The emergency and out-patient departments of medical school affiliated hospitals have always given direly needed and outstanding service to the communities in which they are located. But in recent years these have been expanded by out-reach programs, bringing services to the disadvantaged areas and the ghetto areas of our cities, and rural areas. These out-reach programs servicing the poor and the disadvantaged vary from school to school in direct proportion to their financial ability to maintain such programs and without federal subsidy many of them would be impossible.

Junior and senior medical students in various medical schools are undergoing preceptorships in local physicians' offices, as well as working in comprehensive neighborhod health centers. In many instances they have developed extensive programs to provide medical services in the form of clinics, initiated, organized, staffed and run by medical students in areas of the United States where no medical facilities are available at all; such as the Mississippi Project, instituted by the Student National Medical Association, and the Appalachia Project, instituted by the Student American Medical Association.

Since the tuition fees paid by medical students constitute only a small percentage of the over all operational cost of medical schools, funds to operate the school and to carry on their various programs outside of the medical school must be funded from some source; either by private contributions and endowment funds, alumni support, or state and federal subsidy for expansion of their facilities and the operation of their academic and other programs.

We understand and support President Nixon's move to curb inflation by cutting federal spending. But we hate to see the end obtained at the expense of the health of the nation, and at the expense of depriving needy students of financial support to go to medical school. In President Nixon's budget as it went to Congress in January, 1970 he sought $15,000,000 for health profession scholarships. But under 42 U.S.C. 295G (B), he could have sought $16,800,000. Therefore, he only sought 89 percent of the amount he could have requested. In other words, he sought 11 percent less than the law permitted. Under HEW regulations, 42 C.F.R. 57.604 (A), when the funds are less than that contributed on the basis of $2,000 × 1/10 of full enrollment, then grants to all schools shall be proportionately reduced. When President Nixon cut the appropriations approved by Congress to the Department of Health, Education and Welfare by $7,000,000, we in the medical profession were all shocked and disappointed, because we realized what effect it would have upon the various programs of medical schools to expand their facilities and increase their programs for enlarging the number of medical school graduates.

I would, therefore, recommend that the Subcommittee use its influence in attempts to obtain full grants and appropriations for health profession scholarships and expansion programs as previously authorized by Congress.

As you know, Mr. Chairman, there are approximately 14 to 15 "have not" medical schools in the United States of the total 101. At a recent meeting with President Nixon, Secretary of Health, Education, and Welfare, Mr. Elliot Richardson, and Mr. Robert Finch. I was a part of a delegation from the National Medical Association. I was asked by President Nixon whether I felt that the schools in direst need should have priority in available appropriations and funding grants. My answer to the President was a definite "Yes." It is understandable since these schools have been in the past constantly threatened with the possibility of closing because of fiscal incapability of continuing, and at best have been operating under great duress. Furthermore, in many instances these schools, such as Howard and Meharry, have a higher percentage of disadvantaged poor and black students. And if they close, not only will the total number of enrolled medical students and medical school graduates be decreased, but the number of poor and disadvantaged and black medical student enrollment will be very definitely adversely affected. So I humbly recommend that this Subcommittee support this stand.

As a member of the Health Task Force of the Urban Coalition, in our report of July 1969, we referred to the matter of putting more people to work for improved health services. We stated that "whatever is accomplished in improving the delivery of health services to the urban poor will be conditioned by the availability of manpower. Part of the inadequacy in applying our health resources is the lack of sufficient manpower, and part is the inefficient and ineffective use of what manpower we have. Manpower critical deficiencies cannot be remedied by producing a host of additional professionals who require long years of training. Rather, professionals must identify what part of their jobs can be done by someone with less training, and what part must be done by people with

more advanced training, so that a hierarchy of staffing can be established. Then the added sub-professionals, those people lacking professional degrees, can be trained to enlarge the system of care.”

"Development of 'new careers' through training for jobs that did not previously exist in the health professions would produce more sub-professional personnel to remove part of the burden of care from the professionals, stretching the latter's availability in improving the over-all productivity of the system. It would simultaneously create job opportunities for the poor and the disadvantaged in the community." Many new health careers are begining to be identified, such as, the physician's assistant, surgical assistant, the operating room technician, the ward clerk, the inhalation therapist, and many others.

This view of the Health Task Force of the Urban Coalition should be strongly endorsed by all of us professionals and by this Subcommittee.

Last year and year before last, I attended the meetings of the Council on Foreign Medical Graduates of the American Medical Association, and found it impossible to attend their meeting this August 31, 1970. Suffice it to say that this is a very complex subject, and one that cannot be clearly discussed at this hearing because of its many ramifications. However, if it were not for the thousands of foreign medical graduates who enter this country each year, many of our hospitals and communities would go without medical services that are badly needed. Many of the foreign medical graduates are extremely unhappy about the way they feel they are treated in a discriminatory fashion, and are not given the opportunities that they feel they deserve. In many instances, I feel that they have a rightful complaint. Most of their complaints arise around the matter of licensure; and in most instances, the foreign medical graduate has great difficulty in passing the State Board Licensure Examinations. And as you know, the State Board examinations vary from state to state from one part of this country to the other.

I would recommend only that some standardized techniques be developed to evaluate the foreign medical graduate before he comes to this country; that standardized tests be devised specifically for the foreign medical graduate in order that he can move with even flow through his training into active participation in medical care delivery in this country if he desires to stay. Subjects such as maldistribution and utilization of military trained technicians and others are some not touched.

Mr. Chairman, I apologize for the lengthiness of this testimony. All that I have said has been in good faith, with a hope to be helpful in the expressions of my own convictions on certain subjects, and in trying to touch on certain points that I was apprised you would be interested in hearing. I thank you for allowing me this opportunity to appear before you.

Senator EAGLETON. Mr. Mosley.

Mr. MOSLEY. We have a brief statement we would like to read, since it is not a prepared statement.

First of all, I would like to thank Dr. Whittico for giving us this opportunity to speak, and also thank you, Senator, for allowing me as the representative of the Committee for Black Health, St. Louis chapter of the Student National Medical Association, to speak to you today. Senator EAGLETON. Please proceed.

STATEMENT OF JULIAN MOSLEY, THIRD-YEAR MEDICAL STUDENT, WASHINGTON UNIVERSITY

Mr. MOSLEY. I feel that we should be voicing an opinion at this meeting, since the Committee for Black Health numbers among its members all of the black students at St. Louis University and Washington University Schools of Medicine, Barnes Nursing School, Washington University School of Hospital Administration, the majority of black house staff from the St. Louis University-affiliated hospitals and Washington University-affiliated hospitals, and the interns and residents at Homer Philips Hospital. Therefore, we are all involved in some phase of medical education presently.

We have spoken with many of the people who are testifying before this committee about specific programs and projects that we feel will help solve the problems of increasing the number of blacks in the health careers fields, but now I would like to talk about generalities that I think are being overlooked in the attempt to revamp medical education systems, especially as they concern blacks in this country. The Committee for Black Health, St. Louis chapter of the Student National Medical Association, will be more than willing to discuss specifics at some other time.

If the problem of providing medical education is as serious a problem as it is said to be, I think it is certainly an acutely serious problem in the black community, which has a disproportionately small representation in all the medical allied fields. If the problem of medical education is a difficult problem to solve relative to white medical students, it is an even more difficult problem to solve for black students. That is one of the reasons this organization has been formed, to make committees such as this and institutions like the medical schools and dental schools in this area aware of how this difficult problem might be solved and how it is a different problem.

In speaking about the three broad areas that are involved in the health manpower problem, recruitment of black students, retention of black students in medical schools or allied schools, and the utilization of black students in these institutions, let us state a fact.

I think blacks who are already in, or associated with health career fields, will have to bear the burden of recruiting future blacks. For example, the 10 black students entering St. Louis University Medical School were recruited mainly through the efforts of black medical students at that institution this year, and the four black medical students entering Washington University were recruited, similarly, through efforts of black students at that university. Why must black recruit blacks? Because the credibility gap in this country between blacks and whites, in this instance between black students and white institutions, makes it imperative that blacks confirm the intentions of white institutions. This implies that there must be a real attitudinal change within these schools. No longer can schools say that they are looking for blacks and subsequently demonstrate that they are really only looking for a token number. This change of attitudes must permeate the entire institution, so that the black student once enrolled does not feel outcast, persecuted, or deprived because he is black. The institution must be willing to go out of its way to provide financial assistance and, in most cases, financial needs of black students are greater than those of white students. Likewise, if necessary, the educational needs of these black students must be provided for, to enable them to complete their education. It follows that the more black students admitted and retained now, the more sizable the growth will be later. As well as retaining students, institutions must be sensitive to the needs of all black people, which probably means the alteration of curriculums, so that students will be better prepared to serve the community in which they live.

It must also provide vehicles for students to be of more service to the community in which they are residing. This is another illustration of an attitudinal change in the medical institution which formerly has been academically orientated, but which now must become community orientated. Already we have heard people speak specifically about the things I have just generally reviewed: recruitment, admission, reten

tion, curriculum, financing, and community orientation. The difference is that I have been talking about the need for a real change in attitudes among white institutions that will have to come about in order that any of these erudite schemes so far proposed, or programs so far put before this committee, can work.

No longer can a white person be satisfied with being the most liberal or openminded person at his institution, willing to accept a few blacks where there were none before. This is a time for proof, not token intentions of getting more blacks into medicine.

The Committee for Black Health, the St. Louis chapter of the Student National Medical Association, feels it is important enough to be heard by the members of this group, and your ineptness in not realizing this does not, I hope, reflect an inability in solving the problems with which you are trying to cope.

In listening to the testimony that has been presented at the hearing today, I think the Committee for Black Health has the feeling that we could have added to some of the testimony provided before the committee, especially the portions that concern black people, and we felt that some questions were answered inadequately; therefore, we would like to try to add what we felt about them.

One that I felt should be corrected or at least amended, is the question which has been bandied about during the hearing, concerning where the black M.D.'s graduated from predominantly white institutions, practice medicine, that is, the suburbs? I think

Senator EAGLETON (interrupting). I cited as the only figures I have on that those pertaining to Johns Hopkins in Baltimore County, Md., but I don't claim that to be the national result. I don't know. Those were the figures supplied me from Johns Hopkins.

Mr. MOSLEY. This is obviously a question that in our efforts to increase the number of black students in the various medical institutions we have had to answer for 2 years, and I think we probably have some different answers than the ones you have heard already this morning.

I think you cannot make where he is going to practice a prerequisite of the student's admission or entrance into a medical institution because there are other areas of need in the black health problem besides just ghetto medicine. There are blacks at all levels in this Nation, and there are many medical needs among blacks, especially areas such as academics and research, which have not even been touched on yet.

Senator EAGLETON. Ninety percent of all blacks live in racially isolated neighborhoods. Those are the national census figures released. If they be accurate, then if 90 percent of the black people live in isolation, the fringes of which would not be necessarily ghetto-like, but the inner core of which would obviously be ghetto-like, and I would say 90 percent of black people have about the same kinds of illnesses as the average white guy, and some have heart disease, and some have piles and some have hemorrhoids and some have hangnails. Doesn't it stand the test of reason that medical services are going to be delivered to the people?

Mr. MOSLEY. I think you are missing the point, namely, black physicians provide care for the black community, and where the physicians resides is irrelevant to his delivery of health care. It has been

pointed out before this committee that 90 percent of the medical care delivered to the black community is from black physicians.

Senator EAGLETON. Do you think that is the case in St. Louis?

Mr. MOSLEY. That is the case. I defy you to name me a black physican who is making his living from white patients.

Senator EAGLETON. I don't know that I can. I agree with you. So I am not getting what you are saying. If it is primarily that black doctors are, by and large, rendering medical care to black people, then isn't there some relation, not that you can pass a Federal law "thou shalt not work in this neighborhood," don't we have to pump more black physicians through the medical process, nurses, the whole bit, so that we can get some medical care to the black people?

Mr. MOSLEY. That is true. I think we have to pump more black physicians into the mill so that you can solve the problem.

Senator EAGLETON. I don't think any of the previous witnesses disputed that.

Mr. MOSLEY. I think the onus of your previous statements was that many of the black physicians were denying their obligation to serve the black community and I think that is a mistaken judgment. Some of the other people here on the panel might have something to add to what has been said.

Senator EAGLETON. Thank you, Mr. Mosley.
Miss Scruggs.

STATEMENT OF KAREN SCRUGGS, SECOND-YEAR MEDICAL

STUDENT, WASHINGTON UNIVERSITY

Miss SCRUGGS. As I was listening to you, you mentioned also the small number of physicians who were taking advantage of the "Waiver of Indebtedness" section in the Health Manpower Act and what not, and you wanted to know why didn't more physicians avail themselves of this and go to work in rural communities which were depressed.

Senator EAGLETON. Rural or urban, wherever there is a need by a standard form, an index of poverty, and an index of a shortage of medical manpower.

Miss SCRUGGS. It seems to me that often, people in medical schools who are interested in getting more students and training them specifically to go back to ghetto areas are expecting more humanitarianism of minority group members than they are expecting of the population generally. The minority medical students and other professional students have the same sort of economic pressures to getting ahead in our money-oriented society, as do the white students. Until we canthroughout all areas of our life-impress upon Americans generally the idea that we should become more humanitarian in our outlook and in the way we use our money, our time, and our resources, it is not exactly fair, in my opinion, to stress the fact that the minority and other disadvantaged students, who are going into the professions, have not gone in droves back to the situations from which they came.

Another thing I think which might be relevant to the discussion of the black physician or the black lawyer's movement, or any other professional movement out of his ghetto environment into the suburban area or into a more lucrative practice elsewhere, is that