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As I ponder this crisis in health care to which Senator Magnuson referred, I firmly believe that medical education, itself, including the internship and residency training years, has without intent been productive of the untenable health care predicament in which we find ourselves today. During the desirable and healthy evolution of medical education, with its concommitment, miraculous scientific discoveries and breakthroughs resulting from the scientific discipline and scientific research, important integral components of the health care delivery system were overlooked or forgotten.

It follows as naturally as day follows night that this rapid increase of scientific knowledge and excellence of medical education should be productive of medical specialization and subspecialization. It also normally follows that specialization would be productive of departmentalization and fragmentation of medical education, which also carries over into internship and residency training years. As specialization and fragmentation of medical knowledge became the order of the day, "generalization" of broad-spectrum medical knowledge as it applies to the whole man was lost sight of. Perhaps it is a reasonable analogy to say that in 1900, medical education was productive of scientific medical morons, while today, 1970, 70 years later, medical education is productive of scientific medical spastics. There may be reason to take a hard look at the relative potential for health care productivity of each.

Could it be that current medical education systems have produced our present physician maldistribution problems? Has medical education been so refined and fragmented that its major product-medical specialists and subspecialists can only function and service in large and sophisticated medical centers? When, if ever, has medical education in general or any medical school in particular evaluated its annual productivity, the various members and assortments of specialists which are produced, to see how this output meets the health manpower needs of our communities, our cities, our States, or our Nation? Actually, as yet, is there any substantive evidence that our present process of educating physicians and ancillary health personnel really understands the urgent need for large numbers of broadly-trained family physicians or general practitioners, physicians' assistants, nurse practitioners, and so forth? Are these educators aware of the need to provide for all the people of our country ready access to primary health care, and to have someone available with whom each family and community of families can identify as their own personal advocate for their health needs?

This bill originally will ask for funding up to $5 million and, as Senator Magnuson says, "Fewer than a dozen communities across the Nation will receive care from Corps members." Yet, if this concept with its relatively insignificant funding is implemented, and carefully nurtured as it grows by the competent health professionals who even yet exist in our Public Health Service, it may well come to be our most productive health care delivery system experiment of recent times. This experiment could, in a practical manner, identify for our future benefit the proper mix of specialists, generalists, assistants, nurses, and other necessary personnel needed to provide adequate health maintenance and medical care for all patterns of communities throughout our Nation.

Knowledge and experience gained through excellent Public Health Service guidance of this Corps effort could reasonably be expected to provide new and more productive concepts for the education and assembling of health and medical care teams to move into and remain in any identifiable community of need.

It is largely by chance now that physicians decide to locate in this community or that city to do their lifetime of practice. I know of no meaningful nor effective effort at a regional, State, or national level to identify systematically at a community level, large or small, the relative number of health professionals of specifically identified skills required to provide adequate care for each community. The need for the proper mix of professionals and special skills to match the realistic needs of the community involved is of much too vital importance to be left to chance alone. With proper guidance, this Public Health Service project could begin to cut meaningful patterns leading to the implementation of this concept of efficient planning to meet the needs of identifiable communities. Conceivably, then, medical education, including the education of ancillary medical personnel, could be altered to develop know-how and ability to put together predetermined patterns of teams to meet specific area needs.

There is much of potential productivity to be identified with this bill.

The one other facet of S. 4106 upon which I want to dwell briefly deals with the involvement of the U.S. Public Health Service as the responsible Federal health related agency charged with implementation of this bill. Those who thought this bill through and structured it properly for introduction to both Houses of the Congress of the United States demonstrated keen insight and wisdom when they selected that this act be set up within the Public Health Service. That Senator Magnuson and those able Senators who, with him, support this bill specifically spoke at some length to their interest in revitalizing the Public Health Service and the Commissioned Officer Corps, I believe will prove to be the proper motivating impetus to start the return of the Public Health Service to its proper stature of leadership among health affiliated Federal agencies.

During my 37 years of medical practice at one time or another, I have served as a member or, or in an advisory capacity to, many of the councils and committees of essentially all of the Federal bureaus and departments which were or are concerned with the provision of health care for our American people. In my younger days, the U.S. Public Health Service, under the direction of one of several able and distinguished Americans privileged to become Surgeon General of the U.S. Public Health Service, was the able guardian of the health status of all Americans. Such distinguished Surgeons General as Dr. Leroy Burney and Dr. Luther Terry, along with innumerable subordinate officers and members of the Commissioned Corps, took pride in spending a major portion of their productive lives in continuity, working with and for the American people to maintain and retain a progressively higher level of health and physical fitness. No one questioned then, nor questions now, that these devoted professionals performed at the highest level of excellence.

However, a few years ago in the course of events, some of which were both normal and abnormal, the U.S. Public Health Service came upon

lean years. With the advent of bureaus and bureaucracies-with the advent of high-level, politically oriented advisory councils and task forces, those who were committed to a life work in continuity involved with health maintenance and care for Americans, regardless of the political perspective of the administration in power, came on hard days. Health care and medical affairs became the concern of established bureaucracies. Top echelon bureaucrats at an appointive level became pawns of the whims of vested interests and powerful organizations. It followed logically that the high-visibility bureaucrats at a subappointive level must please and appease their appointed bosses if they were to retain their prestige and place in the sun. Somewhere in this "rat race," about 3 years ago, it was decided, at a high level of bureaucracy, that the U.S. Public Health Service was outdated and obsolete, and should be abolished-so systematically since then, the Public Health Service has been picked to pieces and emasculated. As a result of this unfavorable trend, those dedicated career officers, for whom it was personally and professionally rewarding, have left the service. Due to the Doctor Draft, little talent of any consequence has since come on board. Those, as an aside, that do come on board, are young students and many of them are very knowledgeable and very productive, but they come for only a 2-year stint and then pass

on.

Meanwhile, much of health planning and management in the past few years has been done, to a considerable extent, by those who could hope for little continuity of service and who are or were both personality-oriented and politically expendable. The atmosphere has been nonconducive to long-term, efficient and effective leadership. Perhaps herein are to be found reasons for our somewhat-less-than-desirable or acceptable health care delivery system at the present time.

In conclusion, let me express my approval of, and appreciation for, the apparent sincere intent of those top level Members of the Congress who support this bill to start a revitalization program which can restore the U.S. Public Health Service to its proper place in health leadership-unlike those personality oriented bureaucrats who are here today and gone tomorrow and who have "no pride in past ancestry or hope for future posterity."

Members of the Commissioned Corps of Public Health Service are available and accountable for the results of their decisions and leadership. At all times, they take pride in their success and are humiliated by their failures. Of necessity, their motivations for excellence of productivity and effectiveness have to be of the highest magnitude. I salute with reassurance the revitalization of the U.S. Public Health Service.

Again may I say I support S. 4106 in its entirety.

Thank you, Senator, for allowing me to appear before your distinguished committee.

The CHAIRMAN. Dr. Johnson, just one moment. This is a very informative statement. Since I have been chairman of this committee for the past 2 years, I have been interested in why the Bureau of the Budget was trying to emasculate the PHS, close the PHS hospitals and destroy them as you described here.

I have had people tell me-I am not at liberty to use the namesbut I have knowledge that it didn't start with the Bureau of the

Budget; they are being encouraged to do it by the bureaucrats in HEW.

What I am concerned with is saving the Service. You have given us a helpful and enlightening statement here. I find in you someone that knows the score, and I would like to receive a little more information from you to try to help me to save this great Service.

As you point out, in the past it has been a guardian against yellow fever because of the way they quarantine the ports. So the PHS has been the guardian of the American people for a long time. It provided us with innoculation against typhoid and against pellegra in the South, and against the hookworm of the South; all of these great things the PHS has done.

What we need is cumulative implementation of the best that has been developed. Here the PHS, one of the greatest things we have had in the country, is being cut to pieces. You described it better than I have seen it in my 2 years; you have told us "how" and "why." This is a great contribution in additional support of this bill on a much broader subject, and I thank you for what you have done to help the American people over the years.

Dr. JOHNSON. Senator, I sat by real closely watching this whole business develop just as you have said. The bureaucrats who came and went with the various administrations and with the various surges of different administrations who were in for a few months at a time. In high places, you see, the appointive bureaucrats have the power over those who are career people under them. I have seen this decision, I can almost stake it out as to who was on the fifth floor of HEW when this happened, and how it grew and how the word was passed down, that the Public Health Service is obsolete, that "it is a bit of a threat to our efforts as bureaucrats here representing certain administrations to handle the health problems of this country." These people were coming and going, and this reminds me of when I was a younger man, I played professional baseball-I belonged to the Pittsburgh organization, but I was on one of their farm clubsand we used to say we had three teams. Somebody would ask, "How is that?" And we would say, "We got one coming, we have one here playing, and we have one going," and we were rotating all the time, you know.

And that is what has been happening for the past several years with our health care effort in this country, and it is no wonder that we find ourselves in this sad state of disrepair, because there is no continuity of responsibility for the productivity of our efforts.

The CHAIRMAN. Well, I think this is beyond this mere bill. What you just said may well be one of the greatest contributions made here. I would like to confer with you further about this. How long will you be in the city today, Doctor?

Dr. JOHNSON. As long as you would like me to, sir.

The CHAIRMAN. I will have one of the staff members talk to you immeidately. However, due to the number of witnesses I will not go into it further, but we need to explore how to revitalize the PHS of the United States.

I have offered one bill this year and have been able to push it along to give them the same status in retirement that the officers in the health

field in the armed services get. Even in retirement PHS officers were not getting an equal break. We will push that bill. But it is miniscule compared to the broad problem of authority for the PHS.

Dr. JOHNSON. I have one other comment I would like to make. I think if this bill is passed and implemented, that administratively it must go through the same channels during its inception as do other health projects. I think that it would have to be under the direct responsibility of the Secretary of Health, Education, and Welfare and from there down to the United States Public Health Corps.

The CHAIRMAN. And in that progression downward our problem is that it not become "down and out."

Thank you, Doctor.

Dr. JOHNSON. Thank you, Senator Yarborough.

The CHAIRMAN. The next witness is Dr. James R. Kimmey, New York, executive director of The American Public Health Association. Please proceed, Dr. Kimmey.

STATEMENT OF DR. JAMES R. KIMMEY, EXECUTIVE DIRECTOR, THE AMERICAN PUBLIC HEALTH ASSOCIATION, NEW YORK

Dr. KIMMEY. Thank you, Mr. Chairman.

I am Dr. James R. Kimmey, executive director of The American Public Health Association. I have a prepared statement which I would like to submit for the record, and summarize it for you. I know that time is moving along.

The CHAIRMAN. Yes, it is, and I know that the people here come from different States which are far away, people who have not yet been heard, and some of them may wish to catch a plane. I appreciate your thoughtfulness in this regard, Dr. Kimmey, and I will order your entire statement printed in full at this point in the record, and you may summarize it as you see fit.

(Dr. Kimmey's prepared statement follows:)

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