proud tradition. It has made outstanding contributions to the health of our Nation. It now has an opportunity, through this legislation, to make perhaps its most significant contribution.

Mr. Chairman, the Commissioned Corps has withstood attacks and attempts to phase it out or abolish it. Though the attacks have not been successful to date, the morale of the PHS is at a low ebb. This legislation would strengthen and revitalize the Commissioned Corps at a time when it sorely needs it. Many young commissioned officers are disenchanted with the Public Health Service because they cannot relate their own goals and objectives with any stated goals, objectives, or plans of the Public Health Service.

They are confused as to what the long-range policies are for the Federal health establishment. They recognize a number of national health needs, but are unsure whether the Federal Government plans to involve itself in these areas, and if there is Federal involvement, they are uncertain as to what their role is.

S. 4106 would enable these young officers to fulfill a deep social commitment and at the same time provide an incentive to retain these men as career officers.

Mr. Chairman, we hope that the committee will consider this legis lation favorably, and I wish to express my thanks to the members of this subcommittee for the opportunity to present testimony.

The CHAIRMAN. I have instructed the staff, Mr. Lucca, while this hearing is going on, to put this bill as a crash program at the top of the legislative calendar for health; because time is so short for the session we must give it every possible thrust in trying to pass it.

I am directing the staff to make note of the four points on page 3, the recommendations made for changes in the bill. I know I agree with two of them, and the other two I just need more information on, but the two I am positive I am for, and one of those is provision 3, to increase funding in 1972 and 1973. We should raise the sum.

On this question of morale, Mr. Lucca, I want to direct your attention to Public Law 91-253, signed into law May 14, 1970. My bill, S. 2452, was to amend section 211 of the PHS Act to equalize the retirement benefits for the commissioned officers of the PHS with the retirement benefits provided for other officers in the uniformed services. We did pass that. That is so their retirement would not be less. Mr. LUCCA. You did, and that did do a great deal for morale.

The CHAIRMAN. Retirement alone is not the main factor in life; what a man does during his working life is more important. But retirement is important, and he should not be discriminated against by being downgraded.

Mr. LUCCA. The Commissioned Corps greatly appreciates your efforts.

The CHAIRMAN. On the question of morale and what the Corps has done in the way of its great work, I can only think about when the Public Health Service first was set up in 1798, wasn't it?

Mr. LUCCA. Yes sir, in 1798.

The CHAIRMAN. 1798. Is that when the seaman's hospital first opened? This was under the Maritime Department.

Mr. LUCCA. Yes, I believe that is right.

The CHAIRMAN. Sometime in the 1790's, under our early Government, as contrasted with our present Government and this present

situation. Now, our Government was less than 10 years old when this PHS was set up, wasn't it?

Mr. LUCCA. Yes.

The CHAIRMAN. I hope this generation will have as much judgment about saving this Service as that generation did in creating it. Thank you for your contribution.

Mr. LUCCA. Thank you.

The CHAIRMAN. Our next witness is Dr. Robert L. Nolan, division of preventive medicine, Medical School of West Virginia University, Morgantown, W. Va.

Dr. Nolan, we welcome you here, and in my 13 years on this Health Subcommittee and 13 years on the Education Subcommittee I have marveled time and time again about the witnesses of West Virginia who have made such great contributions in the fields of both health and education.

Here is a State, not large in area and population, and not reputed to be one of the wealthiest in the Nation, yet time after time in health and education laws they have made one of the major contributions of the States. I recall my own long, hard fight to pass the GI bill, and even students in West Virginia gave us more aid than those of any other State in the Union.

So I welcome you from the great State which you represent, great in terms of input to better health and education legislation in the country.

Thank you, Doctor, and proceed in your own way.

STATEMENT OF DR. ROBERT L. NOLAN, DIVISION OF PREVENTIVE MEDICINE, MEDICAL SCHOOL OF WEST VIRGINIA UNIVERSITY, MORGANTOWN, W. VA.

Dr. NOLAN. Thank you very much, Senator.

I want to express my appreciation to you for the leadership you have personally given us who are struggling with others to help improve the health services that this subcommittee and full committee have provided.

I am Robert L. Nolan, M.D., of Morgantown, W. Va., where I am serving as professor and chairman of the division of public health and preventive medicine and professor of pediatrics at West Virginia University School of Medicine. It is a pleasure to have this opportunity to present my individual views on S. 4106, the proposed National Health Service Corps Act of 1970.

In connection with these views I have also submitted appendixes giving information concerning health conditions in the State of West Virginia, which, with the consent of the chairman, might be included in association with the testimony, if that is agreeable.

My reaction is based upon 17 years combined experience as a pediatrician-formerly with the Kaiser-Permanente program in Oakland, Calif.-local public official, and medical school professor in both urban and rural settings.

In West Virginia and other States S. 4106 could significantly contribute to the alleviation of current health needs.

This State is the only one situated entirely within the Appalachian mountains, with the variety of regional and economic problems well

known to the subcommittee. Almost 60 percent of West Virginia population is dispersed in rural areas, many living in relatively isolated hollows, without access to health and medical services.

I would like to offer for the chairman's brief review these relief maps prepared by the Army Map Service, which illustrate the isolation of some of our mountain areas and which are factors in the health problems in those regions.

The CHAIRMAN. Let me say that in one year I flew to Texas and back 60 times. Generally, unless the weather is bad, the flights are practically always over your State. I doubt that anyone else has looked down on the West Virginia area as much in the past 15 years as I have, except professional airline pilots, machinists and hostesses, and people who live in West Virginia.

As I look down at the mountains and those hollows, I often wondered how people get back in the hollows. So you are talking to someone who has gazed down on your State many times.

Dr. NOLAN. Yes, thank you, Senator.

We are very appreciative that you are expressing your concern about our health problems through this legislation and the other bills you have supported.

I want to emphasize that the facilities that we take for granted in more affluent regions are simply nonexistent. There is a severe shortage of physicians and nurses in these rural areas; in some counties there are no practicing physicians or nursing personnel available.

The State's own health task force report in 1967 (see appendix A) noted:

(1) that there were only 96 medical doctors per 100,000 population, compared with a national average of 142 per 100,000. Furthermore, an undetermined number of these physicians, average age 53 years, were not in full-time practice.

In the last 10 years approximately 60 communities with populations of less than 10,000 have been left without physicians as rural practitioners retired and were not replaced. In 13 counties there was only one physician for four times the patient population recommended by the American Medical Association (one per 700), and in six counties the population load for physicians was six times the recommended ratio.

(2) Although it was estimated that the State needed 720 public health nurses, there were only 136 so identified, or one-sixteenth of the need, and even this data is incorrect because only a couple of dozen or less of those 136 were actually trained as public health

nurses;

(3) 32.6 percent of West Virginia families had total incomes of less than $3,000 per year. This represented 150,637 families. Only 44,193 families of this group were receiving welfare assistance. Assistance payments based on 52 percent of need determined in the early sixties. The rest had to fend for themselves and had no organized support for medical care;

(4) Local county health departments in the remote areas typically do not have a full-time health officer and have to rely upon an already overworked local physician for part-time service. Programs and services in such departments are very limited and rarely are able to make a significant impact upon unmet individual health needs;

(5) 120,000 homes were found to be without adequate water and sewage services essential for health;

(6) 375,000 homes (521,142 total in State) disposed of solid waste in such a manner as to create a nuisance and public health hazard; (7) No adequate public transportation in rural areas for either ordinary or emergency medical care was observed.

These and related conditions have their expression in:

(a) Higher maternal death rates: one-third of the 1,343 maternal deaths in the United States per year occurred in rural areas and small towns.

(b) Higher rates of disability and death from accidents (30 to 40 percent).

(c) Higher infant mortality rates in rural areas, one-third higher. (d) Longer periods of disability and hospitalization for specific illnesses.

On pages 2a and 2b of my statement there is some information about a typical West Virginia rural county which illustrates some of the problems.

(The information referred to follows:)

STATISTICS ON A TYPICAL WEST VIRGINIA RURAL COUNTY

Location in West Virginia-North Central.

Population: Preliminary 1970 census, 24,768; 1960 census, 27,233.

PER CAPITA GOVERNMENTAL EXPENDITURES FOR HEALTH CONTRASTING RURAL WEST VIRGINIA WITH URBAN WASHINGTON, D.C.

West Virginia-Combined expenditures of the Departments of Health, Welfare, and Mental Health, 1969-70 Fiscal Year

41,000,000 over 1,700,000 equals $24.12 West Virginia per capita. District of Columbia Department of Public Health, 1969-70: 89,000,000 over 800,000 equals $111.25 District of Columbia per capita.

Dr. NOLAN. I would perhaps call your special attention to the per capita personal income which in 1965 was only $1,271 and the median family income only $3,214 in 1960, and percent of families over $3,000 income was in the minority, only 46.4 percent.

Note also, gentlemen, that the median school years completed in that county were only 8.6 and that only 25.7 completed high school or more educational training.

Our physician-patient ratio at the time of survey, approximately 68, was 1 to 1,885, and since that time we have lost additional physicians in that county and one physician serves approximately 3,500 people now.

Although there were 54 hospital beds in that county, many of them could not be used because there were no health personnel to take care of the individual needs.

Further, at the bottom of page 2b is summarized some of the comparisons between the State of West Virginia per capita expenditures for health, mental health, and welfare departments, which was approximately $24 per person, and a comparison with similar services for the District of Columbia Department of Public Health, which was approximately $111 per person, or 41/2 times the ratio.

In surveys conducted locally by physicians in our division, for example, appendix C, there has been well-documented inadequate housing, absence of water, lack of preventive medical services, and a variety of untreated medical conditions ranging from parasitism to heart disease.

But none of this data, however impressive, tells how the coal in these mountains is generating the power for the light in this room and that in extracting that coal we have robbed a man and his family of his water supply, destroyed some of the most beautiful hills in the world, permanently polluted streams and rivers and left a trail of human misery as a heritage for young children.

In these areas we have made equal opportunity a cruel joke, have crowded children and their families into tiny shacks unfit for human habitation and condemned another generation to a way of life without hope, without adequate food, education, or basic health resources. Despite the fact that these problems have been well-known and documented for decades, there is at present no Federal program that has a specific responsibility or authority to provide personnel for relief of such rural health problems. Local resources have not been and are not able to provide the needed services.