these tragedies can only occur well in community based settings. This is often impossible because, again, we have a fragmentation of the grant programs with which we must deal.

The programs that I'm familiar with do not have grant writers. They are community and migrant health centers. They're health care for the homeless programs. They scrape and try to get together programs that can deal with the problems facing their patients and there are many facets.

Community health centers are a specific example. There are over 6 million individuals that are treated in this primary care delivery system, and it is estimated by recent figures compiled by both the National Association of Community Health Centers and the Bureau of Health Care Delivery Assistance that perhaps 50,000 individuals are infected with HIV in this system.

It is very difficult for these programs when they have to scramble to write grants for six programs to successfully fund the categorical services such as pretest_counseling, posttest counseling, counseling in general, testing, early intervention, education, maybe a little AIDS AZT money and yet they often have not found any support for the primary care service needs of this population and the families that are brought into it.

What has occurred is there are too few resources, too many grant programs, too many audits associated with those grant programs, and, of course, too few services.

A couple specific examples need to be presented. One that is familiar to all and that is Dade County. Dade County has several community health centers that have been targeted with a great deal of the case load of the HIV-infected and AIDS patients in that area. Specifically what they have found is a moral dilemma, the dilemma is created by the fact that the physicians are able to provide the pretest and posttest counseling and testing and once the patient has been identified there's no one or no capacity within the system to take care of those individuals identified as infected or at risk for infection.

It's sort of like Columbus getting to the end of the ocean and the boat just sort of falls off the edge; the current system allows this to happen. Again, this is a missed opportunity for enrolling the family, sexual partners and others involved into a program of prevention that needs to be provided at the same time. The problem is much more widespread than those we are aware of.

Yakima Valley Farmer Worker Clinic in Washington State-the migration of migrant and seasonal farm workers, up and down the western stream of this country who pick our crops, can spread and transmit this virus. Much of what is being experienced is associated with intravenous drug abuse. This health center is dealing with a capacity issue-do I give up one service to deal with another? Should I send the mothers and babies out of my clinics so that I can deal with the case load that I'm now seeing for HIV?

The examples continue. Brownsville, TX, most recently facing a crisis with the introduction of a number of immigrants into this country, not to mention the need of their own population, has found that a local blood bank in town is paying immigrants to donate blood. Appropriate screening measures and public health

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measures are not being practiced. This places additional burdens on local health care providers already overtaxed.

The bottom line has been that there is no significant allocation of resources for service delivery for those infected or those identified as at risk. I really question whether the problem has been recognized at the level of the administration, and one would have to include in that assessment Congress and certainly the Department of Health and Human Services.

The question is, has there been significant leadership provided in the Public Health Service or was it ignored?

Unfortunately, having attended the Charlottesville retreat a little over a year ago for the U.S. Public Health Service, I think the priority was best stated by an NIH official who was quotedand obviously I couldn't make this one up-that we really ought to be funding "air conditioned, and stainless steel macaque cages"and for any who aren't aware, "macaques" are a type of primate, a monkey. These primates are what we're using currently to do research on HIV. The statement implied that despite scarce resources, this was a priority for additional resources, because, "I just don't have enough of them to house these animals."

Well, it shouldn't be that we're fighting one another for these scarce resources. The pie's too small. But what so often happens is there is a tug of war between agencies and programs for these limited resources. It's not appropriate.

I think some small steps have been made and I'd like just quickly to go through a couple of programs that are underway within the Department and then to move to a few recommendations. Small steps, as I say, have occurred, but they've occurred in spite of the current system constraints.

Something that I call the "coffee clubs" have developed between a number of the agencies and some excellent individuals like Dr. Sam Matheny in HRSA and Dr. Stephen Bowen in the CDC have gotten together to say we have to try to do something better and "beat the system." They have asked the correct questions and, significantly, come up with answers.

Can we transfer in small amounts of money from different agencies and get a bigger bang for the buck?

Can we somehow bring money that was targeted for specific isolated health care delivery procedures like pretest counseling and early intervention and bring it together with service delivery so the patients cannot tell that there is this fragmentation in care? Indeed, that has happened, and one specific program is now being brought together between the Centers for Disease Control and the Bureau of Health Care Deliver and Assistance in HRSA to unite those services and provide a continuum of care. It's a small amount of money.

As a caveat, I hate demonstrations because, in service delivery, funding tends to run out just as you have something good going. What this program allows is the establishment of a continuum of care for the patients that are infected, AIDS victims, their families, and sexual partners. Individuals can enter a program that can do prevention, education, early intervention, pretest counseling, posttest counseling, testing, and then get them into a system of primary care, which promotes continuity.

By that I mean that their day-to-day health care needs can be met, their children can get immunizations, if they get sick they're followed continuously into the hospital. There is continuity after discharge, patients are brought back into the system after discharge from the hospital. The linkages with the hospital are in place, and what is also unique is that we anticipated in this program the need for pharmaceuticals. These expenses explain why there is only going to be a couple of programs funded out during the first cycle. I believe it's getting to the place that we need to be bringing all these resources in a community setting together. We don't want the patients to have to go up to different windows to receive the different components of care. The analogy is similar to you having to go to multiple dentists where one dentist will examine, the next will x ray you, you walk down the street and the next one will drill you, you walk down the street a little bit further and they will fill your tooth and you go back for your followup to someone else you never saw previously. That's indeed what we have in place currently.

Now, quickly, some recommendations and I will finish.

First, consistent with what I have said, I believe we need to simplify or eliminate the diffuse grant-application process currently in place and avoid wherever possible demonstration problems. We have too many grants out there.

Second, have to support the concept of comprehensive community based primary care models, whether they are community health centers, migrant health centers, or homeless health care programs, and build on what we have. Do not build new systems. We must urge coordination of Public Health Service efforts. We have to get some teeth into pulling together that team that's there and not prioritize things on the basis of who needs a "stainless steel, air conditioned, macaque cage."

We have to develop and adopt the concept of a continuum of care. When legislation is written we need to demand-demandthat grant programs define the continuum of care. Coalitions can be developed from existing service systems, as was mentioned previously, but there must be continuum for a patient. They must not run around in circles.

Similar to my colleague who testified previously, the National Health Service Corps needs to be rethought. We're not finding or retraining primary care doctors; Dr. Brown mentioned this very eloquently. People are not seeking primary care as a specialty. Part of that reason for this, I believe, is the loss of the National Health Service Corps. We are going to be approximately 800 doctors short in the community and migrant health center program next year if we do not retain physicians we have already.

Malpractice costs are eroding our current patient care budgets and eating into our ability to expand services. We currently do not have the capacity to deal with these issues.

The final issue relates to specific training for those providers of individuals with HIV, whether they are nurses, doctors, or social workers. A portion of the money, currently allotted for the educational and training centers, needs to be targeted to communities serving the underserved.

Thank you very much.

[The prepared statement of Dr. Smith follows:]

DALLAS COUNTY HOSPITAL DISTRICT
Parkland Memorial Hospital
Dallas, Texas

Testimony by David Smith, M.D.

to

U.S. House of Representatives
Committee on Government Operations

Human Resources and Inter-governmental Relations Subcommittee

July 28, 1989

Almost no coordination and precious few resources exist in this country for providing comprehensive health care to AIDS patients. This is because health-care delivery is approached in a fatally flawed and piecemeal manner. Instead of demanding a comprehensive approach to funding and reimbursement, the modus operandi remains categorical and pits one program against another.

We

What we have is special-interest support for specific diseases. have an administration, bureaucrats and Congressmen who want to be known as supporting treatment for one disease but not another. Health-care delivery therefore is further fragmented and communities must bear the responsibility of coordinating services.

This is no easy task. Even the folks who for years have been part of the U.S. Department of Health and Human Services cannot figure the score card of available grant programs. How can someone at the community level get reasonable access to the health-care delivery system?

Funding for AIDS is especially fragmented into so many special categorical programs that there is no capability to provide a continuum of care for infected individuals and those at risk. Indeed, we have not anticipated certain areas of need for AIDS patients. We have provided mostly for research, prevention of the spread of the Human Immuno-deficiency Virus, (HIV), testing and counseling, and have given lip service to providing drugs. But we have not anticipated the need to provide primary medical services to people infected with HIV.

We have danced absurdly around the most critical issue. We have provided for everything but a place to send AIDS patients for the day-to-day management of their health problems. We have created a huge void in health-care delivery to AIDS patients.

A specific example of this exists in Dade County, Fla., where a community health center provides pretest counseling, testing and post-test counseling. Yet, the center is unable to find primary care

services for the patients they identify as at risk of being infected or already infected with HIV. The center is struggling with a moral dilemma. Should it provide HIV testing when it has no capacity to render treatment or refer patients?

This is not an isolated case, but simply illustrates a nationwide dearth of direct patient-care services. Further, it appears that nationally we do not recognize we even have a problem.

No significant allocation of resources has been made for direct delivery of medical services. One can only hope that this is an oversight; however, it appears more likely that the previous Administration did not recognize the severe scope of the crisis. This resulted in a lack of commitment by the previous Administration and Congress to provide the needed resources. The bottom line is that there either has been no leadership or direction provided by the public health arena, or it has been ignored.

Instead, the priorities have been to purchase "air-conditioned, stainless steel macaque cages" for AIDS research. This is an actual statement of priorities by a National Institutes of Health official at the Charlottesville, Va., retreat last year. The leadership of the Public Health Service attended the retreat to outline the nation's attack on AIDS: How have we been addressing AIDS in this country, what do we need to do and how do we identify the needed leadership? The retreat at times became a self-serving conference on how to slice the resource pie.

Service delivery for AIDS remains an abyss of shameful inattention, and we cannot slice the pie any smaller.

Just analyze the Fiscal Year '89 budget for the U.S. Department of Health and Human Services. Of the $1.2 billion appropriated for AIDS, only $45 million was directed to the department's Health Resources and Services Administration (HRSA), which supports two of this country's largest primary care programs: Community and Migrant Health Centers and Health Care for the Homeless Program. Only a small portion of that $45 million was for direct patient care.

The proposed budget for FY '90 suggests an AIDS authorization level of $1.6 billion, of which $56 million would go to HRSA. The percentage of funds for HRSA and therefore the actual delivery of health care decreases from 3.7 percent in FY '89 down to 3.5 percent in FY '90. Things are getting worse, not better.

Such funds are then diffused into many, many small grant programs, further splintering services. For a community health delivery system to successfully obtain a significant amount of funding, it must apply to several agencies and several grant programs within each agency.