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Dr. Terry, I think our next witness is Mr. M. Allen Pond, Office of Assistant Surgeon General for Plans.

I believe Mr. Pond will conclude the list of witnesses from the Public Health Service.

I would like to ask Mr. Pond if he would be willing to summarize his statement for the subcommittee, if that would be convenient for you.

Mr. Pond. I would be delighted to, Mr. Chairman, in view of the fact that many of the points that I wanted to make have been made by prior witnesses, both with respect to the manpower problem and the facilities.

Mr. ROBERTS. That was my feeling.
You may file your statement for the record.
(The statement referred to follows:)

STATEMENT BY M. ALLEN POND, ASSISTANT SURGEON GENERAL FOR PLANS, U.S.

PUBLIO HEALTH SERVICE

MAXPOWER AND FACILITIES

Each of the preceding speakers has identified the importance to the Nation's health of an adequate supply of skilled manpower, and the need for a variety of facilities. It is my purpose to discuss some of the major aspects of the health manpower problem, summarize briefly the role of the Public Health Service in helping to provide facilities of significance to the public health, and suggest certain areas where further attention will be needed in the years ahead.

HEALTH MANPOWER

Present supply and needs

About 2.2 million persons in more than 30 occupational categories are now engaged in health work in the United States. Some categories—medicine, dentistry, and nursing, particularly-have been extensively studied, and we have relatively good estimates of need. But there are many others-nutritionists, laboratory technicians, medical record librarians, clinical psychologists, health educators, medical social workers, statisticians, speech therapists, sanitary engineers, and health physicists, to name only a few--for whom the need is great, but about whom there is less specific information.

Increasing demand for health services which is reflected in increasing need for health manpower is a product of population growth; increasing knowledge about disease processes, including improved methods for preventing, diagnosing, and treating illness; rising economic levels, and especially the increase in thirdparty payments for medical and hospital care; more and better public education; and growing urbanization.

The predicted increase in the population 65 years of age and over from 17.5 million in 1963 to over 20 million in 1970 will itself increase the demand for health services and facilities since older people require substantially more care than do young people.

During the past 30 years, there has been an absolute increase in demand for personal health services. Since 1930 the rate at which people visit physicians has tripled. During this same period the proportion of the people admitted to a general hospital annually has more than doubled.

Treatment of the mentally ill is receiving greatly increased attention. Already some progress has been made in replacing custodial care with intensive therapy, both inside and outside the hospital. But over 600,000 mental hospital patients have the services of only 4,000 physicians and 5,000 professional nurses; or less than 1 doctor and 1 nurse per 100 hospital patients. The Joint Commission on Mental Illness and Health last year recommended that by 1970 the number of physicians and nurses caring for the mentally ill be about doubled.

Improved services for other chronically ill and disabled persons, and for the mentally retarded, for example, will increase the demand for specialized health manpower.

Jedical research will require a marked increase in the number of trained investigators in the sciences, and of supporting personnel engaged in research. Specifically, the number of trained personnel must approximately double over the coming decade, with an increase in medical research manpower from the current level of about 40,000 to about 80,000 in 1970. Much of this increase must be in persons with doctoral degrees in the basic medical sciences.

In environmental health, emerging threats to health as well as expanded knowledge of how to deal with these threats have created urgent needs for scientific and technical personnel in water pollution control, air pollution control, radiological health, occupational health, waste disposal, milk and food sanitation, and environmental engineering. For example, the Surgeon General's Committee on Environmental Health Problems in 1961 recommended substantial increases in the numbers of professional workers and an increase in subprofessional workers from the current 3,000 to 10,000 a year by 1965.

With the committee's approval, Mr. Chairman, I will submit for the record a separate tabulation of available data on health manpower. Training needs

We are not now training enough health manpower. This committee has already carefully considered the situation in medicine and dentistry. The action of the House on Wednesday is heartening evidence of the seriousness that you and your colleagues attach to the situation.

A study of needs in nursing has just been completed by a group of consultants to the Surgeon General. This shows a need for nurses which is far greater than the present potential of our nursing schools. The consultants have recommended as goals for 1970 that there be a 75-percent increase in the numbers graduating each year, with substantial expansion of both collegiate and hospital programs.

Why aren't we training the people that we need? For some professions a major obstacle is the formidable cost of building teaching facilities. The cost of a new medical school is currently about $8 to $10 million for basic science teaching facilities and another $12 to $15 million or more for an adequate teaching hospital. Most universities today find it difficult to meet the space needs of existing educational programs, let alone those of new programs.

Another deterrent to expansion of training capacity is the high operating cost of training programs. The usual budget for 4-year medical schools today runs in the vicinity of $2.5 to $3.5 million a year. Such costs place severe strains on the budgets of parent educational institutions. Additionally, individuals qualified for faculty positions in schools for the health professions are in short supply.

For many health occupations there has been no comprehensive study of manpower needs and training requirements. Such a study could provide a real incentive to the orderly development of training capacity.

Difficulties in recruiting enough qualified students constitute another barrier, In recent years the health professions have been at a disadvantage with relation to science; both because of the present glamor and of the substantial amount of financial assistance available for training in the so-called hard sciences. Expansion of teaching facilities will increase the opportunity for qualified students. But high costs, long training, and great competition from other fields of spe cialization will continue to handicap recruitment. Thus expansion of teaching facilities must be accompanied by measures which will substantially increase the number of qualified students. The present role of the Federal Government

For many years there has been Federal aid to promote specific types of manpower training. In the health field, support has been provided mainly for research training, public health training, mental health services training, professional nurse education, and practical nurse training.

The Public Health Service, as the primary Federal agency dealing with health affairs, has assumed increasing responsibility in the field of health manpower development. Its major efforts have been directed to the study of needs, and to the establishment of training assistance programs. Studies of needs go back 25 years and more, with major attention focused on the total supply of the key professions. During World War II a major concern was the protection of manpower resources for the protection of civilian health, while at the same time meeting military requirements. In the past few years major studies have been made of needs in medicine, dentistry, nursing, environmental health, mental health services, and research. The role of the Public Health Service in training

The training and fellowship programs of the Public Health Service hare increased significantly in the past several years. Indeed, the successful accomplishment of Service-sponsored programs in research, in community health services, and in environmental health-is dependent upon an adequate pool of well-trained manpower. Since the need for trained manpower pervades virtually all programs of the Service, there is almost no unit in the organization without some training interests.

In 1917, training and fellowships made up only four-tenths of 1 percent of the total appropriation for the Public Health Service-less than one-half million dollars. In 1963 they make up 13.6 percent of the total Public Health Service appropriations-about $215 million. This includes (a) traineeships awarded directly by the Public Health Service to deserving individuals applying for financial assistance; (b) training grants that are awarded to institutions of higher education to assist them in improving their curriculum and facilities and in providing stipends for deserving students; and (c) research fellowships which are awarded primarily to train personnel in direct research work.

Although these and other programs of Federal assistance for education and training probably will continue to differ according to special needs, they should be developed with a view to their impact on total health manpower requirements. The Federal Government in cooperation with other public and private agencies and institutions must persist in efforts to develop health manpower policy in such a way as to advance the Nation's manpower and education interests generally, in addition to providing staff for essential health services. The most urgent problems

In looking to the future, the following are areas of special concern in respect to health manpower:

(1) The need for increased production in the key professions of medicine, dentistry, and nursing.

(2) Research and development of methods of making better use of these scarce talents. This should extend to the encouragement of better organization for the provision of services, including group practice, and the greater use of auxiliary workers.

(3) The need for greater attention to training for community services and patient care.

(4) The need for a comprehensive review of the health manpower resources and requirements of the Nation.

FACILITIES

The Public Health Service is engaged in three significant programs to aid in the construction of facilities of public health significance: (1) hospital and other health care facilities; (2) medical research facilities; and (3) municipal sewage treatment plants. In each of these categories, the Federal role is that of partner in financing the costs of building and equipping plants that are owned and operated by public or other nonprofit organizations. Health care facilities

As a result of experience gained during the depression and the years of World War II, Congress in 1946, in passing the Hospital Survey and Construction (HillBurton) Act, recognized the need for Federal financial assistance in planning, building, and equipping local health care facilities. This action was taken in the face of growing demands for hospital care which was unavailable in many rural areas and inadequate in scores of larger communities.

The major purposes of the Hill-Burton Act were (1) to assist the States in making an inventory of existing facilities, in surveying their needs for additional facilities, and in developing comprehensive plans for construction of additional facilities; and (2) to provide the necessary incentive, through financial assistance to the States, for the construction of long-needed public and other nonprofit hospitals, public health centers, and related hospital facilities.

In 1954 the act was amended to provide funds for constructing nursing homes, diagnostic and treatment centers, rehabilitation facilities, and chronic disease hospitals. At the same time the Public Health Service was authorized to conduct and make grants for hospital research. The enactment of the Community Health Services and Facilities Act of 1961 further expanded the research program by authorizing experimental and demonstration construction and equipment projects.

To participate in the Hill-Burton program, each State is required to designate a single State administering agency and to develop an annual State plan for construction, including an inventory of all civilian inpatient and outpatient facilities available, and a long-range program for meeting additional facility needs.

Sums appropriated are allotted to the States in acıordance with a statutory formula which takes into consideration the population and relative per capita income of the States and territories. The formula operates so that the largest per capita share of the Federal appropriation goes to the States with the lowest per capita income, which also are generally those having the greatest unmet need for hospital services. The total minimum annual allotment to a State is now $550,000. Federal participation may range from one-third to two-thirds of the total costs of construction and equipping an approved project.

As of February 28, 1963, a total of 6,573 projects had been approved for Federal aid under the Hill-Burton program. Of this total, 5,205 were completed and in operation. The remaining 1,368 are under construction or in the planning stage. These projects will provide 279,199 inpatient beds and 1,842 other health facilities.

Thus since World War II important progress has been made in providing for health facilities construction from both private and governmental sources. Additional hospital beds and health centers have been provided, and there also has occurred, mainly as a result of the Hill-Burton program, (1) systematic statewide planning for hospital facilities; (2) development of standards of need ; (3) achievement of better distribution of facilities; (4) improvement of hospital design; (5) improvement in hospital Oneration; (6) effective cooperation between Government and voluntary health agencies: (7) improvement of medical care in low-income States and in rural areas; and (S) aid to teaching centers for training physicians and nurses.

Despite the progress made by the Hill-Burton program, there continue to be important unmet needs for health facilities in the United States. Brietis sumimarized, the goals for future action involve the need to:

1. Increase substantially the capacity of acceptable facilities for long-term care, i.e., chronic care hospitals and skilled nursing homes :

2. Increase construction of community-based mental health facilities, and encourare construction, expansion, and modernization of facilities for the mentally retarded;

3. Support replacement and modernizatie of older hospitals:

4. Stimulate community planning for redistribution of facilities in metropolitan areas to achieve balanced urban hospital resources; and develop an integrated program of construction and services for all types of facilities within an urban area, according to a community plan;

5. Encourage construction of general hospitals in those remaining general hospital service areas with demonstrated shortages:

6. Provide for enough construction of all types of in-patient facilities to reduce present shortages and keep up with population growth:

7. Continue the construction of necessary public health centers and other outpatient facilities to improve preventive and ambulatory care:

8. Support new construction, replacement, or rehabilitation of teaching facilities for training medical, dental, and other health personnel :

9. Expand research in support of (a) efficiency of design and operation of facilities and effective use of personnel : (b) the application of new medical discoveries in diagnosis and treatment to reduce the need for in-patient care; and (c) improved organization of community machinery for continuity of care for patients, between the hospital and related institutions. Health research facilities

In 1956, the Congress enacted legislation (Public Law 81835) to authorize Federal matching grants to aid in the construction and equipping of facilities for research in the sciences related to health. This action provided the base for a program that has been extremely effective in helping to provide facilities used in carrying out important medical research.

The Federal share of grants under this program cannot exceed 50 percent of the cost of the project. To be eligible for a grant, the applicant institution must be either a non-Federal publie or a nonprofit private organization, which is competent to carry out the type of health-related research for which the facility is designed.

Various types of facilities are eligible for assistance under the program including not only research space per se, but also specialized facilities used in support of research such as animal resource centers. Projects may be designed for general medical research, or they may be planned to meet categorical disease interests such as research in cancer, communicable diseases, mental health, dental diseases, or metabolic disturbances.

Since this program was initiated there have been more than 1,425 applications for grants, and 1,048 have been approved. These grants have been made to 373 institutions in 49 States, the District of Columbia, and Puerto Rico. The Federal share of the cost of the approved projects has been approximately $230 million. As of December 31, 1962, there was a total of 431 completed projects. These facilities represent a Federal investment of $71,305,841. Supplementary grants for movable equipment in these research facilities have not been included in this total.

In looking ahead, it is likely that there will be increasing demand for assistance under this program in building child health research centers, research facilities in connection with new or modernized medical schools, and specialized centers for the management of health research data and information. It may be necessary, also, to call upon this program to aid in the development of broad environmental health research facilities. Construction grants, municipal waste treatment works

Although Public Law S45 of the 80th Congress had set the stage for the modern Public Health Service water pollution control program, the Federal grants program for municipal waste treatment works was first authorized in 1956 by the Sith Congress (Public Law 660). The 1956 act authorized annual appropriations of $50 million for grants of 30 percent of the cost of sewage treatment works up to a maximum grant of $250,000 for a single project. Allotments to the States were made on a statutory formula based upon population and per capita income.

In 1961, the Congress in Public Law 87-88 amended the Federal Water Pollution Control Act to

(1) Authorize annual increased appropriations of $80 million in fiscal year 1962, $90 million in fiscal year 1963, and $100 million for the fiscal years 1964 through 1967.

(2) Increase the 30-percent grant limitation from $250,000 to $600,000.

(3) Encourage communities to construct joint rather than separate projects by applying the individual grant limitation to each community's share of such projects up to a total of $2.4 million.

(4) Require the reallocation of unused State allotments to States having projects which cannot be approved because of lack of funds. Public Law 87–88 has spurred further increase in construction and encouraged the development of multimunicipal projects. Contract awards rose to $449 million in 1961 and to a tentative $497 million in 1962. The first multimunicipal project application came from San Diego, Calif., where 10 cities joined together in a project costing $49 million. There are now 14 such projects located throughout the country.

Since 1956, 4,219 projects have been approved for grants of $366 million. Local communities have contributed $1,898 million of additional funds to meet the total project cost of nearly $2.3 billion. This is a ratio of 5 local dollars to each Federal dollar in grants-in-aid. These facilities will serve a population of 40 million and will improve the quality of 43,000 miles of streams.

There are indications that the backlog of needed treatment works is beginning to decline under the impact of the increased Federal aid now available. The population of communities discharging untreated raw sewage has been dropping, and significant improvement has been noted among communities discharging inadequately treated wastes. While unsewered communities are not usually important sources of stream pollution, they frequently experience serious ground water pollution and other public health problems arising from the individual disposal of sewage. The population of unsewered communities reported by State health authorities as requiring sewer systems and sewage treatment facilities is now 5.8 million.

The present backlog of needed municipal waste treatment works includes about 5,800 projects costing $2.2 billion. The elimination of the backlog of needs over a 10-year period together with needs issuing from population growth and obsolescence will require annual expenditures of $600 million in terms of current dollar valuation. Disposition of the backlog by 1970 would require annual spending of $700 million. Rising construction costs of about 2 percent per year will further increase these figures.

Construction of waste treatment works is expected to continue its present increase until the full effect of the $100 million annual grants authorization has been felt.

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