Dr. BERSON. That is correct, with one slight reservation. I am not really competent to know whether the scholarship programs for graduate studies in mathematics are sufficient or not. They are present in considerable numbers. The scholarships available for medical students are extremely limited. For instance, my own school has none that is controlled by the school. We have some loan funds. A few schools have some scholarships for medical students, but in very limited amounts. However, next year there will be 10,000 fellowships through only four agencies of the Federal Government for graduate study in sundry scientific fields.

Mr. ROGERS of Florida. Thank you very much.
Thank you, Mr. Chairman.

Mr. ROBERTS. Doctor, this has very little to do with medical scholarships, but I have been greatly concerned, as I am sure you have been, about the report recently made by the Public Health Service with reference to air pollution in the Birmingham area, giving us about a 3-to-1 lung cancer rate over the rest of the country.

Dr. BERSON. Yes, sir.

Mr. ROBERTS. I wondered if, in your opinion, any of these institutional grants that are now being channeled to various parts of the country through the National Institutes of Health could be devoted to this pollution problem?

Dr. BERSON. Yes, sir; I think so. Actually, I believe the National Institutes of Health did support the study that produced the figures that you mentioned and that they are prepared to support other studies.

In my own opinion, it is a tremendously important problem. It does require further study and then it is probably going to require action to remove the dangers, and this action may be a little difficult to bring about. After you identify where the harmful substances are coming from, you have the problem of how to eliminate them without being destructive to some segment of the community.

Mr. ROBERTS. It seems to point up the fact that the problem of air pollution is not just a Los Angeles problem, but it is getting so it will undoubtedly develop in most of the metropolitan areas of the country. The gentleman from Nebraska.

Mr. BROCK. Doctor, you said in your statement that the students who go through these years of training go through also a period of economic privation, but the thought of the better economic life probably leads them on in their period of training.

Could you tell us what the net earnings of the doctors are in the United States at the present time compared to, say, 15 years ago?

Dr. BERSON. Mr. Brock, I am sorry, I do not have accurate figures on that. It is my general impression that they are substantially better than they were, let us say, 25 years ago. Fifteen years ago puts us right at the end of World War II and a rather chaotic situation, but at this time there is a good bit of evidence that the earnings of the doctor with the full practice are substantially better than they were in the late thirties.

Mr. BROCK. Several months ago, we heard evidence on another health bill. One famous doctor focused his attention on the requirements of entrance to medical colleges and he felt that the requirements were too high and that we could bring in other students if we would lower the requirements to medical colleges.

Do you agree with this observation?

Dr. BERSON. No, I would not. Actually, the body of knowledge that it would be very useful for a student to know is tremendous and growing all of the time. The sort of habits and attitudes that a doctor must have and a student must acquire while he is a student are very important. To lower the entrance requirements would only mean we would lose more students unless you also lower the standards of what you require of the student.

In my opinion, this would be a move in the wrong direction. We do not need any more poor doctors. What we need is more good doctors and already the attrition rate in medical schools, even with the best selection we can do, is about 10 percent.

Mr. BROCK. Ten percent attrition?

Dr. BERSON. Yes, sir. In my own school every year the committee on admissions ends up feeling that the first 60 students they selected are good bets and the next 20 are mighty poor risks, and our experience with those students over a period of 4 years confirms their impression. Of course, some of the poor risks turn out well. We win on those guesses and a good many of them turn out just as poorly as the committee thought they would, so I think that to lower the entrance requirements would either result in a higher attrition rate or a lowering of what we really expect of students and later as doctors. Mr. BROCK. Thank you, Doctor.

Thank you, Mr. Chairman.

Mr. ROBERTS. Thank you, Doctor.

Our next witness is Dr. Ernest L. Stebbins, dean of the School of Public Health and Hygiene, of Johns Hopkins, Baltimore, Md.

STATEMENT OF DR. ERNEST L. STEBBINS, DEAN, SCHOOL OF PUBLIC HEALTH AND HYGIENE, JOHNS HOPKINS, BALTIMORE, MD.

Dr. STEBBINS. Mr. Chairman and gentlemen, I appreciate the opportunity to comment on the proposed legislation.

I am here representing the Association of Schools of Public Health of the United States.

Mr. ROBERTS. Let me say, Doctor, it is always nice to have you and you always make a fine contribution to the work of our subcommittee, and we are certainly happy to see you again.

Dr. STEBBINS. Thank you, sir.

I would like to comment briefly on each one of the proposed bills. I feel that the scholarship bills, while they do not apply directly to the schools of public health, are extremely important in that the schools of public health depend upon graduates in medicine to go on for specialization in public health, and the shortage of physicians at the present time makes it very difficult to attract sufficient numbers of wellqualified physicians for training in public health and work in the public health field.

I would like particularly, though, to speak in favor of H.R. 6906, the construction program, which is, in my opinion, one of the most important defects that we face at the present time; that is, adequate facilities for the training of physicians and public health workers.

I would put this as the highest priority because, as you recall, the traineeship program which has been quite successful in attracting

postgraduate students in public health has increased the number of students in the schools of public health and many of them have completely inadequate facilities for the number of students that are now entering.

I believe that the proposal is sound in terms of its magnitude and that it would make it possible to greatly improve the educational facilities and in a reasonable length of time.

I would also like to speak strongly in favor of the bill, H.R. 10341, the proposed institutional grants. I agree completely with the previous witnesses that this would immeasurably strengthen the research program in medical schools and in schools of public health.

Much as we appreciate and recognize the great value of the research grants program of the National Institutes of Health, it is true that there has been a tendency for these grant programs to emphasize certain areas and not provide a well-rounded program of balanced research in the medical health fields.

We believe that the institutional grants program would very materially influence the research program of the schools and in the long run provide a far more effective research program in all of the health fields.

I think that the need for the strengthening of the schools of public health, particularly the expansion of the schools, is clearly recognized, but I would remind you of the conference that was called by the Surgeon General to evaluate the traineeship program.

This conference was held in July of 1959 and a group of experts in all of the health fields met and evaluated the traineeship program and the need for a continuation of it.

One of the most important recommendations of that conference was that there be construction funds made available for the expansion and improvement of the educational facilities of the schools of public health.

I think that that is all I have to say. I certainly second the comments that have been made by the previous witnesses.

I would be glad to answer any questions concerning the subject. Mr. ROBERTS. Doctor, what is the population-physician ratio as far as the public health physicians are concerned at the present time? Dr. STEBBINS. I cannot give you an exact figure because many of the physicians in public health are part time and it is very difficult to get an equivalent of a full-time person. We do know we have never reached the recommended level of one trained public health physician for each 50,000 of the population. It is nearer 1 to 100,000 of the population at the present time.

Another measure of the need is that there are at the present time in the United States more than 500 budgeted physicians for public health physicians that are not filled and we know that it is impossible to fill these positions with trained persons.

There are also estimates that there are more than 1,500 positions in health departments that are filled by persons who have not yet had training, so that there is at least a 2,000 deficit in trained personnel on that basis.

In addition to the obvious shortage of even the budgeted physicians this is a matter of opinion and there might be differences of opinion--I would estimate that we could use to great advantage three

times the number of graduates of schools of public health than we have at the present time.

Mr. ROBERTS. How many schools of public health do we have in the country?

Dr. STEBBINS. We have 11 accredited schools at the present time. Mr. ROBERTS. Is the problem of the public health school pretty much that of the medical colleges?

Dr. STEBBINS. They are very similar. The cost of education is very much the same in the schools of public health as in the medical schools. The schools of public health have not been able to increase their facilities to any material extent in the last 25 years.

Mr. ROBERTS. You mentioned that you could use three times as many trained physicians and I suppose you include sanitary engineers and probably public health nurses in that figure?

Dr. STEBBINS. Yes.

Mr. ROBERTS. What factors make that increase necessary, in your opinion?

Dr. STEBBINS. In the first place, there is increasing demand for public health services. We have heard this morning of the rapidly increasing population and that is one of the important factors in the increased demand and need for trained public health personnel, but more important perhaps than that is the aging of the population, the increasing load of chronic disease that requires public health facilities in order to care for the persons suffering from chronic illnesses.

Mr. ROBERTS. Do you think that the new problems of radioactive fallout, and certainly water pollution is not a new one, but more emphasis is being given to that, air pollution, than any of these others. Also, it might include the dangers of radiological warfare, and call for a greater number of public health personnel?

Dr. STEBBINS. Yes. All of the schools of public health have expanded their educational program to meet these needs. For example, in the last 5 years, most of the schools of public health have created new departments of radiological health to train healthy physicists and radiological hygienists in the attempt to solve some of the problems that we are now facing in increased radiation, but also to deal with the problems that have been in existence for a long time that we have not been in a position to do anything about.

It is not just the new problems of radiation that we must deal with, but rather to recognize the harmful effects of radiation that have been in existence for a long time and we have not adequately dealt with.

Another new activity in the schools of public health, which is extremely important, is the one that you mentioned of air pollution. There is need for research in this field to determine those elements in the polluted air that are of greatest health significance and to devise means of removing these elements from the ir. For example, in our own institution we have a group that is carefully studying the different chemical elements in the polluted air of some of our cities and attempting to devise means for removing these elements from the effluence of industrial plants. That is one of the new areas that we consider to be most important.

All of these require additional space, not only for the research that is necessary but also for the training of special technical personnel, to deal with these problems.

Mr. ROBERTS. Doctor, what percentage of students in your public health school-take your own school-come from outside the State of Maryland?

Dr. STEBBINS. At the present time, about 90 percent of our students come from outside of Maryland. It has been as high as 95 percent. Mr. ROBERTS. Do practically all of these people go into municipal, county, State, or Federal service?

Dr. STEBBINS. More than 95 percent of the graduates of schools of public health go into public service, either in the Federal Government, in State and local governments, or into international health programs. Mr. ROBERTS. Are your courses limited to, say, a year or 2 years? Dr. STEBBINS. Most of them are postgraduate and, for example, most of our students are graduates in medicine and they come for 1 to 3 years, and the majority of them for 1 year of intensive training in public health.

We also have a group in the so-called basic sciences of public health that are not graduates in medicine, but spend 3 to 4 years for training in such fields as microbiology, or biochemistry, or parasitology, industrial hygiene, and then go into laboratories, either research laboratories or in the academic programs in medical schools or in other schools of public health.

Mr. ROBERTS. Is your institution publicly financed?

Dr. STEBBINS. No. We have received, under the program of the National Institutes of Health, rather significant amounts in research grants and training grants for research workers. We have under the temporary Hill-Rhodes Act provision received some funds for the general support and expansion of the educational program. This support, unless new legislation is enacted, would terminate on July 1 of this year.

Mr. ROBERTS. What would be the capital cost of each type of student training that you offer in the institution?

Dr. STEBBINS. This varies somewhat in the different schools, but the average is between $5,000 and $6,000 per year per student and the average tuition is approximately $1,000 per year. It ranges from $500 in some of the State schools up to $1,400 and in the State schools the tuition depends upon whether the person comes from that State. Out-of-State students are usually charged a higher tuition.

Mr. ROBERTS. Does that higher rate of tuition take care of the additional cost?

Dr. STEBBINS. No. In no school does the tuition payment count for more than 20 percent of the total cost of the training.

Mr. ROBERTS. You receive no funds from the State of the applicant's residence?

Dr. STEBBINS. Not at the present time.

There is a proposal and two States have appropriated funds to make a contract payment to the schools of public health in the amount of $1,500 in addition to the tuition. Those two States are Alabama and Kentucky.

Mr. ROBERTS. I am glad my State is one of the generous States as far as that is concerned.

That is all I have. Thank you, Doctor.

Mr. O'BRIEN. Doctor, is there a growing awareness on the part of the local community of the need for the full-time and properly trained public health officer, say as compared with 25 years ago?