percent. The over-all rejection rate for the total of 363,376 applicants examined at reception centers and migratory centers was approximately 3.1 percent.

SERVICES FOR TRAVELERS

The new edition of the booklet, Immunization Information for International Travel, was distributed to Service facilities, health departments, transportation companies, and others concerned with international travel.

Twenty-two additional yellow fever vaccination centers were designated pursuant to World Health Organization requirements, bringing the total to 33 centers in the Service and 68 in other public and private facilities.

Control measures were applied to more than 30,000 airplanes arriving at United States ports, to kill mosquitoes and other insect vectors of disease.

Hospital and Medical Facilities

During the fiscal year, the Congress enacted the Medical Facilities Survey and Construction Act of 1954 (Public Law 482), and this was approved by the President on July 12, 1954. This measure broadened the hospital survey and construction program, originally established in 1946, by authorizing annual allotments for the construction of hospitals for the chronically ill, nursing homes, diagnostic and treatment centers, and rehabilitation facilities.

Authorization was also given for an appropriation of $60 million annually through the 1957 fiscal year to assist in paying part of the costs for the construction and equipment of the four types of facilities. Total amounts authorized annually are: $20 million each for chronic disease facilities and diagnostic and treatment centers, and $10 million each for nursing homes and rehabilitation facilities. For fiscal year 1955, a total of $21 million was appropriated by the Congress to assist in the construction of the four types of facilities. In addition, $75 million was appropriated for the previously authorized construction program.

This program is administered by the Division of Hospital and Medical Facilities. During the year the Division developed guide materials for the States and others on the changes involved in the broadened program, consulted with outside groups, and prepared program plans and policy procedures.

By the end of the fiscal year, most States were well on their way towards completing their inventories and developing comprehensive programs for the provision of ambulatory care and preventive health

services, acute hospital care, long-term hospital and nursing home care, as well as rehabilitation services.

The original Hospital Survey and Construction Act was enacted in 1946. Project approvals by the States and the Public Health Service started under this program in July 1947. The first hospital was completed and opened on October 15, 1948. By June 30, 1955, 2,514 hospitals, public health centers, and related facilities had been. approved; 1,905 of these were completed and 503 were under construction. The remaining projects were in the planning and preconstruction stages.

Projects approved to June 30, 1955, will add 118,814 hospital beds and 547 public health centers to the Nation's resources, as well as many related facilities, such as laboratories and nurses' homes and training facilities. Of the total number of beds, 97,380 are in general hospitals; 11,166 are in mental hospitals; 6,748 are in tuberculosis facilities; and 3,520 are in chronic disease facilities. The total construction cost of these projects is $2,056,000,000, toward which the Federal Government contributed about a third ($671 million) and State and local sources, two-thirds ($1,385,000,000).

Of the 949 completely new general hospitals being built under the program, 525 (55 percent) are located in communities which had no hospitals, and 207 (22 percent) are located in communities where the only hospital was obsolete or unacceptable. Of the new facilities approved, 55 percent are located in communities of less than 5,000 population and only 11 percent in cities which exceed 50,000 population. Of the new hospitals, 57 percent have fewer than 50 beds and only 21 percent have 100 beds or more.

The original State surveys showed that the Nation had approximately 868,000 acceptable hospital beds, with a deficiency estimated to be more than 900,000 beds. While this program has been able to assist in providing almost 119,000 beds, and while almost twice as much hospital construction has been completed without Federal aid, needs are accentuated by an annual population increase which exceeds 2.5 million. In addition, every year large numbers of hospital beds become obsolete or in need of modernization.

Indian Health Services

On July 1, 1955, the Public Health Service assumed responsibility for the provision of medical care and public health services to approximately 315,000 American Indians and 35,000 Alaska Natives. This responsibility was transferred from the Department of Interior's Bureau of Indian Affairs in accordance with Public Law 568, 83rd Congress, enacted in August, 1954. Previously, the Public Health

Service detailed medical and other Public Health Service officers to the Bureau of Indian Affairs for the Indian health program.

A new division-the Division of Indian Health-was created within the Bureau of Medical Services at the start of the 1956 fiscal year to administer this program. About 3,500 employees, most of whom are located in hospitals and area offices in the western parts of the country, were transferred from the Bureau of Indian Affairs with the program.

Also involved in the transfer were approximately 970 buildings and other structures in 23 States and Alaska. These include 56 hospitals, 21 field health centers, 13 boarding school infirmaries, field clinic stations, quarters units, and supporting structures such as heating plants, laundries, warehouses, and garages. The real property inventory is estimated at an approximate valuation of nearly $40 million.

Administration of the health program for Indians and Alaska Natives presents a new challenge to the Public Health Service. In many respects, health conditions among the Indians are similar to those that prevailed in this country about a half century ago, when limited knowledge of sanitation, hygiene, and preventive and curative measures resulted in extensive sickness and early loss of life. Preventable diseases which are under control in the general population still account for high death rates among the Indian peoples.

To meet these problems, the new Division made plans for a twofold approach: (1) expansion of the medical care program to provide clinic and hospital services to as many Indians as possible who need such care; and (2) acceleration of public health and preventive services among the Indians. This will be done through expansion of field health facilities and services, public health nursing activities, maternal and child care, school health, sanitation, health education, and dental services.

Dental Resources

During the year the Division of Dental Resources continued to work toward defining the problems associated with the supply, distribution, and utilization of dental manpower.

DENTAL MANPOWER

At the request of the Oklahoma State health department, a study was made of the future dental manpower requirements in Oklahoma. In this study, the anticipated need for dentists was found to be sufficient to justify the addition of dental training facilities to the State educational system. The study technique used in Oklahoma provides a pattern of analysis for other States anticipating future shortages of

dentists. At the request of the Western Interstate Commission for Higher Education, the Division has undertaken a similar study of all the States in the Mountain and Pacific regions. This study is being conducted in collaboration with an advisory committee appointed by the Commission and with the assistance of the W. K. Kellogg Foundation and the American Dental Association.

A survey of the costs to students of attending dental and dental hygiene schools, initiated in fiscal year 1954 in collaboration with the Council on Dental Education of the American Dental Association, is nearing completion. In the final report, a comprehensive analysis of school and living costs will be presented. Another study initiated during the year is being done in collaboration with the American Dental Hygienists' Association and relates to the problems of the distribution and availability in the labor market of dental hygienists. A third project, completed during the year, provides fundamental information on dental manpower by extending projections of future national needs for dentists from 1955 to 1975.

SPECIAL DENTAL STUDIES

As a result of the growth of medical care and hospitalization insurance programs, there has been increasing interest in similar programs for providing dental care on a prepayment basis. Basic data were collected on time and service requirements for patients; also, on the caries attack rate on dental prepayment, pointing up the effect of water fluoridation on such a program. The Division is planning additional studies in this field in the future.

Nursing Resources

The Division of Nursing Resources analyzes the Nation's nursing needs and takes steps to help meet national requirements for nursing service. In the past few years the Division has conducted research. and provided consultation on fundamental studies such as nurse utilization, job satisfaction, and patient care studies.

THE NURSE AND PATIENT NEEDS

A cooperative study was made, with the Commission on Nursing of Cleveland, Ohio, to discover why most hospitals feel their nursing departments are understaffed. Patients, doctors, and nurses were asked to record what they thought was missing in nursing care. The patients felt there was a nursing shortage because of: (1) insufficient explanation of treatments and diagnoses; (2) insufficient thought given to needs of patients and their families; and (3) nurses were

rushed when caring for patients. The results pointed up needs for better utilization of nursing personnel; training to help nurses use time with patients more constructively; and further training of practical nurses and nurses aides. The three hospitals where the first study was made at once began to make the improvements indicated.

STUDY OF NURSING ACTIVITIES

A work-sampling method of analyzing time distribution of nursing activities in general hospitals, originated by the Division in 1953, was used by hospitals in Michigan, Pennsylvania, Louisiana, and elsewhere. In some States, groups of hospitals cooperated in making the studies, through regional institutes or as part of a State survey with the assistance of Division consultants. Hospital administrators and nursing groups then acted to improve staffing of wards and units to permit nurses to spend more time with patients.

New uses were also made of the basic techniques of the work-sampling method of studying nurse utilization. A modification of the method was used in a project at the Northville State Hospital in Michigan to show how better nursing care can be provided for mental patients. In Grand Rapids, Michigan, a private nursing home successfully adapted the method in analyzing its nursing service.

A study of job satisfaction of nursing personnel was initiated during the year. The object is to devise measurements which will correlate the various dimensions of job satisfaction with turnover. If consistent relationships can be established, this will be very important because turnover in hospitals is especially high and costly.

STATES SURVEY NURSING PROBLEMS

Many States continued to conduct State-wide nursing surveys. In at least two States, Pennsylvania and Louisiana, more fundamental studies were conducted, including nurse utilization, job satisfaction, and patient care studies. Two general findings in Pennsylvania were: (1) patients' satisfaction with nursing care was greatest in the hospitals where nurses spent the most time with the patients; and (2) about 75 percent of the professional nurses desire additional education.

Medical Services for Federal Agencies

The Public Health Service has the legal responsibility for providing medical services to certain other Federal agencies. Through the Bureau of Medical Services, medical, dental, psychiatric, and nursing personnel are assigned on a reimbursable basis to those agencies requesting assistance in the operation of medical programs.