Dr. Howard has called attention to the fact that in the State of Connecticut they are proud of the record that they have set in maternal mortality. We are proud of the State of Illinois, too. It is not as good a record as that of the State of Connecticut, but we have a larger number of people, and we have other problems.

But the fact that in one State you can have a maternal mortality of 10 per 10,000, and in other States, 40 or 50 per 10,000, is not right, particularly when we can provide the same means in those States with a high mortality that we have available for saving mothers and babies in the States in which mortality is low. That knowledge is known

to us now.

We could do at least as good work in one State as we can in another State. That, too, concerns us.

In the State of Illinois, where I am familiar with conditions, in the city of Chicago, the maternal mortality is low; the results are excellent.

But you get down to southern Illinois and you find that you have an entirely different problem. There is a lack of facilities, few hospitals, few well-trained obstetricians, few nurses, and so in one State there may be areas of need and areas where more can be done, but at least we are doing a fairly decent job.

The second question that I asked myself, and which I should like to answer: "If the need for these funds had been established, how can they be spent in a most constructive manner?"

I am one of those individuals who are very much interested in spending our money intelligently. I do not begrudge spending money, but I insist that it be spent intelligently.

It is our feeling that the funds initially, the small appropriations which you asked for in your bill, should be used in those parts of the country where they are most likely to do good. Parts of the country that have the greatest need.

If a State is to receive funds from your appropriation for work in that State, the plan layed down by the State should provide primarily for better maternity care in those parts where that care is needed. We will get the most for our money, and we are likely to establish an ideal maternity care program.

Now, when you go into an area, a rural area, or an area in which there is little or no facility for maternal care, and you establish an ideal program, it yields dividends in many ways. It saves the lives of mothers and babies, but it will do much more than that. If I had the time, I could go into the question of just what additional revenues are derived by having a good maternity care program in an area where there is none today.

You can use that set-up for the training of personnel; and that is one of the weak links in our entire medical care program today. We do not have enough well-trained individuals, doctors, nurses, social service workers at the present time for the extensive program you envisage in this Pepper bill.

Now, the third question I asked myself: "What agency should be designated to use these funds most appropriately?"

I have been identified with the Children's Bureau, Department of Labor, for a number of years, but long before I had anything to do with the Children's Bureau I heard about the wonderful study that

they conducted in 1927 and 1928, a study of maternal mortality in 15 States. That is that study that encouraged many of the subsequent studies that followed.

The New York Academy of Medicine made a study in the city of New York. There was a study made in the city of Philadelphia, and another in the city of Chicago, and I think that, as a result of this initial effort on the part of the Children's Bureau, we all became interested in conditions as they were in the United States, and much of what followed, you are as familiar with as I am.

We had to have some organization, some group of individuals, who would call our attention to the fact that many women that had no business dying in child birth were losing their lives every year in the United States.

The work subsequently, as far as I am concerned, and as far as many of my associates are concerned, has been excellent. They used good judgment. They spent their money wisely, and we feel that this down-hill curve in maternal mortality that you have heard about is in a large part due to the efforts of the Children's Bureau.

So that if there is any extension of maternal care, I think that the Children's Bureau is the appropriate agency to carry on.

Lastly I asked myself the question: "What are the goals toward which we should work?"

At a recent meeting of the advisory committee, the goal was set as the safe delivery of every mother, rich and poor, in the small town, on the farm and in the city, in a good hospital, by a physician who has had some training in obstetrics. We know this is Utopia, but you have to set for yourself high standards toward which to work. If you do not, why you might as well not work, because you do not have the urge to do things.

The delivery of mothers with complications by specialists, qualified to cope with these problems, and the restoration of these mothers to normal health, because a healthy mother is the best safeguard against delinquency in the family, discontent between husband and wife, and is the best guaranty of a happy family.

I have read some of the arguments against the Pepper bill. Some of them say: "Let us wait until we have a national health program. Let us postpone it for a year or two or three." That argument does not appeal to me. It is very much like withholding bread from the starving people of Europe because we cannot send along a lot of butter and a lot of jam to go with it.

Let us make a beginning. We can begin, and begin where the need is greatest, and we can learn and progress.

Progress is slow and tedious, but it is the only way in which you can build on a solid foundation.

Obstetrics has led the way in medicine in many many ways. Obstetrics has pioneered the next epoch in medicine. Years ago our physicians were interested in acquiring knowledge concerning the nature and character of disease, and then there followed the present epoch during which science and medicine provided the cures for many of the ills that afflict mankind.

We are on the threshold of a new epoch in which most of our efforts will be directed toward the prevention of disease. It is easier to prevent than to cure. Obstetrics has long heralded this period of pre

vention. Prenatal care with its many ramifications is designed primarily to prevent the complications of pregnancy and labor. Its aim is to weed out the fit from the unfit, maintain the normal mother in good health, and provide special care for the mother who has complications.

New maternity medical centers and trained personnel will have to be built and developed in order to bring intelligent obstetrical care to all of our underprivileged mothers, and in spite of the splendid achievements of the last decade, and we are all proud of these achievements as I have indicated, we feel that much can be done in the future. Senator PEPPER. Senator Donnell?

Senator DONNELL. Doctor, you addressed yourself very largely of course to the maternal phase of the bill.

Dr. Davis. That is all I am interested in. I am interested in obstetrics.

Senator DONNELL. I wanted to ask you in regard to the treatment of children. Would you prefer not to go into that phase of it?

Dr. DAVIS. I would, sir.

Senator DONNELL. Very well, I shall not ask you about that. I shall ask some other witness on that.

That is all.

Senator PEPPER. Thank you very much, Doctor. I appreciate your coming.

Dr. DAVIS. Thank you, sir.

Senator PEPPER. Is Dr. Underwood here?

(No response.)

Senator PEPPER. Dr. Ella Oppenheimer, director, Bureau of Maternal and Child Welfare, Health Department of the District of Columbia.

STATEMENT OF DR. ELLA OPPENHEIMER, DIRECTOR, BUREAU OF MATERNAL AND CHILD WELFARE, HEALTH DEPARTMENT OF THE DISTRICT OF COLUMBIA

Dr. OPPENHEIMER. I have been asked to come here and discuss very briefly, I understand, the situation in the District of Columbia with regard to maternal and child health services and services for crippled children in relation to the need for legislation of this type.

As a Director of the Bureau of Maternal and Child Welfare in the District of Columbia Health Department I have had the responsibility for the administration of services for maternal and child health, and services for crippled children, since the latter part of 1936 and then in recent years for the administration of the emergency maternity and infant care program.

I would like to say that we have made amazing progress in the District of Columbia in the development of these services, largely as a result of the grants in aid which have been available through the Social Security Act.

Our experience in connection with this leads us to feel that there is a very real need for extension of the services. I would like to speak, first, because not much has been said about this, since I have been here this morning, about crippled children. There are a large group of

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crippled children in the District, as well as all over the country, and I am speaking now particularly of the children with cerebral palsy, for whom a great deal can be done, but for whom a great deal of help is needed in terms of services.

We have developed a very small program in connection with our regular crippled children's program for the care of these children. This program involves general pediatric care, it involves the neurologists, individuals who have had some special training and experience in physical medicine, orthopedic surgean, and groups of physiotherapists, occupational therapists, also speech therapists, to mention only a few of the teams of specialists who have to work together in the interests of training these children.

The need for legislation of this type, in order to make these services available to large numbers of such children for whom they are not available, is clearly evident to us.

We have, for instance, some hundred of such children registered for care. We are not giving intensive care to all the hundred of these youngsters. We have to pick and choose at this moment. We will always have to pick and choose. But at this time, in order to make the best use of the limited facilities and services available, we have to pick the group of children who can profit most from these services, and therefore we have to limit them.

There is a large group of children whom we feel quite certain need diagnostic study over a relatively long period of time with treatment as part of that diagnostic study in order to determine whether they can be helped.

The intent of this legislation, therefore, as it would affect this group of children, seems to me very valuable and worthwhile.

There are other groups of handicapped children for whom we have inadequate provisions in the District, and I am sure this is true in a large number of areas of the country. I speak particularly now of the program for children for the conservation of hearing, for those who are hard of hearing, and potentially hard of hearing. Such a program has been outlined in the Health Department cooperatively with the medical school service, because it is in the schools where most of such children would be found.

We are certain that an extensive program to find, to diagnose, and then to provide for necessary treatment, would render an inestimable amount of benefit to the child's future.

I mention these two large categories in connection with crippled children. I would like to say also that the crippled children's program here is ready to expand, that a number of hospitals have expressed a desire over and over again to participate, and there is a very real need for that.

Groups of various specialists have only of late indicated to me that they desired to participate in this program actively. The only inhibiting factor is funds, in order to go ahead.

With reference to the maternity and child health program, again we have made progress here. We have had a lowering maternal and infant mortality rate, but we can go very much further and the basis on which we can go further lies in extension of services through such legislation as this.

Senator DONNELL. Doctor, you are the head of the Bureau of Maternal and Child Welfare of the Health Department of the District of Columbia?

Dr. OPPENHEIMER. Yes.

Senator DONNELL. About how many children do you annually administer to in that Department?

Dr. OPPENHEIMER. I would have to divide that up. We have registered for direct service in our child health clinic anywhere between 15,000 and 20,000 children a year. It varies.

Senator DONNELL. Is there any means test at all applied?

Dr. OPPENHEIMER. There is no means test applied to the Child Health Clinic service.

Senator DONNELL. Have you found any abuse of that?

Dr. OPPENHEIMER. We have found very little abuse, 'Senator. Senator DONNELL. Dr. Oppenheimer, I am trying to visualize how this would work with respect to children. As I understand it, under this bill the physicians would be, in so far as possible, selected by the mothers themselves. Is that your understanding of the bill?

Dr. OPPENHEIMER. Yes, sir.

Senator DONNELL. But in cases where no selection has been made, I am quoting now from the bill, page 5:

The State plan shall set forth the method by which care will be made available. And then this plan prescribes that the State shall, in its plan, insure payments to individual physicians for care furnished under this title on a per capita salary, per case, or per session basis, or, as was mentioned by an earlier witness, this morning, in the case of emergency visits, to which would be added consultations also, as stated in the bill, on a fee for service basis.

Now, that would mean, would it not, Doctor, that the doctors would be paid by the States respectively for the work they do under this bill?

Dr. OPPENHEIMER. I would understand it that way.

Senator DONNELL. And they would therefore be employed by the States and arrangements made by the States for the terms under which they would render their services. Is that your understanding of the bill?

Dr. OPPENHEIMER. I would say that usually, of course, that is done in collaboration with, or discussion with, advisory groups.

Senator DONNELL. Take a town of 20,000 or 25,000 people where there would be possibly 50 physicians. Is that a fair estimate?

Dr. OPPENHEIMER. I would not know. There probably would not be that many.

Senator DONNELL. Suppose we take a city of 25,000 population. If this bill were put into operation it would mean,, as I understand it, that all of the children in that town would have a right to go to those physicians and have the care that those physicians would give them, and then the State would pay the bill. Is that your understanding of it?

Dr. OPPENHEIMER. I would think so. Of course, the point is that there would be definite arrangements as there is under the EMIC program for care. There would certainly have to be certain standards set up as to the qualifications of the physicians and all that.