million in 1951, and in 1952 $36 million, and 1953 $32 million, aud in 1954, which is this year, of course, it dropped down to $22 million. and now you propose to drop it down to $19 million, approximately. Is that right?

Secretary HOBBY. Yes, sir. That is right.

Senator HILL. You can write all the legislation you want on the books, but if you do not provide the money I do not know how you are going to do it. I am not going to ask Dr. Scheele to comment on that, but I think I know what his comment will be.

You talk about being dynamic and looking forward, but you do not move unless you have gas in your car. Certainly in these programs you do not move unless you have the funds with which to move.

That is all, Mr. Chairman.

Senator PURTELL. Thank you, Mrs. Secretary, and we thank your associates for being here. We look forward to your visit tomorrow, at which time we will discuss the rehabilitation and vocational program.

Dr. Erickson was to be our next witness. He is not here but I am informed Dr. Norton, a member of the executive committee of the Association of State and Territorial Health Officers, will appear in place of Dr. Erickson. Is that correct?

STATEMENT OF DR. J. W. R. NORTON, NORTH CAROLINA STATE HEALTH OFFICER AND MEMBER OF THE EXECUTIVE COMMITTEE OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS

Dr. NORTON. Yes, sir.

Senator PURTELL. Dr. Norton, we welcome you here and we are glad to hear you.

You have a prepared statement?

Dr. NORTON. Yes, sir.

Senator PURTELL. Is it your intention to read that complete statement, or do you wish to read just excerpts from it?

Dr. NORTON. I can read this in about 13 or 14 minutes, if you would like me to do so.

Senator PURTELL. We are very happy to have it, if that is the way you want it, Doctor.

Dr. NORTON. All right, sir.

I would like to say that the Association of State and Territorial Health Officers is a group that does not have a Washington staff, or a full-time office anywhere. It is just the official directors of public health in the various States and Territories who get together with the Department of Health, Education, and Welfare, particularly the Public Health Service and the Children's Bureau.

The reason why I am appearing today is because our president is from Oregon and our secretary is from Wyoming. Being from North Carolina, it was a little more convenient for me as a member of the executive committee to appear here.

Senator PURTELL. We had another excellent witness from North Carolina. I believe it was Dr. Farrell, who helped us a great deal.

Dr. NORTON. Mr. Chairman and members of the committee, it is my privilege to represent, and to speak for, the directors of the official

State and Territorial departments of health, who support in principle S. 2778. As a matter of fact, speaking for the group, I can say we wholeheartedly feel this is a great improvement over the arrangement we have had.

As a member of the executive committee of the Association of State and Territorial Health Officers, I participated in that executive committee's study of, and action on, the bill. Unfortunately, due to lack of time, it was not possible to get the specific recommendations of each individual State and Territorial health officer, as had been planned, but we do have a statement of the 28 States at the end of this document. The committee, however, has authority to make this statement, and I assure you that it reflects as faithfully as we are able to put it the position of our members.

By and large, official responsibility for the advancement of the health of our people with particular emphasis on the prevention of illnesses, injuries, and deaths rests with the State health departments. Actual provision of public health services, varying in each State, is largely the responsibility of local health departments. For many years now there has been developing an increasing effective FederalState-local partnership. Spurred by this Federal-State-local partnership, noteworthy strides have been made in the reduction of such disabling diseases as the venereal diseases, tuberculosis, and the intestinal diseases due to unsafe drinking water, milk, and unsafe sewage disposal. More recently there has been progress in reducing the toll of cancer and of heart disease and in the prevention of aftereffects of emotional disturbances in children. There have been other significant advances in better health for our people such as better nutrition, maternal and infant health, dental health, and so on.

The potential health benefit from these activities is tremendous. So far, however, the activities and returns on this joint Federal-Statelocal partnership investment are only getting well started.

Inherent in many of these forward steps toward better health, there has been potent impetus of the grant-in-aid Federal-Statelocal partnership that has made possible the strengthening of existing, and the initiation of new, preventive services. Congress in its wisdom has provided funds for attacks on specific disease problems such as venereal and mental, tuberculosis, and cancer. These have been designated as categorical grants. S. 2778 amalgamates these specific support funds with that for general health in one package termed a block grant to share with the State and local health departments in meeting the cost of public health services.

As State health officers we have been aware of the need for the greater flexibility the new mechanism would provide in the interest of more effective and economical use of the funds. Relative needs for specific health activities vary greatly from State to State beyond the ability to best cope with them through a single formula. We can adjust to them more effectively in the public interest under the more flexible provisions of S. 2778. Each State will be freer to use funds according to the varying local needs, and bookkeeping and auditing costs will be reduced markedly.

In addition to the vital support provision, the bill encourages States to extend and improve their existing services and to study and develop new techniques that may prove more effective and economical.

Though we would have preferred more time to do a more careful study, we have recommendations as to certain aspects of this proposed bill. For instance, it is our understanding that allocations as to the percentage of funds for each of the three types of grants: (1) support; (2) extension and improvement; and (3) special projects, are scheduled to be determined by another committee when appropriations are made, possibly on a 65-25-10 percentage ratio.

We believe that under present existing conditions public health in our States will be advanced more certainly if about 85 percent of the appropriation is allotted for support, 10 percent for extension and improvement, and 5 percent for special projects. That is on the basis of the decreasing appropriations, which have been discussed in the last few minutes.

Should, for instance, as much as 25 percent of the total be allocated for extension and improvement, worthy as that is, with its biennial reduction of one-fourth of the Federal-fund participation, many of the States would be embarrassed and possibly resentful, as well as hard put to take over so large a part of the load, under our present system of taxation.

Most States would be in a position to do a better job if not more than 5 percent of the appropriation were allocated for special projects. We are of the opinion that since funds are already available to the National Institutes of Health for research in public-health techniques, a 5 percent allocation for special projects would be sufficient. We recommend that special project grants to public and other nonprofit organizations and agencies be required to have the approval of State health, or State mental health authorities, as the case may be, in the interest of coordination and effective use of these funds within each State.

We rely on the sound judgment of Congress to assume continuance of the excellent health progress by maintaining the effective partnership support with State and local appropriating bodies. There are already mounting public expenditures to care for unfortunate older people in our aging population. A significant portion of that expenditure is due to ill health, a part of which could have been prevented. It is sound procedure to enlarge the possibilities of prevention of the need to provide a considerable amount of those funds, particularly in view of the prospect that the total load will continue to grow.

As we get people to take advantage of what is known about sound nutrition and the hazards of overweight as they contribute to heart disease, high-blood pressure, and diabetes, of early detection of cancer, of prevention of rheumatic fever, of the early diagnosis and care and eventual prevention of mental illness, of the prevention and early discovery of tuberculosis, and so on, we can expect to reduce the need for funds to care for unfortunate older people.

There is much that can be accomplished through stimulation provided by Federal funds to advance fuller, more productive living that would not come about without them.

The responsibility of safeguarding the health of the citizens of each State reposes in the State board of health. Local governments have rapidly increased their support to exceed, in some States, the State funds. You saw the overall chart, which showed they had in the country overall exceeded the State funds.

The Federal Government, too, has a clear-cut responsibility to assist in the maintenance of adequate health services within the State for the following reasons:

First, national defense is definitely a responsibility of the Federal Government. Safeguarding the health of the civil population during peace and war is definitely an integral phase of national defense. A healthy citizenship is essential to adequate production of the sinews of war. The Federal Government in times of national emergency does not hesitate to draft manpower for the defense of the Nation. By the same token it would seem logical that the Federal Government should aid the State and local health departments in the execution of a sound public-health program designed to produce physically, mentally, and emotionally sound and robust individuals to serve in an emergency. Our potential enemies outnumber us quantitatively. We must rely on the quality of our defenders.

In the second place, by an act of Congress the United States Public Health Service is charged with responsibility of preventing the interstate spread of disease. It would manifestly be foolish to throw a cordon of officers around each State for the purpose of keeping communicable diseases from crossing State borders. For a number of years the Public Health Service, in cooperation with various health departments, has studied how best this legal responsibility of the Public Health Service can be met.

After years of trial and experimentation it has been a joint conclusion that the best way to prevent the interstate spread of disease is to control it at its source. To accomplish this result some type of public-health machinery is necessary.

Finally, as a result of group thinking the local health department, manned by well-trained personnel, has been found to be the ideal agency for controlling diseases at the source and consequently preventing the interstate spread of disease. Therefore, the allotment of general health Federal funds for the maintenance of local health departments through the State health departments should not be considered a Federal subsidy but as a just payment by the Federal Government to the local health departments for supplying a service which those agencies can perform more efficiently and effectively than can a Federal agency. For these two reasons it is definitely felt that the Federal Government has a moral and legal responsibility to render adequate financial aid to the States in supporting effective health services-State and local.

The above two paragraphs were added also to emphasize the logic of, and necessity for, continuation and strengthening of the traditional tripartite financial support-Federal, State, and local. Changing names and formulas is helpful administratively as S. 2778 provides. The level of appropriations, however, is even more important and with preventive health services a rapidly improving buy this is the time to increase our investment.

The reason why we say it is a rapidly improving buy is because we can accomplish so much more in new areas where formerly we were unable to do anything from the standpoint prevention.

Following this statement we have attached a summarized report from 28 States on their initial reaction to the provisions of S. 2778. As others come in they will be forwarded to your chairman.

Permit me to close with the regret that we could not more thoroughly go into the possible implications of S. 2778 and therefore are in a position only to state that we endorse it in principle with certain recommendations for modification and that adequate financial support for public-health services is more vitally needed than even the administratívely helpful provisions of this proposed bill.

May I express our appreciation for this opportunity to bring these, our recommendations of the Association of State and Territorial Health Offices, to you.

Senator PURTELL. Thank you, Dr. Norton.

Your document containing the State reactions will be made a part of the record at this point, without objection.

(The document is as follows:)

STATE REACTIONS TO S. 2778 RECEIVED SO FAR (MARCH 29, 1954) BY EXECUTIVE COMMITTEE OF ASTHO

ALABAMA

Approves block grant and specifically goes along with the A. M. A. suggestion of lumping type 1 and 2 funds.

Disapproves the fact that fiscal 1956 proposed funds show reductions as compared to fiscal 1955.

ARKANSAS

Approves block grant and would prefer the 85 percent, 10 percent, 5 percent distribution of type 1, 2, and 3 funds.

Opposes direct allocation of public aid funds to any other agency than the public health agency.

CALIFORNIA

Approves block grants. Would prefer 85 percent, 10 percent, 5 percent distribution.

Disapproves the decrease in funds available to California which would amount to an almost 50 percent loss in fiscal 1956 over fiscal 1955.

COLORADO

Disapproves adoption of the bill as it now stands although agreeing that greater flexibility in the use of funds would be desirable. Agrees with Doctor Norton's March 12 statement before House Committee on Interstate and Foreign Commerce on H. R. 7397 in that adequate financial support for public health services is more vitally needed than administratively helpful revisions such as elimination of some of the categorical grant restrictions. Prefers the 85 percent, 10 percent, 5 percent distribution among types 1, 2, and 3.

Disapproves grants being made to projects in the States without clearance through the official State agency.

FLORIDA

Is not enthusiastic about supporting S. 2778 because it proposes to earmark funds for new categories under (2) and (3)—“Extension and Improvement, and Special projects"-when funds are not sufficient for existing categories.

GEORGIA

Agrees with the principle of block grants. Believes 80 percent to 85 percent should be made available to type 1 general support grants.

Dislikes loss of funds in application of new formulae of fiscal 1956 over fiscal 1955.

IOWA

Feels that the block grant could provide more flexibility to the individual State, approves of this.