and reasonably distributed hospital and related facilities is particularly urgent, and in my discussions over the years with my friends back home, wherever matters of broad public health significance were mentioned, it has been the almost invariable conclusion of informed people that the hospital held the key to further public health progress that might be made in my State. More recently I have been equally impressed with the place of high importance which the health center holds in relation to adequate health and medical care.

For these reasons I followed very carefully the progress of this bill in the Senate and have read in detail the published hearings. The facts brought out at the Senate hearings by many distinguished witnesses confirmed almost precisely the observations I had made in respect to the needs in my own State.

I don't recall any substantial legislation dealing with medical matters, that has come before the Congress since I have been a member, in which the testimony of responsible people did not invariably emphasize the mal-distribution of well-trained doctors as the greatest single deterrent to adequate health and medical care for all the people.

Moreover, it is a matter not only on which our medical friends agree, but of common knowledge, that where there is no hospital there will be no well-trained doctors; and conversely where there is a wellequipped hospital, there you will always find competent physicians. This is the case in my own State as I am sure it is in every other State. It was the case before the war and during the war. In my judgment, the tragedy is that a wider and more equitable distribution of facilities do not exist at the moment to serve as inducements for a better dispersal of the doctors being released from the armed services.

Though not a complete answer in itself to all the health needs of the Nation, I, for one, am convinced that the first step toward meeting these needs is the provision of adequate hospital and health facilities, properly distributed.

I am impressed, too, with the overwhelming evidence that here is a field of endeavor that goes beyond the financial competence of the great majority of individual States and where Federal aid is therefore necessary if any material Nation-wide improvement is to be realized. In studying this bill in detail, I have been impressed with the fact that certain broad fundamental principles have been recognized and meticulously preserved. These are: First, that hospitals and other facilities constructed with Federal aid become a part of a long-range planned health program, related to specific health needs as determined by competent local authority, and not as an incident to a public works program or some other purpose not specifically and directly related to health needs as such; second, that States' rights and local initiative be preserved and encouraged as essential to the success of the undertaking; and, third, that the voluntary, nonprofit institution is duly recognized for the place it holds in its contribution to the Nation's health.

Since this intimate copartnership between the Federal, State, and local authorities is such a dominant feature of the bill, I am sure that every member of the committee would agree that the choice of the United States Public Health Service as the agency to administer the program is a wise one. Its long and favorable record in administering other Federal grant-in-aid programs, and its wide knowledge of health and hospital problems are known to all of us. Despite the fullest participation on the part of State and local agencies in developing this

program, there will still devolve upon the Public Health Service, if this bill is enacted, a very heavy administrative responsibility. Without anticipating what Doctor Parran or one of his representatives might testify in this regard, I would point out the fact that the administration of this program will call for personnel of the very highest caliber and in substantial numbers. I venture this statement, first, because of my conviction that the benefits provided in this bill are fundamental to any further substantial progress toward meeting the Nation's health needs, and, second, that the administrative complexities inherent in a program of this character are of almost equal proportions to its importance.

We are glad to have you to appear before the committee as the first witness on this legislation, based on the Senate passed bill, 191.

We all recognize the importance of this legislation, as it would amend the Public Health Service Act. We recognize the fact that you have been with the Public Health Service for a good long while, and are very familiar with the program. Indeed, we are glad to have you as a witness to discuss this legislation at this time.

DR. PARRAN. Thank you, Mr. Chairman.

STATEMENT OF SURGEON GENERAL THOMAS PARRAN, UNITED STATES PUBLIC HEALTH SERVICE

DR. PARRAN. As requested by your committee, Mr. Chairman, I am happy to testify concerning S. 191, the Hospital Survey and Construction Bill.

How that victory has been achieved, our Nation naturally turns its attention to actions which the Federal Government properly can undertake to improve national health. This committee is intimately acquainted with the health problems of the country, since under the chairmanship of Mr. Priest, and that of his distinguished predecessor, Mr. Bulwinkle, this subcommittee has handled a substantial amount of important health legislation during the past decade, including codification and strengthening of the whole body of public health law in the Public Health Service Act of 1944. The bill before you is an amendment to that Public Health Service Act.

The Social Security Act laid the groundwork for a continuing policy of Federal cooperation with the States in matters of public health.

The La Follette-Bulwinkle Venereal Disease Control Act of 1938 providentially made it possible for a Nation-wide venereal campaign to be organized prior to the onset of war. As a result these diseases have been held in check.

The Bulwinkle Tuberculosis Control Bill enacted as a part of the Public Health Service Act in 1944 has made it possible for an aggressive campaign for the control of tuberculosis to be organized.

The National Cancer Institute Act of 1937 established a new precedent in Federal policy, that of giving grants-in-aid to research institutions, universities, and other organizations for studies concerned with the cause and control of cancer. As a result, the bases of our knowledge about cancer are gradually being extended and satisfactory methods of cooperation have been developed between the Government and the research institutions.

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The Friest Mental Health Bill is now before the House with a favorable report of this committee.

I mention the above measures because they have created a pattern in which the bill now before you fits very logically. It is a pattern of cooperation with State agencies through grants-in-aid and technical assistance, and of similar cooperation with nongovernmental institutions. Both types of assistance are provided in S. 191-cooperation with S. 191 in the construction of hospitals, and so on.

It is obvious that in order for the Nation to have good health and medical care-in order for the benefits of modern science to be made available to the people-it is necessary to provide the workshops of medicine, that is, the hospitals and health centers with modern equipment distributed geographically throughout the country in proportion to need, planned with the view to meeting the total facility needs of each State. S. 191 is designed to accomplish this broad purpose in two steps.

First, the bill would provide equal assistance to all States in making State-wide surveys to determine the need for additional hospitals, health centers, and allied health facilities and in planning State-wide construction programs.

Secondly, it would aid the States, in proportion to the relative financial needs of their populations, in the construction of those public and other nonprofit health facilities embraced in the over-all State plans in order of urgency.

Since Mr. Priest has so ably analyzed the provisions of S. 191, I shall confine my testimony to (a) the future place and function of the hospital in contributing to the national health; (b) the overall needs of the country for hospitals and health centers; (c) the progress the States already have made in developing surveys and plans for an integrated system of hospitals and health centers; and (d) the amendments which I would suggest to improve the bill.

The concept of public health has expanded in recent years to include a far greater responsibility for the treatment and care of the individual. This has had the effect of bringing the hospital into the very forefront as an instrument of public health, serving as it now does as the hub around which the whole chain of public health services revolves.

Accordingly, hospitals today face a broader responsibility to society than ever before. The more advanced the science of medicine becomes, the more complex the machinery required for its administration. The modern hospital is a highly complex, technical organization, employing the latest scientific and diagnostic aids, preventive and curative measures, professional skills, and expensive equipment.

The present hospital pattern of the country has been shaped by deeply ingraind social influences. In the community mind the hospital is now almost as much a part of the social structure as the church and the school. The hospital, especially the voluntary institution, is steeped in traditions of service and sacrifice. These traditions are extremely valuable assets.

They should be preserved, shaped to fit changing social requirements, and kept abreast with scientific developments.

Since the Elizabethan poor laws, governments have accepted responsibility for the care of the sick poor. From earliest times, churches have cared for the sick as a natural expression of their chari

table mission. Hospitalization under both of these sponsorships still prevails in important proportions. More recently, however, as hospitals expanded their services to the general public, a new type of institution developed: a hospital owned and operated by and for the community.

Public hospitals are those supported primarily from tax funds and operated by units of government, such as States, counties, and cities. While the public hospitals originally were intended primarily for the case of indigent patients, they serve increasingly both private and indigent patients where the county or city hospital is the only existing hospital facility in the community.

Voluntary nonprofit hospitals serve the whole community, including both private and indigent patients. They are owned by the various church organizations, fraternal organizations, and, more important numerically, by local nonprofit associations. In the service. rendered, there is little difference between the public and the voluntary nonprofit hospitals. The public-service status of the latter is apparent in almost universal exemption from taxation.

The truly private or proprietary hospitals, operated by individuals or groups of individuals for profit, are of relatively less importance quantitatively, and would not be eligible for assistance under this bill. Many of these, nevertheless, serve important functions in many communities, and there is nothing contemplated in this bill that would prevent their continuing to do so.

Around this three-cornered framework of public, voluntary, and proprietary institutions, the hospital structure of the nation has grown, with circumstance or happenstance determining the type and location of the hospitals built. By and large they have been established without much conscious planning.

Despite the great deficits in facilities in the majority of communities-the existing hospital system of the country represents a vast investment-both financial and human. The time is long overdue for this vast network to be reoriented to the increasing problems and expanding opportunities confronting them. Integration of the many units for coordinated service in the interest of national health is, in my judgment, essential.

I should point out, Mr. Chairman, some of the implications and advantages to be gained from such an integration of hospital and health facilities and services. Existing facilities may be broadly classified under four types:

The first is what we might term a "Medical Center." By this is meant a large teaching hospital desirably associated with a medical school. In these institutions there is concentrated the best clinical and medical research brains of the country.

The second type of institution we might term a "district hospital." This again is a large well-equipped and well-staffed institution comparable in quality of service to the medical center but not giving undergraduate medical training and usually less extensively engaged in research.

The third type is the smaller institution and those frequently referred to as "rural hospitals." We think of these as smaller institutions of less than 100 beds and having few, if any, regular training activities, except through affiliation with a medical center.

The fourth type of institution is the "health center." These modern health workshops are needed in health districts of larger cities, in smaller cities and counties, and in the remote rural center, too small to maintain even a rural hospital. Since they are relatively inexpensive to construct and operate, they have great potentialities for benefit in the over-all health plan. In addition to providing for conventional public health work, in many places they will be ideally suited for all local community health activities, including facilities for the private practice of medicine and dentistry. In the rural center also they could include a few beds for emergency care.

This concept of it, I think, is shown graphically and schematically in the material which the clerk has passed to you.

In the past, it has very largely been the practice for each of these institutions to maintain independent types of service with little relationship with each other. Many leaders in the health field now feel that a high grade of health and medical care requires an organic relationship between these several types of institutions. In rural locations, in particular, the community cannot afford comprehensive facilities and medical personnel sufficient to handle the more complicated diagnostic and treatment cases. An integrated service implies a ready means whereby patients may be referred from health centers or rural hospitals to district hospitals or medical centers, as may be necessary, and then be sent back to their home communities. An integrated service implies further that interns and student nurses in the medical center will secure some of their training under supervision in the ancillary rural and other small hospitals, and in general that all of the highly specialized facilities of the medical center may be available even to the most rural communities.

The inadequacy of hospital and health facilities in many States is reflected in a number of ways. For example, while the average infant mortality of the Nation has been reduced to about 40 per thousand live births, that ratio is higher in 23 States, and in several States, more than 100 percent higher. While in some communities nearly 100 percent of births are in hospitals, in others, that figure drops to about 20 percent. Whereas some States have a relatively higher proportion of hospital beds, a large number of these beds are substandard, and in few, if any States, are all communities adequately served, irrespective of the State's over-all average. Of the more than 3,000 counties in the Nation, approximately 40 percent have no registered hospitals. While not every one of these counties may need a separate hospital, many unquestionably need some type of health facility. These inadequacies are not due to lack of interest or initiative. They are caused primarily by a lack of economic means by which hospital and health facilities are acquired. Hospitals are expensive to build and require a high concentration of skills for their operation. It is in the wealthier States and metropolitan areas that the best and most abundant of our hospital facilities are concentrated.

The effect of economic status on the distribution of health facilities has been considered in the variable grants provided in this legislation. Only two factors, State population and average per capita income, are used in determining each State's construction allotment. If all State allotments are completely utilized, the result is an increasingly larger per capita total expenditure in the poorer States, where there is the greater need. Financil ability is further recognized in the provision