Government really got into this field and recognized the importance of it, is that true?

Dr. HOGAN. Yes, sir.

The CHAIRMAN. We have been making progress since then, but we have considerably more progress to make, is that right?

Dr. HOGAN. A great deal because mental health facilities, services for mental health, have lagged behind for one reason or other, other medical areas. We have a long way to go to catch up.

The CHAIRMAN. There has been too much disposition to put these mentally ill people in what would be called an asylum in the old days, close the door, and that is the end, is that right?

Dr. HOGAN. Yes, sir.

The CHAIRMAN. I think one of our greatest strides forward is the idea of these community mental health centers. A lot of these people can be treated in their local communities and many of them perhaps restored to useful and productive lives, is that right?

Dr. HOGAN. Yes, sir. It is hoped with the establishment of these community mental health centers, that earlier treatment would be available to the individual, which means that a chronic condition may not develop, and he will be able to be treated at the community level.

The CHAIRMAN. Doctor, you have brought us a mighty good statement. We deeply appreciate your statement. We certainly want to thank you for it.. Dr. HOGAN. Thank you, sir. I am glad to see you again. The CHAIRMAN. Thank you, Doctor-nice to have you here with

us.

Our next witness is Dr. Donald A. Galagan of Iowa, consultant, Council on Dental Health, and dean, University of Iowa Dental College.

STATEMENT OF DR. DONALD A. GALAGAN, DEAN OF THE DENTAL COLLEGE, UNIVERSITY OF IOWA, ACCOMPANIED BY BERNARD J. CONWAY, CHIEF LEGAL OFFICER, AMERICAN DENTAL ASSOCIATION, AND HAL CHRISTENSEN, WASHINGTON COUNSEL

Dr. GALAGAN. Mr. Chairman, I am Dr. Donald J. Galagan of Iowa City, Iowa. I am dean of the Dental College at the University of Iowa. With me is Bernard J. Conway of Chicago, chief legal officer of the American Dental Association and secretary of its council on legislation.

If I may be permitted a personal privilege before starting my testimony, Senator Hill-as you know, I was a member of the Public Health Service for 28 or 29 years, and during that time I had the privilege of appearing before you on various hearings by the Appropriations Committee and the Committee on Labor and Public Welfare. The CHAIRMAN. I recall your work, Doctor. May I say, you have always been a mighty good witness.

Dr. GALAGAN. Thank you, sir. What I could not say then, because I was an employee of the Federal Government, but what I can say now is that the citizens of the United States and the health professions generally and the members of the Public Health Service in particular are greatly in your debt for the leadership and foresight

you have given to health legislation in this country. And we are very grateful for all you have done over the years.

The CHAIRMAN. Thank you, sir.

Dr. GALAGAN. We have a statement which we would like to file for the record.

The CHAIRMAN. All right, sir. We will have it appear in full in the record, Doctor. You may proceed as you see fit, sir.

Dr. GALAGAN. I would like to amplify the statement in two or three respects.

First of all, you know, the American Dental Association has long worked, for more than 25 years, to upgrade the quality and the scope of dental programs in health departments.

The association has worked diligently to do this, because it felt that the State health departments in the United States, were the keystone of public health programs. And it felt, and I think justifiably so, that State health departments, as the years have gone by, were beginning to miss a great deal of the opportunity for constructive and comprehensive health programs for a variety of reasons, all of which are known to you and to members of the committee.

In the past 25 years, welfare agencies and other agencies have moved into the health field, so today there is a very great fragmentation of health services at the State level.

You will recall, too, Senator Hill, that during these 25 years of effort on the part of the association to get some support for State public health dental programs, that this effort finally culminated 2 years ago in the fiscal 1965 appropriation for the Department of Health, Education, and Welfare in earmarking a small amount of money for the support of State dental health programs-thanks to the graciousness and the consideration of the chairman of this com

mittee.

For this reason, therefore, the American Dental Association endorses the overall intent of S. 3008.

There are two special features of the legislation which the association would like to comment upon.

First of all, the section which provides for the comprehensive planning that section in the opinion of the association is very badly needed and will add a new dimension to the health activities which are going on at the State level, because it will bring into the consideration of the plans for the health services in the State the welfare departments, the medical schools, the dental schools, the nursing schools, and the other health profession schools. It will bring in voluntary agencies with fresh ideas, with new approaches, and will provide, in fact, a new dimension in the supplying of health services in the States, and this feature of the bill the association wholeheartedly endorses.

The second feature of the bill which the association would like to speak to is the proposed interchange of personnel between levels of government, and this feature, too, should provide an infusion of new blood, new ideas, competent workers in State and local governmental agencies, which will add a new dimension to the health activities at the State level.

The American Dental Association has one reservation about the bill, and that reservation, as I am sure you can imagine, has to do with the fact that the categorization of appropriations will disappear

except for that portion which is earmarked for mental health, to which the previous speaker referred.

I am sure that you, Senator Hill, are aware of the experience we have had with general health grants in the 25 years of their existence. I recall some bitter experience in the administration of the program with which I was connected in the Public Health Service, in trying to convince State health authorities that a larger share of these general health grants should be allocated to the support of dental programs, a share which we think is commensurate with the size of the problem. The association recognizes that health needs vary, and therefore there is a serious need for the freedom and flexibility which unearmarked appropriations will provide State health agencies.

Venereal disease may be higher in one State than it is in another, and tuberculosis may be higher in one State than another, but the fact is that dental disease does not vary, it is universal. I am sure that over the years that testimony has been presented to this committee which identifies the scope of the problem.

Ninety percent of the people in the country suffer from dental disease in one form or another. Half of the people over 50 have lost all their teeth.

The problem is that dental diseases are not dramatic. While they are universal, because of their low emotional intensity, State health agencies have tended not to put the emphasis on the support of dental programs which the association feels is necessary.

Therefore, the association would respectfully recommend that the committee consider earmarking a certain percentage for the support of dental programs.

The association would suggest as a possible percentage 5 percent of the formula grants.

That concludes my testimony, Senator Hill.

(The prepared statement of Dr. Galagan follows:)

PREPARED STATEMENT OF Dr. Donald J. Galagan, AMERICAN DENTAL

ASSOCIATION

Mr. Chairman and members of the subcommittee, I am Dr. Donald J. Galagan of Iowa City, Iowa. I am dean of the Dental College at the University of Iowa. With me is Bernard J. Conway of Chicago, chief legal officer of the American Dental Association and secretary of its Council on Legislation. I have served for several years as a consultant to the Council on Dental Health of the American Dental Association and represent that association on S. 3008 today. I have a special dedication to dental public health, having spent 27 years of my professional career in the Public Health Service, the last 5 as Chief of the Dental Division.

The American Dental Association recognizes the importance of many of the major goals of S. 3008. Certainly it is desirable to encourage the States and communities to make comprehensive plans in order to meet in the most efficient manner the health problems in their own areas. And certainly as a general proposition there can be no reasonable disagreement with the objective of giving to the States and communities great flexibility in implementing such plans.

We do believe, however, that the new health services grant program within proposed section 314(d) of the Public Health Service Act could be imporved by providing specific authority for dental public health grants to State health authorities. Later in my testimony I shall spell out the reasons for recommending special consideration of dental health needs.

There are several parts of S. 3008 which could contribute greatly to the Nation's health goals; these provisions, of course, are unobjectionable to the association. The new planning grants, for example, could have a wholesome effect on State and local health agencies.

There are imaginative professionals in the community public health field who should now be challenged to design programs to meet today's and tomorrow's

problems. Unquestionably the new source of planning funds in S. 3008 would give these persons the time and opportunity to chart the pattern of disease prevention and control to meet the special needs of their States and communities. Obviously, too, the stimulus for planning will produce ideas for new and more effective methods for bringing care to our citizens, especially the aged, the handicapped, the institutionalized, and the homebound. We are certain that public health dentists will contribute their share to these new designs.

The provisions for project grants in S. 3008 could also stimulate new approaches to prevention and treatment of the many diseases that affect mankind. The emphasis upon teamwork between government and nongovernment agencies as a requirement for both the planning and project grant awards is commendable. There is a great need to blend the activities of such private organizations as heart association chapters and mental health community groups with State and local health departments. Dental schools could join more effectively with public health agencies to expand and improve oral pathology services, including oral cancer screening programs.

The association also sees much merit in the proposed interchange of personnel between the Department of Health, Education, and Welfare and the State health agencies. This expanded personnel interchange program would be especially helpful to States which have not yet developed effective dental public health units. The association's chief concern with S. 3008, however, is the proposed change in the grant system for State public health services. We are convinced on the basis of many years of unhappy experience with general health grants that Federal support for dental public health activities should be specifically authorized.

The administration is proposing in S. 3008 a single-purpose grant for comprehensive State public health services. This is a significant departure from the special grant programs that have evolved over the past 30 years or more. For almost that long the American Dental Association has urged a separate category for State dental health programs. In 1964, with Senator Hill's leadership, this objective was achieved. It is somewhat disheartening, therefore, to face this new plan which could dissipate dentistry's hard-won gains by weakening the foundation upon which the future of State and local dental health programs must be built.

Let me emphasize that the association is not opposed to the idea of flexibility in using Federal health grants where that is a sound approach to a State's health goals. It is, for example, conceivable that one State may have a significant venereal disease program and little concern with tuberculosis. In another State the problems may be reversed in intensity. Obviously a State should have discretion to use its Federal health allotment to meet its pressing problems. It is a fact, however, that the dental disease problem is a serious one in every State. And the history of State health services illustrates that the dental problem needs special consideration to compete with the more dramatic and killing diseases like cancer and heart disease.

The

Four years ago this committee agreed with our conviction that dental disease is a serious problem in every State and reported favorably a bill (S. 917, 87th Cong.) introduced by the chairman of this committee, to create a special grant program for the prevention and control of dental disease. The 1962 bill proposed a 5-year program of matching grants with authority to appropriate $7 million the first year and advancing in steps to $17 million for the fifth year. testimony of the American Dental Association and the Department of Health, Education, and Welfare witnesses fully proved the need for a substantial dental health grant in 1962; that same need exists today. To illustrate the seriousness of the dental disease problem I shall quote from the testimony presented by the Department witness, Wilbur J. Cohen, then Assistant Secretary for Legislation. 'Dental diseases are the most prevalent of all the chronic diseases which afflict mankind. Tooth decay and diseases of the gums and supportive tissue are experienced by nearly everyone. Among young people, tooth decay is a particularly serious health problem. By the time the average child reaches his 15th year, 11 of his permanent teeth have been damaged or destroyed by tooth decay. Among adults, periodontal diseases are the major oral health problem, the principal cause of tooth loss.

"Other dental disorders, though less prevalent, hold even more serious consequences for those affected. Cleft lip and palate-which occur once in every 800 live births are disfiguring and crippling abnormalities. Today there are a quarter of a million individuals with cleft lip and palate, and 65,000 of these are under age 18. Malocclusion, which numbers one-half of all schoolchildren among its victims, often proves a severe handicap to the normal development of the child. The physiological effects of these disorders is obvious. Left untreated,

they often produce psychological problems which may cripple the victims emotionally for life.

"Oral cancer, which attacks 23,000 people a year, causes 1 in every 40 deaths from cancer. Early diagnosis and treatment would prevent many of these deaths. "Dental disorders are also the most neglected of all health conditions plaguing the American people. Each year, some 60 percent of the population receive no dental care at all, and others receive only the emergency services necessary for the relief of pain. As a result, 3 in every 10 people in the United States past the age of 35-and half of those past 55-are left with no natural teeth.

"The full price that dental diseases exact from the Nation has never been totaled. We do know, however, that the cost is great. It is paid by industry in lost production and absenteeism; by the Armed Forces in meeting the massive backlog of dental needs existing among inductees; and by the public which spends $2.4 billion a year to maintain a standard of dental health in which only 40 percent of the people visit a dentist even once in the course of a year

***

"Dental public health programs are by no means a recent innovation. On the contrary, most State and local public health agencies now conduct some programs in this field, but usually of a very limited character. While the scope and content vary greatly, they may include such activities as public health education in practical preventive measures and the essentials of good dental care maintenance; the provision of dental examinations; and in some cases, of corrective service for schoolchildren; and the establishment of clinical services for segments of the population with special needs or problems.

"Despite the well-established value of such activities, dental public health programs today are grossly underemphasized in most State and local health agencies. In 1961, for example, the Public Health Service made general health grants of $17 million to State public health departments. Yet these departments allocated to dental activities only $125,000—just 0.7 percent of the total. has this gulf been bridged by funds from other sources.

Nor

"Of the more than half a billion dollars spent in 1961 on all State health programs, only $6.6 million-about 1 percent-went to dental health. This pattern

of allocation of public health funds is in sharp contrast with that of private funds, where $15 out of every $100 spent for health care goes for the purchase of dental services.

"So great a disparity cannot be ignored, for the current allocation allows less than 4 cents per person per year for all State and community activities in dental health. And 4 cents per person a year is simply not enough. It does not permit programs which even begin to meet the existing national need."

We look to our public health agencies to solve many of the problems cited by Mr. Cohen in his excellent testimony. But in the majority of States dental public health programs are so seriously undermanned and underfunded that they are forced to operate at substandard levels. States which have the greatest need are forced to conduct their dental programs with only one or two dental health officers. As a result, there are far too few organized programs for bringing dental care to the aged and other homebound, the institutionalized, and the handicapped. Schoolchildren do not recieve adequate dental health education, dental examination, diagnosis, and referral for treatment. There is a serious shortage of dentists trained to treat patients with special physical or mental problems.

We know that dentistry is in a very unfavorable position to compete for funds in State health departments. Even though dental diseases, as Mr. Cohen emphasized, are serious and widely prevalent, they do not have the dramatic appeal of other diseases and to not arouse wide and intense public sentiment. But, at the same time, we cannot continue to sacrifice the dental health of the American people because of a lack of dramatic appeal.

By earmarking Federal grants for the prevention and control of dental diseases, S. 3008 would go far to remove the disadvantages which have made dental health services the stepchild of public health. With an appropriate amendment to S. 3008 State health departments could be induced to expand laboratory services to determine susceptibility to dental decay, to detect oral cancer. Dental treatment could be made available to the indigent of all ages from preschool children to adults; to those who are geographically isolated, homebound, or in nursing homes; to others who are institutionalized.

Additionally State health departments could promote and guide programs for teaching dental health in teacher training schools; they could participate in public health courses in nursing schools, in medical schools, in dental schools in schools of dental hygiene.