged. The special training the police have received in handling these persons has made it completely unneces- sary for them to use any force or physical restraint in bringing them in to this facility. (b) New York Uity.-Through funds from the Vera Foundation, an entirely voluntary program of removing seriously, into?dcated alcoholics from the street was recently initiated. As reported in thC New York Times last month, the vast majority of persons offered assistance have voluntarily accompanied the treat- ment team to the rehabilitation facility. Furthermore, most of such persons have remained in the facility during the period of time designated for the program. (c) Philadelphia.-~Through a grant from the National Institute of Mental ~[ealth, the Diagnostic and Relocation Center has been intensively studying and providing assistance to homeless alcoholics in a "Skid Row" part of Philadelphia. This program has been on an entirely voluntary basis and well over 2,000 men and women have been interviewed and provided assistance through this serv- ice. This agency has experimented with the use of former "Skid Row" men as a means of contacting other homeless alcoholics. This approach appears to have been extremely successful. PAGENO="0128" 122 (ci) iowa.-~-A. compirehensive program iii'the city of D~s Moines-relying ,eu~ tirely on voluntary approaches-has already succeeded i~ significantly reducing the arrest rate among Skid Row alcoholics. It has been possible :to place a sig- nificant number of these persons in positions of emplO~~meiit and to modify their living habits sufficiently so that they are no longer arrested for. public drunkeu~ nessand'become ie5~ of a'cost to the community.' (e) Calif ornia.-At the Mendocino State Mental Hospital there is in opera- tion an extremely large treatment program for alcoholics. All persons a~e ad- mitted to this program on a voluntary basis and are free to leave the hospital grounds at any time. A sizeable proportion of the patients in this program are Skid Row alcoholics from the city of San Francisco. Through the imaginative use of professional as well as nonprofessional staff, it has been possible to create a strong sense of morale and dedication in the treatmėntun'it so' that large mumlers of homeless alcoholics remain for a substantial period of time' and participate in a wide range of different treatment approaches. This experiment also has tended to dissipate the stereotype that alcoholics will not use psychiatric agencies. Mr. ROGERS. I believe you would also have. c,qns~riIction, operating and staffing, maintenance and treatment facilities for~,narcotic addicts. Dr. YOLLES. Yes, sir. This is merely a continuation `of the program under section 402 of the Narcotic Addict Rehabilitation Act of 1966 (Public Law 89-793). Mr. Ro~ns. Wotild this ` be in every community mental l~ealth center? Dr. YOLLES. No, IL would expect they would not be .in every center7 only in certain ones. `Mr. Rooi~its. What does the Bureau of Narcotics estimate is the population of our hard narcotics users? Dr. YOLLES. The estimate is that there are 62,000 hard nareotics users in the United States, as of 1967. We estimate these figures are only roughly 80 percent of the total group. We have no true figure, soit may be as high as 100,000 hard core narcotics addicts. Mr. ROGERS. I don't know if we want to get into a big building pro- gram, but it seems to me this oould be incorporated in your mental health centers. You may need certain staffing, but I would hope you could give us some more- Dr. LEE.. This is really the purpose of the effort to integrate them, particularly in the communities wherein this is a major problem. It isn't a general problem, so we felt it was better to use the project-grant approach rather than a formula grant that would go to all the States. Mr. ROGERS. I perhaps will submit some additional questions, be- cause our time is up, Members of the committee may want to ask addi- tional questions in writing. We very much appreciate your coming. It is a most important program, and I think we are off to a good start. We need to have some details, and I think the committee would want them before we take action. Dr. LEE. We would be pleased to provide whatever you want, Mr Chairman. Mr. ROGERS. Our next witness is Dr. Carleton Chapman, dean of ~he Dartmouth Medical School, who will be appearing for the Associa- tion of American Medical Colleges, and he will be accompanied by Dr. Lloyd Elam, of the Meharry Medical College, Nashville, Tenn, Doctor, it is a pleasure to have both of you here. We appreciate your giving your time so that the committee may benefit from your testi- molly. PAGENO="0129" 123 STATEMENT OP DR. CARLETON B. CHAPMAN, REPRESENTING THE ASSOCIATION OP AMERICAN MEDICAL COLLEGES; ACCOM.. PANIED BY DR. LLOYDS ELAM Dr. CHAPMAN. Thank you, Mr. Chairman. I am Carleton B. Chap~ man, dean of Dartmouth Medical School, and on my right is Dr. Lloyd Elam, who is president of Meharry Medical College. We are on this occasion spokesmen for the Association of American Medical Colleges. Our association represents the 88 medical schools in the United States as institutions, a large proportion of the Nation's medical educators as individuals, and 330 major teaching hospitals. Mr. Chairman, I would like to point out that we would like to speak to the regional medical programs, because medical schools are inti- mately involved in these programs, and while we favor in general the other provisions of the bill, we can claim special expertise in these areas. We spoke before this group in favor of the adoption of the heart disease, cancer, and stroke amendments in February 1965, but em~ phasized that the Nation did not then possess enough trained personnel to carry out the provisions of the proposal. At the time, our spokesman noted that our medical schools, originally set up solely to train physi- cians, were already developing into medical service centers with con- stantly expanding responsibilities in the health field. He went on to say: This experience makes it clear that the professional and institutional relations are complex and delicate. It also makes it clear that it is painfully difficult to procure and maintain an adequate supply of trained manpower. A functioning region~~ complex . . . would make the efforts of the practicing physician more effective, but the development and operation . . . will require a marked hi- crease in trained manpower. He also noted that the success of a regional complex is heavily dependent on the continued and growing effectiveness of the medical school and the medical center. At this time, 3 years later, we consider these observations still highly pertinent. Bat, in general, we believe the discernible effects of Public Law 89-239 to date have been salutary. It has created a mechanism by means of which the Nation's medical schools have begun to relate to community and consumer health needs, and to work with many lay and professional groups in designing new methods of coping with these needs. It has initiated the organizatioh of the Nation into re- gions, for the purpose of delivery of health services, very effectively. And although this organizational process has not yet proceeded to completion,. the results to date more than justify the passage of the law, We are well aware that efforts to implement the legislation have been asSociated with many problems. Regional organizational struc- tures and, for that matter, the definitions of regional boundaries, are in some instances unduly complex anē~ clumsy. Some health pro~es- sionals complain that they do nOt understand th~ intent of the law and some are suspicious of it. Lay and ~rofessiona1 groups whi~h, in some regions, are ~attempting to reach joint ~decisions for the first PAGENO="0130" 124 time, are having some difficulties. And occasionally one hears the ~iew that the medical ~cho4s ar~ attempting to use the la* as ~ means of gaining control of the N~ion's health oare system. But in our view, these difficulties were to an extent predictable and inevitable. The important point is that the law, by mobilizing local initiative, i.s effe~ting a cooperative attack on health problems which, although highly necessary, had not been operative before. In our vi~wIth~ general conseiksus lay and professional is highly favorable tO~the l~w.~' The hi~dical schools themselves have bad difficulties in discharging theirobligations under the law. Many of them, when the law was passed, had no administrįt~ve per~onnel that was ~apable of dealing ~k4th~t4~ese ~iew responsibilities. In some histances programs develop- ihg~ 1u~ncier the law involved commitment of professional personnel that is~ already fully committed. Far from attempting to take over c~mtrol of the program many, and perhaps thost, medical schools have be'en slow to become involved largely owing to shortage of ~rsonnėl. This has been especially acute as the schools move to begin to meet thegrowing shortage of~phy~ieians. Yet there is no doubt in our minds that~oi~r medical schools wish' to beinvoh~'ed as effectively as possible, not to gain control but;in keeping with the dntent of the law, to make their tai~nt~'and facilities n~re readily `avāila~ble to'~ll who need them. ~B~t~this vItal in~t1r&~ and the equally vital matter of imprbving and expanding our educational function, together constitute an ob'li~ gation that cannot be met optimally in a few months, or even perha.j~s in 2 or 3 `years. The medical `schools seek' no special privilege under the `regional medical prograi~ `lawbut' wish, on the aontrary, to as- sist ~ We believe that `the origlna~I l'aW hat 1dfier~ted exceedingiy smoothly, considering the nature of the planning proce~ses it h~s initiated. We also' believe, h ~e~er,'that enough e~~erience has been `or soon will be gather~d to justify a `few' `thi~nór p~o~c~edurai ~lteri~tiOns~. Wh~n' the law first began to be implemented, there ~ič~e~ no ~e~era'l'ly ~lh~ahle' p~ototypes f OF t~gional organiz~ions `&f the gener~l~t~p~s Wecified. A number of different patterns have now emerged, some mor&~&h~e than others. It may, in our view, soon be appropriate for morC defini- tive organizational guidelines to be provided by the Division or Re- gional Medical Programs. It will also be appropriate in the future to recQnsider critically, the geographic structure of the various regions. ~he responsibility and authority of advisory gi~oiip~, mthy of which are too `large to functiOn effectively, require clearer d~fifiitk?n. And the main thrust of the legisiation requires, in our view, tO be' restated and ~iarified. ` It has been frequently noted that its central focus of the law is the patient and ~Iu~ needs. `J~'his is unquestionably true. But a more rele- vant way of saying"the same thing is to indicate that the law proposes' to "~ * * afford to the medical profession and the medical institutions of the NatiOn, through coOper~ative arrangements. the opportunity of making available, to their patients the latest advances in the diagnosis and treatment of the diseases named in the law." In other wOrds, the~law provides us with the means and authority to find ways o'f assi~tin~ ~hysieians and other health workers to pro- PAGENO="0131" 125 vide American citizens, `wherever they may `be, with better health care and'to provide that tare more efficiently. Cooperation between lay and professional groups in designmg such methods `has, in general, been most impressive, `but the balance has not invariably been ideal. Good faith and understanding between such groups cannot be :creathd overnight, `but one of tj~e most striking accomplishments of the original law is that it has set the stage for the development of effective cooperation `between these groups. The original law is accomplishing what it set out to do but the pace at which such developments can proceed mu~t be viewed real- istically. We are not in agreement with those who say~ th~t' the paice is unsatisfactory; on the contrary, the rate at which planning has proceeded `has, to date, ~een very impressive, owing ~in no small measure to the understanding and ~wisdom which have ckaracterized the administration of the law., The next 3 years will be critical ones in tJ~at `what has been done will have to be ~rit4cally~raluated; that which is successful must then be encouraged; that which is ineffective discarded,. At thIs stage, as in the planning phase, `the `medical ~ciools :can, an4 no do~bt will render signal service. We believe, Mr. Chairman, the law should continue to operate for the present without substantive change but that the results it is producing piust soon begin to be critically evaluated and scrutinized. The Nation~s medical schools are now involved, for the most part, to' the extent of their capabilities, not in an effort to gain `control, but rather to help to provide the. Nation a critical service.. And a~ we go abo~it meeting'our obligations under the law, we seek the understanding of our critics; those'whcs feel that We are reaching f~r dominance, no less than those who feel that we `are not moving fast o~ vigoronsiy enough on the other, We are, Mr. Chairman, placed squarely in the middle but we recognize that the essenceof the regional medical program aCtivity is vital to the welfare of the Nation. It is one of several tr~ajor obligations which we must discharge. , Mr. ROOERS~ Thank you, Dr. Chapman, for an excellent statement. I might say, too, that I recall that many of 3rOur suggestions were accepted by this committee in the writing of the original laW: You were most helpful to the `committee. ` ` ` ` ` Before q'uestioning,rif we could have' `a statement from Dr. Lloyd Elam.' , , ` ` " ` ` Dr. ELAM. Mr. Chairman, my name is Lloyd Elam. I am president of Meharry~edical .Coii~ge in `N~sh~ill T~m~ Before `as~uming that position, I was cbairmac~ of~the'Departrnent~ of Psychii~try `at Meharry and for `a brief time, dCanl of `the,&hoo~of~ M~d~ci~e. )) fr I speak `todny as, an `offici~l ~representati~; of ~khe Association of American Medical Colleges and wisWto' `ei~itthertt spcifi~al11y'~on rela~ `tionshipEbetWeen' regiotthlrmedical `prog ~a~II ~idrick~4h~el's. I come be~f ore' ~omtoda~ a~öne `whc ~hi~ haddii'~ct e~pe~IOnü~wjth a regional mediCal~ ~rQgrai~, a program'wh4b~ iskfre~d~y ~M~erin~g the operational plaase after having' made rernatha'blepro~ess in bringing together ve~rjoiis"hoalth re m~es'iipth~ Mi~~ut~i `h~e~id~ing its p~1an~ ning phased ~t ha~ve' a deep'cońcern ab~ the'k~aiiabiiity~h.d' ~ualirty of health care among `the poor, especially in our Cities, I am pariacnlarly PAGENO="0132" 126 interested in what regionul medical programs can do in this critical area. The regrettable fact that my institution, Meharry Medical College, has limited personnel and resources allows me to emphasize the point that the responsibilities we assume under regional medical programs must not become a drain on our finances or our manpower. Thus, as we enter into cooperative arrangements with other health resources of our region, to improve diagnosis and treatmeift of heart disease, cancer, and stroke, we must do so without jeopardizing our primary educa- tional obligation. Within these constraints, Meharry and the other medical schools of the Nation wish to express a strong sense of responsibility for the health problems of the communities that surround us. Regional medi- cal programs offer an opportunity for such involvement. Indeed, we see in them the possibility for strengthening our colleges to carry out ~their unique obligation in community health, especially in the devel- ~opment of better ways to apply new and advanced procedures and im- proved ways of educating health personnel for this task. Let me describe briefly how the Tennessee Midsouth regional medical program came into being and what we expect to accomplish in the next ~few years. The program was initially established through the co- nperative endeavors of a wide variety of interested groups in Ten- nessee and southern Kentucky. The discussions involved Mebarry Medicul College, Vanderbilt Uni- versity School of Medicine, Hospital and Health Planning Council of Metropolitan Nash~ilie, private hospitals, medical societies, public health agencies, and voluntary health organizations. A regional advi- sory group was established and planning funds were received in August 1966. In our area, as in many regions across the country, the bringing together of these interests for planning purposes has resulted in an en- tirely new perception of health problems of the region and of new ways to solve them. Ican indicate the extent of our progress by telling you that in June 1967, a little more than 10 months later, a request was made for operational funds for 34 proj e~ts to be carried out in the region. The projects varied widely in content and in scope, but each was concerned with solving a particular health care problem in heart disease, cancer, or stroke which had been identified during the plan- ning process. One project which typifies the region's activities, and allows me to speak to a particular problem that we at Meharry are addressing, is the regional medical program project concerned with long-term evaluation of the health status of 80,000 underprivileged persons in an urban pov- erty area known as north Nashville. Our department of family and community health, in conjunction with~the Office of. Economic Opportunity, is establishiri~ a neighbor- hood health center for this group of needy people. This is, as you can imagine, a large undertaking and one which requires a great deal of medical skill and effort. One of the major problems is to determine ex- actly what type of health care is actually required by these persons. Another, of course, is to measure the quality of care and to find out if it is actually achieving what it sets out to do. The regional medical PAGENO="0133" 127 program is supplying the means by which Meharry, with the coopera~~ tion of Vanderbilt University, can establish a multiphasic screening laboratory as an adjunct to the neighborhood health center. The co- operation with Vanderbilt involves consultation and computer serv- ices needed for the automated laboratory procedures and recordkeep~ ing. Regional medical program support will help us uncover heart disease, cancer, and stroke in this population in the earliest stages, pro~4de documentation of the incidence and type of these disorders, as~ sist in the initiation of necessary treatment, and aid in evaluating the~ treatment these patients receive at the neighborhood health center. The potential of a cooperative arrangement between a mnltiphasic~ screening laboratory for the identification of need for medical care through early diagnosis and of a neighborhood health center for meet- ing that need is very great. This activity would have been difficult, if not impossible, to undertake without the help of regional medical pro.. grams. Many of the essential and important elements of regional medical programs are present in this one project: The bringing to- gether of previously disparate elements of ~he medical care system-~ providing of manpower and funds to get things done-and thecoming to grips with the really significant health is~iue~ of our region. The involvement in regional medical programs of Meharry and Vanderbilt medical schools and of many other medical schools in this country, is far from superficial. Indeed, in many areas the medical school was instrumental in the establishment of the regional medical program and these institutions have lent their expert assistance in launchingthis major new program. They are accepting responsibilities beyond the traditional ones of teaching medical students and conduct- ing research. They have begun new programs to translate more promj~tly the fruits of medical research into improved care for the people within the regions that they serve. I shall like to close simply by giving my earnest and enthusiastic support to the legislation extending this program. I sincerely hope that you will agree with my estimation of its great importance. Thank you for the privilege of speaking before you today. Mr. R0OERS. Thank you, Dr. Elam. Are there any questions? Mr. KYROS. I have only a few questions. Dr. Chapman and Dr. Elam, I want to welcome you here and thank you for your statements. Dr. Chapman, on page 2 of your statement you include in your re- marks that occasionally one hears the view that the medical schools are attempting to use the regional medical program for the purpose of gaining control of the Nation's health care system, Would you kindly expand on that a little bit? What is the problem there? I didn't know such a problem existed. Dr. CHAPMAN. This is something that has largely begun to dis-. appear, I think. We heard this a good deal when the law was first passed. In addition, we have heard fears expressed that the medical schools might simply take funds that were available under this law and use theni forstandard, ongoing med~cāl sehQol purchases. Of course, this is not possible under the 1aw;~and I think 1 can state with assurance that no medical school i~ doing~tIiat. Most of us have PAGENO="0134" 128 ~ttarni~iL smalL amounth~ reli~tive1y small amoirnts of f~i~ds in ordei to firidt ~the. ~ that~ ~e need~d?~o ~na,bie us~to ~ in~t1uis p~gram, butT don't think, Mr. Kyros, that these enticisms ~r~a1~ the n~ioment very srnlous Mr Kntos Ii~th~ State of Muiue~ I' J~ave beem told by doctors that one of the valuable bene~fits o± this program is that in a~ State where you ~lon't have a niedioa~l ~ohool~ as in Maine-'nnd I imagine there are other States iii ~th~Ui~tecl Stai~s ~that `dom't~have a medical school- you ser~ve~aai eduoatioiiai function by disseminating vital and cur- rent information to doctors who normally would not have that kind of information. Dr. CHAPMAN. Yes~ sir; and many of us who are deans regard many of the most im~ortantiaspect~ of this~ ačtivity to be the continuation educatio~r feature fori pli~siciaąis~ and in &ir ,own northern tier of States, Mr. Kyros-i~of coume, w~ ~epre~eiit~three i~gions there, Maine and Verniońt are separai~ regions, and Maine is tied in with New Ilampsliire. We are meeting re~ulariy with the Maii~e and the Vermont r~gional medical program officials~and one of the mAin things is this: the oon~ tinuation of medical rducat~on. Mr. K~aos. On page 4, you talk: about the desire, perhaps, in the~act to Obtain a more definitive or'ganizätional guideline and to reconsider critically the geo~raphic'structure of the various regions. Whal spe- cifically ate you suggesting ~ Dr CHAPMAN. New England is a good case in i3oint. As you well know, sir, New Englaild for a ~i~si~ time~was been working itself as a region with the northern~ tier of~ States~focusing for many purposes on Boston, and to sonie extent on Nontrea~i and Aiban~ al well. Our present regional structure will undoubtedly have to undergo modification In fact, I would say it already is in a1 functional sense The northern tier of States is ~at similar region in terms of population, climate, geography, audthedic~aii health probiems~ Mr. Knios. On page~4 agAin,;yoü~say cooperation between iay~ and professional groups in designing such~methods-r-that is~ of getting the latest advances in diagnosis and treatment traithlated mto action for the patient have been most imp:rOssiv~, but the balance has not been ifivariably ideal. What does that meant Dr. CHAPMAN. I think it is a matter of groups that have never real- ly worked together before arenow having to do so, and as I said earlier, I thh~k, in the State, some ~uch difficulty was inevitable and indeed predictable. : In our own area, the balance is coming around very nicely, as I see the operating in ~tke~ advisoiy group, `~hich has `brought together people who had certainly never ~approached any serious proposals to~eth~r jointly. ~ S Mr KYROSr Do It understand your testmmon~ this morning to be eu~ tirely ~n f~vor~fthwprogram th~at is set `forth in the act before u~ today~ ~ ~ S Dr CHAPMAN Yes, sir We would consider it very dstressing in- deed' if it ~wer~ n~'t~ continued. ~it ~ at the point now *here we' will begin to obtaiii the teritical' information we need' in order to bring forth a program that will really do the job, and will really carry out the intent of the original act. PAGENO="0135" 129 Mr. Kmos. Are you satisfied with the $65 million provided for fiscal 1969? Dr. CHAPMAN. I am really in no position to speak to that. I believe under the circumstances it will take us the next step. Mr. KYROS. Dr. Elam, I understand your multiphasic screening turned up uterine cancer in patients that would not otherwise have been found. Will that be continued? Dr. ELAM. Yes, sir; and the results of the screening will be sent to a doctor in the anticipation of turning up such things. Mr. Kmos. Thank you. Mr. RoGERs. Dr. Carter? Dr. CARTER. No questions. Mr. ROGERS. It has been helpful to have your testimony, and we appreciate your sharing your knowledge with the committee. I hope that you will let us have your suggestion for any improvement that you think the program should undertake. Particularly I am con~ cerned about bringing in more hospital people. I think maybe this balance that you are talking about the people in the program, along with the medical people-I think it has got to involve more people, and I would like to get more details if you could submit that to us, on your examination program. I think this could be most helpful to the committee. Dr. CHAPMAN. Thank you, Mr. Chairman. Mr. RoGERs. Thank you. The committee stands adjourned. (Whereupon, at 12i :30 p.m., the committee adjourned, to reconvene at 10 a.m., Wednesday, March 27, 1968.) PAGENO="0136" PAGENO="0137" REGIONAL MEDICAL PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS _______ WEDNESDAY, MARCH 27, 1968 HotrsE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTh AND WELFARE, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). Mr. ROGERS. The committee will be in order, please. We will continue hearings on H.R. 15758, introduced by the chair- man, Congressman Staggers of West Virginia, and our first witness today is the Honorable Richard Daley, mayor of Chicago, who cannot be with us, but whose, statement will be read by Miss Phyllis Snyder, who is the executive director of Chicago's Alcoholic Treatment Center. We are delighted to have you with us Miss Snyder, and we will be pleased' to have you read the mayor's statement. STATEMENT OP HON. RICHARD J. DALEY, MAYOR, CHICAt+O, ILL., PRESENTED BY PHYLLIS K. SNYDER, EXECUTIVE DIRECTOR, MAYOR'S COMMISSION FOR THE REHABILITATION OP PERSONS AND CHICAGO'S ALCOHOLIC TREATMENT CENTER Miss SNYDER. "Mr. Chairman, members of the committee, I welcome this opportunity to add my support, on behalf of the city of Chicago, for passage of title III, part A, of H.R. 15758, known as the Alcoholic Rehabilitation Act of 1968. "We in Chicago have long recognized the need for an adequate pro- gram of alcoholism care and control. We are very proud of the fine work being done at Chicago's Alcoholic Treatment Center, a munici- pally supported facility providing inpatent care for 72 males and out- patient services to men and women. This facility has been operating since 1957. "My commission on rehabilitation, comprised of 22 very able, dedi- cated, and knowledgeable citizens, has been studying the city's alco- holic problems and the needs to combat these problems since 1955. Our treatment center is a direct result of their recommendations. "The studies of this commission have confirmed that it is not within our fiscal power to implement the kind of comprehensive program. which is so necessary. Inasmuch as Chicago and Cook County have an estimated 250,000 alcoholics, more than one-half of the total alcoholics 131 PAGENO="0138" 132 in the State of Illinois, passage of title Ill, part A, of H.R. 15Th8~ will be of significant help to us in Chicago. "Enactment of legislation in this area is long overdue. The disease of alcoholism ranks among the foremost health problems of our so~ ciety. tinder present conditions, the primary burden of dealing with the more severe stages of alcoholism on the community level lies with law enforcement, rather than pt~blic health authorities "This situation i as~uth'ealisticns it is iefft~tite. baw-enforcernent authorities, aireacjy burdened with increased re~ponsibihty ~n the area of crime control, are no better equipped to handle incidents of alcohol- ism than medical doctors to handle crime problems in the ccinrnunity. Several Federal, State, and local courts have already transferred re- sponsibthty for handiing~ chronic alcoholic repeaters from law en- forcement to public health agencies. "The President's National and District of Columbia Crime Commis- sion both recommended such a transfer in communities thr~ughout the~ Nation, not only for socund humanitarian reasons, but to relieve law- enforcement ~uth&~ities of an onerous, unproductive responsibility- a responsibility, I might add~ which drains law-enforcement resources away from the real .~ght against crime and criminals taking p1ace~ in the country today. "The legislation being considered by the committee would therefore be extremely helpful to U.S. communities, especially major urban centers, which need assistance~in the development and improvement of alcoholism care and'treatrnent facilities an4 services. "This is p~airticulurly ~true in light of the possible court decisions which would prohibit the crimina1~ detention of chronic alcoholics on charges of public drunkenness. Action must be taken, and soon, to pre- pare communities for thetask of effecting an orderly transfer of corn- munity responsibility for chronic alcoholism from law enforcement to public health hands. "The Alcoholic Rehabilitation Act of 1968 is therefore a vitally needed step toward alleviating one of the most serious urban health problems of our time. It will help the communities to help themselves in developing local progrants to curb the incidence and `prevalence of alcoholism in our society. And let us not forget that in addition to the humanitarian and administrative aspects of this legislation, it will alsobe a step toward reducing the economic impact of a disease costing American induetry an estithated $2 billion annually in lost man-hours and work efficiency. "In conclusion, then, our country urgently needs a comprehensive national ~rogi~am to deal with the health problem of chronic alco holi~th. The Alcohb~ic ~Rehabilit~tion Act of 1968 represents the be- ginning ef such a j~rogram The administration is to be commended fdr ~prOposing it, and'Chairman Sta:ggers for sponsoring it. "On behalf of the city of Chicago, I sincerely hope that your com- mittee will approve, the 90th Congress will pass, and the President will sign to law, this bill that will aid our States and communities in providing services for the careand control of a disease afflicting mil- lions of American citi~ehs. "Ithank you." Mr. RooEns. Thank you very much, Miss Snyder, for this statement from Mayor1~a'1ey. We appreciate his testimony, and 1 think it might PAGENO="0139" 133 be helpful ~or tliecomiuittee if you coidd submit for the record a run- down on your ~lcoholic treatmOnt center, I would be ~er~r ~iiteres1~d to see the staffing, the numbei of people, and the types of treatfaent that are given. : (The information requested was not available a~ time of printing) Mr. ROGERS. I n~tiee you have irt-patieht as well as out-patient care, ~[iss Snyde~r. Mi~s SN~DER. Yes, we do. Mr. ROGERS~ Thank you. Our next witness is an old friend of this committee, Dr. M~cj'iael De Bakey, chairman of the Department of Sur~ery, Baylor tlniver- sity College of Medicine, Etou~ton, Te~. I might say that Dr Dc Bakey was on the President's Commission for Heart, Cancer, and Stroke, which w~s really the guiding force for the formation of the regional medical prog~aIn. It is a pleasure to have you with ns, and we are pieased to receive your testimony at this time. STATEMENT OP DIL MICHA~L De BAXEY, CRAIRMAN, DEPARTMWT OP SURGERY, BAYtOR tINIVERSITY c'OLLzG~ Ol~ ICINE, HOUSTON, TEX. Dr. Dr BAKEY. Thank you. I am grateful for the opportunity to again appear before this committee, as I did on July 7, 1965, in sup- port of the regional medical programs and to report on their progress. I would like to tender my thanks for what this subcommittee and the entire Committee on Interstate and Foreign Commerce have done to deve~op this program, a program which is already setting a pattern for enhanced medical care within the Nation. I come before you in strong support of title I of H.R~ 15758, intro- duced by the chairman of your full committee, Mr. Staggers. I have been a member of the National Advisory Council on Re- gional M~dical Programs since its creation, and I, therefore, have had the opportunity to see this program in its planning phases, and see it develop throughout the country as we hoped it would. There have been times when I have been guilty o~ impatience, but the fact is that this program has developed, I think, at a normal pace and in a very sound way. Now we are at a point where I think we will begin to see the first fruits of this program in terms of its original objective, which was to provide the best possible care for the patient at all levels of our society, and to extend this kind of care to every citizen. This was a need we have recognized but were not able fully to achieve in the past. I believe this program will achieve its main objectives; certainly in the fields of lieart disease, cancer, and stroke, and hopefully in all the related areas. At this time there are certain aspects of the legislation I would like to discuss in more specific terms. You will recall, Mr. Chairman; in the original testimony, and in the original bill, there was much discussion of construction authority. I think the committee was wise in pointing out that without this type of authorization for new construction-~iere was authorization PAGENO="0140" 134 for renovation-that the program would not be jeopardized in the planning phase. Now, however, we are in the area of actual operation, and already there are 11 programs functioning. I would say by the next several months, perhaps 40 or 50 percent of the programs will be in some phase of operation. So we are moving, you see, quite rapidly. As we move into this area, construction needs will become increas~ ingly more apparent, and already we have evidence of this need. This construction is fairly specific in nature and fairly limited in scope. It is not on the same scale as already existing construction needs within the medical centers-construction for which the centers already have the authorization if not the money. Now, the construction authority we need for the regional medical programs applies primarily to the community hospitals and to the more peripheral units, where the past construction has not anticipated this type of program. In the Surgeon General's report there is documentation and outlin- ing of the various types of construction needed. * What I should like to do, Mr. Chairman, rather than take your time now, is to submit a formal statement for the record within the next few days. I had hoped to have this ready for you today, but I got involved in a series of emergencies over the weekend. Mr. RoGERs. We understand, and without objection, your formal statement will be made a part of the record, following your testimony. Dr. DEBAKEY. This is the limited but well-delhied need for new construction. I leave to the committee's judgment as to how this best should be met. Allow me to point out that it is essential for the future of the pro- gram to find means of meeting these needs of the community hospitals. These needs include construction space for classrooms; particular types of diagnostic facilities, laboratory space of special types; and treatment nuts relating to heart disease, cancer, and stroke. The out- lying hospitals simply do not have this type of space available~ and frequently have no means of finding the funds to provide this kind of construction. Finally, Mr. Chairman, I would emphasize that we have reached the stage in this program where we must look to the funding levels over the next 3 to 5 years. As we move more and more into operation, I think the cost of these programs will reach the figures we visualized in our original concepts and the original proposals in the President's Com- mission's report. You will recall that we expect this to reach authorization levels of well over $450 million by the end of 5 years. Now we are beyond that point in our thinking, `and we now have betfer evidence of what the needs are going to be. I would say they will approximate $5 or $10 million in each region within the next 5 years. Therefoi'e, I would hope the committee will contemplate authorization levels of some $500 mil- lion within the 5-year period. This level will nOt be reached soon, of course. However, I would think by 1971 we would be close to `the $300 million level. I would `hope by that time the opportunities to provide funding at this level would be more readily available than at this moment. PAGENO="0141" 135 Mr. Chairman, I will be glad to answer any qi~estions you have. Mr. ROGERS. Thank you very much, Dr. DeBakey, for giving us your viewpoints on this program and its importance. Could you give us an example. of one region that you may be aware of, or maybe you would want to do this in your statement. Dr. DR BAKEY. Well, rather than take your time about it, let my statement provide this information. I would like to discuss an area where they have not only accepted the total concept of the program but are utilizing the program in a most efficient way to provide the particular three elements that I think are essential: research, educa- tion, and patient care. These three elements must be combined at the level at which the physician meets the patient. Mr. ROGERS. This has been my concern with the program, and I realize it is still very young. But I am beginning to get feedbacks that the program is not reaching the practicing physician yet. It is not down to the hospital. It has stopped at a little higher level, at the dean's office. Dr. DR BARRY. This is understandable at the planning stage. Only at the operating stage will they begin: to feel the program. The most important thing to me is the fact that the program is be- coming better understood by the practk~ing physician, and there is developing an enthusiasm for the program at the grassroots level that really is in striking contrast to some of the earlier experiences. Mr. ROGERS. That is right. I remember very vividly. I think it might be helpfuJ to point out some of tjiese areas where you feel the program is being effective in getting to the community hospital, and where the people in the community are really beginning to receive the benefits. This would be helpful to the committee, and also to spread it upon the record so that other areas can see what is being done in the most successful programs. Dr. DR BARRY. I will be very pleased to do this and include it in the statement I will file with you. Mr. ROGERS. Thank you. Mr. Kyros? Mr. Kn~os. We are happy to have you here, sir. These programs of construction that you are talking about would still have to be initiated at the: ideal level and p~ssed on by the A~cl~ visory Council. Dr~ DR BARRY. Yes; and tliey would also have to show justification as being within certain guidelines, as being essential to the efficacy, of this pro~ram. Ther~:are all kinds of construction needs, but we have v~rious types of construction authorities, and I would think the important thing is that we limit the construction to the needs of this program; thait i~ where it can be demonstrated unequivoca~ily that without the ~o~truc- tion space the program couldn't be effective, couldll't be implemented, Mr. KYROS. I doii't know how familiar you, are, ~r, with the money requirements of the `program; bu~t the figures yesterday were that it would be about $30 million ca~ryovCr from the last, fiscal year, and the bill this year carries $65 million. Do you think $95 m1'I1ion"w~ill bd enough foi~,thi~ kind of planining this coming year? , PAGENO="0142" 1g6 Dr. DR BAKEY. Well, if I read, the situation within the next. year correctly, I would s~y we ~.ould cē~i~e QlQs~ to that, certainly; and I don't think it is goin~ to jeopardize the program What I am concerned ,abop~, js when we get into the. operatiQnal phase within the nextr-wźll, say by 1971. I ~rould say within this ~- to 3-year period we are going to see a real escalation in activity and, there- fore~ in funding needs., Mr. Kmos, I understand, thank you very much. Mr. ROOERS. Mi~. Nelsen? Mr. NELSBN. I have no 4uestions. Mr. Roor~ns. Dr. Carter? Mr. CARTER. It is an honor, Dr. De Bakey, to have you here. You are so well known to ma~y of us as being absolutely dedicated to the serv- ice of humanity. We are honored to have you here.. I would like to ask about ho~ the funds that you want-are they to be for something similar to intensive care units in different hospitals? Or. DR BAKEr. Yes. Well,,some of them would be used in that way. For example, let us take the community hospital that is in a program. They need and can use, `and in .a sense can support, an intensive care unit; but the hospital is built in such a way that they can't even reno- rate space. You are familiar from your own experience, I am sure, in your own area of Kentucky, where' hqspitals, even these built with Hill-Burton funds, are now so jammed that it would be denying the use of `the space for some very essential purpose. S~ they need additional spaoe~~ To build this, they have to have money. It may be a relatively smsAl su~m. It may amount to a hundred thousand dollars, but it is still money that is hard to find for this purpose. S An intensive care unit would be on~wing. Another would be-I hope my colleague will point this out in his testimony to you-in terms of acute stroke units. There will be diagnostic facilities of certain specific character. We point out in the Surgeo~i General's report, which the ~ouncilh.,,ad the opportumty to review, the types of space needed they will need classroom facilities. This is the kind of sjiace that is essential to carry- ing out the program. Mr. CARTER. Certainly we~ have seen,~tha~t many.of,ou~ hösp~tals in the smaller areas, and I am sure it is true m cities, that jn the past few years building has taken place, but still it is inadequate Dr. DR BAKEY. Completely inadequate, and also it doź~n't take into consideration these kmd~ of needs They didn't even visualize these needs in the early plans. Their concern was with immediate needs that they had to meet. ,, S Mr. CA1rn~ii~. ,I see the need of these things. Dr.,,D~ BAK~Y~ ~ay I,say ~o you, Dr. Carter, that it was part of your understanding that he~pec~~ produce this program, and I want to thank you again for your insight into this whole program Mr. CARTEIt Thank you, sir. S Dr. DR B4KEY. It 5wa's a tremendous help to us. Mr. ROOERS. Mr. Skubitz? S Mr. SKTJRITZ. Thank you, Mr. Chairman. PAGENO="0143" 137 I have i~to questions, Dr De I3akey, but I wt~nt to join my cQ11ea~ue~s in we1oomii~ig you here today. I am looking forward to receiving your ieconm~endations. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .~ Dr DE BAKEY I want to exjr~s u~y ~tpprecn~tiou to the commit i;ee for the wisdom anti ~i~dn~ss and ge~iierosity tI1Le~y ~iave shown, and it is good to know there are public servants like yourselves. Mr. Rooi~ts. Thank you~ ~ ~ ~ ~ ~ (Dr. De Bakey's prepared statement follows:) ST4~FEMENT OF MICHAEL E. Ds BAKj~y, ~ Pi~orsssog MND ~cHAIEM~N, DI~AEp~~ 3fl~NT OF ~JROJ~EY,~ BAYipR UNiVERSIrY COLLETh~ OF MEDICINE, HOUSTON, Tsx. Mr. C]iairmanahd members of th~ subeomxnittee; I~ am 1V[icha$1 E. De Bakey, Professor and Ohahman of the D epartzar~ht of Surge~y, Baylor Uithrersity Col- loge of Medicine, in }{ouston,Texas. I had the houoroft~ėing named by President Johnstm as `the Ohairaiaf~ ~f `the Commisslų~i oh Piéart Dise~~e, Cańc~r,knd Stroke, whose report led to theY initial recommendation of the Regiona1'Medic~j Programs 1egislatio~ which this committee developed and passed in 1965 Since its creation, I hn:~~eheen `a member of'the National A.dvl'sor~ Cetincil on Regional Medical Programs arid am also a member of the Regional Advisory Group of the Texas Regidnal Medical Pr~graffi `I testify today in strotig~ stt~port of' Title ~l of' if R. 15T58 introdUced by tiT~ distinguished Chairman of your full committee Mr Staggers If enacted Title I would extend the authorl5rng leg~iSlation for Regiehal Medical Programs for an additionlil live y'ears as well as Clarify certain technical aspeCts ~f P L 89-2S9 I ~onld like ~brle'fiy' to reltetitte the `basic Concept of `tl~e Regional Med~eal 1~rograms the future of which this subcommittee is presently considering The Regional Medical Programs comprise a group of urilts added-~wherever possible-to already existing medical centers iii regions t~hroughont the cotiritty The units are part of thč~ overall researCh, teaching, and medical care going on within the medical Centers In regard to heart disease, cancer, grid stroke. These units together make up a national network for research,' for teliehing new developments to doctors and nurses and for care of patients under investi gatbyn. Thus each physiciati Served by this network has, readily accessible to him for his patients the full range of up to date knowledge and skills developed through natloii.wide research. At the same time the doctor c~ntrlbutes to re- search, for his observations add to the total knowledge. Each of these units we are discussing has its oWn facilities and staff though they fWactioli as part of the existing mediclil work force to pull together and strengthen the mOdical `resourc~s now in e~1stence. The Regional Medical Programs as initially authorized placed principal em phasis on regional volutitarism as the means by which their goal might be achieved. Poday I can report that your confidence ln this approach has been well placed Within the last three years 54 Itegiontil Medical Programs have been brought into being By this summer approxi~iately one-half of these will have entered the operational `phase. The remaining regional programs will shortly thereafter begin operation.' With its emphasis on voluntary cooperation the Regional Medical Program mechanism has managed to harness the creative energies of practicing physicians, hospitals medical schools voluntary state and local health agencies All too `frequently in the past these creative energies have been isOlated from onC ariotber ~or, even worse, in competition. Regional Medical Programs make it `posriible for all providers of health services to combine' their strengths to improve the care of patients with heart disease, cancer, or stroke. Thus our aspirations of 1965 :today are working eiititiCS~ ` `~ `~ ~` `~ One Of the most lInpOrUant developments io tIIO large and `incrCįsirig invol~e' ment of the' medical pr~fesSiori) In a recent s~eech the ?rCsident-elect of the American Medical Assoei*tl~n saM,"As a~~Wboie, `the medical profession ~at the beginning o~the year 1968 Is ~prob~bly ~thdredeC~l'~in,Olvefi In the planning process to determine the natrire of the `Regional Medical Programs than it has been in the planning of an~prOrions Federal prOgrata:"' ` Now in considering the future of these Pi~Ograra5 Mr Chairniari I would like to discuss the legislation before your' committee. I was disappointed to. PAGENO="0144" 138 ilnd that Title I of the bill does not propose to broaden the construction authority for Regional Medical Programs. During the initial hearings before the Inter- state and Foreign Commerce Committee on Regional Medical Programs in 1965, there was much testimony that construction authority would be necessary if the requirements of the legislation were fully to be met. The committee in modifying the bill deleted the authority for new construction. In its report on the bill the committee reasoned that the program would not be jeopardized by the lack of such authority in its initial planning phases. Furthermore, the committee felt in those instances in which new construction might be required for Regional Medical Programs, other Federal sources of funding should be sought. Finally `the committee in its report indicated its intention to review this question at the time of the legislation's extension. Mr. Chairman, I would like to commend the committee's wisdom on this matter. In fact, the Regional Medical Programs have not been jeopardized during these past three years, during which they have organized themselves, planned their programs and. begun to enter the operational phase. however, this situation is rapidly changing, Already 12 of the 54 Regional Programs are operational and within the next year or so all of them will have begun operations. Accordingly, their needs for additional facilities will rapidly !ucrease. .`~he Surgeon General's Report to the Vresident anēl The Congress on Regional Medical Programs documents the case for limited Regional Medical Program construction authority It is extremely important to understand that these facilities would. principally be loc,ated in community hospitals, not our medical schools. Exan~ples of needed community hospital construction described in the report ineltide class and conference rooms fOr regional continuing education programs, space fci~ special demonstrations of community patient care, and expanded diagnostic laboratory facilities. These needs are not now being met under existing Federal constrtLction pro- grams. There are twc~ i~iterr'elated reasons for this: (1) The conipeiltion fon Fede±nl funds for the eqnstrtestioi~ of health facilities Jn~ g~owp e~ormous1y as a result of an overwhelming demand for such tacilitid~.. (2) By `dčfinitipii, the nature of ~egional Medical Prograip construction needs goes beyoiid the tieeds of a single institution to the needs of the region. Accordingly, it is unreasonable to assume that any ~ing1e institution would be willing to divert its scarce funds for matching purpose's when the benefits of the facility are intended for many institutions. Since it is eslsentiaA that there be no substantial distortion of the concept of i~tegional Medti~al Programs, I co~cnr that rather strict limitations should be placed on this vitally needed con~'truction ~utbority. The kinds of limitations erie finds in ~he Surgeon General's rep~~t, having to do witb~the amount of funds a~vailable for construction purposes, seem, entirely reasonable to me. Raving ~nsidered the limitations,, what kind of Regional. Program projects aré~ we woi~kiug ~o generate?, ~iow does such a project work? An example of the čffeetiv,e implementation of th~ ,prpgram involving comm~mty hospitals is pro- vided by the Rochester (New )~o'rk) Regional Me,dical Program, which has inaugurated an initial five-part operational program in the area of cardiovascu~Lar disease. Each part is specifically designed to meet ~bserved or expressed needs in, the d~iivery of spe~ialized. pi~dtcal care to the bea~t patient. One project will ~ovide postgra4u~te training in cardiology for general practitioners and inter- nists who practice medicine in the ten counties which make up this region. Sev- eral different tr~ining programs will be offered so as to best meet the individual i~peds of the physicianswho will pa~t~cipate. This program is being persented hi direct response to the reqnest,s of physicians for this type of assistance4 One phase of this program includes visitations to peripheral bospital~ by the cardi- ologists who wiU provide this instruction, Certain au4io~visuaL equlpitient will be placed in these peripheral hospItals for continued use by the local physician. A parallel `program will .pres~nt intensive month long courses to prepare pro- fessional nurses in the management of coron~ry ear~ units. Th~ growth in the number of coronary care units which provide es'senAial medical care during the acute phases of cardiac illness, ha~created an urgent need'for an increased num- ber of well trained nurses; tl~e latest advances in nursing techniques and modern ~ife~~s~ving ~quip~ent demands, specialized instruction in the nursing skills re- PAGENO="0145" 139 quired. Hospitals in the region have already expressed their intent to have nurses participate in this program as soon as it is activated. The objeetives of this program go beyond that of sitpplying specially trained nurses for coronary car~ units in general hospitals; every effort will be made, to train coronary care unit nurses from the smaller community hospitals as well, even though they may not as yet have such a unit. Three additional activities will also be pursued under this initial operational program. A regional laboratory will be established for education anti training of medical personnel in the care of patients wn~h thrombotic and hemorrhagic disorders. This is the first such facility in the region and will be based in one of the general hospitals particijatting in the Rochester Regional Medical Pro~ gram. A region-wide registry of patients with myocardial infarction wtll be implemented which will gather uniform information from the coronary care units of participating hospitals `and provide immediate a's well as longitudinal data for analysis. A relatively small amount of funds has been made `available to the region to develop the first l~arning center in the region where some of the educational programs in heart disease, cancer, and stroke may be presented to physicians and nurse's. The first year award for this multifaceted program in cardiology is $343,749. Having described an example of what we are building, Mr. Chairman, I should like finally `to say a word or two about the level of funding I believe essential if Regional Medical Program's are to have a fair chance to achieve their goal. We all realize that the maintenance of health is assuming an increasingly important role in our socio-economic area of concern and activities~ The health industry today accounts for an expenditure of $50 billion but it is scheduled soon to increase to an expenditure of $75 billion. If the Regional Medical Program is to fulfill its function as the interface be- tween the moving parts of this health care mechanism, it must continue, to be able to influence that increasingly expensive device. We would be short-sighted engineers, indeed, to derive authorization ceilings for the next five years of this program by looking backward at the cost of these programs at the time they were being planned. The cautious development of those programs has unleased a chain reaction of operational activity which will pecessitate substantially increased funding levels. It is already clear that on the average these programs will be operating at a level of between $5 million and $10 million each within the next five years. It is, therefore, necessai~y that an authorization level of roughly $500 million be used as tim yardstick with which one measures the 1~uuding levels of the program contemplated by this extension, Mr. Chairman, I am indeed privileged to again have the opportunity to present my views to the committee whicit has dOne so ~nach to shape health legisla- tion in general and the Regional Medical Programs in partie~ilar. Mr. ROGERS. Our next witiless is Sidney Farber, `director of research, Children's Cancer Research Foundation, Boston, Mass. Dr. Farber is also an old friend of the committee, and he was helpful in the formulation of the original legislation, having served as chair- man of the Cancer Panel of the President's Commission. Welcome back, Dr. Farber, STATEMENT OP DR. SIDNEY FARBER, flIRECTO~ ~ ~S~ARCH, CHILDREN'S CANCER RESEARCH ~Ou~DATION, BOsToN; MASS. Dr. FARBER. Thank you. It is a great honOr to be once more before this committee, whei~e my memories are a~ heartwarming as any meni- ones I have in my entire professional career. I join Dr. DeBakey ~n'd all our colleagues in expressipg' gratitude to this committee and Congress for startm~ what I regard as the, most important program * rn~the field of medicine in the history Of our country that is applied directly to, the care of the patient. I speak strongly in fav~or' of H.R. 15~58, the purpose of ~vhich is, among other things, to amend the Pub'li~c' Health Service Act so as 93~-453----68------io PAGENO="0146" 140 to extend and approve the provisions relating to regional medical health programs. I join my colleague, Dr. DeB~key, in strong recommendation for construction funds, and I will give one example of this later, which will illustrate the great need for construction funds in this program. What we are asking today is authorization for the next 5 years for these funds, with the hope that funds will `be available, released from other sources, which will ma1~, the support of this program and so many other worthy programs before the Congress possible. I would like to say just a few words about these programs. There has been a magnificent beginning already. I want to give evidence that the, administration is excellent under Dr. Marston in the division of regional medical programs, and that the Council and advisory boards aie composed of wise and courageous men who are not afraid to say no, nor are they not afraid to say yes, in the approval of programs that deserve approval. I `have the privilege `as a member .of..the National Advisory Council to represent that council to the Regional Medical Programs Council; this is my second year of watching and listening with great appre- ciation and helping, when I am asked for help, in the deliberations of these advisory boards. The regional medical program represents the first time in the history of American medicine where all segments of society concerned with tiTe beaLlth of our poopie h1ave come together to achieve a common goal of better health, preservation o~ lives, `and the prolongation of good life for people. who suffer~ from ithes~ dread `diseases. This is a great `triumph in itself, and wo~ild be worthy of the entire cost of this program if this were the only `spin-off of wh~a~ has been done. The regional. medical programs, quite simply, are concerned with bringing to everyman, woman and child suffering from these' dread diseases, and eventually, I hope, from all diseases, all that is known today that might save lives or prolong good life. This is accomplished in the simplest terms in two ways. . ` . We JDegin with `the, community hospital. and the doctor. in practice. We give added strength first in manpower in trained personnel in those community hospii~a1s, and, sec~nc1, technical fscilThes for what is lacking. And we link these community hospitals with so-called "certters." These centers are not buildings iii one place. They are not in one building, but they represent a portion of a gi yen re~iou where there is a concentrat]on of expertise in medical schools, teaching hospitals and research institutions, where there are facilities and manpower and expertise that cannot be duplicated endlessly. The country just can~t.afford that,. If we can bring these two segments of the medical community to- gether, the community hospitals and these medical complexes, and with good means of communication in the modern idiom for rendering dmgnostic assistance and therapeutic advice, we wiLl. achieve some- thing that in the field of cancer, and other fields, will bring great rewards. . I want to mention figures that T had the pri vilege of mentioning once before before this committee. PAGENO="0147" l4~f In cancer, i~ we oouid bring~to every5 man, woman and child evei~y.~ thing that is known in diagnosis and therapy today, there would be a saving of ioo;ooo to 300,000 who are destined to die of cancer this year. S in the field of heart disease and the field of stroke, this can be multiplied asevidenees of what this program ~aa accomplish. For the remaining 200,000 of the 00,000 for whom we have nothing available today and who will die of cancer, we require research. The great research programs of the National Cancer Institute and the American Cancer Society~ aud the many private institutipns of tl~ country will providethe researchin. the course ~f time which will bring answers to the problems which cannot be answered today. But if we can focus. our attention on those who caii be saved with knowledge prēsently, available, this ~oaLisworthy enough. S I want to point out. one example in regard to construction. You are iamiliar with the great retn.rns from the privtae seeto'~ to the Hill- Burton Act and to the Health Facilities Construction Act, and so on In those there has been anoiitpouring of private money. Thet will hap- pen here, .too, in those parts of the country where the private sector can aid. In those where the private sector is unable, this, program should shoulder the entire burden, because human life is precious wherever it is. , S The~re is one examplethat I learned about just before coming here. The community of Anchorage, Alaska, in: response to the, needs identified by the Washington-Alaska. regional medical, program, for high-energy ra4i~tio'nfacilities' closer than Seattle,, Wash., is now conducting a campaign to bu,ild the facility. Solicited private funds will be used to construct the housing for the equipment, which is very expensive. S The equipment will be purchased by the regional medical program. The treatment center will be operated as a regional resource by the Providence hospitaj, as planned and approved by the local and and regional advisory groups. , , S ~ S The decision. to.. suppoi~t the aotiyity iu,volves cooperative arrange- ments at another level also, and of this I am very proud. The National Cancer Institute conducted the site visit, which gave assurance of the sound scientific and professional basis of this project Here is a beau tiful example of two segments of the National Institutes of Health cooperating. ~ I have just heard that the Anchoi age Construēti~n Trades Council, comprising 14 unions, have tahen on the construction of th~ ~ui1dang, contributing more. than one-half of the total cost from tkis one source alone. This is heart-warming,. indeed,, to see a community a~ a whole joining with a Federal program ni aiding people sn.fferin~ from can cer by providing a form of treatment that had been lacking in that part of the country. . S . S The time has come now to recommend greater support for this prO~ gi am on the basis of the fine ~progress which has lieen made You, have already heard froni Or Del3akey in response to questions for the a.n~pu,u,t which is recommended for this year. May I mention two other figures? 5 5 5 5 By 1971 this program ~uhould be supported by an amount no les~ than $~00 million, not counting construction. And we should reach PAGENO="0148" 142 the figure of $500 niilhion within 5 years' time if we are to utilize to the full the strength of what has been mobilized in the various regions of the country in behalf of the health of our oWn people. I close these remarks, Mr. Chairman and gentlemen, confident in the belief that the leadership to the Congress offered by your com- mittee will permit these regional medical programs to make a truly great contribution to the health of all of us. Thank you. (Dr. Farber's prepared statement follows:) STATEMENT OF Du. SIDNEY FARBER, DIRECTOR OF RESEARCH, CHILDREN'S CANCER RESEARCH FOuNDATION, BOSTON, MASS. Mr. Chairman and members of the Subcommittee on Public Health and Welfare, it is with gratitude that I acknowledge this opportunity to appear before you in strong support of HR. 15758, the purpose of which is, among other things, "to amend the public health service act no an to extend and approve the provisions relating to Regional Medical Programs." My name is Sidney Farber. I am founder and Director of the Children's Caiicer Research Foundation in Boston, and Chairman of the Staff of the affiliated Chil- dren's Hospital Medical Center. For almost 44 years I have been associated with Harvard Medical School as a student and member of the Faculty, where I am now the S. Burt Wolbach Professor of Pathology. My medical, research, and teach- ing activities have been devpted to children and to the field of cancer. At the present time I am President-elect of the American Cancer Society which derives its great strength in its struggle to control cancer, from more than 2 million volunteers in all parts of the country. Presently I am a member of the National Advisory Cancer Council of the National Institutes of Health, and represent that Council to the National. Advisory Council on Regional Medical Programs. It was my privilege to serve as a Member of the President's Commission on Heart Dis- ease, Cancer and Stroke, as Chairman of the Panel on Cancer. It was this Com- mission Which produced the renowned DeBakey Report which culminated in th6 enactment of P.L. 89-239, the. Heart Disease, Cancer and Stroke Amendment of 1965. It was my privilege, too, to testify before this Committee in support of the original enabling legislation. Today I come before you in support of the extension of tbi~ program which represents~ene of the greatest opportunities in the history of medicine to prevent death from these dread diseases, and to prolong good and useful life for our people. May I summarize briefly a few points concerning the program as a whole, and that portion dealing with cancer in particular: (1) A magnificent beginning in planning, and to a smaller extent in operations has already been made in this very short period of time. The Regional Medical Programs already show convincing evidence that for the first time in American history the various components of a given region of the country concerned with the health of our people can and wfll work together toward the achievement of a goal which ha~ never been so broadly defined. (2) The goal of the Regional Medical Programs, in a few words, is the pro- vision for every man, woman and child suffering' from any of these dread and related diseases, of all that is known as well a~ all sophisticate~l technical iiroce- itures for the prevention of death and the prolOngation of good~life. Ftmdamental to the achievement of these goals are developthents in ddta collection and the per- fection ~f better methods of delivery of medical care, as well as improvements in continuing education for the physician and education of the public. Making use of these invaluable tools, then, the Regional Medical Programs, in the case of cancer; are beginning to create meaningful relationships between community hospitals and those parts of the region where are located the medical schoQls, teaching hospitals, and research institutions `concerned with cancer. The com- munity hospitals must be~ strengthened by increasing the number of members of their staffs, specially trained in the vari'oui aspects of diagnosis and treat- ment of the many different diseases `we call cancer, and the addition to their technical armamentaritim of such special technical devices as radiotherapy units, and other diagnostic and therapeutic equipment. In the medical school complex there will be concentrations of specialists `in the many phases of cancer research, diagnosis and treatment to give expert assistance PAGENO="0149" 143 to any doctor in the region in behalf of his patient. In such complexes where a critical mass of expertise is to be found, primary responsibilities will include continuing education with the help of technical equipment in the modern idiom, demonstratiohs of new techniques for diagnosis of treatment, and consultation services to the community hospitals and all doctors in the region, in addition to the conduct of research designed to proylde solutions for problems in cancer which can not be satisfactorily handled on the basis of present knowledge. (3) It has been estimated by experts that if we could make available to every patient with cancer in the country today all that is known concerning diagnosis and treatment, we could save 100,000 of the more than 300,000 who will die of cancer this year. This is without new knowledge emanating from research labora- tories. It is a goal that can be achieved by the full development of these Regional Medical Programs in the field of cancer alone. (4) As was the case with the Hill-Burton program, and also the Health Fa- cilities Research Construction Program of the National Institutes of Health, in- vestment of Federal money will be sure to call forth investment from the private sector. You will be interested I am sure in one experience in a part of our Country which has serious need for improvements in the field of cancer. The commodity of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska Regional Medical Program for high energy radiation treat- ment facility closer than Seattle, Washington, is now conducting a fund raising campaign. Solicited private funds will be used to construct housing for the equipment, which will be purchased by the Regional Medical Program. The treat- ment center will be operated as a regional resource by the PrOvidence Hospital, as planned and approved by local and regional advisory groups. The decision to support the activity involves cooperative arrangements at another level also, for the National Cancer Institute conducted a site visit which gave assuram~e of the sound scientific and professional basis of this project. I heard just befOre coming here that the Anchorage Building and Construction Trades Council, com- prising some 14 unions have taken on the construction of the building as a project, contributing more than one half of the total cost from this one source alone. RECOMMENDATION The time for increasing the support for these Regional Programs in Heart Disease, Cancer and Stroke has come on the basis of the truly splendid start that has been made. The upward trend of needs-almost double each year- is apparent as more programs reach the stage of actual operation, In fiscal 1967 only 4 programs were operating; in 1968, 20 more will reach that stage. Even to make possible the universal application of such a simple and established technique for detection of cancer of the uterus at the Papanicolaou smear, is an expensive procedure, but one that will be followed by the saving of thou- sands of lives of women each year. We should emphasize~ too, that many seg- ments of our system-in ghettos, rural areas, or old-age homes among others, have little or no access to modern scientific health technologies. We are aware that particularly at this time priorities must be established and that choices must be made. It is our purpose today merely to point out the great good that will come if there is support of programs which have already demon- strated their ability to achieve the goals defined by the President's Commission on Heart Disease, Cancer and Stroke and put into law by the Congress of our Country on the recommendation of this Committee. From the time of the iden- tification of these goals in P.L. 89-239, the Regional Medical Programs have captured the imagination and raised the expectations of the general public and the health provisions alike, Those who have studied the needs of this program most carefully recommend that the ceiling for the national program as a wholO should reach the level of more than 500 millIon dollars within 5 years, and should certainly not be lower than 300 million dollars for 1971 if we are to utilize to the full the strength which has been mobilized in the varous regions of the country in behalf of the health of our own people. I close these remarks confident in the belief that the leadership to the Con- gress offered by your Committee will permit these Regional Medical Programs to make a trely great contribution to the health of all of us. Mr. Rooi~us. Thank you very much, Dr. Farber., We are indebted to you for being here and giving us your opinion on this program. PAGENO="0150" `144 Let me ask you, ~or instance, with the Children's Cancer Research ~ounda4~ion, can y~u give us any example where a new treatment,. perhaps~hws been disseminated through~' regional medi~alpregram? Dr FARBEt~ Ye~, Mr Chairman The Children's Cancer Research i~'otuidation, if I may speak of something with which I have been concerned `for the last 21 years, is~real'iy' a prototype of the Regional Medical Center program. It is a private foundat~ōn, assisted from~ the private sector ~nd receives research funds from the National Can ber 4nstituth and' help from the American Cancer Society. It is sup- ported~by the entire New England community. It provides expert care and diagnosis and treatment for children with leukemia and all fotnis of cancer,'for any `ehil4' sent by a doctor' in the entire region. `Phe doctor takes care of the patient `at home and giv~s the tremendous moral and medical support required by a family which has a'seriously ill child at home. The f~undation provides the techniques and equipment which are much too expensive to be in a doctor's office. It čarries out all these' čxpensi'~~e services without professional charge' to' the pati'ent; at home' the patient ~is the private patient of his private doctor. In 21' year~, Mr. ~hairman~ I have, never had a cothplaint `from a sin~gl& doctor iii this region. We have had remarkable cooperation,. and the community as a whole has cooperated to support something which `they' considered absolutely' necessary for the comfort, the well- being~ and the mental peace of the family, as well as for' the health'of' the child. ` Mr. ThXiERS. Have we had any real breakthroughs in this area, in the treatment of leukemia in children? Dr. FARBER. Mr. Chairman, there has been very great progress. It was 20 years ago last November when the first chemical that could control leukemia, at least temporarily, was administered to a child for acute leiik~mia. There is no cure for acute leukemia, but patients live good lives for several years, instead of a few weeks or a few months. And `there are alive a few' hundred patients, adults and' children; about 1 percent, I estimate, ~f all `the patients with ieukemia `treated, ~ho have lived g6od lives `for 10 to 15 years without evidence of the disease. This is not a thre, in my opinion, but this is very heartwarming evi- dence that' we' are in the right direction in the use of chemicals, and. many supportive programs, such as platelet transfusiOns and so forth. If `we can keep good life going, the next for~rard step in research may come in time for that child. "We have other tumors in adults as well as children, which have re- sponded to surgery, radio therapy, and chemotherapy In one case of cancer of the kidney in children, we are now above ao. percent in long- term survivals because of the addition of chemical, in this case' an anti-V biotic, to' modalities of surgery~and radio `therapy. We have accom- plished' what seemed im'possible 20 years' ago. Once spread'to the lungs had occurred in this kind of tumor, there ~vas ii matter Of 3 to 6 `mbnths of life ahead. `We are now able, in about 60 percent of the children who have had spread "of this cancer to'the ~tnngs, we are a1~le to have complete destruction of the tumor using small amounts of radio ther- apy and an antibiotic. Life has continued in the longest `patient for 13 years with no evidence of the return of the tumor. PAGENO="0151" There are many examples t~iat could be given from the splendid in- stitutions in the country and in other parth of the ~wou~ld *here great est advances have been made The word "cancer" does not apply to a single disease. It im4udes many differeht diCeases,~which may be Un- relatod, all of which are called cancer, so we may ha~e to answer your question instance by ifistance as we record success. Mr. Rc$om~s. I think that i~encotiraging, and I think it is well for us to spread on the record some of these examples, so ~+here you have a technique that is successful, this can be spread quickly through a re gional medical program-_at least that is thetheOry-that~ it c5n getto the local doctors and hospitals. And although we may not haVe the necessary treatment there, it can be arranged. fdr and the treatment prescribed. Dr. FARBER. We hope these regional programs will provide for the community hospital the expertise and the e uipment which will take care of the vast majority of patients with cancer, leaving for ~he cen- ters the new problems which require far greater outlay in equipment and manpower. Mr. Room~s. Thank you. Are there any questions? Mr. Knios. I want to join with you in welcoming Dr. Farber here. Mr. NELSEN. I was interested in your statement that many patients have gone as long as 13 years with no evidence of i~ecurrenee., Is there any specific number of years that th~ medical profession assumes to be past the danger point in radiation treatment of a tumor? Dr. FARBER. This varies from tumor to tumor. In the case of the kidney tumor I mentioned, I have experience for more than 40 years with this kind of tumor. If there is no recurrence or evidence of tumor 2 years after initiation of therapy, we may as- sume with a high degree of certainty that the patient will remain in good health. In the case of other tumors, cancer of the breast~ for ex- ample, although most patients will remain well if they have been well for 10 years, all of us-Dr. Carter, too, I am sur&-have seen patients who have had recurrences 18 to 20 years later. So we must give a different answer for each kind of tumor. Mr. NELSEN. I had in mind a case that I am well aware of, that hap~ pens to be my son who had a brain tumor. It is now 5 years since the radiation treatment was given, and he has been in very good health since this operation was performed. I am always watching, of course. This was 5 years ago, and it would seem he is in very good health at this time. Dr. FARBER. I am sorry to learn you have this personal experience, Mr. Nelsen. I would say the story you give is encouraging. If there is no evidence of tumor after 5 years, this looks very hopeful. Mr. ROGERS. Dr. Carter? Mr. OARTER. I want to say thank you for an interesting and informa- tive-_and I started to say "persuasive" presentation, but instead of that, I am going to say that so far as I am concerned, I am a believer and am fully persuaded in what you say. Thank you. Dr. FARBER. Thank you very much, Dr. Carter. Mr. SKUBITZ. Doctor, I have one statement. PAGENO="0152" 146 You made the statement, I believe, that if we could make avail- able to every man, woman and child the ~vidence that we have on cancer, 100,000 lives would be saved this year or any year. Is this correct? Dr. FARBER. That is correct. Mr. SKUBITZ. Of course, I recognize the task we have in trying to get to every individual, but don't we have a central clearing agency of some sort where information is collected? Dr. FARBER. Yes, we do, through the National Cancer Institute and the American Cancer Society, but the problem is complex. May I mention a few of the complexities? First, we must have the patient come to his doctor early. This is No. 1. The American Cancer Society particularly has had a great educational program for many years in the attempt to have patients come much earlier than is now the case. If we could apply the cytologic diagnos- tic test, for example, to every woman today, we could save thousands of lives, literally thousands, because here is a form of cancer of the uterus which can be cured by surgery, or radiotherapy. But if we can't get the patient examined properly and regularly, we cannot save lives. There is a further point that should be made. It is that there is a lack of facilities in many of the community hospitals of the country where there are good men and well trained men and devoted doctors, but without expensive facilities and without all of the supportive therapy that is extremely costly, one cannot do as much for the patient as we hope to do when these regional medical programs bring support `to every community hospital that is connected with every center, and every center connected with every other center. There are many reasons of this kind, but if this country decided today that it was worthwhile saving these 100,000 lives by bringing the financial support and the administrative relationships that would be required, these lives cQuld be saved. Mr. SKUBITz. Maybe I misunderstood you. I thought you were say- ing that one of our first problems is trying to bring about an aware- ness in the individtial of what the danger signals are, and if they could recognise them, and then get to the proper place for proper medical attention, they would be saved. Am I right? Dr. ~FAT~nER. That is point No. 1. Part of it is what the individual patient will do, and part of it is what the doctor will do. But if these patients come to hospitals which do not have facilities, the doctor, who is already tremendously overburdened with the tremendous amount of good that he is doing in general practice, will be unable to give the optimal treatment, because the facilities are lacking, because of the expense of supportive therapy, because of the number of ex- perts in many fields of medicine, surgery, and laboratory science, are not available for `the patient. But if a patient should receive everything that is known today, he will stand a far, far better chance in such a place than he can otherwise. Mr. SKUEITz. Thank you, Doctor. Mr. ROGERS. Thank you very much, Dr. Farber, for your excellent testimony. PAGENO="0153" 147 Our distinguished col1eag~ie, Congressman Kuykeudall, will in- troduce the next witness. We are p1~ased to hav~ our colleague with us at the committee here and are delighted that you will introduce our next witness. STATEMENT OP HON. DAN KUYKENDALL, A REPRESENTATIVE IN CONORESS PROM THE STATE OP TENNESSEE Mr. KUYKENDALL. Thank you, Mr. Chairman. It is a real privilege to be with the subcommittee for a few moments~, and a particular privilege to introduce a man who for several reasons, I think, is peculiarly qualified to testify on this particular bit of legislation. I think he is qualified for several different reason's.. First, if not foremost, is the fact that our city and area of Memphis is very much a regional city, probably more so than any major city outside of the crowded area of the eastern seaboard, where within 125 miles of our city we have five States. And we have run into problems of Hill-Burton, because of implication's of not getting benefits from a regional concept. We proudly announce that Memphis is a major medical center around our fine university. And Dr. Cannon himself is one of the outstanding surgeons and, maybe more particularly pertinent to this hearing, one of the major contributors to medical education in the whole Nation, having been one of the leaders in the field of medical education for quite some years. So it is a privilege to introduce my fellow Memphian, a good friend and a leading educator, Dr. Bland Cannon, of Memphis. Reluctantly, I have to leave now, and go to my cOmmittee, Mr. Roomis. We understand. Dr. Cannon, we are pleased to have you and welcome you to the committee. I understand you have an associate, Dr. Henry Brill. Dr. CANNON. Yes. I would like to ask Dr. Ruhe, Dr. Brill, and Mr. Harrison to accompany me to the witness table. Mr. ROGERS. We welcome all of you to the committee and will be pleased to receive your testimony. It is my understanding, Dr. Can- non, that you are representing the American Medical Association in giving your testimony. STATEMENTS `OP DR. BLAND W. CANNON, MEMBER OP COUNCIL ON `MEDICAL EDUCATION,AND DR. HENRY BRILL, MEMBER OP COM- MITTEE ON ALCOHOLISM AND DRUG DEPENDENCE, AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY BERNARD HARRISON, DIRECTOR, LEGISLATIVE DEPARTMENT, AND DR WILLIAM RUHE, DIRECTOR, DIVISION OP MEDICAL EDUCATION Dr. CANNON. That is correct, Mr. Chairman. I am a practicing neurological surgeon and a member of the Ameri- can Medical Association's Council on Medical Education With me to present the views of the American Medical Association on H.R. 15758 is Dr. Henry Brill, of Brentwood, N.Y. Dr. Brill is chair- man of the AMA's Committee on Alcoholism and Drug Dependence. PAGENO="0154" Mr Ber~rd L~amson is direc~t~ pf A~A's Leg~si~tive Department, nn4 ~Wi11iam Ruhe is directo~i of AMA's Division of Medical Education. The three parts of E[.R. 15758 affect three programs of special ~ntevesj tp t~Jae Arneric~ar~ Me4ical ~q~iation. I ~yiil o9mr~e~1t on first part whic)a relates to ~th~ ~ens~o~ of the regwn~al ~edica1 pro gram. The secOr~d part 3o~e~ a~i exteflsion ~if th i~O~rkth for grants for health ~erviccsfor migr~ory work~s. Th~th~fJ ~p~j~propo~$ a new prigram f9~a1~oho~c ar~cōti~c a44~Ut~t~Pn. ~ )~r~ii ~i1l prēwide ti'e subcommittee with 1~he assooiation'svi~vy~s on the latter two subjects. STAT~MT di~ rn~ ~Uin w ~ CANNON~ ē a re~u1~ of the concern, of the - of mMi~al ~du~a iat day in'1841, Ii: health care which it believes will b~t provide care for `all patiexM ~` - `-~ The increased 1ong~v1ty which the Aciieri~an ~eop1~njb~$r ,t&da~ i~ a tribute tē me4ical adv~rM~s and t~ie4r ~ car~ of the ~c~th p~op1e ~he ~ jDh~stcikn tod'~y Is prq~ared to render th~ t~est medical c~~re in the wo1~1d b&~aus~ lie i&'~~roduct of ~ constantly im~roving~patl~r~ of the thi~st n~dth~MuSation ~d research; because' his ~portüńi'tj~ for `p*~tg~u `t~e~ b~Hoh ~r~in- excelled anywher~j `~lid~ `beth~se - he ha'~ beqxi thč~1~Ti~ `ń~'at~hlźs~ and ever-advan~ing diagnostic and ei~?4~ehti~ ~e~hn~ues. ,I have made the previous statement~ M~. O-hahthian, beh~s~ s~ild be clear that while we `constantly strive fOr hnprovthierft so ~bh~t*hat we have `today ~i1~be be~ter~iari~ yesterday, and wha~t we o'b~aiń ~t~- morrow w~ll1~til). b~ be~r i~haii tdday,r~v~ muse not~io~e sight of,~the remarkable `a~compiishi~ipi~tb th~t h*~~ iiečn in~vcle in -hOalth care by our, ~nectical edicators;~In~thO~l re a~b~iér~'aM ~acti~Mii~g ~Wysi'cians~. In Ju~ 196~, when, Dr. J~me~ ~eI who was theti `pre~lileht of `the associ'at~oi{~a~p1 ied before ~he~'fu1'l Ii~ttérs'tate- and `Fore~n,',COm~ merce C thmittee to testify on~the bill to est~blish the regjonaI niedical program concept, he voiced the association's concern with certain prO- ~i9W~Q~ t~ie.~biU, tl~ēn befo~e~the cow tteeJ3cc~nse qf~Jli~e. ame~4-~ ments made by the ~ommittee, much of our colicern was qtiieted ~MP began anspi&ously and, since that time, cohtiniie~to-'~romise a hopeful future ~iit~the~ ~re~,still,~oni~ `aqt~1~~1ike tp `see ~i~' rcgjonaJ: medical prpg~an~s a~i-mn,st~ment ~ and iy~n~-of health care to the Ai ~iean J~eople ~on,Jd be changed in some revolu tionary mann'~r. Importantly, this `doe's not appear to be the v~e~v' of those in the adm'inistrat~oi~,pli~rged with the irnplemen±atioiiof Pu1~lic Law 89-239 Dr Dwight L Wilb~ir, pi~$~ident ēilect~ o~ the ~kMA, in addressing the c~n ~r~npe-wor1~shoj ~n ~g~o~n'al',nc~edi'cal. p~ogran~1s;on J~u'~ir~ 18, 1968, no~d 1~ha4~ on an ear~ier occasion D~ R Q~ Marstori, ~chrector of the reg1ona~~medieal programs, l~ad said that EMP faces the challengQ of influenCing the quality of health services without exercising Federal PAGENO="0155" ~ ~r, St~a~ g~vernn~i~ ē~ntro1 over current. pattei~. ofheaJI~ activ- ities. :Di:~ Wilbur theii s~Acj;, If the~p~ogsam Iri~ faet ~n1~ar~i~r ~nedo~i~ed t~ ~at~tl~yze and to facflit,at~éIthe development of better pr~gi~a~n~ than now existto sej~ve patients and~ frI~e~r ~i~si- eian~ it will undot~tedIy receive enthusiastic cooperation from the niedical pro- fession and related groups. Suoh~upport js ee~pe~y icipatio~n RMPby son'~e Qf our outstaaidir~g pI~iy~i~ians~and by co~astitii~ut w~cTiea~l ~ocieti~ qf th~ AM+~\.. In five, o~tj~e~ i~g~ous, ~~te med~i~ ci~y~ tj~ ~Og~am grantee. These are Georgia, the District of Col i~bj~ N~bra~ka, Min~ nesota ~ ~ln ~j~of the other regional p~rogr~ms, the stale medica ~ei~y~i~ ~n~ctiye p tj~c~pa~4~ j~ ~q. ~ We view with favor the early progress cd' ~ ~if~ ~ 1t~ inć~tcj on ex ir~g~pattern~~ of medical cage ~sometim~s~ddiiig!=i~ew teali*es or changing old ones as local demands a~cl resources make possible) and the local flexibility which allows the program to make a real con- tribution to the health care oi~ our nation. At the same time, we recognize that the concept of the regional medi- cal program is still in its very early stage of exi~te~ce and that it is dif- ficult to appraise the~ program. We do not know; fo~ example, how much this program adds to the stress on an already overtaxed~supply of available mc4ioal manppwer, There is some cOncern that the p1~O~ liferation of Federal healthS programs ~ubstantially contributes~ to~the rise in health, care ~osts~ For~ this ~reason, we are pleased~that R.~W 15758 provides for~an evaluatior of the program. We would s~sb, however, that the evialuatiOn begin July 1, i9~8, rath~er t1*nJ~ily :~, 1970, since evaluation should be an integral part o~the plauning..We also suggest that the subcAmmittee consider further amendirig section 102 to:provide that the evaluation shall be made by a non~overnment agency. Se~tjon~ 10~3, 104, and 10~ contain Ųovisio~is ~yhich we believp to be ~alutar~ Section 103 ~frovides jor the iiiclusibn Of the territories undeē RMP; sectio~n~, 104 makes eombi~iatioii of regional medical p~ogra4il agencies eligible for planning and O~perational~anZs; and sectiQi~ 10~ adds a new provision `under whiel~ grants cóttld'be made to public o~r nonpofit private institutions for services needed by; or which will be of substantial use to, any two or more regional medical,programs. We recomniend the adoption of all three changes. As `to other amendments, we recommend' that tho `subcommittee delete the open-en&authorization for funds for `the 4 fiscal yei~rs end- ing after `June 30, 1969. In view of the fact that we are still dealing with `a relatively untried program,1 we believe it would be `wise to l~init the `au~thQriz'alMn `tē such suins `a's this ~ubcomrnittee ~may' determine to be teas'O4able, rwth~r than to ~rovide for "such `suiti~ `aS may bQ necessary foi~ the' next 4 fiscal years." Further, with the same concern, we urge `the subcommittee to extend `the program fo~ `a total Of 3 years rather than the 5-year extension provided i'n~the bill. Both of the pre~ vious witnesses have mentioned 1971 as a landmark in th~ activation of the program. ` ` , Fin'~l'ly, we nOte that sec'ti~n, 105 provide~ for ~n incre~se in the number `of Advisory. `Council iri~mbers from 13 to 17. As this change is made by the subcommittee, we would i~uggest the further amend- PAGENO="0156" 150 ment `to provide that four members of the council `shall be practicing physicians. The current law requires that oniy two be practicing phy- sicians. In view of medicine's involvement with RMP, we believe that having~ `a minimum `of four practicing physicians would be helpful to the Advisory Council `and to `the RMP program. Mr. Chairman, in conclusion, let me say that RMP' has stimulated favorable reaction from the medical profession. Some of our distin- guished medical leaders are participating in the regional program `and many State and county m~dioal `societies are cooperating in the planning of the activity. On the whole, we feel that the programs hold muėh hopeful promise. With your permission, Mr. Chairman, I would now `ask Dr. Brill to continue the association's statement with comments on the remain- ing provisions of H.R. 15758. Mr. ROGERS. Thank you, Dr. Cannon. Dr. Brili, `the comn~i'ttee will be pleased to hear y'our testimony. STATEMENT OP DR. HENRY BRILL Dr. BRHAL. Mr. Chairman and members of `the subcommitee: The Medical Association, on March 4, 1965, testifying before the full In- `terstate `and Foreign Commerce Committee on `a bill to extend the program for health `services to migratory workers, said: We recognize that migrant families can and do present public health problems which are beyond the capacity of some small communities to handle efficiently. The Public Health Service has done ex~e1lent work in alleviating these problems, and we recommend that the Committee favorably consider the request to ex- tend `the program for five years. Title II of H.R. 15758 would now provide an additional 2-year extension of this program. As we did before, we again recommend this subcommittee's favorable action. With our recommendation of support, however, we add this r~ote; In the past, there has been a clear, special nee~(, involved with the health care of migratory workers. While these peopie are commonly of the low-income group, their mobility has made it difficult for theni to obtain medical aid from established welfare agencies. However, the implementation of the title XIX programs under the Social Security Act would help meet this problem, as it moves to the goal of covering all the medically needy in the State. We believe that limiting the extension of the migratory workers' program to 2 years is appropriate, at which time the program can be evaluated in the light of its proper "phasing out" into the title XIX medical assist- ance programs. Now, Mr. Chairman, we would like to turn our attention to the one remaining part of H.R. 15758-title III, entitled "Alcoholic and Narcotic Addict Rehabilitation." Part A of the title refers to alco- holic rehabilitation, and part B to narcotic addiction, Both would amend the Community Mental Health Centers Act. Part A would provide grants for construction, staffing, operation, and maintenance of facilities for the prevention and treatment of alcoholism under- the community mental health centers program. It also provides grants to help communities develop facilities and serv- PAGENO="0157" 151 ices for the homeless alcoholic, even where no community mentaj health center exists. We are in J~ull accord with the provisions of this section which relate to the funding for construction of facilities. The AMA has long stated that "alcoholism is a disease that merits the serious concern of all members 0± the health professions." At its clinical meeting iii November 1967, the House of Delegates of the AMA resolved that the American Medical Association "identify alcoholism as a complex disease and as such recognize that the medical components of this are medicine's responsibility." It may be of interest to the subcommittee to review briefly the AMA's increasingly active interest in the field of alcoholism over the past year: We have issued a new manual on alcoholism for physicians, summarizing the essential considerations in the causes, diagnosis, and treatment of this illness; We are planning an exhibit, based on this manual, for showing at professional meetings; We issue new material for the public on alcQholism and problem drinking; We have published a guide for industrial physicians concern- ing their role in alcoholism programs for employees; We are encouraging more extensive and comprehensive instruc- tion in medical schools in the nature and problems of alcoholism; and We are urging that more and more general hospitals admit alcoholics as patients, recognizing that alcoholism is a disease that should ~not be treated in isolation but one that, needs the concern of the total community. H.R. 15758 gives strong encouragement to the integratiqu of serv- ices for alcoholic patients with other mental health services, in the com- munity. It underscores the complexity of the disease and correctly recognizes that it should not be treated as an isolated condition. In addition, by making provision for the homeless alcoholic, ir- respective of the existence of a community health center, it wisely attempts to cope with what promises to be a growing problem in the view of recent court decisions. These decisions have regarded the public drunkenness of an alcoholic as a, symptom of his disease, rather than an offense punishable by jailing. The preponderant number of persons arrested for this offense Jiave had no adequate shelter, let alone medical' attention. Very often, they look upon a jail cell as a welcome roof over their heads. Now, a sub- stitute, and a more meaningful one, linked with adequate treatment programs must replace the cell. We hope that these facilities will be forthcoming, not only directly through this legislation, but under private auspices, as well, eucouraged by the expression of the national policy' which this bill reflects. We recommend your support for the construction grant provision. `How- ever, we have long felt' that funds for staffing and operation are prop- erly the responsibility of the commuńity,~ on'ce~ the `major `burdeh of construction has been met with Federal assistance. PAGENO="0158" 152 Part B would provide a similar program for narcotic addict rehabil-~ itation. This section, in effect, supplanth that portion of the Narcotic Addict Rehabilitation Act which seeks to assist States and ~ornmu- iiities in programs of aftercare. It amends the Community Mental H~alth Centers Act toprovide granth for specialized prevention, treat- ment, and rehabilitation services. Again, we applaud the move to in- tegrate treatment and aftercare for an identifiable group of sick persons in to the totality of community services. We note, however, that there is no provision fOr the homeless addict similar to the pro- vision' for homeless alcoholics. We believe that communities, irrespec- tive of whether they have comprehensive men1~ai health centers, should be encouraged to make adequate shelter facilities available for nar- cotic'addicts and we recommend to this subcommitte~ that a provision' for grants for this purpose `be included. As we' have stated with respect to the provision for `alcoholic re- habilitation, we support Fed~ra1 assistance in grants for the construc-~ tion of the necessary facilities, but would urge .tha~t funds for opera- tion and staffing be the responsibility of the participating ~omniunities. Finally, we suggest that the subcorn~m±t~ee specify the sums to be authorized under both programs, rather than the o'pen-end author- ization as stated in part C. Mr. Chairman, with regard to both the alcoholic and narcotic addict rehabilitation amendment's, we are hopeful that this `legislation will' reinforce the determined efforts of `all of the health'professions to pre- vent; to control and to treat all aspects of drug dependence, of which alcoholism and narcotic addiction are a part. Mr. Chairman, both Dr. Cannon and I thank you and the members of your subcommittee on behalf of the American Medical Association' for this opportunity to comment on this important legislation'. We will be pleased to attempt to answer any questions the subcommittee may have. Mr. ROGERS. Thank you very much; Dr. Brill, for your statement,~ too, and these statements `that have been presented on behalf of the American Medical' Association. ` ` As I recall, too, Dr. Brill, didn't you help us on the Drug Abuse Contr~l Act'? Dr. Biuu~. Yes, sir. I remember well. Mr. R0OER5. We apprecia~e your coming back to help us again. Mr. Kyi~os? ~. Its.' Thank you, Mr. Chairman. Dr. Cannon, on page 3 of your statement, sir, you say that any evaluation that will `be made of the effects of the rcgional' medical program ydu~prefer should be made by a nongovernmental agency. Whom are you suggesting? Dr. CANNON. There are agencies that do evaluations of programs. There is the Stanford Institute. I think `that the administrators of the program would want to select' a `noci.government agency `anyway for its evaluation~ ` ` ` ` ` ` I think objectivity of such an evaluation would be of more benefit to them. I think they realiz~'that. ` ` ` `` Mr. Kn~os. What is there so far in the operation of this act, es- pecially the section on evaluation, that concerns you at all about this PAGENO="0159" 153 objectivity? Is there any question that they wouldn't be looking for the full effect~ of how to make the program effective, and couldn't tl'ley have the feedback effect of learning something while they are evaluating? Dr. CANNON. No. doubt, but I think they could improve it by having someone from the outside look ~tt their house. Mr. K~mos. Thank you. Mr. ROGERS. Dr. Carter? Mr. CARPER. I want to congratulate the distinguished gentlemen on their presentations here today. There is in the planning stage now, within this committee, on the a~Ivic~e of our chairman, ~Ti~ plan to evalu- ate some of these programs. We do have a very efficient organization in the General Accounting Office which evaluates these things for us, and it i~ responsible only to the Congress, and not to the executive department, which dO~s do excel'ent audits for. us, and has done them in the past. This is a very good ageh~yi~hich Is re~sponsible to us and does work for us. I don't think it is bias~cl, do you, Mr. Chairman? Mr. ROGERS. We hope not. Mr. CARTER. ut hasn't been in Some work they have done for me.. But certainly we would consid~er, or I would consider, a nongovern- mental ageney: Ho'#č~er, we do have confidence in the General Ac- counting Office, because they usuaily- Dr. CANNON. Dr. Carter, T did not mean that there was bias in evaluation of the program. I think that there are institutions avail- able that can give expert analysis that may be of great value to this program. Mr. CARTER. Yes, sir. Dr. CANNON. And knowing those who are administering this pro- gram, I have the utmost confidence that they will sedk such advice, This doesn't mean that you should not haive someone else evaluating it, too. Mr. CARTER. I believe in evaluation to see where we are and to see if we are spending our money wisejy. Dr. CANNON. My statement about objectivity didn't imply bias. Mr. CARTER Tlkank'you, sir, We appreciate that. Now, so far as open-end authorj~ations are concerned, as a usual thing they just don't happen in this committee. Tisually it is limited to 3 years, An'i~ j not correct in that, 1~r. Chairman? Mr. ROGERS. yes. Mr. CARTER, T~ .~ general rule that has been followed in the com- mittee, it is usua~jy limited~ ~o 8 years~ in authoriz~ations. So I t~iink that it is ~n a~eement with tour papM~. Our bill, I believe, is in agreement with Dr. Brill, also, in that the program concerning migratory workers is for 2 years, a~s he suggested, and we do have a great many pr6blems with aleohQlism, and we do recognize it as a disease. It.. is regrettabje that some of our governmental agencies haven't taken to t.his idea, howeyer, because it is very,, very difficult for us, to obtain admission to a. veterans hospital for an alcoholic-very clif- ficult, In fact, it is almost impossible at times~ I should like to see this changed somewhat. PAGENO="0160" 154 I notice the agreement in the construction of facilities for care of alcoholics and addicts. Certainly, I am in agreement with that. Here is the hard part, the difficult part, for some parts of our country. 1f we come from a wealthy area, it is easy for the area to provide funds for operation. But if you happen to come from an impoverished area, as it happens I do, it is very, very difficult, down in Appalachia, to get the funds for running such an institution. At the same time, we have the same problems there which they have in wealthier communities, and I would hope that we would be a little bit charitable to our less fortunate brothers. Thank you, Mr. Chairman. Mr. ROGERS. Thank you, Dr. Carter. Mr. CARTER. I want to compliment you, again, gentlemen, on your excellent presentation. Mr. ROGERS. Mr. Skubitz? Mr. SKtmITz. Dr. Carter raised a question that I had intended to ask. I am wondering whether we shouldn't limit these authorizations to 1 year. When we authorize for 3 and 4 years, the departments do not have to appear before us and justify their program, or tell us what they have done. They are through with us. Would you oppose 1-year authorizations? Dr. CANNON. I think that 1-year commitments could create dif- ficulties. Mr. SKUBITZ. This doesn't stop the agencies from planning for 4 or 5 years. It means they are to come back and report to us and tell us what they are doing. Dr. CANNON. There may be difficulties in effecting the program, in hiring personnel, and many other things, but we wouldn't be Op- posed to your annual evaluations and appropriations. I mean, that j~ a decision for your committee. Mr. SI~uBITz. I don't think the committee wants to abandon the pro- gram. But this is the committee that listens to the testimony. I think it is important for the agencies to come back and tell us what they have done and justify the money they need for the next year. Otherwise, the departments are on their own. We have no control. Dr. CANNON. We are tremendously pleased and have commended this committee for its perceptivity in organizing this program into a meaningful piece of legislation. We still have that confidence in your judgment. Mr. SKuBIpz. I notice, fOr example, in this particular bill there was an authorization for $100 million in 196~T. This makes it appear that the program is starting to leveF off at this time. It doesn't make sense to me. Thank you, Mr. Chairman. Mr. ROGERS. Thank you very much. Dr. Cannon, I notice you still express some concern that this pro- gram might be used to bring about some change in ,a revolutionary manner in health care of the American people. Is this widely felt in the medical community~ Dr. CANNON. I think that there still exists an aura of concern, be- cause some might interpret' the legislation to mean that it can effect the standardization of health care. PAGENO="0161" ~155 Mr. Row~s. 1 th~ught ~e had tl~peJlled that in w~ritii~g the bill. We made every attempt to in this committee. I ~eeali the eoiu~ern when the bill came out of the Senate. It woii4d ~av~ put up medical coin- plexes where patients could be referred, and so forth. But we changed the eo~ioept of the preēram in this committee, as ~on may kreeall, and, I hope~ thspelled this idea, And I woidd hope the American Medi~a1 Association could dispel that viewpoint. Dr. ()M~NoN. I think the amendments have been very gratifying, bnt the shock wave iititia1l~y ~was rather great. And~ as you know, this is something that we have had to graduaUy ~overeome. Mr. HAumSoN. Ma~ I comment,'Mr. Chairman~ that as indicated by Dr. Oannon in his statement, that beenuse of the amendments m&de by this committee ~at the time it ~passed on this bifi, the fears and concern of the association were some~sdmt. quieted. And while there still remains some concern, we have seen much hopeful promise. We have been very moth appreciative of the work clone by this committee in the adoption of th~nnitiai program. Mr. Roo~s. Phank you. I notice ~yoii express concern on page fl-you don't know yet how much this program ma~ add tothe stress ot an already overtaxed sup- ply of available medical manpower. It was my concept in the original legislation, and from hearing testimoney, that rather than add a burden to malwower,. this woii~d perhaps serve as an easing of manpower, beca~use the theory was that you could quickly get to the doctor in his own locality the latest treatments, the information of the latest treatments, and so forth. And teams could be brought in from the university centers to work with them in a cooperative spirit, where it didn't take the time of the local man to have to go someplace for ~ weeks in the summer to do the continuing education that we carry on now. Communications would be improved, and this was, I thought, a hopeful way of helping to ease the manpower problem rather than put a burden on it. What is your feeling on that? Dr. CANNON. I think your point is well taken. The average practic- ing physician is somewhat in a box fo~ time. He bounces around and can't really break away from an educational experience. However, many men, as you know-I would sa~ most of them- are dedicated to continuing self ~education. What I had reference to here was the number of personnel, the demands on an already scarce commodity has been increased, and the utilization of those people who are trained in medical care to admin- ister programs, to particitape in them, to teach, to set up units. `We don't have any specific figures, but we are concerned. Mr. ROGERS. I am interested in having information along this line, because I would see it operating just the opposite, and I would hope it would. Dr. CANNON. May I ask Dr. Ruhe, who is director of our Division on Medical Education, to comment? Mr. RoGERs. Yes. Dr. RuHE. I believe what `you said will ultimately be the case. In the planning and early operational stages, however, it has been neces- sary for all of the regions to accumulate rather large staffs of profes- sional people to administer the program and to direct it. 93-458-68--il PAGENO="0162" `.156 As I recall, and. I am not certain this is the exact numb~r, but I recall one of the larger regions estimated that it would need approxi- mately 90 professional people. Mr. RoGm~s. All doctors? Dr. Rtr:w~. Not necessarily M,D.'s, but persons at that comparable degree level, in order to carry on the administrative work and the direction of the program. Thus, one of the immediate. effects has been a rather considerable increase in the competition for-~~-that isn~t per- haps the right word-but in the available opportunities for employ- ment of professional people at the administrative level We have noticed this already. I think it has been noticed in the medical schools which have been actively involved in the regional activities It has been necessary for them to add additional faculty and' administrative personnel in order to discharge their responsibili~ ties under the program. . These people have to come from somewhere. They were not in great supply before.. A number of `them hav~e come out of practice, and while we feel ultimately this may result in more efficient utiliza- tion of health care services, we think there is an immediate ei~ect here in providing sOme competition for manpower in the health field. This is, I think, the basis for this statement. Mr. RoGERs. Well, now, what I wondered was this: For instance, I envisioned the fact that you would carry on a continuing education program, perhaps through television, where you `have an expert in a medical center giving instruction to your `local hospitals in a certain treatment that may hwv~ just come out; so that you don't have to send instructors out to each hospital, or have each doctor come in and take ~that time to come to `the medical center. But the communication is one of the means that you are going to cut do~wn on the use `of man- power, I would hope. Is this envisioned? Dr. RunE. Yes; it is. Mr. ROGERS. So there are so many things where I think you would be saving the time of the local doctor; so you don't have to have five doctors `where one doctor may do the work of two doctors-for in- stance, where he performs his exam and wants a reading on an X-ray, and he sees something that is wrong,' but he can get it m the medical center where it comes back irńn-iediately with a communication on the diagnosis. Isn't that going to save him time and enable him to see more patients? Dr. RUnE. I think in time it will. Mr. ROGERS. Right; and this is what we are concerned with, getting the health to the people, and this is the reason this program `was en- visioned and adopted I think. Mr. GARTER. Mr. dhairuian, will the gentleman yield? Mr. ROGERS. Yes. Mr. CARTER. I want to say something in behalf of the general prac- titioner in this case, if you plase. I don't think we should sell him too short. He is a man who is known by the fruits of `his labor. If lie doesn't produce, certainly his practice is going to fall off, and he does take part rn schools. lie goes as a member of the Academy of Gen- eral Practice. He is required regularly to go to school. PAGENO="0163" 157 Our universities, too, in cooperation with the medical associations, do provide aid and visiting physicians who come to our hospitals throughout rural America to teach us, and we are glad for this. The general practitioner in most cases2 if he i~ efficient and effective, he has developed channels of communication with universities, and surgeons and dignosticians who can be of help to him. Most of our community hospitals, I would say, have a qualified radiologist who read their films from `time to time. So we have most of these programs already. They have already been developed by private initiative, forced `by the necessity of doing the best type of work. And I should say that most general practitioners do these things. This program, as I see it, is to complement the program which is already existing. Mr. ROGERS. I am not trying to run down the general practitioner. I think he has `done a grand job. We want to help him to do a better job for the American people. I agree with you. I think he has done a great job. We want to help him do a better job with this program. This is a program, really, for the doctors, so I would understand why the American Medical Association would support it. It is really b~i'~ifly for the doctors, to be helpful to them in ~riving good tre'atrner~. Dr. CANNON, Mr. Chairman, may I comment on your statement? Mr. ROGERS. Yes. Dr. CANNON. This is, in essence, why we believe in the expansion of the Advisory C3uncil. We believe it is wise ~o take two new members from practicing profession. Mr. ROGERS. I think it is a good suggestion ii ~ik w~ sh'v d have practicing people, and I don't think we are g ig enough hospital people in there, either, Dr. Cannon, I think v e are getting `too many educators. This is iiatural at first, and we need them. I3ut we have overlooked in this p:.~gram, to date, I think, bringing in a more active participation by practicing physicians and by hospital administrators, `and some of tli~ people who are actually involved with providing some of these services and where the critical units should be. We need a more practical approach in the implementation of what is a good program in theory, and I think your `suggestion is good. I might state that I think the only group that requires continuing education is your group of general practitioners; does it not? Your specialties don't require continuing education. Perhaps they will. This will be good. Dr. CANNON. By our negative reward system, they' require it. Mr. ROGERS. I am sure all the doctors try to keep up as best they can. It is not easy. I can assure you this committee is not gOing to go for open-ended funding. We have made it a practice, as has been expressed by my colleagues here. We will set a certain sum to be authorized, and our normal procedure has been a 3-year program. Let me just ask a couple of questions quickly, since our time is running out. Doctor, I wonder if, on the aicholic and the narcotic provisions of this legislation, you endorsed building these residential areas, the quar- `ters for homeless alcoholics and homeless narcotic addicts. PAGENO="0164" 158 Dr. BaILL. Yes, sir. Mr. RoGERs. Do you envision this as part of the community mental health center, or a separate facility? Dr. BEILL. It can, be a separate facility. Where it is feasible, it can be part of the center, but it can also be associated with the mental health facility orit can `beseparate. Mr. ROGERS. How can we keep themin it? Dr. BRILL. There are a considerable number of persons of~ this type who will stay voluntarily if shelter is offered. They need this as reentry into society. i~ they come from a treatment facility into a com- munity, they tend to go back- Mr. Roonus.' This would be a sort of a halfway house ~ Dr. BRILL. Yes. Mr. ROGERS. They would still have to go to a treatment center or to the mental health center in the community? Dr. B1ULL. This can be used in a flexible way. It can be used for those who can't find their way but need sheltered care ~or a period of time. Mr. ROGERS. Are there any estimates on how many need this type of shelter? I would appreciate it if you could provide that for the com- mittee. (The following letter was received by the committee:) AMERIcAN MEDIcAL AssocIATION, Chicago, Ill., April 3, 1968. Hon. JOHN JARMAN, Chairman. ~8ubcommittee on Public Health and Welfare, Committee on Inter- state and Foreign Commerce, Hosse of Representatives, Washington, DXI DEAR Mn. JARMAN: During testimony on HR. 15758 on March 27, 1968, repre- sentatives of the American Medical Association were requested by Representative Paul Rogers to suppiy information as to the need for ha1f~way houses for alco- holics and narcotic addicts under Title III of the bill. The present estimate of the number of alcoholics who would benefit from the availability of half-way houses ranges between 150,000 and 200,000. Their dis- tribution is generally throughout the United States, with the greatest need being in centers of population. The estimate of narcotic addicts who would benefit from the ay~ilability of half-wa~!= houses is 3;000. Ap~iroximate1y one-half of these individuals are located In New York City, With the remainder being distribttted throughout the centers of population. In sincerely hope that the above information will prove useful to your Subcom- mittee in its deliberations on Title III of HR. 15758. Sincerely, F. J. .L. BLA5INGAME,, Ecceoutive Vice President. Mr. ROGERS. What about narcotics users? Are there about 60,000? I)r. BRILL. 60,000 known ones. Mr. ROGERS. Would you envision this being done by a grant program? Dr. BRILL. The narcotics problem is in half a dozen big cities. Mr. ROGERS. You don't envision doing this in every community health center in the country? .Dr. BRILL. No; I don't think that is necessary. Mr. ROGERS. How about alcoholics? Dr. BRILL. That is diffused. Mr. SKUBITZ. In Chicago, they have 250,000 alcoholics. Dr. BRILL. May I say that the total number of alcoholics, of course, includes a great number of people who wouldn't need this sort of shelter. This refers to the Skid Row alcoholic, who is really a minority. PAGENO="0165" i5~ Mr. Roei~i~s. 1! und~erstand it is estimated in the country that there are 200,000 to 300,000. We ha~e a distinguished colleague from Illinois, who ~may know about the Chicago problem. Congressman Springer is here, our dis- tinguished minority leader on the committee, and he may have some questions. Mr. SPRINGER. Just one or two, Mr. Chairman. Doctor, were you any part of the AMA structure at the time we passed the heart, stroke, cancer bill? Dr. CANNON. If "struettire" is an all-inclusive term, I certainly was. But I was not one of the spokesmen at that time. I am aware of the statements that were made. Mr. SruINGEii. Well, never will I accept the testimony of anyone who com~s before this committee as an expert on a program until I am more than satisfied. The gentleman from Florida and I kept this thing within what we thought were reasonable boundaries `at that time. It came over here from the Senate with one and a half days of he~aring at $W70 million, almost a billion dollars to start a program, and I have never seen such an array lined up for that bill, and I almo~t swallowed it, until I went home and thought about it. Then I just began to make some investiga~ tions to find out what should be done. And despite all the mean things that were said about the distin- guished gentleman from Florida, and me, too, during that time, that we were keeping that bill from coming to the ftoor, we finally got it out at $320 million. We didn't let it out until they agreed in the other body that they would passour bill. If my figures are correct, we are almost at the end of 3 years, and Out of what they called a piddly little $320' million, they have been able to spend $85,200,000 to' date. I am coming back to this for one reason only, and that is that you are now asking for $65 million for the fiscal year 1969, and nothing has been said, I take it, Mr. Chairman, with reference to any possible re- maining 2 years. Mr. RooRns. It has been said, and they are submitting the figures. Mr. SPRINGER. I am glad to see that. I come back again to my colleague in saying that at the time you were speaking on this before, your people doubted that this program could be undertaken. They went on and pointed out why, in terms of personnel available and so on. I am glad that what you said and what I said and Mr. Rogers said~ and a few others on this committee, has come true. Only it has come even more true than we anticipated. This is about the only time we have Qverevaluated a program. This was a program that I supported energetically, once I thought it was within some reasonable means. But I merely point this out, that I am extremely skeptical of anyone who comes before us with figures unless they can be justified. This was. may I say, what I' considered to be the best testimony in the country. But you ought to go back and see `that testimony, from Dr. DeBakey on down. It was presented before this committee, to justify a program for a billion dollars, which turned out 3 years later to have spent $85 million. PAGENO="0166" 160 I just want to put that on the record, because I think it ought to be brought out here that what we get in the way of landslide testimony here is a selling job and snow job claiming that something can be done immediately. Mr. SKtmITz. Mr. Chairman, will my colleague yield? Mr. SPRINGER. Yes. Mr. SKUBITZ. Was $320 million authorized and $320 million appro- priated? Mr. SPRINGER. Fifty-nine and 200. Mr. SKUBITZ. But how much money was appropriated? Mr. SPRINGER. $85,200,000. Mr. SKTJBITz. That is all they spent. How could they spend any more if more wasn't authorized? Mr. SPRINGER. The fact is they didn't spend all that was appro- priated. They appropriated more than $85 million. Thank you, Mr. Chairman. Mr. ROGERS. Thank you. I do think it might be brought out at this point that I would coin- mend the administration of the program in the fact that they haven't just gone out and spent money. So I think this is rather com- mendable, that they have held up some 8 million on last year because they felt they were not at a stage to spend it. So this is commendable, and I would want to put that on the record, too, that we don't want them, just because we may authorize something on it may be appropriated, that expect them to go out and spend it unless they are at that point where it could be done effectively. So I think whether we reach goals that we may have set is not neces- sarily the determination on the spending of the money. We want to make sure that it is appropriately spent and even though the goals may have been set above that. So I think the administration of it has not been in error in that regard. Dr. RimE. May I comment on that? I think we would support this fact. We have been reassured and encouraged by the way this program has been administered. I think in defense of the program, one thing can be said, that in the early stages, very careful attention has been given to the planning and the preparation f or the operational stage of the program. This has been one of the things which has kept the expenditures down at the present time. But as the program gets moving into the operational phases, I think it is reasonable to expect that the costs would increase greatly. We feel that the program has been administered very well, and with restraint and good judgment. Mr. ROGERS. Thank you. Mr. SictnnTz. That brings me back to the question I raised a few moments ago, the necessity of limiting these authorizations and having the agencies come back and present their case and prove their point. If we authorize for 3 years, they don't have to come back. From that moment on they go before the Appropriations Committee- Mr. ROGERS. This is right. Dr. RUnE. There is one problem in that, if I may. That is, from the standpoint of the region which is attempting to recruit personnel, if PAGENO="0167" 161 there is any question whether the program is going to be continued for the indefinite future, it would be extremely difficult to get good people to change their careers and come into this program. Mr. S1~uBITz. Doctor, you sound like a Government bureaucrat. We hear the same statement' time and again we must have a 3- or 4-year program, or we can't get the people. But for some reason, the Gov- ernment has no trouble hiring peopie. Mr. ROGERS. It may be the doctor is looking at what happened to the Congress on only a 2-year contract, and he is disappointed. [Laughter.] Mr. HARRIsoN. I would like to comment on Mr. Skubitz' question, The association would generally support, if it was the committee's good judgment, an authorization for a single year which would re- quire the program people to come back and give the committee an opportuntiy to examine `the program again. If that was your judge- ment, and we would support that movement. Mr. SKTJBITZ. You had better stay with the chairman. I am the low man on the totem pole. [Laughter.] Mr. ROGERS. As a matter of fact, Mr. Sku'bitz, you might be inter- ested to know that we did a special study on HEW and recommended yearly authorizations. Mr. SKUEITZ. I am glad to hear that. Mr. ROGERS. We haven't `been able to move it in committee yet. Thank you very much. Your testimony has been most helpful. Dr. OANNON. Thank you, Mr. Chairman. Mr. ROGERS. Our next witness is Dr. William Likoff, immediate past president, American College o'f Cardiology, from Bethesda, Md. We are very pleased to have you with us, Dr. Likoff. STATEMENT OP WILLIAM LIKOPP, M.D., IMMEDIATE PAST PRESI- DENT, AMERICAN COLLEGE OP CARDIOLOGY; ACCOMPANIED BY WILLIAM D. NELLIGAN, EXECUTIVE DIRECTOR Dr. Ln~orr. I am pleased to introduce William Nelligan, executive director of the college. I appreciate the privilege of appearing before this committee to present the views of the American College of Cardiology regarding bill H.R. 15758. The goals and philosophy of Public Law 89-239, the progress recorded by the regional medical program during its short life and the future promises embodied in this endeavor are pertinent to your cur- rent considerations and, therefore, prompt this testimony. Medical science in this country is favored by superb talent, com- petence, and abundant resources. This committee, however, is par- ticularly aware that the distribution of these assets, specifically in terms of patient care, is shamefully uneven. The basic goal of Public Law 89-239, the authority for the regional medical program, is to bridge this unequal gap between science and service and to provide an efficient health care system which will assure the transmission of the best in scientific knowledge `to all people of this country suffering from heart disease, cancer, and stroke, or struggling to avoid these catastrophies. PAGENO="0168" 16~2 The concept regulating the regional medical program is remark- ably simple and in the best tradition. of this country's genius for effec- tive action. It holds that modern medical advances can be made available to all people when needs are identified at a regional level by individuals involved in regional affairs and when available re- sources and manpower are properly exploited through cooperative arrangements linking discovery with learning and application. Critical analysis of the activities of the regional medical program uncovers an unusual record of accomplishment toward that goal over a relatively short period of time. Federal funds have stimulated the planning for a health care system in approximately ~O regions encom- passing about 90 percent of this country's population. Operational programs have been activated in 11 additional regions. Solicitations for planning and operational grants for areas not yet involved are being constantly prepared and reviewed. The speed with which Public Law 89-239 has exercised its impact and the wide area of its maturing influence is most impressive almost denying the complexities of establishing a new administering organization and staff within the Public Health Service and the difficulties in assembling for planning and action representatives of diverse scientific and con- sumer groups in a myriad of local communities. The first dynamic engagements with the problems of organization, defining regional needs in health care and interrelating local resources for their correction have revealed a number of specific tacts. Those who have worked in the field developing a program for a specific region, almost without exception sense that institutions and men representing medical, paramedical, and consumer interests welcome the challenge and opportunity to serve. They are applying themselves unstintingly to the search for sound administrative structures and for effective voluntary cooperative arrangements which will assure the success of the program. They share a positive view about the likelihood of obliterating the void now separating the conversion of knowledge to service. They appreciate local needs and they are creative in their plans to meet them. From early experience it also appears that the funding provisions of the act are adequate and that the Public Health Service is awarding these funds judiciously and in keeping with the needs and sophistication of the applications from the petitioning regions. However, and in contrast to some of the statements made to this point, the community is extremely sensitive to the limitatiofis imposed by the fact that the program has not been established on a continuing basis. The paradox of contesting with long-term needs and long-range objectives under the umbrella of a short-term act is uncomprehensible. It impairs the harnessing of manpower; it constricts programs to the immediate; dedication is diminished; promise is aborted; potential threatened. In a frank acknowledgement of clear fact, Public Law 89- 239 has evoked the type of robust response that deserves the assurance of continuing support and inclusion of logical areas of involvement not heretofore embraced. At least a portion of these are recognized in H.R. 15758. Certainly the provisions to in~rolve areas outside of the 50 States is consistent with our ttaditional obligations; those improving imple- mentation through interregional cooperative, those seeking invoive- ment of Federal hospitals and providing for construction funds are necessary logistically and functionally. PAGENO="0169" 163 The American College of Cardiology enthusiastically endorses the ob:jectives `and philosophy of the regional medical program because they embrace an unchallenged need and seek to use forces which require only release and coordination. We support the planning and opera- tion of every regional program where we possess manpower and resources. The college is certain the program will elevate the health of the Nation. It pleads for a favorable action on bill H.R. 15758. rrhis amend- ment to the Public Health Service Act extends and expands the medical regional program to a1 new and amplified potential and hope- fully to the status of the most distinguished medical `program con- ceived in our time. I am grateful for the opportunity of expressing these views. Mr. ROGERS. Thank you very much, Doctor. We appreciate your testimony. Did your associate have any statement? Mr. NELLIG~N. No, sir. Mr. ROGERS. Doctor Carter. Mr. CARTER. No questions. Mr. ROGERS. Mr. Skubitz? Mr. SKUBIPZ. No questions. Mr. ROGERS. I might say that the committee, in adopting a 3-year program rather than aS- or 10-year program, feels that this is one way for this committee to carry out its responsibilities to the Congress and the American people, because otherwise we have no review of the program. Dr. LIKoF~r. I understand that philosophy, Mr. Chairman, but I do wish to tell the committee, and particularly Mr. Skubitz, that we in the field have found it difficult to construct long-range, vital orga- nizational programs and planning in view of the uncertainty from time to time of the funding required to support these ventures. Something we plan for a decade ahead cannot be accomplished on 2-year appropriations. How you get Government workers under these conditions, I don't know. We are having difficulty. Mr. ROGERS. I am sure it would be desirable to set programs `for as much time as we wanted with as much money as was wanted, but we have to equate the economy of the Nation. But this is the `committee's function, and that is what we will do. We are grateful for your testimony in support of this legislatio~i. It will be helpful to us in our consideration. Our next witness is Dr. Clark Millikan, of the'Mayo Clinic~ who will appear and give testimony for the American Heart Association, Inc. Dr. Millikan,' we are delighted to have you here, and will be pleased to haste your'testimony. If you would like to put your statement in the record and just sum up for us, it would be acceptable, or if you prefer, read it. STATEMENT OP DR. CLARK MILLIKAN, CHAIRMAN, COUNCIL ON CEREBRO VASCULAR DISEASE, AMERICAN HEART AS~GCIATION Dr. MULIRAN. Mr. Rogers and members of the subcommittee, it is not only an honor, but a responsibility, to take part in the construe- PAGENO="0170" 164 tion of the continuing legislation. I would prefer, actually, to just make some comments. Mr. RoG1!~as. That will be done. Without objection, Dr. Milhkan's statement will be placed as part of the record following his remarks. Dr. MILIJIKAN. I represent the American Heart Association, being chairman of the association's council on cer~brovascular disease. This program has turned out to be a untque opportumty and a practical, recognizable entity for cooperative and collaborativ9 ar- rangements, not only between ~he university centers and practicing physicians but between government and nongovernment agencies and personnel. The Heart Association, for instance, has taken an extraordinarily active part all over the Nation, not only at the level of regional advi- sory committees but in smaller community affairs~ Last week there was a meeting in New York at which over 400 volunteers were present, and one of the firm decisions arrived at at that meeting was to en- courage further the participation of Heart Association personnel, which can bring a great deal to the implementation and the purposes of the past bill and the new bill. This exemplifies the kind of feeling and the loyalty, for instance, that is being generated by the very wise provisions of this act, and we heartily endorse tihe continuation of these basic principles, in- cluding the business of originating ideas at the local level and having administration remain at the local level. Commenting about the matter of the finances, $65 million is a sug- gestion for fiscal 1969, and as is brought out, there is to be some holdover. You are aware that there are now actually about 11 operational pro- grams, and within the next few months there will be a total of 30 to 35 operational programs. It is extraordinarily important to consider that we are thinking in terms of a graph of continuity here. And as this program develops effectively, gaining momentum, it is mandatory that we not put a fence in front. of it at any point in time with the attendant loss, in possible instances, of personnel. This whole program relates to people, whether at the administra- tive end or the practicing physician end, or at the patient end. And if we do something which cuts back the momentum in the year 1968 to 1969, we have lost more than 1 year of progress, and so I would emphasize the need for the continuity of fiscal support for this whole business. Now, on the matter of construction money, that has come up in reference to the new bill. It would seem highly important that there be authorization for this.. As Dr. DeBakey mentioned and Dr. Farber added, there are areas of activity for which new construction funds will undoubtedly be necessary at the level of 2, 3, or 4 years from now, which should be evaluated at that point in time. It does not need to be done now in terms ,f assigning an amount of money. But it should be looked at precisely later on. But the cardiac intensive care unit, or a stroke unit, or a matrix which requires space-that is not the issue at the moment. But for adequate planning in the future there should be the authorization PAGENO="0171" 165 for the potential of including new construction somewhere in the course of time. Now, a comment in the area of stroke, because this is the area of my particular interest. The American Heart Association has been much interested in stroke and has formed a council on cerebrovascular disease and has been active in promoting teaching and spreading the word in communities. I believe that RMP offers us an opportunity to produce a greater matrix where we are really going to do something about stroke. You are aware of the need for treatment in terms of acute facilities for rehabilitation, reentry of the patient into the community, but we are now beginning to accumulate data which, if we can get the infor- mation to the population and to the physicians, will significantly affect stroke prevention. And this is the kind of thing that RMP is designed to do, among other things. S One of the most interesting items that is coming on the agenda now is the word "hypertension," or high blood pressure, and we now have definite epidemiological evidence through programs which have been supported and originated by you people that hypertension is as im- portant in stroke as it is in heart disease, certain categories of heart disease in particular, and that via the detection and treatment of hypertension, we may cut significantly down on the incidence of stroke. The Heart Association is designing programs to interrelate to RMP and provide screening and detection mechanisms to find these people. Some 20 percent of hypertensives are not even detected at this point in time. In relationship to the very important subject of hypertension, the regional medical programs offer an excellent matrix for the evaluation of antihypertensive drugs. As programs for screening, detection, and diagnosis of high blood pressure are constructed, funds should be avail- able for evaluation and comparative trials of drug agents; including drugs already known and those which will come out of developmental laboratories. These are simply summaries of some of the comments that. are in the formal record. I don't waut to belabor these issues, but to me, we are dealing with the national resource, the health of our people, and we couldn't be discussing a more important subject. .1 congratulate and commend you on all of the things that you have done, and in this particular frame of reference your wisdom in guiding RMP has been unique. (Dr. Millikan's prepared statement follows:) STATEMENT OF DR. CLARK MILLIIcAN, CHAIRMAN, COUNCIL ON CEREER0VASCULAR DISEASE, AMERICAN HEART ASSOCIATION I am Dr. Clark Millikan, Chairman of the American Heart Association's Coun- cil on Cerebrovascular Disease. Representing the Association I welcome the Op- portunity of testifying in support of EL R 15758 the five year e'rtensiop of the Regional Medical Program (P. L. 89-239). As one of the organizations instru- mental in promoting the original Regional Medical Program in 1965 n e are pleased with the significant contribution it has made to the application of new medical knowledge to the diagnosis and treatment of heart dilsease and stroke. We are particularly pleased that the Regional Medical Program has provided, as intended, an effective vehicle for governmental and non-governmental co- operation in combatting the three diseases taking the greatest toll of life in PAGENO="0172" 166 American society. Maximum responsibility has been on local leadership and regional cooperative arrangements. Heart Associations across the country have been active on almost all Regional Advisory Committee~ planning programs, gathering data on health manpower requirements and analyzing available health facilities and services. We expect continued participation during the five years of the proposed renewal as the em- phasis of the program shifts from the planning to the operational phase. Last week in New York City 400 American Heart Association volunteers and staff from across the nation planned ways in which we can improve our pro- gram. One entire discussion group was devoted to the Interrelationship of the Regional Medical Program and the American Heart Association. We discussed the ways in which the relationships between Heart Associations in the various states and the governmental agencies in their areas could be reinforce~l. It was decided at this national meeting that part of our future program would be to encourage our membershipto take everyavailable advantage of Regional Medical Programs, so that Eteart Associations would be playing their maximum role to the maximum benefit of their communities. The original law provided over a three-year period increasing grants of from $50,000,000 to $200,000,000 for the fiscal year ending ~Tune, 1968. We note that H. R. 15758 specifies $65,000,000 for fiscal 1969 and "such sums as may be neces~- sary for the next four fiscal years." We are aware that nearly $35,000,000 of unobligated funds are available in addition to the $05,000,000 provided in this bill for the next fiscal year. However, we would prefer that specific funding for fiscal years 1970 through 1973 had been included in this bill to assure the maxi- mum growth of this suecessfizl program. If the $65,000,000 for fiscal 1969 is appropriated and authorized, we under- stand 30 of the 54 Regional Medical Programs will be receiving their initial operational grants and 14 will be in their second or third year of operational grant activity. It is to be expected that in the following four years operational recjuirements will increase; yrt the legislation under consideration here today leaves the program to the unknown quantity of annual Congressional appropria- tions after fiscal 1969~ We have some reservations as to the wisdom of this ap- proach since long-range planping is essential to the success of this program. One final word as to funds, we stress the minimal necessity of the full $65,000,000 requested in H. H. 15758 for 1969. Among the promising developments in the Regional Medical Program of par- ticular interest to us has been the recent emphasis on extending the development of coronary care units and the necessary trained personnel to hospitals not now having these lire-saving facilities. It is our understanding that the Regional Medi- cal Program has many applications for funds ~or this purpose. We thoroughly applaud the establishment of these life-saving facilities in every hospital caring for coronary artery problems and hope that in the future even more funds will be available for coronary care units. As the Chairman of the American Heart Association's Council on Cerebro- vascular Disease, I can speak with particular knowledge of the constructive pur- poses the Regional Medical Program has `and will continue to serve in mobilizing professional attention and funds for community-wide stroke detection programs and treatment. Teaching units in many medical schools have shied away from involvement with the stroke patient. As part of the planning and operational grants of `the Regional Medical Program, new interest in this problem has been stimulated in a eonstructFve way. iPhis promising development must be en- couraged in the next five years of the Regional Medical Program and adequate funds suppliedfor this purpose. Section 103 of the bill extends the Regional Medical Program to areas outside the United States which should be the beneficiary of this program. We endorse the inclusion of Puerto Rico, the ~TIrgi~ru Islands, Guam, American ~amea and the Trust Territories of the Pacific Islands. Value to citizens of the states withth the United States should not be hoarded but sh'a~ed with areas not part of, but historically connected t~ the United S'tates~ Additionally, the American Heart Association endorses the use of grants for `two or more Regional Medical Programs, as proposed in Section 910, This provision will permit the economical development of teaching films, videotapes and other educational materials for use by several regions on a national basis. This pro- vision also permits the kind of flexibility the American Heart Association has always envisioned for this program. PAGENO="0173" 167 The inclusion of referals to Regional Medical Program facilities by practic- ing dentists proposed in Section 107 is of particular importance. Dentists can play an important role in preventing the recurrence of rheumatic fever and bacterial endocarditis if aware of this opportunity. Their inclusion along with physicians in this program is therefore of significance to the alleviation of some forms of cardiovascular disease. In relationship `to the very important subject of hypertension, the Regional Medical Programs offer an excellent matrix for the evaluation of anti-hyperten- sive drugs. As programs for screening, detection and diagnosis of high blood pressure are constructed, funds should be available for evaluation and com- parative trials of drug agents; including drugs already known and those which will come out of developmental laboratories. Finally, the American Heart Association endorses the inclusion of federal hospitals (Section 107) in the total operation of the Regional Medical Program. The broadest possible range of community medical facilities enlarges the scope of health services to the public contemplated in the original purpose of the program. Despite one reservation expressed at the beginning of this testimony, the Ameri- can Heart Association strongly recommends the enactmei~t of H.R. 15758. Mr. IRooi~ns. Thank you very much, Dr. Millikan. We appreciate your testimony, and I would agree with you that stroke is an area where we need to do great work, and much needs to be done to improve the health of the people in this area. I think it has been overlooked a great deal from the testimony I have heard. Dr. Carter? Mr. CARTER. No questions. Mr. RoGERs. Mr. Skubitz? Mr. SKUBITz. Doctor, the point I am trying to get across is, I have no objection to a continuing program. But I want the agency to come forth each year, justify what they have done and prove how much additional money is needed. Maybe $65 million is sufficient for 1969, `but who is to say how much we need in 1970 or 1971 without the Department coming before us and reviewing the program. Maybe we need $200 million next year, in 1970. And maybe the year following we may need $300 million in- stead of $100 million. I don't know. What I want is for the Department to come in and justify its request from year to year. If it can't justify them, then I see no need of carrying the program forward. Dr. MITJLIKAN. May I ask a question? Are you addressing yourself to just filing the authorization's, or the amount? Mr. SKUBITz. The amount. Dr. MILLIKAN. I believe these are different things, in essence. It seems to me that the record is now being written on the justification of this program, and that we are seeing significant changes `in the interrelationships between the laboratory and teachers, on one hand, and the practicing physician community, on the other hand, which are going to accrue `to the benefit of patients all over the Nation. Mr. SKUIIITZ. I don't think there is much doubt about that. I am sold on the program. Dr. MILLIKAN. It seems to me that if the question is how much money i~ to be allocated per year, that is really in the province of the com- mittee, as you deliberate how you establish mechanisms to find out about this. Mr. SKUBITZ. My point is, though, that if we authorize $200 million for 19~T0 and $300 million for 1971, the Department does not have to PAGENO="0174" 168 come before this committee anymore. It goes to the Appropriations Committee. Mr. ROGERS. Mr. Kyros? Mr. Kynos. Dr. Millikan, I found your testimony most interesting, not only in support of the program, but particularly what you say about money. And, again, as a man who has just come to Congress in the last year or so, it surprises me to see doctors come before this com- mittee and ask for this money and for the continuation of programs. I used to think that doctors in the American Medical Association took a different view. I am in full agreement with your position as it is expressed here. Dr. MILLIKAN. Thank you. Mr. ROGERS. Thank you very much. It is my understanding that one of our witnesses has a 3 o'clock plane to catch back to California, and if the committee would bear with us, if we could hear his testimony now, it would be helpful. Dr. Lester Breslow, professor of health administration and chief of the division of health services, School of Public Health, TJniversity of California, Los Angeles. Dr. Breslow, we appreciate your helping the committee, and we will be pleased to receive your testimony. If you would like to file your statement for the record and make appropriate comments, we would be pleased to follow that procedure. STATEaVIENT OP DR. LESTER BRESLOW, PRESIDENT-ELECT, AMERICAN PUBLIC HEALTH ASSOCIATION Dr. BRESLOW. Thank you. I am appearing before you as ~resident- elect of the American Public Health Association. I would lik make some remarks based on the written statement which has been ~ :iitted for the record. Mr. ROGERS. Your statement will be made a part of the record fol lowing your remarks. Dr. BREsL0w. The effective organization and utilization of the - sources that we now have, and the unique contribution of the ori~ ~ cooperative arrangements, are made possible by this program. The unique contr~butioris are to extend the excellence of the medic~ centers out into the communiti.es, and to accelerate the progress that is being made. I think it is unfortunate that the American people still do not realize the advances that are being. made against heart disease, cancer, and stroke, and the point of this program is to accelerate progress. When we speak about regional cooperative arrangements, it is im- portant to note that these are developing as a two-way street. The extension of expertise is not only from the medical centers out into the community but also from the point of view of the practicing doctor, from the community hospitals, back to the medical centers. They then begin to appreciate the real problems physicians are up against in the day-to-day handling of medical problems. This is a truly cooperative arrangement and a two-way street, with motion in both directions. I would like to say a few words thout the progress that is being made in California. From the outset, the California program has PAGENO="0175" 169 sought to effect cooperation between the hospital associations, the medical associations, the medical schools, and the State health depart- ment, Cancer Society, and Heart Association. There has been estab- lished a network of good communications, now, through area commit- tees around every medical school and extending into every area of the State. Consequently, effective working bodies around many of the community hospitals and practically in all of the counties in the State are tied in with medical centers. A couple of advances are being made. We are going to submit, on April 1 and 2, for consideration by our national site review, 14 pro- posals for operating grants in California. Among these will be a proposal to establish coronary care unit service in the coastal areas of California, a stretch of several hundred miles of small communities. If this program is approved these units will work with the university medical center in San Francisco, in order to extend this whole program out to the periphery of the State. In the southern part of the State there is a proposal that would bring together the medical faculties of two of our universities there. This proposed program also would bring the medical faculties of these schools in contact with the practicing physicians in the Watts-Willow- brook area, in the center of Los Angeles-a scene of past violence and serious problems. The medical faculties of these schools would work along with the county and hospital administrators of the region who would then develop a postgraduate medical education program with concentration on heart disease, cancer, and stroke. I mention these two projects merely to emphasize to the committee that this program is going to bring better care to persons not only in the medical centers hut also into those parts of the State which have been relatively neglected in the past, such as the ghetto areas in the cities and the rural areas over the great stretches like in California. Thank you, Mr. Chairman. (Dr. Breslow's prepared statement follows:) STATEMENT OF Dn. LESTER BRE5LOW, PROFESSOR OF HEALTH SExvIcEs ADMINIS- TRATION, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA AT Los ANGELES Mr. chairman and meinibers of the Comthi1~tee, I am Lester Bresiow, Professor of Health Services Administration in the School `of Public Health at UCLA. I have previously `been the `State Health Officer for the State of California. I have come today. to sp~ak in support of H.R. 15758 and `particularly that section of the bill which would extend the authority for the Regional Medical Programs. In my professional career I have long been concerned ~With `the need for a m~ore effective organization of our vast health endeavor, and I view the Regional Medical Programs as having great potential for making a very important con- tribution to this objective. In recent years this Committee has heard a great deal of discussion about the current difficulties of our health-care system. For this Nation, these problems are not aiways the lack of health resources but rather the effective organization and utilization of the many resources with which we are `blessed, including our resources of talent and knowledge as well as capital, equipment, and personnel. In passing this legislation three years ago, the Congress expressed a public feel~ ing that the benefits of medical science were not being `applied `uniformly enough to all segments of our population. This `expresSion was part of a growing recogni- tion within the health field that the present complexity and specialization of health care requires exploration of improved patterns of organization. The legi's. lation carried through with this concern by placing emphasis on the development through the Regional Medical Programs of "regional cooperative arrangements" PAGENO="0176" 170 among the health personnel and institutions `on a regional basis as a necessary prerequisite to accomplish the objectives of reducing the unneceSsary toll from these diseases. The Regional Medical `Programs become then an exciting new venture in the development of an im~rorsre;d health system-creating new relationships and ca- pabilities while preserVing `and building upon the great strengths of our existing iustitution's, agencies, and personnel. The history of past efforts at creating a regionalizeci approach to health serv- ices provides ample evidence that the task set for the Regional Medical Programs will be difficult and progress at times will seem slow. There have been previous beginning efforts at regi'o'nalized health activities in various parts of the country, some of which wer'e described `by this Committee in the report on the original legislation three years ago. Now the pressures of an increasingly complex health enterprise and the rapid advances of medical science and technology have added a considerable urgency to the need for regionalization' in the health field if our people are to benefit fully from these advances. The pressures generat~d by the rapid rise of health-care costs and the increasing urbanization of our society add to this urgency. The Regional Medical Programs are beginning to show some effectiveness in providing part of the answer to these problems. The activities of the Regional Medical Programs are helping to define the opportunities for improving the excellence of the health services within each region and the contributions that each element of the region's health resources can make to that excellence. The programs are establishing a permanent fra'me~Vork within the regions that be- comes a `two-way street whereby the expertise in the great medical centers becomes more readily `available to the practitioner and institution at the corn- munity level, while ht the same time the definition of community health needs an'd the involvement of commun'ity resources is made m1ore relevant to the spe-. cialized capabilities of the large centers. I have seen this process at work in California where we face a more complex task than most of the regions `because of `the great size of the `region. This is the largest region with about 20 million people,, and the development of the Regional Medical Program is following a `some'what different pattern than other regions, reflecting the commendable flexibility of `the legislation in allowing each regional progra'm to `develop according to the particular pattern most suitable for th'at region. The amount `of `cooperation involving all of the medical schools, the medical professi'on, the hospitals, the public health agencies, arid interested public `in California has `already made an invaluable contribution to the development of `the essential basis for cooperative action. Even before the Califorina Regional Medical Program has received `any operational funds, the progres's of the program during this planning phase and `the esta'blishment of much Improved lines of communication among the `many element's involved constitute substantial progress. In the interest of time, I would like t'o `submit to the Committee a fuller statement of the accomplishments to date under the California Regional Medical Program. (See attachment A.) I think there is still a long way to go in developing the program in C~1ifornia when `the `progress is measured `against the magnitude of the task. By that same measure, however, we in California are very pleased that the flece5mry initial steps in the development of `the program are now well underway. I believe that the Regional Medical Program's for heart disease, cancer, and stroke are a very important `component of the development of health care on a regional basis in this country. With their emphasis on medical excellence, the involvement of medical centers, the practicing physicians, and the hospitals, the programs are a necessary part of t'he effort to bring the `best in health care to the American people. Regional Medical Programs, however, can only make their full contribution in concert with the `many other activities devoted to that goal. The scope of the challenge `is too `broad to be totally accomplished `by any one program. The development of effective interrelationships among `the Regional Medical Programs, Comprehensive Health Planning, and the wide variety of other health programs-~Federal, State, an'd loca'l--will be essential. I bel'ieve that the development of cooperative relationships among many diverse interests already underway through the Regional Medical Programs is a basis for `hope th'at this cooperation can be extended to a broader level and that the effective inter- relationships will be developed `in ways appropriate to serve the diversities of the various areas of the country. PAGENO="0177" 171 As an essential component of this broad effort, the authority for the Regional Medical Programs should be extended and support should be provided for their continued development. Thank you very much for this opportunity to appear before you today. [ATTACHMENr Aj STATEMENT OF LEsTER BEESLOW, M.D., ON THE CALIFORNIA COMMITTEE ON REGIONAL MEDICAL PROGRAMS, MARCH 27~ 1968 The California Regional Medical Program has been funded for only 1~ months and although it would be premature to claim that lives had been saved, never- theless, it can be said with confidence that the stage has been set for the pro- vision of greatly improved health care services for heart disease, cancer, stroke, and the disorders related to them. Just this week a study was launched by the California Health Data Corpora- tion to gather information on the origin of every patient admitted during the entire week to every hospital in California. The study, never before undertaken on so large a scale, will show where each patient came from, what his diagnosis was when he was discharged from the hospital, and other information. While these may seem little more than a set of dry statistics, the results should reveal with great accuracy th~ kinds of medical services needed for Californians and others cared for In the State. Other data gathering studies, which are expected to lead very shortly to operational programs, will be described later. From the very beginning, planning for the California Regional Medical Pro- gram embraced all the major medical and health interests in the State. The Cali- fornia Medical Association, spokesman for the State's 23,000 practicing physi- cians; the California Hospital Association, representing virtually all of the 660 short-term acute general hospitals in the region; the California State Depart- ment of Public Health; the California Heart Associations; the California Di- vision of the American Cancer Society; the deans of all of the eight medical schools in California, and the deans of the two major schools of public health were joined by eight public representatives of the consumer. Together they con- stitute the legal advisory committee for the region and are known formally as the California Committee on Regional Medical Programs. The Committee has met many times, has gained strength, grown gratifyingly more confident of it- self as an entity and has increasingly been able to resolve differences amicably. As for operational programs, we are looking forward to a two-day site visit in California on April 1 and 2 by a review committee of the National Advisory Council for Regional Medical Programs. They will examine the merits of 14 operational proposals generated by local community interest in five of the State's eight planning areas, and by the California Heart Association. These first op- erational proposals are heavily weighted toward continuing education, and in- clude Some promising innovative experiment's. The greatest single topic of interest among these early operational proposals concerns coronary care units, reflecting a growing consensus `throughout the Na- tion that such units, properly equipped and with highly-skilled doctors and nurses to run them, can bring about a dramatic reduction in deaths due to myocardial infractions and other cardiac emergencies. Four of the 14 proposals deal with the training of physicians and nurses and the equipping of coronary care units. One proposal would offer nurse training in several commpnitles throughout North- western California, stretching from the Bay Area to the Oregon border along the Pacific Coast, and would include intensive training for physicians at the San Francisco General Hospital, under the tutelage of University of California cardi- ologists. Similar proposals would be offered through se~reral hospitals in the highly concentrated Los Angeles basin and include the beefing up of the intensive coronary care unit at the Los Angeles County General Hospital. A joint proposal by the University of Southern California and the University of California at Los Angeles would join with the Charles R. Drew Medical society and others to establish a postgraduate medical school in the Watts-Willo'wbrook ghetto area of Los Angeles. Internship and residency programs would be generated along with inservice and pOstgraduate training for doctors, nurses and allied health professionals, close relationships with the faculties at USC and UCLA and detailed planning to meet heart disease, cancer and stroke needs in the area At Rosevffle, a community of 20,000 citizens 18 miles northeast of Sacramento, the University of California Davis Medical School has encouraged local physi- 93-453---68-----12 PAGENO="0178" 172 clans to establish a "living laboratory" involving the whole community. Contin- uhig education, training for licensed vocational nurses and other paramedical personnel, stroke treatment, handling of central nervous system malignancies, establishment of a tumor board, selected multiphasic screening and community education programs are involved. The California Heart Association proposes a substantial expansion of its suc- cessful student research projects, bringing highly qualified science students into cardiovascular research laboratories. In Los Angeles, special training in angiography-the visualization of the blood vessel system with the aid of radioactive dyes-would be presented for practicing and qualified radiologists. Two proposals-one for the Sacramento Valley, the other for the lower San Joaquin-would make use of videotape recording units which would be moved from one hospital to the next, covering several score hospitals. The units would be accompanied by medical television tapes, for instruction of each hospital's staff members, and each local staff could record its own grand rounds, lectures and demonstrations, then, by playing the lesson back, improve its own teaching skills. The California Heart Association proposes a substantial expansion of its sue- pitals in the State, would be expanded to other regions. The development of simple learning languages in a computer program available for undergraduate, graduate and postgraduate instruction to several regional medical program areas would he encouraged in another proposal. The Loma Linda University School of Medicine has a highly intriguing pilot project based on a third-generation computer, and proposes to expand its library services to practicing physicians throughout its vast service area. The computer demonstration would test the feasibility of using a remote display, very much like a television set, on which a physician in a community hundreds of miles from the school could, by picking up the telephone, hook into the computer and ask it to analyze the electrocardiograph readings being taken on the patient lying by the physician's side. The computer analysis would be done in real-time, and the answer would return in 2 or 3 minutes. Such it project might provide needed services to small, remotely located hospitals and communities now lacking medical specialists. These 14 operational proposals are under immediate consideration. Several others, submitted in the March, 1968 quarter, will be briefly detailed In a moment. All have been developed following planning activity which began in January, 1967. The first year's planning activity involved, among other things, the lay- ing down of a data base from which operational proposals are being projected. Construction of the data base has gone through two phases. In the first phase simple, readily available data were arranged in forms most useful for planning in each of the eight areas of California. De*,nograpltic data were acquired from the State Department of Finance. Mortality data were gathered from the State Department of Public Health. Also from the State Health Department, with added information from the Qalifornia Hospital As- sociation, came material for a complete hospital roster for each of the Cali- fornia Regional Medical Program areas. Finally, the first phase of data acquisi- tion entailed analysis of less readily available types of information involving, for example, transportation and the many varieties of morbidity data. During the second half of the first planning year, six planning studies were undertaken on a region-wide scale. All were approved by a data needs subeom- mitee on which each of the California Regional Medical Program areas was represented. Each study aimed at relatively deeper penetration into some aspect of the data base needed for planning. At the same time each pointed clearly to the shape of operational proposals in the making. Patient origin sts~ty.-This study, rescribed briefly in the opening paragraphs of this statement, will Include important material for morbidity analysis, partic~ ulary if the survey can be repeated at intervale. At the same time, the survey In Is first round is expected to yield information needed for transportation and facil- ities planning in conjunction with the rendering of optimal care for heart disease, cancer and stroke patients. Training facilities inventory.-Many of the ideas for operational projects, which began to take shape in the first planning period, concerned manpower needs and the possibilities of training programs for key health services, in addition to physician services. It was found, though, that little information had been gathered on the simple question of what training facilities now exist. PAGENO="0179" 173 The California Regional Medical Program, therefore, contracted with the Survey Research Center at UGLA to make an analytic region-wide survey of existing training facilities for health service manpower of all sorts. The survey, besides being an inventory of facilities, includes analytic details as to capacities, present enrollments, expansion possibilities, curricula and ne~ programs. It will serve as a basis for second-generation studies and operational proposals in the man- power field. Physician referral patterns.-The Stanford Research Institute, in cooperation with the California Medical Association, is completing interviews with a random sample of physicians throughout the State on the subject of referral patterns for patients with heart disease, cancer and stroke. Here, too, material never gath- ered before is being acquired. Questionnaires already completed contain valuable material of two kinds. As a basis for improved delivery of medical service in cases of heart disease, cancer and stroke, referral patterns, both as to physicians and facilities, are being discussed. And, the needs seen by family physicians, and other physicians of first reference, are being recorded and analyzed for the first time In this context. Registries.-A cooperative undertaking involving the System Development Corp. of Santa Monica and the UCLA School of Public Health is doing feasibil- ity testing for possible registries in stroke and heart disease. California has al- ready had rich experience in the development of a tumor registry, covering roughly a third of the hospital beds in the State and providing cancer incidence data of unique significance. The System Development Corp. study is, therefore, moving on to a preliminary examination of registry construction in stroke and heart disease. At the same time, the Director of the California Tumor Registry is cooperating with the California Regional Medical Program in connection with cancer registration and follow-up. Use of medical scoiety review mechanisms.-Ori a trial basis, local medical orga- nizations in three California counties are cooperating with the flegional Medical Program to determine the value of local medical review mechanisms-generallv associated with claims review in health insurance programs-for case identifica- tion heart disease, cancer and stroke, review of prevailing community stand- ards and practices in management of such cases, and possible development of postgraduate medical education and other programs. In each case, the county medical group has agreed to cooperate with the appropriate university medical center in the review. Specialized resonrces in hospitals.-Tbe sixth and last of the first-generation California planning studies is based on questionnaires sent to all the acute, gen- eral hospitals in the State, through the cooperation of the California Hospital Association. The hospitals are reporting whether or not they have various items on a detailed roster of specialized resources or facilities needed for treatment and overall management of patients with heart disease, cancer and stroke. This material, too, has not been gathered before, and is expected to highlight ma- terial lacks, oversupplies or maldistributions. At the same timź~ the study will bring manpower training requirements to a sharper focus as California's Re- gional Medical Programs enter their aperational phase. All these data gathering ~tudies have been integrated into the 14 operational proposals described earlier. They have also been incorporated into the five op- erational proposals and the two additiOnal requests for funds especially ear- marked by Congress, submitted by the California Committee on Regional Medical Programs during the March, 1968 quarter. This second set of proposals includes the expansion of existing clinical cancer diagnosis and treatment, social service consultation, radiological physics, nuclear medicine and computer retrieval of pertinent data to 26 hospitals in northern California, a coordinated year-round general practice residency, Intensive coro- nary care training for physicians in small hospitals, and the establishment of a medical library and information service network. The first of the projects seeking earmarked funds involves a sixth area in California-Orange County, the planning for which has been assigned to the University of California at Irvine-proposing a pediatric pulmonary demonstra- tion center. It would be only the fourth of its kind in the Nation. The second project would expand and improve an existing hypertension program of the UC San Francisco Medical Center. Taken all together, these first operational proposals can be seen as the begin- ning broad outlines in the development of a region-wide comprehensive blueprint, PAGENO="0180" 174 whose cohesion and effective potential ~or vastly improved health care services are emerging, almost on a day-by-day basis, ever more clearly. Mr. RoGERs. Let me ask this. Is your program getting to the ghetto areas? Could you give us a quick rundown on that? Dr. BnasLow, One program that is being considered-I perhaps should not prejudge the issue-is the proposal which has been devel- oped by USC and UCLA faculties. It would transfer the medical expertise developed by these two centers, in the field of heart disease, cancer; and stroke, to the Watts-Willowbrook area. It is in this area that the county plans, to build a' new hospital with the aid of Hill- Burton support. The aim of this program is to build around that hospital, brmging'in the practicing physicians in the community, a program of postgrad- uate education, emphasizing heart disease, cancer, and stroke. We think this will have a remarkable `effect in mobilizing the services of that portion of Los Angeles to provide better care. Mr. ROGERS. Thank you, and I am delighted to see you have given us a statement on the California program, which we will go into in detail. Mr. Kyros? Mr. K~itos. No questions. Mr. ROGERS. Dr. Carter? Mr. CARTER. I am delighted to know you are making all these services available for the Watts area. I wonder what you are doing for the areas around Watts. Dr. BimsLow. Our programs extend into the Watts area and also around the Watts area, not only throughout the metropolitan region of Los Angeles,' but in the mountainous areas, and so forth. Other projects- Mr. CARTER. I `believe in those surrounding areas we are liable to have more heart attacks and strokes. [Laughter.] Mr. RooE1~s. Thank you very much, Dr. Breslow. We `appreciate very much ~your coming here. I understand that we will try to hear one more witness here. Reverend Works, you and Dr. Price, I understood, were going to have to get away. Could you come forward, then? We will be pleased to hear your testimony. Mr. Macdonald, your Congressman, wanted to come and introduce you, but the committee knows of your work, and we are delighted to have you here with us, and Dr. Price. And if you would like, we will make your statem~nts part of the record, without objection and they will appear following your re- marks. And if you could then summarize for us the points that you think wolud be important, this would be helpful to the committ~e. STATEMENTS OP REV. DAVID A. WORZS, EXECUTIVE VICE PRESI- DENT, THE NORTH CONWAY INSTITUTE, BOSTON, MASS., AND REV. THOMAS E. PRICE~, DIRECTOR OP TILE DEPARTME1cT OP ALCOHOL PROBLEMS AND DRUG ABUSE, GE~'ERAL BOARD `OP CHRISTIAN SOCIAL COIICERNS OP THE METHODIST CHURCH Dr. Wom~s. Thank you, Mr. Chairman. My name is Rev. David Works, of Topsfield, Mass., and North Conway, N.H., an Episcopal clergyman. I am the executive vice PAGENO="0181" 175 president of the North Conway Institute, an interfaith, totally ecu- menical fellowship of lay people and clergymen. We have been studying, praying, working, and waiting for a new or more effective way for the churches and synagogues of the United States to help all people prevent alcohol problems. In addition to my responsibilities with the North Conway Institute, which is now permanently located in Boston, Mass., I am also a member of the newly created task force on alcohol problems of the National Council of Churches, which was created to do two things: (A) Study the report of the federally financed cooperative com- mission on alcohol problems with special emphasis on Dr. Thomas Plant's Book, "Alcohol Problems: A Report to the Nation," and (B) To recommend to the National Council of Churches and through the National Council of Churches of Christ, United States of America, to its constituent members, a broad, comprehensive pro- gram to prevent problem drinking. In addition to my role as a member of the Protestant Episcopal Church and a full-time professional worker in our Lords' vineyard, I am also a very grateful recovered alcoholic who, along with my wife and children and other members of my family-especially my mother and brothers and sisters-wish to express our deep gratitude to this distinguished committee and to you, Mr. Rogers, Mr. Kyros, and other members of this committee, and to the other Members of the 99th Congress and to the present administration for the privilege of adding my words of strong support for hR. 15758. Starting in 1951, in a small mountain village in the White Moun- tains of northern New Hampshire, an ever-increasing group of com- petent and dedicated church people have been planning out a church program. After 10 years in New Hampshire and the neighboring State of Maine, and in Congressman Peter Kyros' neighboring state of Maine, His Eminence Richard Cardinal Cushing of Boston asked the religious leaders of the Greater Boston area to help sponsor our North Conway Institute program. We plan to do four things; I will quote from "Alcohol and the American Churches," published by the North Conway Institute in 1967. We call upon the people of God to join efforts in an ecumenical spirit to at- tack this major social problem by action in four areas: A. THE PASTORAL CARE ųF ALCOHOLICS AND THEIR FAMILIES IN THE COMMtTNITv WHERE THEY LIVE Each congregation must bring to the alcoholic and his family a redemptive ministry based `on compassionate understanding and loving concern which seeks to help them withstand `the `stress, tension and anxiety of modern life by pro- Viding hope, acceptance, and spiritual guidance to a reliance upon God, B. ALCOHOL EDUCATION OF THE ECUMENICAL COMMUNITY'S OWN CONSTITUENT MEMBERS We urge all religious bodies to place a new emphasis on the importance of educating their constituents with regard to the personal and social issues in- volVed in drinking. 0. ALCOHOL EDUCATION FOR THE PUBLIC WITHIN THE COMMUNITY The ecmnenical community should `take the initiative in seeking the cooper- ation of other community organizations in the sponsorship of edacational activ- PAGENO="0182" 176 tiles designed to acquaint the total óommunity with objective facts about the role of alcohol In the life of the community, the several problems that grow out of it, and the responsibility of the, community to deal with these problems. IL SOCIAL AND LEGAL CONTROLS We urge 4ihe people of God to work constructively for the creation of attitudes which will constitute a social control over the drinking customs of the populace by establishing high values on the virtue of sobriety and strong sanctions against the Irresponsible use of alcohol Including drunkenness. We urge the appropriate public agencies to enforce the present legal regula- *tions on the distribution and consumption of alcoholic beverages and urge the general public to obey these regulations In the interest of public welfare. At the same time, we urge `that new forms of legal control based on scientific understanding be developed. In particular, we urge the courts to expand practices under which chronic offenders for drunkenness may elect to receive treatment in lieu of jail sen- tences. We note the `special need for constructive controls over the increasing problem of alcohol-related traffic `accidents. The churches then, to sum up, are helping people to prevent alcohol problems through three major avenues of concern: First, we have a department of research and development headed by David Barton. Second, we have a department of pastoral services and training which is headed by a native son of Oklahoma, the Reverend William Sprague. Third, we have a department of communications which is headed by Simons L. Roof, and which is responsible for issuing our various publications. All of us work at therapy or helping folks and communities who are already afflicted with not only alcoholism but many other types of alcohol problems. The average Episcopal minister spends Th percent of his pastoral time with parishioners who have alcohol-related problems. What we need are facilities `such as will eventually grow out of the Alcoholic Rehabilitation Act of 1968. The responsible churches of America will evidence our long-time continuing interest by giving members of this committee our strong support in your attempts to achieve a new enlightened concept. The North Conway Institute `is a product of the ecumenical move- men't, which is sweeping the religious community. It is both' interfaith and interdisciplinary. The institute has serving on its board of trustees individuals representative of the three major faiths-Protestant, Catholic, Jewish-and the health, education, and welfare professions and volunteer service groups. A wide spectrum of religious opinion from liberal to conservative is represented by the membership of the board of trustees. One of the notable achievements of the institute was the endorse- ment of a statement by prominent church leaders of Metropolitan Boston in 1966. The statement was drafted by the Ecumenical Coun- cil on Alcohol Programs and was endorsed by leaders from 16 differ- ent churches ranging from Roman Catholic to Salvation Army. The key'paragraphs read as follows: We believe that alcoholism and alcohol-related problems are a serious threat to the health, happiness, and welfare of many people a'nd to the stability of families and communities. PAGENO="0183" 177 Among other consequences of excessive drinking which call for remedial action are the breakup of family life, the stimulation of crime and juvenile delin- quency, the mounting of welfare costs, and the loss to industry through absenteeism and inefficiency. These problems are not new, but they are acute and are made more so by an attitude of complacency and irresponsibility on the part of the general public in whose hands the final determination of social policy lies. It is urgent that churchmen and others concerned with human needs and the moral foundations of our society endeavor to create a more responsible public attitude toward drinking. We believe that we may all unite on the ground of the virtue of sobriety. This can be practiced in two ways. One Is by total abstinence from beverage alcohol for religious motives. The other is by true moderation in the use of alcohol, also for religious motives. On this common ground the virtue of sobriety may be prac- ticed both by abstainers as well as by those who drink moderately. Although differences of conscientious conviction in relation to certain current drinking customs exist among us, the area of our agreement with regard to drunkenness and alcoholism is sufficiently large and significant as to enable us to unite our best efforts for the alleviation and ultimate ~o1ution of these alcohol-related problems. As churches move closer to one another and understanding increases, Congress will find more and more support among their constituents for health measures to help communities help the alcoholic and his family. ll.R. 15758 is a major step in that direction. In conclusion, may I strongly urge you to recommend the passage of a comprehensive national program to deal with the health problems of families and communities dealing with chronic alcoholism. The Alcoholic Rehabilitation Act of 1968 represents a real step forward in the beginning of such a program. Again, 1 commend the Democratic administration for proposing this legislation, for Con- gressman Staggers of West Virginia for sponsoring it. And I hope you, Congressman Jarman, will get your subcommittee to approve this bill so the Congress can pass it shortly so our President can sign it into law. Thank you very much, Mr. Chairman, for your gracious courtesy in allowing me to testify. (Dr. Works' prepared statement follows:) STATEMENT or REV. DAVID A. WoRKS, EXECUTIVE Vicn PREsIDENT, TIlE NORTH CONWAY INSTITUTE, BOSTON, MASS. My name is The Reverend David A. Works of Topsfield, Massachusetts and North Conway, New Hauipsbire, and Episcopal clergyman, who is the Executive Vice President of the North Conway Institute, an intet-~aith, totally ecumenical fellowship of lay people (m~n and women) and clergymen (Roman Catholic, ?rotestant and lewish) who have been studying, ~waylng, working, and waiting for a new or more effective way for the Churches and Synagogties of the United States to help all people prevei~t alcohol problems. In addition to my responsibilities with the North Conway Institute, which is now permanently located in Boston, Massachusetts, I am also a member of the newly created Task For~e on Alcohol Problems of the National Council of Churches which was created to do two things: (a) Study the report of the Federally financed Cooperative Commission on Alcohol PrOblems with special emphasis on Dr. Thomas Plant's book, Alcohol Problems: A Report to the NU~tion. (b) To recommend to the National Council of Churches and through the National Council of Ohiirches of Christ, United States of America, to its con- stituen.t members a broad, comprebensh~e program to prevent problem drinking. In addition to my role as a member of the Protestant Episcopal Church and a full-time professional worker in our Lords' vineyard, I am also a very grateful recovered alcoholic who, along with my wife and children and other members PAGENO="0184" 178 of my family-especially my mother and brothers anti sisters-wish to ex~ress our deep gratitude to this distinguished committee and to the other members of the 90th Congress and to the present administration for the privilege of adding my words of strong support for HR. 15758. Starting in 1951, in a smell mountain village in the White Mountains of Northern New Hampshire, an ever-increasing group of competent and dedicated Church people have been planning out a Church program. Aftee ten years in New Hampshire and the neighboring State of Maine, Hi& Eminence. Richard Cardinal Cushing of Boston asked the religious leaders of the greater Boston area to help sponsor our North Conway Institute program. We plan to do four things: I quote from 4lcahol anel the American Churches published by the North Con- way Institute in 1067, pages 24-25: "We call upon the people of God to join efforts in an ecumenical spirit to attack this major social problem by action in four areas (a) T/tepastora~j care of ctleoholior and their families in the communtty where they live.-Each congregation must bring to the alcoholic and his family a re- demptive ministry based on compassionate understanding and loving concern which seeks to help them withstand the stress, tension and anxiety of modern life by providing hope, acceptance, and spiritual guidance to a reliance upon God. We urge our congregations to take the initiative iii offering such a ministry by training some of its members to join with the profemtonal clergy to constitute a fellowship of redeeming love within which the alcoholic and his family may find the help they need. Included in such a ministry should be the effort to detect those who arc begin- ning to rely on alcohol as a crutch and to help them find new spiritual resources for handling their problem. In addition, to their own direct ministries to the alcoholic and his family, the churches should help stimulate Community action to provide adequate treatment facilities for the alcoholic and adequate social services for his family. Clergymen should work ~s part of a therapeutic team which includes members of the medical, psychiatric, social work, rtpd vocational rehabilitation professions, They should help develop reciprocal referral services between the churches and the public and private welfare agencies of the community. (5) Alcohol education of the ecumenical community's own constituent mem- bers.-We urge all religious bodies to place a new emphasis on the importance of educating their constituents with regard to the personal and social issues involved in drinking, With each communion estabjisbing goals and methods in harmony with their own traditions relating to the use of alcohol, we recommend that the following be among the educational objectives to be a~tained: To help the membership understand the role of `alcohoj in society and the gravity of the problems connected with its use. To help persons understand their own motivations for drinking or abstain- ing so that an individual choice may be made free from the necessity to confirm. To provide better understanding between those who practice tIm virtue of sobriety through moderation and those who practice it througJ~ abstinence. (c) Alcohol education for the public within the com4nunity.-Phe ecumenical community should take the initiative in seeking the co-operation of other com- munity organigation~ in the sponsorship of educgtional activities deSigned to acquaint the total community with objective facts about the role of alcohol in the life of the community, the several problems that grow out of it, and the responsibility of the community to deal with these problems. We urge tb~t the members of each of our comjuunion~ engage in conversation with others in the community for the purpose of helping to form new attitudes of responsibility in which all forms of excessive d~-ipking are morally and socially unacceptable. When there is no satisfactory general alcohol education program in the com- munLty notably in the schools and the churches, the ecnmen~c~l leadership should initiate the development of one, giving inter-faith support to school officials and offering every possible assistance, Such a program should assist individuals to make mature and responsible decisions about use or non-use of alcohol in keeping with one's own beliefs and individual needs. It should also present scientifically accurate information about alcohol and the nature of the illness, alcoholism. Tt should foster understanding between persons who follow the abstinence and moderation traditions without seeking to impose either. PAGENO="0185" 179 (d) f~oo~ai ant legal controls.-~-We urge the people of God to work construc- tively for the creation of attitudes which will constitlite a soei*I control over the drinking customs of th~ populace by e~tabllshing high values on the virtue of sobriety and strong sanctions against the irresponsible use of ak~ohoi including drunkenness. This should include the enunciation of neW norms of etiquette which bold it to be an act of impoliteness to urge anyone tO drink against his will and which dictates that when alcoholic beverages are served, non-alcoholic alter- natives also be provided as a matter of course. We urge the appropriate publh~ agencies to enforce the present legal regula- tions on the distribution and ~onsnmption of alcoholic beverages and urge the general pflblic to obey these regulations in the interest of public welfare. At the same time, we urge that new forms of legal control based on scientific under- standing be developed. In particular, we urge the courts to expand practices under which chronic offenders for drunkenness may elect to receive treatment in lieu of jail sentences. We note the special need for constructive controls over the increasing problem of alcohol-related traffic accidents." The Churches, then, to sum up are helping people to prevent alcohol problems through three major avenues of concern: First, we have a department of research and development headed by David Barton. This is our "learning" arm. Second, we have a department of pastoral services and tthining which is headed by a native son of Oklahoma, The Reverend Williath Sprague. This is our teaching" or sharing arm of our Institute. Third, all of us work at therapy or helping folks and communities who are already afflicted with not only alcoholism but many other types of alcohol problems. This is our "caring" or healing arm. In addition we publish a number of publications and other statements and newsletters. Eventually, I believe the malor churches and synagogues will also handle problems of drug abuse-including alcohol when it Is misused through this thre&fold approach of learning, sharing, and caring (i.e. Research, training, and therapy). In 1968 the churches are now beginning to tackle six major areas of concern: (1) Feople and alcohol and alcoholism. (2) People, alcohol and youth education-including in many places in- creasing emphasis on drugs along with the drug alcohol. (3) People, alcohol and drunken driving. (4) People, alcohol, and the liquor and beer control systems. For example, you will note in our paper, The Churches and Alcohol on page five: "In 1966, the Federal government collected approuimately three billion, eight hundred million dollars ($3,800,000,900) in beverage alcohol taxes ~witb an eXpéndi- ture of about ~ev~e millIon dolldrs ($7,000,000)]. Po this amount should be added comparable tax revenue collected by the States. Obviously no estimates are available Ss to the los~O~ of tax revenue chargeable to the illicit manu- facture, sale, and use of alcoholic beverages." The church people are increasingly wondering if this is a fair proportion for a National Federal Program of research, training, and therapy as well as education for prevention. (5) People, alcohol and the police court problem. Already mention has been made in these hearings of the impending United States Supreme Court decision on "Powell vs. Texas." In The North Conway Institute along with the Methodist Board Of ChriStian Social Concerns is one of the Amici Curiae. Also, since the first of ~Tanuary 1968, a small Task Force of professional people have been meeting in Boston to plan a concerted attack on "police court alcoholic." We will, however, need funds to help implement this pro- gram which we are developing in New England as you in the United States States Congress and in the Lyndon Johnson-Secretary Wilbur Cohen Ad- ministration are developing herein Washington. (6) People, alcohol and the indifference of the two hundred million (20,00O,00~) Americans. After uTmost a quarter of a century of satisfied sobriety, I can state emphatically that people are not so much indifferent to problems connected with alcohol as ~re are frustrated. The average Episcopal clergyman spends T5% of hi~ pastoral time (i.e. with peopel in trouble or in distress) with parishioners who have alcohol-related problems! PAGENO="0186" i~o What we need are facilities such as will eventually grow obt of the alcoholic rehabilitation Act of 1968. The responsible Churches of America will evidence our long time continuing interest by giving members of this committee our strong support in your attempts to achieve a new enlightened concept. The North Conway Institute ~s a product of the Ecumenical Movement which is sweeping the religious community It is both inter faith and interdisciplinary The Institute has serving on its Board of Trustees individuals representative of the three major faiths-Protestant, Catholic, Jewish-and the health, education, and welfare professions and volunteer service groups. A wide spectrum of religious opinion from liberal to conservative is represented by the membership of the Board of Trustees. One of the notable achievements of the Institute was the endorsement of a statement by prominent church leaders of metropolitan Boston in 1966. The statement was drafted by the Ecumencial Council on Alcohol Programs and was endorsed by leaders from 16 different churches ranging from Roman Catholic to Salvation Army. The key paragraphs read as follows: We believe that alcoholism and alcohol-related problems are a serious threat to the health, happiness, and welfare of man.y people and to the stability of families and communities. Among other consequences of excessive drinking which call for remedial action are the break-up of family life, the stimulation of crime and juvenile delinquency, the mounting of welfare costs, and the loss to industry through absenteeism and inefficiency. These problems are not new but they are acute and are made more so by an attitude of complacency and irresponsibility on the part of the general public in whose hands the final determination of social policy lies It is urgent that churchmen and others concerned with human needs and the moral foundations of our society endeavor to create a more responsible public attitude toward drinking. We believe that we may all unite on the ground of the virtue of sobriety. This can be practiced in two ways. One Is by total abstinence from beverage alcohol for religious motives. The other is by true moderation In the use of alcohol also for religious motives On this common ground the virtue of sobriety may be practiced both by abstainers as well as by those who drink moderately. Although differences of conscientious convictioh in relation to certain current drinking customs exist among us the area of our agreement with regard to drunkenness and alcoholism is sufficiently, large and significant as to enable us to unite our best efforts foi the ailviation and ultimate solu tion of these alcohol-related problems. As Churches move closer to one another and understanding Increases Congress will find more and more support among their constituents for health measures to help communities help the alcoholic and his family ii R 15758 is a major step in that direction. In conclusion, may I strongly urge you to recommend the passage of a com- prehensive National Program to deal with the health problems of families and communities dealing with `chronic hlcohollsm. The Alcoholic Rehabilitation Act of 1968 represents a real step forward in the beginning of such a program Again I commend the Democratic Administration for proposing this legislation for Congressman Staggers of West Virginia for sponsoring it, and I hope you, Congressman Jarman, will get your sub-committee to approve this bill so the Congress can pass it shortly so our President can sign it into law. Thank you very much, Mr. Chairman, for your gracious courtesy in allowing Inc to testify. Dr. WORKS. I would like to introduce the Reverend Thomas E. Price, director of the department of alcohol problems and drug abuse, the General Board of Christian Social Concerns of the Methodist Church, who is also a member of the board of directors of the North Conway Institute. I will be glad to answer any questions you have. Mr. ROGERS. Thank you very much, Reverend Works, and we are pleased to have you, Dr. Price. PAGENO="0187" 181 STATEMENT OP REV. THOMAS E. PRICE Dr. PEIOE. I am director of the alcohol problems for the Metho- dist Board of Social Concerns. I am here to register the church's con- cern for the kind of programs called for in ER. 15758. Now I of course have the statements of the Methodist Church on alcoholism and the needs. I would read the final paragraph,.the concluding paragraph of my statements which is to say that the Methodist Church, whioh has a long tradition of abstinence, and it is not prepared to surrender its conviction that abstinence is an answer for many problems associated with it, not the least of which is alcoholism, but it is prepared to enter the public realm to encourage, to support, to cooperate with com- munity-wide efforts at the national, State, and local levels to treat and prevent drinking problems through the most effective means available. We consider H.R. 15758 an effective means, because of its provisions to facilitate State and community developments of model programs. (Dr. Price's prepared statement follows:) STATEMENT OF Ray. THOMAS B. PRICE, DIRECTOR, DEPARTMENT OF ALCoHoL PROBLEMS AND Dnua ABUsE, GENERAL BOARD OF CHRISTIAN SOCIAL CONCERNS, TilE METHODIST CHURCH My name is Thomas B. Price and I am testifying in my capacity as Director of the Department of Alcohol Problems and Drug Abuse, the General Board of Christian Social Concerns of The Methodist Church. I am an ordained Metho- dist clergyman with a Ph.D. from Boston University. As administrator of the Methodist Church's national program of alcohol education, and rehabilitation I am here to register the Ohurch's interest and concerti In support of the program called for in HR. 15T58, Title III, "Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968." POLICY StATEMENTS OF TIlE METHODIST OHUROH I call your attention to the position of the Methodist Church on alcoholism and narcotic addiction as stated by the 1964 General Conference, the highest policy making body of the Church: Methodists are called by love not only to abstain but also to seek healing and justice for the neighbor who is victimized. Concern for the alcohOlic and for all those in trouble because of beverage alcohol Is the clear mandate of the Christian faith. Abstinence is not enough. We also urge our people to join with those en- gaged in positive and constructive programs seeking solutions to alcohol problems. These include education in church and school, rehabilitation for alcoholics, strongest attainable legal controls and the stimulation of sound empirical research Christians who love God and their fellowmen can do no less. (Paragraph 1822, 1964 Methodist Disoipl'tne.) Alcoholics are sick persons. They can be helped. The church has a unique role to play in the healing process which must be physical, mental and spirituaL Methodists should take the lead In establishing community agencies for alcoholism education and rehabilitation which are inter-faith and inter- professional in nature. (Miscellaneous Resolution 1964 General Conference.) And on narcotic addition: Society must provide through public and private facilities for the treat- ment, rehabilitation, and after-care of narcotic addicts and other victims of drug abuse. The church should support carefully designed plans to control the traffic in narcotics and to rehabilitate the addict. We urge the reform of existing legal barriers for successful rehabilitation of the drug offender. ]Dxperi- PAGENO="0188" 182 mental pro~rarns of: re billtation must. be expanded iflcluding those involving the administration of controlled amounts of drugs under strict ipedical supeJ~vjsion, Cburcb~s ~henld assist In l~velapi~ig bait-way houses and similar centers to provide a therapeutic and supportive community for addicts. (1964 Methodj~t Disctplhje, `Pulragraphs 1820 and 1822~. The provisions of flit. 15758, Title III, for constructing, staffing, operating, and maintaining new facilities in the treatment of ~t1eob~l and narcotic addicts is a basic step toward providing the kind of compreben~i'v~ care needed, if society is going to take seriously its responsj'j~fl'ity toward those afflicted by alcohol and drug problems. We ate' grateful for the steps already taken by the Congress and Execntive branch of governmen~, and believe that ER. 15758 will make avail- able much of the necessary funding to implement plans already envisioned. THE NEES FOR H.R. 15758 O~vio.usly the Congress was qware of the pressing need for facilities, to prevent and treat alcoholism and narcotic, addiction or this 4~ill wosid neither have been drafted nor would these hearings have been held. Others will document this need with statistics, so just let me underline the urgency of this legislation by citing one image' of the enormity of the problem of alcoholism. According to the report of the Ooopera~ive Commission on the Study of Alcoholism if all the psychiatrists and all the social workers in the United States were `transferred to California, they could give only minimum care of one individual interview per week and one home visit per month to the alcoholics and their families in that one state. (I would remind the committee that, even though narcotic addiction is a dramatic and urgent problem, narcotic addicts are numbered in the thousands while alcoholics are numbered in the millions.) This astounding fact calls for a massive effort on the part of the whele nation to provide compre- hensive care for the sufferers of this disorder of mind, body, and spirit and an equa~Iy massive effort to prevent others from being afflicted. ER. 15758 is a highly commendable beginning because it provide~ for both treatment and prevention and specialized `facilities such as half-way houses. We should not fail to see this legislation within the context of the President's Commission on Civil Disorders, as well as the' Pre~ident's Commission on Law Finforcement and tustice, `because the Commission on Civil t~isorders noted the well known fact of the `high rate of alcoholism and narcotic `addiction in our inner cities. Implementing some of the recommendations of the Commission regarding jobs, education, and housing will get at many of the root causes of these twin illnesses, but in the meantime our urban poor need Services. ER. 15758 is on'e way of dea~ing with the crisis in the nation. THE ROLE OF TIlE CHURcHES The sheer size of the problems of alcoholism `and narcotic addiction has moved the churches to unite in inter-faith efforts to deal with the problems. No `single, denomination or religious tradition has all of the resources of Insight and competence to provide all the answers, but jointly, In cooperative ways that complement one another, the relIgious community can provide a relevant minis- try to the' total community. The National Council of the Churches of Christ said in 1958: The churches share a pastoral concern for alcoholics, problem drinkers and their families... Alcoholics are persons hi need of diagnosis, understanding, guidance and treatment. They are especially in need of pastoral care and the divine love which the church can `bring them. There need `be no condoning of their behavior, but neither should a church permit its antagonism to alcohol to prevent its offering an effective ministry to alcoholics and their families. (The Churches and Alcohol, 1958.) At the same time the churches have been moving together to form a united ministry, they have been joining with forces in the community, professional and volunteet, to support and take .their place on the inter-disciplinary team we know as the care-giving systems of our society-health, law, education, wel- fare, volunteer service groups, and religion. Again 1 cite the 1958 statement of the National Council of Churches: PAGENO="0189" 183 We look to the mewber churches of the National Council to encourage the establishment and maintenance of clinics and other appropriate thera- peutic facilities when competently conducted, for the victims of alcoholism. We urge the churches to give any help possible especially to those organiza- tions which seek to include the resources of the Christian faith hi working toward the cure and rehabilitation of alcoholics. Alcoholism and narcotic addiction does not exhaust the concern of the ~hurehes for alcohol and drug problems in our society. The churches are also aware of problems such as driving mider the influence of alcohol and drugs, yoiltbful drinking and drug taking, effective legal controls of the manufacture, sale and distribution of alcohol and drugs, and the abuse of alcohol and drugs such as stimulants, sedatives, and hallucinogens in every level of our society. The report of the Cooperative Commission on the study of Alcoholism has demonstrated how alcoholism is interlocked with these other alcohOl problems, and I am sure the same thing Is true of narcotic addiction and drug abuse prohlems~ Therefore, the churches are beginning to develop a comprehensive program to deal with all alcohol and drug problems. The provisions of HR. 15758 are vital ingredients in this comprehensive program. The primary role of the church is in prevention, but the remedial task before us of providing comprehensive care services for the great nutxitsrr of alcoholics and narcotic addicts already afflicted is so urgent that passage of HR. 15Th8 Is an imperative priority. RuCOMMENDATWNS We feel that H.R. 15758 could be strengthened by two additions: 1. "Part C-Alcoholism" would be strengthened by adding a section pro- viding for the training of personnel to work with alcoholics and their families just as Section 252, "Part P-Narcotic Addict Rehabilitation" pro- vides for training of workers with narcotic addicts. Training programs for alcoholism workers are needed simply because they are in such short sup~ly and the need for professional and sub-professional workers so great. ELR. 15758 is an excellent vehicle for providing them and I urge the addition of such a section. 2. A premable to "Part C-Alcoholism," such as the one suggested by Mr. Dimas who testified on behalf of the North American Association of Al- coholism Programs, would strengthen H.R. 15758 by explicitly relating alco- holism to existing health and welfare legislation. Alcoholism is already gen- erally covered in these other programs such as the O~11ce of Economic Opportunity, the Veterans Administration, the Department of Housing and Urban Developmei~t, the ~ustice pepartmmat, and the operating agencies or the Department of Health. Educgtion, and Welfare, but p~es&ntly alcoholism seems to be a low priority iteni, l~eeause of the complex nature of alcoholism and the implications of it ~for the woi~k of these other programs, the addition of such a pr~earnble would enpress strong congressional intent that they be i~ioPved in the treatment and prevention of aictiholism. CONCLUSION The Methodist Church Is not prepared tb surrender its. eoflviction that ab- stinence is a desirable practice in view of the confusion and ambivalence sur- rounding alcohol use and the mapy, pi~oblems associated with it,. not the least of which is alcoholism, in this country; but it is `prepared to enter the public realm to encourage, support, and cooperate with community wide efforts at the national, state and local levels to treat and to prevent drinking problems through the most effective means available. H.R. 15758 is considered an effective means because its provisions will facilitate state and community development of model programs such as the one incorporated in HR. 14300 for the DIstrict of Columbia which the House of Representatives has already passed without objection. Mr. ROGERS. Thank you very much, Dr. Price. I am sure the com- mittee is interested in the participation of the churches in the N ation in helping to meet these health problems. It would be an important part of trying to bring about some cure to have the interest of the churches in the Nation join with the medical people to help do some- PAGENO="0190" 184 thing about these very serious problems, and certainly with the fam- ilies affected, here is an area where so much needs to be done in the community and with the church groups which the medical people can necessarily help in. Thank you for being here. Mr. Kyros. Mr. Kn~os. I want to join with you in your remarks, and in wel- coming Reverend Works and Dr. Price here. I can think of no better institution in our society than the church for doing the things before us. In rehabilitation from alcoholism and drugs, I think the church hasn't been active enough in the past, and I appreciate your being here today and being in favor of title III of the bilL Dr. WORKS, I know the hour for adjournment for lunch is at hand, Mr. Chairman; however, 1 would like to. make just one additional statement. About 6 months ago, the North Conway Institute undertook three major studies for the Presbyterian Church, U.S.A., which dealt with the middle-class suburban housewife and alcohol; the Negro ghetto and alcohol; and the "hippie" community and drugs. We found that the problem of drugs-including alcohol, which we regard as a drug-to be almost overwhelming. When we sought possible sources of funds for a national resource center on drugs and a research program which could develop into decent therapeutic and educational facilities, we were told that there were no funds available for either treatment or prevention. Today the Washington Post carries the ~tory on page 1 of the stabbing death of 24-year-old Linda Marshall of Cambridge, Mass., whose mother and father are de~r and beloved personal and family friends. The New York Daily News wonders on page 1 if a drug insaned "hippie" killed Linda Marshall. Some of us wonder if the streets of Cambridge, Mass. are as safe as Saigon, South Vietnam; and we ask you in the US Congress about what can be done for adequate funds to finance alcoholism as well as other drug related pi ogranis From 1956 until January 20, 1961, I served as chairman of a Federal Government commission on alcoholism among the American Indians, the entire Federal budget just a decade ago was about $126,000. Therefore, I do appreciate the increase to the figure proposed in this legislation of $7 million. The time is long past for such tiny and insignificant sums. Sometime in the future, maybe we can do something effective in the area of alcohol education and the prevention of alcoholism as well as drug abuse and drug dependence-especially with LSD, "speed," and other mood-changing chemicals. We have now a seminary student from the Harvard Divinity School working in a small home in the Cambridge-Somerville, Mass., area where runaways from all over New England-including, Mr. Kyros, the state of Maine-are congregating. Most of these youngsters are using illegal drugs, and they need help now. I know you are a man of great conscience about drugs, Mr. Rogers. You also know how effective is the great Florida State program on alcoholism which is located in Avon Park. You know that I would PAGENO="0191" 185 be remiss in my responsibility as a clergyman if I did not remind you of the Episcopal vestryman's prayer, "0 Lord, You keep him humble and we'll keep him poor." The people back home need financial resources. Mr. ROGERS. Thank you. I hope it will be encouraging to you to know this, that this is one approach we are considering now, but Mr. Kyros and I have joined in introducing legislation to do something about the LSD problem, the hallucinogens, the barbiturates, and we are trying to get initiated an effective educational program, and 1 think we are pushing in the right direction here, and I think this is going to come about as the result of the work of this committee. it is going to take time, of course, but I think we are well along our pathway to reaily accomplishing something in constructive pro- grams to meet those problems. Dr. WoBics. May I add for the record here a brandnew drug pam- phlet which the North Conway Institute has just published entitled, "What You Need To Know About Drugs * * * Stimulants, Depres- sants, Hallucinogens, Narcotics, Deliriants, Alcohol." I would like to add this pamphlet as part of my written statement for the record. Mr. ROGERS. The committee would like to have that for its file. (The document referred to has been placed in committee files.) Mr. ROGERS. Thank you so much. (Whereupon, at 12:45 p.m. the committee recessed, to reconvene at 2 p.m. the same day.) A~I'ER RECESS (The committee reconvened at 2 p.m., Hon. Paul G. Rogers presiding.) Mr. ROGERS. The subcommittee will come to order, please. We have some witnesses who have to catch planes. We will `try to get to them in order as rapidly as possible. I believe the one who .has to catch the first plane is `George Dimas, who is president of the North American Association of Alcoholism Programs and executive director of alcohol studies and rehabilitation section, State mental health division, Portland, Oreg. Mr. Dimas, it is a pleasure to have you, and we are delighted to hear from you now. If you want, we will make your statement a part of the record, without objection, following your remarks. If you could give us your comments, this would be helpful. STATEMENT OP GEORGE C. DIMAS, PRESIDENT, NORTH AMERICAN ASSOCIATION OP ALCOBOLISM PROGRAMS; ACCOMPANIED BY GuS HEWLETT, EXECUTIVE SECRETARY; AND BERNARD LARSEN, FORMER MEMBER, BOARD OP DIRECTORS Mr. DIMA5. Because of the limited time, we are going to suggest again that we would like `to submit our entire testimony for the record, and attempt in a short period of time to give you a condensed form of our presentation. We want to thank you for the chance to appear before you today. I have with me Gus Hewlett, to my right, who is executive secretary, and at this time I would like to extend to you `and your committee PAGENO="0192" 186 and your colleagues the services of Mr. Hewlett, who has his offices in Washington, D.C. Mr. ROGERS. Yes; we know Mr. Hewlett, and the good work he does, and we appreciate that offer. Mr. DIMAS. I have Mr. Bernard Larsen from North DakoM, ~ former State legislator from that State, and a former member of our board of directors, and a person well informed on the legislative effort. Mr. ROGERS. It is a pleasure to see you today. Mr. DmrAs. Our association is comprised of 42 or 43 governmental programs. The governmental programs are parts of other govei~- mental health bodies such as mental health division, such as health departments, such as public welfare departments. I emphasize this point to you, because the alcoholism programs do have a wealth of strength to gather from, rather than working autonomously, as ~s~me people might imply at times. We have an additional 72 agencies which are goveriwiental pro- grams involved in treatment and rehabilitation programs related to alcohol problems. The association also is considered the profess~ional orgawzation in the field. By this I mean~ professional people do belong to this association. The North American Association of Alųoholism Programs strongly supports the provisions of title III, part A of H.R. 15758. We com- mend Chairman Staggers for introducing this progressive legislation. We also commend this committee for taking early action on this significant legislation. In prior testimony reference has `been made to the President's Crime Commission reports. Many recommeijdatio~~ in these reports are embodied in the provisions of title III, part A of the bill. I would like to make reference to a February 29 report of a special committee of leading traffic safety experts to the Secretary of Health, Education, and Welfare who recommended `a massive Federal pro- gram to eradicate the disease of ali~oh~olism', Reference h~s also been made in priOr testimony to `the two district court decisions that held that a chronic `offender could not be con- victed for the offense of' public intoxication. Reference `has been made to The pending Supreme Court `decision in the Powell ~. Z1ewa.s case. You gentlemen are aware of~ the amicus briefs that have been pre- pared. There was ~a broad spectrum o~ interested groups supporting this brief, which included the American M~edical Association, the North American Judges Association, and other similar organization. These court decisions certainly represent a humane~ logical advance from the outmoded custom of punishing sick people. We applaud these decisions, but we recognize they present major problems to localities. I believe communities are ready to accept the decisions, but they are not ready to develop health services rather than criminal services for these clientele. We feel strongly that the Federal Government can not and must not assume the total responsibility for providing the necessary facilities and other resources to meet this pressing need. We believe that the PAGENO="0193" 187 States and communities have an essential responsibility in this area. However, the Federal Government does have a clear duty to help other governmental jurisdictions to meet the needs of our society. Enactment, implementation and funding of title III, part A of H.R. 15758 will be a significant step by the Federal Government in fulfilling that duty. Passage of this act will provide much needed impetus for the States to expand their own existing alcoholism care and control programs and to the establishment of new facilities and resources to meet the impending need. This will be in the beginning. At this point I would like to make three suggestions concerning the provisions of H.R. 15758. One relates to emergency care. It is felt by the association that emergency facilities should be specifically desig- nated as one of the types of facilities eligible for Federal assistance in the construction, staffing, maintenance, and operation provisions of title III, part A, of H.R. 15758, with a specific provision authorizing emergency care facilities, the possibility of adequate care for in- toxicated alcoholics will be substantially reduced. Two~ existing health, welfare, and rehabilitation legislation. Com- prehensive Federal assistance to States and communities can also be generated through the whole spectrum of Federal health and welfare programs. Congress has passed much solid legislation relative to th~ activity of various Federal agencies under which alcoholism help is available. Alcohol agencies are receiving almost no consideration by these agencies, and they have a low priority in others. Evidence of this is seen by the fact that a total of only $11.2 million was spent by the Depatrment of Health, Education, and Wel- fare d~iring the current fiscal year despite the fact that the former HEW Secretary has called alcoholism the most neglected health prob- lem facing the Nation today. For the same fiscal year, the amount appropriated to the National Cancer Institute was $183,356,000. Added to this figure were millions of dollars appropriated to the cancer control branch, the Veterans' Administration and the Atomic Energy Commission. There are approximately 1 million people under treatment for cancer. Alcoholism, with approximately 5 million victims, is currently receiving less than 5 percent of the Federal attention which cancer receives. Similar statistics can be given to heart disease, vocational rehabil- itation, and mental retardation. These are all worthwhile endeavors, but aicohoUsm should be accorded far greater recognition tha~n it is currently receiving. We ~vouid therefore strongly urge the Congress to reassert its intent that existent social, health, welfare, and. rehabilitation acts must and should be utilized to aid in programs of alcoholism control, and control where applicable, care and control. The third recommendatiort is regkrding training prQgramS., Train- ing professional personiiel to staff alcoholism treatment ftciliLTies is a crucial need In the field. A very limited number o~ professionally quali- fied personnel are devoting time and energy to the problems of alco- holism. This, coupled with the new acute problems posed by the court decisions makes necessary a large number of workers in the field. 93-453-68-13 PAGENO="0194" 188 The above points, emergency care, existing health, welfare and re- habilitation legislation and training, we respectfully submit, could be in a preamble to title III, part A, of H.R. 15758. On pages 6 and 7 of my formal testimony a recommended preamble is included. The inclusion of such a preamble would, in our judg- ment, greatly strengthen the bill without affecting the amount of funds necessary to be appropriated by Congress. We respectfully urge your consideration to include such a preamble. The last two comments, significant existing Federal efforts: Two significant developments have taken place as a result of the President's Health Message to Congress on March 1, 1966. One of these was the establishment of the National Advisory Com- mission on Alcoholism, the purpose of which is to advise the Secre- tary of Health, Education, and Welfare on appropriate alcoholism related activity of the Department. The second was the establishment of the National Center for the Prevention and Control of Alcoholism within the National Institute of Mental Health. Both of these actions were administratively imple- mented. Our association believes that these important governmental activities should be made statutory by Congress and that the amount of the appropriations and the size of the staff of the National Center should be increased to a level permitting the degree of services and research commensurate with the magnitude of the problem. Although the court decisions have pointed up the need to handle the large numbers of patients found to be alcoholics, it must be pointed out that the chronic alcoholic coming to the attention of the court makes lip a small part of the alcoholic population. Enactment of this legislation will be of great help in the efforts to control the disease. This will stimulate professional people to become involved, and aware- ness of all sectors of society will insure that progress will be made on this most complex problem. (Mr. Dimas' prepared statement follows:) STATEMENT OF GEORGE C. DIMAS, PRESIDENT, NORTH AMERICA~r ASSOCIATION OF ALCOHOLISM PROGRAMS The North American Association of Alcoholism ?rogra~s strongly supports the provisions of Title III, Part A of HR-15758 to be known as the "Alcoholic Rehabilitation Act of 1968." We cOmmend Ohairman Staggers for intl~oducing this progressive legislation so urgently needed to cope with what is now recog- nized to be a major medical-social problem by medical authorities, social Sci- entists, members of the Bar and Bench and law enforcement authorities. We also commend this committee for taking early action on this significant legislation. Alcoholism is a major problem-there being between 5 and 6 million Americans who have the disease. This illness knows no socio~cono1njc or ethnic boundaries. It is a problO~ recognized by Congress to be in need of early federal action. That this recognition and interest is non-partisan is seen t~y the fact that of the 95 membey~ of the 90th Congress who have sponsored alcoholism legislation both political parties a1~e heavily represented, In two messages to Oongress the President gave~ substantial attention to the needs in this field of interest. Further, the 19134 Republican Platform contained a significant state~~ mont concerning the need for the federal governmept to become actively engaged in combating alcoholism. This is a problem above partisan consideration and the~ Administration as well as Congress has clearly demonstrated this fact, which is doep~y appreciated by those in the field. The President's Commission on Law Enforcement and AdministraUon of Justice, and his Commission on Crime in the District of Columbia both found arrests for public drunkenness to be an unnecessary and unwarranted waste. of PAGENO="0195" 189 law enforcement resources. One of every three non-traffic-related arrests for the nation in 1965 was found to be for public intoxication. The arrests for this offense in several urban areas numbered up to one-half of all non-traffic arrests. Specific and similar recommendations were made independently by both Com- missions concerning this problem. Many of these recommendations are em- bodied in the provisions of Title III, Part A of HR-15758. A February 29 report of a special committee of leading traffic safety experts to the Secretary of Health, Education and Welfare recommended . . . "A mas- sive federal program to eradicate `the disease of alcoholism' . . ." In 1961 the National Institute of Mental Health supported a 5-year compre- hensive study in depth of the problems of alcohol in American society. The recently published report of this Commission reflects the vital need to make sweeping changes in the techniques of dealing with these problems. The provi- sions of Title III, Part A, of HR-15758 meet several of these needs at the federal level. The January 22, 1966 ruling of the Fourth TJS. Circuit Court of Appeals in the case of Driver v. Hirnvavt declared it violative of the 8th amendment of the U.S. Constitution to held alcoholics criminally liable for public intoxica- tion. Such long-established practice, held the Court, constitutes "cruel and un- usual punishment." The decision o~ Easter v. District of Columbia, similarly precluded convicting an alcoholic for his public intoxication. Municipal courts in Philadelphia and Atlanta have since made similar rulings. Thus, in five states an several municipalities it is now against the law to punish chronic alcoholics for public drunkenness charges. This ruling is likely to be extended across the land within the next two months when the U.S. Supreme Churt is expected to render a decision in the case of Powel v. Texas, a case similar to the Driver and Easter cases. The high court heard oral arguments in the Powell case on March 7, 1968. Amid Curiae representing a wide spectrum of interests have urged the Supreme Court to hold in the Powell case that a chronic alcoholic may not be punished for his public intoxication. In addition to NAAAP, Amid Curiae that took this position were: American Civil Liberties Union, American Medical Association, Correctional Association of New York, Methodist Board of Chris- tian Social Concerns, North American ~udges Association, North Conway Insti- tute, rrexas Commission on Alcoholism, Washington I).C. Area Council on Alcoholism. In their amicus brief, these organizations supported the recom- mendations of the President's Crime Commissions that public drunkenness statutes should be repealed and replaced with humane and effective public health measures. Thus, these organizations support legislation of the scope and thrust being considered here today. Another organization, the National Council on Alcoholism, filed a separate brief in support of Mr. Powell and that organi- zation also supports Title III, Part A, of HR-15758. These court decisions represents a humane, logical and progressive departure from the outmoded and primitive custom of punishing sick people for displaying symptoms of their illness. While NAAAP applauds these decisions, wO recognize that they present major problems for state and community health, welfare and alcoholism treatment facilities which must trar~sfer responsibility for the chronic homeless alcoholic from the criminal system to a public health, welfare and rehabilitation system. The implications of the expected Supreme Court decis ton can best be seen from a description of what took place in Washington, DC. following the Easter decision. The nation's Capital was, as is the entire country today, totally unpre- pared to handle the many patients found by the courts to be chronic alcoholics. In the first six months following the Easter decision, more than 2,000 chronic alcoholics were referred by the court to the D.C. Health Department. The number today is in excess of 5,000. Chaos resulted because of the completely inadequate resources available in Washington to treat alcoholics. It has now been two years since the Easter decision, during which time a 425-bed inpatient diagnostic and tratment unit has been established, along with a 50-bed detoxification unit (an emergency care facility where patients suffering acute intoxication are cared for on a temporary basis). Further, a Community Mental Health Treatment Center has been established with a 50-bed unit for alcoholics~ A halfway house for alco- holics has recently been established. The D.C. General Hospital and St. Elizabeths Hospital both have bad to expand their services for the treatment of alcoholism. Still, the District Health Department's outpatient treatment center for alcOholics, PAGENO="0196" 1~o which existed many years before the Easter decision, remains inundated with court-referred alcoholic patients. Prior to the Easter decision this facility, though very inadequate to serve the needs of the community, did provide helpful therapy to alcoholics who were not homeless, who still maintained families and jobs and were still productive members of society, but who were, in fact, problem drinkers. Now, these patients have no public facility from which they can receive the kind of help which they so desperately need. They have been displaced by the thousands of cases referred by the courts. The District of Columbia, despite the tremendous increase in the number of beds and facilities available to help the city's alcoholic population, still has inadequate programs and facilities to meet the need. The House of Representatives on December 13, 1961', unanimously passed HR- 14330, a bill Introduced by Congressman G. Elliott Hagan of Georgia, to provide adequate services for the treatment of alcoholics in the District of Columbia to meet the needs resulting from the Easter decision aud to implement the recom- mendations of the President's Commission on Crime. This bill will also serve as model legislation for rates and communities in coping with similar problems throughout the nation. 1~'or indeed, no state or community in the land is yet pre- pared to meet these needs. Of the forty-four state-level programs on alcoholism and the many municipal alocholism programs in the nation, not one state or com- munity is adequately equipped to handle the problems, and not one will be able to establish the very minimal facilities and resources necessary without signficant aid from the federal government. Additional model legislation is being developed by a joint committee of the American Bar Association and the American Medical Association which will also serve as a much-needed instrument In guiding legislators on the needs at the state and community levels. NAAAP feels strongly that the federal government cannot and must not assume the total responsibility for providing the necessary facilities and other resources to meet this pressing need. We believe that the states and communities have an essential responsibility in this area. However, the federal government does have a clear duty to help other governmental jurisdictions to meet the needs of our society. Enactment, implementation and funding of Title III, Part A, of HR-. 15758 will be a significant step by the federal government in fulfilling that duty. Passage of this Act, along with the excellent model legislation Introduced by Mr. Hagan and that being prepared by the AMA and ABA, will provide much needed impetus for the states to expand their own existing alcoholism care and control programs and to the establish of new facilities and resources to meet the impending need. EMERGENCY CARE: SUOGESPIONS CONCERNING PROVIsIoNS OF HR-16758 Because of the major emphasis placed on the need for detoxification services by the Crime Commissions, which was graphically demonstrated in the District of Columbia following the Easter decision, it is felt that such emergency care facilities should be specifically designated as one of the types of facilities eligible for federal assistance in the construction, staffing, maintenance and operation provisions of Title III, Part A, of HR-15758. We, therefore, strongly urge that Congress specify this eligibility within the appropriate section of the Act. We would point out in this regard that the ideal location, for such emergency care facilities would be In existing general medical facilities, such as general hos- pitals and comprehensive health clinics, or at least closely affiliated with them. Without a specific provision authorizing construction of emergency care facili- ties, the possibility of adequate care for' intoxicated alcoholics will be substan- tially reduced. RXISCING IIRALPH, WELFARE AND REHADILITATION LEGISLAuI0N Comprehensive federal assistance to the states and communities can also be generated through the whole spectrum of federal health and welfare programs. These lueluēle the Justice Dpartment, the Veterans' Administration, the Depart~ ment of Housing and Urban Development, the Social Security Administratj~n, the Office of Education, the Office of Economic Opportunity, and the Social Rehabilitation Administration, as well as the Public Health Service and Na- tional Institute of Mental Health. Congress ha~ passed much sound legislation relative to the activity of these agencies under the provisions of which alco- holism programming assistance is ostensibly available. In practice, however, PAGENO="0197" 191 alcoholism related project applications for assistance are receiving almost no consideration by many of these agencies and they enjoy only a very ~ow priority in a majority of the others. Evidence of this Is seen by the fact that a total of only tL.2 million dollars was spent by the Department of Health, jl~ducation and Welfare during the current fiscal year, despite the fact that the former HEW Secretary has called alcoholism the most neglected health problem facing the nation. For the same fiscal year the amount of appropriations to the activity of the National Cancer Institute was $183,356,000. Added to this figure were millions of dollars appropriated to the Cancer Control Branch, PHS, the Veterans' Ad- ministration and the Atomic Energy Commission. There are currently approxi- mately one million citizens under medical care for cancer with an expected addi- tional half million new cases for the coming year. Alcoholism with an estimated 5 million victims-3 times the incidence of cancer-is currently receiving less than five percent of the federal attention which cancer receives. Similar statis- tics can be given for heart disease, vocational rehabilitation and mental retarda- tion. These are all worthwhile endeavors for which more federal activity is Indi- cated. But alcoholism should be accorded far greater recognition than it cur- rently receives. We would, therefore, strongly urge the Congress to reassert In IIR-15758 its intent that existing social, ~heaith, welfare and rehabilitation Acts must and shall be utilized to aid in, programs of alcoholism care and control where applicable. TRAINING PROGRAMS Training of professional personnel to staff alcoholism treatment facilities is a special and crucial need in the field. Because of the historically low governm~fl- tal agency priority for alcoholism projects, only the most highly dedicated and motivated people have been able to withstand the frustrations heaped on the professional worker in this field. Consequently, a very limited number of profes- sionally qualified personnel are now devoting time and energy to the problems of alcoholism. This, coupled with the now acute problems posed by the court deci- sions, makes mandatory the training of large numbers of professional workers in the field. Suggested Preamble: The above points, we respectfully submit, could be covered in a preamble to Title III, Part A, of HR-15758 such as follows: The Congress hereby finds that- (a) Alcoholism is a major health and social problem afflicting a significant proportion of the public, and is not receiving the attention required from federal state and local governments. (b) Alcoholism treatment and control programs should: 1) be communit37~ based whenever possible, 2) provide a comprehensive range of services, in~ cluding emergency treatment under proper medical auspices on a coordi- nated basis in existing and new facilities, and 3) be integrated with and involve the active participation of a wide range of public and non-govern- mental agencies. (o) The handling of chronic alcoholics wIthin the system of criminal jus- tice perpetuates and aggravates the problem. A public health approach per- mits early detection and prevention of alcoholism and effective treatment and rehabilitation, relieves police and other law enforcement agencies of an inappropriate burden that impedes their important work, and better serVes the interests of the public. The Congress further declares that- (a) Major federal action and federal assistance to state, regional and local programs are required 1) to conduct and foster `research relating to the cause, prevention, diagnosis and treatment of alcoholIsm, 2) to develop and demonstrate new mctbods and techniques for the prevention of alcoholism and the treatment and rehabilitation of alcoholics, 3) to improve and coordi- nate services for the prevention of alcoholism and the treatment and rehabili- tation of alcoholics, 4) to support programs for the training of persons to carry out the purpose of this Act, and 5) to p~omote full and equal access to humane care, effective treatment, and eventual rehabilitation for all alco- holics regardless of their circumstances. (b) In addition to the funds provided for under this Act, other federal leg- islation providing for federal or federally~aSSi5ted state i~esearch, preven- tion, treatment or rehabilitation programs in the fields of health and disease PAGENO="0198" 192 must and shall be utilized to help eradicate alcoholism as a major health problem, The indlusion of such a preamble woulc1~ in our judgment, greatly strengthen the bill without affecting the amount of funds necessary to be appropriated by Congress. We respectfully urge your consideration to include such a preamble. SIGNIFICANT EXISTING FEDERAL EFFORTS Two significant developments took place as a result of the President's Health Message to Congress of March 1, 1966. One was the establishment of the National Advisory Committee on Alcoholism, the purpose of which is to advise the Secre- tary of Health, Education, and Welfare on appropriate alcoholism related activ- ity of the Department. The second was the establishment of `the National Center for the Prevention and Control of Alcoholism within the National InStitute of Mental Health. Both of these actions were administratively implemented. NAAAP believes that these important governmental activities should be made statutory by Con- gress and that the amount of appropriations and size of the staff of the National Center for the Prevention and Control of Al~ohol'ism should be substantially increased to a level permitting the degree of services and research commensurate with the magnitude of the problem. CONCLUSION Although the court decisions have pointed up the immediate need to establish adequate facilities and staff to handle large numbers of patients found to he alco- holics, it must be pointed out that the chronic alcoholics repeatedly coining to the attention of the courts make up only a small, though very visible, part of the entire alcoholic population. Enactment of this legislation will be of great help in the nationwide efforts to control this disease and care for its victims. This action will stimulate profes- sional people to become involved, and the resulting awareness and concern from all sectors of society will insure that progress wlll be made on* this most complex problem, Mr. ROGERS. Thank you very much for an excellent statement, Mr. Dimas. Some of your suggestions are well taken and they will be helpful. In your projection of how this problem should be met, do these treatment centers effect a cure? Mr. DIMAS. Are you referring to the detoxification centers1 or the compressive centers, sir? Mr. ROGERS. Either. Mr. DIMAS. We feel the terms altering behavior or controlling be- havior are much better used. If services commensurate to other Services in the community pith people with illnesses and problems, the rate of success in helping people is just as effective. Mr. ROGERS. I was wondering how many times we have to run a man through this-. Mr. DIMAS. In dealing with the, chronic offender, I think we have to take into consideration the term "chronic," as we do have the chronic heart patient, the chronic diabetic and the chronic in many other kinds of illnesses, which means there is going to be some kind of a repetitive factor. I think one of the philosophies of treatment is how you control the problem over a longer period of time. I would say in some cases some of these chronic offenders can be rehabilitated and never return to this chronic kind of problem. I would say other kinds of individuals, the period probably will be prolonged, from 1 week to 6 months to ~ year. PAGENO="0199" 13 Mr. ROGERS. Should we have a provision in the law that if these fa- cilities are used, it must be at the request of the person? Mr. DIMAS. Well, I would say that we do have present laws for in- voluntary basis, or a basis in which the crisis could be created so the person could be referred to the service. We do have our present corn- mitinent laws which allow us now to take a chronic alcoholic and commit him for his own protection. Mr. ROGERS. What I was thinking of was if a person agreed to begin a treatment that he must have, and in that voluntary commitment agreed to the conclusion- Mr. DIMAS. I would say if he does not agree to stay to its conclusion. If he does not, some other measures might be taken. Mr. RoGERs. Would you give us your thinking on how that might be incorporated in what we are trying to do? Mr. DIMAs. I think the St. Louis experience shows that nearly 91 percent of these clients accept the treatment and complete the de- toxification treatment. Mr. ROGERs. I would be interested in seeing how many repeats there are. Mr. DIMA5. I think this afternon or tomorrow you wifl be hearing from Dr. Pittman, who is the founder of the United States first de- toxification center. Mr. ROGERS Dr. Carter? Mr. CARTER. No questions. Mr. ROGERs. Thank you very much. The next witness, Mr. Nathan J. Stark, group vice president for operations, Hallmark Cards, Inc., Kansas City, Mo. STATEMENT OP NAThAN J~. STARK, CRAIRMAIc, MISSOURI REGIONAL MEDICAL PROGRAM Mr. STARK. My operations have nothing to do with medicine. Mr. Roomis. I am not so sure. Don't you give get-well cards or something? Mr. STARK. I have been accused of that. I am pleased to have this opportunity to be at this hearing on regional medical programs. I am, as you note from the title, a non- expert in the health field. A businessman interested in health programs is my category. As I listen to all these experts, many of whom I have heard of, and several of whom I have known, I asked myself the question, "What am I doing here?" But perhaps this is the new look in the nonprofessional's view of the health field. `I think that the need for citizen participation has been rather un- familiar to most ~f those in many parts of the health field, but I believe it is fast becoming consumer oriented. My credentials in the health field are as president of the Kansas City General Hospital and Medical Center, and as chairman of the Missouri regional medical program, and it is to this latter role that I wish to address my remarks. My statement will be restricted to the Missouri program, since this is `the one I am most~ 1~amiliar with, and it may be typical, or may be typical of what other programs' are. PAGENO="0200" 1~4 The final focus of our program is on the cooperative delivery and planning of the best possible health care to patients suffering from heart disease, cancer, stroke, and other related diseases, regardi~ss of economic, educational, or geographical status. The program utilizes maximum local planning and initi~tive With regional emphasis upon coordinaion of efforts and review of the qual- ity of endeavors. Policy is set by a council representative of the public and professional leadership with advice from all groups in the region who have a bona fide interest in the delivery of health care. Because of the stated intent of the program which was to improve care by increasing the effectiveness of present systems, attention in the Missouri program was directed to early detection of disease, method- ology for systems to provide maximum economy and effectiveness, and initially a small number of models of delivery systems, planning for a service to a specific population of people without regard to the exact place in which that service might be rendered, but with empha- sis on delivering the care as close to the patient's home as is consistent with economy and quality. In other words, we are people oriented. Primary emphasis has been placed on the development of supportive services which utilize the newest in scientific technology. This includes a variety of services which can be furnished both to the physician and to the patient quickly and economically at any time anywhere in the region. The present testing of computerized interpretation of EKO's for physicians in rural areas is a precise example. For screening purposes, and for the first time in history, the private practitioner participating in the model system has consultation for heart disease immediately availab}e to him at every hour, 168 hours a week, at an estimated cost of less than $3 per interpretation. Each interpretation can be backed up by a dial-a-phone lecture reference source, recorded on tape and also automatically available at all hours at the cost of a phone call. These backup lectures will develop on a demand basis in accord with experience. A model of delivery systems is found in the Smithvilie project. Here building upon an existing rural system, maximum effort has been placed by the local advisory group and the State university medical school upon a sophisticated consultation and referral program. In Smithville, the system extends into home care utilizing all avail- able ancillary and auxiliary personnel. Faculty members of the uni- versity teach and consult with the local staff. Financial `assistance was given with a specific terminal date, at which time the system of care is projected to be self-supporting. The program provides for careful change of quality of care as a result of intensified suprrt. It is the plan of the Missouri program to establish and te±mi1ii~te final support for all demonstration projects in this manner in order to provide the opportunity for cooperative programs with a maximum of communities in the region Supporting services and later innovations will continue to be made available on a financially self supporting basis to these cooperating communities so long as these are found to be mutually helpful A final facet of the program is the interdisciplinary research group in the university who are studying intensively the delivery system PAGENO="0201" 195 for health in the region, scientific devices which are needed but lack- ing at present, a communication facility which possibly could be adopted for purpose of the program. The research group functions as a medical experiment station draw- ing together the talents of all uthver~ity disciplines which can con- tribute to the definition or solution of health care problems. Of the 21 bioengineerin~ projects now active, I should like to men- tion two. One result of this researdi has been the development of a diagnostic chair, which simplifies the taking of a heart tracing. The chair reduces the tim~ required for an EKG from about 20 minutes to less. Another piece `of equipment developed by the engineers and the physicians working together is an electrolytic unit which has proved extremely helpful in speeding the healing of leg and body ulcers for the diabetics or patients who must be in bed for long periods, and these compact units can be taken home. An added feature is an alarm system which reminds the patient to keep the bandage properly dampened. Future programs could be summarized as the design of more model delivery systems in cooperation with the public and health profes- sional involving finally the entire region, continued concentrated study of appropriate services designed to be self-supporting, the assistance to programs in providing for treatment of disease and rehabilitation of patients suffering from these categori~s of disease, and last, a translation of new ideas into action on behalf of the patient or the potential patient. This is indeed an exciting, though wearing, time to be involved in health affairs. The regional medical program, to my mind, offers one of the best means for achieving optimal health for all people, who are in effect the real beneficiaries of regional medical programs. I would certainly urge the support and the continuation of this program. Now I have here an organization chart of the Missouri regional program which I would like to offer for the record. Mr. ROCERS. The committee would be very pleased to have that, and it will be made a part of the record at this point. (The document referred to follows:) MissouRi RsGIONAI~ M~.TCAL PRoGRAM ORGANIZATION 1. GOAL SETTING (a) Policy is set by representativeS of the public and the practining profession upon advice from: Medical athools. State depa'tments related to health. V~l~ntary orgai1i~atloTiS Alt he~iltb professional organizations (A total of more than ~O people read and comment upon each Proposal) (b) Planning is for a selected popplation of people regardless of where they may ultimately p~ceive their care This permits maximum use of communication mechaikisnis already established between the many involved groups. (c) Planning and operations are kept administratively separate. 2. ORGANIZATIONAL PATTER1N The Project RGvIew Oomwittee eon~ists of the head or his delegate from the schools of osteopathy and medicine the Division of I~ealth Director of Welfare and Director of Mental Diseases. This cOmmittee ser~.res as an advisory body to the Council on all proposals. PAGENO="0202" 196 An Advisors ~oundll, nominated by the Project Review Cothmitt~e and ap- pointed by the Governor, serves as the governing body. The 12 members serve staggered terms, no person's service to exceed six years. Members may not be drawn from University staff. The Liaison Committee is composed of elected or appointed representatives sent by each state-wide voluntary or professional organization which has applied to and been accepted by the Council. The 24 members serve as a reaction panel on all projects for Council. The University of Missouri serves as trustee for funds for the Missouri Regional Program. 8. SPECIAL URBAN ORGANIZATION For the Kansas City area a special Metropolitan Liaison Committee has been formed.' Members include five local citizens and two representatives from each of the Advisory Councils of the two regions (Kansas and Missouri) which overlap in the Kansas City area. This committee also serves in an advisory capacity to the two Regional Councils for all projects which fall within the six county urban area of Kansas City. A special, local planning force has been assigned to Kansas City by the Mis- souri regional program. No matter how a region is described, ultimately it must interact with other regions. Modifications of the Kansas City committee have been developed with three of the other adjoining regional programs and similar plans! are under clis- cussion with a number of other regions which also adjoin Missouri, Mr. STARK. I submit for the record three separate publications of the Academy of General Practice as evidence of cooperative efforts between the practicing physician and the program. Mr. ROGERS. We will receive those for the committee ifie. Thank you very much. Dr. Carter? Mr. CARTER. I just want to compliment this gentleman upon the paper that he has delivered here today, and to say that I think it is a very healthy sign when men of his evident ability take part in such programs as this. Thank you. Mr. ROGERS. I would like to second those sentiments. I think it is excellent, and we do need more and more people to involve themselves in ~he health field other than just the scientific community, and I won- der if you could give us an example-~-you say the design Gf more model delivery systems. What is your thinking there? Mr. STARK. Two that I have specifically in mind: On~ would be the Smithville project located in a rural area abont 15 miles from Kansas Qity where they are designh'ig a program for the first tune to give complete continuity.of care from the time the patient is seen in the diagiiostic stage through the treatment stage and then into the rehabilitation stage. ` ` Another one is that taking place in Springfield, Mo. at the com- munity hospital. A cardiovascular progmm' is in force where they are treating the cardiac patient and also training nurses and ~loctors in the care, treatment, and rehabilitation of cardiac patients. This is a part of the current operational grant and is working out very well. There are six or seven programs in operation, or being proposed how, in community hospitals. Mr. ROGIIRS. Thank you very much. We appreciate your being here today. Our next wjtness who `has a 4 o'clock plane, I believe, is Dr. Amos Bratrude. We appreciate your presence here today. Your Congress- PAGENO="0203" 197 man, Tom Foley, spoke to me on the floor an~d said he wanted to be here to personally introduce you to the committee and regrets he can- not be. He is in committee himself. STATEMENT O~' DR. AMOS BRATRUDE, WASItINGTON 1VtBDTdAL ASSOCIATION, AND ASSOCIATION OP GENERAL PRACTITIONE1~S Dr. BRATRUDE. I was sent here today by the Washington Medical Association, and I have the blessing of the Association of General Practitioners. I am Dr. Amos P. Bratrude and am in general practice in Omak, Wash. I have a common failing with all people who have moved West, and that is our adopted home has become very important to us, and ~o you'll excuse me if I give you a few words about Omak. It is a rather typical western community of about 4,500 people. The prime industries are logging, apple orchards, and cattle. The biggest single event of the year is the Oniak stampede with what we consider, a world-famous suicide race. It is a nice community and my 9 years there have been very pleasurable. I am married and have four children, and as a father am beginning to experience the rigors of a teenage daughter~ I was raised in the Middle West. My father wa~ a general practi- tioner in a small town by the name of Antioch, Ill. Upon deciding where to practice, there were several things I was sure that I wanted. I wanted a community with a hospital in it. I have always been very interested in general practice but could see no reason to choose a com- munity that was large enough to have a well established specialist. group. I wanted to choose a community that I felt had some promise of growth so that I could eventually have the type of medical practice that I was interested in. This; namely, is a group of three, four, or five doctors who are quite interested in the practice of medicine, but also want to be free to pursue academic and recreational activities. I am now the senior man of a four-man group, and the reason that I can be here today is that I have three excellent partners that are cover- ing for me. Those were the practical reasons for choosing Omak. The emotional ones are that the country just immediately appealed to me. I enjoy * hunting and fishing and being outside, and all these things were avail- able. We have been 15 months in a new hospital with 32 beds, and a staff of seven physicians. Of course, four of these are of our group. It * is quite interesting to me to go to various meetings and seminars and hear people discuss the problems of a small hospital. Invariably these people consider anything from 100 to 150 beds to be a small hospital. Consequently, their discussions of problems that might occur there have no bearing at all on what happens in a hospital of 32 beds. I had always been quite interested in the broader problems of medicine, and when the opportunity came to me from the Washington-Alaska reg~ional medical program I welcomed it. I would be the first to admit that I had a rather biased viewpoint when I joined the Washington-Alaska regional medical program hoard. I had been raised of fairly conservative parentage and had a decidedly jaundiced opinion of the role I thought Government was playing in medicine. It is quite surprising to find out at the first advisory coin- PAGENO="0204" 198 rnitthe m~e~ing that most of us had the same feeling. Then it was inter- ~Stthg to see the ehatige iii e~veryone ~s the meeting progressed It seemed that most of us had very de~Ait, but very erroneouc ideas of what the r~gional i~iedical program wouid be and how it would work. It was explained `in the first session in May of 1966 that the regionaf medical program was not going to be a vehicle to transport the patient to "supercenters" but rather was going to be a vehicle to. transport. knowledge, techmque, and assistance to the local level to improve patient care in places such as Omak. I, of course, was very suspicious that this was just the bait to lure us into the' trap. I have now corn~- pleted approximately 20 months on this committee, and I am convinced that at least the Washington-Alaska program has not altered from this ideal; that is, to `attempt' to improve the level of care for victims of heart disease, cancer, and stroke and related diseases into local com- munities. I was also prejudiced in another area as I approached the work on the regional medical program. I am in a very rural commu- nity. I think it is wonderful to have great research projects and a large amount of what we call ivory tower medicine. But I also feel there is a tremendous amount of medicine that has to be practiced on a day to da~ basis to help the people receive proper care I aisohad many preconceived ideas about physician education pro- grams that I felt were fairly worthless. I have taken these prejudices and conveyed them into ideas for our group, and am afraid I have helped to sidetrack certain programs I felt had little practical value. I do want to say that I feel there is a definite place for complicated research projects, and without them many of the advances we enjoy. today would not be here. But I feel, as the only general practitioner on the Advisory Committee, that I have wasted very little time ar- guing for the aspect of medicine because many thout me are. In regard to specific problems that were present in the practice of medicine in north-central Washington these are some. `There are certainly many `other problems which deal with rural areas, and many of these would fall in the categorical areas of the heart, cancer, and stroke program. We are looking forward to' taking advantage of th.e coronary care unit training programs that are cur- rently being established by our RMP and are looking forward to many other benefits from it. I think the point that I would like to make so strongly is that the RMP has offered the first opportunity for local medical communities to feel that it is worthwhile to get in- volved and `interested in because their opinions and problems are being sought. There certainly has been a considerable change in stance of the average physician in regard ~o Government in medicine. Just a few years ago no cooperation would be offered, and if preferable no inter- ference would be tolerated. Today `we find the average physician understanding that the Government will be involved in medicine and that a cooperative venture of sothe kind would `be most desirable. The RMP with its emp~hasis on regionalization has, I believe, caught the fancy of the medical communities of the United States. As I travel to various meetings with colleagues who are scattered across the coun- try, I find that quite often they have thany favorable comments con- cerning the `aims and goals o'f this program. I think that if this' pro- PAGENO="0205" 199 gram were to be significantly curtailed or even dropped, you would find a considerable disillusionment in the medical piofession I think most of us feel there is a strong chance that the RMP is going to offer all of us help and cooperation, not interference, from the Government on our local medical problems. I think that if it were possible to establish a long period, such as 5 years, the RMP could then `do sig- nificant future planning and the medical community would know that the program was here to stay. I have certainly enjoyed the experience of coming to Washington, D.C., and' appearing before this committee. Thank you very much for the opportunity. Mr. ROGERS. Thank you very much, Dr. Bratrude. Your testimony is the type I think the committee needs to hear, from a practicing physician. We are delighted that you took time to present this testi- mony to the committee. Dr. Carter? Mr. CARTER. I certainly want to congratulate the gentleman upon his presentation. He is one of the men who applies the tools which have been given him, and in addition will evaluate and use what other tools are given him by our regional groups. I am impressed by his paper, and the depth of what ~he says. I am happy to have such a young physi~ian before us today. Mr. ROGERS. Let me ask you: You say you are the only general prac- titioner on the Advisory Committee for your region, or is this a subregion? Dr. BRATRtTDE. I am the only one for the Washington-Alaska meet- ing. We have six practicing specialists from various disciplines; in addition, of course, to many physicians in the universities. Mr. ROGERS. But there are six out of 30 whom you would classify as practicing physicians? Dr. BRATRUDE. Seven, counting me. Mr. ROGERS. How many hospital administrators do you have? Dr. BRATRUDE. Two. Mr. ROGERS. Do you think this is a good ratio? Dr. BRATRTLTDE. It is difficult to put everybody there. We have six or seven lay people, we have two nurses, we have a dentist; and by the time you are done, we really aren't heavily laden with the medical school people. Mr. ROGERS. Would it be more of a problem getting away if you were not in partnership? Dr. BRATRTJDE. I would like to speak about this a bit. I think the concept of the practicing physician is changed somewhat. As we are trained today, we are totally convinced that we have to stay current, and I think, as we set ourselves into practice, many of my colleagues in our county are in independent practic~, such as Bill Henry, one of the doctors there. He feels it is important enough, and has educated his patients enough that he gets away for courses. I believe thst group or no group, this is the way it is going to `be in the future. Mr. ROGERS. You don't think it can be brought down to the'hospitai level? Dr. BRATRUDE. I don't mean that. We have hospital stalf'ineetings, and visiting professors who come for seminars, and the gentleman PAGENO="0206" 200 from Missouri, some of his programs sounded outstanding. When you think about help that you need-it is 3 o'clock in the morning and you have a cardiac problem; you don't need a seminar, you need someone to give you Some help. It sounded like this aspect of his program was very exciting. Mr. ROGERS. Thank you so much. We appreciate the benefit of your advice. Our next witness will be Dr. Carl Brumback, who is appearing for the American Public Health Association. Dr. Brumback is from my own home county of Palm Beach County, Fla. He has done an exceptional job, and really some of the pilot proj-. ects with migrant health programs, and I am particularly pleased to have you appear before the committee again, because you were helpful in our previous legislative hearings. You may proceed. STATEMENT OP DR. CARL L. BRUMBACK, MEMBER, EXECUTIVE BOARD, AMERICAN PUBLIC HEALTH ASSOCIATION Dr. BRtTMBACK. Thank you. The American Public Health Association appreciates this oppor~ tunity to present our views of H.R. 15758. I am here as an executive board member of this association, which now has over 20,000 members. I have a prepared statement which has been given to the staff, and I would like to have your permission to summarize these remarks. Mr. RoGERs. Certainly, and your prepared statement will be made part of the record, following your remarks. Dr. BRU1\IBAOK. My comments refer to the migrant health portion of the bill. It is unnecessary, probably, to recall the fact that nearly one-fourth of the Nation's 3,100 counties depend upon migrant labor to harvest the crops. We all depend on this labor for much of our food. Approximately 1 million men, women, and children migrate each year in response to this need. Although these people perform essential work, their annual income, $1,400 average per worker in 1965, seldom allows them to rise above the poverty level. Furthermore, the places in which they work and live are usually far removed from sources of health care, and clinics are usually held at a time when they are working, and they seldom qualify under wel- fare residence requirements for usual forms of assistance. Treatment of illness becomes difficult. Actually, the migrants' need for health care is greater than that of the rest of the population. En- vironmental conditions predispose them to illness and injury. Lack of education and knowledge of where to turn for help compounds these problems. Statistics confirm the fact that migrants have more health problems than the rest of the population. Infant mortality was over 30 per thousand live births in 1964 among the migrants, compared with .less than 25 for the national average. The rate from tuberculosis and other infectious diseases was 26 per thousand, compared with 10 for the Nation as a whole. Through the Migrant Health Act, health services specifically de- signed to meet the migrants' needs have become available in many PAGENO="0207" 201 parts of the Nation. Recent figures indicate 115 projects in 36 States and Pureto. Rico. The number of migrants having access to these services is now estimated to be over 300,000. However, it should be pointed out that this is still less than one-third of the total migrant population. Also those migrants now reached by existing projects receive only `basic or minimal services fo'r' the most part, and these are available to them throughout the year. Migrant progress has been esseutial to make a beginning to give these people resources, but it takes a long time to make up fo'r years of neglect. We are only now beginning to see benefits from our projects in Palm Beach County, which have been underway for 12 years. Services must be made available and acceptable. This is a strong argument for keeping this program separate. The absorption into the general program at this time would destroy the most beneficial settle- ments that have been achieved. The fact that only part of the migrant population is being reached in a minimal way, indicates that the program should be continued and he expanded. Thank you. (Dr. Brumback's prepared statement follows:) CLARENCE L. BiIUMBACK, M.D., M.P.H., MEMBER, ExBcuTIvJs BOARD, AMERICAN PUBLIC HEALTH ASSOCIATION Mr. Chairman, Members of the Committee: The American Public Health Asso. elation appreciates this opportunity to present its views on H.R. 15758, a bill to extend the authority for the Regional Medical Programs, for migrant health services and to initiate a much more active program dealing with the seltere problems of both alcoholism and narcotic addiction. I appear before you as spokesman of the APHA in my capacity as a member of its Executive Board. I shall spare you the details of a description of our Association-~we, and I, have appeared before you sufficiently often in the past to acquaint you with both- except to tell ron that our membership now totals in excess of 20,000. MIGRANT HEALTH The APHA has traditionally expressed a deep concern for the welfare of the nation's migratory workers. Prior to the passage of the Migrant Health Act of 1962, the APHA advocated health services for migrant laborers including: child care; pre-natal assistance; control of communicable diseases through vaccination, and dental health. In the past, the extreme mobility of the nation's migrant work- ers, together with their dire economic need, prevented them from enjoying ade- quate medical attention. Sinée the passage of the Migrant Health Act, important strides have been made in providing essential health facilities for the seasonal agricultural worker. These accomplishments were made possible through joint Federal, State and local funds. During the past five years, migrant health projects have provided remedial care for workers and their dependents, immunization, family planning services, nutrition counseling and the continuing of medical care when workers move from one area to another. Additionally, during this time span, the workers' environment has improved through the joint efforts of employers and local health workers working to' improve housing and sanitation facilities. Migrant workers have slowly `been educated as `to the availability of health services at their disposal. So successful has this instruction been, that today the services of existent projects are deficient in relation to the demand. Despite advances made in this field, current health services fall short of their goals. One principal handicap t'o the migrant health program is the hardship `it places on local participating hospitals, resulting from the payment, on the average, of only 60 percent of total hospital costs. Many communities find it difficult `to make up this deficiency due to the rising costs of hospital care. PAGENO="0208" 202 At present, the number of medical professionals is insufficient to adequately meet ~rowJng medical needs. In Order to cope with health problems of migrant laborers, more physicians and dentists must be employed to narrow the gap between the medical and `dental care received by migrant workees and those services received by the nation as a whole. In additIon to the expahsion of the professional ranks, it is alsQ necessary that more aides be trained as liaisons to serve as a link between the professional health worker and the migrant laborer. These aides would assist the worker in utiliaihg health services created for his benefit. With this goal achieved, the migrant worker would then become more of an economic asset to his country rather than a liability. A healthy labor force will alleviate costly health emergencies, thus reducing ecOnomic drain as a consequence of unnecessary Illness and disability. In order `to illustrate the need for increased funds, I would like to use an example with which I am most familiar-the health program of Palm Beach County, Florida. The migratory health projects in my county have expanded greatly since 1962. At the outset of these projects we were faced with the same problefns plaguing the rest `of the nation in administering to its migrant workers' health needs. These problems were partially solved `by services furnished by Federal, state and local money. These funds provided the means for developing services tailored to the specific needs of the worker. As t'he program progressed, more migrant laborers `became a'ware of the facilities open to them. As a conseqnence of the 1962 Migratory Health Act, significant advances were achieved in enviromnenital health. State. laws `and regulations have established guidelines for migrant housing and sanitation; su'ch programs would not have been possible without the a~sistance of the Migrant Health Act. Migrant workers are finally learning where to turn for assistance in treating their i'llne~ses. Yet we have only `begun to teach them the value of the preventive measures and positive health. Much has been done to a'id the migrant, but `more must be done if his environment is to be raised to acceptable standards. Once accomplished, it will require continual effort to maintain these levels. In the case of Florida, funds for extended bospitaliaation and the `staffing of physicians are completely `inadequate. Consequently, ob't'aiu~1ng adequate treat- ment is often difficult except in the case of extreme emergency. In some instances hospitals and their `physicians have provided medical care withoqi reimburse- ment. Therefore, if local health facilities are to furnish satisfactory medical care for migrants in the future, more funds must `b~ made available through amendments to `the Migrant Health Act. Speaking in behalf of the APEA, I strongly urge that the increase in funds conform at a minimum with the amounts recommended in HR. 12756, introduced by Congressman Paul Rogers of Florida. Only when we meet the overwhelming `task at hand with sufficient resources will `the migrant worker then achieve the same degree of medical aid now available to the general populace. ALCOHOLIsM PROGRAMS The interest and concern of the American Public Health A'ssocia;~ion in the promotion of alcoholism programs is well established: 1. In 1963, the Association adopted a resolution recognizing alcoholism as a major public health problem and urging all State au4 local health departments to initiate programs. 2. The Association ha's prepared a "Guide to the Community Control of Alcoholism" which will be published later this ye'ar. 3. Through it's regional offices, the Association has cqnducteu a series of training programs intended to stimulate local health *`or~ers `to implement tkiei'r skill's in dealing with the rroblems of alcoholism in th~lr communities. 4. The staff of the AssOciation has served in advisory awl consultative capaci- ties to national agencies, voluntary organizatlon~ and state agencies in the development of programs for dealing with alcoholism. 5. The APHA previously ha's testified before Congress concerning alcoholism bills. The need for a major effort to combat alcoholism is apparent. Great numbers of persons are afflicted with the condition. The toll that it takes in terms of broken homes, lost ipan hours, employee inefficiency and physical suffering, is unmeasurable. In addition, the Supreme Court is presently considering the case PAGENO="0209" 203 of Powell vs. Texas which may change our courts' methods of ~lealing with chronic drunkenness offenders. If the Court rules in favor of Powell, It will be ~ield unconstitutional to sentence alcoholics to correctional institutions. The result- lug inicreased need for clinical facilities for treatment of these alcoholics will have to be met by the health care system. The establishment of s~eh centers as proposed in H.R. 15758 will provide a portion of the resources needed for meeting the crucial treatment needs of the alcoholics in this country. However, we respectfully submit that the present bill meets only a small portion of the total requirement. Treatment faciltiies also should be supported in conjunction with other health care units such as general hospitals and health departments. In addition, consideration must be given to the following, if a truly comprehensive public health approach to the problem is to be ~ticcessfuUy initiated: 1. Research in the etiology, treatment, rehabilitation and prevention of alco- holism. Research in the cause, effect and prevention of alcohol problem. Train- ing of appropriate professionals to apply new and existing knowledge in the con- trol of alcoholism and alcohol-related problems. 2. Appropriate measures to direct national attention to alcoholism as an im- portant as an important medical-social problem-measures which will encourage the utilization of existing knowledge such as that concerning the treatment of alco~iolics, and techniques of education of special groups about alcohol and alcoholism. 3. Efforts to insure that consideration of community alcoholism problems be a part of every comprehensive health plan. 4. Full use of the potential resources and services of governmental agencies. 5. Of particular importance in the implementation of Federal programs to deal with alcoholism and alcohol problems is the newly organized National Center for the Prevention and Control of Alcoholism in the National Institute of Mental Health. This Center should be given authority, finances, and respoi~sibilitY for the coordination, implementation and development of comprehensive programs. Unless and until reach of these important progr~im elements are fully imple- mented, efforts to cope with this serious health problem will be proportionately less than adequate. Therefore, although we support these provisions, we also must emphasize that a truly comprehensive program to deal with alcoholism must include a variety of concerted approaches on a multitude of fronts. Again, we appreciate this opportunity to present our views on this important health legislation. We respectfully request your consideration of our recommenda- tion~ Thank you. Mr. ROOERS. Thank you. Dr. Carter? Mr. CARTER. Nd questions. Mr. ROGERS. In the program there in Palm Beach County, could you just give me a brief summary of, for instance, the housing condi- tions in the camps, and what you have been able to do with this through the migrant program? Dr. BRTJMBACK. Yes, sir. We have over 100 camps. We actually have in Palm Beach County more agricultural migrants than in any other county in the Tjnited States. We have over 27,500, according to the last count. These people live in the county, all over the county, in all sorts of housing. Through the Migrant Health Act we have been able for the first time to acquire a staff through which we have actually been able to get into all of these places, inspect them and upgrade the housing. As a result, environmental health situation for the migrants in Palm Beach County is immeasurably better now than it was. However, there is a great deal left to be done, and we have to continually pro- vide supervision and maintenance of this program in order to keep the benefits that we have achieved. Mr. Roonns. What about your mobile unit? Don't you have a unit that can go to the field where the migrants are, with a doctor and nurse and so on? 93-453-68--14 PAGENO="0210" 204 Dr. BRUMBACK. Yes, we do. This clinic was acquired through this program, and we can go out in the fields and provide the services there. In the beginning even though we took the services to them, they were afraid to come and take advantage of them. They had been abused and refused service so long that they didn't know what to expect. Now they will come long distances to reach these services, and there is much more demand than we can see. We estimate that we have pro- vided personal health services to only about 11,000 of our 27,000 migrants. Mr. ROGERS. Does this include the children? Dr. BRUMBACK. Yes. To some degree. Some of these services, of course, do reach other migrants. Mr. ROGERS. I know that you put out a report each year on your particular program, and I would be interested in having a copy of that for the committee. Dr. BRUMBACK. We will send you a copy, Mr. Chairman. (The document requested was not available at time of printing.) Mr. ROGERS. Thank you for coming to lEt us have the benefit of your views on this legislation. There is a call for Members to come to the floor, and so I think with your concurrence, Dr. Carter, we will recess to allow Members to answer the call, and then we will begin again as soon as we can get back from the floor. The committee will stand in recess for 10 minutes. (Brief recess.) Mr. ROGERS. The committee will come to order. Our next witness is going to be introduced by Mr. Staggers, chair- man of our full committee. We are very pleased to have the chairman of our committee with us this afternoon. It is the chairman's bill that we are considering and taking testimony on, so it is a pleasure to have him recognize the gentleman now for introduction. Mr. STAGGERS. Thank you. We are glad to have Dr. Carter here, too. At this time, I would like to present Mr. Louis S. Southworth. Would you come forward, sir, and take the stand. Mr. Southworth is assistant supervisor of the Division of Alcohol- ism of the West Virginia Department of Mental Health, and he is presenting a statement regarding alcoholism on behalf of and for Gov. Hulett C. Smith. I know the Governor wanted to be here. He told me personally he felt this was important and he has appeared before this committee several times, but he selected the next best man to come over and present his views for him, and I guess they were prepared by you, Mr. Southworth. I understand you also have statements by Dr. M. Mitchell-Bateman, the director of the West Virginia Department of Mental Health, and also a statement of Donald Dancy, supervisor of the Division of Alco- holism. We are happy you are here, and we are pleased that West Virginia is taking an interest in these issues, and is going forward in this work. We are trying to complement what the States are doing. We realize it is not only a State problem, but a Federal problem all over the Nation. So we are happy to have you. And tell the Governor we are sorry he couldn't make it. You may proceed. PAGENO="0211" 205 STATEMRNT OP HON. HULETT C. SMITH) GOVERNOR OP THE STATE OP WEST VIRGINIA, PRESENTED BY LOUIS S. SOUTHWORTH, ASSISTANT SUPERVISOR, DIVISION OP ALCOHOLISM, WEST VIE- t+INIA DEPARTMENT OP MENTAL HEALTH Mr. SOUTUWORTU. Thank you, Congressman Staggers, Mr. Chair- man and Dr. Carter. I would like to make a few remarks prior to presenting the Gov- ernor's statement. It is a pleasure, a privilege and an honor to come before you today in support of title III, part A of H.R. .15758, and I appreciate this op- portunity to speak in favor of sound alcoholism legislation such as you are considering today. We support the testimony given by Mr. George IDimas, president of the North American Association of Alcoholism Programs. The in- terest in West Virginia in this kind of program is longstanding. Gov- ernor Hulett Smith of West Virginia and our Secretary of State, the Honorable Robert D. Bailey, Jr., previously submitted statements for the record before the full Committee on. Interstate and Foreign Commerce, at the hearing in September 1965. Their statements re- flect the sentiments of the entire State government of West Virginia in support of this sound legislation. Governor Smith asked me to tell you that he deeply regretted that he could not appear here today in support of this bill. He did, how- ever request that I read to you the following statement voicing his complete approval of this important measure. "As throughout the Nation, alcoholism is a serious public health problem in West Virginia. During the past 4 years, our State has taken positive action. With State moneys and a small Federal grant, we have established the base for a comprehensive alcoholism progrftm. We now have eight alcoholism informa.tion centers and three treat- ment facilities. Even though West Virginia has had national recogni- tion for what it has done, the facilities we now have cannot begin to meet the need for services demanded. Each of the treatment facilities has a long waiting list and our local alcoholism information centers have a caseload far beyond their capacity to provide adequate serv- ices * * * and the caseload continues to mount. "We are one of the States under the jurisdiction of the U.S. Fourth Circuit Court of Appeals. The decision by this court that `we can no longer treat the alcoholic as a criminal * * ~ but as a medical prob- lem,' has resulted in a very noticeable impact on the need and demand for alcoholism services. The current case now before the Supreme Court, Powell v. Texas, will no doubt have a still greater impact and create a still greater demand on our limited resources. This problem of alcoholism that we now face in West Virginia and the Nation is so great that State and local resources cannot cope with the problem. Federal action is essential. Money for staff and facilities is a must, and time is of the essence. "This bill on alcoholism that we are considering here today was in- troduced by our own Congress, Harley 0. Staggers. The State of West Virginia is proud that our Congressman had the courage and foresight to take the leadership for legislation on this most serious public health problem. PAGENO="0212" 206 "As Governor of West Virginia, I personally urge thIs committee tp take favorable action on title III, part A of H.R. 15758, `The Al- coholic Rehabilitation Act of 1968.'" Mr ROOERS Without objection, the statements of Di Mitchell Bateman and Mr. Dancy, referred to earlier by Mr. Staggers, will be made a part of the record at this point. (The statements referred to follow:) STATEMENT OF M. MITCIIELL.BATEMAN, M.D., DIRECTOR, WEST VIRGINIA DEPARTMENT OF MENTAL HEALTH During the past four years, the Department of Mental Health has endeavored to establish the base for a comprehensive alcoholism program as part of our- state mental health plan. As we have progressed, our Division of Alcoholism. has made every attempt pOssible to provide a complete range of services needed.. We have used existing facilities In our state hospitals and local mental health clinics and worked with other ageneies~, trying to meet the ever increasing demand for alcoholism services requested by our citizenry. We are proud of what we have accomplished but, in essence, the work we have done is just the beginning of what must be done in the future. The problem. of alcoholism and the many related problems of the families of the alcoholic must not only be recognized as a joint responsibility of the federal, state and local governments, but must be cooperatively funded if we ever hope to treat alcoholism as a serious medical and public health problem. The Alcoholic Rehabilitation Act of 1968, as introduced by Congressman Staggers, can be the breakthrough for developing comprehensive programs a~d services as an integral part of our Comprehensive Mental Health Centers Act.. Favorable action on this alcoholism bill by the Sub Committee on Public Health and Welfare, can lead to the eventual passage of the bill with adequate federal funding -to make the "Great Breakthrough." I urge favorable committee actioin on this bill. STATEMENT OF DONALD It. DANCY, M.P.H., SUPERvIsoR, DIVISION OF ALCOHOLISM,. WEST VIRGINIA DEPARTMENT OF MENTAL HEALTH The passage of the propesecl "Alcoholic Rehabilitation Act of 1968" is essential. Title HI, Part A of H.R. 15758 can be the beginning of a real federal, state, and local cooperative effort to meet the ever increasing demand for alcoholism fa- cilities and service in West Virginia and the Nation. In West Virginia, a small state of 1.8 million people, we have at least 75,000 persons with alcohol problems, plus three more persons per case (family mem- bers) indirectly involved. This makes a total of 300,000 peraons adversely affected by alcoholism problems. From sample surveys n~iade in urban and rural areas, we found the following: 1. ~etween 102 to 1966, records of on~ urban police department showed 52 pci cent of all arrests were for drunkenness 744 percent of the eases appearing before Justices of the Peace were for Offenses involving drunkenness, and 66.2~ percent of misdemeanors appearing in the county court involved drunkenness. 2. In a current study (not yet complete) the indications are rather conclusive that at least 40 to 50 percent of all arrests in rural areas are for public drunken- ness. Drunkenness arrests plus ether charges that involved drunkenness show a range of 60 to 70 percent of all arrests involve a drunkenness offense. West Virginia State Police arrest records for 1966 show 537 per cent of all misdem~pe~. arrests were for drunkenness Arrests for movm~ violation showed 45 per cent were for drunken driving Of all arrests made by the West Virginia State Highway Patrol, 1263 per cent involved either drunkenness or a drinking driver. A survey of State Mental Hospitals from January 1 through June 80, 1967, showed 35.29 per cent of admisslbns reported that, "excessive use of alcohol was. a major factor eontri~uting to their illness." This 35.29 per cent plus vnluntary admisslons to our alcoholic intensive treatment units (3.4 per cent) makes a total of 38.69 per cent of all admissions to our State Mental Hospitals who have serioun prohlems with excessive use of alcohol. PAGENO="0213" 207 From information and data available on prisoners in our abate institutiOflS, between 75 and 80 per cent of all prisoners are ab~o'holi~ or have a related `alcohol use problem. A survey of alcoholic patients receiving intensive t~eatment in one `of our more advanced alc~h~l1c treatment units shows that 66.4 per cent have responded very favorably to treatment. Of these, 38,8 per cent have refrained from drinkh~g and made improvement in other areas of adjustment to life, and another 27.6 per cent have had less than one 24~hour drinking episode per si~ months `during the last year and improved in `other areas of social `and personal adjUstment. In one study at public drunkenness offenders, `the records of 140 such offenders showed an average of 23.3 arrests per each individual. From 116 of these cases referred to a local alcoholism information center fo'r counse1in~, guidance and treatment, only 21 have reappeared in court over a period of one year. Although the study is not complete, these current findings definitely Indicate that the old system of prosecution is outdated, outmoded and `inadequate, and that proper referral, education, counseling, and treatment `is effective and an econ~ymically sound investment. A recent study by the West Virginia Division of Voeatlcnal Rehabilitation shows the average cost of service for rehabilitating an alcoholic is considerably less than any other disability category. The average `cost per `alcoholic w'as $103. Ooiuparatively, the `next lowest disability category cost was $217 an'd the highest ~category was $876. The problem `of alcoholism In West Virginia is beyond our financial and human resources. We need more facilities for treatment and staff to expand `the treat- ment facilities we have. We need more local alcdbolism information centers and the staff to operate them. In short, we are only providing `a token of what is needed. I respectfully request that the S'ub-Oom'mi'ttee on Public Health and Welfare favorably consider the proposed, "Aic~hoii'c Rehabilitation Act of 1968." Mr. SOUTHWORTH. Mr. Chairman, West Virginia recognizes `the size and extent of the problem and we take pride in the positive steps we have made in creating `a division of alcoholism in the Department of Mental Health and in allocating State moneys `to start our program. We have tried to make `maximum use of our moneys `and other exist- ing resources. We have worked cooperatively and established `inter- agency programs with the West Virginia Association of County Of- ficials, the division of vocational rehabilitation and other related agencies. This has enhanced our progress. Still, without substantial assistance from the Federal Government, we have reached `a point where further progress will `be extremely limited. West Virginia is in desperate need of the kind of Federal assistance proposed by Con- gressman Staggers in the Alcoholic Rehabilitation Act of 1968. Mr. RoGERs. Thank you, Mr. Soutbworth, for being `here `and for presenting these statements. They will be most helpful in the con- sideration of this matter by the subcommittee. While you are still sitting there, I i~ant to recognize the pres6nce of one of oirr distinguished colleagues from West Virginia who `has come into the hearing room, the Honorable Ken Hechler. I~ you have anything to `say, Mr. Hechler, the committee would be glad to `hear you. STATEMENT O~ lION. KEN IIEOBLER, A REPRESENTATIVE IN CONGRESS PROM TIlE STATE OP WEST ViRGI1~lIA Mr. HEcuu~. Thank you. I would like to echo the `statement on the need for this legislation in the `State of West Virginia that Congressman St'agger~ `is spoti- soring. The statistics that have been presented to the committee, I think, show conclusively the need for thi's legislation. The fact that over PAGENO="0214" 208 one-third of the Occupants, inma~tes, of our mental institutions are affected by alcoh6lism prOblems I think is a point which the committee should consider, The fact, also, that such a large percentage of the inmates of our prison institutions in the State of West Virginia are affected with problems associated with alcoholism I think is also some- thing that should be considered by this committee in favorably report- ing this legislation, which I think is necessary for the. Nation. Mr. Roonus. Thank you very much for being here and giving us the benefit of your statement. Mr. }JEcHn~u. Thank you. Mr. RoG1~RS. Our next witness is Dr. Cha1mbers, Medical Associa- tion of Georgia, Atlanta, Ga. It i~ a pleasure to have you here, and we know of you through your good friend, Congressman Jack Flint of Georgia. Dr. OIXAMB~R5. I would like to submit a copy of this journal for t]~ie record. Mr. ROGERS. Without objection, we will accept the journal for the files. (The publication referred to, "Journal of the Medical Association of Georgia," April 1967, was placed in the committee files.) Mr. RoGEUS. You may proceed, Dr. Chambers. STATEMENT OP DR. L W, C~AMBfl$, REPItESENTING TItE MEDICAL ASSOCIATION OP GEORGIA Dr. CHAMBERS. Mr. Chairman and members of the committee, I am in private practice of medicine in La Grange, Ga., associated with a fee for service group practice. La Grange, Ga., is a small city of 25,000 population in a county of 50,000 population. There is one hospital in our community; it has approximately 220 beds and is an accredited hospital. I appreciate the courtesy of this committee in hearing a voice from the "grassroots support" of II.R. 15758. it is my belief that the health professionals in our regiOn consider the original legislation, Public Law 89-239, as important as any that has been passed by the Congress in many years, and we feel that it deser~res continued support. Our interest In this program, however, began befOre Public Law 89-239 was passed. This wars evidenced by discussion among repre- sentatives of the Medical Association of Georgia, Emory University School of Medinine. i~ Atlanta, the ~Medioal COllege of Georgia in Augusta, the Georgia Heart Association, and the Georgia. Division of the American Cancer Society. These discussions were expanded during 1966 to include the representation from the Georgia Hospital Asso- ciation, Georgia Department of Public health, Georgia Medical Asso- ciation, Georgia Dental Association, Georgia Pharmaceutical Associa- tion, Georgia Division of Vocational R~habilitation, Georgia State Nurses Association, Georgia State League for Nursing, Georgia De- partment of Family and Children Services, Community Council of Atlanta Area, Inc., and~ the Planning Council of Metropolitan Savaniiaia. S In addition, the Georgia Nursing Home Association and knowledge- able and interested laymen were included. From such discussions, PAGENO="0215" 2® involving these diverse groups, a plan was developed for the~organiza- tion of a regional advisory group composed of approximately 125 knowledgeable and iiiterested persons broadly representative of our region. Evidence of the interest of the physicians of Georgia i~n the regional medical program has been shown by the fact that the entire April 1967 issue of the journal of the Medical Association of Georgia was devoted to the Georgia regional medical program. This is the journal I asked to be put in the record. Although the program had only officially begun on January 1, 1967, the responsibility for leadership by physicians was already keenly felt. In fact, the Medical Assiociation of Georgia was unanimously aleoted by the regional advisory group to serve as applicant~ for the Georgia region. May I quote briefly from an editorial entitled "A Unique Oppor- tunIty for Leadership," which appeared in the April journal. The regional medical program for Georgia provides the membershiP of the Medical Association of Georgia a unique opportunity for leadership in "pro- inoting the science and art of medicine and the betterment of the public health." However, the role of leadership can only be effectively assumed as physicians understand the program. The legislation which established this program was the result of the report of the President's Commission on Heart Disease, Cancer, and Stroke, commonly called the DeBakey report. However, Congress gave thoughtful consideration to mans' medical leaders and organizations before passing Public Law 89-239 in October 1965. As a result, this law provides for local medical programs which can and will be developed by people in the areas involved for the people in the areas to be served. This is inherent in the legislation through the lan- guage of "cooperative arrangements," and "without interfering with the pat- terns, or the methods of financing, of patient care of professional practices, or administration of hospitals." The regional medical program for Georgia has been planned carefully by Georgia people in a truly cooperative atmosphere during the past 15 months. This can best be judged by the membership of the program's Georgia advisory group. The program is practical .and will provide the tools for every practitioner to improve not. only his own medical capabilities but also to improve the quality of medical care provided for each and every one of hi~ patients~ This is a challenge for each member of the Medical Association of Georgia and may well be our greatest opportunity in ottr time for exhibiting responsible leadershiP. Another factor which we feel recommends the extension of the regional ~nedical `program is'.the already demonstrated marked im- provement in conimunleation and dialog, not' only' t~mong teachers, ~nedioal schools, ~nd practitioners, but also among all of the l-ieaith professions in the region. In short, we h~r~e begun what we believe to be successful treatment of the "tOwn gown" syndrome in our region. The long-range effect of this will be improved care of patients. The original program plan for the Georgia region takes into account that new knowledge from the medical centers must flow to every area of the region and equally important, the knowledge and needs of the practitioner and others in the small towns must flow to the medical centers. Still another recommendation for the extension of this program, we believe, has been the demonstrated mechanism for developing a. pro- gram of public education to stimulate lay people to want and to seek good medical care. There are many economically disadvantaged people PAGENO="0216" 210 whom we hope to educate to want adequate medical care, but there may be just as many medically deprived people totally unrelated to economic circumstances. Included in this group ~re many of cur most talented and capable citizens who simply do not seek medical care that could be classified as adequate. Finally, Mr. Chairman, we believe that the key to the success of tii~ regional medical program in Georgia is the involvement of community hospitals. This, no doubt, is true in every region in the country to, a greater or lesser extent. Very early in the development of plans for the Georgia program, the regional advisory group recognized that the vast ma~ority of physicians, nurses and others involved in `the regional pro- gram relate themselves to one or more hospitals. Therefore, each hospi- tal in the region has a vital role in the program and in the future of medicine This includes the large hospital, the small hospital, and the hospital in the. medical center, and the hospital remote to the medical center. At the present time there `are about 19,~00 hospital beds in Georgia distributed among 178 general and limited services hospitals of all sizes. Over 3,000 physicians serve on the staffs of these ho~pitals. To emphasize the role of hospitals in the program, it is planned that each hospital will become a central focal point through which the `objectives of the regional medical program will be carried out. Every hospital will become a teaching hospital This does not imply that medical students and house staff need to be present; but, it does imply that physicians, nurses, dentists, pharmacists, administrators, members of the public, and all of the allied health professionals shall organize themselves into an educational program. Each hospital has been asked to submit the names of `a group of persons to serve as a local advisory group to the regional medical program. It was suggested that a physi- cian (as chairman), a hospital administrator, a iiurse, and a member of the public be the minimum number to comprise each designated group. This local advisory group may be as large as the local hospital or community desires, but it must be named by and through acceptable administrative mechanisms. These groups of local hospital representatives are functioning well Of Georgia's 178 hospitals, 121 have appointed local advisory groups This represents approximately 90 percent of the general hospital beds in the region It is pertinent to this presentation that the chairman of the local advisory groups met in Atlanta on Sunday, 1\larch 24, 1968, for a day of planning and discussion According to the registration, 87 hospital representatives were present Similar meetings, as approved in the program plans for Georgia region, will be held at least twice during each calendar year. This method of affiliating local direction at the grassroots with the overall program of health planning is, in our opinion, a sound and effective approach. Although health planning has been going on `in our region for many years, this is the first time that representatives from all interested groups have deliberated together in an attempt to coordinate their health care planning into a unified plan for progress. Both interest and participation of the practicing physicians,. local hospitals, and medical schools have been excellent. Close communication with other agencies, organizations, institutions, and Government programs is PAGENO="0217" 211 assuring complete coordination of all activities in the area of health in the Georgia region, and the purposes of Public Law 89-239 are being achieved. Thank you again, Mr. Ohairman, for this opportunity. Mr. RoGERS. Thank you for an excellent statement. I notice that you say 87 hospital representatives were present at your last meeting out of what? Some 178? Dr. CHAMBERS. Potentially 178. Of that number 121 have already set up the local advisory groups. The ones who have not are primarily the extremely small hospitals, Mr. Chairman, maybe as few as 15 to 20 beds. Mr. RoGERS. But you feel the major hospitals in the State have? Dr. CHAMBERS. We have 90 percent of the beds covered. Mr. RoGERs. Even though they don't attend the meeting, they have signed up for this? Dr. CHAMBERS~ Yes. These same' ones ate not the ones who were at previous meetings, necessarily, but this percentage is a pretty good attendance, for a region our size. Mr. ROGERS. I~ the region too large? Dr. CHAi~c~a~s. No, we do not think so. We are beginning to get sub- regionalization now. This is what we hope to accomplish. Mr. Rowr~s. How long have you actually had the region formed? Dr. CHAMBERS. Our program, Mr. Chairman, actually began Jan- uary 1, 1967, so we are only about 15 months old. Mr. ROGERS. You present a very encouraging picture. Dr. CHAMBERS. We feel we have accomplished a lot in 15 months, sir. If the committee would be interested, sir, I would be glad to leave a copy of the operating rifles and regulations of our programs. Mr. RoGERs. I would like very much to have that for the committee files. Thank you very much, Dr. Chambers. Our next witness will be Thomas Carpenter, president of the Na- tional Council of Alcoholism, Inc., New York. STATEMENT 013' THOMAS P. CARPENTER, PRESIDENT, NATIONAL COUNCIL ON ALCOHOLISM, INC.; ACCOMPANIED BY WILLIAM MOORE, EXECUTIVE D'IEECTO'R Mr. `CARPENTEE. I have with me Mr. William Moore. He comes to us after a distinguished executive career with the Heart Association. I know the previous testimony has covered many aspects of the problem. We have a brief statement identifying ourselves and our particular interests. Mr. ROGERS. You may proceed. Mr. CARPENTER. The National Council on Alcoholism is the volun- tary health agency concerned with alcoholism. It has 82 affiliates serv- ing the major cities, plus 11 group members in smaller communities throughout the United States. Each affiliate has a volunteer board of directors and a citizen constituency. These boards, like the national board of directors, are representatives of the legal, medical, educa- tional, civic, religious, business, and industrial iuterests ~vhich are coi teemed with the disease of aleoholi~rn. PAGENO="0218" 212 The National Council on Alcoholism directly speaks for nearly 11,000 U.S. citizens who are involved in its programs and vitally con- cerned about the prevention and control of alcoholism. The council represents a unique citizen response to this problem, and has been leading the attack against this disease foz~ ~3 years. This national voluntary health organization, concerned as it is with the third largest public health problem of modern times, also se~ks to change community attitudes toward alcoholism and the alcoholic. Long regarded as a personal and moral problem, alcoholism has only in recent times been recognized as a major medical and social problem affecting a broad spectrum of health, welfare and social areas of con- cern. The National Council on AIcoholi~m, through its programs of pub- lic and professional education, attempts to bring a message of hope and help to the community regarding alcoholism. The basic points of this message are: alcoholism is a disease; it can be treated ~uecess- fully; it is a public health problem and a public responsibility. The affiliates of the National Council on Alcoholism have ongoing programs of public education which are reaching increasing numbers of citizens where they live. Affiliates also sponsor professional seminars for physicians, nurses, social workers, and other professional persons to enable them to deal more effectively with alcoholics whom they see in the course of their regular work. These activities comprise the por- tion of the National Council on Alcoholism's program which is in~ tended to transform public and professional attitudes toward alco- holism, thus making it easier for the alcoholic to seek and accept treatment. In addition, each affiliate of the National Council on Alcoholism maintains an alcoholism information center which serves as neutral ground for alcoholics and their families to obtain information concern- ing alcoholism, and which makes referral to treatment resources and facilities. Because our local voluntary councils on alcoholism have of necessity, in some places, had to fill the vacuum created by a lack of community facilities for the treatment and rehabilitation of alcoholics, we are particularly concerned that this legislation be approved by the Congress. The establishment of specialized facilities for alcoholics as provided in title III, part A, H.R. 15758 is a major contribution toward creation of a comprehensive community attack on the problem of alcoholism. As president of the National Council on Alcoholism, I commend the members of this subcommittee and the leaders of the House of Repre- sentatives for their concern for the health and social welfare of their constituents who suffer from, and are threatened by, alcoholism. I am happy to testify in favor of title III, part A, H.R. 15758, which, if passed, will insure that specialized facilities for alcoholics will be in- cluded in the Community Mental Health Centers Act. By this wise and humane gesture, facilities will be provided which will help advance the control of alcoholism in the United States of America. I pledge to you anything that the National Council on Alcoholism can do in the way of support or the furnishing of any additional in- formation which may be helpful to you. Thank you very much. PAGENO="0219" 213 Mr. ROGERS. Thank you, Mr. Carpenter and Mr. Moore, for being Ihere. I think it would be helpful to the committee if you could give us the number of alcoholics, the number which you have made studies of in major cities, or by State, and those areas where the problem Gf the homeless alcoholic is greatest, and any facts like that. Also, I would like to have soitie mernorahditm from your organiZa-~ tion as to how they feel these emergency rooms or facilities would operate, how the domiciliary care would work as proposed in the bill, If you have any experience that we could go on, I think it would be helpful, because I think the committee is going to want to know more facts about this, rather than to get into the beginning of a large building program. Can't this be integrated within the community health center, in this program we have already done, as an adjunct there? Must it be separate and apart, or how much is it supposed to be tied together? If you could let us have your thinking on this for the record, we would appreciate it. Mr. CARPE~NTER. I will, be happy to supply that information. (The following supplemental statement was subsequently submitted by Mr. Carpenter:) SUPPLEMENTAL STATEMENT OF THE NATIONAL COUNCIL ON ALCOHOLISM, INC. ALCOHOLISM STATISTICS Statistics on the incidence of alcoholism are necessarily rough estimates, based on inferences derived largely from the prevalence of cirrhosis of the liver in communities. Obviously, it is not possible to use routine questionnaires and sampling techniques in deteri~ining the number of alcoholics in a given state. It has been noted that denial of the condition of alcoholism is a symptom of the disease. Because of the effects of social stigma, those who have alcoholism are not likely to state that they do. Efron and Keller have published a state-by-state breakdown' for 1960 of the number of male and female alcoholics, the rates of alcoholism and the rank order of the ~tates by rate. It should be noted that these figures are unquestlon- ably a conservative estimate. For eXample, the California Department of Public Health in March 1905 estimated 850,000 alcoholics in the State of California, while Efron and Keller estimate a total of 023,400. Similarly, Colorado's State Department of Health in October 1907 declared that there were 275,000 alcoholics in the state; Efron and Keller estimated there were 42,500. Other states have also estimated that they have many more alcoholics than the Efron and Keller study would indicate. Hence it may be said that the statistical analysis presented here probably represents the least number of alcoholics, rather than `the opposite. The viewpoint of the National Council on Alcoholism is that regardless of whether estimates ~f the number of alcoholics in the United States are 5 million or 8 million, the basic fact Is that alcoholism is a health and social problem of immense magnitude. When it is considered that every active alcoholic affects at least four other persons, the significance of the problem Is apparent. One of the principal objectives of the National Council on Alcoholism is to make coni- munity leaders and the general public aware of the very large number of Amer- icans whose lives are blighted by alcoholiSm. The statistical data follows as Appendix A. DETOXIFICATION CENTEIIS AND HALF-WAY HOUSES A detoxification center Is generally understood to be a short-term treatment facility for the acute symptoms of withdrawal from alc~bolism, i.e., delirium tremens, alcoholic convulsions, etc. The usual duration of emergency treatment is approximately 5 days, although some have reported adequate detoxification in 72 hours. PAGENO="0220" 214 Essentially, detoxification centers provide withdrawal ~from alcoholism under medical supervision and with minimum risk of death to the patient during the withdrawal period. They are designed to replace the hit or miss searching by concerned friends and relatives for a health facility which will accept alcoholics or the potentially dangerous "drunk tank" in jails, which ma3r or may not proS- vide any medical supervision, and invariably baa minimal facilities for treat- ment of the physical symptoms of alcoholic withdrawal. Although a few detoxifi- cation centers in the United States and abroad have reported some effort at beginning rehabilitatioti of patients, their prime function is not long-term treat- ment of alcoholism. They are a way of returning the patient to a physical condi- tion which allows him to be free from the dangers of withdrawal from acute alcoholism. Half-way houses, on the other hand, are temporary residential facilities which provide a "substitute family for the person in the course of his treatment. . ." This ". . . transitional facility provides a peer group experience for the mdi- vidual to learn how to live without the help of chemical crutches." See Ap~ pendix B for description of a model half-way house. After a detoxifi~ation period, some patients with alcoholism find they are unable to benefit from treatment unless their environment is conducive to it. Since they may have failed to develop a ae~se of community orientation, or through their alcoholism may have lost this sense, they need the reassurance of an orderly existence among congenial persons who have the same problems. A half-way house can serve as a bridge between the disorienttaion of late- stage alcoholism, and the ability to lead a normal life characteristic of the majority of Americans. A half-way house is not usually thought Of as a custo~ dial institution. Its residents are encouraged to find work aS soon as they are able to do so, and they henceforth pay for their room and board. The goal of the half-way house is to enable its residents to take their place in the community as self-respecting and self-supporting individuals, free of their disease. Half-way houses are heartily endorsed by the National Council on Alcoholism as a means of providing help to homeless alcoholics. It should be pointed out, however, that the homeleSs alcoholic represents no more than 10% of the total number of alcoholics in the United States. Hence the provision of half-way houses,. while eminently desirable, does not in any sense deal with the entire population affected by alcoholism. Detoxification centers also are endorsed without qualification by the National Council on AlcoholismS These faeilities would provide emergency treatment for alcoholics in the acute stages of withdrawal from alcoholism regardless of eco- nomic status. They will do much to close the gap which e~tiSts between emer- gency facilities available to alcoholics and the number of alcoholics requiring such facilities. We would find it highly desirable for the legislation to specifically mention the construction, maintenance, staffing and operation of detoxification facilities under the provision of HR 15758 Title III, Part A. ALCOHOLISM AND COMiflTNIP'T MENT~&L HEALTH CENTERS The U.S. Department of Health, Education and Welfare, National Institute of Mental Health, has publi~hed an excellent pamphlet entitled "The Community Mental Health Centel~ and Aivoholism Prog~ams." It is felt that this pamphlet is so concise and well ~re~erted that an appropr~ate quotation will be adequate to cover this question of the Committee. There f~ilnw~ a section of the pamphlet which sketches the various wgys that alcoholism pro~rains may be meshed into the eommunjtyme~tal health centers,: "Complete `integration' of cslpoh~.li~m services with other activities of the mental health center. Under such an arrangement all services of the center are open to problem drinkers with no special arrangement~ made for their care. This presupposes that staff are adequately trained and well motivated to work effectively with these patients. "$pecial alcoholism services or `units' within the mental health center. Under this arrangement services for persons with drinking problems are physically located within the center's facilities and the alcoholism staff is administratively responsible to the dirnet&r of the éenter. "$pecial alcoholism services or `units' as an administrative part of the mestat health center program but not physically located in the center's facilities. Under this plan, overall program direction is the responsibility of the center's director, PAGENO="0221" 215 "Special alcoholism programs not administratively part of the center bnt closely coordinated with it. In communities where adequately staffed alcoholism services already exist, formal administrative integration with the center may be neither possible nor desirable. However, such alcoholism services should work collaboratively with the mental health program to assure continuity of care and appropriate referral and consultation. "Specialiced treatment personnel in the community mental health center, but no separate alcoohlism `units.' Staff with particular interest and training can be designated as `alcoholism specialists,' available to work with problem drink- ers, as well as other patients. They can also serve as the center's alcoholism consultants. "Special personnel to function primarily in stonolinical roles, but no alcoholism `units.' This type of personnel engages in little or no treatment but works pri- marily to ensure that problem drinkers receive appropriate attention in all the activities of the community mental health center. In this capacity they function not only as consultants and as liaison persons with other community agencies, but also as a kind of `conscience' for both the mental health center and the total community in relation to aléobol problems. They act principally as `cata- lysts' and `change agents' rather than as therapists." This presentation appears to cover all possible methods of jncluding alcoholism in the community mental health center complex. The position of the National Council on Alcoholism regarding the community mental health centers has been enunciated in an address delivemd by Thomas P. Carpenter, President of the National Council on Alcoholism, in New Orleans, Louisiana February 9. The following quotation from this statement indicates the thinking of NCA in this regard: assuming that community mental health centers all over the country be- come operative with a full range of services as outlined above-both the required and the suggested services-and assuming that alcoholism is included in the services (as I fervently hope) there still remains a critical gap with respect to alcoholism. This gap is the function that the Alcoholism Information Center was invented to perform. "Dr. Fritz Kant in his treatise oii "The Treatment of the Alcoholic" stated It this way: `Discussions of treatment always assume that the patient Is under the care of the therapist. To get him there is often the greatest difficulty.' "He goes on to note that public education has made some Impact and: `More awareness and better recognition of the impending danger of alcoholism has on the whole improved the situation by bringing the patients for treatment earlier than would have been the case 10 years ago.' "This, however, is only part of the problem. It is not just the `increased aware- ness and better recognition of the impending danger of alcoholism' that removes the blocks to effective treatment and prevention. Availability for treatment im- plies more than the mere getting together of the patient and the therapist, as I am sure Dr. Kant would agree. The major block to effective treatment of the alcoholic and to the establishment of effective programs for such treatment, wohld seem to lie more in misconceptions of the nature of the problem and therefore what kind of measures are Indicated. .. ." "I think it its apparent that the community mental health center as con- ceived is in this respect lacking for effective service to alcoholics. I have little 41oubt but that the prospectuses of many, if not most, community mental health centers will include `services for alcoholics.' Likewise, I predict, that they will be programmed on the assumption that the patient is already there under the care of the therapist, is there by his Owt ~holce and has faith in the therapy offered. "Obviously, the thing that throws most people off In their thinking and planning about alcoholics is that these are entirely warranted assumptions in the case of most illnesses. Most sick people lr~ our society `know' that their problem Is Illness and they `know' what kind of help Is effective and where and how to find it. Moreover, they approach the helping source-person or institution-with faith and willingness to cooperate. "People are not born with this knowledge or these attitudes; they are taught- very carefully taught-by the society in which they live. In fact, in his respect, we might say that the alcoholic is a very good citizen-he believes implicitly about himself, the same things that his society bel1eves~ ~iifbiFtunateiy these beliefs prevent him from av~tlling himself of whatever effective help thei~e is PAGENO="0222" 216 and ho is even accepting of the barbarous methods o~ his society for handling his behavior. "}~emedyirig this situation is the function that is missing in the mental health center outline and it is the function to which the Alcoholism Ini~ormation Center addresses itself. Thus the Alcoholism Information Center fits into the general plan as a necessary adjunct at least until such time as the community changes and undertakes this therapeutic function as it does in other illnesses-which I presume will be some time from now" [APPENDIX A] ESTIMATES OF ALCOHOLICS WITH AND WITHOUT COMPLiCATIONS, UNITED STATES, BY STATES, 1960, AND RATES PER 100000 ADULT POPULATION (AGED 20 YEARS AND OVER) 1 Number of alcoholics Rates of alcoholism Rank order(by rate> Alabama 32,700 1,800 48 Arizona 22,500 3,000 29 Arkansas 29,700 2,863 32 California 623,400 6,388 2 Colorado 42,500 4,088 16 Connecticut 76,300 4,838 Delaware 10, 700 3,963 18 Florida 108,900 3, 538 23 Georgia 55,300 2,513 39 Idaho 7,200 1,900 47 Illinois 315,300 5050 6 Indiana 106,800 3,850 28 Iowa 45,700 2,763 35 Kansas 32,000 2,413 48 Kentucky 57, 100 3, 238 26 Louisiana 70,100 3,925 19 Maine - 24,200 4,175 14~ Maryland 73, 800 4, 000 17 Massachusetts 184,800 5,713 4 Michigan 200, 100 4,350 11 Minnesota 66,500 3,313 25 Mississippi 26, 700 2,288 41 Missouri 143,100 5,038 7 Montana 14,300 3,663 21 Nebraska ~. 25,600 2,988 30 Nevada 11,700 6,638 1 New Hampshire 13, 200 3, 563 22 New Jersey 184,900 4,838 10 New Mexico . 15, 800 3, 050 28 New Yark 583, 100 5, 463 5, North Carolina 51,600 2,013 45 North Dakota 12,500 3,463 24 Ohio . 247,600 .4,263 13 Qklahoma.., 29,600 2,088 44 Oregon 27,400 2,538 37 Pennsylvania 302,100 4,325 12 Rhode Island~~ 31,600 5,913 3 South Carolina 34, 000 2,700 36 South Dakota 10,100 2,525 38 Tennessee 59,800 2,900 31 Texas.. 153,200 2,763 34 Utah - - - . 9, 500 1, 988 46 Vermont.... 9,400 4,138 15 Virginia 44, 600 2, 275 42 Washington. 49,000 2,788 . 33 West Virginia 3~, 200 3, 100 27 Wisconsin 117,800 4,988 8 Wyoming . 4,400 2,263 43 District of Columbia 27, 000 5, 300 I Selected statistical tables on the consumption of alcohol, 1850-1962, and on alcoholism from 1930-4960. Prepared by Vera Efron and Mark Keller. Published by Rutgers Center of Alcohol Studies, New Brunswick, NJ~ Note~ These estimates are derived by theoriginal Jellinek formula;the rates (on which the number~s are based) are those of the year 1945, with R~=5, applied to 1960 populations. The formula may be less reliable in units with smaller populations. These estimates should beconsidered asvery rough approximations. Numbers are rounded to nearest hundred.. [APPENDIX B] "Mobici)' IJALr-WA~ HOUSE The surireryed half-way houses give the impression that there' is a good deal of varie~t3~ in the operations Of these houses. Nonetheless, even with these differ- ences in approach, all of the half-way houses have had some success. We would PAGENO="0223" 217 like to select the best features from this survey to fabricate a composite picture of what, to the writers, would be a model half-way house. The location of the facility deserves careful consideration. ft should be in a central urban arch where there is low cost public transportation, and near cen- ters of occupation, particularly unskilled and semiskilled, employment. it should also be in a city near the homes, or former homes and families of the men. It should be located in a respectable residential neighborhood whose social status is neither too high nor too low, and not close to Skid Row habitats or concentrations of bars. It is also desirable to choose a central urban location so that qualified staff, including part-time, consultive, volunteer, and either unpaid personnel, may be obtained and can travel with relative ease to the treatment center. This would also enable the half-way house to use existing educational, research~ and training facilities that are available in such archs. As for physical charactertistics, the half-way house should be `a "family" type residence wi'th furnishings that are adequate though simple, and furni'turei that has firm rather than stylish construction. There should be space for offices, meet- ings, recreation, a lounge for quiet reading and relaxation, dining facilities', and sleeping accommodations. Regarding sleeping accommodations, the Belmont Re- habililtation Center in Worcester, Massachusetts, has worked Out an interesting and successful system. The men live closely at first in dormitory style. As' self- improvement progresses, the men are advanced to accommodations for three. And finally, when a man is considerably improved he is "graduated" to a single room. Each step in this ladder-like progression provides mo're comfo'rt, greater convenience, and added prestige through a concrete recognition of his progress. But whether or not some system is used for assigning differei~t accommodations within the plant, it would seem that the model half-way house should have different types of arrangements and, above all, emphasis should be on creating a home and club-like atmosphere. The bed capacity should be limited to 80. Admission and eligibility require- ments should be decided by the administrator and staff with consideration in particular of age, sex, and sobriety. The residents must agree to abide by some general rules and regulations such as curfew, schedules, house chores, program attendance and the like, which should be designed to maximize chances for recovery. Fees should be waived initially, but when employment is obtained the resident should pay a reasonable fee of $15 weekly. On entering the program of the model half-way house each indl~Idual should undergo a three-day orientation phase, beginning with an initial interview and ending with a commencement of the regimen of daily activities. In this orienta- tion period the man would receive a physical examination and would be introduced to procedures `and rules, the program and methods, the philosophy and, its bear- ers. At this time be would learn what he can expect from the staff, fellow resi- dents, and the half-way house in general. and what is expected of him. At the same time the staff would formulate suitable plans for his future participation in the program. The program itself should provide for participation in some kind of coun- seling or psychotherapy, either individually or in a group. An AA group should be formed for residents only, using their own and outside speakers, and they occasionally should attend outside meetings. The men would also participate in frequent group meetings concerned with daily problems and policies related to government and management of the center. Using principles of self-govern- nient, the men themselves would exercise responsible authority in enforcing the rules and policies which govern the behavior of residents. Each man should be helped to find employment as soon as possible after completing orientation, and should receive both casework and vocational counseling in this regard as required. Arrangements should .be made for clergy of various denominations to be available for religious counseling and spiritual help at the `request of the men. The staff for carrying out the program should' include a top-level professional with training in the social or behavioral sciences who wotlId be the director. He should have some experience in administration, supervision, institutions work, treatment, and research. An assistant director with simila~ qualifications, although of less experience, would aid the director. There also should be a resi- deht `supervisor, perhaps a recovered alcoholic who has clearly demonstrated a capacity to assume responsibility. The latter individual is a key figure, for he must se& that the affairs of the institution are run smoothly, and be available to meet the needs of the men hi times of stress. The director, assistant director, and PAGENO="0224" 218 resident supervisor would be full-time. In addition there should be on. the part- time consulting staff one psychiatrist, two social workers, one psychologist, and one researcher. These part-time consultants would be diagnostic work, and would plan and conduct treatment. All personnel must be equipped with warmth, maturity, and understanditig. Emphasis In the last stages of the program sl~ou1d be placed on easing the mem- ber back into a less protected situation in the community. Length of siay in this program should be limited to 90 days, This is not an arbitrary figure, for prag- matic experiences indicate that 3 months is in many ways the optimum length of time: it Is a suitable period for the majority; it avpids excessive dependency on the protective balf~way house; and from the practical point of view it will allow for a reasonable `amount of turnover. Readmission policies, however, should be flexible, depending on staff judgment of the individual case. And in any case, opportunities for the use of the recreational and physical facilities should be made available to successful "graduates" of the program, so that discharge does not come as a kind of weaning shock. For discharge, like orientation, is a critical period. It is a time of erisl~ and decision making. Every possible measure should be taken to avert failure. Efforts, which begin several weeks before discharge, should be directed at finding housing, re-establishing family, religious, and other non-Skid Row relationships, and strengthening all routes of rejntegratio~ into society. CONCLUSION These ingredients for a model half-way house are presented mainly as guide- posts. Local conditions and the relative youthfulness of the half-way house con- cept of rehabilitation demand that flexibility and continued self-evaluation be a guiding philosophy. Whatever the sp~ciflc ingredients, however, the general goal that we commend to any half-way house program is that it' `attempt-through its plant, program, personnel and procedures--to combine the bj~st fe!atutosj of a relaxed home an4 a therapeutic milieu. . A great many ~roblem drinkers have been and wiu be helped ~y half-way house rehabilitation. Through this method they gradhally gain increasing per- sonal strength and ability to deal with inwardly and outwardly induced frustra- tion and anxiety in ways that preclude the use of alcohol. Thereby they rebuild their self-respect and sense of dignity, restore their use~~1uessi occupationally, recover thei'~ social relatiopsbips an~l eventually ease the heavy burden they bad put on'the community. `And this is ąccothplisbed with "unreachables !" Mr. RoGERs. Our last witness today is Eugene Sibery. May I `say we will make your statement `a part of the record, follow- ing your remarks. Now, if you would give us your comments, it would be `helpful. STATEMENT OP D. EUGENE SIBERY, EXECUTIVE DIRECTOR, GREATER DETROIT AREA HOSPITAL COUNCIL Mr. SIBER~-. I shall paraphrase the important'items, so that I shall not make a 15-minute com~inent~try on a 7-minute formal statement. Mr. Chairman a1nd members of the subcommittee, I am P. Eugene Sibery~ executive director of t'he ~reater Detroit' Area I1o~pital ciouu~ oil. I also serve as chairman of the American Hospital Association's Council on Research `and Pianfting, and I am the president of the As- sociation of Health Planning Agencies, i ~ras the acting coorcjinator of the Michigan regional medical program during its initial, organiza- tional period, and, now serve on that program's regional advisory group. I `am here today to speak `in support of title I,'IT.E. 157~8., to ~kteiiU the authorization for regional medical programs. for heart diséa~e, cancer, and stroke. As a health planner involved with, the coordinathd planning a~- tivities of `a hundred hospital's in one of the `Nation~s most h~avily PAGENO="0225" 219 urbanized areas, I am strongly attracted by the potential of regional medical programs and impressed `by their progress. The strength of these programs stems from the `spirit of voluntary cooperation which underlies them, and which was written into the law `largely by your committee 3 years ago. This voluntary, cooperative approach to problem solving isn't as swift `as a more direct approach might appear to be, but I hope that you will be persuaded that it i's far more sure. Regional medical programs are becoming strong and successful forces in our society because they challenge the ingenuity of the par- ticipants. They are, becoming strong `and successful forces in `our `so- ciety `because they exist to meet specific local problems, not problems that have been rendered `sufficiently vague to be labeled national prob- lems. And finally, regional medical programs are becoming strong and successful forces in our sociOty because they~ar~ `based' iipoiipl~ns and decisions made `by those who `must carry' out the plans' `and decisions, and. by those who will be affected by them. The last point-~-broad-'bas~d ihvOlvem~u~t, for co'operath~e plan- ning,and ac'tion-i's't'he paramount reason regional medical programs will ultimately succeed in the inner `cities of Amerik~a. It is a program, that health planners have long awaited, a program~ to draw together the hospitals, physicians,, public health agencies, an'd all of the other elements necessary to provide efficient, effective, and economic health services. ` It is also a program' which muist incorp'oi~ate the opinions and' thoughts of the public to `be served by thesO health resources, and this, too is a terribly difficuilt task. The population of our inner cities is tie- pressed in mind and spirit, handicapped by lack of, eduication "and opportunity, and all `but overwheith~d by poverty and need. This must, not deter us. Without the cooperation an'd the suppOrt of these `people, no program can succeed. ` ` , ` ` ` ` The development of regional, medical programs has se~em~4 stow in the inner cities, but there has'been progress. It's not unlike the con- struction of a building. Until the foundation is laboriously dug and built, and the main structure begiiis to `z'i~e, progr~ss is not apparent. Regional medical programs `have been digging their foundations with a process of careful planning, and the `structures beginning to merge- the operational programs-will be `all ~the sounder' `auid stronger fOr this every effort. Briefly stated, from thO riationa~1 idOw, the progre~s~ of regional medical programs has been dramatic. Less than 2 years ago, there were no regional medical programs; today `there are 53 organized and at work.' ` , ` ` , ` ` There is one further reason why I view the period of planning as so essential, The experience gained in this program-I wish to stress' this point-for heart disease, cancer, and stroke can serve as a guide to make it far easier for other health programs to meet the needs of our country's entire population, including our urban areas. Significant changes in the traditional methods, of delivering health care must be effected. I believe with active and meaningful involvement of all health professionals, the regional medical programs will provide the mechan- ism fur the health professionals to markedly improve the patterns of organization and distribution of health, care. 93-~453-6S---15 PAGENO="0226" 220 I believe our experience in Michigan is not atypical. I do think it is important for us to understand the soundness of the program which is under way, the marshaling together of resources~ the inno- vation which characterizes all of the planning activities in the founda- tion for the program which is being well laid at this point in time. To help these programs, I would certainly hope that a~ great deal of emphasis will be p'aced on the need for the efforts under compre- hensive health planning programs and the cooperative regional ar- rangements developed under the Regional Medical Program Act, to be compatible and in conformity. I think they are complementary with respect to goals and activities, and I think at the local level we must do everything possible to be certain that these are not in conflict, but in fact do cooperate and sup- port each other. I do believe there is a real need, as the statement indieajes, for limited construction funds, and I would hope that as a part of the introduc- tion of my formal statement in the record that you would also include the appended article entitled "IElospitaJs and l~egional Medical Pro- grams, a Plea for Coordinated Action," which wt~s in the December 1967 issue of hospitals magazine. This was written by my good friend, Dr. Robert Evans, and I think amplifies eloquently on the point that I would mai~e, that there is a real need for limited construction dollars. Mr. Chairman, I certainly hope that this bill Will be supported by your committee and will be adopted. I think the progress so far is sound, because we have gone cautiously. I believe the operational pro- grams will speed the day that we will get to every area in Michigan, to every citizen in Michigan the benefits that this program was de~ signed to bring. I should be pleased to answer any questions you might have. It has been a pleasure to appear. (Mr. Sibery's prepared statement follows:) SPATRMm~T OP D. Euon~ Sinnn~, ~I~ECIJTIVE DIRECTOR, GREATER DETROIT AREA HOSPITAL CouNCIL, DETROIT, MICH. Mr. Chairliian and members of the subcommittee, I am P. Eugene Sihery, ex- ecfttive ~h~ector of the ~reater Detroit Area Hos~lta1 Cotincil. 1 also serve as chairmth of the American ItOspita1 Association's Council on 1~esearch and Plan- fling, and I am the ~presideiit of the AssocIation of health Planning Agencies. I was the acting coordinator of the Ml~h1gan Regional Medical Program during its initial, oi~ganizationai period, and now serve on that Program's Regional Ad- visory Group. I am hefé t~da~ to speak in support of Title I, ER. 15758, to extend the au- thorization for Regional Medical Programs for heart disease, cancer, and stroke. As a health planner involved with the coordinated planning activities of a hun- dred hospitals in one of the Nation's most heavily urbanized areas, I am strongly attracted b3r the potential of Regional Medical Programs and impressed by their progress. The strength of these Programs stems from the spirit of voluntary cooperation which pnderlies them, and which was written into the law largely by your com- mittee three years ago. This voluntary, cooperative approach to problem solving isn't as swift as a more directive approach might appear to be, but I hope that you will be pcr- suaded that it is far more sure. Regional Medical Programs are becoming strong and successful forces in our society because they challenge the ingenuity of the participants. They are becom- ing strong and successful forces in our society because they exist to meet specific local problems, not problems that have been rendered sufficiently vague to be PAGENO="0227" 221 labeled national problems. And finally, Regional Medical Programs are becoming strong and successful forces in our society because they are based upon plans and decisions made by those who must carry out the plans and decisions, and by those who will be affected by them. This last point-broad-based involvement for cooperative planning and action- is the paramount reason Regional Medical Programs will ultimately succeed in the inner cities of America. It is a program that health planners have long awaited, a program to draw together the hospitals, physicians, public health agencies, and afl of the other elements necessary to provide efficient, effective, and economic health services. It is also a program which must incorporate the opinions and thoughts of the public to be served by these health resources, and this too is a terribly difficult task. The population of our, inner cities is depressed in mind and spirit, handi- capped by lack of education and opportunity, and all but overwhelmed by poverty and need. This must not deter us. Without the cooperation and support o~ these people, no program can succeed. The development of Regional Medical Programs has seemed slow in the inner cities, but there has' been progress. It's not uhlike the construction, of a building. Until the foundation Is laboriously thig and built, and tb~ main struetute begins to rise, progress is not apparent. Regional Medical Programs have been diggIng their foundations with a process of careful planning, and the strucI~tires begin- fling to emerge-the operational programs-will be all the sounder and stronger for this early effort. *Briefiy stated, from the hational view~ the progtés~ of Regional Medical Programs has been dramatte: Less thäil two years ago, there were no Regional Medical Programs; today there are 53 organized and at work. There is one further reason why I view the period of plahuing as so e~$~ntlal. The experience gained in this program fOr heart disease, canėer, and stroke can serve as a guide to make it far easier for other health programs to meet the needs of our country's entire population, including our urban areas. Significant changes in the traditional mOthods of delivering health care must be effected. I believe with active and meaningful involvement of all health professionals, the Regional Medical Programs will provide the i~iechanism ~or the health pro- fessionals to markedly impi~ove the patterns of organI~ation and disti~ibutioh of health care. I believe dur experience in Michi~gan is not a typical. With the $1,~94,449 kl~ailt awarded the Michigan Regional Medical Program almost a year ago, the Fed- eral Government has essentially bought a bluepriflt for the initial stages' of action. Most tangibly, this initial blhepri~it is a 504-page document, omfl~ first operational grant request, which defines what w~i mpust do and cominit~ u~ to doing it. It is not a sterile plan devise4 in some ivQr~ tower~ It repre~ents a realization that previously fr~gmeüted health res~nuces can i~nite to bro~rlde the best possible patient care for heart disease, canQer~ and ~roke, a reaiizatioi~ held by the scores of men and women who live in the real world and who have contributed and will continue to contribute to this planning task. It represents our entire Michigan cduntryside. From my point of view as a health planner concerned with the tott~1 health needs of my metropolitan area, one of the most important facets .of this Michigan Regional Program is the series of linkages which have been made with a great number of groups and institutions engaged in health planning and providing health services in our Region. I hope that the staffs and Advisory ~lroups of all Regional Medical Programs share my zeal for coordination of activities In this regard. Specifically I believe Regional Medical Programs and Comprebensive Health Planning programs, both authorized by legislation enaCted by the S9th Congress, are quite complementary and mutually supportive of their activities and goals. Every effort should be made by the staffs of these two programs, at the local levels, to ensure this cooperation and coordination exist. To help make these Programs more effective, I urge your approval of 11'itle I, HR 15758, with one change: Give the Regional Medical Programs limited authority for construction to meet regional needs as stated in the Surgeon General's Report on Regional Medical Programs to the President and the Con- gress and as eloquently amplified in an article entitled~ "Hospitals and Regional Medical Programs: A Plea for Coordinated Action". This article appeared in the December 16, 1967, issue of Hospitals magazine. It was written by my good friend Dr. Robert L. Evans, Director of Medical Education at the York (Penn- sylvania) Hospital, and immediate past president of the Association of Hospital PAGENO="0228" 222 Directors of Medical Education. Dr. Evans assisted me in preparing my te~ti- mony for today, Mr. Chairman, and I would like to request that his article be inserted in the record of this hearing. I hope, gentlemen, that Dr. Evans' article will `convince you of the need for Regional Medical Program construction autho~ity. Thank you; that concludes my statement. [From the Journal of the American J-Iospit~i Association, December 1967} HOSPITALS AND REGIONAL MEDICAL PROGRAMS: A PLEA FOR COORDINATED ACTION (By Robert L. Evans, M.D.Z) To say that in the last three years our medical cai~e system has been subjected to close scrutiny, deep con~ern, and an i~comprebensible quantity of ad~rice is both trite and insufficient. Since early 1965, Our medical care system has existe~X in a holocaust of suggestion, pressures for change, `and internal' and external examination which has involved tile President of our nation on one hand and vOlunteer ~l$Vers ,of `pur neighborhood aiubulance clubs on the other. OrganiEātions re~*es iUng every level Of medical care and medical education in om' voluntary `system and virtually every executive and legislative branch of our' national, state, and local goyermnents `have had their say-and are still taikhig Beginning' with the Coggeshall report iii 1965 and progressin~ thi-ough the DeBakey commission, the AMA task forces on education, and' care, the lViillis commission, the pending reports of the ~ational Advisory Comn~ission on `Health Manpower and a similar Coxgniission on the' Cost of Medical Care, our system, its voluntary hospitals, `organized 4ledicine, n~dicaI colleges, and the role of' our federal and state governments have been studied by so many grOups and ipdivid- uals that often there have seemed `to be more bacteriologists, than bacteria com- posing the culture. There are no indications that this treed will stop. There shoul4 be no desire for t1le~ces~aUon ~f' these ,~ctivities unless ,tliey are threatened with the mumps of miniscuhty from which they may emerge sterile 4h~od health is now a fundamental right together with life liberty and the pursuit' of happine~s. Examination of the systeth that ensures this health is now in the public domain. , ` ` LRGISLATIVE ACTIVITX Complementing the stUdie~ and investigatioith ha~ been a host of bills `i-epre senting the greate~t activity in social legislation our nation ha~l eirer e~perienCed. This began with the legislation `encompassing hospithl and medical care f~r `the aged and indigent, follb~ed l~y the vEnOus héaltb'earOer training acts, and tnore recently has included the `programs' for planning On a regional `nonpolitical' base and on: ~ nonregional, political base (Publie Law 89-239 and Public' Law' 89-JT49). This legislativO onslaught is `aimed ,at producing `bettOr health f~r the citizOns of our nation, although: ih son~e respects it replaces pr'operly~ aimed rifle ~1re with poorly, aimed shotgun charges. No one can predict with any degree of accuracy the eventual effect of the activittOs of the rnid-1960s on Our' voluntary cai~e `sys- `tem-indeed, to attempt an intelligent appraisal is a staggering and incomprehen- sible task. This' paper is' concerned' with onl* a small and comprehensible portion of the studies-the planning legislation-that portion concerned with the Re~lonal Medical rrograms of the National Institutes of Health, continuing education in medicine, their relatiOnships to o~ur hospitals and medical colleges, and their governmental support system. Beginning in the 19~Os, but accelerated productively by' World War II, two parallel governmental funding systemi~' ,have bad a vital impact on medical care and knowledge: (1) billions of dollars' of federal support and additional millions of voluntary foundationS suppOrt have' gone into basic biomedical research, and (2) additional billions have gone into hospital and facility construction. While expenditures for research were producing almost indigestible quantitie~ of new knowledge designed to be productive in the prOvention, diagnosis,' and treatment of disease, other monies in smaller quantity were developing a vol~ untary system of hospitals and other community facilities that are structurally 1 Robert L. Evans, M.D., is director of medical education, York (Pa.) Hospital, and president of the Association of Hospital Directors of Medical Education. PAGENO="0229" 223 modern and usually competent. New medical knowledge has been produced largely in major medical college research and teaching hospital complexes, but the majority of health care has been delivered to our people through a distinctly separate system of community medical institutions. Communication between medical education and research centers and com- munity health care delivery centers began to deteriorate before and during World War II. It has become increasingly ineffective through the 1950s and lt~6Os. Unq,uestionably, the federal system of research support has been productive in terms of knowledge, but it has served, through tender trap of "soft money," to enhance greatly the difficulty in communication, between the teach- ing and research centers and the community hospitals. Patterns of human be- havior dictate that an individual infected with the virus of discovery-whether through financial or personal suasion-and whose. job and family support are functions of continuing success in discovery, will lose interest at a rapid and predictable rate in the more mundane, functional application of his discoveries, except as such application might, further prove his theses. Understandably, as the Midas touch of research support produced more full-time faculty members who received their major support from investigal4on r'athcv than teaching, less and, less of their time became available to, transmit and validate information from the medical college to the functional arm of the, medical ,care. system. These attitudes are both inevitable and defensible within the s~stem~ that has produced them. , , At the receiving end of this scierotically deterio~rating pipeline of communica- tion between educational centers and'care centers, other disruptive forces were at work. Most of the governmental support to our voluntary medicai Care system, as represented by our community hospital, is, directed at bed needs. prQvable demographic studies, leading to indicated increases in bed capacity, produce the highest priority of funding, in hospital construction. Very little support h~s gone into the creation of diagnostic or treatment facilities unlem they are im- mediately defensible by bed capacity. Almost no support has, gone into non~ia- tient care and supportive facilities of an educational, `evaluative, or. analytic nature. Acerediting bodies stress in ponderQi~s manner the necessity for smooth operation and recording of the administrative and business functions of a hos- pital and its medical staff, but pay almost `no attention to the actual quality o~ the staff, or to any system Of assuring the continued quality of the staff ,in terms of updating of knowledge and techniques. , The exceptionS' to `this `insi~tefice on administrative and directive function have occurred' in relation to two active forces: ~l) incidental to approval of gradnkte programs' `(irite'rn'shit~ and `residency), the American Medical Associa- tion's Council on Medical Education does insist'on minimal~stanc1~trds, of graduate educatiOn and on evidence Of' departmental educational activities in th~ose de- partments operating aj~roved programs; aM' (2) the American `Academy' of General Practice for some years' ba~ had an' established minimum requirement ~n continuing educāti~n `for its `membership, which the academy~itself recognizes as a minimal figure. ` , `, ` ` ` ," " ` ` " ` EMPHAStS O~ BUSINESS TJNC~TON The predominantly lay boards and lay administrators'of our voluntary hospital system freqnently have contributed ` further emphasis upoń~'bed capacity and di.rect'bed ~upport~' It is a paradox tha'tindividual hospital ioąrd members; wb~ are'invoived in~ corporate structures' that `place tremendous emphasis' on' `continu- ing education in' management techniques, psychology, and' evaluation for' their management personnel, neither insist upon, nor are oriented toward, the same emphasis on comparable continuing education activity in the medical staffs of the hospitals that are their community charge. The development of this orienta- tion is again both understandable and defensible within the sUsten~ that, has produced it. Businessmen tend to regard'hopsitais as businesses aM to stress their business function `to the administrative group. Government and accrec~iting"bodiCs under- standably have I~een reluctant to impose continuing education `requirements on the medical profession. Many examples around the country show that'when the necessity for continuing education and its basic purposes In relatiOn to medical practice are explained in a clear and knowledgeable manner, most board members and administrators are quick to recognize' its import, but still may assign PAGENO="0230" 224 it a low funding priority in an overall system that directs insistent light upon bricks, mortar, sy~te~s, and machines. ATTITUDES OF MEDICAL STAFFS Hospital medical staffs have been both active and passive in adding plaques to the sclerotic communications pipeline. The measurable shortage of physician man- power tends to confine their Immediate thought to the care tasks at hand, which are all too time cor~sumin~. Physicians have tended to regard the medical col- leges, which spawned them, as Sophisticated purveyors of a type of intellectual exercise that is impractical in terms of temporal, physical, and emotional pres- sures in the community setting. With some justification, they look on medical college faculties and functions as consuming inordinaiely large numbers of phy- sIcians, in both intern and resident programs and staff positions. Their plea to the medical colleges too frequently has been based on what they believe to be a clearly demonstrated need for house staff in the operation of their hospitals ~nd for passive spoon-fed, time-consumjn~ contintiing education programs. Pbat these pleas have fallen on deaf and unsympathetic ears is understandable In view of the content of the pleas and the nature of the institutions and in- dividuals to whom they are directed. Althou~h many ot~ier factors have contributed to a lessening of effective com- munication between the sources ~f our linowle4e and the institutions of its appli- cation, those discussed would seem to be the most important and relevant to the effects of federal support on the individuals and institutions at each end of the "knowledge to application" transport system. ~uddeti1y, into this potpourri of understanding, misunderstanding, interest, and disinterest has ē~ome a tremendous force for motlv~ting change. After decades of providilig major fund support fo~ both medical research and medical care instItutions, the federal go~eriiment, representaflve of the cq~wymers of our product, recently ~as discerned tba.t much of its investment in rese~jrc'h has beep unproductive because the information, teeI~niques, apd skills pro~uced in the research centers have not been tr~nsmitted effectively to the operational arm of the medical care system-~th~ community hospital and its medical staffs. Whether the failure of effective transmission is due to simple lack of informa- tion transfer i~ open to serious question, even though it is a convenient theorem. Campbell Moses, medical director of the American Heart Asociation, identifies the real problem as validation of know1edge__.t~~ is, iaabi1i~y of the practitioner to accept and adopt new kuowledg~ or technique until he has h~d the expe~ence ~f "~ee~ng" it used and using it i~nder direction. Perhaps the "information gap" I~ ~eal~y a "vttiid~tion gap,' but pro&~ably it is bot~h-certain1y the therapy for eith~er lies ii comtinuin~ education. Forcea wit~ith. go~e~nm~nt ~ls~ are beginning to recogni~e that much of the suppo~t aselgned~ to the construction of conupunity medical care facilities ~ias beep less th~u~t~ta4iyre~eethe in ucin~ eflicjent and ~OIQwled$eab1e delivery of ~djcat care. Fup4~ng jnsteg~ l~p~ pro~uc~ an overeipphaa~ on inpatient care dud medical staff direction thul administration, to the detriment of a cQordin~ted system of patient care involving logical division of inpatient and outpatient activities, and to the detriment of the continuing updating of physician knowl- etig~, tcJ~aiquea. and skills. With the ye gitiths~~of~tu lea han mp1eteaieee~ecjn the paat~ the consumer., g~opp, represented by the Regional Medical Programs, the Na~tiq~aJ institutes of JietiLth, and their parent body, the l~epartmexmt of Health, Elducation, and Wej1~are, hpve come up with a very efticlent and alniost certain to be ef&~ctive iuecbanim~m to correct some of the past inadequacies. A "SHOTSUN wnnlgNc" Stated simply, medical care and medical education, the two ends of our sclerotic pipeline for the transmission of know1edg~ and understanding, are about to be subjected to one of our more common social rel~itjoas'1~ipa-the inevitable progression from the spurned proposition, to the proposal, to the engage~nen~, and finally to the marriage, Considering the divisive factors above, this is certain to be a storn~y junction, but it is just as certain that it will be consummated and productive, for it i~ a "shotgun wedding." The people of our nation are holding the shotgun. It is loaded with cash-the greatest motivator in our society. Of PAGENO="0231" 225 a moment, the disinterested and apathetic governmental father of the research years has become the kindly, interested, but extremely firm, future father-in-law. (That be may become an overbearing tyrant is possible, depending upon the success of the courtship.) The imminent wedding is complicated by the fact that we are not quite certain who is the. bride and who is the groom. If educational ability, facility, and personnel are the measure of virility, then the medical college system must be t1~e groomi, It is doubtful tl~a't the father will listen for long to any disclaimers of ability of the groom to effectively support the bride without further prodding or promise to help with support. It also is doubtful `that any disclaimers' on the i~art of the bride (the medical care delivery system) as to her ability to assume educational or analytic duties in the household seriously will affect the future of the marriage. ~imiles aside for the moment, let us consider this union between medical education and research and medical care and examine the factors necessary for its sttccess. Three areas require close scrutiny: (j) the depth of the quality, the ability, and the personnel of our educational and research facilities; (2) the sophistication, the quality, the ability, the personnel, and the functional pattern of our medical care institutions; and (3) the question of facilities support and construction subsequent to a productive union of the educational and research institutions and the medical care institutions-perhaps recognizable as the eventual arrangements* for housing the family. The medical college system at present is rich in all three areas. Over the last four decades, it has built up a l~rge cadre of e4ucationally oriented indi- viduals, in spite of research emphasis. The very ngture aud primary task of the medical college system provides it with adequate classroom, audio-visual~ instructional, and other material aids to education. Its hospitals are equipped for the most sophisticated care-a signifleant portion of it on a research or re~ search-connected basis-and are largely modem and relatively well staffed. Although the medical college certainly will need some additional support to help it in its new role as the resource of both content and some instructional ability for the transmission and validation of knowledge, It is relatively well equipped to cope with its role as educational breadwinner. The distaff side-the tom- munity hospital, which will consume and utillac the educatIonal paycbeck-ls much less adequately prepared. NONUNIVERSITY HOSPITALS The nonuniversity ho~pitals divide into those that have graduate educational programs and those t~at do not. A recent survey conducted by the Association of hospital Directors of Medical Education shows that although graduate teaching hospitals are much smaller in number, their total bed capacity and total number of staff physicians are approxl1~1atel~T equal to the total bed eapa41iy~ an4 total medical staff physicians of the hospitals that do not conduct teaching programs. The same survey indicates that even a~nong those hospitals conducting graduate programs, less than~50 per cent have nm~sU~ adequate te~ebing faeilies~aad less than 10 per cent have the ~ervice~ of trained educators, evaluators, or sociologists available, e'tren b~ consultation. There is little difl!ere~ce b~tween the two types of ~o~upiversity hospitals in most of the important parameters we shall measure. The major differepee seems to be that those hospitals. eou~ucting graduate programs may be a little furth~r advanced in educational philosophy. Their staffs, however, frequeqtly are coin-' posed largely of physicians wh~ do not actively participate in the teaching pro- grams, and their educatlonal facilities, with a few notable exceptions, tend to be little different from those present in hospitals that do not conduct graduate pro- grams. Consequently, for the purposes of this discussion, the two typos of non- university hospitals may be discussed as a common entity, The fact remains that the emerging strident necessity for the nonuniversity hospital is that it assume its proper role as the center of continuing education for the physicians 04U1 allied health personnel of its area. Most nonuniversity hospitals are modern, quite sophisticated, and relatively well equipped to render medical care. When one compares them with the medical college hospital, the difference in the area of medical care is a difference between acceptable sophistication on the part of most nonuniversity hospitals and proper ultrasophistication on the part of the medical college hospitals. This is a tolerable and appropriate difference. PAGENO="0232" 226 INTQL~RABLE DIFFERENCE The difference betwee~i the unhrersity and community hospitah~ in educational facility and ability, however, is so great as to be intolerable, even under present loads in continuing education in the nonuniversity hospital. These community institutions have th~1r ultimate direction residing in the hands of boards and administrations Who, in a proper and 4edicated fashion, represent the voice of the community in the operation of its medical care facilities. Very few of the medical staffs and educationally oriented physicians in these hospitals have been able to impress upon their boards and administrators the overriding im- portance of co~titinuing education to the ~ompetence and survival of our medical practice system and its hospitals. ~ome of the blame foi' this failure to impress directive bodiesmust reside in the medical staffs, who have not made a c6ordi- nated effort to educate and thus produce a change in the attitude and behavior of their boards nnd administratiOns. Sinlilarly, with:fault resting in medical staffs as well as directive bodies, nom university teaching hospitals havetended to look upon graduate (intern and resident) educatiOn programs as tOlerable apd interesting because they appear to raise the level of medical care, and beea~ise they provide additional hands with which to supply that medical tare. However, even in relation to graduate education, it has been difficult to bring boards and administrators to spending patient care income on edacational ~acilities, or to ~upply within the hospitals physicians whose base purpose is `graduate or continuing education as oPposed to the deilveryof medical care. With the rapidly rising cost of hospitalization, and the clamor this rise has produced; one certainly must have sympathy with our hospital boards;and administrators in their reluctance to utilize patient care funds for educat1onį1~ facilities and personnel, even though the dollars spent on education are the best purchaSe the p~fieiit might make. The concept is sufficiently abstract to make dir~ct continuity of purpose and decision difficult to achieve. PROPOSAtS A~D PRAOTIOALXTIES In addition to being the subjeOt of studies and recommendations by various commi~sions and individuals,: our medical care and education system has been evposed to many different proposals in relation to Continuing education. One hears of universities with and without walls, nationwide closed circuit television, application of the national educational television network to medicine, two-way radio, television tape, and ~ host ~of other novelty approaches. When one digs beneath the veneer, he is forced to the inescapable conclusion that, in spite of all of these proposals ahd gimmicks, the only praetWcil place to educate the prer- hieing phijsioian in aic atinuing dnd~productive maimer i~ in the milieu in whicit heworks, tredts hiS patieats,' cmd:earns his liping~_~.his ho'spital. While it i~ trtte that in,leadihg a `hdtse'to auter,bne~th~y ń~t foree'hi~i to drink, the hOrse i~ a great deal rnorelikOly~to drink If the water :j~. updOr his nose' constantly.' Whiletlie ~nivers1ti~S hnd their ~Mi~i centers ~md~ be the central nervous system om continulageducatlon and:Qf the Regional Medical Program~, thefe cannot be must doubt that~thOńoi~unlversity Community hO~1tal~ will bC the muselu of these programs. No~pOrtion o~ the kno'*ledgeproduced by the billions of dollars spent in basic research in the last 4~ years ca~n be productive until it is in the hands of IhO individuals whO' care fOr the majority of the pe~p1e of our natien-~-the physicians' of öin~ communit~r hospital thCdical s~Sffs.. The Iiebple of our nation--~-our coiIsumets-~in the form of Congress have spoken in a loud and clear voice. ` : The ba~i~pur~ose of the Itegionkl'Medical ,l~o~grarnb fs, to translate knowledge into iinderstanding and thence `into thCdieaI care, in a `cooperative, regional, and efficient `matiner. Thus, the basic and initial form `of the activities, `Of the Regional' Medical Prograrnsmust be reparative education in bringing physicians and other health professionals up to'date. ~fbis must be followed by continuing edu~ation to maintain their cOmpetence.~ ` OncO education is well under way, attention may be paid to providing the facilities in which the newly understood knowledge, techniques, and skills may be applied in a coordinated manner. It is senselO~s to btiild the facilities until the system of educotion that will assure their proper usage i~ established and functloning~ with the explicit purpOse of taaking the billions of dollars they have spent in research productive in the'care of our people. PAGENO="0233" 227 HOSPITALS NEED HEtP At this time, the educational muscle of the nonuniversity hospital system is so weak that it is difficult or impossible for it to handle it~ presently assigned tasks in education. If it Is to become the eornqrstone and functional arm of; the Regional Medical Program, then the nonuniversity hospital peeds a great deal of help. This help must be twofold: (1) an informational campaign that stresses the importance of an educational foundation to underlie all patient care ac- tivities so that the boards, administrators, and medical staffs of our hospitals assign proper recognition and importance to the educational activities of their institution; and (2) direct financial support to establish the skeletal frame- work of facilities and personnel necessary to support the educational functions. The first of the requirements for help to the nonuniversity hospital in educa- tion is well under way. The publications of the Regional Medical Program divi- sion of the National InstituteS of Health place constant stress on this area. Programs within other portions of the government are designed to stimulate the medical colleges and organized medicine to a more active recognition of continuing education as unquestionably the most important portion of the spec- trum of undergraduate, graduate, and continuing health profession education. Accediting organizations and institutional groups, such as the American Hospital Association, should play a more impor.tant role In the stimulation of interest in the educational function of hospitals; they are just beginning to evidence interest in this activity. The Association of Hospital Directors of Medical Education, composed of key individuals in stimulating and directing continuing education, continues to increase its voice,, competence, and activity. Oontinuation and expansion of these Initial activities on the part of all the interested groups and organizations will assure proper emphasis to a function that will produce more good patient care in the future than any other single area of endeavor. The second need, that of funding support, becomes increasingly Important as more emphasis is placed on continuing education. The initial direction of funding in the Regional Medical Programs and in the comprehensive com- munity planning programs properly has been toward the commitment of monies for integrated planning of an approach to the problem of opening the com- munications pipeline between medical education and research and medical care. Once these groups have planned to communicate effectively, we still, are faced with the problem of a bride and groom who are geographically separate, and who, therefore, must be pi~ovided with the meanS to communicate appro- priate to their desire to do so. FACILITIES AND EQUIPMENT Funds must be `provided, for eduoatio'nal,. faculties and equipment in non- university hospitals. Facilities include most impQrtanUy, auditorium and con- ference room space and their accoutrements, library facilities and materials, audio-visual materials and departments, and areas specificily designed for edu- cational demonstrations in patieut care. These require brick, mortar, and ~quip- meat funds, which most hospitals simply cannot supply from monies currently available in their communities, the Hill-Harris program, or as a result of their patient care efforts. These are the very, basic facilities that all hospitals must have to adequately perform their task in educating their staffs and personnel. They are multiuse facilities and, thus, can serve for the continuing education of allied health professionals as well as physicians. Design and construction of facilitiesmay occupy a considerable period of time; thus, their funding should be of first priority. Concurrently, however, funding should be available to ensure proper and complete utilization of these educational facilities. To make these new facilities really functional will require two addi- tional factors: (1) Investigation and measurement to assure the most produc- tive content of the programs they will house; and (2) adequate numbers of educationally competent personnel to assure the productive application of the identified curriculum content and the facilities. Two of the greatest problems for individuals with practical experience in continuing education are curriculum design and content and the motivation of the practicing physician who is the student. These two factors are inextricably interwoven with a need to know patterns, of medical care and physician func- PAGENO="0234" 228 tion. The area where need for inform~ttion and the presence of misinformation is most apparent is in the field of function-the activities of physicians in the delivery of medical care and the identification of their needs and motivation in relation to continuing education. There is sore need for support within the nonuniversity setting for the measure- ment and evaluation of continuing education to assure its efficiency and perti- nence. Additional need relates to the measurement and evaluation of the physi- clan's performance, so that he can be helped to become more efficient and prOduc- tive in the delivery of medical care. In short, we should be attempting now to identify what we should teach and what changes in behavior we are trying to bring about through continuing education. I~STABLISH REGIONAL UNITS It would seem of great importance that within each of the Regional Medical Programs there be one or more nonuniversity hospital granted funds to construct and staff units to measure and devaluate systemically patient care and its delivery, thus to assist in determing need, content, and motivation in continuing education. These units should be staffed by physicians, educational personnel, and sociologists. Because each region by definition is singular in quality, it is probable that each tegion will have sufficiently different needs to require dif- ference in approach and measurement techniques. To establish just one or two national institutions or units involved in this type of research would be inefficient and insufficient. This investigative function cannot be carried on in the university setting, for we are studying a nonuniversity organism. Once identification has been begun of need, content, and pertinence In relation to continuing education, it will be necessary to ensure that sufficient educationally oriented, able and motivated individuals are present within each community hospital (or available to it) to ensure productive usage of the information gleaned and facilities added. This assurance, in the form of trained personnel~ might vary across a spectrum encompassing highly skilled, formally trained educators in the larger and more complex hospitals, to individUal staff members who have had the opportunity to receive additional understanding in educational philosophy, skills, and techniques in Smaller hospitals and communities. One might regard these individuals as the "marriage counselors" of our simile. They are vitally important to a marriage that has little solid foundation in previously existent love or mutual respect between its partners. Only after the establishment and support of competent and productive con- tinuing education programs should attention be turned to large-scale support of patient care facilities. While such devotion to competence in continuing edu- cation, orientation, and ability would somewhat delay the construction of actual physical facilities for more omplex and sophisticated patient care, the delay would serve to ensure that these facilities would be properly utilized by physi- cians. Some programs could be cootdinate and concurrent. Caring for p~ttients is, after all, the primary putpose for the existence of our entire medical care system. A PLEA FOR ACTION In summary, this presentation Is a plea for a cogent and logical progression of activity in relation to Regional Medical Programs, perhaps the most impor- tant pottiori of the socially oriented legislation that has arisen in recent years. By simile, it is a request for good, sound premarital discussion and orientation by the groom and the father-in-law to ensure that the bride of our "marriage" has the knowledge and the necessary appliances and counsel to keep house properly. Community hospitals and their health professionals must be properly prepared to accept and use the knowledge that will pour from the perviously sclerotic communications pipeline. The medical care system must have initial funding support for identification of educational need and provision of educational space and personnel. Such funding will prepare it for the proper and productive utilization of the health care system and facilities to be established In the future as the result of coordinated regional and community planning for the delivery of medical care. To paraphrase Winston Churchill, "We are not at the end, nor the beginning of the end, but perhaps we are at the end of the beginning." It is of vital impor- tance that we be sure that this "beginning" represents a solid foundation for a productive and functional future. PAGENO="0235" 229 Mr. RoGERs. Thank you. We appreciate your being here. Are we getting enough representation from hospital administrators, from local people involved with the delivery of services in the councils ~ Mr. SIBERY. From my vantage point I cannot generalize. I would say that because of my American Hospital Association responsibility, I hear some say we do not have enough hospital involvement. Others say it is fine. Hospitals are certainly welcome to participate. Generally, I believe they are eagerly invited to participate, so I don't have much sympathy for those who say they have not had an op- portunity to be an integral part. I think that our experience in Michigan might help you to see that this is not just a continuing education program for our medical schools, but in fact is a program that was designed to develop truly cooperative regional arrangements, and it took us many months to develop `a working mechanism for the three medical schools to co- ordinate their efforts and communicate because they had never done this in a similar way before. I think the very fact that I as executive director of a hospital council was asked to take the initiative in trying to draw together the program and develop the grant application is a good indication that in our State at least the hospital role was well identified. Thank you very much. Mr. ROGERS. Thank you. Your testimony has been most helpful. This concludes the hearing for today. The hearings for tomorrow will be held, I understand, in the main hearing room, which is on the first floor, room 2123, and so the committee will now stand adjourned until 10 o'clock tomorrow morning. (Whereupon, at 4:15 p.m. `the committee adjourned, to reconvene at 10 a.m. Thursday, March 28, 1968.) PAGENO="0236" PAGENO="0237" REGIONAL MEDICAL PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS ______ THURSDAY, MARCH 28, 1968 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Wa$hington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2123, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). Mr. Roo~s. The subcommittee will come to order. We are continuing our hearings on H.R. 15758, and our first witness this morning is Mr. Clinton M. Fair, who is the legislative representa- tive of the AFL-CIO here in Washington, D.C. Mr. Fair, we are pleased to see you this morning, and thank you for being present to give testimony. STATEMENT OP CLINTON M. FAIR, LEGISLATIVE REPRESENTA- TIVE, AFL-CIO; ACCOMPANIED BY RICHARD SHOEMAKER, ASSISTANT DIRECTOR, SOCTAL SECURITY D1~PARTMENT Mr. FAIR. Mr. Chairman, for the record, my name is Clinton Fair. I am with the legislative department of the AFL-CIO, and with me is Mr. Richard Shoemaker, who is the assistant director of our social security department, Mr. Chairman. Mr. Rooi~s. We are delighted to have you with us, too. If you would like to, you can make your statement a part of the rec- ord, following your remarks, and you may sum up for us. Mr. FAIR. Thank you, Mr. Chairman. Let me read in part from the statement, only because I can then add the emphasis that I would like to add. Through the extension and improvement of the regional medical programs, this legislation strikes at the cause of death for seven out of 10 Americans. In extending the migrant health program, this legislation helps bring better health to some of the Nation's 1 million migrant farm- workers and their families and brings us closer to the day when we will have corrected what has been called America's shame. The alcoholic rehabilitation amendments in this legislation will help provide proper treatment for the 5 million persons-more than twice wthe population of the entire Washington, D.C., area-who with their (281) PAGENO="0238" 232 families suffer the physical and emotional problems which result from alcohol addiction. The narcotic addict rehabilitation amendments in hR. 15758 will ~ in carrying on and expanding what must be an aggi~essive eaort to stem the rising number of drug addicts, especially amoi!ig the Nation's young people. IL would Iil~e to make one commei~t, turning to page 2, with regard to the regional medical programs. The regional medical program has within the short time it has been in operation in our opinion made remarkable strides in developing cooperative arrangements with the medical profession, our medical col- leges, and our health institutions. This program holds great promise in making available to patients the latest advances in diagnosis of heart disease, cancer, stroke, and related diseases. This coordination of effort also holds great promise of avoiding the needless cost of duplication and wasteful proliferation of diagnostic and treatment centers in our hospitals. We realize, of course, that the evaluation of the program is quite difficult at this time. The program is new, and the great bulk of ex- penditures to date has been for planning activities. But we would point out further examples, which are in our testi- mony, Mr. Chairman, and which we think spell great promise for the program. The second part of our testimony deals with the migrant health program. The migratory provisions of H.R. 15758 would extend this 6-year-old migrant health program for another 2 years. The plight of the migrant farmworker in this country has been widely publicized in recent years, but the publicity in no way cushions the shock that must be felt by every thinking American upon being reminded that people living in this country today, working amidst plenty, must endure such squalor. I would point out on page 6 of our statement are Some of the sta- tistics in this area. Of more than 1 million migrants, 650,000 still live and work outside the area served by existiiig migrant health projects. By conservative estimates, this group includes over 6,500 persons with diabetes who are without adequate medical care, over 5,000 migrants with tuberculosis, and over 3,000 children under the age of 18 who have suffered cardic damage as a result of rheumatic fever. Many children have untreated iron deficiency anemia, and &ver 250 infants will die in the first year of life as a result of congenital malformation or disease. Over 16,000 expectant mothers will find it difficult to obtain pre- natal care, and beetween 20,000 to 30,000 individuals have enteric or parasitic infestations, resulting in most cases from poor sanitation. I would point out, as the testimony does, that as these people move from crop to crop, tl~e necessity for the program is greater because they move from one area where a program is now in operation to an urea in which it is now nonexistent. And if they are to get the kind of medical care we think they need, the program needs the expansion so as these people move from one area to another they have the facili- ties available to them. PAGENO="0239" 233 As you know, our migratory workers today may have a community in which he lives, but on the whole he is moving for long periods of time away from that area. The alcoholism provisions in H.R. 15758 would authorize a 2-year grant program of building, staffing, and operating facilities for treat- ing alcoholism, using the same types of mechanisms as provided in the Mental Health Centers Act. The `ocal centers it will provide will aid the alcoholic, replacing the neglect and abuse which in the past resulted all too often in his eventual destruction. It will also aid the less than 10 percent of alcoholics who are the homeless men and women, hopefully putting an end to the revolving door cycle of arrest, jail, release, drunkenness, and arrest again. The narcotic addict rehabilitation provisions extend and make the very logical placement of narcotic addict rehabilitation activities in the mental health centers authorized under the community mental health centers programs. To enable the centers to absorb their new responsibility, the new legislation, would authorize a 2-year grant program for construction, staffing, and operation and mainte- nance of new facilities and for training of the necessary personnel. Drug addiction as a symptom of mental illness has been recognized in the act. As with the alcoholic the drug addict is a hazard to his family and his community as well as to himself. Now, while the number of centers provided for treatment of ad- dicts is small, the number of addicts is increasing. By providing this as part of the complex of mental health centers, it gets treatment to persons who need it in places where they can get it, and allows for efficient use of existing facilities. Psychological dependence, if not addiction, is a problem for young people today, and I would add that there are other dangerous drugs in addition to narcotics, as this committee knows, which have become a problem in recent times. We would hope that this program will be extended to them as well as to the narcotic drug addicts. We hope this committee will report favorably this program. We believe this legislation will stand as a model which the States may use in developing and modifying their own legislation, and certainly treatment of drug addicts and alcoholics and organization of medical service. It includes incentives and assistance from which each State can benefit in assuring that the medical fields of its citizens are met. Most certainly the Federal influence in the advance of medical knowledge and the application of that advance for the benefit of all citizens should continue. In the past much of this influence took the form only of financial assistance to various State programs. Today this influence also assumes the form of acting as a clearinghouse, and as techniques are developed and tested by those closest to the problems. We trust that approval of H.R. 15758 by this committee will indi- cate a continued willingness to maintain Federal support of health programs to the highest degree possible. And we urge your favorable consideration of the bill before you. Mr. Chairman, we thank you kindly for the opportunity to appear in support of these various programs. (Mr. Fair's prepared statment follows:) PAGENO="0240" 234 STATEMENT OF CLINTON M. FAIR, LEGISLATIVE REPRESENTATIVE, AMERICAN FEDERA~ TION OF LABOR AND CONGRESS OF INDUSTRIAL ORGANIZATIONS Mr. Chairman, H.R. 15758, the Public Health Service Act Amendments which tills committee is now considering, is a package of important extensions ond improvements to existing legislation as well as extension of the Community Mental Health Centers Act to provid~ facilities for alcoholics and drug addicts. Through the extension and improvement o~ the Regional Medical Programs, this l~gislati'on strikes at the cause~ of death for seven out of ten Americans. In ex~nding the Migrant Health Program, this legislation helps bring better health to some of the nation's one million migrant farm workers' and their families and brings us closer to the day wheh we ~vill have corrected what has been ~called "America's Shame." The Alcoholic Rehabilitation Amendments in this legislation will help provide proper treatment for the five million persons- more than twice the population ~f the entire Washington, D.C. area-who with their families suffer the physical and emotional problems which result from alcohol addiction. The Narcotic Addict Rehabilitation Amendments in H.R. 15758 will aid in carrying on and expanding what must be an aggressive effort to stem the rising number of drug addicts especially among the nation's young people. REGIONAL MEDIcAL PROGRAM The President's Commission on Heart Disease, Cancer, and Stroke, described three years ago the severe toll in human suffering whiCh these diseases inflict on the American public, each diminishes the strength of our nation. The American worker looks forward to the day when major inroads will be made against these diseases through medical research and when the fruits of such research can be made available to him at a price he can afford. The nation's poor, whose ill health is virtually inseparable from their way of life, look forward to the day when they can share fully in the fruits of modern medical science. Since the Report of the C'om.mitite on the Costs of Medical Care was published in 1932, the regularization of health services has been considered necessary in order to bring about a more rational allocation of our health resources, but until the passage `of P.L. 89-239, very little had been accomplished to implement such goals. The Regional Medical Program has, however, within the short time it has been in operation, made remarkable strides in developing cooperative arrangements with the medical profession, our medical college~ and other health institutions. This program `holds great promise of making available to patients the latest a'dvances in the `diagnosis and treatment of hea'rt disease, cancer, stroke and related diseases. This coordination `of effort also holds great promise', not only `of providing the `best of care for those `afflicted, bu't also of avoiding the needless `costs of a duplication and wasteful proliferation of diagno'stic and treatment centers in our hospitals. We realize, of course, that evaluation o'f `the program is `difficult at this time. The program i's too new and the great bulk `of expenditures, to da'te, have been for planning activities. A total of 53 grants have been made for `such planning, and it will be some time before `plan,s can be implemented. However, `the Surgeon General's Report on Regional Medical Programs to The President And The Congress, submitted by Dr. Stewart last June, indicated some `of the program's early accomplishments. A few special examples of programs already in Operation `deserve mention here. In `the notorious Watts section in California, too large a proportion `of the population has been virtually cut off from the m'ainstream of mo'dern medicine. Under the Regional Medical Program proposed there, the medical `schools of the University of Southern California and the University of California at Los Angeles and the Charles R. Drew Medical Assoc:iation are cooperating to devise a plan for bringing `some `order into the `health service vacuum now existing there. A 485~bed hospital .an'd a `proposed Postgraduate Medical School are later phases of the program's bold plan. The Albany Regional Medical Program has developed a comprehensive program of education, organization, record-keeping, and follow-up examinations in an attack on cancer o'f the cervix. This disease, which now kills some 14,000 women each year, could be eliminated as a major cause of death `if the disease is di'agnosed and acted u'pon `at an early stage. During the first year, the cancer control program is being inaugurated in seven hospitals in New York and Massachusetts. PAGENO="0241" 2S5 A symposium will be held next month (April) in New York City dedthated to educating people in health careers. Through the Regional Medical Program, planning for health careers now involves all seven universities and the coin- mun1ty colleges of the five boroughs. It would indeed be an unthinkable waste of public planning funds as well as a severe setback to a new spirit of cooperation that has developed among the many separate find independent professional and institutional components of the health enterprise not to extend this legislation-a program with so much promise, which is so widely accepted and on behalf of which so many public spirited professional and non-professional people ha~e made substantial contributions of their time, needs continuing Federal support. MIGRANT HISALTU PROGRAM The Migratory Workers provisions of H.R. 15758 would extend the six-year old Migrant Health Program for another two years. The plight of the migrant farm worker in this country has been widely publicized in recent years, but the pub- licity in no way cushions the shock that must be felt by eye'ry thinking American upon being reminded that people living in this country today, working amidst plenty, must endure such squalor. The average annual income of the migrant farm worker in 1965 was $1,400. While the average annual expenditure for per- sonal health care is more than $200 for all Americans, the figure is only $12 per year for the migrant, including $7.20 in Federal funds and $4.80 from other sources. At present only an estimated one-third of the total migrant population has access to Migrant Health Act project services. During the 1967 fiscal year, one- fourth of the Nation's migrants bad access to project services for a brief period only. This means that of the one million men, women and children, who travel the migrant stream, only about 350,000 have access to Migrant Health Act project services. By August 1, 1967, 115 public or private nonprofit community organizations were using migrant health grants to help them provide medical, nursing, hos- pital, health education and sanitation services to their seasonal migrants; but, three-fifths of the counties identified as migrant home-base or work areas are still untouched and service coverage remains weak in many of the areas where projects are now receiving grant assistance. One or more migrant health projects operate in 36 states and Puerto Rico. Each project serves migrants in from one to 20 countries. Community-based projects offer personal health care to migrants in abdut two-fifths (270) of the 726 counties thus far identified as migrant work or home-base areas. They offer sanitation services in most of these and an additional 142 counties. About 40 home-base counties, reporting an estimated outmigration of 200,000 persons, are included in migrant health project areas in southern Florida, Texas, New Mexico, Arizona, southern California and the bootheel of Missouri. Continuity of care becomes more possible as project services are provided at strategic points along major migration routes. Personal health records carried by the migrants facilitate continuity and help to avoid duplication or gaps in services, Project reports indi- cate that from 10 to 90 percent of the migrants contacted present a personal health record upon reē~uest. A few state-level projects provide sanitation, nursing or other services throughout the state wherever a major migrant influx exists. This is most likely to be true in the case of sanitation services. For continuity of care and protection, migrants need access to health services in every county where they live and work temporarily. Because geographic cov- erage by project services is still far from complete, a total of 750,000 migrants bad no access to personal health care provided through projects in 1966. The remainder had ready access to personal health services for only part of the year. Only one out of three counties with migrants offered grant-assisted personal health care geared to the special needs of migrants during 1966. Only six out of ten counties offered protection of their living and working environment through sanitation services with grant assistance. Lack of contin~uity of health care will remain a problem as long as many communities have no place to which a migrant can turn and expect to find needed health care. Recently, in one of the wealthiest states in the nation, a migrant with an emergency illness was refused care by 4 hospitals because be could not assure payment of the bill. At the fifth hospital where be obtained attention, doctors said that the patient would have died if he had had to shop around for hospital treatment for another two hours. 93-453--68-------16 PAGENO="0242" 236 Migrant farmworkers are not commuters. They travel so far from their homes that they must establish a temporary residence in one or more other locations during each crop season. On the average, the people live and work in two or three locations annually. They may move several times from far~n to farm or camp to camp at each location. At each of his temporary homes the migrant needs access to health services and a safe home and work environment; but his home base and work communities are typically r~iral, isolated, lacking in both eco- nomic resources and health resources. As a result the typical migrant home is small, overcrowded, and of substandard construction. it often lacks facilities for food storage and preparation. It often lacks adequate and safe water supply for drinking, dishwashing, bathing, and laundry. The area too often lacks adequate sewage and waste disposal facilities which attracts insects and rodents. There are no recreational areas or facilities. The typical places where they work are exposed to heat, cold, wind, dust, chemicals and mechanical hazards. They lack safe and accessible water for drinking or washing and they lack adequate toilet facilities. On some farms there are no faci1itie~ at all. All of us have a stake in the continuation and extension of this program. The migrant's road to health care is beset with obstacles-as the side of the fl1igrant is poverty, lack of health knowledge, isolation, fear of non-acceptance by the community. On the side of the community are legal restrictions against serving nonresidents, legal exclusion from protective legislation, health planning priorities that exclude migrants, inadequate health manpower, inadequate finan- cial resources, problems of serving a mobile group and resistance to minority groups. Many of the communities where migrants live and work temporarily are themselves considered poverty areas. Little wonder then that the accident mortality rate for migrants is 1964 was nearly three times the U.S. rate. It was 6 percent greater than the U.S. rate 30 years ago. Migrants' 1964 mortality from tuberculosis and other infectious dis- eases was 2% times the national rate, approximately the national average of over a decade ago. Their mortality from influenza and pneumonia was more than twice the national rate and slightly in excess of the U.S. rate for 1940. The infant mortality rate reflects like an index the results of our nation's apathy toward these workers. In 1964 the infant mortality rate among migrants was at the level of the country as a whole for 1949. The maternal mortality rate is 1964 was the same as the national level of a decade ago. Of the more than one million migrants, including workers and their depend- ents, 650,000 still live and work outside the areas served by existing migrant health projects. By conservative estimates, this group includes: 1. Over 6,500 persons with diabetes who are without adequate medical care. 2. Over 5,000 migrants with tuberculosis who are traveling and working with their disease undetected and untreated. 3. Over 3,000 children under the age of 18 who have suffered cardiac damage as a result of rheumatic fever. These children are not likely to receive treatment for prevention of reinfection and further cardiac damage. Such treatment in ordi- narily available to most nonmigrant children in their communities. 4. Approximately 9,800 children have untreated firm deficiency anemia. This increases their susceptibility for childhood infection and interferes with their normal growth and development. 5. Over 250 infants who will die in the first year of life as a result of con- genital malformation or disease. Early, adequate medical care will not be avail- able for these infants. 6. Over 16,000 expectant mothers who will find it difficult to obtain prenatal care. Infant and material mortality rates can be expected to be significantly higher under such conditions. 7. Between 20,000 to 30,000 individuals who have enteric parasitic infesta- tions-resulting -in most cases from poor sanitation. Such a problem is almost nonexistent in the general public. Before the passage of the Migrant Health Care Act in 1962 the migrant farm- worker had virtually no medical care available to him and to his family. Only in grave emergencies did he get care, and even then he was frequently denied the needed medical services. Much progress has been made since 1962 but there is still a long way to go before the migrant farmworker and his family will have avail- able even the barest minimum of medical services. Certain facts are highlighted which show progress is being made, but there is also evidence that the progress is too slow, and only a small segment of the migrant population is the beneficiary of the migrant health program. PAGENO="0243" 237 1. The migrant health program provides prenatal and postnatal care, obstetrics service, immunization, examinations, and treatment for ordinary ailments. Of these s~ervices only about 250,000 out of the one million men, women, and children who make up the migrant stream get this care. Also, this care is not continuous as not all communities have migrant project services facilities and as the migrant moves from camp to camp and from state to state these services become episodic, periodic or nonexistent. 2. Continuity of health care services for all migrant workers and their families is of the utmost importance for a rational nation-wide health care program. The American people today feel that health care services are a right. This concept should certainly encompass the men, women, and children who work in this country's fields and who make it possible for our people to be the best fed nation in the world. The AFL-CIO not only urges the extension of this program, but strongly rec- ommends the authorization of $9,000,000 for fiscal 1969 be substantially increased. ALCOHOLISM AND DRUG ADDICTION Te Alcohol and Narcotic Addict Rehabilitation Amendments in H.R. 15758 represent a meritorious effort to cope with two insidious and destructive behavior problems. An estimated 80 percent of the nation's five million alcoholics are living with their families, holding-Or tryng to hold-some kind of job, and trying to maintain a place in the community. The cost of their alcoholism to American industry is an estimated $2 billion a year as a result of absenteeism, lowered efficiency and medical insurance expenses. The suffering which the alcoholic inflicts on his family is immeasurable. His community may spend as much as $100,000 on an alcoholic and his family during his lifetime. The safety of the alcoholic, of his family, his coworkers and indeed of the entire community is endangered by his habit. According to Dr. Daniel P. Moynihan's recent ad- visory committee report on traffice safety, made to the Department of Health, Education and Welfare last February, as much as every tenth car encountered on the road may be driven by an alcoholic. Problem drinking is cited as a factor in at least 30 percent of the more than 40,000 motor vehicle deaths occurring annually. The alcoholism provisions in HR. 15758 would authorize a two-year grant program building, staffing and operating facilities for preventing and treating alcoholism, using the same types of mechanisms as provided in the Mental Health Center Act. The local centers which this legislation will provide will aid the working alcoholic, replacing the neglect and abuse which in the past resulted all too often in hiS eventual destruction. It will also aid the less than ten percent of all alcoholics' who are the homeless men `and women, the so-called Skid Row inhabitants, hopefully putting an end to the revolviug-door cycle of arrest-jail- release~druflkenne55 and arrest again. We very definitely endorse this effort to fight the disease of alcoholism with the humane and intelligent treatment that is required. The Narcotic Addict Rehabilitation provisions of HR. 15758 extend and make the very logical placement of narcotic addict rehabilitation activities in the mental health centers authorized under the Community Mental Health Centers Act. To enable the centers to absorb their new responsibilitY the new legislation would authorize a two-year grant program for construction, staffing, operation, and maintenance of new facilities and for training of the necessary personnel. Drug addiction as a symptom of mental illness has been recognized officially in the two-year-old Narcotic Addict Rehabilitation Act. As with the alcoholic, the drug addict is a hazard to his family and community as well as to himself. The need for providing treatment and rehabilitation is apparent when we con- sider the 40 percent increase in the number of narcotic addicts recorded by the Bureau of Narcotics during the past ten years. Our conce~rn over the drug addic- tion problem is also due in no small part to the fact that drug abuse is a behav- ioral illness of the nation's great labor centers. More than half the addicts re- corded by the U.S. Bureau of Narcotics are residents of New York State. Cali- fornia, Illinois, New Jersey, and Michigan, have a larger proportion of addicts than other states. While the number of centers providing treatment for addicts is small, the num- ber of addicts increases. Providing this treatment in facilities which are part of the complex of the community mental health centers, gets treatment to persons PAGENO="0244" 238 w.ho need it in places where they can get to it, and allows for eMcient use of exist- ing facilities. Psychelogical dependence, if not addiction, is a problem for younger people today. There are other dangerous drugs in addition to narcotics as this committee knows. We hope the committee will report favorably this program. We believe this legislation.will stand as a model.which the States may use in developing and modifying their own legislation concerning treatment of drug addicts and alcoholics aiēid organization of medical services. It includes incentives and assistance from which each state can benefit in assur~g that the medical needs of its citizens are met. Most certainly the Federal influence in. the advancement of medical knowle~1ge and in the application of that advancement for the benefit of all citizens ahoüld continue. In the past, much of this influence took the form only of financial assistance to various State programs.. Today this influence also assumes the form of acting as a clearinghouse and disseminator of medical information and tech- niques developed and tested by those who are closest to the problems. We trust that approval of ILR. 15758 by this committee will indicate a con- tinued willingness to maintain Federal support of public health programs to the highest degree possible. We urge your favorable consideration of HR. 15758. Mr. ROGERS. Thank you, Mr. Fair, for an excellent statement, and I am impressed particularly with some facts you gave on migrant health problems. I am very interested in it and have been since helping to write the original legislation. As a matter of fact, I was concerned with health, where we give block grants to the State. It was the thinking of the Bureau of the Budget that, at first, they would not continue migrant health as a sepa- rate program. But, `as a result of the interest some of us have shown-I introduced a bill for continuation for 3 years of this program-we have gotten them to go along with a 2-year extension. We appreciate your support on this. I think it is a very necessary program. And we appreciate very much your testimony. Dr. Carter? Mr. CARTER. I have no questions. Mr. FAIR. Thank you, Mr. Chairman. Mr. ROGERS. Our next witness is David J. Pittman, director, the Social Science Institute, and professor of sociology, Washington Uni- versity, St. Louis, Mo. STATEMENT OF DAVID ~. PITTMAN, PH. D., DIRECTOR, THE SOCIAL SCIENCE INSTITUTE, AND PROFESSOR OF SOCIOLOGY, WASHINc+- TON UNIVERSITY, ST. LOUIS, MO. Mr. PIrI'MAN. It is a pleasure to be here, and I have a statement that can be entered into the record. Mr. ROGERS. Without ob~jection, the formal statement will be made part of the record following your remarks. Mr. PITTMAN. The part I would like to bring to the attention of the committee is in reference to the recent court decisions. I have for 10 years served as a consultant to the St. Louis Metropolitan Police Department, as well as consultant to the President's Commission on Law Enforcement and the Administration of Justice, which recom- mended that communities should establish detoxification centers to remove the offenders from jail, the so-called "revolving door" process. The first detoxification center in North America was in St. Louis, Mo., and this was under the aegis of the St. Louis Metropolitan Police Department., a Catholic nursing order, and Washington University's PAGENO="0245" 239 social science institute. The center has been in operation for 17 months and has become a model for the whole Nation. The results thus far have surpassed all expectations on the first `followup studies of patients going through the center, who are from the homeless and lower income group. Twenty-One percent are abstinent at the end of 3 months. Mr. ROGERS, Twenty-one are what? Mr. PITTMAN. Twenty-one percent are abstinent for 3 months. Mr. ROGERS. That is excellent. Mr. I~ITTMAN. This was far beyond any expectancy that any of us had concerning that particular program. Mr. `ROGERS. How long has this been going on? Mr. PTTTMAN. For 17 months. In fact, the results were so good that in October 1967 the St. Louis Board of Aldermen unanimously passed a new statute governing public intoxification in that city, without any court pressure being needed. The essence of the statute is that chronic alcoholism is a posithe defense to the charge of public intoxification. However, very few such cases find their way to the court anymore, as they are handled in the detoxification center. The 30-bed facility is a . cooperative effort. The Department of Justice helped on this, and the Missouri State Legislature appro- priated $150,000 for this work; the St. Louis Board of Police Com- missioners, with the approval of the board of apportionment in the city, has appropriated somewhere close to $150,000 for the city of St. Louis. The detoxification center in St. Louis handles approximately 80 percent of all "drēink on street" cases and graphh~ally demonstrates what a community can do when it is. willing to move on this major problem. I think the unique aspect is that Federal, State, and local coo~eratien has been brought to bear in' terms of providing a `facility "frOm scratch," so to speak, and we have been' deeply appreciative Of the support of press, radio, and community' organizatiOns in these efforts. Now, I would like to indicate, in terms of the Federal Government action in alcohOlism and partiCularly in reference to this bill, `that the bill is not as specific as it should be in terms of noting that detoxifica- tion' facilities Or emergency care faėilities,' or resources, should be' eli- gible for construction grants as well as providing for' `staff, operation, and maintenance grants. Unless these.' emergency. facilities are pro- vided to intervene rapidly into the treatment of these individuals, we will continue to see a sizable proportion of alcoholics who do not have full access to treatment. Unfortunately, a sizable portion of general hospitals and com- munity mental health centers do not pro~vide, or are unwilling to provide, emergency care for chronic alcoholics. This was the case i~ St. Louis, as well as other cities, which have now pioneered in emer- gency care facilities, such as Des Moines, Washington, D.C.~ and so forth. Therefore, I respectfully request that the subcommittee give con- sideration to making emergency detoxification facilities eligible for support under this act. The recovery rate can be much higher than was anticipated if treatment is immediately brought to bear, and this is PAGENO="0246" 240 reflected in the case of the city of St. Louis. This is a manageable problem. I would like to close by indicating that we who have been involved in the alcoholism movement for the last few years are deeply apprecia- tive of the interest of the Congress of the TJnited States in reference to this particular problem which has been ignored for so long. Thank you. (Mr. Pittman's prepared statement follows:) STATEMENT OF DAVID J. PITTMAN, PH. D., EXECUTIVE VICE CHAIRMAN, GOVERNOR HEARNES' ADVISORY COMMITTEE ON ALCOHOLISM, STATE OF MISSOURI, PAST PRESIDENT, NORTH AMERICAN ASSOCIATION OF ALCOHOLISM PROGRAMS, DIRECTOR, SOCIAL SCIENCE INSTITUTE, AND PROFESSOR OF SOCIOLOGY, WASHINGTON UNIVER- SITY It is indeed a pleasure to teStify in support of HR 15758, Title III. Part A, "The Alcoholism Rehabilitation Act of 1968." The introduction of this Bill by the eminent Chriirman of the Committee, Mr. Harley 0. Staggers of West Virginia, is indeed a forward looking aM progressive Step ~fl copying with one of Amer- ica's most neglected health problems. One of the most neglected areas of health care in American Society today is the provision of treatment facilities for the alcoholic. The presence of around six million alcoholics in the United States makes this one of the nation's foremost medical and social problems, but an equally salient fact is that the expansion of treatment facilities arid resources has lagged far behind the growth of the alcoholism problem. Title III, Part A, of this Bill would be a major step forward in providing increased resources to meeting this complex problem. As the former president of the North American Association of Alcoholism Programs and as the Executive Vice Chairman of the Governor's Council on Alcoholism in Missouri, I am keenly aware of the desperate need for increased federal involvement in ptoviding resources for coping with alcoholism to supple- ment the increasing efforts by state and local authorities, both private and public. The United States remains one of the few countries in the Western world without an enacted legislative program of alcoholism control at the national level. National alcoholism programs now exist in both Western and Eastern European countries and have had a major impact in ameliorating this problem. Therefore, it is a heartening sign to see the Congress of the United States con- cerned with this major problem. RECENT COURT DECISIONS Recent United States Courts of Appeals decisions in Virginia and the District of Columbia have ruled that chronic alcoholism may be used a~ a positive defense to the charge of pnbli~ intoxication. This change in legal Interpretation must be placed against the backdrop of the fact that in 196f about one-third of all arrests made by American police was for public intoxication violations. New Medic~1 and social approaches ~1ll have to be mounted iii American com- munities. As the President's Commission of Law Enforcement and Administration of Justice recommended, communities should establish cilil detoxification cen- ters to remove the chronic drunkenness offenders from the status degrading process of arrest, jailing, and re-arrest, which in an earlier work I termed the "revolving door process." It is indeed a source of pride to note that the first Detoxification Center in North America to systematically remove chronic alcoholics (whose only offense is public intoxication) from the jails is in St. Louis, Missouri. The Detoxification Center is an undertaking of the St. Louis Metropolitan Police Department, under the leadership of a most able past president, Col. Edward L. Dowd, along with the cooperation of the Sisters of St. Mary's and the Social Science Institute of Washington University. This Detoxification Center in St. Louis in the 17 months of its operation has become a model for the whole nation, and the results thus far obtained have far surpassed our expectations_approximately 21 per cent of the chronic inebriates being abstinent when interviewed in the com- munity three months after treatment. In October, 1967, the St. Louis Board of Aldermen unanimously passed a new statute governing public intoxication in our city without any ~court pressure PAGENO="0247" 241 being needed. The essence of our new statute is that chronic alcoholism is a positive defense to a charge of public intoxication. However, very few cases of public intoxication involving chronic alcoholics find their way to the court any more as they are handled in the major medical facility or Detoxification Cehter. This thirty-bed facility is supported in a cooperative endeavor of federal, state, and local agencies. The federal government, through the Office of Law Enforcement Assistance in the Department of Justice, provided the original grant; the Missouri State Legislature in its recent special session just concluded this month appropriated $150,000 for the partial support of detoxifica- tion centers in our major urban centers of St. Louis, Kansas City, and Spring- field; and the St. Louis Board of Police Commissioners has appropriated mu- nicipal funds with the approval of the Board of Apportionment and Estimate. The Detoxification Center now handles approximately 80 per cent of all "drunk on street" cases in St. Louis and graphically demonstrates what a community can do when it is willing to move on this major problem. The goal of our state and municipal agencies and their personnel is the total removal of chronic alcoholics whose only offense is public intoxification from the jail cells of America. I would like to note for the Committee that the support of the press, television, radio, and community organizations has been completely behind these new actions to remove chronic alcobolics from the judicial process to the medical, rehabilitation, and social context. On March 7, 1968, the Supreme Court of the United States heard arguments on the Powell vs Texas case, and the Court has been asked to rule on the con- stitutionality of the public intoxication statute's use in cases involving chronic alcoholics. It is expected that the Court will rule that chronic alcoholism is a positive defense to charges of public intoxication and that these Individuals are not to be incarcerated but must receive medical and social treatment. Thus, there will be a crisis in treatment resources unless bold and imaginative steps are taken by local communities now. But the tragedy is that the implementation of court decisions with new pro- grams and facilities has been so difficult to obtain-individuals are still dying in jail cells of America from chronic alcoholism. FEDERAL GOVERNMENT ACTION But for local and state initiative to be successful in combatting this major health problem there must be more vigorous leadership shown at the federal l4~vel. Past e1~efts to cope with alcoholism on the national level have been fragmentary and do not represent a hatienal attack on alcoholism. Last year the Federal Government spent only eleven million dollars on alcoholism control. This miserly expenditure of funds on a national problem of great importance occurs despite the fact that over one-third of the arrests in America are for public intoxication, despite the fact that 40 to 50 per cent of all fatal traffic accidents involve chronic alcoholics or heavy drinkers, and despite the fact that hundreds of Americans die needlessly in jail cells from the effects of chronic alcoholism. This Bill should be more specific in noting that detoxification facilities or emergency care resources sho~ild be eligible for construction grants as well as staff, operation, and maintenanc~ grants. Unless these emergency facilities are provided, we wijl continue to see a sizeable proportion of alcoholics who do not have full access to medical and social care. Unfortunately, a s.izeable proportion of general hospitals and community mental health centers do not provide, or are unwilling to provide, emergency detoxification care for chronic alocholics. This was the case in St. Louis a~ well as in many other cities, such as Des Moines, Washington, and Denver, where new detoxification centers have been establIshed to care for the homeless, chronic inebriate population. Therefore, I respectfully request that the Subcommittee give consideration to making emer- gency detoxification facilities eligible for support under this Act. In the last four years in connection with the North American Association of Alcoholism Programs, I have traveled from coast to coast, from border to border, and I can assure the members of this Committee that there is a ground swell of support for the enactment of systematic federal legislation to aid the states and the municipalities in coping with this major medical and social problem. I am sure that the people of America are wholeheartedly in support of vigorous federal action for alcoholism rehabilitation, control, and eventual prevention of this major health problem. PAGENO="0248" 242 Mr. ROGERS. Thank you `very much, Dr. Pittman. It is a very inter- esting statement. S Mr. Nelsen? S Mr. NELSEN. No questions, except to comment that the `success you have had is outstanding, and it would indicate the merit of the' pills before us. S Mr. ROGERS. Dr. Carter? ` `,, S , , Mr. CARTER. Certainly we realize the great problem that alcoholics present to our country,' and I want `to commend you on your efforts ~in' this direction. I support the part of this bill for the treatment of chronic alcoholisth, ,, S ~` There is one thing that interests `me, of course.' As yo'ti state, some of the courts have held that chronic alcoholism is a defense against arrest for intoxication. ` S How are you gQing to manage acute alcoholics wh'o are on the streets and who are some danger to the pnblic? How will you take care of th'em? Mr. PITTMAN.' The procedure We have developed in cooperation with the police an4 the district attorney's, office, ,as in `the case' of an accident victim, or a coronary case that may collapse on the street, is, taking the individual to the "medical `facility for treatment. The law as it is revised does not remoVe the ai~resting process for pi~blic intoxication.. The determination comes in a court hearing. But, briefly speaking, `anyone `brought by the police to the detoxification center has a summons left `with him. If he undergoes the treatment, then the summons is canceled, and that is the end of that particular episode. There is a volunteer p~rogram, and the ultimate sanctioning, of course, is in the statute itself. If the individual `goes to court, l'~e `can plead chronic alcoholism and under the statute certain options are open to the judge, that is~ a voluntary referral to a private doctor or a psychiatrist. The compulsory sentence in the ~orkhouse' is' "still there for the nonalcoholic. Mr. OARTEU, ~& cowpulsory ~entence to. .t~ workhouse? I hardly see how that would be possible for such an offense. But how are you `gthng to handle the intoxicated people on the streets? Mr. PITTMAN~ We have ,had a training program `for 10 years on how to handle the chronic alcoholic. It is not a very diffi~u1t matter. The police officers have had' intensive experience in tei'ms of handling these individuals, and in our experience it' has not resulted' in an~ violent episode. * Mr. CARTER. Describe the method of handling them. Mr. PITTMAN. Well, actually, the officer, when he sees the intoxi- cated person on the street, a'sks him to go along with `hi'm to the center, The minimal degree of force is used. There is no handcuffing, no use of extreme measures. The talking pro- cedure is used first, and it has not been necessary to restrain any of the individuals. It may be necessary very rarely for two officers to `take an individual to the center. Mr. CARTER. Where are they taken, then? Mr. PITTMAN. They are taken to the St. Mary's infirmary, which is a 30-bed facility with 24-hour service and a hospital staff. PAGENO="0249" 243 Mr. CARTER. You have treatment facilities there for one who has delirium tremens? Mr. PITTMAN. Yes. There have been `few cases of delirium tremens. They are brought immediately into treatment, and care is provided so that there is rapid recovery. Mr. CARTER. Sometimes even with the best treatment we see this. If you see many alcoholics, you will see delirium tremens. There is no question about that, and it does take a great deal of care and atten- tion, and there is the problem of how to apprehend promptly those who are in this state as a result of the ingestion of alcohol. That is a problem. Mr. PITTMAN. I think your point is well made. It is a matter of training on the part of the police, the nurses, and so forth. This can be reduced to a minimum. Mr. ROGERS. I am interested in how your detoxification center works. What is your budget, or do you have it here? Mr. PITTMAN. I would be glad `to send the whole exhibit to the committee for the record. But, briefly, approximately $350,000 yearly. (The following information was received by the committee:) U.S. DEPARTMENT OF JUSTICE, OFFICE OF LAW ENFORCEMENT ASSISTANCE GRANT' ADJUSTMENT NOTICE Grantee: St. Louis Metropolitan Police Department (Grant No'. 284-(S-093)). Title of project: St. Louis Detoxification Diagnostic and Evaluation Center (Adjustment No. 1). Nature of adjustment: Budget Change (Date, 2-20-68). To grantee: Pursuant to your request of Pebruary 19, 1968, the following change, amendment, o'r adjustment in the above grant project is approved, sub- jec.t to such conditions' or limitations' as. may be set forth below: DA,NIEL L. SKOLER, Deputy Director, Office of Law Enforcement Assistance. Approval of the attached revised project budget for the project, with changes as follows: ` .,... ..-,.... , , ` Dec. 1, 1967, to Nov. 30, 1968 Original Revised approved . Change budget . budget . personnel $79,850 -$21,668 $58,182 Supplies and communications~__~ +3, 151 3,151 Other: Space rental (St Mary's Infirmary) +8, 107 . 8,107 Food (patients) +9,S35 9,635 Laundry ±525 525 Emergency patient fund +250 250 Total award 79, 850 0 79,850 Grantee contribution 263, 402 +47 263,449 Total 343, 252 343,299 PAGENO="0250" 244 `~ O~'C. 0 [/~f EN O'C \` De:~icci z~rc;cc~ ifuf~~~ o Corap!c:a Pr~jec~ Perka from ~ _________ o Firat Year Oa!y (projcc~s exceeding 16 momi~a) Througl~ ~ Pc~cnt of Annul ~ D=dS;11a17 of OLE\ -~ ______ * -- - ~ c __________________ B. ac Tranormtku and Sebsiu~rncc) (flciiec) ____________ ~rnrionsancfl~pro(Jtej~~e ~ ~ _____________ L~~______ ____ PAGENO="0251" 245 (~ ~ 0 0 0 .~ ~2c~ ~o~O `~ C) 00 ~ a-.~ 0 ~3~_j -o d (`4 0) (Si] CO C C C,, C) 0 0 0000 00 0-C,, >- 0 C- C) C) 0) C) 43 0 0 C) C) 0)2 PAGENO="0252" 246 00000 00000000000 o o o ~ oo oo o 00 Q 000000 oo 00 ooooc~oo 00 000000 ~0 000 0 0 0 c'~J0 ~r) ~C) 0 Co 0 ~ 0 0 0 0 - o~~: -o c~0~ ~ r- r-~ 2~ - - ~-a~~$ ~i ~0 C~) E v) 0 0 0 0 o 0 ~ - C~4 ~0 E 0 ~ ~- E Un Co00 r.4 1- C,) >- 0 a- I- PAGENO="0253" 247 [Continuation sheet-p. 3, item CJ Requested Police Police Total of OLEA Department Department annual (ian. 1, 1968- contribution contribution cost Mar. 31, 1968) (Apr. L 1968- for December Nov. 30, 1968) 1967 C. Supplies, communications, and reproduction: 1. Office (pencils, paper, etc.) $500 2. Telephone (local and long distance), tele- graph, postage. 1,000 3. Medical supplies and medications (for patient treatment) .. 10, eoo. . 4. Replacement of sheets (6 sheets per bed, per year equals 180 at $3.28 each) 591 5. Replacement of pillow cases (6 pillow cases' per bed, per year equals 180 at $0.78 each)_ 141 6. Replacenient of towels (50 dozen at $4.90 per dozen) - 245 ` 7. Replacement of wash cloths (50 dozen at $1.35 per dozen)7, 68 8. Laundry ssap (46 pounds per month at $0.11 per pound ` 61 Total 12,606 $125 250 ` 2, 500 ~ 148 ` 35 . ` 61 ` ` ` 17 15 $333 667 6, 670 394 ` 94 164 45 41 $42 ~ 83 830 49 12 20 . 6. 5 3,151 8,408 . 1,047 tContinuation sheet-p. 3, item DI 0. Other (equipment, miscellaneousand indirect costs); I. Rental for 3d and 2d floors at St. Mary's In- firmary (19,074 square feet, utilities, 30 beds and bedding, hospital furniture) at ` $1.7oasquarefoot $32,462 2. Food for high protein meals (based upon a food cost of $4.05 per patient, ~er day, and an average daily patient population of 26)_ 38, 540 3. Laupdry (a fixed flat fee to be paid on a monthly basis at $175.16 per month) 2,102 ` 4. Emergency patient fund 1 1, 000 ` 5. Ipsurance-For payment p1 comprehensive ` . ` general liability and hospital professional insurance 2,000 TotaI_~ 76,OO~ ` . - . $8,107 9,635 . 525 .` 250 ` 0 ` . $21,617~ $2,702. 25,693 ` . 3, 212 . 1, 402 . 175 . 667 83 . 2,000 . :. 0 ` 18,517 .. 51,379 ~,i72 . `The emorgency pati~n't fund cd $1,000 Is necessary to provide indigent alcoholics with bu~ fare for employment inter- views and housing arrangements. These moneys ~il~ insure transportation of the indigent to the other pgencies of referra' which are part of the rehabilitation program. It also provides for temporary food and lodging while the indigent is awaitin~ empldyment and/or his first paycheck or admission to another helping referral agency. Thisfurid, likewise, will cover other necessary minor expenditures of the indigent. . . APPLICATION FOR GRANT ` . . - BUDGET NARRATIVE Begin below and add as many continuation pages (4a, 4b, etc.) as may be needed to complete the required justificaiton and explanation of the project budget. A. PERSONNEL (EMPLOYEES AND CONSULTANTS) 1. Elmployees.-The budget of this application indicates that a total of forty- seven (47) people, excluding medical students,, will be involved in the op~ration and administration of the St. Louis Detoxification Center. During the period of December 24, 1967 `through March 31, 1968, OLEA funds will provide for the employment of: two (2) Registered Nurses, five (5) Licensed Practical Nurses, eleven (11) Attendants (one on a half-time basis), the Medical Students, the Secretary, and the housekeeper. it is to be noted that during the period of January 26, 1968 through February -9, 1968, OLEA funds may have to be used for the salary of two Secretaries, and this revised budget includes the funds `necessary to cover this situation. The Secre- tary is terminating employment on January 26, 1968. The replacement Secretary, if obtained, will start employment on January 26, 1968 to provide for a one day "break in" period. Thus, the payroll may include two Secretaries during the period .of January 28, 1968 through February 9, 1968. PAGENO="0254" 248 During the eight month period of April 1, 1968 through November 30, 1968. OLEA. funds will provide for the employmc~nt of five (5) Licensed Practical Nurses and four (4) Attendants (one on a half-time basis). During the seven month period of December 1, 1967 through June 30, 1968, the State of Missouri will assume the payment of salaries by placing the following positions on its payroll: Medical Director, Assistant Medical Director, Chief Social Worker, Staff Social Worker, and one (1) Registered Nurse. In addition to these positions, the State of Missouri will also assume the payment of salaries during the five month period of July 1, 1968 through November 30, 1968, for the following positions: two (2) Registered Nurses and three (3) Attendants. The. St. Louis Metropolitan Police Department assumed the Detoxification Cen- ter payroll cost as a grantee contribution for the period of Deceitiber 1, 1967 through December 23, 1967. During the three month period of April 1, 1968 through June 30, 1968, the St~ Louis Metropolitan Police Department will pFovide funds fOr the employment of the following positions: two (2) Registered Nurses, seven (7) Attendants, the Medical Students, Secretary, Housekeeper, and the consulting Psychiatrist. During the live month period of July 1, 1968, through November 30, 1968, the St. Louis Metropolitan Police Department will provide i~unds for the employment of the following positions: four (4) Attendants, 4be Medical Students, Secretary,, Housekeeper, and the consulting Psychiatrist. The St. Louis Metropolitan Police Department will contribute the services of eight (8) Planning and Resegrch Division personnel and the services of David J. Pittman, Ph. D., Consultant. The Sisters ō~ St. Mary will contribute the serv- ices of eleven (11) St. Mary's Infirmary personnel. 2. Consultants-The Medical Director (Project Co-Director) and the Project Co-Director from the St. Louis Police Department will have available to them, on an as-needed basis, the consultation of two recognized experts in the fiel dof alcoholism and alcoholism treatment. These experts, David J. Pittman, Ph. D., Director of the Social Science Institute of Washington University, St. Louis, and Laura E. Roots M.S.W., Director of the Alcoholism Education Program of the Social Science Institute of Washington UnivO1~5ity, St. Louis, will provide guid- ance to insure the proper operation and administration of the Center. 3. PICA, Retirement, etc. FIOA costs have been calculated at 4.4% of the total salaries requested of OLEA. Workmen's ~3ompensation has been estimated according to the rates that cur~ rently apply to St. Mary's Infirmary, with an allowance for a rate increase. To~ calculate the cost at the current rate, the total salary for Professional (8833) Employees is multiplied by a rate of .28%. The total salary of the Other (9040) Emtdoyee~, which lhclude~ oni~' the hoi~isekeep~r, Is irailtiplied I~y a rgte of 1.28%. These tsyo O~tiiets fi~O thOń ~ah1tfl~lied b~ fin nxperience credit of 7~% for ho~ pitals operated by the sisters of St. Mary. Mr. ROGERS. This is a 30-bed facility? Mr. PITTMAN. Yes. Mi. RoGERs. How many peop4~ ~1o you take care of a year? Mr. PITTh~AN. In the first 12 ip.o~it~ pf o~peration, about 1,~0O per- sons were sent through the center. This is about 80 percent of th~ "drunk on street" cases. Mr. ROGERS. What is the staffing of this center? Mr. PITTMAN. It involves two physicia~ns~ ~ne psychiatrist, and a consultant, one psychiatric resident, and a full complement of staff,. approximately five nurses. Mr. Roa~iis. You operate on a 24-hour basis? Mr. PITTMAN. Yes, full medical coverage, 24 hours a day. Mr. ROGERS. All the patients brought in are kept in bed? In other words, do you do any, in effect, Outpatient treatment? Mr. PITTMAN. Immediately, they enter into the acute treatment phase, which Dr. Carter was mentioning, in which delirium tremens or hal1uci~ations are treated, and then they are moved to the ambula- tory part of the unit in which a group of social workers attempts to~ make a plan with the individual, in terms of aftercare, to utilize rnenta1~ health resources in the community. PAGENO="0255" 249 One of the major deficiencies are the transitional resources, or the halfway houses, or the facilities that are involved in the third part of IFLR. 15758. But the social workers attempt to make a plan for out- patient care, referral to other agencies for more intensive care or long- term care in the State hospital, and so forth. An emergency diagnostic center might be another way of putting it. Mr. ROGERS. So they can then be referred from there if they need long-term care? Mr. PITThtAN. Yes. Mr. RoG1~ias. Do you have any difficulty in getting them into long- term care? Mr. PITTMAN. Yes, sir. We have had extreme difficulty in getting long-term care for some of these patients because they are at the bottom of the economic ladder, and their eonditiohs are e~treineiy complex. But that has improved dramaticafly~since the State division of mental health has become involved in this p~rticula~ project. Their facilities are now available. Mr. ROGERS. Could you give me a typical case that is brought in? Row long would he stay in emergency? Mr. PITTMAN. Approximately 24 to 48 hours in the emergency unit, approximately 4 to 6 days in the ambulatory part. Mr. ROGERS. Did I understand you to say this is voluntary? Mr. PITTMAN. No, it is run by the police, so it is not voluntary. It has taken the place of the drunk tank. Instead of taking people to the jail- Mr. Rooi~s. Instead of that you bring them here, so it is not really voluntary, then. Mr. PITTMAN. No. Mr. ROGERS. Suppose they wef-eto leave? Mr. I~EI~r~~IAN. If they le~av~ against medical advice, the procedure is presently no prosecution of the `summons. In other words, if tbey leave, then we emphasi~e the voluntary aspect within the polh~e pr~dr~re. sir. ROe~ER5. So th~e is nothing to compel them, then, but if they go through this proeedure, the eas~ is not-~----~-- Mr. PII~T~AN. Not heard in court. ~r. ~ Is ther~ any proced~ire where you `wait until there is a clearance given by the doctor and then dismiss the case? Mr. PIP~A~. If they remain in the center, the summons Is auto- matically canceled. Mr. Rooints. Suppose they leave. Would the case be prosecuted? Mr. PITPMAN. It could be, but it is not. Mr. ROGERS. As a matter of fact, you don't. Mr. PITTMAN. No; we don't. Mr. ROGERS. Is this tied in with a community health center? Mr. PITTMAN. Originally, it was not, and it was necessary to ener- gize the community mental health center to become involved. It is now partially supported by the State division of mental diseases in Mis- souri, and this required the mobilization of community concern. We had originally hoped these people would be treated in conimu- nity mental health centers. Mr. ROGERS. Is there any reason why community mental health cen- ters could not undertake this treatment? PAGENO="0256" 250 Mr. PIPrMAN. There is no reason they shOuld not if they have the desire, motivation, and willingness to do it. Mr. ROGERS. What do you estimate the population ē~f the alcoholics in the area served by this center to be? Mr. PPrTMAN. In' the city, we carry an estimate of approximately 50,000 alcoholics, of `which approximately 5,000 to 6,000 would fall into this area. Most alcoholics are not police cases. Mr. ROGERS. Can someone come in for voluntary treatment? Mr. PITTMAN. Not to this facility, but we have t'h~ con~munity ,nien- 1a1 health center unit, and they are referred to `them. Mr. ROGERS. Are the 30 beds sufficient to serve the population? Mr. PITrMAN~ No, sir. We have had `great fina~cial problems in the sense of slowly but. surely, increasing from 24 to ~0 beds, and we feel that appro~i~nately. 36 to 40 beds will coiter it. Mr. ROGERS. That would be about correct for this. service for this 5,000 or 6,000 patients that you `feel~ai~e~ehronic? , Mr. PIPTMAN. Yes. Mr. ROGERS. What would. that ultimate cost be?' ` Mr. PITTMAN. Approximately $400,000 is the estimate. Mr. ROGERS. What is'the overall populationof St. L~uis? Mr. PITTMAN. 700,000 inSt. Loui~City. Mr. ROGERS. If you would let us have a complete breakdown, it would be helpful to the committee. Mr. PITrMAN. I will be glad to d~ that. (The fOllowing document was received by the committee:) PRELIMINARY I~VALUATION REPORT OF "THE Sr. Louis DETOXIFICATION DIAGNOSTIC ANI~ EVALUATION CENTER" , INTRODVOTION The St. Louis DetoXification Cėntet~ has. beer'in'~erEtioh since `November 18, 1966 under funds provide~ by grant No, 93 fi~Om the `Office of;Law Enforcement Assistance; Act. ~be, follew,iig isa preliminary `evaluaUo~i o~f some of the re~u~ts achieved in the initial period of this operation. The underlying philosophy of the Center is a humanitarian theme which acknowledges that th~ `alcoholic offemler is a sick `lndlVidtta'l who invaltia%tarily `dispidys the sythptoms of his disease. It has long been recognized that.tbe "revolvir~g door" process of arrest, incarceration, release, and rearrest has no rehabilitatIve effect upor~ the. tutU- vidual. Rather than achieving rehabilitation, this process caused further harm and suffering to those individuals whom we might term `the chronic police case inebriate. Th~ Detoxificatiop Center is a major forward4ool~ng step in eliminating the "revolving door" process. It effectively removes these individuals from the criminal process and places them in the context of a medical, social and psycho- logical treatment milieu. The r~esults reported b~lOw, although prellmin~ry, demonstrate explicitly that the Center has been successful in both goals. In addition to these long range goals,, there exists a knowledge that criminally processing these individuals is a time consuming procedure which creates a heavy burden not only on law enforcement, but upon the courts and correctional sys- tenis as well. In terms of both the grant stipulations and the continued impact of the socio- legal reform movement in this area, a comprehensive evaluation of the Center is being carried out. The evaluation can be dichotomized into the following cate- gories. The macro-social category deals with the impact of the Center's operation on those agencies and institutions traditionally endowed with the responsibility for dealing with this social problem. This section will consist of a simple cost accounting procedure to weigh the costs of the treatment program against the costs of the continuance of the old criminal process system. Tangible gains would be in the form of patrol time saved, reduced clerical operations, adminis- PAGENO="0257" 251 trative efficiency and the reduction of supplies and other resources consumed in support of the criminal processing of these individuals. These savings on the part of the affected agencies and institutions, rather than reflecting budgetary excesses are in fact merely "paper economies" which show what proportion of their present resources may be reallocated to the other pressing problems' in our society. This report leaves aside the first category of the evaluation and focuses on the infra-social level of analysis. The clinical evaluation of the patient population for both before and after treatment gives the positive side of what can and has been accomplished by treating the revolving door chronic inebriate. As a demon- stration project, the Center has been a pioneering effort, particularly in terms of its sponsorship under the St. Louis Metropolitan Police Department. It is not, however, a demonstration in the sense that it is an untried or untested idea. This would be tantamount to saying that we need proof that treatment measures are better than current punitive procedures under the criminal justice system. There can be no argument that rehabilitation is better than simply punitive incarceration. It is rather the job of this evaluation to show how much better and in what ways our resources can be better utilized in 4ealing with the chronic police case inebriate. THIII CENTER IN OPERATION The first question which must be answered is simply, "Who are these people whom we are treating?" `Since the Center opened, until July 1, 1967 therO has been a total of 548 admissions. A profile of this group demonstrates that we are indeed treating the chronic police case inebriate, Some of the indices which clearly point this out are the demographic characteristics of race, sex, age, marital status, educational level, income, etc. By comparIson, the similarity between the patient population and the drunkenness offender for the year of 1906 shows high congruence. If we limit ourselves to those individuals who were arrested three or more times during the year 1966, the parallels are obvious. Average Percent Percent Pprcent Percent age male female White Negro 1966 arrestees (chronic) 494 91 9 71 26 Treatment group as of July 1, 1967 48. 1 91 9 83 17 A breakdown of the marital status of the treatment group lends further sup- port to the idea that we are reaching the target population for whom the Center was designed. Treatment group as of July 1, 1967 Percent Single 40 Divorced 27 Married 21 Widowed - 6 Separated 6 A further analysis of the treatment group yields the statistic that per ad- mission these individuals bad an average of 1.6 arrests during the year 1966. Many individuals have extensive police records, some of whom had in excess of 100 arrests for public intoxication previous to treatment. These personal characterI1i~ics are highly consistent with the findings of other studies of the skid row alcol~iolic or the chronic police case inebriate. The pa- tients averaged less than an eighth grade education. Approximately 47 percent of those admitted bad an eighth grade education, or less. Only 29 percent en.- tered but did not finish `high school, while only 24 percent have an education of high school or beyond. Less than 1 percent completed college. The average weekly income of the patients at the time of admission was $48.75. Fully 34 percent were not gainfully employed at the time of admission. Some of these, however, are receiving income through old age pensions, disability payments, and very few are on relief rolls. Not only can it be demonstrated that the Detoxification Center is dealing with the revolving door inebriate, but is also effectively eliminating the revolving door process in St. Louis. The Center is drawing from three out of a total of nine police districts. It serves those districts which accounted for 82 percent 93-453---68---17 PAGENO="0258" 252 of all public drunkenness charges registered in 1966. Below is a table which shows `the arrests for the time the Center has been in operation and the com- parable period of the previous year. December January February March April May June Arrest totals for previous year (1965-66) Arrest totals while center in operation (1966-67) Decrease of (percent) 205 82 60 162 56 66 145 64 56 223 76 66 221 84 62 173 75 57 202 86 58 These figures represent the total drunkenness offenses for the entire City. The foregoing data leave no doubt that the Center is indeed treating the chronic police case inebriate, for whom it was intended. EVALUATION OP TREATMENT PROGRAM Before proceeding with the patient analysis, an over-view of the referral network and after-care program is presented, Of the 548 patients admitted as of July 1 of this year, approximately 7 percent are leaving before the end of the seven-day treatment~ This is a very low percentage considering that the treatment program is administered on a purely voluntary basis. Another 8 per- cent of the patients were transferred to various state and city institutions to continue their physical and mental rehabilitaion. Many in this latter group without the treatment and diagnostic services of the Center would have suffered serious consequences, possibly even death due to other complicating diseases. The following dispositions can be reported for those who went directly back into `the community after treatment. Approximately 43 percent were found not to need assistance in employment. Seventeen percent were offered and ac- cepted referrals for employment. This then is 60 percent of the patient popula- tion who upon their return to the community bad a productive self-supporting role to fulfill. Fully one-third or 33 percent were offered employment assistance but refused our help in this area. Many of these people stated they preferred to "make it on .their own." Another 7 percent were not offered employment assist- ance. For the most part, this latter group was composed of retired and/or disabled persons who received some form of support or were adjudged to be unemployable. In the area of housing it was found that 43 percent had a relatively stable residential setting to return to, another 23 percent were offered and accepted referrals for living accommodations. This means that approximately 66 percent of those returning to the community had adequate housing awaiting them. As in the case with employment, 33 percent refused referrals for housing. These were, in the main, individuals who preferred to return to the more familiar, though inadequate, accommodations they bad in the skid row environment. Less than 1 percent left the Center without the benefit of the offer of adequate housing arrangements. It was anticipated that since we admittedly are dealing with a chronic disease, a certain percentage of the patients would return for treatment more than once. In the more than eight months of operation since the Center has opened, the readmission rate is presently 28 percent. Seventy-six percent of the treatment group have been admitted only once. Another 14 percent have two admissions, while only 10 percent have been admitted more than twice since the Center opened. Although no complete statistics have been compiled to date, there do seem to be significantly fewer police contacts with the treatment group after treatment as compared to the arrest rate prior to the opening of the Center. Once one accepts the chronicity of this disease and is aware of the fact that on the average our treatment group has been unsuccessfully coping with their alcoholic problem in excess of 14 years, this readmission rate seems low, particularly in comparison with the revolving door process prevalent in some other major cities. The above results indicate the opportunities provided by the Center's treatment program and referral network. For the most part these individuals are the chronic police case inebriates who have become "institutionalized." Their life cycle exhibits not only a dependency on alcohol but also dependency on the various agencies and institutions of our society which contribute to the maintenance of their bare existence. PAGENO="0259" 253 PRELIMINARY CLINICAL EVALUATION Among those subjects being treated at the Center, a detailed clinical evalua- tion is being conducted on a sample to determine the rehabilitative gains from this therapeutic setting. The evaluation consists of a series of before-treatment characteristics on which each individual studied is rated. Follow-up interviews are conducted after a minimum period of 90 days from the patients' first dis- charge. Three areas are rated by the use of scales which have been developed specifically for this treatment population. The scaled items are residential accom- modations, employment and drinking patterns. The scales used are not presented in full in this report; however, a complete description of all instruments will be given in the final evaluation. At present the evaluation is past the mid point. One hundred patients have been located and follow-up interviews conducted. As the study is not yet com- plete, the findings in this preliminary report are tentative; however, these trends seem to he a good approximation of the final results. The data used for the before treatment measure are drawn from the patients' admission form~s, medical records, social histories (conducted by a social worker at the Center), and the records of the St. Louis Police Department. The simple before and after design was deemed most appropriate in that each patient would set his own standard in assessing any change. This retrospective-prospective model to a great extent avoids the necessity of establishing success standards. This rationale rests on two assumptions, first, that alcoholism is a progressive disease. Deterioration in the individual is markedly uniform in the alcoholic's life, this is particularly true for the chronic police case inebriate). Second, with- out some therapeutic intervention into the disease progression, the prognosis is hopeless. Succees then in this study rests on the ability of the measures to demonstrate either the arresting of the disease progress or improvement where found. The decision was made to focus on the qualitative changes after treat- ment. It was feasible to set up categories within some of these scales so that a continuum appeared imparting the qualities or ordinal ranking between classi~ fleations. ~fi~5 is made possible due to the above assumptions that in the advanced stages of alcoholism, there is a pronounced downward movement in the socio- economic ranking and, the clustering of certain variables (which are actually indices of socio-economic standing) is uniform enough to allow the generalizations implicit in the classification scheme. In dealing with the scale items, the lower the ranking the lower the socio- economic standing of the individual. For one to move into higher categories on any of these scales would represent a significant positive change in his life style since receiving treatment. RESIDENTIAL ACCOMMODATIONS The high mobility of this problem group has been characterized in a number of ways by the experts in the field of alcoholism. The homeless man stereotype illustrates the migratory patterns and social isolation of this group. This would seem to be of a piece with other personality and social characteristics of the indigent `a1coholi~ all of which points to his inability to assume responsibility and/or function in a stable capacity. This scale deals with tw~s correlated vari- ables: first, the frequency with which the subject finds shelter and, secondly, the type of shelter or lodging to which the individual typically has access. Ratings 1 2 3 4 5 6 7 Total Before treatment 6 5 8 20 28 11 22 100 After treatment 6 2 6 18 31 14 23 100 Of the first 100 patients evaluated, approximately 14 percent evidenced some significant improvement in their living arrangements. Eighty-three percent re- mained at about the same level of housing after treatment, while only 3 percent showed a decline in the frequency of shelter or the quality of their living ar- rangements. Below is a table which gives a breakdown number of individuals assigned to each category before and after treatment. On this scale a rating of four or lower would place the individual in an undesirable and/or unstable residential setting. PAGENO="0260" 254 In the before rating of these indivicjuals, 39 percent had what would have to be considered inadequate housing arrangements. In the after treatment rating, 32 percent were still in the categories which would have to be considered inade- quate. The average rating before treatment is 4.8 while on the after measure the average is 5.0. This is not an impressive change. A rating of four could be charac- terized as an individual who is a regular inhabitant of the missions, shelters and transient lodgings in or surrounding the skid area. This individual will aver- age six days a week in some type of shelter and finds himself sleeping in streets and alleys of the city iess than once a week. Category five is characterized as a structured environment such as a half-way house, accommodations with friends, relatives or some form of semi-permanent address with some food arrangements within the housing situation. The after treatment ratings (categories five through seven) indicate that 68 percent were at the time of the follow-up interview, living in a more or less stable structured or home-like environment. By far, then, the majority of patients after treatment had adequate residential accommodations. EMPLOYMENT Even with the progression of alcoholism, many of these individuals are still capable for some varying lengths of time to maintain their present job skills, if any, and to continue at a steady job. Progressively, as the individuals move lower find lower on the scale into the skid row environment, many other factors such as declining health, emotional instability, as well as such subtle factors as one's personal appearance, all enter to negate the possibility of steady employment. The employment scale takes into consideration both the type and frequency of employment. At the time of intake, 34 percent were totally unemployed; that is to say for a period of three months prior to admission these individuals had not been gain- fully employed. A rating of four or below would have to be considered under- employment. Categories five through seven may, depending on the individual's needs, i.e., dependents, housing, etc., be adequate for some of these individuals. The average rating for the first 100 cases evaluated was 3.8. This rating in terms of our scales must be considered inadequate by any criteria. The after-treatment ratings average 4.4. Although this is a statistically significant change, it would still have to be considered inadequate employment. Twenty-five percent of those followed-up bad shown some significant improvement in their work patterns. This means that they were either working with more frequency or had achieved some stability in an occupational role. Sixty-six percent evidenced no significant change either positively or negatively. The interpretation of this figure must be tempered by the fact that some of these individuals already had adequate em- ployment. We were unable to rate four of the individuals (or 4 percent) studied due to their being institutionalized for the majority of the time since their release. Only 5 percent according to our scales showed a decline in their employment. Rating 1 l 2 3 4 5 6 7 Total rated Before treatment After treatment 18 14 8 8 17 13 3 2 10 8 19 10 9 25 84 2 f3Ų 1 Excluded are 10 retired patients and 6 individuals receiving disability compensation. 2 4 patients at followup were institutionalized. This table shows 38 percent of the study group having "regular" employment as evidenced by a rating of five or higher at the time of admission. Forty-three percent bad achieved this level by the time of the follow-up interview. This latter figure of 43 percent is not indicative of the complete employment picture. Ten percent of the study group were retired and 6 percent received disability benefits, hence, a total of approximately 59 percent could be reported as self- sufficient to an appreciable degree three months afte.r receiving treatment. INCOME Since the modal occupation of the treatment population is casual day labor, income was best estimated on a per weekly basis. The gross average weekly income of the study group was $48.75 at the time of admission. This figure PAGENO="0261" 255 represents all forms of cash income including peti~iOns, disability payments, welfare, etc. Fifteen percent repoI~ted no income th ilib Ililake rating. `rho same was true of only 10 percent on the after-tF~itmēfit iIke~ure. At the time of the follow-up iritervl?w the average weekly inėo~ne for the ~tiId~r ~roup had riSen to $l~3.27 for a het average gaffi o1~ $4.52 per wthk. Sixteen of the study group ate responsible fot this increase. These, who shOwed improvemźht, averaged a rise in weekly income amounting to $21.92. Seventy-two percent remained at approx- imately the same level with 8 percent having decreased income. The remaining 4 percent were not scored as was the case with employment. HEALTH At the outset it was felt that the most immediate and marked effects of treat- ment were to be found in the areas of health. None of the evaluation team can claim competency in the area of medicine; hense, this measure froved to be un- scaleable. In an attempt to achieve some assessment, this evaluation is based on gross factors which are readily available during the interview process. In order to achieve a rating of "improved," the patient must display a significant change evidenced by such things as weight gains, increased appetite, cessation of or a decrease of polyneuritic pains, or the disappearance of other complicating symptomatology (DT's, blackouts, etc.). Fifty-six of the study group showed marked improved in their physical well-being based on the above factors. Thirty- five percent displayed no significant improvement and 9 percent showed a decline in overall health. For half of these individuals, the Centrr represented the first medical treat- ment they had received for alcoholism. Almost all subjects indicated during the follow-up interview that the care they received at the Center was the first sign, in a long time, that "somebody cared about me." The interviewers expressed the opinion that perhaps the therapeutic effects were even greater for the individual's mental health than upon his physical self. The mere fact that a seven-day prO- gram of nutrition, sanitation and mental hygiene would leave its effects on such large numbers of these individuals three months after the treatment period is evidence of the accomplishments which can be ixiade with thth group of "hope- less people." DRINKING The area of drinking is the most crucial test to be applied to the treatment program. Rehabilitative gains in any other area must be seen as temporary unless a concommitant improvement is displayed in the indi+idual's drinking patterns. The question is not simply a matter of sobriety or inCobriety so much as how well the individual copes with his problem. Primarily, this scale measures the frequency and duration of the drinking bouts in ratio to the periods of sobriety as representative of one's ability or inability to deal with his depend- ency on alcohol. At the time of admission the medical rating was category I. This rating repre- sents a prolonged drinking pattern wehre the individual woi1ld hav~e~to be drink- ing steadily (daily) for more than two months pti~oi~ lb i~ątihg and the quantity of alcohol consumed would have to exceed a~rproximateiy two fifths of wine or one fifth of whiskey, gin, vodka, etc. per day. The average ratimig on intake was 2.9. On the basis of our experience with these scaiCs it would appear that a rating of four or lower negates the n1~intenance of any semblance of a~le- quate functioning in the areas of familial or employment roles or a stable residential setting over any appreciable length of time. Seventy-six percent of the paitents admitted were rated four or below. The remaining 24 percent were marginal jn ~ function with any degree of normalcy. No one achieved a ratthg of seven at the time of admissioti. The after~treatment ratings showed 51 percent of the patients studied dis- playing some significant improvements in their ability to control their consump- tion of alcohol. Approximately 49 percent demonstrated no significant improved control, while only 3 iiercent actually deteriorated in their drinking pattern. The average rating achieved at the time of the follow-up imm~erview was 4.1 for an average increase of 1.2 in the study group ratings. The frequemicy distribu- tion of ratings was bi-modal being equally distributed with 21 individuals in both categories 1 and 7. For the categories of 5 through 7 which could permit some degree of stability or normalcy to prevail in the individual's life style we now find 51 percent after tteatmeni as opposed to only 24 percent prior to treatment. PAGENO="0262" Ratings 1 2 3 4 5 6 7 Total Before treatment 31 18 12 15 15 9 100 After treatment 21 12 9 7 14 16 21 100 Following are two histograms which graphically illustrate the transitiotis in ratings achieved from the before-admission drinking patterns to the after-treat- ment drinking patterns displayed at the time of the follow-up interview. ~` r~- 12 -9 RATD:cS BASED 0i~ DiW~KING PATTERi~S 256 These results greatly exceeded those anticipated by all concerr~ed. Fully 21 percent of the study group had been for all practical purposes dry since discharge until the time of the follow-up interview (see category 7). This time averaged a lapse of approximately 120 days of total sobriety. Certainly, by any standards, this 21 percent would represent unqualified success in treatment outcome. Below is a tahie of the ratings for the before and after treatment measures. Befor~ Treatment 31 30 2S 20 18 S 0 DflIEXINC SCALE Total Rated 100 TotaL Rat~id 100 1 .2 3 S 6 7 20 10 5 0* DISPLAYED - I (most sovore) to 7 (least severe) PAGENO="0263" 257 One of the unusual findings during this study was that Negroes were dispropor- tionately represented in this 21 percent who achieved what mi~ght be termed total success. Seventeen percent of the entire treatment population were Negroes. Eighteen percent of the study group were Negroes while 25 percent of the "drys" were Negroes. Of the possible alternative hypotheses, two are most reasonable and complementary. First, that the treatment they received initiated by a police contact was totally dissonant with all their expectations. In all cases the Negroes found themselves `better clothed, better fed and more well cared for than they could ever remember. Somewhere in the treatment process their initial disori- entation was turned into a positive motivational attitude. Although in retrospect the same process was noted with the white `patients it was perhaps not of the same degree. Another very plausible explanation of this finding is that perhaps the Negro subculture has not imposed quite the same rigid value structure upon these individuals as one would find in the more middle class oriented whites. This would mean that the Negro offender would not experience the same degree of guilt over his drinking problem and hence, as a result, have one less problem to deal with at the time of discharge. In all discernible characteristics the stdy group was representative of the total patient population, i.e., age, race, marital status, years of alcoholism, etc. One qualification exists; whereas females compose 9 percent of the patient population none was included in the follow-up study. Further, it was found that those achiev- ing a rating of 7 after treatment on the average had slightly higher ratings in the other scales before admission. The significance of this has been demonstrated in other studies of this type, namely, that the type of treatment administered is not the determining factor for prognosis so much as the social setting the individual is taken out of and the setting into which he is placed after treatment. The Impli- cations of this finding are even more crucial in a program designed to handle the "revolving door" clientele. A strong referral network and an intensive after-care program is essential. ARRESTS The area of arrests has been left until this point because of the scant data available. The seasonal nature of this type of arrest rules out comparing equal time periods before and after treatment. Further, a significant percentage of the patients had been residents of this area for less than one year; hence, any measure based on a comparison of specific months for the year prior to opening the Center or since its opening could be grossly misleading due to incomplete data. It is hoped that by the time of the final report this dilemma can be resolved satisfactorily. Earlier in the report the arrest figures for the City of St. Louis were cited showing a tremendous decrease. Even after adding the number of admissions to the current arrest rate there would still be a total decrease of 28 percent in police contacts with drunkenness offenders. The findings on our study group were an average of 1.6 arrests for 12 months prior to treatment as com- pared to an average of 0.4 after treatment. This latter figure is arrests plus read- missions over an average period of six months. This should be interpreted can tiously as the parameters of these figures have not been fully explored. However, it is safe to say that a significant decrease in police intervention can be noted after treatment. The following table is presented in summary. The interpretation of these figures should be unequivocal. Where improvement is reported, it must be of a significant magnitude to the extent that the individual has, at least in some areas of his life, reversed this deterioration process. Many individuals who have received ratings of "remained the same" may well be in the process of establishing a new claim on life. It may prove to be unrealistic for this evaluation to demand significant demonstrable change in such areas as housing and employment in a three or four month period. This idea would seem to be supported by the findings in the area of drinking which would indicate more improvement than shown in the other scales. Further, improved control over one's drinking pattern is certainly a precondition to improvement in the other areas of life. Markedly improved (percent) Remained same (percent) Deteriorated (percent) Unable to rate Drinking Employment Income 51 25 16 46 66 72 3 5 8 0 4 4 Health 56 35 9 0 Housing 14 83 3 0 PAGENO="0264" 258 Aside from this clinical picture one might ask the question "What has the impact Qf the Center been on the police ?" Other than arrest figures, man-hours, and increased efficiency, this question m~ty never be ahswered fully. The impact on the patrol officers has been as remarkable as in any other area under study. Many who were openly skeptical of the treatment program have expressed un- qualified enthusiasm as a result of some of the Center's success cases whom they have known. Some have even gone so far as to volunteer their services both on and off duty in any way that they might further the treatment program. St. Louis has always had a non-punitive approach to the problem of public intoxication. At the individual level officers are so sensitized to this problem that they have donated clothing and other useful articles to the Center. The ac- ceptance of the treatment program on the part of the line officers could not help but be recognized ~5rhen investigators In this research began to hear of informal shuttling procedures being conducted so that an individual would be found in one of the districts being served by the Center. Mr. Roonus. And any suggestion you have as to how this could best be incorporated into the community health centers that we already have authorized. This is most helpful, and this is what we need, some specific information. Mr. PITPMAN. Thank you, sir. Mr. ROGERS. Thank you. The next witness is Mr. F. Morris Lookout, industrial representa- tive, Tulsa Council on Alcoholism. We ltppreciate your presence here. STATEMENT OP P. MORRIS LOOKOUT, INDUSTBIAL REPRESENTA.. TIVE, TULSA COUNCIL ON ALCOROLISI4~ Mr. LooKouT. Mr. Chairman and members of the committee, my name is F. Morris Lookout, and I represent the Tulsa Council on Alcoholisth, Tulsa, Okia., for which I serve as industrial representa- tive. It is indeed an honor and a privilege to appear before this distin- guished committee-and I thank you, Mr. Chairman, for the oppor- tunity to testify in support of the Alcoholism Rehabilitation Act of 1968. In my position with the Tulsa Council on Alcoholism, I am pres- ently working with 30 business firms in the Tulsa area. Each of these firms now recognizes the significant impact of alcoholism on their company productivity. They also know by experience that it is much more profitable for them to treat their alcoholic employees and to rehabilitate them than it is to deny that the problem exists and to discharge summarily those employees with drinking problems. This enlightened concept is now implemented by many firms of the Nation's business community. Eastman Kodak, North American- Rockwell, Western Electric, Pittsburgh Plate Glass, and many other major firms across the country have recognized the economic feasibil- ity of rehabilitating alcoholic employees who, aside from drinking problems, have proven to be productive employees. I deal primarily in education, yet I know only too well there must be a balance between education and treatment. I know that before an alcoholism rehabilitation program can work for a company, it must have therapeutic resources to which the alcoholic employee can be referred. In Tulsa, and throughout Oklahoma, such facilities are rare and, in terms of the need, totally in~dequate. PAGENO="0265" 259 Thus, in view of jhe Supreme Court decision to be hai~ded down within the next 2 months, which is likely to make it unlawful to hold alcoholics criminally liable for public drunkem~es~ charges, the very limited number of facilities now available for treatment of company employees and others with less complicated cases of alcoholism, will be overwhelmed with caseloads found by the courts to be alcoholics. The provisions of title III, part A, of H.R~ 15758 would make possi- ble, immediately, the implementation of a much-needed alcoholism treatment program within the Tulsa `Community Mental Health Cen- ter and other community mental health centers throughout Oklahoma. Without new facilities we face the same grave situation as was the case here in the Nation's Capital following the Ea$tei~ decision. Comprehensive programs of alcoholism care and control must be- come a part of the pivotal, basic institutions of our society. The provisions of title III, part A, of H.R. 15758 will provide a very con- structive beginning to such needed comprehensive programs. It will provide a stimulus to legislators and to a broad spectrum of allied professional disciplines. And, as more and more of these key persons become interested and involved, more professionals will seek the train- ing provided by title Iliji, part A, of H.R. 15758. That industry is vitally concerned throughout Oklahoma, not only in their own obvious stake in the problem of alcoholism but in the broader social and cultural implications, is evidenced by the fact that I am an ex officio member of the Tulsa County Bar Association, serving as technical adviser to its grievance committee, and I also serve as tech- nical adviser to the Tulsa Division of the State Department of Cor- rections. These extra activities resulted from my industrial contacts. I am a full-blooded American Indian and have a great interest in the problems of the Indians in this country, and I know that alcoholism is one of the most serious of those problems. I also know that, in those municipalities with a significant Indian population, the Indian con- tinues to be jailed for public drunkenness on the slightest provoca- tion. Yet the major proportion of these Indians are suffering from the illness of alcoholism. They should be treated as sick people and not as criminals. I am therefore doubly pleased with the provisions of the alcoholism bill, title III, part A, H.R, 15758. It will serve a longstanding need from the business community standpoint, it will provide congressional intent that all alcoholics should be treated medically and not as criminals, and it will provide Federal resources to help accomplish a more humane and effective method of dealing with this tremendous problem in all communities. Thank you, Mr. Chairman. Mr. ROGERS. Thank you very much. We appreciate the testimony you have given. Mr. Nelsen~ Mr. NELSEN. I have no questions. I wish to compliment the gentle- man for his appearance. I wondered, are you acquainted with Congress- man Reifel from South Dakota? Mr. LooKouT. No, I am not. Mr. NELSEN. He is a Sioux Indian, and he speaks the Sioux language. He is a competent Member of Cougress, and he is very concerned about PAGENO="0266" 260 the American Indian. He served with the Indian Bureau for a number of years. You should meet him while you are here. Mr. LooKouT. I will do this. Thank you. Mr. ROGERS. Dr. Carter? Mr. CARTER. I want to compliment the gentleman on his excellent presentation. . Mr. ROGERS. Our next witness is Richard S. Cook, Chief, Division of Alcoholism, Illinois Department of Mental Health, Springfield, Ill. STATEMENT OP DR. RICHARD S. COOK, CHIEF, DIVISION OP ALCO- HOLISM, ILLINOIS DEPARTMENT OP MENTAL HEALTH; ACCOM- PANIED BY WILLIAM N. BECKER, JR~, ASSISTANT CHIEF, ALCO- HOLISM PROGRAMS Mr. ROGERS. The committee is delighted to have you here with us this morning. We will make your statement a part of the record following your summary. If you will, just sum it up for us. Dr. COOK. I would like to introduce to you Mr. William N. Becker, Jr., who is assistant chief of the alcoholic programs in our State. Mr. ROGERS. We are delighted to have you with us, Mr. Becker. Dr. CooK. Mr. Becker has worked for many years with alcoholics in our State institutions. I have worked an equally long time with emphasis on outpatient care. I would like to bring to you the wishes of Hon. Gov. Otto Kerner, who yesterday indicated that I should convey his request to you for the passage of this bill. Also, the director of our department of mental health is in full support of this legislation. I would like to read part of my statement to you. The State of Illinois has forged ahead in providing a continuum of services on a statewide basis. We believe that bill, H.R. 15758, is a wise, timely, and urgently needed step in the right direction. We urge its passage to provide the leverage enabling the delivery of a full range of services to alcoholics at different levels of severity and varying stages of their illness. In endorsing this bill wholeheartedly we feel it incumbent to remind the committee that at present with the combined facilities available we treat less than 10 percent of the alcoholics in Illinois. This bill reflects the needs of the Nation and has been hammered out of pooled experience of thousands of people in close cooperation with the legislators here in Washington, D.C. Those of us working in this difficult field believe that this pending legislation shows that you have heard us and have written down pronouncements and rules that go a long way to establish direction with us and to implement our efforts to gain control over this vast public health problem. I would like to turn to the situation in Illinois to illustrate how well this legislation can fit with the progress in the State with regard to comprehensive community medical centers and comprehensive com- munity mental health centers. While it is occurring throughout the State, I would like to focus on the metropolitan area of Chicago, where the problem of alcoholism is especially acute. PAGENO="0267" 261 In Chicago the city has been divided into many areas for medical and mental health planning. Plans are being made as rapidly as pos- sible, translated into actual programs involving construction, assem- bly of staff, and offering of services. It is most timely that we in the section on alcoholism programs be enabled to urge the appropriate authorities to include in their planning, programing, and services a complete continuum of care for the al- coholic in Chicago. We believe that the time is now for reestablishing the alcoholic as a legitimate patient for coverage in every mental health, public health and welfare program. We believe each community throughout the State should provide the entry and some responsibility for the con- tinuum of services for the alcoholic, and that it can he obtained through a program as provided in this bill. We have been successful in Chicago in persuading some general hospitals to accept alcoholics for treatment during the acute phase of intoxication. We are providing a program of follow-up care designed to meet the need of each particular patient. rrhis comprehensive service for the alcoholic is in accordance with other welfare programs throughout the State. To carry out this conception of establishing facilities for alcoholics in all of the newly planned and realized medical, mental health, public health, and welfare programs we need the provisions of this bill which amends the Community Mental Health Centers Act. We have plans, we have ideas for special facilities, and we are eager to carry through with research. We urge that you make these hopes and visions attainable through enactment of this legislation. (Dr. Cook's prepared statement follows:) STATEMENT OF RICHARD S. Coos, M.D., CHIEF, ALCOHOLISM PROGRAMS, STATE OF ILLINOIS DEPARTMENT OF MENTAL HEALTH The State of Illinois has forged ahead in providing a continuum of serviees to aicholics on a statewide basis. We believe that Bill HR-45758 is a wise, timely, and urgently needed step in the right direction. We urge its passage to provide the leverage enabling the delivery of a full range of services to alcoholics at different levels of severity and varying stages of their illness. In endorsing this Bill whole- heartedly we feel it incumbent to remind the Committee that at present with the combined facilities availa~jle we treat less than 10% of the alcoholics in Illinois. This Bill reflects the needs of the Nation and has been hammered out of pooled experience of thousands of people in close cooperation with the legislators here in Washington, D.C. Those of us working in this difficult field believe that this pending legislation shows that you have heard us and have written down pronouncements and rules that go a long way to establish direction with us and to implement our efforts to gain control over this vast nublic health problem. It is clear that three powerful forces are tied together by this Bill. One force is the combined effort of the 50 states to deal with alcoholism and to find ways and means of coping successfully with its many aspects. This involves highly trained specialists in increasing numbers who have reflected and expended great effort to learn about alcoholism. This force has been substantially aided by grants from such agencies as NIMH, VItA, and other Federal agencies. The second force which exerts power by accelerating change is that of the Fed- eral courts. The pending decisions by the Supreme Court regarding the status of the chronic alcoholic is setting in motion already many agencies, public and private, which must meet the potential thrust of new conditions. If it comes to pass that the acutely intoxicated man cannot be arrested for public intoxication if he is a chronic alcoholic, then the jail must be replaced by health agencies in PAGENO="0268" 262 dealing with the chronic alcoholic. It is not news that available facilities are woefully inadequate to measure up to the consequences of the possible Supreme Court decision. The third force is that of the Congress `of the United States which can act to consolidate the power of the national effort thus far and `the possible tumultuous consequence of the Supreme Court action. The eiiactme'nt of favorable legislation could add the greatest impetus `to the national effort in the management and re- habilitation of the chronic alcoholic. Thus, we from Illinois see greatly the immediacy and necessity of the passage of this superbly conceived bill. I would like at this moment to turn to the situation in Illinois to illustrate how well this legislation could fit with the progress in the State in regard to compre- hensive community niedical centers and comprehensive community mental health centers, While it is occurring throughout the State, I would like to focus on the metropolitan area of Chicago where the problem of alcoholism is especially acute. In Chicago the city has been divided into many areas for medical and mental health planning. Plans are being made `as rapidly as possible, translated into actual programs involving construction, assembling of staff, and `the offering of services. It is most timely that we in the Section on Alcoholism Programs be enabled to urge the appropriate authorities to include in their planning, programing, and services a complete continuum of care for the Chicago alcoholic. We believe that the time is now for re-establishing the alcoholic as a legiti- mate patient for coverage by every new medical, mental health, public health, and welfare program. We believe sincerely that each community throughout the State should provide the entry and some responsibility for this continuum of serVices for the alcoholic and that it can be most effectively attained through a comprehensive alcoholism program, as provided in Bill JIR-1~7~8. We have been successful in Chicago in persuading some general hospitals to accept intoxicated alcoholics for treatment during the phase of acute intoxication. Pollowing the medical management we are providing a program of follow-tip care Which will be designed to meet the particular n~eds of each patient. This comprehensive planning of services for the alcoholic is in accord with other health and welfare planning programs throughout the State. To carry out this conception of establishing facilities for alcoholics in all of the newly planned and realized medical, mental health, public health, and welfare programs we need the provisions of this Bill which amends the Commtinity Mental Health Centers Act. We have plans, we have ideas for special facilities, and we are eager to carry through with research. We urge that you mahe these hopes and visions attainable through enactme~it of this legislation. Mr. ROGERS. Thank you very much. Mr. Nelsen? Mr. NELSEN. No questions. Mr. ROGERS. Dr. Carter? Mr. CARTER. No questions, Mr. ROGERS. I recall the testimony received from the Bureau of Mental Health in operation in. Illinois, and from the Governor, too, and the work that you had done there served as a model, somewhat, in drawing this legislation. Do you anticipate these centers will be run in conjunction with your community mental health centers? Dr. CooK. We are trying to provide treatment of alcoholics, but we feel we need funds through grants to enable the alcoholic to be treated. Mr. ROGERS. Would you anticipate that perhaps a wing would be built onto the community mental health center? Dr. CooK. Yes, it could work like that. I talked to Dr. Paul Neilsen, who is head of the Mile Square Area Community Mental health Center, and in his plans, he envisages a building for, say, the care and treatment of alcoholics after the acute phase. He is willing to treat them in his hospital for acute intoxication and then have an after- care program in another building less expensive to operate. PAGENO="0269" 263 Whether this is a new building or he would take over an existing building, he would include the alcoholics. Mr. ROGERS. Would you have a detoxification center, in effect? Dr. CooK. We don't want a separate, large detoxification center. We would like each medical center to accept and treat the alcoholic. We are providing funds for detoxification. We will pay on a con- tractual `basis, or we could establish a unit with funds from some source in a medical or mental health center. Mr. RoGERs. Would you let us `have a rundown on `how you would do the operation of this? Mr. BECKER. We have recently submitted a proposal for a grant, and approximately $350,000 from the State legislature for this pro- gram `of buying medical care for the indigent alcoholic. Funds would also come from public aid to purhase medical coverage. The idea is to `contract for these services on a per diem basis. Par- ticularly in the city of Chicago, we have a problem. In any one given day, we would have anywhere from 150 to 200 patients coming in. This could soon inundate a single program, so we are in the process of continuing to develop `citywide programs in concurrence with the comprehensive `health program services. Each of these programs will utilize the hospital in t'hat area. We will contract with them for their medical services in aiiy one year. Mr. ROGERS. Wha't is the estimate of your population of alcoholics? Mr. BECKER. Using the information we have, our public health statistics indicate we have in excess of 500,000 alcoholics in the State of Illinois. Over 80 percent of these reside in the Greater Chicago area. During 1967 we admitted `on a voluntary basis somethixig like 7,000 alcoholics, and over 4,509 of these were in the Greater Chicago area. So we `have `been involved in the detoxification process for a long time. We do need the opportunity for some comprehensive backup support that this comprehensive bill would supply. Mr. ROGERS. Are y'ou having any success with bringing about abstinence'? Dr. CooK. We are having a good deal of success in our State hospital program's, but what we are trying to do `is keep the alcoholic in his local area, in his `community ~or detoxification, and refer him there for f'oll'owup care, and save our State hospitals for special treatment centers for the a~ic'o'holic `who needs 30, 60, or more d'ays of continued treatment. Mr. ROGERS. Do you get into the treatment of narcotics? Dr. COOK. In our State we have a council on narcotics, which is established by the legislature and appointed by the Governor. Mr. ROGERS. Do you handle th'is in your program yet? Dr. Coon. Not yet. The pilot project is being established to try to determine what would be the best statewide program for narcotics. Mr. ROGERS. What is your narcotics population? Dr. `CooK. About 60,000 would be an estimate. Mr. ROGERS. Thank you very much. If you would, let us `have a breakdownon your operation. Dr. `CooK. Yes, sir. (The following information was received by t'he'committee:) PAGENO="0270" 264 STATE OF ILLINOIS DEPARTMENT OF MENTAL HEALTH, Springfield, III., April 1, 1968. Hon. PAUL G; ROGERS, Comm4ttee on Interstate and Foreign Commerce, U.S. House of Representatives, Washington, D.C. DEAR CONGRESSMAN ROGERS: First may we extend our appreciation for the privilege of appearing before your Committee. We hope that our contribution may help in some small way to assist you in reaching your decisions. As you recall, during the Committee Hearings you requested information on our General Hospital Detoxification Program which I am enclosing. Again, our deepest appeeciation, and should you feel that we can be of assist- anc to you in any way, it will only be necessary for you to so advise. Sincerely yours, WILLIAM N. BECKER, Jr., Assistant Chief, Division of Alcoholism. Enclosure. PROJECT Section on alcoholic programs, Department of Mental Health, deto~if1cation program PROPOSAL To provide emergency care for acutely intoxicated indigent persons in general hospitals. In this proposal the main emphasis is on a situation which involves the Chicago metropolitan area but it is our intention to include the entire state in our plans to offer care to acutely intoxicated patients. RATIONALE During the past five years it has become increasingly apparent to the Section on Alcohol Programs of a need for a program of mass management of the acutely intoxicated person at the community level. It is common knowledge in the field of alcoholism that the federal government, and the Nation as a whole, is becoming vitally aware of the need for more adequate care and treatment of the acutely intoxicated person. It is equally known that (a) the Supreme Court of the United States will issue a decision regarding compulsory care of the inebriate, the acutely intoxicatel, and the chronic alcoholic; (b) that the American Bar Association and the American Medical Association are jointly sponsoring model legislation to assure the appropriate medical management of the alcoholic; (c) that the President of the United States recommended the "Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968" (ilL 15281) (Appendix V) to the 90th Congress, With full knowledge of the above, the Section on Alcohol Programs strongly proposes the immediate establishment of a pilot project for the mass management of the acutely intoxicated and/or inebriated and/or the chronic alcoholic. In addition to preparing for the effect of the inevitable legislative action, this proposal will have a marked effect on the management of our present problem with acute and chronic alcoholics. During the last nine months of the last fiscal year, 1,830 persons were assigned to the Department of Mental Health facilities through the hospital referral service for chronic alcoholics. (Appendix I), It is estimated that, as of 1967, there are in excess of 500.oOo alcoholics in Illinois with the majority of them residing in Cook County. Utilizing 1967 statistics provided for us on February 13, 1968, by the Department of Mental health Data Processing Division, there were 7,059 admissions to the Department of Mental Health for alcoholism, representing 30.3% of the total admissions to thirteen state hospitals and four zone centers. (Appendixes H and IV) Our experience with this increasing number of alcoholic patients, particularly in the metropolitan Chicago area, indicate the following: (1) that the ma- jority require medical management; (2) a large number of these patients do not want, will not, or cannot accept or benefit from treatment or rehabilitation in the alcoholism programs provided in our state hospitals; (3) a substanital number of this group could benefit more by being treated for the acute phase of intoxication and then referred to a variety of ancillary programs for appropriate Care; (4) a reasonable number require no emergency medical or psychiatric care but do require direction for the above mentioned ancillary programs; PAGENO="0271" 265 (~) that once these patients are inappropriately assigned to our state hospital alcoholism programs (a) they will continue to return, (b) they are inclined to leave before medically discharged or recommended discharge, (c) they tend t~ interfere with more effective programming for those who are more able to benefit f rum the programs. OBJECTIVE To establish a cooperative program between the Department of Mental Health, Section on Alcohol Programs, the Illinois Department of Public Aid, and the Cook County Department of Public Aid; To provide emergency psychiatric care of indigent persons in general hospitals for acn'te intoxication; To short-circuit the general flow of the alcoholic patient away from the state hospital alcoholism programs to the community agency programs. PROGRAM In response to this situation, we have developed a program which provides medical treatment for acutely intoxicated patients in certain acceptable general hospitals. (Appendix VII) Hospitals, where this care can be given, are available. Aside from the money requested by this grant, the cost of this care will be covered by payment from the Department of Public Aiēl and its county repre- semta:tives in situations in which patients are eligible for coverage for medical expenses. We believe that some category of assistance will compensate for this ~ervice in a majority of cases. In other instances the cost will he paid by the pa:tient's insurance, family, or by the patient himself. However, funds requested in this grant are vital because there will be a significant group of patients unable to pay from personal resources and yet not eligible for payment through any of the categories of assistance available through Public Aid. Funds from this grant request, also, enable us to assure each participating hospital against loss incurred through caring for our indigent patients. This program will include the entire state, depending upon where this programming is indicated and where local arrangements permit its development. The present most pressing situation is in metropolitan Chicago. It is our expectation that this program will be a solution, or a very substantial step toward a solution, of the three conditions which we have long recognized as needing correction. This innovation of service is much more far-reaching in its implications. First, it is a step toward anticipating the tremendous demands, previously mentioned, which these changes will make on our health services. A, second significant point is that this program is very much in keeping with the current decentralization of health services in general. We believe that it makes much better sense to treat the alcoholic patient in his own community and in existing health facilities or in those facilities which are being planned than to direct further effort toward establishing special installations for the care of the acutely intoxicated at this time. The providing of medical treatment in general hospitals for acutely intoxicated people is only one phase of our plan. The question of intake is highly relevant. At the outset, patients would be admitted chiefly from the Hospital Referral Serivees and from the admitting service of other to be dsaignated programs, but our chief mission is to pick up patients before they arrive at state hospitals. Since our program includes several general hospitals, we include a "clearing center" which would keep carefully compiled information regarding the move- ment of patients in and out of beds set aside for acutely Intoxicated patients. This clearing center would s'erve all sources of referral, both in and out. Also, our net work of ancillary programs will be expanded to permit referral for ongoing aftercare. (Appendix VI) At the outset, this program would not be sufficient to deal with all patients seeking hospitalization because `of acute intoxication. For example, `this program would have to be greatly expanded before it could accommodate the hundreds of intoxicated patients who are now jailed daily until they recover from the acute stages `of intoxication. The criteria for admission for medical treatment of the acute intoxicated would involve the following: (1) acute intoxication with or without compli- cations; (2) indications that the patient cannot he restored to a n'ontoxic state in hi's home; (3) `acceptance of hospitalization on a voluntary basis; (4) behavior compatible with `admission to a general hospital. PAGENO="0272" 2~6 The period of hospftalj~a.tion would be brief, three to five d~ys, in as many instances iL~ po~t4~lbie, Scfeei~ing `ann diagnosis would be done before discharge as much ~s ptactjčabič, btit `thi~ eóüld b~ `čO~npletčd at the cioaring center. Based on the seree~itig and diaguiosia, an aftercare plan will be thade on each case with appropriate referral to existing facilities in the ared ~1O~es~ t~ *heu~ the patient resides. Referral could be to outpatient clihies, state hospital programs, halfway hoases, missions, service centers? vocational re1~abllitation, Veterans Adininis- tration, eińployjment agencies7 and public aid. Emphasis will be on follow-up from the very ~utset, although this is & very challenging task. We visualize this program a's a model for future e~p~nSion into both exisfing and planned medical se1~iees. IMPLEMENTATION Tentative plan~ hive been made with three Chicago area genenal hospitals to initially involve themselves in `this project. (Appendix VI) An attempt has been made to dete~,mine a per diem cost ~or each of the Participating hospitals based on the latest cost analys~s, as published by the Department of Public Health, Pending the approval of tbio grant, we have received a fir~n a&reement with the Martha Washington Hospital (Appendix VII) tentative per diem anlounts from Alexian Brothers and Grant Hospitals. As indicated in Appepdix VII, the per diem rate for Martha Washington would be $50 and it would appear that the other two hospitals would vary between that amount and $60. The per diem amounts that we, are attempting to establish with the `Participating hospitals include all charges excepting surgical and Psychiatric services, Where it can be readily assessed that the patient requires either prolonged or intensive care for conditions other `than detoxification, he would not be referred to this program. Realizing that over 3,000 patients were admitted to Chicago area state hospitals in 1967, and that the rate of alcoholism admissions across `the state rose 2,000 patients in 1967 over 1966, it would be extremely difficult to immediately meet the obvious needs, rather it is our intent to establish a pilot program with whatever funds are available and to `extend the program as additional funds become available from other `sources. BEQUEST In view of the above, the Section on Aleųhol Prograp'~s request~ your con- `sid6ration ~f funds in the amount of $250~0oQ for the remaihdQr of the present biennium. These funds augmen~ed by funds from the Depgrtn~en~ of Public Aid and the cost sharOd by third parties, in behalf of our pa~iei~tS, will en~b1e us to establish a pilot program for the m'anagemep~ of the indigent a~pOholic Patient in *the nietropolitan Chicago area. Recognizing that the same problem's exist in other arčd~ throughout the state, we further recommend consid~ration of an amount of $100,000 to seed these programs where other funding and programs are not `available. ADMINISTERING AGENTS That the Section on Alcohol Prog~aths be re~ponsible for the `administration and supervision of the funds reques~e~, APPENDIX I (Following Paragraph extrapolated from Departme~~ of Mental Health Annual Iteport-Juiy 1960-June 1967.) The number of persons with a primary diagnosis of alcoholism continue to comprise more than one third of the non-emergency applications processed through this Unit, During the last nine month.s of the past fiscal year eighteen hundred and thirty (1830) persons were assigned to Department of Mental Health facilities as chronic alcoholics. Many had previous records of hospitai iza- tion. This group of patients demand services, and all too often misuse available facilities. Many are in Reed of medical attention, which is often denied at the only medical resource available to them. Many are undomiciled, estranged from families, and unemployed They see in Department of Mental Health facilities PAGENO="0273" 26r7 a temporary room and board situation as Well as a place where medical attention is availa~leif s~eeded. It is felt repeated r~tquest for reaGmission may be due to it lit~l~ of kdequilte services for the alcoholic in our facilities, a~ well as a lack of motivation for change on the pitrt of the patients. This writer is aware of the shortage of staff and space, however, a more concentrated effort to coordinate our present resources may prove definitive in the care and treatment of the alcoholic. APPENDIX II Estimated number of alcoholics in Illinois according to the Jelliaek estimating formula, calendar years 1952-66 Estimated number of Year: alcOholics 1952 308, 150 1953 333,450 1954 322,250 1955 303, 100 1956 331, 350 1957 358, 600 1958 341, 750 1959 360, 750 1960 371, 250 1961 372, 800 1962 392, 650 1963 404, 850 1964 413, 200 1965 403,650 1966 1~o,15o 1967 (plus) ~50o, 000 Subject to revision pending reporting of new facilities. 2Pending Revision. Source: Department of Mental Health, Division of Planning and Evaluation Services, Statistical Research Section, June 30, 1967. APPENDIX Ill MALE ADMISSIONS TO ILLINOIS STATE ~IOSPITALS, FISCAL YEARS 1954-66 Year Total admissions Alcoholic admissions Percentage 1954 8, 314 1955 8,0113 1956 9,179. 1957 9,707 1958 9,~24 1959 8,972 1960 9, 703 1961 ~. 10,044 1962 10,361 1963 9, 9111 1964 10,244 1975 11,467 1966 12,951 1967 - 2, 95~ 3,141 3,860 4,433 3,918 3,565 4, 142 4,279 4,120 4, 094 3,955 4,665 5,263 7,059 30, 5 311.9 42.1 45.7 420 ~g-~ 42. 7 42.6 39.8 41. 0 38.6 40.7 1 41. 4 ~30.3 1 Subject to revision pending reporting of new facilitied. 2 Pending revision. Source: Department of Mental Health, Division of Planning and Evaluation Services, Statistical Research Section, June30 1967. 93-453---68-----1S PAGENO="0274" 268 APPENDIX IV Admission of patients to Illinois state hospitals with a diagnosis of al~ohol4sm fiscal year 1953-66 Number oJ Year admissions 1953 3,233 1954 3,287 1955 3,470 1956 4,247 1957 4,861 1958 4,283 1959 3,937 1960 4,487 1961 4,695 1962 4,556 1963 4,499 1964 4,346 1965 5, 140 1966 15,906 1967 27,059 1 Subject to revision pending reporting of new facilities. 2Pending Revision. Source: Department of Mental Health, Division of Planning and Evaluation Services, Statistical Research Section, June 30, 1967. APPENDIX V NORTH AMERICAN ASSOCIATION or ALCOHOLISM PROGRAM, Washington, D.C., Pebrnary 15, 1968. NEWS MEMORANDUM Re: The Administration Alcoholism Bill. To: All members. From: A. H. Hewlett, Executive Secretary. Following through on President Johnson's alcoholism legislative recommenda- tions contained in his recent Crime message to Congress, Representative Harley 0. Staggers (Democrat-West Virginia), chairman of the House Committee on Interstate and Foreign Commerce, has introduced the "Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968." This bill (HR-15281) would amend the Community Mental Health Centers Act to include three new titles-one for Alcoholic Rehabilitation, the second for Narcotic Addiction, and the third a gen- eral title relating to the funding of both. Title I-Alcoholism. The proposal would add "Part C-Alcoholism" to the Community Mental Health Centers Act and would provide: A. Construction grants for facilities for the prevention arid treatment of alco- holism. Such grants may be made only to public or nonprofit private agencies or organizations, the applications of which must meet the requirements for ap- proval set forth in clauses 1) through 5) and clause (A) of Section 205(a) of the Community Mental Health Centers Act. Applicants for such grants would be required 1) to show the need "for special facilities for the inpatent or outpatient treatment, or both, of alcoholics"; 2) to show satisfactory assurance that the services would be principally for persons residing in or near the particular community or communities in which the facility is to be located and that the facility services will provide at least those ~essential elements of comprehensive mental health services, and services for the prevention and treatment of alcoholism, including post institutional aftercare and rehabilitation that are prescribed by tile Secretary of HEW; 3) to assure that the application has been approval and recommended by the single State agency designated by the State as being the agency primarily responsible for care and treatment of alcoholics in the State, and, in case this agency is different from the agency designated as the Mental Health authority, assurance must be shown that the application has also beei~ approved and recommended by the Mental Health authority; 4) to show that the project is entitled to priority over PAGENO="0275" 269 other projects for treatment of alcoholism; 5) to show that adequate provision has been made for furnishing needed services for persons unable to pay in accordance with regulations of the Secretary under Section 203(4) and for com- pliance with State standards for operation and maintenance; 6) the amount of any such grant may not be in excess of 66% percent, as the Secretary may determine. B. Staffing, Operation and Maintenance Grants under Section 261 of the Com- munity Mental Health Centers Act may be made to any public or nonprofit pri- vate agencies and organizations for new facilities or for new services in existing facilities for prevention and treatment of alcoholism. Grants under this section would be made only on applications meeting require- ments under part B of the Mental Health Centers Act. In making such grants, the Secretary would consider relative need for services, population of the area to be served and financial need. Federal matching funds would be available over a 10 year period, the first year of which the Federal percentage would not be more than 90%, 80% for the second year, 70% for the third, 60% for the fourth and 50% for the next 6 years. C. Specialized Facilities. Grants from appropriations under Section 261 of the Mental Health Centers Act would also be made for projects for construction, operation, staffing and maintenance of specialized residential and other facilities, such as halfway houses, day care centers and hostels, for the treatment of home- less alcoholics. Such grants would be made only for facilities which 1) are affiliated with a community mental health center meeting the essential elements of comprehen- sive community mental health services prescribed by the Secretary, or 2) are not so affiliated but with respect to which satisfactory provision (as determined by the Secretary) has been made for appropriate utilization of existing community resources needed for an adequate program of prevention and treatment of alcoholism. D. Short Title. This part (everything outlined above) is to be cited as the "Alcoholic Rehabilitation Act of 1968." Title IT-Narcotic Addiction. HR-15281 would further amend the Community Mental Health Centers Act to include "Part D-Narcotic Addict Rehabilitation" which would provide: A. Grants under Section 261 to assist in projects for constructing, operating, staffing and maintaining treatment centers and facilities (including post hos- pitalization treatment centers and facilities) for narcotic addicts within the states. This grant program, as it deals with the kinds of activities authorized by parts A and B of the Mental Health Centers Act will be carried out consistently with the grant programs under that Act except to the extent that in the Secre- tary's judgment, special consideration would make differences appropriate. B. Grants may be made beginning July 1, 1968 through June 30, 1970 to public or nonprofit* private agencies and organizations to cover part or all of the cost in 1) developing specialized training programs or in~terials or in-service training or short-term or refresher courses with respect to the prevention and treatment of narcotic addiction; 2) traIning personnel to operate, supervise and administer such services; and 3) conducting surveys and field trials to evaluate the adequacy of the programs for prevention and treatment of narcotic addiction. Title Ill-General. HR-15281 would anthoribe appropriations for both parts above-to begin July 1, 1968 through June 30, 1970, to provide such sums as may be necessary (to be determined by Congress) for project grants for construction, operation, staffing and maintenance of facilities described above. Further, appropriations beginning with the years July 1, 1970 through the next eight years would be authorized to be made for continuance of those projects begun prior to June 30, 1970. This title would further amend Part B of the Community Mental Health Cen- ters Act to add a new section (Sec. 225) for "Facilities Relating to Rehabilita- tion of Alcoholics or Narcotic Addicts." This new section would specify that alcoholism or narcotic addiction projects undertaken by community mental health centers would come under the requirements and provisions set forth in the new titles proposed for alcoholism and narcotic addiction outlined above. Cost of Administration. This bill would also amend the Mental Retardation Facilities and Community Mental l{ealth Centers Construction Act of 1963 to provide up to one half of the administration expenses annually except that not more than 2 percent of the total allotments for any one year, or $50,000, which- ever is less, shall be available. PAGENO="0276" PAGENO="0277" 271 Mr. ROGERS. Our next witness is Dr. Isadore Tuer1~, commissioner of mental hygiene, State of Maryland, accompanied by Mr. Harry Schnibbee. STATEMENT OP DR. ISADORE TUERK,, REPRESENTING THE NA- TIONAL ASSOCIATION OP STATE MENTAL HEALTIt PROGRAM DIRECTORS; ACCOMPANIED BY HARRY C. SCHNIBBEE, EXECU~ TIVE DIRECTOR Mr. ROGERS. We are delighted to have you here, gentlemen, and appreciate your presence. Mr. TUERK. I am Isadore Tuerk, M.D., commissioner, Maryland Department of Mental Hygiene. I am here today representing the National Association of State Mental Health Program Directors, and I am accompanied by Mr. Harry C. Schnibbee, executive director of the association. The members of our association are responsible for the administra- tion of the major portion of the residential and outpatient public mental health programs in the United States. We administer 1,161 treatment facilities, both residential and outpatient. We have under treatment annually 1,500,000 perso~is. Last fiscal year the State mental health program directors admin- istered programs funded at $2.4 billion, which is 21/2 times bigger than all other State public health programs combined. In 31 States the director of the State mental health program is also responsible for administering the treatment program for alcoholics, and virtuaJly all major, public narcotic addict treatment programs are under the administration of our members. It is from our experience in administering these vast public pro- grams, and especially the alcoholism programs, that I wish to speak today. Mr. Chairman, in general we endorse and support both the objec- tives and the specific approach of H.R. 15758. Alcoholism and drug addiction are serious public health and social problems. The impact of alcoholism in terms of human suffering, phys- ical illness and complications, financial and economic loss, disruption of family life, highway accidents, and suicides, is incalculable. Physicians and psychiatrists and other professional personnel have only recently begun to involve themselves with the important problem, despite the fact that for some time the American Hospital Associa- tion and the American Medical Association have urged that alcoholism be considered a disease and that physicians and general hospitals pro- vide treatment for the alcoholic. There has been encouraging progress in the treatment of the alco- holic, but still much needs to be learned in coping with this grave disorder. Alcoholism is a chronic illness which cannot be treated cx- clusively in a hospital setting, and any attempt to evaluate the effec- tiv~ness of the treatment program must depend upon the availability of a wide variety of treatment facilities, programs, and resources. Individual psychotherapy, group therapy, antabuse, Alcoholics Anonymous, tranquilizing drugs, general health mailagement, churches, industrial counseling, family group therapy, utilization of family agencies, welfare departments, departments of education, PAGENO="0278" 272 schools, parole and probation, courts, labor, et cetera, are all valuable and necessary elements in a comprehensive approach to the treatment of alcoholism. A comprehensive community mental health center program should include among its elements facilities and programs for the treatment of the alcoholic. The comprehensive community mental health center is in a strategic position to integrate the many resources and programs necessary for a coordinated comprehensive approach to this probleni. The elements of a spectrum of services in a broad approach to this problem would include detoxification centers, treatment of the acute phase of alcoholism in a general hospital, inpatient treatment for such complications of alcoholism as delirium tremens or acute hallucinosis, general hospital care for such complications as cirrhosis of the liver and peripheral neuritis. Halfway houses, diagnostic clinics, outpatient long-term treatment resources, public health nursing, long-term rehabilitation centers for `the chronic alcoholic who had little or no personal resources', shelters for those who have reached the point of chronic dependency with no capacity for rehabilitation, with our current knowledge of the treat- ment of this illness. Many of these programs can be related to a community mental health center. Some should begin to develop apart from community mental health centers, particularly where such centers have not yet come into existence but could then become affiliated with, and integrated with, community mental health centers as they emerge. The following motion was unanimously adopted by the members of the National Association of State Mental Health Program Directors in meeting at the Drake Hotel, Chicago, Ill., March 14,' 1968: The proposed Federal alcoholism legislation should provide mecha- nisms to strengthen services to alcoholics and drug addicts and en- courage the development of these services as components of programs of comprehensive community mental health services rather than as separate autonomous units. Federal support of such developments, both in terms of concept and in terms of financing, will go far in overcoming current resistances to developing programs, and will emphasize and stimulate the urgent desirability of including programs in behalf of the alcoholic in the community mental health services now taking shape throughout the country. Another powerful factor at work is the judicial decisions which have already occurred and which are now in the process of being formulated by the Supreme Court making it illegal to punish the chronic alcoholic for public intoxication and requiring his treatment as a sick person instead. Drug addiction and drug abuse have become significant in recent years as challenges to psychiatric and medical knowledge `and enter- prise and have provoked professional leaders to develop liaison with other innovating personnel in the antipoverty programs and the war on crime. Drug `addiction and drug abuse play salient roles in the perpetuation of poverty and in the incidence of crime. Effective treatment program's and prevention programs in the areas of drug addiction and drug abuse should have an important impact PAGENO="0279" 273 upon the reduction of illness and human suffering, but also in the reduction of crime and the alleviation of poverty. Treatment of drug addiction is still a very perplexing `and difficult problem. It requires more than an inpatient j~rogram. The experience of hospital programs alone has been that fairly prompt rel'apse into drug addiction occurs upon the release of the patient back to the community. An effective spectrum of services would require treatment of addicts in the community with such measures as methadone, counseling by cured drug addicts, vocational rehabilitation, vigilant monitoring of urine for evidences of relapses, appropriate involvement of courts and probation officials, ministers, general practitioners, public health nurses, family agencies, and Narcotics Anonymous. Facilities should include hospital programs, clinics, self-help groups such as Syn-Anon and related residential treatment centers and half- way houses. Many addicts who are incarcerated after having committed a crime should be prepared for return to the community by appropriate programs in t'he penal institutions. Many addicts have concurrent problems with alcoholism, and both problems need to be treated by professionals knowledgeable in `both fields. It is imperative that research and evaluation be an important part of the approach to the treatment and prevention of alcoholism and drug `addiction. Education of industrial leaders `and management is important in enabling both addicts and alcoholics to regain effective roles as citizens through appropriate employment. As is the case with the alcoholics, the community mental health centers would be in a strategic position to coordinate and integrate a great variety of programs and resources in behalf of the addict. However, I would w'ant to emphasize that many such programs for the addicts may need to start prior to the `development of community mental health centers and then become integrated into the total pro- gram of the community mental health center as it evolves. It is my hope and concern that facilities `and programs for the alcoholic's and drug `addicts, which are a part of comprehensive com- munity mental health centers, will not compete with the amount of money available to such centers, `but will attract sufficient fund's from the Federal sources to add to available financing for existing com- prehensive community mental health centers and community mental health centers whic'h will come in'to existence in the future. As in the case for the alcoholic, so would it be in the case of the addict, that Federal support and stimulation of programs in behalf of drug addiction will encourage professional personnel, hospitals, community mental health centers, community mental health services, to bring to bear whatever talents are available in coping with a serious threat to the health and social well-being of this Nation. I now wish to address myself, Mr. Chairman, to a particular section of the bill, page `6, section C', starting at, line 6 `and ending at line 14. This matter involves the efficient administration of the new program. The section on page 6 says that an application for a grant for con- struction of alcoholism facilities may be made only if it contains satis- PAGENO="0280" PAGENO="0281" 275 Mr. Chairman, I now refer to section 305 on page 14 of the bill. This section adds language to the Community Mental Health Cen- ~ers Construction Act of 1903, providing for a set-aside of 2 percent of the construction money allotted to each State. This 2 percent, when matched 50-50 by the State, is to be used by the State, for "proper and efficient" administration of the State plan for construction of mental health certters. This is a long-overdue amendment, and it was at the specific request of our association to HEW officials that this amendment was included in the draft bill sent to Congressman Staggers, which is now H.R. 15758. Matching Federal assistance to State central offices for admin- istration of Federal grant programs is an integral part of many exist- ing laws. Thus, there is broad precedent for adopting section 305 of the bill before you. Actually, this provision should have been in the original law, and this association was derelict in not forcing this i~suč several years ago. A provision similar to the one we now have in the bill before you has been in the Public Health Service Act for years. Section 606(c) (2) of the P115 act provides to the State Hill-Burton agency 2 percent of the federally allotted money for administration of the State plan. Last year your committee initiated a bill, which became Public Law 90-170, which authorized each State to use for administration purposes up to 2 percent or $50,000, whichever is less, of the $30 million Federal allotment for construction of facilities for the mentally retarded. In the Elementary and Secondary Education Act there is admin- istration money available to the States under several sections of the act: Five percent is available to the States for administration of the school library resources program. Five percent is available to the States for administration of the edu- cation of handicapped children program. One percent is available to the States for administration of the Federal school aid programs for education of children of low-income families. The maximum amoitnt of money available to a State agency under this provision is $150,000. Seven and one-half percent is available for administration of the supplementary educational centers and services program. The maxi- mum amount of money available to a State agency under this pro- vision is $150,000. Under the Vocational Rehabilitation Act as amended, section 2, authorizing grants to States for rehabilitation services, provides that a portion of the State allotment may be used by the State agency for administration of the program. There is no limitation on the amount of money the State agency may request for this purpose. You will note, Mr. Chairman, that in several instances the maximum sums available to the States for administration of the various Federal programs is $150,000. In the bill before you the sum, on line 20 of page 14,, is $50,000. We consider this an inadequate share, and we recommend that the sum be $100,000 per State. The Federal Government through this fiscal year will have granted about $125 million toward development PAGENO="0282" 276 of community mental health centers in the States. The States are administering this $125 million with no Federal help. Iii Public Law 90-170, extending the mental retardation centers program, the Congress allowed $50,000 per State for a $30 million annual program. The community mental health center program in- volves annual grants twice the size of the Public Law 90-170 program, or $60 million. The administration proportion should be $100,000. PROGRAM EVALUATION MONEY We suggest a further amendment of section 305, Mr. Chairman. We recommend the addition of language on line 19 following the word "part." Strike the semicolon and all language through line 24 and add the following language: and for evaluation of the programs, by the State agency, under Part A of Title II; except that not more than 2 per centum of the total of the allotments of such State for a year, or $100,000, whichever is less, shall be available for the purpose of administration for such year, and not more than 1 per centum of the total of the allotments of such State for a year, or $50,000, whichever is less, shall be available for the purpose of evaluation of programs for such year. Payments of amounts due under this paragraph may be made jfl advance or by way of reimbursement, and in such installments, as the Secretary may determine. Our proposed amendment would provide a small amount of money to each State central office, to be matched by the State, for purposes of evaluating the community mental health center program as it func- tions in each State. Again, there is strong precedent in recent Federal legislation for provision of funds to evaluate a program to determine its efficacy and judge whether or not the congressionally authorized and appropri- ated money is being spent wisely. In the Elementary and Secondary Education Act there are at least six separate sections of the law in which "program evaluation" money is made available. The Office of Education has asked the Congress for $14 million to fund these programs, most of which will be carried out by State agencies. In the extension of the partnership for health program, Public Law 89-749, which originated in this committee last year and passed the Congress as Public Law 90-174, you included "program evaluation" money for several parts of the law, namely: 314(d), 314(e), 314(c), 304 and 309. Your committee made the following comments about "program evaluation" in your Report No. 538 (August 3, 1967), and we heartily concur: As a basic tool of program implementation and development, evaluation is insurance that the health research, service, facilities, demonstrations, and re- lated activities proposed in this bi-1 will fully accomplish their purposes. Evaluation studies and analyses should be conducted to identify and extend the application of those program methods and approaches which show high suc- cess and to spot program weaknesses in time to permit steps to be taken to im- prove program performance. Although the funds available for evaluation will be a small fraction of those available for the programs which are authorized, no more than 1 percent, the committee feels that making these funds available for evaluation will contrib- ute substantially to the success of the programs proposed in the bill. What we now ask is that everything you said about the need for program evaluation be applied to the community mental health centers PAGENO="0283" 277 program, and we respectfully request that your committee adopt the amended bill language we have provided today in this testimony. Mr. Chairman, I thank you for your courtesy in hearing the testi- mony of our association today, and, as always, we stand ready to assist the committee and its individual members in any way that we can. Mr. ROGERS. Thank you very much. Your testimony is most helpful, and we have, I guess, all of your proposed amendments now. Thank you very much. Our next witness is Dr. Jacob Fishman, professor of psychiatry, Howard University College of Medicine, and director, Howard TJni- versity Community Mental Health Center. STATEMENT OF DR. 3ACOB PISHMAN, PROFESSOR OP PSYCHIATRY, HOWARD UNIVERSITY COLLEGE OF MEDICINE, AND DIRECTOR, HOWARD UNIVERSITY COMMUNITY MENTAL HEALTH CENTER Mr. ROGERS. We are delighted to have your comments. Dr. FISHMAN. Thank you. I appreciate the opportunity to testify as an individual here on behalf of the bill, and in particular on behalf of the alcholism and narcotics addiction programs contained therein. I would certainly like to lend my support for the alcoholism addic- tion components of these programs, particularly stress the importance of these programs in the poverty areas of our urban centers, since, as we all well know, alcoholism and addiction are a major problem in the mental health of the poor, particularly as they are related to the social, educational, employment, and psychological factors connected with poverty and the general problems of the urban ghetto. However, I am here particularly to speak to one aspect of alcoholism and addiction programs as they relate to community health centers, and that is to urge the committee to stress consideration of the em- ployment and use of local residents as nonprofessionals in new careers providing alcoholism and addiction services in these health centers. In our experience in community mental health work, we have found that there are enormous advantages to the systematic recruitment, training, and employment of such persons in the delivery of services. They increase the effectiveness of services in these communities because of their unique backgrounds in connection with the community and experience. They provide an important link between the professional and the client population, with whom frequently the professional has had little real life experience. They provide an important vehicle for helping people to help them- selves in the community, and they also provide an important potential vehicle in these local health centers for meaningful employment and career development for the poor. Now, this is true in general for community mental health programs. it is particularly true in addiction and alcoholism where we find that the use of ex-addicts and ex-alcoholics is a potential manpower re- source of very significant effect. Because of their previous personal experiences, contact with others in the community, and the knowledge of their own living situation, when they are given structured training, en~ployment opportunities and career potential as nonprofessionals in these programs, they give PAGENO="0284" 278 very important, extremely significant assistance to the professional in providing treatment and rehabilitative services for alcoholics and addicts. In fact, there are some who feel that in many ways you ean'~ run an effective program for alcoholics and addicts without the use of such subprofessionals providing a kind of treatment resource. I would urge you to emphasize this approach for the staffing and organizational patterns for these centers. And, in fact, if it were possible to c~evelop an ~mendmexit to the existing legislation for com- munity inehtail health centers to provide foi' the development of sys- tematic programs for the uste of such subprofessionals in new careers, I would urge that, too. It is especially important in developing manpower resources for these centers to recognize that today there is an extreme shortage of trained manpower for all community mental health programs, par- ticularly for alcoholism and addiction. This manpower shortage focuses on some of the basic problems in the philosophy of approach to treatment. We have found in our či~perience iii Washington, and in many other communities of the country, that in reassessing the issue of manpower utilization in these centers (which I must add is an extremely urgent problem for all centers and all programs) a great deal can be gained by considering the use of local residents, employing them and providing them with subprofessional careers in these programs. It gives the subprofessional and the people in the community a way of participating in the development and delivery of services in their own commuthty, which has generally been denied by the typical staffing pattern in which the middle-class professional who lives in the suburbs spends the hours 9 to 5 in the ghetto and knows little else about the lives of the people there. The use of such people adds a new dimension to these programs, and we feel it is essential to their implementation. I would further urge that it is extremely important in the develop- ment of this model to consider the need for upward mobility possi- bilities so that these people do not wind up, as has been generally the pattern in health services, in dead-end jobs, doing low-level tasks, without the possibility for educational or financial advancement, or for new responsibility. Such career ladders, when linked with more experience and training, provide additional opportunity for the poor, particularly the Negro poor in our communities, to move into responsible positions in hetdth services which are generally denied to them because of existing educa- tional, training, and employment barriers. The current opportunities as nursing assistants in a variety of health service programs provide only dead-end situations for these people. Consequently, the turnover is rapid, there is a great deal of frustra- tion, and their potential as a treatment resource and real help to the professional is generally lost. We find enormous benefit for the center and the community as a whole. I would urge the committee and the people who will be making operational such centers and programs to develop systematic and struc- tures programs for subprofessionals and professionals in new careers PAGENO="0285" 279 in alcoholism, addiction, and in all the other components of the com- munity mental health center so that health services can be significantly improved and these people provided an opportunity for advancement. Thank you. Mr. ROGERS. Thank you very much. Let me just ask you: Have you done this in your center? Dr. FISHMAN. Yes, we have; in all fields, including alcoholism and addiction. Mr. ROGERS. How many people have you used in this capacity? Dr. FISHMAN. We have at this point trained and utilized 70 to 80 such people. Mr. ROGERS. Have they been given the opportunity to advance? Dr. FISHMAN. Yes. We have developed three levels of subprofes- sional advancement, beginning with the aide, on to the mental health assistant, mental health associate, and mental health technician. Mr. ROGERS. Do you give them education aloug with the in-house training? Dr. FI5HMAN. We have programs to supplement the training, and are now negotiating with the Washington Technical Institute for a joint program that could lead to an associate of arts degree. Mr. RoGERS. It might be well if you gave us your setup. Dr. FISHMAN. I would be glad to. (The following information was received by the committee:) STATEMENT OF DR. JACOB FISHMAN, DIRECTOR, HOWARD UNIvERSITY COMMUNITY MENTAL HEALTH CENTER, ON CAREER DEVELOPMENT AND RELATED PRAINING AND EDUCATION FOR PERSONNEL IN THE MENTAL HEALTH PROGRAM In the past several years of experience with job and career development and related training and education we have found the following to be critical elements in the success of any such programs: i. JOB DEVELOPMENT The creation of permanent subprofessional positions in community mental health facilities or other agencies which can lead to career advancement is the ultimate test of the acceptance of a new level of personnel. Without such posi- tions, training of mental health aides can have no real effect as a vehicle for social change or delivery of services. The initial step, therefore, should be an analysis of structure and manpower needs of the facility, the climate of acceptance or resistance to Innovative ap- proaches, and the possible ways in which the subprofessional can help fill some of the gaps in the delivery of services in the community. Usually the mental health aide job description includes primarily community outreach functions and group leadership. It is the mental health aide who pro- vides treatment assistance to the professional team and acts as liaison between the alcoholic or the addict and the professional staff. 2. CAREER LADDERS The availability of opportunities and career steps that will enable a person to move toward a desired career is necessary for continued motivation. This re- quires a linkage of the products of job development into a series of entry level, second, third and fourth level jobs with the potential for upward mobility built in. Local educational resources can provide the necessary training programs and certification for movement from one jo~ to the next. This is a crucial component of the model and requires the combined efforts of the employing agency, civil service and the educational institution. An example of the career ladder as used for the mental health aide in the Community Mental Health tk~nter is PAGENO="0286" 280 a. Community Mental Health Aide b. Community Mental Health Assistant c. Community Mental Health Associate d. Community Mental Health Technician For each step upward on the ladder there are increased responsibilities, addi- tional in~service training, increaised salary and decreased supervision of the subprofess'ioual by professional staff. 3. TRAINING The most important goals of New Careers training for entry level positions are: a. To prepare the trainee in the shortest possible time to successfully and responsibly undertake the duties and roles of the entry-level position; b. To ensure that the trainee, in his on-the-job training is quickly given `the responsibility of performing relevant and meaningful tasks, and c. To provide the trainee with a number of basic skills and attitudes that can be put into practice in the job as soon as possible. This provides him opportunity for identification with a role and for the reception of feedback on skills and performance. It allows the individual as well a's others to see his competence, `and is the liaise on which further skills can be built. This, train'ing for role rather `than simply learning a set of skills is an important `and successful approaeh~ In `order to get maximum returns from the `training peogra'm, several principles should be followed. First there should be training in generic issues as well as specific entry-job training, `basic training in a particular human service area, and remedial training. These training elements should `be provided within the con- text of a small group. Secondly, the're should be basic generic training `in `a par- ticular area of human services such as health or mental health. There should also be specialty skill training for the `specific entry position. Lastly, a super- vised `on~the-job work training experience is essential for each trainee. 4. EDUCATIONAL LINKAGES The first step in career oriented training for disadvantaged a'nd under-edu- cated people must be directed toward enabling them `to acquire high school equiv- alency diplomas. Some aecrediting agencies, for example, the District `of Colum- bia Board of Education and the New York State Board of Regents, have pro- vided guidelines for high school and college accreditation of work experiences and on-the-job training. For advancement beyond the high school level, to the associate of arts or bachelor's degree, linkages must be established between the community educa- tional institution and the human service agency, in which the school would pro- vide `accreditation for `on-the-job training and field placement, as well as assist- ance to the agency in j~b `and career development. 5. TRAINING OF TRAINERS For many of the professioi~als, this will be the first experience in training or supervising disadvantaged people. They will have many un~poken doubts about the ability of trainees to be `of any help to other people and about their `own ability to te'ach or supervise the trainees. Therefore, careful training and prepa- ration of trainers and orientation of employing agency staff is `a necessary com- ponent of the New Careers training model. Without thiS `there is loss of motiva- tion, confusion, `conflict between trainees and professionals, and loss of effective- ness. Dr. FISHMAN. We have been particularly gratified with the results, contrary to the usual expectations that these people would have oniy dlfficultles, and that the "vulnerable could not help the vulnerable." Mr. ROGERS. We would be happy to have material on that. Dr. FISHMAN. I will be happy to supply it. (The following information was received by the committee:) PAGENO="0287" 281 STATEMENT OF Da. JACOB FISHMAN, DIRECTOR, HOWARD UNIVERSITY COMMUNITY HEALTH C~NTER, ON PARTICIPATION OF SUBPROFESSIONAL AIDES IN REHABILITA- TION TREATMENT PROGRAMS In several years of experimentation with such training programs at the Howard University Institute for Youth Studies and in other research centers in various parts of the country, it has been found that this approach is highly successful. Two brief examples of this kind of program follow: 1. A group of 125 youths, ages 17 to 21, who were school dropouts or unem- ployed, with multi-problem backgrounds, were trained and employed in the human services, including mental health, education, welfare and child care. During training, students were assisted in working toward high school equi- valency and increasing their general knowledge and skills. Eighty-seven percent of the trainees finished the training program and were subsequently employed. A study done from one to two years after employment began showed that 52 Per- cent were still in the same jobs in human services and each job change had been accompanied by an incrOase in salary. 2. A program was developed at Cardozo High School in Washington, D.C., for similar students which combined human service training with the regular curric- ulum leading toward both a diploma and a certificate of training. Part of the day was spent in classroom work, part of the day in supervised on-the-job train- ing in local human service agencies. The trainees received stipend's for the latter. Students were selected from the bottom of the class. On graduation, these stu- dents filled jobs in the agencies in which they were trained. A few went on to higher education such as community college or college. Half of these students spent their on-the-job training as classroom aides in elementary schools and half as health aides in local health facilities. There are several programs in Washington, D.C., which have demonstrated success in the use of ex-addicts and ox-alcoholics in treatment centers. The D.C. Public Health Department has a Drug Addiction Treatment and Rehabilitation Center in Northwest Washington. Over half the staff are ex-addicts who have been trained at the center to work with addicts. There are five Drug Addiction Counselors, at the GS-5 level and five Mental Health Aides at GS-4. These sub- professionals assist the other staff in such areas as determining which of the patients are sincerely motivated in the direction of breaking the habit, and which are trying to "work the system," as well as tasks such as screening, intake records, and therapeutic techniques. At the Rehabilitation Center for Alcoholics (RCA) at Occoquan, Va., another D.C. Health Department facility, 65 subprofessionals are employed as alcoholic counselors. A large proportion of the counselors are or have been alcoholics, themselves, and are currently members of Alcobolic~ Anonymou,s. They were trained at RCA and are rated at the GS-7 level. Their duties include security, training, control and counseling. Each counselor acts' as "house father" for a group of eight patients which he follows throughout their stay at Occoquan. The counselor orients the patient to the program at RCA, teaches good work habits, conducts the Alcoholics Anonymous program, refers the patient to pro- fessional staff members for medical or other services when necesSary and in general observes, evaluates and advises. The close relationship developed between the counselor and the patient enhances the therapeutic aspects of rehabilitation. The use of local community residents' as subprofessionals in alcoholic and nar- cotic addict rehabilitation centers has' been proven successful in various programs throughout the country. The subpro~fesslonal increases the effectiveness of serv- ices in these programs because his background and familiarity with the com- munity from which he comes enables him to provide the important link between the client and professional, where it possibly would not otherwise exist. The important therapeutic effect on the subprofessional, his family and his com- munity cannot be overlooked. Significant and lasting `behavioral change has been found in these people, through training and employment for nonprofessional careers in mental health and other human services. The concept of helping oneself through helping others is an aspect of this effect. The local resident now undertakes to deliver the services of which heretofore he was only the dependent recipient. In addition, this is a most significant answer to the critical problem of training effective manpower which is now confronting alcoholism, addiction and other mental health programs. New Careers training can provide a motningful em-- PAGENO="0288" 282 ployment and career npportunity for the chore population. I would like to urge the committee to emphasize in this legislation the use of local residents and former addicts as subprofessionals ~n New Careers in these programs. Mr. RooFils. Thank you very much. Our next witness is Dr. Gerald L. Kierman of Yale University and director of Connecticut Mental Health Center. STATEMENT OF DIL `GERALD L. KLERMAN, ASSOCIATE PROFESSOR OP PSYCHIATRY, SCHOOL OP MEDICINE, YALE UNIVERSITY, AND DIRECTOR OF CON1~TECTWIlT MENTAL HEALTI~ CENTER Mr. RoGEns. We appreciate your presence. We will make your state- ment a part of the record, following your summary. Dr. KLERMAN. We welcome the proposed legislation, and in par- ticular I wish to support those provisions which link these new special- ized facilities for alcoholic and drug-dependent and narcotic indi- viduals to the newly developing mental health centers. I will not read the entire statement, but I would like to address myself to one question that came up earlier. The question has come up: "Why make these centers part of the community health centers?" "Why not create separate centers for alcoholism and drug addition?" My belief and experience indicates that the development of separate facilities unrelated to community health centers would be a serious error, and I would like to offer a number of reasons for this judgment. First, there is substantial evidence that alcoholic and narcotic addict patients have a high proportion of associated medical and psychiatric conditions. These require active involvement, consultation, and collaboration with neurologists, internists, and other health specialists. Our Connecticut Mental Health Center, like many other c~enters, is located adjacent to a general hospital, to which it is linked archi- tecturally, and programmatically. Thus we have `available X-ray, laboratory, surgical~ and other treatment resources on an immediate basis without red tape. Second, I wish to emphasize the desirability of treating the indi- vidual in his own community. Treatment at distant resources, even such excellent ones as Lexington and Fort Worth, have unfortunately resulted in high rates of relapse when individuals are returned to theii~ own communities. Programs of after-care are needed, and these require the continued involvement of the patient's family, neighborhoods, clergymen, and local institutions. This is true where the new drug techniques are being used. Mr. ROGERS. May I interrupt there? How is methadone used. You say you are using this? Dr. KLERMAN, We are about to initiate a project on long-term methadone therapy. Mr. ROGERS. Have you not yet gotten into this program? Dr. KLERMAN. Not yet. We have used methadone in the withdrawal phase. In order to initiate such projects~ you must be in continual contact with the addict, there must be facilities for special laboratory PAGENO="0289" 283 tests, as well as for pharmacy and for other things. This can only be done in the local community and if the person in treatment has a sense of trust and rapport with the treatment team. I feel that a community resource has a distinct advantage. Ideally the same staff treating the patient during the acute detoxifiaction and rehabilitation phase should be involved with the patient in the fob lowup phase. The third reason is that cooperative linkages already exist with established community agencies such as police, social welfare, and neighborhood groups through present programs developed in many community mental health centers. The effectiveness of on~oing al- coholism and narcotic addiction programs, I believe, can be increased by strengthening existing linkages rather than having to establish new ones. Fourth, our experience and the experience of others mdicaites that the families of addicts have associated emotional problems, and a more comprehensive approach is more readily facilitated. Fifth, recruitment of qualified and experienced personnel who are scarce. Currently, the areas of alcoholism and addiction do not have made public acceptance. Integration of mental health centers with this program, particularly those linked with medical schools and hospitals will help recruitment. I have discussed this problem with Mr. Ernest Sheppard, of our department, and with Dr. W. B]oomberg, Commissioner of Mental Health. We all agreed that one of the major obstacles to the develop- ment of quality programs in these fields has been the resistance within the health professions to assume an adequate responsibility for these important public problems. This is evidenced by inadequate instruction upon these topics in medical schools and in training programs for psychiatrists, social workers, nurses, et cetera. Moreover, only a small fraction of mental health professionals are devoting themselves to the sub-specialties. There is an air of pessimism and an air of pervasiveness that these are hopeless. Our society continues to attach stigma to these con- ditions. While this legislation would go a long way to improving this con- dition, I would like to recommend amending the regulation for men- tal health centers so as to make the inclusion of facilities of addicts and alcoholics part of them. The current regulations do not include these important public health areas as necessary components for community mental health centers. In my opinion, consideration should be given not only to permissive legislation, but to a future mandatory requirement, so that a community center with specialized facilities on panels for alco- holic and drug addiction must be included along with the existing five essential components of in-patient, out-patient, emergency, partial treatment and education. I reajize that this proposal may seem radical to some of my col- leagues, but it is my prediction that within a decade we will come to expect that just as emergency treatment in today's hospitals is part of the mental health center, so will the treatment of alcoholism. I also wish to offer my special enthusiasm and support for section 252, which authorizes grants for training and evaluation of programs~ 95 453*--6S--------i9 PAGENO="0290" 284 We must acknowledge that our current treatments have only limited efficacy. However, new and exciting treatments are being developed, and there is promise that they will be joined by other techniques. The recent introduction of drugs such as methadone and cyclazocine is attracting bright young scientists and professionals into the field. However, research is needed to undertake field trials to assess the long-term efficacy of these programs. Investigation should include followup studies to ascertain the long- term consequencies of alcoholism and drug addiction. It is my conviction that the enactment of this legislation will fur- ther strengthen these programs. (Dr. Klerman's prepared statement follows:) STATEMENT OF GERALD L. KLERMAN, M.D., AsSocIATE PROFESSOR OF PSYcHIATRY, YALE UNIVERSITY SCHoOL OF MERIOINE AND DIREcToR, CONNEcTICUT MENTAL HEALTH CENTER My name is Gerald L. Kierman, MD. I am an Associate Professor of Psychia- try at Yale University School of Medicine and Director of the Connecticut Mental Health Center. The purpose of my testimony today is to support the proposed legislation to amend the Community Mental Health Centers Act to make provision for specialized facilities for alcoholics and narcotic addicts. My support for this bill is derived from my general experience in psychiatry and mental health, and my recent experience as Director of the Connecticut Mental Health Center in New Haven. It has long been my conviction that the problems of alcoholism and narcotic addiction are best treated as integral parts of a comprehensive mental health program `rather than in isolation. As part of this comprehensive program, I recoin- mend that adequate training be provided for mental health workers, general physicians, personnel in the police and law enforcement agencies, and other groups to enhance their understanding of `the nature and effects of alcoholism and drug addiction. I also strongly support the need for further research, especially in the development of new treatments. THE CONNECTICUT MENTAL HEALTH CENTRA AND THE NEW HAVEN COMMUNITY These convictions have been reinforced by very recent experiences in the year ar~d a half since the opening of the Connecticut Mental Health Center in July, 1966. Phce Connecticut Mental Health Center is a facility of the Connecticut State Department of Mental Health, and is operated jointly by that agency and Yale University School of Medicine. Located in the center of New Haven, imme~ diately adjacent to the Yale-New Haven Medical Center, it represents the first such facility in Connecticut. We are proud that while the center was initiated and constructed prior to the enactment of the federal program for community mental health centers. our building and program embody the essential elements called for by the federal legislation and regulations, including in patient and out patient treatment, day hospital, emergency treatment, and community con- sultation and edi~cation. Early in our operation we applied for and were awarded a National Institute of Mental Health comprehensive community mental health center stalling grant to support our activities in a catchment area composed of the Hill neighborhood of New Haven and the city of West Haven, a population of 80,000 persons. In addition to providing comprehensive mental health services for this eatehment area, we are involved in less intensive ways with the remainder of greater New Haven. Furthermore, as part of our university involvement we have major teaching and research programs in concert with our patient care and community activities. Let me say a few words about the Hill neighborhood, on whose periphery the Center is located. Phe Hill is a typical inner city neighborhood, with character- istic social unrest and high rates of mental illness, `accompanied by pervasive unemployment, sn~bstandard housing, poor schools, and racial discrimination. This neighborhood is in the midst of marked social transition; relatively large num- bers of Blacks and Puerto Ricans have moved in, following upon the exodus of PAGENO="0291" 285 Ithlian, Irish, and Jewish groups to the suburbs. This neighborhood was recently selected for `a Model Cities program. It was also, significantly, the neighbor- hood where the "riot" in New Haven broke out in August, 1,967. Yale Medical School is making major community health commitments `to' this neighborhood and our mental health program is part of this commitment. I mention these social factors because our experience indicates that in neighborhoods like this, alco- holism `and drug addiction are prevalent and are part of a destructive cycle. I shall return to this later. In the year and a half since the Center has been in operation we have learned that the extent of alcoholism arid narcotic addiction in this neighborhood and in all of New Haven is far greater than had either been expected or planned for. Moreover, facilities, staff, and skills are limited in these problem areas and we are not able to deal adequately with patients with these problems. NARCOTIC ADDICTION AND DRIJO DEPENDENCE Before discussing the programmatic aspects of narcotic addiction, I would like to say a few words about `the terminology. While it is true that narcotic addiction, particularly to heroin, is the most serious problem, there are other drug-related areas. We also recognize problems of 1) illicit experimentation such as glue sniffing and use of LSD and marihuana 2) misuse of medications in excess of recommended or prescribed dosage, and 3) abuse: the repeated exces- sive use of drugs short of dependence. We have also fou'nd it more useful to use the term "drug dependence" as recommended by the World Health Organization as having broader scope. Narcotic addiction thus is one form of drug depend- ence. I mention this because a community mental health program probably should best be designed to deal with all forms of drug abuse and drug dependence, not exclusively drug addiction. In New Haven, as in other cities, the predominan't, although not exclusive, involvement with narcotic addiction is through the use of heroin among young negro males. Members of my staff estimate that there are between four and six hundred active heroin users in the New Haven area, only a fraction of whom are known to medical or law enforcement agencies. At the Connecticut Mental Health Center we do not have specialized facilities for detoxification treatment or rehabilitation of narcotic addicts, nor do they exist anywhere else in the New Haven region. The nearest in patient facility is a't the Connecticut Valley Hospital, a state mental hospital thirty miles `away to which patients' must be escorted by ambulance or the police. This geographical separation creates special hardships for the family and social agencies, and limits programs for after care and rehabilitation. `Connecticut has recently enacted a far sighted and pioneering Drug Depend- ence Law which allows for treatment and rehabilitation as alternative's to crimi- nal sentencing. In the past two years, admissions `to public mental hospitals for drug-related problems have more than doubled, even before this law became operative in October, 1966. Judges, court officials, and probation officers tell us that existing treatment facilities are grossly inadequate. As a result, the goal embodied in this new legislation may be undermined because of inadequate facilities to care for those patients who can now be referred for treatment rather `than sent to correctional institutions. As a member of the recently estab- lished Connecticut Drug Advisory Board, I have become increasingly aware of the many difficulties encountered. My experience as' a psychiatrist has been supported by contracts with jurists, lawyers, and correctional officers. In Connecti- cut, as elsewhere, each of our communities, and particularly the urban commu- nities, need specialized facilities where detoxification, treatment, rehabilita- tion, and after care can be provided. We are especially interested in initiating treatment programs with methadone and cyclazocine, new drugs which, in early studies, offer hope for interrupting the cycle of illegal narcotic dependency and thereby facilitating the narcotic addict's rehabilitation to a useful and pro- ductive life. As I have mentioned, narcotic addiction has highest rates among underprivi- leged minority group's, especially young negro and Puerto Rican males. Our contact with neighborhood group's, including the black militants, indicates to us that within the inner city neighborhoods drug addiction is regarded as a problem of very high priority. Residents of the neighborhood and city officials insist that the problem is not being dealt with adequately, innovative and imag- inative programs for narcotic addicts offer critical opportunities to relate mental health to the racial crisis of our urban centers. I hope that the mental health professions will not avoid this opportunity. PAGENO="0292" PAGENO="0293" 287 family work, with a community mental health center than if the alcoholism facility or drug addition center are separated administratively, geographically, and architecturally. Fifth, recruitment of qualified and experienced personnel to separate facilities for these groups is difficult. Currently, these areas do not have the professional prestige and community acceptance they merit. Integration with community health centers, especially those linked to medical schools and general hospitals, will facilitate recruitment. It would also contribute to the needed cadre of expe- rienced workers who can train others while also educating personnel in associated health and social welfare fields. The question may arise as to why mental health centers and general hospitals cannot treat these patients within existing facilities and programs. We have learned that specialized facilities and equipnient, properly trained staff, and an accumulated body of knowledge and experience are required. Our attempt to treat alcoholics and narcotic addicts in our regular adult programs have proven frustrating and ineffective. Experience indicates the desirabIlity of specialized units with associated laboratory facilities and trained personnel devoted to these problems. I have recently bad discussions about this problem with Mr. Ernest Shepherd, Director of the Drug and Alcoholic Dependence Division of the Connecticut Be- partinent of Mental Health, Dr. Wilfred Bloomberg, Commissioner of Mental health, and other leaders in the Connecticut area. We are all agreed that one of the major obstacles to the development of quality programs for treatment and prevention in the fields of alcoholism and drug dependence ha~ been the resist- ance within the medical professions to assuming responsibility for these impor- tant areas. For too many decades, alcoholism and drug dependence have been stepchildren within the mental health family. This is evidenced by inadequate instruction on these topics in medical schools and in training programs for psy- chiatrists, psychologists, social workers, and psychiatric nurses. Moreover, only a small fraction of mental health professional have devoted themselves to these important subspecialties. Within the mental health profession there is a myth of fatalism and pessimism because of the pervasive conviction that these are hope- less conditions for which no effective treatment programs exist. While our treat- ments have their limitations, pessimism and fatalism are unfounded. The evidence indicates that properly integrated and supported programs can achieve substan- tial results in reducing mortality and morbidity, returning patients to the com- munity, aild facilitating their social and vocational readjustment. These professional attitudes are related to the stigma which our society con- tinues to attach to these conditions. Alcoholism and drug depedence have long been regarded as legal, rather than medical, problems. I am concerned that current attitudes toward alcoholism and drug dependence are similar to the attitudes toward the psychoses and other mental health problems held by our society a hundred years ago. Let us remember that when Dorotbea Dix began her crusade for humane treatment of the mentally ill, many were being treated as criminals, housed in jails and county poor houses, rather than in medical facilities. I think we are at a similar historical point in the social attitude toward alcoholism and drug dependence. A crucial turning point would be the transfer of these problems from purely legal and correctional approaches to medical and social welfare programs. While this legislation will go a long way towards improving this situation, I would recommend that, ideally, consideration be given to amending the regula- tions for community mental health centers so as to make the inclusion of programs and facilities for alcoholics and narcotic addicts among the essential and required services of community mental health centers. The current federal regulations do not include these important ttreas as necessary components of community mental health center programs. In my opinion, consideration should be given not only to permissive legislation, such as is proposed here, but also to mandatory requirements so that to be truly considered a community mental health center, eligible for federal funds for construction and staffing, specialized facilities and programs for alcoholic and drug addiction must be included in the plans. I realize that these may be radical proposals fec today, but it is my prediction that within a decade we will expect this, as we now expect that emergency treatment and day hospitals are parts of mental health eenter~ along with in patient care and out patient care. PAGENO="0294" 288 CONCLUSIONS In conclusion, I wish to offer my special enthusiam and support for Section 252, which authorizes grants for training and evaluation of the program. As our nation in general, and the mental health professions in particular, have come to realize the extent of the problem of alcoholism and drug addiction, we have also become aware of the inadequacy of trained personnel and the limitation of existing treatment methods. As regards training, it is increasingly apparent that because physicians, social workers, psychologists, nurses, and other profes- ionals are poorly trained in their fields, they have insufficient knowledge about the nature of narcotic addiction and the newly developed methods for detection, treatment, and rehabilitation. Most important~ we must acknowledge that our current treatments have only limited efficacy. New and exciting treatments are being developed, and there is promise that they will be joined by other new techniques. For example, the availability of methadone and cyclazocine, drugs I have mentioned previously, has attracted bright young professionals and scientists into this field by gen- erating new optimism. However, research is needed to undertake field trials and to assess the efficacy of these programs. This investigation should include follow up studies to ascertain the long term consequences of alcohholism and drug addiction and the success of treatment programs in promoting a healthy life of abstinence and family, social, and occupational adjustment. The National In- stitute of Mental Health has recently strengthened its research programs in these areas and the activities of its staff is having a beneficial effect throughout the mental health field. It is my conviction that the enactment of this legislation will further strengthen these programs. Thank you very much. Mr. RoGERS. Thank you very much, Dr. Kierman. In your mental health center, could you let us have your staffing and the number of people you serve? Dr. KLERMAN. I would be delighted to. (The information requested was not available at time of printing.) Mr. ROGERS. Is the number of people you serve connected with any number of alcoholics? Dr. KLERMAN. We do not have the specialized facilities we would like. Our estimates indicate that about 10 percent of our admissions have associated problems of alcoholism and drug dependence, but we know we are turning away people with these problems. And large numbers of them still go to the State hospital at Middletown, which is 25 miles away. One facility was originally planned for 100 beds, but because of financial difficulties, only 50 beds were finally constructed. So we do not have the specialized facilities that this legislation would allow to be included and for further construction and staffing. Mr. ROGERS. Actually, there is a provision that psychiatric services could be provided. Dr. KLERMAN. I realize that that was the intent. I would submit that in practice- Mr. ROGERS. This hasn't been done. Dr. KLERMAN. It would be like ours. We had underestimated the magnitude of the problem and also the desirability of specialized facilities. Mr. ROGERS. Thank you. Our next scheduled witness is Dr. Walter Barton, who is medical director of the American Psychiatric Association. Is he present? Dr. Barton is not present but he has submitted a statement for the record. (Dr. Barton's prepared statement follows:) PAGENO="0295" 289 STATEMENT OF DR. WALTER BARTON, MEDICAL DIRECTOR, AMERICAN PSYCHIATRIC ASSOCIATION H.R. 15281 (S. 2989) now before the Congress, would amend the Community Mental Health Centers Act by providing for specialized facilities for alcoholics and narcotic addicts. In the view of the American Psychiatric Association the purposes of thas legislation are altogether. laudable and its detailed provisions are entirely satis- factory with a single possible exception noted below. Recently, the Joint Information Service of the American Psychiatric Associa- tion and the National Association for Mental Health published a report of a comprehensive study of psychiatric treatment facilities for persons with alcohol problems. (See The Treatment of Alcoholism by Raymond Glass'c'o'te, Thomas F. A. P]iaut, et al, American Psychiatric Association, Washington, D.C., 1967). Per- hatps the most salient observation of the report is quoted as follows: "Services for alcoholics must be greatly expanded in quantity. There is no city in the United States where the amount of service begins to approach the already manifest need." In several states alcoholism is the largest single diagnostic category for male first admissions to the state mental hospitals. In Maryland, for example, the figure reaches 40%. Some forty different states have alcoholism programs, but a number of them are limited solely to public education. Other states have some limited grant fundis to assist outpatient clinics and occasionally some inpatient services. Altogether there are about 125 outpatient clinicis for alcoholics in the nation as a whole, but many of these are part time only and offer very limited services. Many general hospitals in our country will not admit alcoholics as such, and when they do, the services they render tend to be brief, snperfici;ai, and inadequate. As for the community mental health centers now getting under way, it is too early to evaluate how effective they may become in treating alcohol problems, but one may confidently expect that this legislation, if passed, will further ensure the success `of their efforts. Specifically, the legislation provides for grants to suitable agencies in areas where a need for special facilities for inpatient and outpatient treatment of alcoholicis is demonstrated and when the proposed plan is adjudged satisfactory according `to various `sensible criteria. There is just one provision (Sec. 241 (C)) which in our judgment needs some modification. It is stated "that the application (must have) been approved and recommended by the single state agency primarily responsible for care and treatment of alcoholics in the state . ." The problem here is that in many states the "single state agency" is in fact a politically appointed commission whose responsibility is confined largely to public education programs. The members of these commissions are not representative of the expertise in the treatment of alcoholism to which this legislation primarily addresses itself. Experts in treatment problems are rather to be found in the offices of mental health authorities, departments of institutions and corrections, etc. This pro- vision should, at the very least, in our view, eliminate reference to the "single state agency designated by the state as being the agency primarily resi~onsible for care and treatment of alcoholics." Rather a phraseology should be substi- tuted to the general effect that a state will appoint a single agency to administer the program and comprising the essential expertise that should be brought to bear on the execution of the entire program. No exception is taken to the mode of financing that is proposed for construction and staffing. It is most especially praiseworthy that the legislation allows funds for a variety of treatment modalities such as specialized residential facilities, half-way houses, day care centers, hostels for homeless alcoholics, and the like. In short, the more flexibility governing the use of the grant monies the more promising and effective the program will be in our view. Title II of HR. 15281 provides for grants for constructing, operating and staffing treatment centers and facilities for narcotic addicts, including the development of specialized training programs for personnel involved in treating addicts and the evaluation of programs for the prevention and treatment of addiction. No exception is taken to any of the provisions of Title II. In sum, the American Psychiatric Association strongly supports this legisla- tion hoping that the provision about approval of grant programs by the "single state agency" may be further refined to ensure that appropriate professional expertise is brought to bear on the total program. The growing and widespread PAGENO="0296" 290 acknowledgment of alcoholism as a disease (including the tendency of the courts to so label it) together with the appalling poverty of the nation's resources for treating it, is evidence enough of the urgency of such legislation. The same massive need exists in relation to the addiction problem. Mr. ROGERS. Dr. Gilbert Geis, California State College in Los Angeles. Is he present? Dr. Geis has submitted his statement for the record. (Dr. Geis' prepared statement follows:) STATEMENT OF GILBERT Guis, PROFESsOR OF SoCIoLOGy, OALIFORNIA STATE COLLEGE COMMUNITY TREATMENT OF NARCOTIC ADDICTS Narcotic addiction, we now know, can best be controlled in community setting. It will probably remain necessary ta incarcerate some addicts either in pr1~ons or under the auspices of civil commitment programs, particularly addicts who perform criminal acts of a nature not directly associated with their addictio~ or of a kind that society cannot reasonably tolerate. But, for the most part, it appears not only important, but also imperative that future efforts toward con- trolling and reducing narcotic `addiction be included as part of the work of community mental health centers. The reasons appear compelling. For one thing, we have consistent evidence that the incarceration of addicts produces only minimal rehabilitative results. In Californi~, we have learned that incarceration in prison of narcotic addicts plus routine parole aftercare will bring about a success rate (measured by abstinence from drugs and lack of criminal difficulty for one year subsequent to release to the community) of about thirty percent. There has been no substantial increase in this success rate when parole caseloads are reduced, nor when parolees are placed in a halfway house. Neither, for that matter, has the massive civil commit- ment program for narcotic addicts, pioneered in California, managed to improve upon the success rate of earlier approaches to the problem. We believe now that the reason for the failure to increase success rates is tied rather intimately to the fact that the addicts' success and failure to remain abstinent is closely tied to their self-image. This self-image most usually is one defining addiction as an intransigent behavior and establishing the myth that "once an addict always an addict." For substantial rates of cure to be realized, it appears necessary that the addict not become immersed iii prison or civil commitment cultures and not be allowed to wallow in the self-justifying ration- alization that his difficulties are insurmountable. Support for the validity of this thesis can be derived from the experience of Synanon, a self-help program originated in California, which transmits to itS recruits the idea that addiction can and will be conquered. Synanon does this by putting on display its own successes, men who were addicts, but have been clean for many years and have made their way in "square" society. The Synanon program, community-based, indicates clearly that addicts can be helped without the constraints or lessons imposed by institutional life. The Synanon experience is further supported by data from California which show that medical doctors who become addicted to drugs are able to cease their use of such drugs in some 92 percent of the cases, though the penalty imposed on them is nothing more than the withdrawal from them for five years of their Prescription-writing privileges. Allowed to remain in the community, allowed the opportunity to retain the prerogatives of their professional performance (includ- ing status and money), the medical doctors in an overwhelmingly large number of cases conform to social demands. We would argue that incarceration of the same doctors would produce a much lower rate of subsequent abstinence. It seems apparent, therefore, that community~base~ programs for rehabilitative work with addicts offer the most hopeful opportunities for success. Such pro- grams can provide counseling, can refer persons for employment, can deal with family difficulties as they arise. Equally as important, they can permit the addict to retain his self-confidence in his ability to ultimately live a drug-free existence. I would finally call attention to the early su~cess that we have been having with a community-based program in Los Angeles which employs 28 ex-addicts to work with practicing addicts in the Boyle Heights area, a neighborhood with the highest addiction rate in the State. Paid decent salaries, supervised with some PAGENO="0297" 291 care, the ex-addicts have to date demonstrated a reassuring willingness to work hard and well in discovering and caring for other men currently using drugs. It is our belief that the Boyle Heights program has had an impact upon the rate of drug use in the area, and concomitantly the rate of crime, particularly crime against property. The employees of the Boyle Heights project report that mean- ing has been imparted to their lives, and their clients note that the object-lessofl of successful former addicts, the opportunity to remain in the community while they deal with their addiction, and the clear understanding of their problem by those who once shared it, all have contributed to their own willingness and ability to refrain from drug use. It is in terms of experiences such as that which we are having in Boyle Heights, as well as a review of previous experiences with prison programs, federal public health operations, and civil commitment that the proposed legislation to in- corporate narcotic addiction within community mental health center programs seems preeminently decent and desirable. Mr. ROGERS. Mr. lET. Leonard Boche, director, Department of Social Welfare of the Board of Christian Social Concerns of the Methodist Church; and president, Association of Halfway House Alcoholism Programs of North America. STATEMENT OP H. LEONARD BOCHE, DIRECTOR, DEPART1VI:ENT OP SOCIAL WELFARE OF THE BOARD OP CHRISTIAN SOCIAL CON- CERNS OP THE METHODIST CHURCH, AND PRESIDENT, ASSOCIA- TION OP HALFWAY HOUSE ALCOHOLISM PROGRAMS OP NORTH AMERICA Mr. BOdE. Thank you, Mr. Chairman. It is a pleasure for me to have this opportunity to meet with you. Mr. ROGERS. We will make your prepared statement a part of the record following your remarks. May I interrupt just a minute? I see one of our distinguished mem- bers on this committee, Congressman Stuckey, of Georgia. We are always delighted to have colleagues of this committee come in and visit. - Mr. Bocun. I would like to highlight only a few points from my pre- pared statement. I come before this committee primarily out of my experience. Previous testimony has clearly indicated the value of a complete continuum of care in the treatment of alcoholism. I would like to point out that the halfway house, or the aftercare facility has theoretically come of age, but in practical terms there is a social lag which has not included the halfway house, in fact, in the total continuum of care. This has largely been related to the inadequate philosophy of funding that has beenassociated with halfway house programs. These programs have grown up out of the concern of individual citizens and have not been fully incorporated into the community plan. Hence, I come before you in support of this bill, es~eeially that sec- tion dealing with halfway houses and aftercare facilities. I raise with you for your consideration that the existing halfway house alcoholism programs, be seriously considered to be included with- in the act as well as new and expanded facilities. The crisis of the halfway house is that it is unable to do the task under the financial structures that presently exist. The halfway house is an economical way, of protecting the public investment in detoxifi- cation and inpatient treatment. 93_453-68---20 PAGENO="0298" 292 We find, as in the testimony uf Dr. Pittman, the exp~rience of Des Moines `and other inpatient treatment facilities that afteroare and half- way houses are urgently needed if we are going to be able to adequately capitalize on the amount `of investmei~t that is made in inpatient care and in detoxification itself. And so I would like to call this to your attention, Mr. Chairman, and members of the committee, for I believe that the structure of this bill may very possibly provide the theoretical model and the means by which the halfway houses can be, in fact, integrated within the total continuum of care in the treatment of alcoholism. The halfway house uses as its mechanism and as its dynamics pri- marily the community of mutual support which is generated by people who have similar afflictions and who join together out of their weak- nesses and contribute to each other's recovery. The principle that the afflicted can help others afflicted to recover has been demonstrated by Alcoholics Anonymous. This has been applied over `and over again in a multitude of self-help organizations now in exist!ence. This applies to the halfway house where a shared experience of hope can be developed and the learning experience necessary to live in a complex world without chemical assistance and chemical crutches. I support this bill for I believe that it develops public policy which will integrate the halfway house into the total community of treat- ment. I urge the committee to amend the bill to cover existing halfway house programs which meet the `appropriate standards and which are integrated into the total community plan. If existing programs are not included, a premium will be placed on the development of new programs rather than using the experience of existing services. Any financial plan for halfway houses `must take into accourit that supplementation must come from some source, either pub- lic or private, if the programs are to carry out their intended purpose. We believe that this sdurce, most appropriately, is through some type of public funding, which is outlined in this proposed bill. I come su~pporting this bill because I believe that the halfway house makes each dollar spent on treatment of the addicted significantly more productive. (Mr. Boohe's p~rep'ared statement follows:) ~TATEMFNT OF H. LEONARD BOCHE, DIRECTORS DEPARTMENT OF SOCIAL `WELFARF~ OF THE BOARD OF OHRI$TIAN SOCIAL OONQEnNS OF THE METHODIST CIrCECH, AN~ PRESIDENT, ASSOCIATION OF HALFWAY HOUSE ALCOHOLISM PROaR~~ OF NORTH AMERICA Mr. Obaintpan, and members of the committee, my name is Leonard Boohe, and I come in my own behalf before this committee to testify out of my experience as the director of a community alcoholism program, co-founder of a halfway house for alcoholic women, and now as' president of the Asso~iatjon of Halfway House Alcoholism~~rograms of North America. The Association has 96 members in 3$ states and thi~eprovinces of Cana~. 1 come before this ~ommittee to support ELE. ~L5758, espe~ial1y that portion (See. 243 (b)) dealing with halfway houses and after care facilities. ~or reasons which shall be kJven, I urge the cOmmittee to give consideration to provisions for sUpplementing existing halfway hb~use programs and programs developed under t~hi~ act, The concept of the halfway house as ~ transitional facility in the treatment of a variety of~condltions is rapidly ronaing into its own, As one listens to compre- hensive health plans, or tunes Oneself to thh ~are and need of the retarded, thO mentally ill, ~ziēl to the field of corrections, the e&nlmon grOund Uniting the~n all PAGENO="0299" 293 is their interest In the use of transitional facilities. On a theoretical basis, a discussion of the continuum of care in any one of these fields, as well as in addiction, has integrated within it the concept of the halfway house as a means by which the afflicted Is introduced into the ~omplexities of modern society. The theoretical model has come of age, but there is a sinable lag between the concept and its application in the affairs of people in need. The one overriding consideration which seems to unite the many and diverse programs under the label of halfway house is their lack of consistent financing. It seems that it is the lack of financial security which unites, as much as the pro- gram services which are provided. When talking to administrators of halfway house alcoholism programs, the common problem which all face is funding. Few consistent patterns have emerged so that each program looks almost unique in tern's of its `fiscal structure. What I believe is needed is the development of a philosophy of halfway houses and funding. halfway house alcoholism programs may be able to exist on the basis of getting funds where they can, but it will not be until consistent funding is worked out will the halfway house be able to relate effectively to the total community structure. The halfway house `can best be thought of as a bridge. A means by which the Individual moves from one point of his addiction to another point which repre- sents successful treatment. In most `instances we are relating to in-patient intensive care on one hand, to out~patient supportive care within the ~ialfw'ay house, and tthen, finally, to independOnt living within society. I am well aware that halfway houses have at times been seemingly forced into the situation of being a treatment facility, but it is my firm conviction that the primary in-patient role is not the proper area of the halfWay house and every effort should be used to divest the progi~ain of that element of responsibility. The reason for this is that the `halfway house is simply not equipped by either its facilities or staff to carry on the intensive in-patient care that is often needed in the treatment of alcoholism. The halfway house makes its main contribution in providing a substitute family for the person in the course of his treatment and is not a substitute for the primary treatment of alcoholism. The transitional facility provides a peer group experience where the individual can learn how to live without the help of chemical crutches. It is a transference of dependeimy from chemical means to interpersonal relationships that are characteristic of the family setting. Many individual who find their ways into the cycles of `addiction ba~te flever learned how to live so the process `of socifilizing is very difficult for persons with addictive histories. This can be most effectively accomplished within the living situation in which there is a common identity and supportive staff. The dynamics of the `halfway house are in the community of mutual support which is generated by people who have similar afflictions, wh~ join together not out of `their strengths, hut out of their weaknesses and contribute to each other'a recovery by providing support, identification, and hdpe The principle that th~ afflicted can help others who are afflicted recover has been drajMkh~ally demom strated within the program of Alcoholics A'nonylnous, and this ptinčiple has been accepted and re~applied over and over ag~aifi in the multitude of self-help organizations which are no'w in existence. The same principles apply `to the halfway house where out of a common experience o'f misery; there can develop a shared experience of hope and th~ learning experience necessary to live a new life. In that the community of mutual support is the basic therapeutic ingre~i~nt of the halfway house, therefore I believe that halfway bųuses will invariably, of necessity, be specialized facilities. The individuals entering the halfway house `are often by definition incapable of accepting the ~road sjectirum of community maladies and are so prtocc'upied with their owu state of misery tha't `they are able only to identify with people of simitaf e*perienee. I can foresee that there will be those who `are interested in comprehensi+e planning who will wa'nt to seriously consider multi~purpose typM of halfway house's, but I cannot see `practical application. I defend as a practical consideration that the specialization `of halfway house facility is necessary and there L~ need to provide specialized facilities and to adequately fund them. The claim that halfway houses can be self-supporting `outside of ~a~ital in- vestment hns `often been made in a *wel1~intentioned way to insure the private donors that there would be a limitation on the appeals made in behalf~of half- way house facilities. Time has been the teacher and we have come to learn PAGENO="0300" 294 that ge~x~ halfway houses must be supplemented `on an an~uai basis. half- way houses which have become financially self-supporting do so invariably at the cest `of `staff, and they degenerate too often into boarding house situations rather than adequate halfway houses where people learn how to live. The present dilemma in which we find oursel've~ is that all of the elements of sound halfway house program development are present but are not coordi- nated or blended in a harmonious way. The private halfway house is having its effectiveness curtailed by the demands which are made `on the staff and the board of directors in fund-raising `activities. Its effective resources are being devoured in the struggle with survival, curtailing its essential functions of "bridge building" in the lives of the afflicted. Program budgets are being starved in the face of economic necessity. In an attempt to go beyond the mere definition of the problem, let me attempt to create a model program which could blend the many constructive elements in a harmonious and creative way. It will of necessity be `a joint venture between the voluntary agency and public responsibility in funding. The private v'olnn- tary halfway house has the tools to do the job if it. can be given financial security and the means to provide sound programming. The basis of this joint venture is the familiar phrase that has become a byword to the people working In the field of alcoholism, but nevertheless profound In its ramifications, "Alcoholism Is a public health `pvobjem and hence a public responsibility." The establishment of this public responsibility has been `developed `on a vo~un'tary basis as well as through the coercive activity of the court as In the Driver and Easter `cases, and hence it is a real factor today. It is necessary to `affirm again the valid `contribution that the halfway house makes in the care and treatment of the alcoholic. It is a legitimate and neces- sary element in the continuum of care If alcoholics `are in fact to be success- fully reha'bi'li,tated. The detoxicatjon units In Des Moines and St. Louis, as well as inpatient facilities across the country, have clearly seen the need of after care facilities if the money the public spends on detoxication `and treatment is to be a sound investment. Detox&cati'on and returning the alcoholic back on the street `can be a new rev~Jvlng door somewhat more humane but nevertheless just `as `revolving. The halfway house provides the vehicle which can m'ake the detoxicatlon center a worthwhile investment. The voluntary private halfway house makes its contribution to the whole field of alcohol treatment `In its ability to mobilize the needed multi-disciplinary pommunity of interest necessary to develop a sound recovery program. It is able to Involve people within `the whole process which can give content and substance to program. The partnership which emerges is the volunteer program supplemented by publk ~nnd~. The private voh~n~eer halfway house has Its financial crises in the area between income received from the residence and the cost of the program needs. This is th~ area mentioned before in terms of the need of supplementation. This is the au~a where historically the private halfway houses have struggled to scratch up do'1lar~ and pennies to keep the programs alive. But if the halfway house is really going to be integrated within the total health program, it is going to have to be underwritten by `public policy and public money I support this bill for I believe that it develops public policy which will inte- grate the halfway house into the total community of treatment. I urge the committee to amend the bill to cover existing halfway house programs which meet the appropriate standards find which are integrated into' the total com- munity plan. If existing programs are no included, a premium, will be placed on the development of new pro~rams rather than using the experience of existing services. Any financial plan for halfway houses must take into account that supplementation must come from some source, either public or private, If the programs are to carry out their intended purpose. The halfway house makes each dollar spent on treatment of the addicted significantly more productive. Mr. ROGERS. Thank you very much, Doctor, for your testimony. Dr. Carter? Mr. CARTER. No question. Mr. ROGERS. Let me ask you this: Who would run the halfway houses? PAGENO="0301" 295 Mr. BOCHE. Halfway houses have been staffed for the most part by recovered `addicts who have been especially trained. Now, this is not- Mr. ROGERS. I mean, would it be a `staff that runs the community mental health center, or would it be private groups? Or who would establish it, in other words? Mr. BOOnE. IL think a strong point can be made for the private non- profit, community-oriented group wo'rking on a voluntary basis in cooperation with the community mental health clinic. I think the big value of this is that you provide in this kind of organization, an army of volunteers which can help in the resociali- zation process. Mr. Roo~s. Could you let us have a rundown of examples of half- way houses, the `costs of maintaining them, th'e services provided, maybe some examples of success, or problems? Mr. BOCHE. Yes. I could deliver for you outline's of some of the more successful and ideal programs. (The information requested by Mr. Rogers and submitted by Mr. Boche may b'e found in the committee files.) Mr. ROGERS. If `it is going to be voluntary-that is, you don't envi- sion that the people running the halfway house would all be voluntary? Mr. BoonE. Oh, no. I am saying that in terms of its organization and board of directors, that we are dealing with a voluntary agency which hires a staff and then is able to enroll and bring in an army of volunteers. Mr. ROGERS. Yes. This would provide shelter, I presume. Mr. BOOnE. Yes; we find the halfway house is providing a substi- tute home, with all the productive possibilities that a substitute home can provide. Mr. ROGERS. This is what would be covered, I assume, in the legis- lation by residential- Mr. BoonE. Yes, `sir; or after-care facilities on a live-in basis; yes. Mr. RoGERS. Do you estimate how much would be needed? Mr. BOOnE. This is very difficult. Out of the experience of St. Louis, for instance, they could probably use, without any difficulty, six or eight facilities o'f 30 beds each. The b'ig advantage that the halfway house has is that it is `able to operate at significantly less cost, and that approximately-in facilities for men-about half of the cost of running the house comes from their own contribution. With women, this runs approximately a third. Mr. RoGERs. While they are in the halfway house, is it essential that they take treatment? Mr. BoonE. We believe `that before a person comes to `a halfway house that they `should be involved in `significant inpatient treatment, and that such after-care as indicated by the professional community be carried on when the resident is living in the halfway house, so that when he leaves the halfway house he basically takes with him all of his therapeutic relationships. Hence, we do not believe that these kinds ,of supportive thera- peutic relationships `should be contained within the house, but rather within the community, `so that this continuum of care can be con- tinued beyond this living-in situation. PAGENO="0302" 296 Mr. ROGERS. Is there any compulsion, or is this all voluntary? Mr. BoonE. Well, there is, `of course, `a question `always raised, Is alcoholism ever voluntarily treated? Working in a community pro- gram, I have known of many instances where `a man went voluntarily to get help because if he didn't his wife was going to divorce him. So there are many forms of coercion. Mr. ROGERS I mean in `a legal sense. Mr. BOOnE. In a legal sense, no. The halfway houses in operation do not use legal means to keep a man in residence. At the present time we have had no experience in that area, Mr. ROGERS. Thank you very much. We `appreciate your help to the committee. The record may stay open fo'r 5 days for anyone to make a statement, if they desire. There are no other witnesses. This concludes the hearings. The committee is adjourned. (The following material was submitted for the record:) STATEMENT 0]? JUDITH G. WIIITAKER, EXECUTIVE DIRECTOR, AMERICA1V NURSES' ASSOCIATION, Ixo. The American Nurses' Association wishes to record its support of the provi- sions of HR. 15758 which will extend and improve the provisions of the Regional Medical Program, extend the special grants for behith of migratory workers, and provide for specialized facilities for alcoholics and narcotic addicts. We believe that the Regional Medical Programs, P.L. 89-239 is one of the very significant p'rogramls enacted by the Congress in the last few years. It is demonstrating that it has great potential for making more readily available to the people of this country the results of the latest advances in the treatment of heart disease, cancer and stroke and related diseases. Physicians, nurses and other health personnel have the opportunity through `the p'roglrams to become familiar With these advances and to update their skills in caring for patients. The programs `have further stimulated cooperation between members of the health professions as they prepare to give the highest quality of service to people. The legislation was devised as a means of reducing the gap between care pos- sible in a medical center ~nd that available Ito persons remote from the center's~ To achieve this end we have encouraged active participation of the registered nurse as a member of the health team in both the planning and the Implementa- tion of the law. Title II of HR. 15758 proposes the extension of the special grants for health of migratory workers. We urge that this extension of the special grants for health proposed in the bill. Migrant workers have always faced difficulties in obtaining adequate pre- ventive and therapeutic health services. Studies show the disease rate for farm workers to `be `three `times that of industrial workers. Forty percent of these diseases result in permanent disability for regular work as compared with twenty-seven percent among industrial workers. Women in farm worker families reecive no prenatal care or late care in 33% of cases as compared with 6% in skilled worker families. Special means `have to be taken to correct these serious deficiencies in the provision of health and prevei~tive care services. Assistance from the fe'deral government is essential. Many states alone are unable'to provide such services because of insufficient resources. Also, eligibility to' receive medical and health care services is often governed by the residence requirements of a state. Since migrant farm workers move from state `to state, establishing resi- dency Is frequently not possible. The Association also supports Title III of HR. 15758 which proposes con- struction grants and staffing, operation and maintenance grants fo'r centers for the treatment and rehabilitation of alcoholic and narcotic addicts. We urge the Committee to act favorably on ELR. 15758. PAGENO="0303" 207 STATEMENT OF MYRON ~(0WALS, ASSISTANT DIRECTOR, SEAPPLE MENTAL HEALTH INSTITUTE Alcoholism in particular has long been a critical problem In the Seattle areaS Facilities such as the Pioneer Fellowship House, the Women's Studio Club, the Lewis Martin Home, and the Alcoholism Treatment Clinic, have been struggling to devote services to alcoholics in an effort to promote their rehabilitation. How- ever, `the financing of these projects is a constant struggle. We recognize alco- holism as a mental health problem which is properly the province of the com- munity mental health center and therefore these facilities dealing with the problem of alcoholism should be funded under community mental health centers legislation. Due to the immense problem of lining up state and local support in order to permanently fund `these facilities, it is felt that a declining federal support over a period of ten years would give the facilities the best chance for permanent success. Because the Seattle Mental Health Institute feels so strongly about the problem of alcoholism a great effort was made to establish working agreements with the alcoholic facilities as part of the grant application for community mental health centers staffing funds. Even though SMHI felt that alcoholism was a mental health problem and therefore should be included in the service centers, it is still im- portant that the legislation puts clearly into writing the eligibility of the alcoholic rehabilitation facilities. However, to allow a period of ten years of federal support alcoholic facilities and at the same time to limit community mental health centers in general to a period of support of 51 months seems to me to be putting the cart before the horse. Every effort should be made to amend the bill to lengthen the period of support for community mental health centers in general to a period longer than 51 months. It is my personal belief that community mental health centers can be supported by state and local sources without any permanent federal support, but achieving this will definitely be a challenging task. State legislation is going to play an important part in establishing the permanent sources of non-federal support. County funds can also be expected to play an important part in local support. However, promoting state legislation to provide the support funds would take considerable work in more than one session of the legislature. Under the present federal law the level of support by the fourth year of funding of a community mental health center is at a critical low level. If two sessions of the legislature were sufficient to provide legislation for the funds needed by the time the laws became effective the centers would have already experienced considerable financial difficulty. If community mental health centers are unsuccessful within the 51 month period in lining up sources of support to supplant federal funds it is inevitable that these centers will gravitate towards the serving of the paying patients. This will result in a drastic cut-back of service to citizens who are unable to pay or capable of paying only a portion of the cost. Naturally this would defeat the piftpose of the federal community mental health legislation. I strongly urge the committee to consider amending the bill in such a fashion as to provide longer period of support than 51 months. To wait for community mental health centers to begin failing before doing so would be indeed short- sighted. I believe there is enough evidence to this date to show that the entire burden of the community mental health centers cannot be shouldered by state and local sources in such a short period of time. STATEMENT OF THE NATIONAL CoNsUMERs LEAGUE The National Consumers League has for over half a century concerned itself with the problems of the migratory agricultural workers, the most neglected segment of our working population, and in their behalf wishes to go on record in support of extension of the Migrant Health Act of 1962, as amended in 1965~ provided for in the Health Services Act of 1968, H.R. 15758. It is estimated that there are about one million Americans-migrant farm workers and their families~-wbo suffer from inadequate health care. Until the Migrant Health Act was passed in 1962, health care for migrants was practically nonexistent. Since that time, some real progress has been achieved, but the "health gap" among this group is still shockingly large. Only about one-third of the migrants have received health services under the program, and almost 40% of the counties where seasonal migrants work still have no grant-assisted project PAGENO="0304" 298 -services. Six out of ten of tite counties serving as "home base" for migrant work- ers have no personal health care for farm workers. Among tlii~ group of workers deaths from influenza, pneumonia, tuberculosis, infant diseases and accidents are from one and a half to four times the national average. National per capita health expenditures are almost twenty times' greater than the per capita health ex- penditures for migrants. Until this gap is significantly narrowed, the need to continue the special pro- gram of Migrant Health Services is urgent. Not only should present projects be continued, but new ones must be established in those communities which now have none. The National Consumers League therefore strongly urges that you extend the Migrant Health Program for at least two years, and that at least $10 million be authorized for each of the fIscal years ending June 30, 1969 and 1970. [Telegram] CARMEL, CALIF., March 27, 1968. flon. JOHN JARMAN, Chairman, Suboo~inm'Lttee on Public Health and Welfare, House of Representatives, Rayburn Building, Washington, D.C.: The Board of Directors of the National Council on Alcoholism, Monterey Penin- sula Area, Monterey County, Chlifornia, composed of physicians, clergymen, judges, lawyers, educators, and businessmen, voted unanimously today to convey to the Subcommittee on Public Health and Welfare concerns for the vast unmet need of alcoholics in this area and throughout the Nation. We heartily approve the purposes of H.R. 15758, especially its provision for facilities for alcoholics. With very limited facilities to date our community has demonstrated the unlimited potential for conservation of human resources through alcoholic rehabilitation. The need for more facilities is crucial to prevent needless waste. We urge favor- able action on HR. 15758. GEORGE B. RIDGWAY, President. [Telegram] SAN RAFAEL, CALIF., March 25, 1968. Subject: Hearings on HR. 15758. Hon. JOHN JARMAN, Cha/irman, Subcommittee on Public Health and Welfare, Rayb-urn Building, Washington, D.C.: Legislation pertaining to recognition and treatment of alcoholics is long over- due. Presently only small fraction of alcoholics are being reached by public and private agencies. Features in this bill represent important steps toward meeti'ng imminent tremendously increased demand for expansion in all areas of field. ALLEN SKINNER, Chairman, Alcoholic Recovery Homes Association, San Francisco, Calif. HOUSE OF REPRESENTATIVES, Washington, D.C., March 26, 1968. Hon. JOHN JARMAN, Chairman, Subcommittee on Public Health and Welfare of the Committee on Interstate and Foreign Commerce, U.S. House of Representatives, Washing- ton, D.C. DEAR MR. CHAIRMAN: Hearings are currently being held by your Subcommittee on H.R. 15758, a bill to amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the au- thorization of grants for health of migratory agricultural workers and to provide for specialized facilities for alcoholics and narcotic addicts, which was Introduced by the distinguished Chairman of the Committee on Interstate and Foreign Com- merce, the Honorable Harley 0. Staggers. Because of the increasing involvement in medical programs in the Pacific by the relatively young University of Hawaii School of Medicine, I would like to take this opportunity to comment specifically on Section 103 of the bill, under the subtitle "Inclusion of Territories." PAGENO="0305" 2~9 This section apparently is designed to extend the regional medical programs to Guam, American Samoa, and the Trust Territory of the Pacific Islands, as well ~as to other areas. The extension of such programs would promote the acquisition and dissemination of medical knowledge and skills throughout U.S. territories in the Pacific. Medical research and training in which the University of Hawaii School of Medicine is presently engaged In several cooperative ventures in these Pacific areas, would be strengthened and improved. The result of all this Is that the people in these areas would receive the full benefits and assistance of Amen- ~an medical science and technology. For the foregoing reasons, I strongly urge that Section 103 be retained in the measure that is reported out by your Subcommittee. It is requested that this letter be included in the record of hearings on H.R. 15758. Aloha and best wishes. Sincerely, SPARK M. MATSTJNAGA, Member of Congress. AMERICAN H05FITAL AssOCIATION, Washington, D.C., March 26, 1968. Hon. HAIILEY 0. STAGGERS, Chairman, Interstate anti Foreign Commerce Committee, House of Representatives, Washington, D.C. DEAR CONGRESSMAN STAGGERS: This statement expresses the views of the Ameri- can Hospital Association on H.R. 15758 which amends the Public Health Service Act so as to extend and improve the provisions relating to regional medical pro- grams, to extend the authorization of grants for health of migratory agricul- tural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes. REGIONAL MEDICAL PROGRAMS This Association strongly supported the development of the legislation which resulted in P.L. 89-239. We were pleased that certain recommendations, which we felt were essential to the most effective development of the program, were incorporated in the law. We have continued to follow carefully and with great in- terest the progress of the program. The past two years appear to have been spent in the main in the establishment of regional programs and in their planning. The operating stage of the program is really only just beginning with a limited number of projects having been approved to date. Though good planning is highly essential it is to be hoped that the program will move forward rapidly in its application. We have always believed the purpose of the bill is to establish a bridge between the science of medicine and its full application to the care and treatment of patients. In the coming months, therefore, it is to be hoped that the programs developed will be felt by the pu~lic in terms of a broadened application of knowl- edge in the treatment of these diseases covered under the program. We urge the ~Committee to authorize the full amount requested for the program for the fiscal year ending June 30, 1969. The Association has continued to feel that implementation of the intent of the law would necessitate a full involvement on the part of hospitals and their medical staffs. This will necessitate not only the participation of the medical schools and the larger teaching and community hospitals but the smaller hospitals spread throughout the nation which provide a focal point for medical care and treatment in smaller communities. We have been disappointed at the extent of involvement of hospitals and particularly the minimal participation of these smaller community hospitals which is so essential if the program is to have meaning to the public at large. Therefore, the American Hospital Association will undertake a nu~mber of steps which it is hoped will result in a much wider involvement of hospitals. We have also noted that very little emphasis has been given thus far to preventive care and long-term patient care and we intend to stimulate leadership on the part of the hospital field in fostering such a broad upproach to the regional medical programs. We will continue to work closely with the administrators of the program and to work for the fullest participation of the hospital field. PAGENO="0306" 300 We recognize fully the merit of thorough planning as a basis for the develop~ merit of regional medical programs. Such plans, of course, must involve the facilities, personnel and services pertaining to the illnesses covered under the program, However, the Congress under P.L. 89-749 initiated comprehensive health planning thereby establishing planning mechanisms throughout the nation to be involved in over-all health care and to specifically include health facilities, services and personnel. It is obvious therefore, that rather complete duplication of planning now exists between the two programs and from reports which we receive we are just beginning to witness the confusion resulting from this conflict and overlapping. If health planning, which we strongly approve, is to be developed in an orderly manner, any overlapping and conflict must be resolved. At present the existing provisions go far towards encouraging com- petitive activities for domination of the field. We recommend, therefore, the Congress take action to eliniinate the existing overlapping and confusion by requiring that the cooperative regional medical programs developed under P.L. 89-239, and the results of the planning developed under P.L, 89-749 be in conformity. HR. 15758 proposes to increase the membership of the advisory council from twelve to sixteen members. In order to facilitate further the closest possible coordination between this program and the comprehensive health planning pro- gram, we would urge that additional representation of council members be required to include individuals directly engaged in area and state wide planning activities. We are pleased to note that the bill, as in the original Act, does not propose to authorize funds to be appropriated for construction purposes. The program is of such magnitude that we believe the funds should be expended for the operational phases of the bill; Further, we feel it would be unwise to duplicate the construc- tion authority now provided for in other acts. The bill requests clarification so that grants may be made to agencies and institutions for services which will be useful to two or more regional medical programs. There are various services which can be developed most efficiently and effectively for larger areas than would be encompassed in a single region. We believe, therefore, that the authority to make grants as suggested here is desirable. MIGRATORY AGRICULTURAL WORKERS The bill proposes to extend the program of grants providing for health services to migratory agricultural workers for an additional two years. We strongly sup- ported the original legislation and later urged an increase in the program so as to permit payment to hospitals for care provided migratory workers and their families. Our recommendations were made after a study of the problem of migratory workers in considerable depth. We found that hospitals in various parts of the country were providing care under emergency circumstances and with very sizable costs for services and for which no reimbursement was avail- able. We were, therefore, very pleased that the Congress provided funds which could be paid to hospitals for inpatient care. The major portion of the funds which have been made available go for the provision of public health services and preventive medicine with a very modest amount being made available to pay for inpatient hospital care. We urge, there- fore, that the funds to be provided under the bill be increased to at least $15,000,- 000, with $5,000,000 of this amount being allocated for reimbursement of hospitals providing inpatient care. Because of limi.ted funds, the administrators of the program have necessarily restricted payments to hospitals under the program to areas which had an over-all public health program for migrants. Therefore, no provision has been made for assistance to migratory workers in transit or in areas of the country which had no over-all public health prbgram for migrants. The increased au- thorization which we have recommended should enable the administrators of the program to provide inpatient hospital care to migrants wherever it is needed. Further, we recommend that the program be authorized for a period of four years instead of the two years called for in the bill. We have no comment at this time on other provisions of the bill. We would appreciate your making this statement a part of the rectn-d of these hearings. Sincerely, KENNETH WILLIAMSON, Associate Director. PAGENO="0307" 301 NATIONAL TUBERCULOSIS AND RESPIRATORY DISEASE AssooIA'rIoN, New York, N.Y., March 20,1968. Hon. HARLEY 0. STAGGERS, Cha4'rmctn, Interstate and Foreign Commerce Committee, Honse of Representatives, Washington, D.C. DEAR MR. STAGGERS: The National Tuberculosis and Respiratory Disease As- sociation wishes to express its support for continuation of Regional Medical Pro- grams as provided for in H.R. 15758. Although Programs have been largely de- velopmental, reports of progress throughout the country indicate that the majority will shortly be initiating operational activities. Reports indicate an earnest desire on the part of persons concerned with this Federal program to fulfill the purposes of the legislation; namely, that the American public receive improved medical services through coordinated and more efficient delivery of medical and paramedical skills and talents. Authorization for funds must be adequate to meet the growing needs of the Programs in the next few years if they are to achieve their goal. The momentum of this Federal program, which involves relationships with many agencies and groups, is accelerating as operational activities are due to begin. Readiness to perform will be affected by the amount of Federal funds available. Therefore the Committee should consider whether or not the authorization of $65 million for fiscal 1969 is large enough to permit implementation of the extensive plans developed over the past few years. The NTRDA is particularly eager that Regional Medical Programs be suc- cessfully launched into operational activities because of the great need to improve services for chronic pulmonary disease patients. At time of appropriating funds for fiscal 1968, Congress specified that between one and two million dollars of the RMP appropriation for that year be devoted to chronic respiratory disease programs. The NTRDA had requested such action by Congress because of the critical situation in diagnosis and treatment of these diseases, particularly emphysema. Incidence of emphysema has so accelerated that it has become the second most frequent disease for which benefits are granted to workers who are retired for disability prior to age 65, at an annual cost of about $90,000,000. Other diseases of pulmonary insufficiency, such as chronic bronchitis, are widespread and responsi- ble for much illness and restricted activity. Deaths from emphysema have been doubling approximately every five years in the recent past and along with asthma and chronic bronchitis now represent the tenth cause of death in the United States. The seriousness of the chronic respiratory disease situation impelled the Public Health Service and the National Tuberculosis and Respiratory Disease Association to convene a Task Force in the Fall of 1966 to discuss how the control of these diseases could be improved. The critical needs in medical services for patients hecame a focus for much of the discussion and led to one of the Task Force's major recommendations; namely, that provision be made for pulmonary function laboratories, respiratory-care units, home-care, and rehabilitation pro- grams. Data indicate that the lack of such resources is widespread. Many community hospitals are even without the necessary apparatus to take care of seriously ill respiratory disease patients. Organized home-care programs exist in only a small percentage of our general hospitals, while outpatient clinics which can play a full role in rehabilitation and counseling of respiratory disease patients are virtually non-existent. The community practitioner is particularly at a loss to help patients with chronic respiratory disease except for recommending hospitalization when the illness becomes critical. The average general practitioner is the victim of in- adequate education because of the recency in the rise of these diseases. Thus, the type of supervision needed to protect patients from acute infections and to maintain their physical condition at as optimal a level as possible cannot be provided in most communities under existing conditions. It is obvious that direction and supervision of high quality chronic respiratory disease programs must be provided by medical schools and medical centers. Demonstrations of patient diagnosis and treatment must ie brought to the com- munity practitioner through continuing education courses offered by these institutions and facilities. The Regional Medical Programs offer the most PAGENO="0308" 202 expeditious way to achieve this goal. Interest in improving programs for chronic respiratory disease patients exist in many areas and it is our belief that this interest will generate development of such programs. TB-RD associations will help stimulate interest in such programs, utilizing their background of experience in promoting better patient services. In the past, many associations have supported medical education in pulmonary disease~ and have demonstrated the need for screening surveys and diagnostic and treatment services. TB-RD associations were influential forces In communities for many years in promoting more adequate services for tuberculosis patients. In the same way, associations have been in a position to witness the dearth of help for emphysema and chronic bronchitis patients today and because of this, they will be good community partners to the RMP in seeing that the urgent needs of respiratory disease patients are met. The American Thoracic Society, the medical section of the National Tubercu- losis and Respiratory Disease Association, has provided leadership in medical standards and research in tuberculosis and other respiratory diseases. Staff of our organization will continue to work closely with the Division of Regional Medical Programs `to promote high standards of diagnosis and care for chronic respiratory disease. The NTRDA is pleased with the proposal in H.R. 15758 `to expand the number of Advisory Council members from twelve to sixteen. At the time Congress speci- fied that attention be paid in Regional Medical Programs to chronic respiratory disease, it also requested that one of the members of the National Advisory Council have competence in this particular medical field. Expansion of Council membership will provide more scope for ensuring representation of the various areas of medicine which are of necessity involved in the many activities of Regional Medical Programs. We question if evaluation of Programs, as provided in Section 102 of the bill, should be performed solely by the Secretary. It would seem more satisfactory for both the Department of HEW and the public, to require that such evaluation be done by outside groups. We are certainly in support of extension of grants for health services for migratory workers and our only reservation is that these seem very minimal amounts considering the high rate of disease in this segment of our population. Tuberculosis rates are high in these people because of their low economic status and because their living conditions favor spread of the disease. We support provision of funds for construction of special facilities for inpatient and outpatient treatment of alcoholism. Alcoholics have a high rate of tubercu- losis, and extensive difficulties have arisen in recent years in hospitalizing many of these persons in community hospitals, including tuberculosis hospitals. Some of these difficulties would seem to be obviated by the provisions suggested. How- ever, recognition of the high rate of tuberculosis in alcoholics is essential in planning adequately for treatment facilities. It gives us great pleasure to recoi~d our support for extension of Regional Medical Programs. Sincerely yours, JAMES E. PERKINS, M.D., Managing Director. AMERICAN DENTAL ASSOCIATION, Washington, D.C., March 27, 1.968. Hon. JOHN JARMAN, Chairman, Subcommittee on Public Health and Welfare, Committee on Interstate and Foreign~ Commerce, House of Representatives, Washington, D.C. DEAR MR. JARMAN: Pursuant to the announcement of March 18, 1968, the American Dental Association wishes to submit its views on H.R. 15758, the Health Services Act of 1968. The Association's brief comments will be limited to those provisions of the bill which would extend and improve the Heart Disease, Cancer and Stroke Amendments of 1965 and the Migrant Health Act of 1962, as amended. As part of its commitment to improving the total health of our people, the American Dental Association is sympathetic to the goals of H.R. 15758. The dental profession has particular and long~standing concern with respect to oral cancer and some forms of heart disease. Additional research into the pre- PAGENO="0309" 303 vention and treatment of these disease manifestations is needed and can and should be included in the regional medical programs authorized In H.R. 15758. When the Heart Disease, Cancer and Stroke legislation was under consideration in 1965, the Association submitted to this Committee details regarding the inci- dence of oral cancer and the low survival rate of victims of the disease. At that time, attention was directed to the need for more research into the specific causes of oral cancer and the methods of treatment and rehabilitation of patients Who~ suffer from it. The Association is pleased to note that considerable progress is being made in this field and that members of the dental profession and several dental schools are participating in, the programs that are being developed, The Association also is pleased with and supports fully the amendment included in H.R. 15758 which makes it clear that a practicing dentist as we'll as a phy- sician may refer a patient to a facility engaged In research, training or demon- stration activities which are supported by regional medical progam funds. With respect to the provisions of the bill extending the migrant health pro- gram, the American Dental Association recognizes the need for iiicreasing the availability of dental care for migrant workers and their children. The Associa- tion supports the extension of the program but agrees that as soon as feasible,. this activity should be included in the regular public health programs of states and comiuunitien The American Dental Association appreciates the opportunity to present its views on this legislation and respectfully requests that this letter be included in the record of hearings. Sincerely yours, JOHN B. WILSON, D.D.S., Chairman, Council on Legislation. UNIVERSITY OF HAWAII, ScHooL OF MEDICINE, Honolulu, Hawaii, March 13, 1968. Re H.R. 15758. lion. HARLEY 0. STAGGERS, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C. DEAR REPRESENTATIVE STAGGERs; House Resolution 15758 includes a paragraph on "inclusion of territories" which would bring Guam, American Samoa, and the Trust Territory of the Pacific Island's within the scope of the Regional Medical Program. The Medical School of the University of Hawaii is involved in medical research and teaching in many areas of the Pacific. We have been asked by the health administrators in American Samoa to develop an affiliation between the new Lyn- don B. Johnson Tropical Medicine Center and the University of Hawaii School of Medicine. The same applies, but at a somewhat more preliminary stage, with the health administrators of the Trust Territories, with special regard to the hos- pital that will be built on Ponape. These programs will be mutually advantageous as we will provide continuation education for the ~medica1 and nursing staffs, and they will provide facilities for research and certain aspects of education for our faculty aud students, ~E would urge your support of the paragraph in question because this would facilitate the cooperative ventures described. Sincerely yours, / WINDSOR C. CUTTING, M.D., Dean. Tun CHRISTOPHER D. SMITHERS FOUNDATION, INC., New York, N.Y., March 21, 1968. Hon. HARLEY 0. STAGGERs, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR CONGRESSMAN STAGGERS: I am pleased to learn that you have scheduled hearings on HR-15758. If it is appropriate, I request that this letter be made a part of the record for those hearings. PAGENO="0310" ~O4 As you know, this Foundation participates primarily in activity associated with alcohOlism. We support the activities of all the major organizations `at work in this field. I have read with much interest the provisions of Title III, Part A of fiR- 15758, to be known as the Alcoholic Rehabilitation Act of 1968. In my judgment, it is an excellent piece of legislation which, when passed and adequately funded, will provide much needed Federal assistance to 4the states and communities. Because oi the humane and progressive decisions of the courts in recent years to the effect that late stage alcoholics should be treated as sick people and not as criminals, the states and municipalities must now prepare to meet the needs in treating large numbers of persons found by~ the courts to be suffering from alcoholism. The size of this problem and the urgency for new facilities and trained personnel make it impossible for the states and cities to meet their needs Adequately without significant Federal assistance. The enactment of Title III, Part A of HR-45758 will provide the kind of Federal assistance necessary in a most commendable way. Sincerely yours, R. BR.INKLE~ SMITHERS, President. ALCOHOLISM COUNCIL OF PALM BEACH COPNTY, Lantana, Fla., March 22, 1968. Congressman PAUL G. RoGERs, Harvey Bwilding, West Palm Beach, Fla. DEAR CONGRESSMAN ROGERS: Your endorsement of Bill U.S. H.R. #15758, Title `3, Part A would be greatly appreciated. It is our feeling that this legislation would be extremely helpful in rebabili- ±ating the 12,000 alcoholics in Palm Beach County. Sincerely, RICHARD A. CONLIN, Chairman. TAMPA, PTA., March 20, 1968. ~Congressman PAUL G. ROGERS, house of Representatives, Washington, D.C. DEAR CONGRESSMAN Rocnms: We have just starte~l our Florida Regional ~Ledi- val Program and not too many `physicians are yet aware of its great potential ~for improving the quality, and efficiency of medical care through improvements in communications and in continuing medical education. The Regional Medical Programs mttht develop into ongoing operational proj- ects and `therefore the administrations bill to extend and slightly modify Regional Medical Programs is highly desirable. This is the `type `of coi~gressiŲnal legis-' lation the physician in practice and in education ttill favor. Cordially yours, `IT PITILLIP HAMPTON, M.D. GATEWAY COUNCIL ON ALCOHOLISM, Xetckikcsn, Alaska, April24, 168. The CHAIRMAN, . . Subcommittee on Public Health and Welfare, Committee on I'nterstate and For- eign Commerce, House of Hepresentatives, Washington, D.C. DEAR Sin: I have recently received a publication from the North American Association of Alocholism Program oiitiliiing the hearings of March 26-28 on HR-15758. I was not present to represent the Icetchikan Gateway Council on Alcoholism during those hearings, but would nevertheless wish to voice our opinion of that bill; especially the section Title III Part A, known as the 4'Alcobolic Rehabilitation Act of 1965". Under the Alcoholic Rehabilitation Act of 1965 we uncl~atan~d that a1coholi~ facilities and ~rogvams will be tied directly with the existing mental health centers of each state. And that provisions fOr receiving aid for construction, staffing, aEd specialized facilities will be reqtiisited by this direct tie with the mental health centers. , PAGENO="0311" PAGENO="0312" 8