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Wheras adequate funds for the development of needed school-health programs are not available; and

Whereas there is a serious lack of knowledge and techniques by which schoolhealth programs may be made a significant factor in improving the health of communities; and

Whereas it is important that measures be taken to bring about the correction of remdiable physical defects found among school children; and

Whereas the school-health program is a significant factor in the child's learning process, thus accounting for the acquiring of erroneous concepts or ideas as a result of improper school-health programs: Be it therefore

Resolved, That responsibility of school-health programs be recognized as a joint responsibility between the health and education departments on Federal, State, and local levels. In the development of improved school-health programs, joint committees of health and education departments should work out the details of the program together. In general, health education and physical education of school children should be regarded as a primary responsibility of the departments of education working in cooperation with, and with the assistance of, departments of health. Health and medical services rendered by physicians, dentists, nurses, and other technical workers including the follow-up in the home, constitute a responsibility of the health department, working in cooperation with and with the assistance of, the department of education. In order that the educational programs may be kept abreast of the most recent scientific and publichealth knowledge, it is essential that health and education departments work together constantly on the content of school-health instruction; be it further Resolved, That appropriate Federal agencies be requested to—

1. Carry out research and demonstrations in order to develop improved techniques for school-health medical services and to evaluate existing techniques; 2. Carry out surveys to evaluate current practice in this field and to determine needs for expansion of services;

3. Seek Federal funds for the expansion of school-health programs in accordance with established needs, such funds to be allotted on a grant-in-aid basis to State health agencies.

At a meeting held in Washington in December 1946, the Association of State and Territorial Health Officers took the following action pertaining to school health services as was presented by its committee on maternal and child health:

(b) The committee further reaffirms a resolution adopted by the Association of State and Territorial Health Officers on April 12, 1945. That responsibility of school health programs be recognized as a joint responsibility between the health and educational departments on Federal, State, and local levels. Also, that Federal agencies be requested to continue to carry out research and demonstrations in order to develop improved techniques for school health medical services and to evaluate existing programs.

(c) That the Children's Bureau and the United States Public Health Service carry out surveys to evaluate current practice in this field and determine needs for expansion of the same.

(d) It is further recommended that Federal funds for the expansion of school health programs be provided in accordance with established needs, such funds to be allotted on a grant-in-aid basis to State health agencies.

(e) It is the opinion of the committee that the expansion of any school health program should be channeled through existing Federal and State health agencies. (f) In the consideration of any proposed legislation in reference to school health programs, a member of this association should be present at any congressional hearing pertaining to such legislation.

(g) The committee recognized the total inadequacy of rural school health programs, and, therefore, recommends that State health agencies should give consideration to the development of a program to include physical examination, protective environmental sanitation, and the detection of defects and follow-up for the correction of the defects.

It becomes at once obvious that the State and Territorial Health Officers have for many years realized the shortcomings of the school programs and that we have over a period of years expressed an interest and a willingness to create improvements in accordance with facilities as they became available. We have gone on record upon numerous

occasions, expressing the need for additional facilities, which pertain not only to the educational aspects of the school health program but also to what may be called the medical service aspects.

The examination of the school child is not in itself the end of the health program. The examination of the school child should be thorough and complete and should be utilized as both an educational and diagnostic procedure. It is, in itself, but a tool which is employed to attain the objective of the school health program. The objective may be stated simply: It is to render possible to every child the opportunity to develop fully all those faculties endowed him by nature that he may receive the full benefits of his school work and secure the best educational results so that he may in later life enjoy the greatest benefits from opportunities offered him in gainful study or employment.

Perhaps we might be as bold as to say that the primary purpose of a school is not to teach the three "R's" but, rather, to teach the child how to live and how to preserve his body and mind that he may be able to meet emergencies in his own life and those of his nation as they arise. Thus, we are convinced that the school child must not only be taught the rudiments of care of his person but must be given every opportunity to preserve those attributes with which nature has so generously endowed him.

To discover a defect upon a physical examination is, in itself, but the beginning. Provisions must be made for conferences among teacher, doctor, nurse, and parents. Facilities must be found for the adequate follow-up services to make certain that, if correction of a defect be possible, such correction should be made. This means, in some instances, referral to the proper agencies; in others, it may entail actual financial assistance for the provision of services.

At any rate, the total facilities of the community must be mobilized to meet the problem of each child. It is important to remember that the school child is a member of a family and of a community. He is not a school child throughout the year, or even throughout the day. He is a school child only during the hours of the school. Obviously, the health program designed for the school must be integrated with the total community-health program. It is for this reason that State health officers have for periods of years urged the integration of the school-health and community-health program under the same supervision and leadership in each area.

For many years the State and Territorial Health Officers have been urging the coverage of the entire Nation with adequate local health services. At the present time approximately 40,000,000 people are living in areas without the benefit of services rendered by local health departments. It is imperative, therefore, that amendments to the Public Health Services Act provide increased funds to be used for general health purposes.

Such funds as grants-in-aid to States should be of sufficient amount to enable the States to subsidize local units of government on a matching basis so that all of the people would receive the benefits of public health. To these services we might add the administration of a schoolhealth program. It is our conviction that such services as maternal and child health, school-health services, the control of communicable diseases, special provision for tuberculosis, venereal diseases, cancer and other chronic diseases, laboratory diagnosis, nutrition, health education, vital statistics, medical social work, and other accepted

functions of public-health agencies are a means of preserving the health of the Nation.

Without these services we cannot efficiently or economically administer our national economy. Our primary objective should be the maintenance of good health and the prevention of illness. Certainly, it would be foolhardy to embark upon a school-health program unless it were thoroughly and completely integrated with these other activities whose total objective is the preservation of the health of the community.

We find no quarrel with the difference in the appropriations provided in S. 1290 and in H. R. 1980. The eventual goal is the same. The approach in the Senate version is somewhat slower, but either, we believe, is consistent with the best estimate of the availability of personnel and facilities. It is difficult to begin a new program at this time or to expand one which has been going on at a more or less steady pace over a period of years. For these reasons we are not concerned with the Senate version's somewhat lower appropriation allotted for this program during the first and second year of operation as long as for each succeeding fiscal year thereafter such sums as may be necessary to carry out the purposes of the act are authorized.

The National Advisory Committee on School Health Services created by this bill is very much needed for the integration of this program with the various interested groups who are concerned with the school child. We believe, however, that the Committee's advice to the agency, in the form of reports, should be made public through the provision of facilities for publication of these reports.

It would be well to have representation on this Committee of schoolhealth physicians who perhaps are the closest to the administration of this program. We are not in favor of that portion of the clause referring to appointments to the National Advisory Committee which specifies:

* * * one half of the members shall be selected from panels of at least five names each submitted by representative national organizations *

*

The reason we object to such representation on a National Advisory Committee is that such persons who sit on National Advisory Committees act as representatives of their respective organizations and rarely as individuals who are willing to offer their personal opinions.

Thus, when an Advisory Committee is called, no action is taken at all as each of the representatives of a national organization feels it encumbent upon himself to refer to his parent organization for consultation and advice. Since many national organizations have only annual meetings and interim meetings of directing or executive committees, obviously there is but little opportunity for the rapid exchange of opinion and advice as may be necessary at a meeting of a National Advisory Committee. We believe that persons who serve on such a committee should serve as individuals concerned primarily with the viewpoints of the public and those persons rendering the services. They should not be representatives of any official or professional organization.

The Association of State and Territorial Health Officers has studied closely the two versions of the House and Senate. The first major difference is contained in section 2 wherein the declaration of policy is differently worded. We do not believe it is a major difference in

the declaration of policy between the two bills. However, we would be inclined to favor the House version as being simpler in language and more to the point.

In section 3 there is a difference in the amount of appropriations. We have already discussed this difference and are not greatly concerned about the somewhat lowered amounts in the Senate bill. We believe that either plan would be acceptable.

The next change occurs in section 4, "The National Advisory Committee." In the House version the National Advisory Committee is appointed by the Federal Security Administrator whereas in the Senate version the Committee is appointed by the President. We do not feel that the appointing authority is necessarily the determining factor. The appointment of the Committee by either the Federal Security Administrator or the President would be acceptable to the State and Territorial health officers as it is our opinion that the President would seek quite naturally the advice of the Federal Security Administrator before making his appointments.

We have previously analyzed that portion of the House bill which specifies that

One-half of the members of the National Advisory Committee be selected from panels of at least five names, each submitted by representative national organizations.

We have presented our reasons for not concurring with this method of appointment. To recapitulate, we do not believe that members of a National Advisory Committee should be representative of any official or professional organizations. We do believe that school-health physicians should have representation on this Committee.

The next change and perhaps the most important in the House and Senate versions is in section 5, entitled "Allotments to States." Naturally, the extent of the program will be limited to some extent by he availability of funds and, as possible administrators of this program, we wish to make certain that the funds are distributed on an equitable and fair basis between the States and Territories.

Some of the States, particularly in the last year, have been somewhat concerned about the evaluation of financial needs, especially when such evaluation is performed by an agency which is primarily a social or welfare agency rather than one which is experienced in dealing with health matters. We are, therefore, earnestly desirous that any formula for the allotment of funds takes into consideration three important factors: First, the size of the problem, which is determined in this instance, by the number of children between the ages 5 to 17, inclusive; second, the special needs of a State or the ability of such a State to utilize the funds for the provision of additional facilities.

It has been shown by experience that certain States which do not have many facilities at inception of a program are unable to develop rapidly enough to absorb total Federal grants-in-aid made available for that program. Therefore, it seems only fair to take into consideration not. only existing facilities but also the ability of a State to expand these facilities, and to give due regard to the existing standards of services rendered. The services which are rendered in one State may be of a much higher standard than those of another State.

Certainly, while we may be desirous of raising the standards of the Nation as a whole, we should not at the same time pull those States

with the highest standards to the same level as those with a lower standard. We should endeavor to raise the standards of the Nation as a whole and to supplement those States having the higher standards with additional facilities so that they may furnish the necessary leadership in the improvement of health services for the school child. Therefore, we repeat that the second factor to be used in allocation of funds should be special needs as demonstrated by, first, estimate of existing facilities; second, the standards and quality of medical services being rendered to the school children; and, lastly, the ability of the State to provide additional facilities.

The third important factor in the determination of the allotment to a State should be the financial need. Financial need does not necessarily have to be determined by either the House version or the Senate version. In the past, the agency contributing Federal grants-in-aid to States usually utilized the per capita income as the basis for the determination of the financial need. States with the highest per capita income were thus given lesser amounts of money than States with lower per capita income.

Unfortunately, a broad formula of this type may leave to the discretion of the administrating agency such wide authority as to make it possible to weigh the formula in either direction to the extent where some States, perhaps those in the higher income bracket, may feel that they are not being given a just allotment. Conversely, States with the lowest per capita income may feel that due to the discretionary authority placed in the hands of the administrative agency they are not receiving a sufficient allotment of funds.

For this reason, the discretionary authority placed or vested in the Federal agency which is to administer Federal grants-in-aid and which is therefore concerned with the determination of financial need should be specifically limited. In such a way the evaluation of a financial need would be determined by an exact formula in the law. This is based on our experiences over the past years when one-third of the States comprising the highest per capita income bracket felt that while they were entirely in sympathy with making additional funds available to the less well-to-do States, at times the disproportion in the amount of money going to some of these less populous States as compared with the amount of money coming to the more populous States was so great that they seriously questioned the fairness and equity of the allotment formula used.

It is, therefore, our suggestion that financial need be determined in a precise manner as has been done in some of the other bills recently passed by Congress. We suggest, for example, the language which has been employed in Public Law 725 of the Seventy-ninth Congress, entitled the "Hospital and Survey Construction Act," which reads as follows:

B. Out of the sums made available for allotment to the States for each fiscal year pursuant to section 3, the Federal Security Administrator shall allot onehalf (in addition to the allotment made under subsection (a)), as follows: He shall allot to each State a sum bearing the same ratio to such one-half as the product obtained by multiplying (1) the number of children in such State between the ages of five and seventeen, inclusive, by (2) the differenc between one and the ratio of the average per capita income payments in such States to twice the national avrage per capita income payments for the three most recent consecutive years which satisfactory data are available from the Department of Commerce, bears to the sum of the corresponding product for all States having approved plans.

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