educators about 15 percent; and social workers and sanitary engineers about 10 percent.

Training is conducted both within and outside the Service through long-term and short-term courses. The Division conducts a career development program with a number of assignments reserved for such training. Training schools are operated by the Division for dental assistants, practical nurses, and sanitary aids; almost all the students are Indians.

Collection and dissemination of health statistics

To measure the magnitude of, evaluate trends, and develop measures for the control of the infectious diseases which are significantly more prevalent among Indians than in the population as a whole, or which are unique among Indians, the Division of Indian Health has a reporting system for collection of specific data. Besides the usual notifiable diseases, reports and trend data cover gastroenteritis and diarrhea, trachoma, pneumonia, and influenza.

In addition to use in program planning and development, these reports are made available on request to university groups making special studies, to State health departments, and to investigators conducting research.

International health functions

The Division of Indian Health exchanges information on program operations with other nations working with indigenous populations under similar climatic conditions.

This is accomplished by: (1) Periodic assignments of foreign nationals who work on Indian health and sanitation facility construction programs; (2) reciprocal visits to foreign countries, such as Canada and Greenland, to review operations; (3) participation at multination conferences such as the World Health Organization-sponsored Conference on Medicine and Public Health in Arctic and Antarctic Areas, at Geneva, Switzerland, in 1962; and (4) furnishing other nations in the World Health Organization with program material developed by the Division.

Factors affecting health needs and activities for the future

Population trends.-Upward of 550,000 American Indians and Alaska natives were counted in the 1960 census. Not all are beneficiaries of the Federal health program. Some 380,000 Indians, Eskimos, and Aleuts depend in varying degrees on the PHS Indian health program for health services. They are increasing in numbers over the years (nearly 2 percent annually in the last decade) and have a birth rate which is almost twice the rate in the country as a whole.

Notable in the decade 1950-60 was the mobility of the Indian population and migration away from reservations to adjacent communities and other cities where employment opportunities were more plentiful. Although the total Indian population is increasing, projected estimates for the 23 States with Federal reservations reflect a proportionately lower increase for the "service population." The American Indian and Alaska native populations are young. Nearly 57 percent of the people are under 20, in contrast to about 38 percent of the general population. The median age for Indians and Alaska natives is about 16.5 years, compared with 29.5 years for all races in the general population.

Illness and death rates.--Health problems among Indians and Alaska natives in many respects resemble those found in the rest of the Nation a generation ago. Most illnesses and about one-sixth of the deaths are due to infectious diseases. Death rates for influenza and pneumonia, tuberculosis, and gastroenteric diseases are two to seven times greater than in the general population. Accidents lead as a cause of death. Heart disease ranks second, and influenza and pneumonia, third.

The American Indian's life expectancy from time of birth is about 62 years in contrast to almost 70 years for all races in the general population. The average age at death for Indians is about 42, compared with an average of 62 years for all races in the population.

Although the Indian infant mortality rate has dropped about 30 percent since 1954, it is nearly twice the rate for the general population. The Indian death rate for babies aged 28 days through 11 months stands in sharper contrast-about four times higher. Leading causes of infant deaths are influenza, pneumonia, and other respiratory infections, and diarrhea and dysenterydiseases which are in large measure associated with environment. Lack of basic sanitary facilities, gross insanitary practices, unavailability of safe water supplies nearby, and crowded living conditions are major factors.

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In anticipation of the continuing reduction in premature deaths and mortality from infectious diseases, program emphasis, and resources management are gradually being reoriented to meet the changing characteristics in mortality patterns and illnesses.

Progress against tuberculosis

Advances in medical techniques and modern drugs have had particular impact on Indian health. An 80-percent reduction in mortality from and incidence of tuberculosis-the "scourge" of Alaska-has been among the most dramatic gains in Indian health. Through the ambulatory chemotherapy crash program initiated in 1954 (use of isoniazid in combination with sodium para-aminosalicylic acid-PAS) remote native villages were reached and thousands of tuberculous patients or suspects were treated while awaiting admission to hospitals. Ambulatory chemotherapy became a major element in tuberculosis control. The severity of tuberculosis has been lessened, premature deaths have been prevented, and the length of stay in hospitals has been reduced from well over a year to an average of 6 to 9 months.

Chemotherapy has been equally successful among hospitalized and nonhospitalized Indians in the "lower 48 States." The hospital tuberculosis patient census has dropped about 70 percent in 7 years. Today the health resources released are being brought to bear on other major health problems of Indians.

Control of trachoma.—Trachoma is rarely found in the United States today except among Indians. Thought to have been brought under control in the 1930's, recrudescence was revealed in the 1950's. Differential diagnosis and treatment procedures were developed for the Indian health program under direction of an internationally recognized ophthalmologist.

Because of frequent surveys, close surveillance, and an effective ambulatory treatment program, the cure rate is high, and the disease is being brought under control. The trachoma manual developed by a PHS consultant primarily for Indian health staff is the most definitive work of its kind published in the United States. It has been widely used in other regions of the world for training of health staff in recognizing trachoma and in treating it.

OTHER FEDERAL AGENCIES

Federal prisons medical service

In January 1963, in the Medical Center for Federal Prisoners in Springfield, Mo., a 21-year-old prisoner underwent major chest surgery for tuberculosis. He is serving an indeterminate sentence for auto theft. This was the first big step in the long process of attempting to lead the young prisoner toward a useful and constructive life as a citizen. A Public Health Service surgeon performed the operation and the patient has now recovered.

More than 30 years ago the Congress directed the Public Health Service to assume the responsibility for conducting comprehensive medical services in the Federal prisons. There are 23 hospitals and 7 infirmaries in the prison institutions for the 23,689 prisoners. The Public Health Service staff includes 281 full-time employees, assigned by the Bureau of Medical Services. About 900 prisoners are assigned to assist with health services. Many of them are being taught skills in medical technical fields which will give them a means of employment after they have served their sentences.

Medical research is being conducted in several of the prison hospitals. Current research includes a study of cold virus, investigations on malaria, and a project on muscle tone related to space travel.

U.S. Coast Guard

The Revenue Cutter Service became a beneficiary of the Public Health Service by the act of 1798 authorizing medical care for sick and disabled seamen. Over the years the Revenue Cutter Service Service became the U.S. Coast Guard, and the Marine Hospital Service became the Public Health Service.

Today nearly 100 Public Health Service officers and other staff members are conducting medical and dental care for Coast Guard personnel who man the indispensable services to seagoing and airborne commerce-weather ships in the Atlantic and Pacific; icebreakers on duty in the Arctic and Antarctic; and long-range navigation aids placed strategically throughout most of the nonCommunist world-in the Atlantic and Pacific, the Mediterranean, Caribbean, Japan, and India. PHS physicians alos assist the air-sea rescue operations of the Coast Guard.

Bureau of Employees' Compensation

A Government employee was critically injured by electrical burns when he was helping to unload a 20-ton transformer and a crane struck a high-tension wire. He lost both legs and his right arm. His left arm was disabled.

The Bureau of Employees' Compensation, in the Department of Labor, arranged a closely coordinated program of rehabilitation services for the man. After months of training he learned to walk again with artificial legs; he learned to write and was taught a new skill. Today he is working for the Government as a radio dispatcher.

This case illustrates the value of the medical program of the Bureau of Employees' Compensation which is conducted by medical officers of the Public Health Service at the request of the Department of Labor.

There are about 125,000 new injury claims among Federal employees each year.

Maritime Administration

A Public Health Service officer is detailed as Chief Medical Officer of the Maritime Administration in the Department of Commerce to advise on health and safety.

The Service also furnishes the medical and dental staff for the U.S. Merchant Marine Academy in Kings Point, N.Y., to conduct the health program for the 700 cadet midshipmen. This includes operation of the Academy's Patten Hospital where there are more than 500 admissions each year; examinations and outpatient treatments; and a dental health program.

B. EXTENSION AND IMPROVEMENT OF HEALTH SERVICES FOR THE PUBLIC

Dr. TERRY. The second major area which I would like to cover is our role in extending and improving services for the public. This will be covered in more detail in the hearings tomorrow. Consequently, I will direct my remarks toward providing some general perspective.

Our role in this area is very different from the programs I have just described. First, our role is national in scope in contrast to limited beneficiary groups. Second, our role is generally indirect.

In the hospital system, our own staff provides care for the patient. In the area we are now talking about, we bring about the desired result by working through others who deliver the service-or by making it possible for others to deliver the service. The recipient of the service seldom is aware that the Public Health Service had anything to do with the service he receives. Our role is to see that within our authority the means for health are made available to the people.

It is important to make a distinction between two interrelated but different aspects of health services to the public.

First, there are the preventive health services-those services often referred to as public health services delivered mainly through governmental tax supported health agencies. In this area, the Public Health Service has a fundamental and broad role.

Second, there are what we call personal health services-those services rendered primarily in the doctor's office or in the hospital. In the main, this is a private, non-tax-supported system based on fees for service. In this area, the role of the Service is to assist communities and States in developing better organized health services designed to make health care available to people where and when they need it.

We like to think that everything we do benefits the public in one way or another—and, frankly, I believe this is true. However, the

means by which we pursue this objective vary considerably, as I shall try to describe.

The first area I will describe is related primarily to preventive or public health services.

1. The Federal-State system: Our approach from the beginning has been to support and strengthen a nationwide network of State and local agencies through which public services are rendered. This is accomplished in various ways:

(a) The first way is through general or special purpose grants to the States. In fiscal 1963, $77 million was available for such purposes. Some of these grants are made on a formula basis, specified in law, and require matching by the States. Fifteen million dollars is for the so-called general health grant. This has the purpose of strengthening and improving basic local public health organizations, staff, and services through which the more specialized disease control programs can operate effectively.

The remainder of these grants are directed toward specific health problems: Tuberculosis control ($3,250,000), cancer demonstration and control ($3,500,000), heart disease control ($7 million), chronic illness and aging ($13 million), mental health services ($10,950,000), radiological health ($1,500,000), and water pollution control ($4,700,000). Formula grant funds are awarded to the States on the basis of a State plan which must be approved by the Surgeon General. Project grants constitute another and more flexible means of supporting specific health activities in State or local health agencies, or in other nonprofit agencies or organizations. These are generally awarded on the basis of a specific application. The law requires no State or local matching. In practice, however, all such projects have some local participation.

Preference is usually given to those projects with substantial local financial and other participation because experience has shown they are more likely to be successful and have an enduring effect. These projects are also categorically oriented and are available for activities in the following areas: Chronic illness and aging ($6 million); tuberculosis ($1,250,000); cancer demonstration ($4,750,000); venereal disease ($4,335,000) (all fiscal 1963 data).

(b) Technical assistance: Upon request, the Service will supply experts to help States, or through States help local agencies in problem solving, in devising more effective programs, and in studies and investigations. At times, the Service may undertake cooperative projects with State or local agencies. The Service may assign personnel to work full time in State or local agencies, upon request. Technical assistance is a major activity, which in fiscal 1963 accounted for $53 million in our budget.

(c) Specialized services: A number of devices are available which, in effect, supplement the capability of State and local agencies. These are actually another form of technical assistance. For example, the Service maintains special laboratories that have a high degree of capability in diagnosis of communicable diseases, in water pollution, air pollution, milk and food, and other areas. The States can take advantage of these for special analyses, for improvements in their own laboratories.

Health education materials are produced and made available. The States receive regular and special reports on communicable disease

prevalence, mortality, morbidity, and other vital statistics. The Service conducts many types of field studies which have direct applicability to State and local health problems.

(d) Training: The Service regularly conducts short-term training courses for many types of State and local health personnel. In addition, funds are available for formal academic training of public health personnel. Awards may be made directly to individuals or through training grants to institutions to provide a year or more of postprofessional academic training. Four million dollars were available for these programs in fiscal 1963.

The Service also makes grants to schools of public health and to ertain schools of nursing and engineering to enable them to expand and improve the training they offer, and to enable them to increase enrollments; $3.9 million was available in fiscal 1963 for these programs.

Training funds are also provided for certain special categories of public health personel that are in critically short supply, e.g., air pollution ($150,000), water pollution control ($1.1 million), and radiological health ($2 million). These funds are available as individual awards or as institutional training grants.

2. Facilities construction: The second major role which the Service has is to make better health services possible for the public by the support of health facility construction, i.e., Federal support in constructing the hospitals and other facilities through which the public receives service. These activities have impact on both preventive and personal health services. There are three programs in this area:

(a) The Hill-Burton program. This is the largest program of this type. It was authorized by Congress in August of 1946. Since it will be discussed tomorrow, suffice it to say here that the program has had a tremendous beneficial impact in increasing the number, the quality and the distribution of general hospitals, as well as other types of health facilities.

More than 216,000 general hospital beds and 2,600 health centers, nursing homes, and other health facilities have been added to the Nation's resources through this program. Dollarwise, it is our largest program with $220 million available in 1963, not including the extra impact of the accelerated public works program (more than $44 million).

(b) Waste treatment works construction grants: This program supports municipal sewage treatment plant construction. It was authorized in 1956. Ninety million dollars was available for this program in 1963, and an additional $44,150,000 has been made available thus far through the Accelerated Public Works Act.

In the 6 years, 1957-62, grants have been made to 4,178 communities to help them invest more than $2 billion in sewage treatment works. These facilities serve 40 million people and improve water quality in over 42,000 miles of our streams.

(c) Health research facility construction: This program also was authorized in 1956. Fifty million dollars was available in fiscal 1963. The Service also has had several smaller and more specialized programs which involve research facility construction. These, Mr. Chairman, also will be discussed tomorrow.

(d) I would like to mention in this connection, and I guess what one might say in a hopeful manner, health professions educational assist