A symposium will be held next month (April) in New York City dedicated to educating people in health careers. Through the Regional Medical Program, planning for health careers now involves all seven universities and the community colleges of the five boroughs.

It would indeed be an unthinkable waste of public planning funds as well as a severe setback to a new spirit of cooperation that has developed among the many separate and independent professional and institutional components of the health enterprise not to extend this legislation-a program with so much promise, which is so widely accepted and on behalf of which so many public spirited professional and non-professional people have made substantial contributions of their time, needs continuing Federal support.

MIGRANT HEALTH PROGRAM

The Migratory Workers provisions of H.R. 15758 would extend the six-year old Migrant Health Program for another two years. The plight of the migrant farm worker in this country has been widely publicized in recent years, but the publicity in no way cushions the shock that must be felt by every thinking American upon being reminded that people living in this country today, working amidst plenty, must endure such squalor. The average annual income of the migrant farm worker in 1965 was $1,400. While the average annual expenditure for personal health care is more than $200 for all Americans, the figure is only $12 per year for the migrant, including $7.20 in Federal funds and $4.80 from other

sources.

At present only an estimated one-third of the total migrant population has access to Migrant Health Act project services. During the 1967 fiscal year, onefourth of the Nation's migrants had access to project services for a brief period only. This means that of the one million men, women and children, who travel the migrant stream, only about 350,000 have access to Migrant Health Act project services.

By August 1, 1967, 115 public or private nonprofit community organizations were using migrant health grants to help them provide medical, nursing, hospital, health education and sanitation services to their seasonal migrants; but, three-fifths of the counties identified as migrant home-base or work areas are still untouched and service coverage remains weak in many of the areas where projects are now receiving grant assistance.

One or more migrant health projects operate in 36 states and Puerto Rico. Each project serves migrants in from one to 20 countries. Community-based projects offer personal health care to migrants in about two-fifths (270) of the 726 counties thus far identified as migrant work or home-base areas. They offer sanitation services in most of these and an additional 142 counties. About 40 home-base counties, reporting an estimated outmigration of 200,000 persons, are included in migrant health project areas in southern Florida, Texas, New Mexico, Arizona, southern California and the bootheel of Missouri. Continuity of care becomes more possible as project services are provided at strategic points along major migration routes. Personal health records carried by the migrants facilitate continuity and help to avoid duplication or gaps in services. Project reports indicate that from 10 to 90 percent of the migrants contacted present a personal health record upon request. A few state-level projects provide sanitation, nursing or other services throughout the state wherever a major migrant influx exists. This is most likely to be true in the case of sanitation services.

For continuity of care and protection, migrants need access to health services in every county where they live and work temporarily. Because geographic coverage by project services is still far from complete, a total of 750,000 migrants had no access to personal health care provided through projects in 1966. The remainder had ready access to personal health services for only part of the year.

Only one out of three counties with migrants offered grant-assisted personal health care geared to the special needs of migrants during 1966. Only six out of ten counties offered protection of their living and working environment through sanitation services with grant assistance. Lack of continuity of health care will remain a problem as long as many communities have no place to which a migrant can turn and expect to find needed health care. Recently, in one of the wealthiest states in the nation, a migrant with an emergency illness was refused care by 4 hospitals because he could not assure payment of the bill. At the fifth hospital where he obtained attention, doctors said that the patient would have died if he had had to shop around for hospital treatment for another two hours.

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Migrant farmworkers are not commuters. They travel so far from their homes that they must establish a temporary residence in one or more other locations during each crop season. On the average, the people live and work in two or three locations annually. They may move several times from farm to farm or camp to camp at each location. At each of his temporary homes the migrant needs access to health services and a safe home and work environment; but his home base and work communities are typically rural, isolated, lacking in both economic resources and health resources. As a result the typical migrant home is small, overcrowded, and of substandard construction. It often lacks facilities for food storage and preparation. It often lacks adequate and safe water supply for drinking, dishwashing, bathing, and laundry. The area too often lacks adequate sewage and waste disposal facilities which attracts insects and rodents. There are no recreational areas or facilities. The typical places where they work are exposed to heat, cold, wind, dust, chemicals and mechanical hazards. They lack safe and accessible water for drinking or washing and they lack adequate toilet facilities. On some farms there are no facilities at all. All of us have a stake in the continuation and extension of this program.

The migrant's road to health care is beset with obstacles-as the side of the migrant is poverty, lack of health knowledge, isolation, fear of non-acceptance by the community. On the side of the community are legal restrictions against serving nonresidents, legal exclusion from protective legislation, health planning priorities that exclude migrants, inadequate health manpower, inadequate financial resources, problems of serving a mobile group and resistance to minority groups. Many of the communities where migrants live and work temporarily are themselves considered poverty areas.

Little wonder then that the accident mortality rate for migrants is 1964 was nearly three times the U.S. rate. It was 6 percent greater than the U.S. rate 30 years ago. Migrants' 1964 mortality from tuberculosis and other infectious diseases was 21⁄2 times the national rate, approximately the national average of over a decade ago. Their mortality from influenza and pneumonia was more than twice the national rate and slightly in excess of the U.S. rate for 1940.

The infant mortality rate reflects like an index the results of our nation's apathy toward these workers. In 1964 the infant mortality rate among migrants was at the level of the country as a whole for 1949. The maternal mortality rate is 1964 was the same as the national level of a decade ago.

Of the more than one million migrants, including workers and their dependents, 650,000 still live and work outside the areas served by existing migrant health projects. By conservative estimates, this group includes:

1. Over 6,500 persons with diabetes who are without adequate medical care. 2. Over 5,000 migrants with tuberculosis who are traveling and working with their disease undetected and untreated.

3. Over 3,000 children under the age of 18 who have suffered cardiac damage as a result of rheumatic fever. These children are not likely to receive treatment for prevention of reinfection and further cardiac damage. Such treatment in ordinarily available to most nonmigrant children in their communities.

4. Approximately 9,800 children have untreated firm deficiency anemia. This increases their susceptibility for childhood infection and interferes with their normal growth and development.

5. Over 250 infants who will die in the first year of life as a result of congenital malformation or disease. Early, adequate medical care will not be available for these infants.

6. Over 16,000 expectant mothers who will find it difficult to obtain prenatal care. Infant and material mortality rates can be expected to be significantly higher under such conditions.

7. Between 20,000 to 30,000 individuals who have enteric parasitic infestations-resulting in most cases from poor sanitation. Such a problem is almost nonexistent in the general public.

Before the passage of the Migrant Health Care Act in 1962 the migrant farmworker had virtually no medical care available to him and to his family. Only in grave emergencies did he get care, and even then he was frequently denied the needed medical services. Much progress has been made since 1952 but there is still a long way to go before the migrant farmworker and his family will have available even the barest minimum of medical services.

Certain facts are highlighted which show progress is being made, but there is also evidence that the progress is too slow, and only a small segment of the migrant population is the beneficiary of the migrant health program.

1. The migrant health program provides prenatal and postnatal care, obstetrics service, immunization, examinations, and treatment for ordinary ailments. Of these services only about 250,000 out of the one million men, women, and children who make up the migrant stream get this care. Also, this care is not continuous as not all communities have migrant project services facilities and as the migrant moves from camp to camp and from state to state these services become episodic, periodic or nonexistent.

2. Continuity of health care services for all migrant workers and their families is of the utmost importance for a rational nation-wide health care program. The American people today feel that health care services are a right. This concept should certainly encompass the men, women, and children who work in this country's fields and who make it possible for our people to be the best fed nation in the world.

The AFL-CIO not only urges the extension of this program, but strongly recommends the authorization of $9,000,000 for fiscal 1969 be substantially increased.

ALCOHOLISM AND DRUG ADDICTION

Te Alcohol and Narcotic Addict Rehabilitation Amendments in H.R. 15758 represent a meritorious effort to cope with two insidious and destructive behavior problems. An estimated 80 percent of the nation's five million alcoholics are living with their families, holding-or tryng to hold-some kind of job, and trying to maintain a place in the community. The cost of their alcoholism to American industry is an estimated $2 billion a year as a result of absenteeism, lowered efficiency and medical insurance expenses. The suffering which the alcoholic inflicts on his family is immeasurable. His community may spend as much as $100,000 on an alcoholic and his family during his lifetime. The safety of the alcoholic, of his family, his coworkers and indeed of the entire community is endangered by his habit. According to Dr. Daniel P. Moynihan's recent advisory committee report on traffice safety, made to the Department of Health, Education and Welfare last February, as much as every tenth car encountered on the road may be driven by an alcoholic. Problem drinking is cited as a factor in at least 30 percent of the more than 40,000 motor vehicle deaths occurring annually.

The alcoholism provisions in H.R. 15758 would authorize a two-year grant program building, staffing and operating facilities for preventing and treating alcoholism, using the same types of mechanisms as provided in the Mental Health Center Act. The local centers which this legislation will provide will aid the working alcoholic, replacing the neglect and abuse which in the past resulted all too often in his eventual destruction. It will also aid the less than ten percent of all alcoholics who are the homeless men and women, the so-called Skid Row inhabitants, hopefully putting an end to the revolving-door cycle of arrest-jailrelease-drunkenness and arrest again.

We very definitely endorse this effort to fight the disease of alcoholism with the humane and intelligent treatment that is required.

The Narcotic Addict Rehabilitation provisions of H.R. 15758 extend and make the very logical placement of narcotic addict rehabilitation activities in the mental health centers authorized under the Community Mental Health Centers Act. To enable the centers to absorb their new responsibility the new legislation would authorize a two-year grant program for construction, staffing, operation, and maintenance of new facilities and for training of the necessary personnel. Drug addiction as a symptom of mental illness has been recognized officially in the two-year-old Narcotic Addict Rehabilitation Act. As with the alcoholic, the drug addict is a hazard to his family and community as well as to himself.

The need for providing treatment and rehabilitation is apparent when we consider the 40 percent increase in the number of narcotic addicts recorded by the Bureau of Narcotics during the past ten years. Our concern over the drug addiction problem is also due in no small part to the fact that drug abuse is a behavioral illness of the nation's great labor centers. More than half the addicts recorded by the U.S. Bureau of Narcotics are residents of New York State. California, Illinois, New Jersey, and Michigan, have a larger proportion of addicts than other states.

While the number of centers providing treatment for addicts is small, the number of addicts increases. Providing this treatment in facilities which are part of the complex of the community mental health centers, gets treatment to persons

who need it in places where they can get to it, and allows for efficient use of existing facilities. Psychological dependence, if not addiction, is a problem for younger people today. There are other dangerous drugs in addition to narcotics as this committee knows.

We hope the committee will report favorably this program.

We believe this legislation will stand as a model which the States may use in developing and modifying their own legislation concerning treatment of drug addicts and alcoholics and organization of medical services. It includes incentives and assistance from which each state can benefit in assuring that the medical needs of its citizens are met.

Most certainly the Federal influence in the advancement of medical knowledge and in the application of that advancement for the benefit of all citizens should continue. In the past, much of this influence took the form only of financial assistance to various State programs. Today this influence also assumes the form of acting as a clearinghouse and disseminator of medical information and techniques developed and tested by those who are closest to the problems.

We trust that approval of H.R. 15758 by this committee will indicate a continued willingness to maintain Federal support of public health programs to the highest degree possible. We urge your favorable consideration of H.R. 15758.

Mr. ROGERS. Thank you, Mr. Fair, for an excellent statement, and I am impressed particularly with some facts you gave on migrant health problems. I am very interested in it and have been since helping to write the original legislation.

As a matter of fact, I was concerned with health, where we give block grants to the State. It was the thinking of the Bureau of the Budget that, at first, they would not continue migrant health as a separate program. But, as a result of the interest some of us have shown-I introduced a bill for continuation for 3 years of this program-we have gotten them to go along with a 2-year extension.

We appreciate your support on this. I think it is a very necessary program. And we appreciate very much your testimony. Dr. Carter?

Mr. CARTER. I have no questions.

Mr. FAIR. Thank you, Mr. Chairman.

Mr. ROGERS. Our next witness is David J. Pittman, director, the Social Science Institute, and professor of sociology, Washington University, St. Louis, Mo.

STATEMENT OF DAVID J. PITTMAN, PH. D., DIRECTOR, THE SOCIAL SCIENCE INSTITUTE, AND PROFESSOR OF SOCIOLOGY, WASHINGTON UNIVERSITY, ST. LOUIS, MO.

Mr. PITTMAN. It is a pleasure to be here, and I have a statement that can be entered into the record.

Mr. ROGERS. Without objection, the formal statement will be made part of the record following your remarks.

Mr. PITTMAN. The part I would like to bring to the attention of the committee is in reference to the recent court decisions. I have for 10 years served as a consultant to the St. Louis Metropolitan Police Department, as well as consultant to the President's Commission on Law Enforcement and the Administration of Justice, which recommended that communities should establish detoxification centers to remove the offenders from jail, the so-called "revolving door" process. The first detoxification center in North America was in St. Louis, Mo., and this was under the aegis of the St. Louis Metropolitan Police Department, a Catholic nursing order, and Washington University's

social science institute. The center has been in operation for 17 months and has become a model for the whole Nation. The results thus far have surpassed all expectations on the first followup studies of patients going through the center, who are from the homeless and lower income group. Twenty-one percent are abstinent at the end of 3 months. Mr. ROGERS. Twenty-one are what?

'Mr. PITTMAN. Twenty-one percent are abstinent for 3 months. Mr. ROGERS. That is excellent.

Mr. PITTMAN. This was far beyond any expectancy that any of us had concerning that particular program.

Mr. ROGERS. How long has this been going on?

Mr. PITTMAN. For 17 months. In fact, the results were so good that in October 1967 the St. Louis Board of Aldermen unanimously passed a new statute governing public intoxification in that city, without any court pressure being needed.

The essence of the statute is that chronic alcoholism is a positive defense to the charge of public intoxification. However, very few such cases find their way to the court anymore, as they are handled in the detoxification center.

The 30-bed facility is a cooperative effort. The Department of Justice helped on this, and the Missouri State Legislature appropriated $150,000 for this work; the St. Louis Board of Police Commissioners, with the approval of the board of apportionment in the city, has appropriated somewhere close to $150,000 for the city of St. Louis.

The detoxification center in St. Louis handles approximately 80 percent of all "drunk on street" cases and graphically demonstrates what a community can do when it is willing to move on this major problem. I think the unique aspect is that Federal, State, and local cooperation has been brought to bear in terms of providing a facility "from scratch," so to speak, and we have been deeply appreciative of the support of press, radio, and community organizations in these efforts.

Now, I would like to indicate, in terms of the Federal Government action in alcoholism and particularly in reference to this bill, that the bill is not as specific as it should be in terms of noting that detoxification facilities or emergency care facilities, or resources, should be eligible for construction grants as well as providing for staff, operation, and maintenance grants. Unless these emergency facilities are provided to intervene rapidly into the treatment of these individuals, we will continue to see a sizable proportion of alcoholics who do not have full access to treatment.

Unfortunately, a sizable portion of general hospitals and community mental health centers do not provide, or are unwilling to provide, emergency care for chronic alcoholics. This was the case in St. Louis, as well as other cities, which have now pioneered in emergency care facilities, such as Des Moines, Washington, D.C., and so forth.

Therefore, I respectfully request that the subcommittee give consideration to making emergency detoxification facilities eligible for support under this act. The recovery rate can be much higher than was anticipated if treatment is immediately brought to bear, and this is