Secretary GARDNER. I would like to ask the Surgeon General to comment but first I would like to make one or two basic points. First, the international program does not involve as many physicians as you indicated.

It would be closer to 400. The second thing is

Mr. YOUNGER. Just a minute. As I recall the testimony-I am not talking about physicians, I am talking about the total personnelas I recall the figure was given of between 800 and 1,000 at the time of the testimony.

Dr. LEE. Mr. Younger, the international health programs will include a number of other types of health workers-sanitarians, public health workers, and a variety of other types. That is right. Mr. YOUNGER. But they are all to be trained under the program? Dr. STEWART. Mr. Younger, under the international health bill the training was beyond the M.D. degree. They would already be doctors. Under that program they would be trained in international health work. That bill was dealing with professionals: doctors, dentists, nurses. This bill here is talking about the allied health professions which is a different group of people.

Mr. YOUNGER. Yes, but you have to have facilities to train them. You have to have teachers to train them.

Dr. STEWART. The Health Professions Educational Assistance Act and the amendments of 1965 are building medical schools and dental schools, and the Nurse Training Act is building nursing schools. We are expanding our capacity for doctors, dentists and nurses. We do not have the capability of training a person in international health work after he has become a doctor, dentist, or nurse.

Mr. YOUNGER. You do not have the facilities?

We

Dr. STEWART. No. We do not have the training programs. do not have the means to send the people to those training programs. That is what the international health bill is for.

Mr. YOUNGER. But you would have to provide that, normally it would be in the medical schools would it not?

Dr. STEWART. It may be in medical schools. It could be in schools of public health.

Mr. YOUNGER. Schools of public health or whatever, you have only so many facilities for training. It would not make any difference whether the doctor was already a doctor, he has got to be trained, he has to have a facility to be trained in.

Dr. STEWART. Yes, but I think you are thinking of a medical school as a facility. A university medical center now may be a whole complex of facilities.

Mr. YOUNGER. That is right.

Dr. STEWART. It may be a variety of schools. It may include a nursing school, dental school, and health allied professions school.

Mr. YOUNGER. True. In every one you are short today, in every training facility. I don't care what it is, whether it is a podiatrist or who it is, you are short on training and you are short on personnel. Dr. STEWART. That is correct.

Secretary GARDNER. May I comment, Mr. Younger?

Mr. YOUNGER. Yes.

Secretary GARDNER. I think your point is well taken. We are short everywhere, we have very, very pressing demands on us. I would simply make the point that with our scarce resources and with the need to allocate those scarce resources we must not only have then in mind the very important tasks of helping sick people in rural areas but we have to try to construct the kind of world in which our youngsters don't have to go to war every generation.

One of the main purposes of the international health act was to initiate the process of international collaboration in an area in which we could work peaceably with people, or mutually understood and agreed upon objectives, in the hope that this kind of peaceful activity could knit together a world that is now torn with war. That too is

important.

Mr. YOUNGER. Well, as Shakespeare said that is a "consummation devoutly to be wished," but our experience with foreign aid does not bear out much hope for progress in that field. My 5 minutes are up, Mr. Chairman.

Mr. FRIEDEL (presiding). We are going to adhere to the 5-minute rule.

Mr. Dingell.

Mr. DINGELL. Thank you, Mr. Chairman. Mr. Secretary, I note in your statement that this language appears on page 10:

It is certainly necessary to see whether total loan forgiveness can be accelerated. Rates specified in this bill will provide the necessary attraction but as you well know there are other factors involved which apparently outweigh purely financial

concerns.

Now in the past, Mr. Secretary, this committee has supported partial forgiveness of loans, as you well know. I think the committee might well consider supporting the total forgiveness of the type you have indicated here if it were pretty clear that the committee could expect that it would work.

Your statement here indicates a rather clear reservation as to whether or not this loan forgiveness will in fact work or not;

What I am saying, Mr. Secretary, is that you appear to have hedged your bet on this point. What I am asking is, How on the basis of the reservations that you indicate can you expect the committee to support total forgiveness as embodied in H.R. 13196.

Secretary GARDNER. I would simply say that we tried to state what we regarded are the facts as honestly as we could. I would not say that we doubt that it will work. I think we were trying to state as clearly as possible that it is a partial solution and in a situation of this sort it is a very difficult situation, partial solutions are well worth turning to.

Mr. DINGELL. Do you have any statistical evidence or basis of experience that you can communicate to the committee at this time that would indicate that this will help meet the shortage of the particular kind of people referred to, the shortage of medical personnel, the type referred to in the act?

Dr. LEE. We have some evidence from certain programs that have been going on in States and we can certainly get that information and make it available to the committee. We do not have it immediately available.

62-707-66- -3

(The information requested follows:)

STATE SCHOLARSHIP-LOAN PROGRAMS FOR MEDICAL STUDENTS, as an Incentive FOR PRACTICE IN RURAL OR OTHER SHORTAGE ÁREAS

Some States for a number of years have supported programs for loans to medical students, repayable wholly or in part by practice in areas of physician shortage. The loan programs vary in their provisions, but a common pattern is to require 1 year of service in a rural or other shortage area in exchange for every year of loan aid.

Although there is little published information on the effectiveness of such programs in recruiting needed personnel, available data suggest that their success is mixed. Some loan recipients perform their obligated service as intended; others choose to repay the loans in cash. Of those who do perform obligated service, by no means all remain to make a career in the area.

For example, of 222 students receiving Virginia rural physician scholarships between 1942 and 1964, and entering practice during that time (i.e., no longer performing military service or completing internships), 94 or about two-fifths have repaid all or part of their indebtedness through practice in an approved location. A slightly higher proportion have repaid their loans in cash and the remaining cases are pending. A recent followup survey of University of Virginia and Medical College of Virginia graduates who aid obligated service showed that somewhat over half were still engaged in general practice in the same area.

Experience in other States has tended to be similar, with some variation in the proportion of graduates meeting service requirements. Among the deterrents to rural practice are reported to be the desire to enter specialty practice, professional isolation in small towns, lack of nearby hospital and laboratory facilities, heavy workload of rural general practitioner, and preference for city living. The following reports give some idea of experience to date:

ALABAMA-MEDICAL SCHOLARSHIPS PROGRAM

(Information from Ira L. Myers, M.D., Secretary, Alabama Board of Medical Examiners, February 1966)

In the years 1953-59, 46 scholarships were awarded. Seventeen of this number, or about 40 percent, have repaid their loan in money rather than service. Several are delaying their repayment pending military service or special training obligations.

The experience since 1960 is incomplete since these obligations have not yet become due.

There has been considerable disappointment with the program as a device for inducing physicians to work in sparsely populated areas. In May 1965, the program was amended to provide for relatively shorter service requirements for persons practicing in communities of less than 5,000 population, among other changes.

ARKANSAS-MEDICAL STUDENT LOANS

(Office of Education Survey of State Scholarship and Loan Programs, 1960–62)

Of 27 medical students awarded loans in the 5-year period 1953-58, 2 had already repaid their loans in cash and 3 had had loan payments canceled by medical practice in rural communities (as of 1960).

FLORIDA-MEDICAL SCHOLARSHIPS PROGRAM

("A Brief Summary of Florida's Medical Scholarship Program, Nov. 18, 1965." Obtained from Dr. Robert V. Schultz, Training Coordinator, Florida State Board of Health)

Since 1955, 123 scholarships have been granted to medical students, including 6 to osteopathic students. Of these students, 87 have graduated; and the status of the graduates is as follows:

Twelve have engaged in practice in areas of need, as designated by the State board of health, repaying all or part of their indebtedness in this way. Eight are serving internships.

Twelve are pursuing residency training (one in violation of scholarship contract).

Fifteen are in military service.

Thirty-eight have repaid in cash, are in the process of repaying, or are subject to collection proceedings.

Two are pending.

GEORGIA MEDICAL STUDENT LOANS

(Office of Education Survey of State Scholarship and Loan Programs, 1960–62) During the 9-year period 1953–62, 343 medical students received loans. By July 1, 1962, 13 physicians had completely repaid loans totaling $36,500 through service in the smaller Georgia communities, 23 were serving 1-year residencies, 13 were in the Armed Forces, and remainder were still in medical school, serving internships, or fulfilling their obligations through service or monetary repayment. Letter from L. R. Siebert, secretary of State Medical Education Board of Georgia, June 24, 1960:

"At the present time there are approximately 30 doctors who are repaying their scholarships by practicing in rural areas. There will be approximately 15 additional doctors to begin practice on July 1, 1960 * * *.

"We feel that the program. *** is a very effective means to provide the State with much needed physicians ***"

KENTUCKY-RURAL MEDICAL SCHOLARSHIPS

(OE Survey of State Scholarships and Loan Programs, 1959-62)

As yet experience with the loan cancellation option of the program has been so limited that it is not yet possible to tell what effect it will have on supplying physicians to the counties most in need of medical service.

Letter from J. P. Sanford, secretary, Rural Kentucky Medical Scholarship Fund, June 21, 1960:

"Medical students receiving loans since the inception of the program total 197. Of this number, 115 have completed medical school. Of the 56 practicing in rural areas, 27 have fulfilled their moral obligation to the fund and 29 are now in process."

MISSISSIPPI'S MEDICAL-STUDENT LOANS

(D. S. Pankratz and Julis C. Davis. “A Review of Mississippi's Medical Education Program." Journal of Medical Education, April 1960.)

Of a total of 609 participants in the program, 511 had graduated and their status was as follows:

Total___

Completed obligated service__ _

Still performing obligated service_

Practiced 2 or more years and repaid balance of loan___

On military leave, in internship or residency training-
Deviated from contract_-_.

¡Excludes students who failed or withdrew, died, or were still in school.

NOTE. Since 1960, loan recipients in Mississippi must do obligated service and also repay loans plus interest.

NORTH CAROLINA-LOANS FOR STUDY IN SELECTED HEALTH PROFESSIONS

(Information provided by William F. Henderson, Executive Secretary, North Carolina Medical Care Commission, Feb. 9, 1966)

Of 184 medical students who received loans since the beginning of the program in 1945, 138 had graduated and their status was as follows:

Twenty-seven were in postgraduate training or military service.

Seventy-six had completed obligatory practice (51) or were engaged in it

(25).

Thirty-five had defaulted on their service obligations.

SOUTH CAROLINA-MEDICAL SCHOOL SCHOLARSHIPS

(Information provided by Dr. G. S. T. Peeples, South Carolina State Health officer, Feb. 3, 1966)

Of the students granted scholarships (eight annually), only about 10 percent have fulfilled their service contracts to date. About 70 percent have repaid the money

with interest.

VIRGINIA-STATE RURAL PHYSICIAN SCHOLARSHIPS

(Letter from Mack I. Shanholtz, M.D., State health commissioner, Department of Health, Commonwealth of Virginia, Jan. 7, 1966, and attachments) Since 1942 Virginia has had a program of scholarships to medical students who agree in return to practice in rural or certain other shortage areas for a specified length of time. The program currently provides for 20 scholarships annually to the University of Virginia School of Medicine, 20 to the Medical College of Virginia School of Medicine, and 10 to the Virginia State College for Negro students attending Meharry Medical College.

Originally the law provided that the scholarship could be repaid as a loan, but this item was deleted in 1948. In the current law, provision for repayment as a loan is allowed if the recipient withdraws from the program before graduating, if he fails to maintain his scholastic standing, if he becomes permanently disabled, or if at any time he "demonstrates a peculiar and unusual ability and aptitude in a special branch of the medical sciences and, in the opinion of the faculty *** would be a loss to the field of medical research and science if he did not go into that branch of medical science for which he has demonstrated extraordinary ability." The latter provision has been used three times.

As of May 1965, experience with practice obligations among medical students through the 1964 class was as follows:

Mr. DINGELL. Now there are some other questions here that I would like to discuss with you, and in referring now to the student loan provisions, is it fair to say that it is the experience of the Department of Health, Education, and Welfare that NDEA student loan provisions have worked well over the years in terms of stimulating educational activity?

Secretary GARDNER. Yes, sir.

Mr. DINGELL. Is it also fair, Mr. Secretary, in saying that this particular program has operated with fairly limited cost to the Federal Government?

Secretary GARDENER. Yes, sir.

Mr. DINGELL. One of the virtues of this particular program, as I understand it, has been the relatively simplicity of the program. Am I correct?

Secretary GARDNER. Reasonably-reasonable simplicity; yes. It has not always been simple for the colleges to administer these programs. And it certainly will not be simple in the future as the number of loans, the number of students covered rises rapidly.