They could pick up the cost if they can be rehabilitated back to employment. In some State agencies, they do not do that; because, of course the numbers, if you do not play the numbers game, this is not the way to do it.

For the same amount of money you get fewer numbers in rehabilitating paraplegics and quadraplegics than if you buy false teeth and eyeglasses and these fall into the same agency. So some States play the numbers game and do the simplier things and get a few more numbers.

Ours is extremely liberal and they do a very good job in picking up these cases.

But in our case-for instance, we have free bed funding, we raise money in Chicago to pick up the cost of people who have nothing, but they are paid for by insurance, the DVR, particularly in Illinois, the free bed fund, at the institute, and the welfare agencies.

Frankly, we get free bed funds to get people off welfare because people with modest means obviously can be devastated by this.

I cannot stress enough the matter of education; I mean, the training, of the allied health people and the doctors. All our patients are referred by doctors. If you track it down, you will find most of them are referred by social workers and nurses.

Some social worker in maybe a little hospital, or a nurse who heard of rehabilitation, who says, "Doctor, why do you not think of sending that patient on?" These people are vital to this thing, and not just spinal cord injury, but arthritis and stroke and all these disabilities.

Senator STEVENSON. Dr. Snelson, the chief of prosthetics at Rancho Los Amigos Hospital, suggested in his testimony that the proposed section for providing for national spinal cord injury centers be amended to include amputees' rehabilitation.

What is your view on that suggestion?

Dr. BETTS. I have not thought about that.

In other words, they would be spinal cord injury and amputee

centers.

Senator STEVENSON. Yes.

Dr. BETTS. It is not a bad idea. I mean, the problem of amputees is massive. My only hesitation is-well, for instance, we have a very large putee program and one of the major prosthetic schools, as does Rancho Los Amigos, and we have spinal cord injured, as does Rancho Los Amigos, a very large spinal cord injury center.

As far as combining the two, financially and administratively and everything

Senator STEVENSON. That was my understanding. If you would like to think about that proposition a little more, it would be very helpful if you. after doing so, would submit a statement for our record. Dr. BETTS. All right.

I hope, in my hesitancy, I do not imply a lack of interest in amFatees, because it is a massive problem, just trying to figure the orga5.zational aspects. He is going to speak to that, or has he spoken to

Senator STEVENSON. He will make that suggestion in the course. of these hearings.

Dr. BETTS. The training would be in that, too?

Senator STEVENSON. He did not discuss training. We do not know what his views are.

Dr. BETTS. I would think if the research and training were separated out, as I suggested, I think it would be good to put it in a separate title, that you could superimpose that on the spinal cord injury centers and on the amputee centers.

The training of prosthetics is absolutely vital, too. These schools are exemplary. I mean, they have done a massively good job in training prosthetists, and training people to understand the use of these and training doctors, and so on.

It seems inconceivable that about 20 years ago that was really pretty sloppily done. People went down to their friendly neighborhood carpenter or somebody and got a leg as best they could. Now, they get something that really is quite phenomenal.

Senator STEVENSON. Dr. Rusk testified last week to a sort of malaise which has set into SRS and RSA in recent years. He suggested they had been overburdened with solving too many of society's burdens and that they would long for the good old days when rehabilitation had a clear meaning, or at least a clearer meaning.

Do you share those views of Dr. Rusk?

Dr. BETTS. In every way, I suppose. It is just human nature, I guess. Well, that is a pretty complex problem.

The great strides in rehabilitation for the physically handicapped unquestionably was done by Mary Switzer and that agency under her leadership, probably because she was an incredible woman, great bureaucrat, and political mind and so on; and maybe partly because it was separated out and very visible, and partly because it had the early energy of people like Dr. Rusk, and so on, to be here in Washington, and people concerned about it. I do not know.

Anyway, for that little agency that I referred to first, it did an absolutely incredible job. It now is absorbed into an agency that is concerned with-I do not know all the things it is concerned with-but certainly it is concerned with welfare; it is concerned with drug addiction and alcoholism. I cannot remember everything. But anyway, an awful lot of major, national issues.

I know that Mr. Twiname is very concerned about rehabilitation and that the rehabilitation agency is under his aegis, and I know he is smart and I know he brings to the agency the kind of expertise that probably we all could use, or at least, in my place, I find it very useful, the expertise of business people who have had to deal with efficiency, even based on profit, and so on, brings a very vital thing to this cause. I mean, it is good for us do-gooders, or whatever we are, to have these people around. It is very, very useful.

What Dr. Rusk is referring to is that the good old days are gone. It does not seem possible that people could just come to Washington and talk to Mary or talk to whoever they knew and accomplish their goals. I do not know all the goals of that agency.

It is really rather a mystery to me now. We have had a lot of cooperation with them in the regional office and at the Federal level.

It does seem conceivable to me that considering the national interest, if I were in charge of all of that, as the days went by, that maybe the rehabilitation of the physically handicapped would not be the thing that I heard most about every day, particularly when welfare is on my back, which seems to be one of the two or three issues that the Nation is most worried about.

The other thing is that they have said to us in the centers-I should not say "they," because it is rather vague-in my mind, this came up about 5 years ago, when Mary Switzer was still alive, in Lexington, Mass.; and I can remember when I first heard this, we were told, Now, you rehabilitate an impoverished group; that is, the physically handicapped; we will say "impoverished"-now we want you to take your team and apply that to the other kinds of impoverished groups; take your team into the inner city and consider the unemployed of all kinds and the problems of minority groups and the problems of addets and problems of alcoholics; take your team and rehabilitate all those people.

There may be a line of logic to that. I do not know.

All I can tell you is that I was not trained to do that. I was just simply trained to treat people, because of handicaps-I wonder if perhaps it might not be better for the people who are expert in these areas to make observations of the utilization of our time and take those experts and form teams on their own.

I really do not know.

When I go to the regional office in Chicago, which is an exemplary ore, I remember John Simpson, in my office, really from Buffalo, and I know the problems that he has to face with that whole region of the M.dwest, of nursing homes had burned down; he was going to have to spend months on that; addiction, alcoholism, housing, transportation for the physically handicapped, problems of inner city, problems in the black ghettoes, and physically handicapped.

Hopefully, I was supposed to be able to say, I can use my team in the rehabilitations to take on all of that. I am not criticizing him, becase he has made no pressure on it. It is quite overwhelming.

Our field is not very old, you know, and we have put a lot of effort into this matter of physically handicapped, and we think they deserve it and we would like to pursue that.

As a citizen, I am willing to pursue any of this. Obviously, there are vital causes.

Now, you talk about the malaise: I doubt if there is a malaise in the agency. Whether the organizational structure is right, to be able to carry out all these goals is way beyond my capability of understanding.

You have management consultant people all over Washington and business people who ought to be able to determine how this must be carried out most efficiently. That is not exactly my area of expertise. There are problems in this concept of how to carry it out. There is no dat about that.

I hate watering down the effort with the people to whom my group Las dedicated their life, for areas in which we are really just amateurs; but I do not want to give the impression that anyone has come and 1: You have to do it.

I think throughout the Nation in all these agencies, it is probably per that they say to us: Do not consider it just any physically andicapped, particularly consider the poor physically handicapped, be physically handicapped from the inner city. I have no objection

that at all."

I think we should be told that over and over again; because that is where the trouble is these days; no doubt about it.

I do not mind hearing that at all.
Does that answer your question?

Senator STEVENSON. That is very helpful; and I thank you again,

Dr. Betts.

Senator Cranston has returned now.

Senator CRANSTON. I regret very much I was not here during your testimony, but I was well represented by staff members, and I will myself read your statement in the record.

I thank you very much.

Senator Stevenson, I thank you very much.

Our next witness is Roy Snelson, chief, Prosthetics Amputee Center, Rancho Los Amigos Hospital, Downey, Calif.

We are particularly pleased to welcome you to this hearing.

Because of my interest in the field of rehabilitation, I have been aware of the outstanding work which has been done and continues to be done at your hospital in concert with Rancho Los Amigos Hospital, University of Southern California.

I want to thank you for taking your valuable time and coming such a long distance to give us the benefit of your experience and background and the sharing of your views with this committee.

I know your testimony will add to our knowledge and aid the committee in its study of the bills now before us.

STATEMENT OF ROY SNELSON, CHIEF, PROSTHETICS AMPUTEE CENTER, RANCHO LOS AMIGOS HOSPITAL, DOWNEY, CALIF.

Mr. SNELSON. Thank you, Senator.

I have submitted a written statement, and I think in the interest of time, I would like to summarize it.

Senator CRANSTON. I appreciate that a great deal because we do have some time problems. Your prepared statement will be submitted for the record at the conclusion of your testimony.

Mr. SNELSON. Our present system of care for the amputee was designed primarily for the World War II amputee, who was a young male in an area where other young males had the same problem; and it is product oriented.

Most of the research and training in the area of prosthetics has been product-oriented. This was satisfactory when we were dealing with young people.

However, today, about 90 percent of our amputees are in the older population; about 55 years of age.

Because of recent advancements in surgical care of amputees, about 80 percent now have their legs amputated between the foot and the knee, as opposed to 10 years ago when 80 percent of the amputations were between the knee and the hip.

This advancement of making these people below-the-knee amputees has created greater groups of patients with rehabilitation potential. The older patient, generally, if the leg is amputated above the knee, is not a candidate for ambulation.

The problems are different in the older amputee. Amputation is really a catastrophic illness. We have a tendency to look at things technically instead of an entire patient and his problems.

We have services available, but they are sometimes fragmented. For example, in some county hospitals a patient can come in if he

lives in that area, and if he has no means; but if he lives across the county line, or is not an indigent, he is not available for care.

I think we need someone who understands what is available for the patient and sees that the patient is made aware of it. We have a Vocational rehabilitation system, but they cannot do anything until the patient has been referred to them by someone, and unfortunately the advent of medicaid has reduced their efforts in this area because in the past, in order for a patient to find funds for a phosthesis, he would be referred to a vocational rehabilitation counselor, and then enter the program.

Now the funds are available through group insurances; medicaid and other methods, and they may receive only a part of the care which really is not good.

The criteria we use in the United States for providing prosthetic care for older patients should be changed. It is: "Will they walk?" I think a patient has a right to feel normal, and if part of his body has been removed, it should be replaced whether he is going to walk

or not.

The greatest problem the patient has is not being able to walk again; it is the family problem. The average older amputee is about 55 years old and has children either in college or about that age. He faces the loss of a job, and, too many times, I see people who are in the middle-income bracket, who have had an amputation, and have great psychological problems.

They are out of work, and they do not know when they are going to go back to work. They lose their jobs. Once they lose their jobs, many t.mes the family breaks up. Then the individual becomes indigent, and they are eligible for care in an amputee center.

I do not think this is correct, and it is certainly not the most inexpensive way to handle the problem. As a matter of fact, there are some agencies in some States that require a patient to survive a cancer operation for 5 years before they will provide prosthetic care, which is not a very humanized system.

In a center where you bring these people together, you have a tendery to treat them more as a whole person. They have the advantage of seeing other people in the center with the same thing wrong with them. You can lay out a program so they will have a better idea of where they are going, and when they are going to get back to work.

Almost anyone can survive 2 or 3 months away from his job. If he is going to be gone 6 months, 8 months or a year, then he is going to be replaced, and trying to get someone into a job who has had an amputation is much more difficult than getting back into the job he had before. I believe it will be a terribly expensive thing to do, and I recommend to the committee that it establish provisions for amputee centers simiar to the spinal cord injury centers. I do not, of course, propose they be placed together because these are very different problems. Amputaton to an older person is a catastrophic disease, and I think it would be a savings if we could get these people working rather than having them become unemployed. Once they become unemployed and become dependent, it is extremely difficult for them to return to work.

I believe that is all I have to say.

Senator CRANSTON. I thank you very much for that succinct summary. Your entire prepared statement will appear in the record.