Dr. MOUNTIN. I recognize fully that the title of this bill which has aroused greatest interest and controversy, and which is most important from the standpoint of its social implications and the money involved, is title II, Prepaid Personal Health Service Benefits.

However, I hope that we shall not overlook certain other features of the bill which are complementary to title II. In themselves they are quite important; they are also necessary to complete the program. For example, let us consider Title I, Part A, Grants to States for Public Health Services. This section in a sense amplifies what is now going on. For a number of years the United States Public Health Service has administered financial grants and has otherwise cooperated with States and localities to establish and improve public health departments. These departments now exist primarily for the purpose of giving the fullest possible application to preventive measures. Under the proposed act, they would serve another very important purpose-that is, they would furnish a framework of organization through which other parts of the health program would operate.

Title II of S. 1606 expresses a distinct preference for the utilization of State and local governmental agencies in carrying out the personal health service benefits of the bill. In other words, State and local health agencies would constitute the administrative machinery. But first we need to perfect that machinery.

At the present moment, that machine is far from satisfactory About one-third of the counties are without local full-time health organizations under the direction of competent medical authority This is an obvious defect and should be corrected. Perhaps, not every county would need a full-time health officer of its own-some of them are sparsely populated, or are low in economic resources. Such coun

of

ties might be combined into districts that would represent a more substantial base on which to build the type of structure that is needed for giving full application to preventive measures and for administering a medical care program of the magnitude that is proposed. Much of the gain we have already made in lengthening the span life has been due to the prevention of diseases such as typhoid fever, diphtheria, malaria, and in reducing infant mortality. All such gains need to be maintained. Here I should sound a note of warning. Even though these conditions have been brought under control, they can arise again and they very definitely will if the controls are relaxed. Many European countries before the war, for example, had reached a very high state of sanitation and were practically free of typhoid fever. With the break-down of sanitation and community organizations, typhoid fever has reappeared. Under a similar breakdown in sanitation, I am sure the same situation would quickly occur in this country, because the causative organisms have not been completely eliminated. Malignant diphtheria also has become a great problem in Europe and tuberculosis has taken on epidemic proportions.

We have protected our people; we have reduced the chances of infection, but once protective measures are relaxed, the same conditions will arise again, and then we will have not alone the burden of ordinary illness which I shall describe in a moment, but many preventable conditions also. For humanity's sake and for the purpose of cutting down the costs of this program, we need to expand and to utilize prevention to the utmost.

So, you see, this feature of the bill-public health services-very definitely should not be overlooked. Since other who come to testify may fail to stress prevention, because of their interest in medical care, I am perhaps spending more time on that section than I otherwise would.

There is one new feature in the public health section of the bill that I might mention. At present, Federal grants-in-aid are given under a variety of formulas. Congress may appropriate sums of money which varies from year to year, fortunately these have been gradually increasing, and these sums in turn are parcelled out to the States in accordance with criteria specified in the statutes.

This bill goes much further than that. It recognizes a continuing partnership between the Federal Government, the States and the localities, and it establishes a single matching ratio. In other words, the Federal Government will go along with the States on their expenditures within the matching range described in the bill. That is a very important feature of the bill, and I shall be glad to discuss it further if you wish.

PROPOSED AMENDMENT

The other point that I would make regarding title 1, part A, is in the nature of an amendment. The bill, as it is now written, limits public health services to the ordinary preventive work of health departments, health education and other activities commonly spoken of as community-wide services. We would recommend that that definition be expanded so as to include the support of hospitals for chronic diseases, especially tuberculosis and mental disorders.

These conditions are excluded, or virtually so, from the benefits under title II of the bill. There are sound administrative reasons for

such exclusion, but this leaves programs for the care of these conditions without any Federal support.

Senator AIKEN. They are not covered under other legislation. Mr. MOUNTIN. Partially so, but only in a general way. There is in our present Tuberculosis Control Act a provision whereby tuberculosis sanatoria could be aided. The sums appropriated, however. are only sufficient to carry on case-finding and general preventive

work.

Senator AIKEN. If it appeared that this bill would not be enacted into law, would you favor existing legislation to cover the situations which you have just presented to us?

Dr. MOUNTIN. Tuberculosis hospitalization could be covered under existing law, but I would question whether we could include grants for mental hospitals under existing authority. A mental health bill has passed the House, but that features research training of personnel and community clinics in the interest of mental hygiene.

Senator AIKEN. You mean the bill that we have already had hear ings on before this committee?

Dr. MOUNTIN. Yes, aid to mental hospitals, perhaps, could be handled by it but some clarification or even amplification of the intent of the bill very likely would be necessary. There is a very definite need for bringing the Federal Government into the whole chronic disease field on a broad base. Now, the States are required to support these institutions themselves. There is wide variation among the States, in the extent to which they have developed these institutions. That variation is determined directly by their economic resources. That is true of mental and tuberculosis hospitals as it is of other aspects of medical care.

The second part of title I, part B, provides grants to States for the support of maternal and child health services. It is my understanding that representatives of the Children's Bureau will give testimony later on this phase of public health work, and I shall not go into it in any detail.

RELATION BETWEEN ADMINISTRATIVE AGENCIES

There are, however, certain administrative aspects of part B on which I should like to express the point of view of the Public Health Service.

Yesterday, you will recall, Senator Pepper introduced certain amendments which would more closely integrate maternal and child health work with various parts of this bill. The proposed amendments also would incorporate into S. 1606 some of the features of the bill which he had introduced for maternal and child health services, S. 1318.

The point I wish to make and to stress is the essential unity of all public health work which should be maintained at Federal, State and local levels. This essential unity should include financial support, administration, and the actual delivery of services.

At the present time, we have the anomaly of two important health agencies set up in different departments of the Government, the Children's Bureau in the Department of Labor and the Public Health Service in the Federal Security Agency.

Perhaps that separation has not been so important in the past because the sums of money, at the disposal of each agency were not

large, and in any event the funds were brought together at the State and local levels. But now, much larger sums are proposed, together with great expansion in the scope of service. The need which has existed previously for closer integration will be increased many times. I understand that governmental reorganization is now being considered by the President. Perhaps this is not the occasion upon which to discuss the details of reorganization, since it is not part of this legislation.

However, I trust I am not out of order in saying we hope that this committee will consider provisions for integration in any redraft of the bill, so as to bring about unified administration of all Federal health services under a common over-all authority.

There is no question about the need for expansion of maternal and child health programs. This also applies to other special phases of public health work-such as programs in the fields of venereal disease, tuberculosis, cancer, geriatrics and mental hygiene. In other words, there will be certain phases of the general program at different stages of its evolution which will need to be sharpened up and brought into closer focus through specialized programs. All specialized programs, however, should operate within the same general framework of organization.

Senator AIKEN. This may not be the time and the place, as you said, Doctor, but do you think that health, security, and education are closely related so that they could well be administered under the same head, or maybe you still think that this is not the time and place to answer that.

Dr. MOUNTIN. Some phases of education have little or no relation to health, while others are closely identified with it. Senator AIKEN. You have got medical inspect` in the school, and dental correction, which you can hardly separate fron education. Dr. MOUNTIN. I would hope that when this bill is enacted, school medical services would be brought into the general scheme of health organization, since they constitute a medical service to a particular age group, and are commonly administered by health departments. I might say, too, Senator, that the need for developing these services in the educational framework has largely risen out of past neglect by health agencies. Educational departments, quite appropriately, stepped into the breach and have endeavored to make up for the deficiencies in the health organization. This whole program has been deficient in that there are few provisions for doing much about defects of childhood after they are discovered-no follow through to cor

rection.

I think that as we develop and piece out those deficiencies, the need for education in the administrative picture will lessen.

However, there is another phase of health in which cooperation between health and educational authorities is needed very much, and that is health education. A large part of that very definitely should be carried out through the framework and under the administration of school authorities. Also supplementary feeding through school lunches and that sort of thing, obviously, is more closely identified with education from a functional standpoint.

Senator AIKEN. We know that when a child has good health and good eyesight, that the work of the truant officer is cut down, and the work of the sheriff is probably cut down in later years.