Senator EAGLETON. We now have Dr. Sam Pagano, D.D.S., president, Greater St. Louis Dental Society, and Dr. Russell Buchert, D.D.S., president, Missouri Dental Association.

STATEMENT OF SAM PAGANO, D.D.S., PRESIDENT, GREATER ST. LOUIS DENTAL SOCIETY, AND DR. RUSSELL BUCHERT, D.D.S., PRESIDENT, MISSOURI DENTAL ASSOCIATION

Dr. PAGANO. Mr. Chairman, I would like to thank you for the opportunity of being here this afternoon. I would like to point out some observations made here this morning.

It seems that most of the emphasis has been placed on medical schools and medicine. Total health care demands adequate dental care. We need more trained doctors of dental surgery. Congressman Symington's statement this morning was very true when he said you don't meet the needs of people when you close schools. The closing of St. Louis University Dental School is indeed felt in the St. Louis area and this loss will continue to get worse.

All new federally supported and proposed health care legislation seems to ignore or offer only a minimal amount of dental care for the U.S. population. I ask the question, why is this so when we know that dental care is the most prevalent disease in America today.

The impact of the United Auto Workers requesting dental care for themselves and their families will place a new and larger demand on departmental manpower in the St. Louis area. This is in addition to the already existing McDonnell-Douglas insurance plan which has created a new segment of the population requiring dental care. This is also in addition to the paramount needs of the medically indigent. To me, from most of the preceding statements, dentistry and dental care seems to be a voice in the wilderness. We are alluded to but faintly not heard. True, you do not die from a toothache, it is not dramatic to be a dental cripple. One of our eminent Presidents, Franklin Delano Roosevelt, was a cripple with polio. Had he been a dental cripple of equal magnitude he would never have been elected, because his speech and appearance would have been impaired. Yet, dental decay can be prevented, restoration of dental cripples can be effected, and good oral health for the population can occur, but this occurrence cannot take place if we ignore the acute problems facing the profession of dentistry in providing dental care for the American populace.

In conclusion, I would like to ask that dentistry be included completely in your definition of total health care.

Senator EAGLETON. Fine, Doctor. Thank you.

For the record, of all institutional Federal grants given last year, 56 percent went for medicine, 22 percent went for dentistry, and there are approximately, although I don't have exact figures, twice as many medical schools in the country as dental schools. Do you have the exact figures on how many dental schools in the country?

Dr. PAGANO. Fifty altogether.

Senator EAGLETON. How many medical schools in the country?
Father DRUMMOND. 101.

Senator EAGLETON. Dr. Buchert.

Dr. BUCHERT. Senator, I would like to thank you for extending this invitation to me as president of the Missouri Dental Association. I

want to point out several things. Unfortunately, we will not receive any more additions to our dental manpower from St. Louis University School of Dentistry. In the past 5 years there were a total of 245 graduates of the dental school. This is from 1965 to 1969. Of that total, 49 were Missouri residents, or 20 percent. Those that graduated, 74.69 percent, or a total of 183, were licensed to practice in Missouri, which means that we had 20 percent residents coming into the dental school, and possibly we retained that 20 percent and picked up another 54 percent who stayed in this area to practice. We will lose that from here on out, that is, approximately 65 dentists every year.

Senator EAGLETON. I have heard so many statistics. Do you recall what Dr. Bensinger said insofar as how much of that slack Washington University could possibly pick up?

Dr. BUCHERT. I do not recall.

Senator EAGLETON. It will be in the record.

Dr. BUCHERT. I think about four or five students a year.

Senator EAGLETON. So a net loss of 61. Was that an annual—what was this year's graduating class, this being the last at St. Louis University?

Dr. BUCHERT. I have heard for 1969, 50. There were 60 in 1970. I do not have the figures for this year for the simple reason that the Missouri board was just given about 2 months ago and this information is not available at this time.

We have heard an awful lot about the medical profession becoming community oriented. For some reason or other we forget that dentists are a part of this medical community. The activities of any dental school are closely interrelated with community life, primarily because of patient treatment aspects of the educational program and because of minimal fees assessed for clinical treatment. High quality professional care is thus made available to many individuals from the lower income levels to whom treatment might otherwise be denied because of limited public health facilities within the community.

Although primarily a teaching institution, and not oriented to treatment as its primary goal, St. Louis University School of Dentistry for many years has played a major role in providing dental health care for the St. Louis metropolitan area. There are a number of facilities in this area which will be lacking in dental manpower because of the closing of the school. The private practitioner cannot possibly pick up this slack. We're certainly not going to graduate enough students to staff these programs.

It's amazing to me that the previous witness who gave us the figures on the Yeatman Center, where there were six white dentists serving in that Yeatman Center. I was of the opinion that there was one dentist, and he was a black orthodontist, so apparently the white dentists are working with the community program.

Senator EAGLETON. Well, at the Yeatman Center is Mr. Henley still with us?

How many white dentists are practicing dentistry in North St. Louis other than at the Yeatman Center?

He's gone. My suspicion is zero. Do you suspect otherwise?

Dr. BUCHERT. I don't know. I don't even know who the individuals are, unfortunately. I wish I did.

Senator EAGLETON. Washington University has a dental school and there is one at Kansas City operated by the State.

Dr. BUCHERT. Right.

Senator EAGLETON. Do you know how many black students are currently enrolled in Washington University Dental School?

Dr. BUCHERT. I do not know, sir.

Senator EAGLETON. Do you know how many are enrolled at Kansas City Medical School?

Dr. BUCHERT. I do not have those figures.

Senator EAGLETON. Do you find that the trend in dental area of medicine is pretty much as in the physician area, that black physicians, it has been said, tend to minister to the needs of black patients; black dentists would tend to minister, I guess, to the needs of black patients likewise?

Dr. PAGANO. Yes.

Dr. BUCHERT. I think this is true in large communities. As you get out into the outstate areas, then you find that the white physician and white dentist is treating both black and white.

Senator EAGLETON. I take it that's the case. I don't know of any black dentist or orthodontist practicing in Sikeston, for instance. Dr. BUCHERT. No; but I point out the white physician and dentist is treating the black patient in these areas.

Senator EAGLETON. Do you think that along the lines of statements of some of the preceding physician witnesses, that a greater emphasis has to be placed in dental education on minority groups, specifically blacks, Mexican-Americans, Puerto Ricans, where they are in great abundance, for instance, in the New York area?

Dr. BUCHERT. I think this is true. I think that dental education has to be geared to all groups. This is one of the problems that we have had in the practice of dentistry in that dentistry has a very low priority in the economic want list.

Approximately 85 percent of the population seek and buy what they want, whether they need it or not. I'm not talking about the 15 percent of the 200,000-plus that are economically deprived of financial means, but there is 85 percent that buy what they want whether they need it or not, and they still have a low priority on dentistry. In other words, they do not understand the importance of good dental health care.

Health education has to be geared to all segments of the population, not just the economically deprived.

Senator EAGLETON. I think that makes sense.

Dr. BUCHERT. This is something that the American Dental Association is trying to correct.

Senator EAGLETON. Thank you, doctors. We appreciate it very much. We will now have four witnesses appearing simultaneously; Sister Mary Stephen, dean, Nursing and Health Services, St. Louis University: Dr. William Stoneman, program coordinator, bistate regional medical program; Dr. Charles Berry, associate dean, Nursing and Health Services, St. Louis University; and Dr. Oliver Duggins, chairman, Life Sciences Department, Forest Park Community College. Would Sister Mary Stephen and the three gentlemen come forward? Dr. Stoneman's area of authority goes bevond the allied health services, but his work is related and he has a deep interest therein, so we asked him to join in this four-member presentation.

Dr. Stoneman, why don't you start off?

STATEMENTS OF SISTER MARY STEPHEN NOTH, S.S.M., SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS, ST. LOUIS UNIVERSITY; WILLIAM STONEMAN, M.D., PROGRAM COORDINATOR, BISTATE REGIONAL MEDICAL PROGRAM; CHARLES E. BERRY, A.B., M.Sc.H.A., J.D., ASSOCIATE DEAN, SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS, ST. LOUIS UNIVERSITY; OLIVER H. DUGGINS, PH. D., CHAIRMAN, LIFE SCIENCES DIVISION, FOREST PARK COMMUNITY COLLEGE

Dr. STONEMAN. Thank you, Senator. I would like to thank the subcommittee for inviting me.

If I may, I'll try to distill and present the prepared remarks in the order in which the questions were addressed in your letter.

With respect to the question of increasing the involvement of health professional delivery service, I think my remarks have been pretty well covered in the comments that were made by witnesses who spoke to the past history of the funding mechanisms that have seemed to put research and health care delivery at odds with one another at this time. I think that the dilemma we are faced with at this point in time is, in part, a measure of the success of American medical research efforts. We are now confronted with more tools of delivery or tools for treatment of disease than it seems we can use well, and while more human resources must be directed toward solutions to this delivery problem, it should be clear that the research which deals with health care delivery ought not to be abandoned.

At the same time, as a result of departmentalization in our schools, and as a result of the strong Federal emphasis on basic research funding as a mechanism for producing changes in schools, we have developed a system which probably lures many of the most promising medical students away from clinical practice, and I think this has to be changed. The Government can't continue to stimulate, by infusion of dollars, a system which immures a great part of our human medical resources into intramural research programs which don't relate to community need.

What, then, is the responsibility and the role of the medical center? That was the next question in your letter.

The value of the medical center, particularly the university-based medical center, I think, is its great potential to mobilize its resources as an educational and service institution to assist in providing the elements we need to improve the delivery system. The medical centers have been at the core of regional medical efforts to assist the providers of health care. Now we are talking about helping a $60 billion private sector "industry" to meet the problems with which it's faced, and the resources for doing this are extremely limited. They are obviously limited to the extent that they can't impact significantly in terms of total additional dollars to pay for additional service. In relation to a $60 billion industry RMP resources are minuscule, but where regional medical programs have been effective around the country, the strong efforts of medical centers, particularly university-based medical centers, have been central to their success. Where they have been less effective, generally, one will see on examination that there is a lack of strong commitment by university medical centers.

An RMP should have a role here. It, I think, constitutes the planning partnership between community hospitals, consumer groups, professional groups, voluntary health agencies, and the medical centers themselves that can overcome the parochial interests and the towngrown jealousies that in the past have kept all these components in our health care system frequently at odds with one another. A medical center can commit itself to these efforts to the extent that resources are made available.

Now, I think that in the old research funding model for support of the medical school we have created a competitive situation which really drives medical centers or universities apart from each another. They have been competing for funds. If Washington University gets thousand dollars, everybody looks in the paper and wants to know why St. Louis University didn't get some research money, and this, in the past, has provided a kind of antipathy among institutions.

We have now reached a point where the universities have come to see their identity of interest and have begun to work together. I think, with respect to support for training physicians to perform delivery services, that commitment of these funds on a regional basis, with decisions made jointly among all of these components of the health care system on how they can best be used in a region rather than by an isolated bureaucrat in Washington, might make sense.

Federal programs assisting education and the health professions: To recite Government efforts to assist education in the health professions is a dreary list of well intentioned programs which have produced a crazy quilt of overlapping, unrelated, frequently conflicting programs that are too numerous to count and are administered by a bewildering number of bureaus. There are more cabinet level departments involved in training for health care delivery than are not.

At the local level, here where the action is, we could only find funds for a badly needed operating room technician's training program, and a second program for the training of aide and assistant level personnel for the neighborhood health centers through the MDTA mechanism. Department of Labor funds are earmarked for training the unemployed, certainly a laudable goal. But a program geared to rehabilitating dropouts, and a program primarily aimed at meeting critical shortages of skilled technicians in the health care system, are two programs which proceed from different basic assumptions which are difficult, if not impossible, to reconcile in program development, particularly when both sources of funds are bound in rather rigid guidelines.

As Mr. Henley said, if the bulk of the health manpower funding efforts which are now spread through myriad agencies were brought together, with one set of guidelines, under one agency, a great obstacle to program development would be removed, and if responsible and imaginative local planning bodies which can move the providers of health care, and which can move the educational institutions, were given the local mission of coordinating efforts to meet local needs under a competitive system of quality review, progress would really begin to be made in this area. My prejudices in favor of the potential of the RMP mechanism in this application should be very clear. I really can't overstate it in this connection.