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

that the Federal contribution on each construction project is to range from 33 percent in the wealthiest State to 75 percent in the poorest State.

In order that the committee may gain a more exact picture of the magnitude of the over-all needs, the Public Health Service has carefully analyzed available data on existing hospitals and health centers and their distribution, and from this analysis, have estimated by broad categories the needs which are considered most urgent. These needs are shown in the attached table.

Dr. PARRAN. I might add, Mr. Chairman, that the estimates which we have made are in substantial agreement with the expressed views of hospital authorities throughout the country.

In referring to this table here, I would merely point out to the committee that in order for our health facilities machinery to become geared to the needs of the Nation, our general hospital beds must be increased by about 36 percent, tuberculosis beds by about 68 percent, mental hospital beds by about 43 percent, and chronic disease hospitals and public health centers by several times.

Mr. HARRIS. Did you intend to include this in your statement?
Dr. PARRAN. With your permission, I should like to submit this for

the record.

Mr. HARRIS. Without objection, it will be received. (The table is as follows:)

1 Includes the 48 States, District of Columbia, Alaska, Hawaii, and Puerto Rico. 2 On the basis of 4.5 beds per thousand 1940 State population and after deducting existing general and allied special beds listed in the 1943 hospital number of the Journal of the American Medical Association.

3 On the basis of 2.5 beds per tuberculosis death as applied to the average annual number of such deaths in each State during the 3-year period 1941-43 and after deducting existing tuberculosis beds listed in the 1945 hospital number of the Journal of the American Medical Association (with the 1942 directory of the National Tuberculosis Association used as a check).

4 On the basis of 5 beds per thousand 1940 State population and after deducting existing mental and nervous and mental beds listed in the 1945 hospital number of the Journal of the American Medical Association. On the basis of 2 beds per thousand State population estimated by the U. S. Census Bureau as of July 1, 1944. Since no deductions were made here for existing beds, this is a gross need figure, balanced to some extent by the deduction of existing allied special beds from the gross need figures for general beds. See footnote 2.

6 On the basis of 1 public health center per 30,000 State population estimated by the U. S. Census Bureau as of July 1, 1944, with no deductions made for the relatively few existing adequate public health centers. 7 Based on the assumption that 25 percent of existing facilities in each State need to be replaced, with that 25 percent reduced by any excess in existing facilities over the standard ratios.