AAMC Chairman Dr. William G. Anlyan has called for developing a strategy program, as he puts it, by "working the domino theory backward." He suggests that medical schools and practicing professionals develop a blueprint of highly visible health goals with a specific target date in the future, for example, 1985. Then health experts could determine what resources would be needed in 1980, 1975, and back, to achieve that goal.

After medical experts develop the blueprint, presumably government would respond. We will have an opportunity to begin such an examination next year when the 1968 Health Manpower Act comes up for congressional renewal. I am confident that these hearings, and we should all be grateful for them, Mr. Chairman, and to you, and the distinguished St. Louisans who will testify, will be helpful in that

review.

I know of no community in the Nation of medical men and men of science which has contributed or can contribute more to the total knowledge in this field than the Greater St. Louis area medical profession.

In the meantime, and finally, Mr. Chairman, if the prognosis for our national health is to improve, we must rearrange our budget and put the medical bill at the top.

Thank you very much.

Senator EAGLETON. Thank you very much, Congressman Symington. I think you pointed out an interesting and vital legislative fact, in addition to the very thoughtful commentary on the general situation, where you mentioned that the 1968 Health Manpower Act does expire next year, on June 30, to be exact. It is the basic act that deals in this area, at least the basic one now on the books which deals with construction grants and institutional grants, student assistance, and the like. Thus these hearings will have an influence and are of significance in either readopting that law or, hopefully, in considerably improving it to plug those areas where it hasn't proven to be successful or where it has been too meager in either its authorization or its funding.

I think you have made a significant contribution by your presentation here today.

We would like to invite you, likewise, to join us, Congressman. Mr. SYMINGTON. Thank you, Mr. Chairman. I would be happy to. Senator EAGLETON. Let me add, at this point, that all other Congressmen from the general metropolitan or contiguous areas of St. Louis were invited to attend or participate in these hearings, but the others could not because of other commitments and obligations which they had.

One in particular was Congresswoman Lee Sullivan who tried to cancel some commitments she had because she views these hearings as being vitally important, and we are very sorry that she won't be here. She will submit a statement to us that will be made a part of the record. I want to pay particular tribute to Mrs. Sullivan because she, as much as any other one person, did yeoman work in pursuing and pushing the St. Louis University application for the $9.5 million NIH grant which was announced a few weeks ago, and I know Senator Symington shares my sentiment. Without her help and her knowledge and her effort in this cause, that grant perhaps would not have

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been forthcoming, so I think the record should make clear those facts with respect to Mrs. Sullivan.

Senator SYMINGTON. Naturally, I was interested, Mr. Chairman, in the report made by the Congressman. There is just one little story I would like to add that has to do with my interest in this field for so

many years.

The late great Senator from West Virginia, Matt Nealey, told me many years ago that because of increasing concern about the need to find the cause of cancer, he recommended a $200,000 appropriation to look into cancer research. That was cut to $100,000 in committee and to $50,000 on the floor of the Senate. At the time he told me the story, he also said that the annual research being done by the Federal Government in cancer at that point had reached $200 million, but that the cost of cancer to the United States at that time was $10 billion a year when it was all counted.

Then he named the two men who opposed him the most in his efforts to obtain more funds. I shall not name them but I remember their names, it is perhaps poetic justice that they both died of cancer. In closing that short story, there is also the sad postscript that Senator Matt Nealey himself also later died of cancer.

Thank you, Mr. Chairman.

Senator EAGLETON. Thank you, Senator.

(The prepared statement of Congressman Symington follows:)

PREPARED STATEMENT OF HON. JAMES W. SYMINGTON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MISSOURI

Mr. Chairman, in addressing the problem of the manpower shortage in the health care fields, I must admit at the outset that I come to you-not as an expert in the medical field, but as a student of the problems we face in meeting our nation's health care needs. As a member of Congress from St. Louis County, my primary concern is the federal government's role in meeting health manpower needs and specifically meeting the dire needs of our own community.

Last year, President Nixon noted with alarm that we faced a massive crisis in the field of health care. "And," he predicted, "unless action is taken both administratively and legislatively to meet the crisis within the next two or three years, we will have a breakdown in our medical care system which could have consequences affecting millions of people." I share the alarm which the President expressed.

Authorities agree that at this moment, the United States needs at least 50,000 more doctors, 17,800 more dentists, 150,000 more nurses, and 266,000 more people in allied health professions, including 45,000 in environmental health.

The problem, however, is more than a numerical one; it is also a problem of maldistribution. Medical personnel are heavily concentrated in Eastern and affluent suburban areas, giving rise to the analogy of American medical care to the little girl with the curl in the middle of her forehead-where it is good, it's very very good, but where it's bad its horrid.

We may like to invoke the politically popular cliche, calling for adequate health care for all, but this phrase will remain empty until the critical personnel shortage is attacked. To attack this shortage-and there are a number of creative proposals to this end-adequate funds must precede and accompany any progress. In the past two decades, the Federal government has assumed a sizeable share in the cost of educating and training for the health profession-through grants to medical schools for research and construction, loans to students, and programs to train paramedical personnel. The need for this funding has increased-not decreased as the medical training institutions, like the rest of society, must cope with rising costs due to inflation.

And yet, given these obvious shortages in crucial health manpower, the President requested only $1.5 billion for the National Institute of Health for fiscal 1971. The American Association of Medical Colleges recommended an appropriation of $2 billion to meet minimum needs during the coming fiscal

year. Thus the President's request was $500 million less than the AAMC's estimated requirement. Where is the sense of the impending massive crisis?

Fearing a Presidential veto, the House of Representatives defeated an amendment to the proposed Labor-HEW bill which would have come closer to the AAMC's estimate by appropriating almost $2 billion. This $400 million in added funds which the House voted down, is equivalent to the cost of only 5 days of the Indochina war. Why can't we translate our expressed concern over the crisis in health care into the necessary spending priorities?

Why is it, in the area of health care, we calculate our costs in dollar terms, when the real cost of our neglect will be paid in human terms? We can begin to see these costs in the St. Louis area. St. Louis University School of Dentistry graduated its last class in June of this year. Missouri Baptist Hospital's School of Nursing faces the prospect of closing, after 73 years, because it will not receive a $340,910 grant for construction. This grant, for which we have been working, was part of the added $400 million which the House failed to approve. It was encouraging to learn, however, to learn that St. Louis University's Medical School will receive a $9.5 million NIH grant to update its facilities.

But on another side of the meager health care coin, the dean of St. Louis University's Medical School has noted that the tuition raises necessitated by cutbacks in federal funds, coupled with the decreased appropriations for student loans, are "pricing the poor boys out." St. Louis University has been attempting to meet both numerical and distribution manpower needs by increasing its enrollment and offering opportunities to minority students.

The health care manpower crisis is only one illustration of the frequentlycited need for reordered priorities. Funds for domestic programs-education, housing, hospital construction-have been vetoed as inflationary. But as Senator Pell has noted, inflation in health costs is due to a lack of money, rather than an excess of money. Without increased funds for health manpower, the inflation in our health system, due to inadequate manpower, will persist.

The conclusion, then, is that as long as federal money continues to be spent on the basis that crises abroad are worth spending 73 times the amount spent on crises at home, any new creative programs for dealing with health needs can only come to a dead end.

But if these funds were available to us, what are some programs which might benefit?

We might follow the AMA's suggestion that greater public outlays be utilized to train medical practitioners, and a smaller percentage be allocated to pure research.

Incentives might be offered to encourage more medical students to enter general practice, supplementing the specialists and enhancing the availability of the family practitioner to serve a larger number of patients, especially in less affluent areas.

Programs like the Medex experiment at the University of Washington, where personnel trained by the armed services receive further development in their health-oriented skills could be expanded.

The Allied Health Professions Personnel Training Act, passed by Congress on July 30, would provide assistance for construction of facilities to train allied health professionals, as well as grants and traineeships to develop better methods for teaching health technologists. These efforts must be implemented so that paraprofessionals will be enabled to relieve doctors of some of the more routine aspects of patient care.

If federal support were available, universities could establish demonstrational centers, attached to their medical schools, which would train and place allied health workers-such as pediatric nurse practitioners, physicians' assistants, dental hygienists. These paraprofessionals-along with doctors-would constitute health teams, serving a three-fold purpose-their own education, experiments with new divisions of medical labor, and community service-helping to ensure a better distribution of health care. Such a plan might be incorporated with AMA President Dr. Walter Bornemeier's suggestion that the government finance ghetto clinics to be operated by medical societies, medical schools, and private doctors.

I shall introduce legislation to help resolve the distribution problem when the House reconvenes on September 9. This bill would encourage physicians, dentists, optometrists, and other medical personnel to practice in medically deprived areas. The Federal government would repay the loans a student incurs while in medical school, if he agrees to practice for three years in a location where

a critical health manpower shortage exists. This act would both allow graduating doctors to begin their practice debt-free, and give them the incentive to go into communities which desperately need their services.

These innovations will require a commitment of both dollars and energiesand will constitute only the first steps toward guaranteeing that the right of every citizen to adequate health care becomes more than a cliche.

Besides these specific measures geared toward meeting immediate manpower shortages, a comprehensive national health plan to deal with the problems of recruitment, training, and distribution could assure that medicine in America would move beyond a crisis-response situation. AAMC Chairman Dr. William G. Anlyan has called for developing a strategy program by "working the domino theory backwards." Dr. Anlyan suggests that medical schools and practicing professionals develop a blueprint of highly visible health goals with a specific target date, for example 1985. Then health experts could determine what resources would be needed in 1980, 1975, and backward to next year. After medical experts developed the blueprint, government would respond and react. We will have an opportunity to begin such an examination next year when the 1968 Health Manpower Act comes up for Congressional renewal. I am confident that these hearings and the distinguished St. Louisans who will testify will be helpful in that review.

If the government is to respond to health needs to solve the problem of manpower in all its manifestations-we must start with the tools at hand. If the prognosis for our national health is to improve, as a nation we must be prepared to rearrange our budget and to put the medical bill at the top.

Senator EAGLETON. We will now hear from four witnesses simultaneously, as it were, all in various capacities affiliated with St. Louis University, our host today for these hearings.

Mr. Ben F. Jackson, the chairman of the Medical Center Committee, St. Louis University Board of Trustees.

The Reverend Paul C. Reinert, president of St. Louis University. The Reverend E. J. Drummond, vice-president for the Medical Čenter of St. Louis University; and

Dr. Robert Felix, the dean of the School of Medicine of St. Louis University.

Would Mr. Jackson, Father Reinert, Father Drummond, and Dr. Felix join us.

May I say, gentlemen, each of you has a prepared statement, and I want to point out for the record, that all prepared statements will be printed in the record in full.

Mr. Jackson, Father Reinert, Father Drummond, and Dr. Felix, you are each at liberty to read your prepared statement in its entirely, or summarize it, or elaborate on it, as you see fit.

STATEMENT OF BEN F. JACKSON, CHAIRMAN, MEDICAL CENTER COMMITTEE, ST. LOUIS UNIVERSITY BOARD OF TRUSTEES

Mr. JACKSON. Thank you, Mr. Chairman.

Senator Symington, Representative Symington, any other members of the committee who may be present, as you mentioned earlier, I am presently a member of the executive committee of the board of trustees of St. Louis University and chairman of the Standing Committee for the medical center of the university.

My interest in the field of health and hospitals has covered a period of over 25 years. I have served on the board of directors of several community hospitals, and I am currently also chairman of the Joint Board of Health and Hospitals for the city of St. Louis.

I have also served in connection with the United Fund of Greater St. Louis in allocations to hospitals and other agencies here, and I am

currently serving as a member of the Regional Advisory Committee of the BiState Regional Medical Program and as chairman of the committee on communications and public relations of that program. I deeply appreciate the opportunity afforded me and these other witnesses to appear before you to discuss the subject of education for the health professions and several of the problems related thereto.

It has become increasingly evident that the need and demand for more and better health services has spread throughout the entire country. In the past, different segments of the population have been served on different bases related partly to their ability to pay for the health services they believed they needed and partly on their understanding of their need for various health services, both preventive and corrective. Many of our citizens, unfortunately, have either been unaware of the services available or unaware of their need for these services. In recent years this situation has received a great deal of attention from the executive and legislative branches of our governments at the National, State, and local levels. Unfortunately, this attention has not been uniform in all areas of the country.

What are the responsibilities of a medical center in this important area of citizen and community needs? I believe that a medical center has several important roles to play. Perhaps foremost, it is responsible for the training of health professionals, including physicians, nurses, the various allied health professions, such as dietetics, medical records, medical technology, physical therapy, radiologic technology, and hospital administrators. As knowledge in the field of medicine and allied areas has increased so greatly in recent years, specialized training has become more and more important. Medical centers have become more sophisticated, and the costs of training have increased proportionately. Another responsibility of a medical center is to assist in rendering direct service to members of a community. This includes not only the operation of its directly controlled hospitals but also assistance in rendering service in affiliated institutions.

St. Louis University Medical Center has affiliations with the following institutions at the present time: Cardinal Glennon Memorial Hospital for Children, St. Mary's Hospital, St. Louis City Hospital, Cochran Veterans' Administration Hospital, and Bethesda Hospital. The value of this association cannot be underestimated. Two purposes are served, delivery of health services to members of the community and important assistance in the area of teaching.

My own association with the city hospital system, as well as with other hospitals, strongly supports this position. In our own St. Louis University hospitals, I mean Firmin Desloge Hospital and David P. Wohl Memorial Mental Health Institute, a considerable part of the service rendered, something over $750,000 per year, is rendered on a free or partially free basis to members of the community who would be unable otherwise to pay for the service and would, therefore, become a responsibility of hospitals supported by public funds.

A further responsibility of medical centers is the development and continuance of research studies which relate to the field of both preventive and corrective medicine. Research of the type I refer to is directly related to the teaching function, so that the health professionals will have direct contact wtih research methods and thoroughly understand their importance during their periods of training.