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Dr. PARRAN. The table to which I have just alluded also reflects some estimates of costs. At this point, Mr. Chairman, I would draw to the committee's attention, the contrasts between these estimated costs and the appropriations authorized in the bill. The differences are actually greater than here shown because the cost estimates are based on prewar price levels.

Assuming that each State annually utilizes its full allotment by contributing its proportionate share, the total expenditures of both Federal and non-Federal funds need would meet only about 23 percent of the estimated costs of new facilities and only about 18 percent of new and replacement facilities combined. This great disparity between over-all costs and appropriations authorized means that the purposes of the bill can be only fractionally served.

Mr. Priest, in his opening statement, made the pertinent observation on the effects which well-equipped hospitals have upon the geographic distribution of doctors and other health personnel. I consider this aspect of the problem to be of the very greatest importance.

Many rural areas were being drained of their medical practitioners before the war, largely because of the lack of clinics and hospitals. Under the present circumstances, it is extremely doubtful that these areas will attract any appreciable number of the young physicians leaving military service who have never engaged in private practice and who in their service experience have known only the best in medical facilities and teamwork associations. There is little or no possibility of reversing the trend of migration of physicians away from rural areas unless the conditions of rural practice everywhere are made more attractive through accessible modern facilities.

The value of a modern hospital is reflected not only in its services to bed patients, but also in the fact that it virtually guarantees the availability of a doctor in the community and great enhances the scope of his effective operation. While about only 1 out of every 10 persons in a community may be admitted as a hospital patient during the year, many times that number.will require the services of a physician.

Recent studies by the Public Health Service show that areas having an average of 4.6 general hospital beds per thousand population just prior to the last war had approximately 1 doctor for every 600 persons, whereas areas having less than 1 hospital bed per thousand persons had approximately 1 doctor for every 1.350 persons.

Mr. HARRIS. Since it relates to the statement you just made, the Army provided a doctor for every how many men. How many?

Dr. PARRAN. Six per thousand strength.
Mr. HARRIS. Six per thousand personnel?
Dr. PARRAN. That is right.

The original table of organization was eight, but because of the large demands for the military service and the need of keeping the home front protected, at least with a skeleton force, requirements were reduced from 8 to 6.

Mr. Brown. That is what has been wrong in the United States for the last 2 or 3 years. The Army and Navy took about 3 times as many doctors as they actually needed or used for any good purpose. Is that not correct?

Dr. PARRAN. I am not in a position to answer that, Mr. Brown.

Mr. Brown. They had better than 60,000 of the doctors and physicians of the country out of 81,000 that were available for use, or were able to practice in any way, and they had just as many medical officers per unit assigned to training camps as were assigned to combat units, with the result they did not have nearly a sufficient number of doctors and surgeons up on the battle lines as were needed, and had doctors sitting around twiddling their thumbs in a lot of other places where the Army and the Navy were in charge, and we have had an awful time getting them out. We are finally getting them back home, now, thank goodness.

A lot of men were taken that should not have been taken, and were never used to good advantage. The result was that we had a critical situation in this country. We were also not very wise in our taking of all sorts of scientific students, and even young fellows out of medical schools, in spite of the provisions written in the law by the Congress, and we have seriously injured our future supply of physicians and technicians.

Have you found that to be true!

Dr. PĂRRAN. Certainly, that has been true as regards scientific personnel,generally. We shall have an intellectual chasm in the postgraduate training of needed scientific personnel, especially in the physical sciences, chemistries, physics. The Army and Navy did insure the continued training of medical students who had been enrolled and assisted in the pre-medical training of certain students. Recently that program has been terminated, and since most of the 18-year-olds are being taken in the Army, there is a serious question as to whether or not the medical schools will get the needed number of medical students from returning veterans.

Some of us are hopeful that they will get their quota from that

Mr. Brown. Do you know of any other country on the face of the earth that was engaged in that war that did that?

Dr. PARRAN. I am not intimately familiar with what was done in other countries. I was told just recently that in Germany, the scientific personnel was excused, was not disturbed, generally, from certain of their scientific institutions, but we must recall that Germany lost the war and we won it.

Mr. Brown. But Great Britain also won the war along with us, and they did not do it, and Canada did not do it, and France did not do it, and a lot of other Nations?

Dr. PARRAN. In connection with Great Britain, the system that was followed there, I can only say, in determining in alloting doctors as between civilian and military service, the system which was developed there at the onset was essentially the one which was followed here, through the Procurement and Assignment Service.

I think, Mr. Brown, your statement was not entirely complete on the number of doctors. There are about 165,000 doctors in the country; of those, Army and Navy had around 60,000 or a few more.

Mr. Brown. They had more than that, if I can recollect. They had 47,000 in the Army on VJ-day, and they had 26 or 27 thousand in the Navy on VJ-day, so my figures were low.

Dr. PARRAN. The over-all figure of doctors in the country is about 165,000.

Of course, I was keenly aware, during the war, of the draining of civilian medical service; the medical care of the civilians deteriorated

source.

rapidly. At least 40 percent of the effective medical manpower of the country was in the armed forces.

Mr. Brown. Your figures do not coincide with mine, Doctor, but you understand, out of the other group left here, were all of the ineffectives, the men who were still licensed to practice medicine, but because of age or illness, were not actually practicing, so that we were down to very low number of practicing physicians on the home front.

There was no desire on the part of any one to keep from any man in the Army or the Navy any needed medical attention that he might desire or require, but I am reminded of the fact that case after case was called to the attention of members of this committee where there was absolutely no use whatsoever being made of the available military and naval medical personnel.

I recall a case, for instance, of Rome, N. Y., where they had a little emergency airfield, and they closed the airfield down so far as technical work was concerned, but practically a year later, when they only had 19 men in the Air Corps assigned there, they still had 27 medical officers, if I remember the number correctly, and something like 40 or 50 nurses, and I do not know how many medical corpsmen, sitting around taking care of the few men in the Air Force.

Those are the conditions that I am talking about, and that the administration of your medical personnel was not good, the work that the individual medical officer did on the battlefield and in the hospitals was phenomenal--it was really remarkable.

Dr. PARRAN. There is no doubt about that.

Mr. Brown. We all agree on that. So I am not criticizing the men who served in the Medical Corps. I am only criticizing the failure to always make good use of those who were made available to the Army and Navy.

Mr. HARRIS. Of course, that situation did cause a great lot of concern throughout the country. I assume I have had just about as many complaints regarding that as any one, in fact all members of the Congress as well as the public generally and the Government officials, but we do recognize the fact, as has just been stated, that our military personnel probably was given better medical attention than has ever been known in the history before. Not only has it been true of the Medical Department of our armed services, but other branches of the service, where in the Army felt they had a job to perform; not knowing just the extent of it from day to day, they were taking no chances, and therefore, provided, in many instances, far in excess as to what we ultimately found was the need.

Mr. WINTER. That is not the question or point before this committee, is it?

Mr. HARRIS. I am sorry. I asked the question originally in order to compare the number of doctors per unit in the Army, as Dr. Parran stated was recommended, with civilian personnel.

Mr. WINTER. What I meant was that had nothing to do, in any effect whatever as to whether or not we have sufficient hospitalization in the country or are going to have in the country.

Mr. HARRIS. I think the experience might have something to do with it.

Mr. Brown. That is my thought on it.

Mr. HARRIS. Might have some bearing with reference to the consideration of this problem; that is an important problem to the health and welfare of this country.

You may proceed.

Dr. PARRAN. The remarks have a substantial bearing on the legislation before us. We recognize the fact that doctors have been drawn away from their home communities; we are confident that very few doctors who have been in the military service and have had the advantage of most modern of medical facilities for the practice of their profession, will go back to the cross-road town or the rural area or the small town unless there are modern workshops in which they can practice their profession.

Mr. WINTER. What do you classify as the cross-road town and small towns; what population cities and counties are you referring to?

Dr. PARRAN. The population of the immediate village itself is not so important as the total population in the back country. We have in the country as a whole one doctor for about 900 people. I should like to see those doctors distributed geographically in proportion to the need for their services rather than to continue the maldistribution we now have in which, as I pointed out earlier, in communities well served by hospitals, there is one doctor to every 600 people, while in the community with few hospitals, the ratio is more than double that figure.

Mr. Brown. Do you include all of your specialists in making that average ?

Dr. PARRAN. Yes, sir.

Mr. Brown. Of course, your specialists, naturally concentrate in the larger medical centers.

Dr. PARRAN. They do.

Mr. Brown. It is the general practitioners who you find out in the rural community.

Dr. PARRAN. I would point out that the number of qualified specialists is only a relatively small fraction of the total number of registered physicians.

Mr. BROWN. Would it be your idea, if this bill was adopted that you would put specialists out in every small community?

Dr. PARRAN. By no means, Mr. Brown. We would hope, through the system of integrated hospital service

Mr. BROWN. I understand that system.

Dr. PARARN. Their services would be available as needed for consultative purposes, that would be referred by the general practitioner, from the rural area, either to the district hospital or the medical center, as needed.

Mr. Brown. I have looked at this booklet. I am wondering if this is not exactly the same system that has grown up under the present plan of hospital construction and use and medical service; in other words, we see these medical centers in the larger cities; we see medium sized hospitals in medium sized cities, and we see the very small hospitals or the

Dr. PARRAN. That is right.
Mr. Brown. Or the country doctor's office out in the rural district.

I come from a small community-from a rural district. Certainly, we want the best medical service we can have, but there are some of us who still appreciate that in a community, such as my home town, we cannot possibly have all of the facilities, from a medical standpoint, that the city of Cincinnati, which is about 35 miles from us, can have.

And, therefore, we depend upon our local doctors and our local facilities for our normal health needs, and we depend upon the hospitals of Cincinnati for our specialists, and so on.

Dr. PARRAN. That is quite correct. The scheme outlined here is not novel. It represents an elaboration of our present system or the system on which a beginning has been made.

The difference I would hope to see in the future would be that the larger institutions would take more professional responsibility for the small outlying institutions, that there would be a more organic relationship developed between the two rather than have it on the basis of, one might say, accident.

In this general connection, Mr. Chairman, I should like to emphasize the importance of the health center, the concept is not new, but I should like to point out that it is just as essential as the modern hospital is essential for the diagnosis and treatment of illness.

What these figures do not show, but what we know to be true is that the physicians in communities isolated from hospital facilities are not only less numerous, but also are mostly in the older age brackets and incapable of carrying a large general practice.

An important provision in this bill is that for construction of public health centers, the term “health center" is not new in this country but its concept has within recent years undergone substantial change. Just as the modern hospital is essential for diagnosis and treatment of illness, the public health center is necessary as the proper workshop for the modern health department. In addition, particularly in more remote areas, the health center may be the only means of providing needed emergency beds.

Mr. Chairman, I consider as indicative of the importance of the problems encompassed by this bill, the fact that they are already under active consideration by official bodies of one kind or another in nearly all the States and Territories. Numerous State-wide surveys are now in progress to determine health facility needs. In fact, intensive surveys under official auspices are either in progress or being planned in all 52 States and Territories except 12, that in building hospitals in the future, the idea has grown, they should be consciously planned and not as competing institutions but to meet the total community needs.

In 1945, fifteen States enacted legislation authorizing State-wide surveys of hospital and health center facilities and the planning of State-wide construction programs. In almost all the remaining States the surveys in progress are being carried out under authorization of the governor.

Mr. Chairman, I have here a table showing the States of these survey and planning activities by States as of February 1, 1946.

Mr. HARRIS. Without objection, it will be received and included in the record.

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