often underserved and underrepresented or not served or represented at all-in Federal and State programs which should be serving them and their basic needs.

What good is it, for example, to provide even inadequate medicare benefits to the rural elderly if there are too few physicians, dentists, nurses, physical therapists, audiologists, and long-term care beds to provide the health care the rural elderly need?

Similar questions might be asked about the various programs and services provided for under the Older Americans Act and other Federal programs for the elderly in the areas of information and referral, legal assistance, housing, senior centers, congregate meals programs, and readily available and convenient transportation services.

In most if not all of these, the rural aging and aged have been overlooked and neglected. Part of this, I am sure, is due to the fact that there was no Federal emphasis on this aspect of the aging problem. State agencies on aging and, indeed, area agencies on aging found themselves so caught up in the day-to-day business of establishing new programs and services, trying to work out the meaning of State and Federal mandates and directives, seeking adequate funding for desirable programs, and lacking manpower trained in the field of aging, simply were unable to give adequate attention to the special needs of special groups such as the rural elderly.

DESIGNATING PROBLEM AREAS WITHIN STATES

As I have reported on previous occasions, it is possible to divide various areas of a State-such as counties or planning and service areas on the basis of the general weight of the problems such areas face because of the relative dependency needs of the elderly citizens which make up a portion of their population.

It turns out that what I fondly call high-senescity counties—those with a high proportion of older citizens are essentially in rural areas, while low-senescity counties comprise the urban areas of the State of Iowa.

I was interested, Senator, that among the materials that were distributed this morning was a copy of the Senate hearings you conducted in Washington on April 28, 1975.1 Those of you who are interested will find in that a description of what I just referred to, highsenescity and low-senescity counties, and a map of Iowa shows where those counties are.

The southern two tiers of counties are our most high-senescity counties.

Senator CLARK. Why is that true, if I could just interrupt you 1 second?

Dr. MORRIS. Well, I believe it is essentially true because people are moving out of these counties, particularly young and middle-aged people, and they are the people of child-bearing age. The end result of all this is that the people who are left tend to be those who are older or very, very young. This leaves a proportion of the population in these counties, which is in the range of 20 percent or more, in the age range of 65 and over.

1 Hearing. "The Older Americans Act and the Rural Elderly," U.S. Senate Special Committee on Aging, Washington, D.C., Apr. 28, 1975.

One of the aspects of serving the needs of the elderly in rural areas is related to the density of the population in high-senescity counties in contrast to the population density in low-senescity counties.

Density data are of some interest because, in a gross way, they reflect the relative concentration or dispersion of the people who are entitled to various governmental services. It would be easier, for example, to serve 100 people living within the confines of a single square mile area than it would be to serve 100 people scattered over an area of 50 square miles.

That is all this concept means. The former situation is more characteristic of populated areas such as cities; while the latter are more typical of rural areas.

Relating this to congregate meal sites suggests that it is conceivable that a single nutrition site could easily provide services for 100 elderly people in an urban setting and none would have to travel very far to reach the site.

In the other hand, in a rural setting elderly participants would either have to be transported several miles to reach the site, or more sites would have to be provided so that they would be more accessible to the elderly.

In either case it will be more expensive to mount a satisfactory program in a rural area than it would be in the urban setting. In general, these same factors-senescity, density, and related factors-will operate to effect the establishment of senior centers under title V of the Older Americans Act, just as they are now affecting the congregate meals program under title VII.

ACCESSIBILITY IS KEY FACTOR

Accessibility to services, then, becomes a key factor which must be taken into consideration if those we wish to serve are to receive the services to which they are entitled and for which the programs were designed.

In this connection, it is obvious that one of the most important variables to be considered is to have as you heard from the panel repeatedly this morning-a comprehensive transportation system.

In general, it is safe to say that programs now underway have not been designed to take accessibility to services into consideration when funds are allocated either by the Federal Government to the States, or by the State of Iowa to its constituent area agencies.

Furthermore, it will be difficult to do this at this point in our history without making some basic changes in the policy of both Federal and State governments to recognize the special needs of the rural elderly.

It will be difficult because the area agencies have, for a period of years, become accustomed to their portion of the Older Americans Act and other funds as they have been allocated to them. To change the formula now, without adjustments, will mean taking funds away from some areas in order to make them available to the rural area agencies.

Similarly, if corrections are to be made now in the formula allocating Federal funds to the States to take into account the rural features of some States, it will mean taking funds away from the more urban States.

In addition to the two particular programs mentioned earlier, rural areas differ significantly from urban areas in a number of other important ways. Time does not permit me to discuss all of these this morning, but let me just note a few.

They include a higher percentage of families living below the accepted poverty level, greater severity of poverty, lower population density, fewer primary care physicians, lower accessibility to the services of primary care physicians and dentists, and a less desirable relative health status index.

Finally, it seems to me that what is called for is a truly national policy regarding the provision of programs and services to the rural elderly of our Nation. Such a policy would serve to focus attention on the special situations of the rural elderly, their special needs, the requirement that specially devised progams need to be developed to respond to those needs, and that these programs be specially funded so that State units on aging will be able to respond to the grass-roots requests from the area agencies on aging.

PRESENT DATA UNDER STUDY

Senator Clark, there is much more that needs to be said about the rural elderly. We are beginning to collect relevant data at the University of Iowa and data are available and under study at Iowa State University.

Senator CLAPK. Thank you very much.

I think you have spoken particularly relevantly to the question of accessibility of services because, after all, it may well be that the Federal Government has the service or that the service exists from some other source, but if one cannot get to it, it really does not make much difference.

As you say, the allocation of funds in the past and at the present have not been made on the basis of how difficult it is to deliver those services. I wanted to get your judgment on two or three specific programs that are now being funded, how you think they might be improved, or what your assessment is of these programs in rural areas.

First of all, the question of housing. Is it your judgment that we have an enormous way to go yet in our rural areas in providing the kind of housing that we talked about at the Plaza which I saw this morning? Have we begun to meet the need there, or do you think it has not been reasonably met?

Dr. MORRIS. No, I don't think it is being reasonably met at all. I am delighted that there are programs. I have not seen a recent survey of available housing programs for the elderly in Iowa, and you are going to hear later in this week from Governor Blue who is more expert in the field of housing that I am. He has been interested in this for many years.

I was visiting with Governor Blue just last Friday and one of the things he said to me was, now that he and I are no longer going to be intimately involved on the Commission on Aging, perhaps we and some others could work together toward providing more adequate housing for elderly people throughout the State, with particular emphasis in the smaller towns and cities in the rural areas of the State where housing is, I think, desperately needed.

I think we have a long way to go yet.

Senator CLARK. What about health care in rural areas? What do you see as the greatest need there? What should we be working toward as far as this State is concerned?

Dr. MORRIS. You are going to have an expert in a few minutes. Dr. Fickel will be talking with you about one of the most fascinating programs in the State, and Bruce Brenhold is here from the University of Iowa College of Medicine, and he has been working with Dr. Fickel on these programs.

My personal attitude toward this is that the college of medicine. is working in the right direction toward developing an approach toward a solution to some of these health care delivery problems.

BETTER ORGANIZATION STRESSED

The approach is, in essence, to develop units which will provide a demonstration of how a community can organize itself better-particularly the health care community can organize itself better-to provide care throughout the community and the surrounding area.

I think if the college of medicine can continue to work toward the development of such approaches throughout the State, and if other communities will read the story of the development of a program such as the one you will hear about later in Red Oak, the whole State can lift itself up by the bootstraps.

In essence. that is the story of Iowa. You are also going to be conducting a hearing in Ottumwa. Ottumwa is in an area of 10 counties which incorporated and called themselves Tenco. This was designed to do the same thing for that whole area in general-to pull itself up by the bootstraps-by its own efforts.

This is the kind of thing I look forward to. I think this would do the most good in the health care area, the housing area, and a lot of other areas.

Senator CLARK. Good. We thank you very much, Dr. Morris, and we appreciate your coming down from Iowa City to testify.

Our last panel is going to be made up of Joe Pals, Louise Forsyth, and Dr. Jack Fickel, who has just been referred to.

We are asking each panelist to try to limit their remarks to 4 or 5 minutes so we will have plenty of time for questions. I am hoping, too, that we might end soon enough to get some questions from the audience of the panelists or members of the staff of the committee. First, let's hear from Joe Pals who is the former executive director of MATURA Action Corp. in Orient, Iowa.

STATEMENT OF JOE J. PALS, FORMER EXECUTIVE DIRECTOR OF MATURA ACTION CORP., ORIENT, IOWA

Mr. PALS. Senator Clark, staff, and friends, I have heard it said. that if you are getting a lot of static, you are not tuned in to the right wavelength. So I hope you keep me on the right wavelength this morning.

I am suposed to talk to you this morning about some of the programs that we had at MATURA-winterization and services or programs for elderly, and the future of CSA.

CSA is the national name. MATURA began in Creston, Iowa, April 25, 1966, representing six counties: Madison, Adams, Taylor, Union,

Ringgold, and Adair. At that time we were known as OEO-Office of Economic Opportunity-better known as the poverty program. The words "poverty program," I think, is one of the things that took us out, because it was more or less downgrading, or I have always thought so at least. About a year ago, our name was changed from the Office of Economic Opportunity to Community Services Administration. CSA are the initials we use.

Our primary function or mission is to help people help themselves, by referral to other agencies or into other programs or jobs. Our philosophy from the very beginning was that of cooperation with other agencies, rather than competing. Having worked in public works a good many years before I came with MATURA, it was my thinking that the only way we could accomplish anything was to work with other agencies rather than to try to compete. A new agency coming into the community, I think, probably made some of the other agencies wonder. "What are they going to do? Are they going to be taking part in what we are doing?" There were some agencies that were somewhat apprehensive about what part we would play within the community. It has been a long road. How did we build it? I am going to talk a little about linkages for just a moment. What do we mean by linkage and linking the programs together? For example, at the Corning Center, the county board of supervisors and the AAA-the area agency on aging-bought an old school bus. We at MATURA furnished the money for the gas and oil and the part-time driver to operate the bus. So you see, you have three various entities there. You have three agencies operating together or working together to provide a service within that community.

Then what was the service for? The service was for transportation. Again we have transportation coming up, and I am sure, from what all the others have said, that we are pointing out the need here for transportation. We served approximately 45 people from towns like Carbon, Mount Etna, Brooks, Nodaway, and Prescott. These people were picked up in the rural areas and brought into different towns to buy groceries, to see the doctor, or whatever services they might need.

Besides that, there were approximately 35 people picked up within the town of Corning that were taken to the meal site within Corning itself by this same bus. MATURA also furnishes a driver and pays mileage for the car that the driver uses. The driver-in this case it happens to be a lady-uses her own personal car. She is paid mileage for this. We have transportation from Bedford and Lennox to take people to Clarinda, Maryville, Grant City, Creston, and Corning.

FEW MEDICAL FACILITIES IN AREA

This is mainly for medical and dental care. This is pointing out what Dr. Morris said a little bit ago, medical care being what it is now. We are thinking in terms of the number of doctors in the area-there aren't many. In all of these small towns, there are just no medical facilities, so somebody has to see that people get somewhere so that they can be taken care of.

Again, we are pointing out that transportation is a very, very vital thing in the area, and so is medical care. As Dr. Morris said, social security is not keeping pace. These people out there are below the poverty line at the present time, and they are underserved; some are not served at all. I think that was a statement that was very well put.