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I hope that the statement from the Committee of Physicians for the Improvement of Medical Care, Inc., will soon be completed and will be helpful in the improvement of this contemplated legislation and in its enactment.

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The United States Senate, Washington, D. C.

MY DEAR SENATOR: I have just returned from a field trip in the southern area in connection with a health survey for the National Urban League and I find your letter of October 24 with enclosed copies of the bill, S. 1318, and the speech made by you in reference to this act. I have read these with a great deal of interest and I should like to make the following observations.

1. Since the establishment of the Social Security Act in 1935 with the provision for maternal and child health and recently through the funds provided by the EMIC, the United States Children's Bureau has done a commendable job to stimulate the development of programs for the protection of the health of mothers and children throughout this country. Therefore, this bill with its increased appropriations should provide the opportunity for this organization to do a more extensive and intensive job.

2. Althought the maternal-mortality rate, the infant-mortality rate, and the well-being of mothers and infants in this country has markedly improved during the past several years, yet in many sections of the country, particularly in the rural southern area, the death rate of our mothers and children are still alarmingly high for a civilized nation such as ours.

3. Certain minority groups, such as Negroes, Mexicans, still are suffering from deficiencies in clinic services, hospital facilities, nursing care, and orthopedic treatment. Therefore, there is a need of extension of these services to these groups.

4. There are certain special problems affecting all groups which have not been given sufficient attention, such as care of premature infants, the large number of stillbirths, and the high mortality of infants under 1 month which certainly must be attacked if we are going to make progress in the total field of maternal and child health.

The above observations, of course, are not the only ones, but they are sufficient to demonstrate in my own thinking that there is need for the passage of a bill such as S. 1318 so that we can remedy many of the present difficulties.

I should like to offer you and the other Senators who have joined you my commendations and my appreciation for your thoughtfulness in these efforts. Please accept my thanks for giving me this opportunity to make these statements.

Very truly yours,

PAUL B. CORNELY, M. D.

Head, Department of Bacteriology, Preventive Medicine, and Public Health,

Senator CLAUDE PEPPER,

EXHIBIT 12

SUPREME LIBERTY LIFE INSURANCE CO.,
Chicago 15, Ill., June 19, 1946.

United States Senate, Washington, D. C.

MY DEAR SENATOR PEPPER: First I want to register my complete approval of S. 1318 and to add merely a few supporting statements. These statements may be some which others may not have stressed or they may be repetitions which will serve to strengthen similar statements by other people.

I particularly wish to speak for colored mothers and colored children, and especially for those in the South where medical, nursing, dental, and hospital services are even more restricted for them than they are in the North. I cannot

single out a title which would be less important than any other in this bill. The provisions of each title bear heavily upon the needs of colored mothers and children.

Under title I there is no more desperate situation than confronts the colored mother and child than at time of maternity. The maternal-death rate for Negro mothers in 1943 was 143 percent higher than for white mothers in the same year. The infant-death rate for Negro babies during their first year of life was 64 percent higher than for white babies. Three-fourths of the white babies born were born in hospitals during that year compared with only one-third Negro babies born in hospitals.

During the past a good deal of the maternal care and even early child care has been in the hands of Negro "granny midwives." About 20 years ago the health departments began to try to supervise these untrained women. For example, during 1925 there were about 9,000 such "granny midwives" in the State of Georgia; in 1944 this number had been reduced to 2,200. It is rapidly going down. No replacements are being made and a serious situation confronts both white and colored mothers in rural areas where they are likely to have no care at all. Of course, some of this slack has been taken up by expanded hospital care. There is a desperate need for trained nurse-midwives to tide these situations over until more doctors and more hospital beds are available for all mothers in all parts of the country.

Under title 2: Colored children again are desperately in need of services and care for crippled conditions. Nobody knows how many colored crippled children there are because too often they are hidden under the superstitious feeling that crippling is an act of God. Certainly medical care has not been available in the past, and unless some such bill as this is passed there will be even less in the future.

Under title 3: In too many places there will be little or no care for neglected and delinquent colored children nor for the prevention of this neglect and delinquency unless some such measure as is projected becomes a law. There is hardly a place in the entire country where the foster care of Negro children is even attempted, much less being adequate. In other words, with the Negro child furnishing much too often a disproportionate share of crime and illness, I would want to use him as an example of the needs of all children. What happens to the colored child is the same thing which happens to all children in proportion to the medical care and the welfare services which are available to protect them.

Yours very truly,

M. O. BOUSFIELD, M. D., Vice President and Medical Director.

Senator CLAUDE PEPPER,

EXHIBIT 13

HAROLD H. MITCHELL, M. D.

LONG ISLAND CITY 5, N. Y., June 20, 1946.

United States Senate, Washington, D. C. DEAR SENATOR PEPPER: I have your telegram addressed to me as secretary, American School Health Association. While I am a past president of this association, I am not secretary and not able to speak authoritatively for the organization. I have wired to Dr. A. O. DeWeese, Kent State University, the content of your telegram, as he is secretary. To express the views of an association of professional workers would, in my opinion, be misleading unless specifically authorized by a resolution of the association.

However, I should like to express a personal opinion that S. 1318 does not make proper provision for a sound Federal organization. The health functions of the United States Children's Bureau should be joined with those of the United States Public Health Service in a single Federal agency under a Cabinet officer.

Of course, I am in favor of the objectives of this bill (S. 1318) but I believe the wording of section 103 (a) (3), page 4, would jeopardize those objectives,

because it would be revolutionary to make the services "available to all who elect to participate in the benefits." Of course, there should be no discrimination because of race, creed, color, and so forth, but it will take time to make the services available to all. To set up such a plan without permitting any form of means test, even at the local level with local control, must assume that the services have been organized and available. It is not enough merely to provide funds to pay for a doctor without a period of development to make those medical services worth while and of high quality.

I have read most of the testimony and discussion in favor of S. 1318 and S. 1606 and there seems to be a lack of understanding of the importance of proceeding in an orderly manner to evolve the governmental organization necessary to maintain high quality of medical service, and to provide the special diagnostic and laboratory facilities with auxiliary personnel and continued post-graduate medicaleducation facilities. To pass S. 1318 with section 103 (a) (3) as it is, would in my opinion result in such poor quality and poor reputation for the service that is financed by the Federal Government (or likewise by social insurance; e. g. S. 1606) that Federal aid would receive such a serious set-back that it would never recover. Such a revolutionary change would develop such a cleavage between the individualistic medical practitioners and public-health officials who administer the service and distribute the funds that the public would have little faith in the public service. On the other hand, if good service is developed gradually, with more and better service by increasing grants-in-aid and the development of complete coverage with health departments, hospitals, and diagnostic services and the many other needs for high standards, we can develop those facilities for group practice and complete coverage that will fully meet the objectives. There must also be funds for education of the public in order that it may better know how to obtain and how to cooperate in the prevention and treatment of disease. This will require many more public-health nurses and social workers to get into the homes and carry on this education.

After more than 30 years of full-time public-health experience in national public-health agencies and in governmental service, I am confident that we shall make the best progress if we develop the grants-in-aid program further and strengthen local administration and not attempt with one stroke of legislation to revolutionize medical practice. We can and should change and improve medical practice, but even more urgent is the extension of those public-health and preventive services that we know how to do well.

I should urge the passage of Senate Joint Resolution 137 introduced by Senator Morse on January 29 with provision for administration under a single health agency or a health and welfare department, as proposed by President Truman. Senate Joint Resolution 137 should have inserted, page 1, under (2), "and health departments", line 9, to read "offered by schools and health departments," and also should have inserted "and other handicapping," to read "for the correction of physical and other handicapping defects of children."

Of course, S. 191 is essential also as a next step for orderly development of a national program for maternal and child health.

There are so many other good features of S. 1318 that I cannot write about them in detail, but I hope you may agree to a plan that will be acceptable through an orderly and evolutionary development and not allow disagreements concerning revolutionary changes to hold back progress.

Sincerely,

HAROLD H. MITCHELL.

EXHIBIT 14

JUNE 24, 1946.

DEAR SENATOR PEPPER: I acknowledge with thanks your telegram of June 17 concerning your bill (S. 1318).

I am in complete sympathy with the purposes of the proposed bill.

I am in receipt also of the analyses of your bill and the Wagner-Murray bill (S. 1606) by the Association of State and Territorial Health Officers.

I believe that more careful consideration should be given to their criticisms of the bills as they now stand.

Sincerely,

ROBERT B. OSGOOD, F. A. C. S., R. R. C. S.

EXHIBIT 15

Senator CLAUDE PEPPER,

THE UNIVERSITY OF ROCHESTER,
STRONG MEMORIAL HOSPITAL,
Rochester, N. Y., June 20, 1946.

Chairman, Subcommittee on Wartime Health and Education,

United States Senate, Washington, D. C.

DEAR SENATOR PEPPER: I am appreciative of the opportunity to express my views on the maternal and child-welfare bill,. 1318, which has been drafted for the purpose of improving the health and welfare of the children and mothers of this country. I am entirely in sympathy with your objective and approve of the general purpose of the bill.

As I see it, the bill is designed to encourage the individual States, through matching grants and outright allotments, to develop new, or expand existing, maternal and child-health and welfare services. The system of allotments will undoubtedly increase the volume and raise the standards of care in the poorer States. In addition, the shifting of a substantial portion of the cost of existing programs from State and local revenues to general Federal revenues will tend to increase the quantity of service in the wealthier States, even though they will bear a proportionately greater share of the total cost than they now do.

The most important and controversial part of the bill is the provision relating to eligibility for service under titles I and II. It is not clear whether the participating States are to be permitted, required, or forbidden to apply a means test. If a means test is to be permissive or required, this bill should be classified as a general public-health and welfare measure and the question of any change in the present economic scheme of medical care should not enter into the discussion. In my opinion, the application of a means test should be permissive with the individual States, thus permitting experimentation and the development of local programs in accordance with local wishes. In any event, this point should be made entirely clear by amending the language of S. 1318.

The adequacy of the amounts appropriated depends upon the employment of a means test. If such test is to be forbidden, or if it is to be permissive with the States, the appropriation would seem to be insufficient.

The benefits of title I seem so comprehensive that it is questionable whether title II is needed, since the benefits of the latter are or could be included in title I. Under titles I and II only 10 percent of the available funds are to be allotted on a matching basis. Although the desirability of increasing the quality and quantity of care in the poorer States is appreciated, it would seem that relatively more money should be allotted on a matching basis, and that specifie limits should be placed on the amount any one State may receive as an outright allotment.

Although the Chief of the Children's Bureau is required to consult a conference of State officials, and an advisory committee which he names, before formulating general policies, he has a free hand in making policies and rules and regulations. I believe it would be better if there were some separation of powers, and if a more independent status were accorded the Federal advisory committees. This might be accomplished by having a board appointed by the Secretary of Labor (or Federal Security Administrator, as the case may be) which would have the power of enacting rules and regulations consistent with law, upon the request of the Chief of the Children's Bureau.

The adoption of S. 1318 would at once present an administrative problem of great magnitude, further complicated by the fact that many States would be found to have insufficient numbers of physicians, dentists, and nurses to meet the demands for service. It is suggested that a reasonable approach to this vast problem would be to cover initially a smaller segment of the population-perhaps children under 8 years of age, who make up about 10 percent of the population. When a satisfactory administrative system had been worked out on this modest scale, the age limit could be progressively raised as warranted by available personnel and facilities.

Yours very truly,

BASIL C. MACLEAN, M. D.

EXHIBIT 16

THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA,
COMMITTEE ON PUBLIC HEALTH LEGISLATION,
Pittsburgh 22, Pa., June 18, 1946.

Hon. JOSEPH F. GUFFEY,

Senate Office Building,

Washington, D. C.

DEAR SIR: It has come to our notice that there will be a hearing before the Senate Committee on Education and Labor on Saturday, June 22, on S. 1318, maternal and child-welfare bill, of which you are a cosponsor.

The house of delegates of the Medical Society of the State of Pennsylvania last October passed a resolution opposing this bill for the following reasons:

1. This bill is unnecessary because these services could be provided for through the original Social Security Act plus its amendments and supplements, publichealth-service law, and appropriation bills, also by the Wagner-Murray-Dingell bills, S. 1050, S. 1606, and S. 2143.

2. We can see no reason for providing services by the Federal Government for those plenty able to pay for themselves.

3. This bill is too comprehensive because it will take care of all the mothers and children up to 18 years of age in the United States through Federal tax funds.

We, therefore, suggest that this bill be held in committee until hearings are complete on all the bills which have medical-care and health provisions in them, and then assemble the testimony and try to evolve something more practical and more along the lines of a democratic form of government. Sincerely yours,

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The State Medical Association of Texas with a membership of 4,764 physicians will appreciate your courtesy in making this part of the official record in the forthcoming hearing on Senate bill 1318. Through action of its house of delegates the State Medical Association of Texas has officially gone on record as opposing this bill. We opposed the so-called Pepper bill for the following reasons: The bill seeks to place a great percentage of the physicians in the United States and in Texas under the control of a Federal bureau in Washington. Doctors, so far as child and maternal care are concerned, would be regimented and the relationship between physician and patient disrupted by Federal intervention. Children are designated as persons under 21 years of age, which we think is absurd since this exceeds the military age. According to the provisions of this bill any mother and child may submit to Federal medicine regardless of their financial circumstances. Many mothers will wish to employ their own physicians and pay for medical care. There should be local rather than Federal determination of need. We believe that every community should see that its indigent sick are afforded full and free medical care. The proposed bill calls for tremendous and indefinite Federal taxation. We believe it is contrary to the public welfare, and definitely and dangerously detrimental to public health.

By direction of President C. C. Cody.

STATE MEDICAL ASSOCIATION OF TEXAS,
HOLMAN TAYLOR, Secretary.

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