Mr. KUYKENDALL. I was actually intending to ask you is this case more political, and I am sorry I didn't get a chance to ask the doctor yesterday, if you had arrived at any ideas as to how to solve this political hotbox on fluoridation.

Mr. Pickle is gone. I grew up close to Mr. Pickle's district. One of these areas had natural fluoridation and, like myself, you see people down there 60 and 70 years old without a cavity. I happen to be one of those who have not had cavities and I am sure a champion, and yet I can always start a fight on the streets of Memphis by just bringing up the term.

I am hoping you have some answers.

Governor SMITH. No; we have the same fights.

Mr. KUYKENDALL. Thank you.

Mr. WATKINS. Will the gentleman yield?

The CHAIRMAN. Yes.

Mr. WATKINS. I say that there is a mutual admiration between the Governor and my distinguished colleague on the question of rate fixing. For a matter of clearing the record, my opinion wasn't on rate fixing, but there is one thing that I would like to call to my colleague's attention and also to the great Governor of the State of West Virginia that there better be some control of the expanding costs of these hospitals or you are going to break the whole wagon down, and I am sure that I don't put it in a form of price fixing, but there must be a real interest from the States to find out and set costs on these hospitals or all of the programs are going to start falling, because hospital costs jumping from $22 a day to $60 a day need some explanation and if I were Governor I think I would want to know it.

Governor SMITH. Thank you.

The CHAIRMAN. Mr. Devine.

Mr. DEVINE. I have no questions. I would like to welcome Governor Smith here before the committee and, having heard the comment of my fine colleague from Pennsylvania, I heard someone say the other day that if everybody climbs in the wagon who is going to pull it. Thank you, Mr. Chairman.

The CHAIRMAN. Governor, I again want to say that we appreciate your coming. Since this bill is known as a partnership for health I am hoping that other Governors of the United States will come in and testify as you have and answer questions.

I think you have done an excellent job in fielding all of these questions on a broad front-just as fine a job as any person who has ever come before the committees. I want to congratulate you and say you have added immensely to this record. We appreciate your taking the time and coming up and giving the benefit of your advice.

I think it will mean a great deal when we start marking up the bill. Governor SMITH. Thank you very much Mr. Chairman. If there is any additional information that we can furnish to the committee for the record at any time, I hope you will call on us.

The CHAIRMAN. Thank you very much.

Our next witness is Dr. J. B. Stocklen, National Tuberculous Association.

Mr. VAN DEERLIN (presiding). Welcome to the hearings, Dr. Stocklen. Will you proceed with your statement, please.

STATEMENT OF JOSEPH B. STOCKLEN, M.D., REPRESENTING THE NATIONAL TUBERCULOSIS ASSOCIATION

Dr. STOCKLEN. Thank you, Mr. Chairman and members of the committee my name is Joseph B. Stocklen. I am a doctor of medicine and I am a resident of Cleveland Heights, Ohio, which is a suburb of Cleveland.

My official position is tuberculosis control officer for Cleveland and Cuyahoga County. I am here today to present testimony on H.R. 6418 for the National Tuberculosis Association. I am a member of the board of directors of that organization. I filed a statement with the committee and will try to give a very brief summary of the content of this

statement.

The National Tuberculosis Association is the oldest voluntary health agency in the United States, and has affiliated associations throughout the country. Our specific interest, of course, is in the control of tuberculosis and other respiratory diseases, but we pride ourselves on a long record of being interested in general health.

We know, for example, that tuberculosis occurs in poor populations where the incidence of other disease is high and when we have a population which is relatively free from other diseases, we don't have tuberculosis. The National Tuberculosis Association supported the legislation which led to Public Law 89-749, because we were fully aware that persons had to be free not only of tuberculosis but other diseases to have a healthy population.

Our support was only qualified to the extent that the new grant program would allow for continuation of sufficient funds to lead toward our goal of eradication of tuberculosis. The Public Health Service several years ago recognized the complexity of the problem of tuberculosis, the fact that it is a disease which occurs in one of two ways.

In the first place, some persons who become infected with the disease, that is, inhaling the organisms that float around the air, come down with it immediately, and this is particularly true of children, but other persons come down from old infections.

In other words, a person may have a dormant infection for 50 years and then come down with the disease without ever having come in contact with it again. Since we have 30 million infected people in the United States, eradicaton of tubuerculosis is going to require a program of long surveillance. So in 1963 the Surgeon General of the Public Health Service appointed a Task Force on tuberculosis control whose function was to outline the type of campaign needed to eradicate this disease.

Persons in public health recalled that some years before, medical science had perfected a cure for syphilis. This was probably as effiective a cure as we had for any disease. One large massive dose would render the person not only noninfectious, but also cure him.

We became complacent about syphilis and I think you know what happened. The disease increased and is continuing to increase. This failure led to recognition that it wasn't enough just to know the medical facts about a disease, but that the social facts identified with a disease must also be taken into account.

Tuberculosis is preventable. We have good drugs; not as good as some for syphilis, but they can cure most cases. Yet, last year we had about 8,000 deaths and 50,000 new cases. It is rather shocking to realize that we have some 40,000 active cases in hospitals, some 60,000 active cases outside hospitals.

The task force recommended a certain level of appropriations for project grants for tuberculosis control and money has been made available in line with these recommendations. The Public Health Service has developed an excellent program aimed at caring for active cases outside of the hospital and identifying those persons who have been infected who are most at risk of breaking down with the disease. In the opinion of the National Tuberculosis Association the program has been highly successful.

The task force plan called for a recommendation of $25 million for the third year of an accelerated program which is fiscal 1968. Actually only $171 million has been authorized in the 1968 budget.

With the advent of this legislation and the change in the method of financing, funds to support control will come from project grants for all health services for which $70 million is proposed this year. If we were to get the amount recommended by the task force on tuberculosis, which we feel is vitally needed, this would amount to over a third of the total $70 million.

We believe that there should be sufficient funds for other programs. Even if only the $17 million which has been earmarked were received, this amount would still be a quarter of the $70 million. Either other programs will have to suffer or the tuberculosis program will have to suffer unless the authorization for all project grants is increased substantially.

I would think they should be increased to the neighborhood of $100 million.

We believe that it isn't just a matter of controlling TB but of eradicating it. As long as there is a person with TB then we have a hazard to the whole population. So our goal is one of the eradication and not simply of control.

The National Tuberculosis Association has also been interested in recent years in other respiratory diseases because they are very closely allied to tuberculosis.

I am referring particularly to chronic bronchitis and emphysema. These are diseases which the medical profession has somewhat neglected over the years. They were assumed to be diseases of older people that just naturally occurred; they were alleged to be degenerative types of conditions.

We have reason to believe now that chronic bronchitis and emphysema are not naturally occurring degenerative diseases, but they are probably affected by environment. There is unquestionably a relationship between chronic bronchitis and emphysema and cigarette smoking. Whether it is caused or not no one can know for sure. There very probably is a relationship between air pollution and emphysema.

In Great Britain, where air pollution has been a way of life since the industrial revolution these diseases occur far more frequently than they do in the United States. However, the mortality rate from emphysema in this country is alarming; it has doubled every 5 years since 1950. This may be a matter of reporting and recognition of the

disease, but we think there has been an actual increase. We don't know much about emphysema, what causes it, how much of it really there is, but I think it is time that we must find out.

This legislation, H.R. 6418, will provide funds to help us find out more about this disease, to disseminate information to the medical profession, to screen the population, and to really attack this problem as it should be.

In summary, the National Tuberculosis Association wishes to emphasize its unreserved support for the concept of Public Law 89-749, for comprehensive health services based on cooperative planning with all concerned groups.

Such an approach is long overdue and it offers the only logical solution to our fragmented system of delivering public health service. However, we must express our deep concern that the needs of patients with TB and other pulmonary conditions may not be adequately taken care of unless greatly increased funds are authorized under this legislation for both the formula and grant programs.

Mr. Chairman, I want to express appreciation for myself and on behalf of the National Tuberculosis Association. I deeply appreciate this opportunity to appear before this committee and give this statement. We will of course be very glad to supply any additional information that we can.

Mr. VAN DEERLIN. Thank you, Dr. Stocklen. Your full statement will of course be carried in the record.

(Statement referred to follows:)

STATEMENT OF THE NATIONAL TUBERCULOSIS ASSOCIATION, PRESENTED BY

JOSEPH STOCKLEN, M.D.

The National Tuperculosis Association endorsed the principles of the Comprehensive Health Planning Act when this legislation was proposed last year. Support of the legislation which resulted in P.L. 89–749 was consistent with NTA's traditional efforts to strengthen health department services for protection of the public health.

As an organization dedicated to the eradication of tuberculosis in the U.S., the NTA Board of Directors qualified its support only to the extent that tuberculosis control efforts would continue to receive the amount of Federal support deemed necessary in the December 1963 report of the Surgeon General's Task Force on Tuberculosis Control.

In February 1967, the NTA Board adopted the following resolution relating to P.L. 89-749:

The NTA Board of Directors supports a supplemental appropriation of $9 million as authorized for planning purposes for fiscal 1966-67 in order that the planning aspects of the legislation can be implemented without delay.

It supports an increased authorization for formula and project grants for 1967-68. An amount should be authorized which will permit the scope of Federal financing for tuberculosis control recommended as necessary by the Surgeon General's Task Force on tuberculosis for accelerating the campaign to eradicate the disease. Increased Federal financing is also urgently needed for initiation and expansion of activities to control other chronic respiratory diseases, such as emphysema, which are increasingly significant as causes of disability and death.

TUBERCULOSIS

Tuberculosis remains the major communicable disease problem in the United States, a fact which is the more unacceptable in view of the availability of methods to control it. The Surgeon General's Task Force in 1963 recommended a ten-year plan to accelerate control activities. From evaluation of past experience they believed such a program could only be accomplished by the appropriation of substantially increased Federal funds.

They recommended that major Federal financing be by means of project grants which could be concentrated where the problem is most critical-in the poor enclaves of large urban areas where tuberculosis has continued to flourish and in other areas of poverty where special factors have combined to deny people those improvements of the environment which have helped vanquish the disease in the more fortunate. The House Committee's report which accompanied P.L. 89-749 describes the use of project grants as clearly intended for such situations.

However, elimination of categorical tuberculosis grants could well result in a severe loss of support for tuberculosis control. The Congress by its generous appropriations in the past few years indicated its concurrence with the recommendations of the Task Force. In the current fiscal year the Tuberculosis Program, PHS, received almost $15,000,000 for project grants.

According to the Task Force report, the amount of project grant funds which should be committed to tuberculosis control in the third year of the accelerated plan, which is 1968, is $25,000,000. Funds would remain at this level for an additional three years until, hopefully, progress in reducing the tuberculosis problem would make possible a reduced Federal appropriation. The Federal budget for 1968 includes $17,500,000 for tuberculosis project grants, $7,500,000 less than recommended for the third year of the Task Force Plan.

Formula grant funds have also given valuable support to tuberculosis control; in fact, they were the bulwark until project funds furnished a crucial boost to basic methods of control in many areas. Project grants have furnished a way to concentrate efforts in tuberculosis control not possible under formula funds. But tuberculosis services are now and must be increasingly in the future an integral part of total health department services. Even if tuberculosis is eventually reduced to the status of a minor disease, control efforts cannot be relinquished; they must always be maintained to guard against possible resurgence. It is unfortunate that the same handicap posed by inadequate authorizations for project funds exists for formula funds.

Authorizations recommended last year by the Administration and the Senate for PHS grant programs for comprehensive health services were almost double those finally approved in P.L. 89-749. With the amounts originally proposed, it would have been reasonable to assume that States could obtain funds sufficient to finance tuberculosis control activities in the magnitude necessary for an eradication campaign. However, with the competitive pressures of other established programs and with the identification of new health problems, it seems unrealistic to accept the fact that tuberculosis control can continue to receive the intensified support it needs from such insufficient appropriations as are now authorized. In our opinion, the increase proposed in H.R. 6418 for project and formula grants is not enough to assure the level of support for tuberculosis control necessary to fully implement the Task Force plan. Without substantial Federal funds to support tuberculosis control, a combination of factors will result in neglecting a disease whose true significance is not understood by the public. An editorial in a recent issue of the Canadian Journal of Public Health referred to tuberculosis as the "Great Delusion," pointing out that progress has been far outstripped by the optimism and premature relaxation of physicians. Stating that one recent small outbreak of tuberculosis in Canada cost $500,000, the editorial stressed the need for continuing public support.

As a part of its program to control a communicable disease, the National Tuberculosis Association also wishes to express its support of the section of H.R. 6418 which provides for improving the quality of laboratory services. A recent survey by the NTA of laboratory services for tuberculosis patients indicates that great deficiencies exist in these services in many areas. Few State health departments are able to provide routine surveillance of laboratories which perform tests of sputum to determine presence of tubercle bacilli—a fact which poses a serious question as to the reliability of results of these tests in many nonofficial laboratories.

Advanced techniques which shorten the time of sputum clutures, and which can thereby bring the patient under medical supervision sooner, are lacking in about half of all State health department laboratories. In many States, adequate tests to determine if the newly diagnosed patient's infection is resistant to the commonly used drugs are not available. Delay in prescribing other effective drugs for the patient who may have such resistant organisms can be very serious for his prognosis.