Although this fiscal year Federal health expenditures are expected to reach $20.6 billion, depending upon the administration's willingness to spend the money Congress appropriated, I have been told without this proposed act, S. 4106, no funds can be expended for the needed services of the proposed statute.

In the past year I have gone from one Federal branch to another within the Department of Health, Education, and Welfare without being able to get any support for basic health services in our isolated mountain regions.

In March and April of this year I had the privilege of participating in a study of migrant health conditions which included my own visits to southwest Texas and southern Florida, supported by the Field Foundation. The testimony of my colleagues who worked with the Field Foundation, with which I completely agree, was presented before your Subcommittee on Migratory Labor on July 20, 1970.

I personally saw the adverse conditions for migrant families in these areas of Texas and Florida that were similar to those in the most depressed areas of Appalachia. This proposed act could also make a substantial contribution to alleviating the health problems of this severely disadvantaged group of migrant families.

Even in relatively affluent California where I practiced for 12 years, large numbers of urban families in segregated areas were functionally isolated from needed health and medical services.

In none of the areas involved, rural Appalachia, seasonal agricultural regions, or segregated urban areas has it been possible heretofore to influence sufficient physicians, dentists, nurses, and other health personnel to settle. S. 4106 is needed to help relieve this disparity of distribution.

In such areas innovative approaches including physician assistant programs, and new health delivery systems have been impaired in development by the absence of a nuclei of professionals with whom new methods could be developed.

I would like at this point to call attention of the subcommittee to the report of the President's National Advisory Commission on Rural Poverty issued in September 1967, entitled, "The People Left Behind,' and draw specific attention to its recommendation No. 4, printed on page 69, which states: "The Commission recommends that a National Rural Health Corps of trained volunteer health personnel be established to work in rural areas with serious health needs."

I would hope that the fact that that report was issued under a preceding administration would not cause its work to be forgotten. In summary, I am in support of this proposal, S. 4106, since its provisions offer an important step in the direction of

1. Meeting serious current health needs of disadvantaged residents in both rural and urban areas;

2. Providing experience in the development of new health delivery techniques;

3. Permit the more efficient use of existing facilities;

4. Enhance the regionalization of health services;

5. Reducing hospitalizations and unnecessary costs by making prevention of illness and early treatment possible for isolated families;

6. Relieving the burdens of many dedicated overworked physicians still in practice in the understaffed areas; and

7. Demonstrate to our young people the commitment and relevance of a Government that does care about its citizens and their health.

If we really believe in a national goal of effective and dignified health care for every American, no matter what his station in life or where he lives, then S. 4106 could move us in that direction.

The only major qualification that I would offer is that the effectiveness of S. 4106 and the achievement of its goals will require more funds than the proposed $5 million per year. I hope the committee will consider at least a $20 million annual expenditure for this program no later than the second or third year of operation.

In addition, there is one technical question I would like to call to the chairman's attention in regard to section proposed 3991(c)(3)(b) with regard to the functions of the council that would be created by this proposed act. In (b) reference is made to taking into consideration the willingness of the community or area and the appropriate governmental agencies therein to assist and cooperate with the corps in providing effective health services throughout the community or

area.

I would like to suggest that that be modified to add after the word "governmental" the words "and private" so that private groups and agencies that have interests and concerns including consumer groups as well as professional groups, could be taken into consideration in the same way as formal governmental agencies.

Thank you very much for this opportunity.

The CHAIRMAN. Well, thank you very much, Doctor, for your very knowledgeable contribution, being based not only on your experience in West Virginia, but California and Texas and other areas.

I raise a question about your proposed amendment to subparagraph (b) of subparagraph (3) of subparagraph (c) of section 3991, which is line 23, page 5, of the bill.

Do you have the bill before you?

Dr. NOLAN. I do.

The CHAIRMAN. "The appropriate governmental and private agencies."

Do you mean if there is a private hospital there, perhaps there is no doctor there? By urging of health care to the American people, some people got an idea I am opposed to the medical profession, and of course I am not. They are the people we rely on to get the health care to the people.

I just want to expand it. I want more people to be a part of this health profession and this great expert medical expertise, so we do not stint the people.

One time when I first returned from overseas service as a staff officer within a division in World War II, I was employed by the Medical Association of Texas to draft certain legislation and present it, and got it passed.

I had two different bills. While working on those, I learned that at that time, right after World War II, we had 254 counties in Texas and 26 counties without a single medical doctor.

Some of the cases that were mentioned in here by Dr. Bergman, and others, out in Alaska or in the hollows of West Virginia, some of these would not be considered rural communities in Texas, with an impediment to a doctor going there, because most of Texasand my fellow Texans might not appreciate it-most of Texas is relatively flat. You get in your car and the difficulty is that it is so flat and you can see so far, you have difficulty in trying to hold your automobile down to some reasonably safe speed above the legal speed limit.

If you get up over 100 miles an hour on this one site, the policemen will stop you. You can roll out and roll 100 miles or 200 miles to a football game Saturday night, with little difficulty because the roads are so flat in the country, with a good road system.

I think the highway system is one of the best in the Union, though our public health pushes down to 40th, and education about 32d-we have done a lot more for the concrete than for the people. We have excellent highways.

So we do not have the isolation in Texas as you have it in many of the rural communities, yet we have difficulties of getting a doctor to go to a rural county or town.

The data you have are most interesting, and you present a typical county. The collective data would be about representative of a rural county in Texas.

We have two of the 10 biggest cities in the Nation, three of the 15 biggest cities, we have 20 percent of all of the 10 or 15 biggest cities in this Nation, whatever number you want to take. Yet our rural counties are losing population, and as is true of the whole Nation, over 60 percent of the counties lost population in 1940 to 1950, over 60 percent lost population from 1950 to 1960, and in the preliminary figures 1960 to 1970, we have about 80 counties gaining in population, with about 170 losing in population, so the number of counties losing population is increasing.

I think one of the amenities of real living itself is having medical care. I don't think the growing imbalance of the population, favoring a few great cities, presents any sociological or economic reason for optimism here. I think the worst imbalance comes in a concentration of population.

Thank you very much for this very informative paper. Thank you very much, and as for your recommendation for greater funding and other recommendations, I direct the staff that every recommendation for amendment is to be carefully considered.

The CHAIRMAN. The next witness is Dr. Robert Shannon, vice president, Student American Medical Association.

STATEMENT OF DR. ROBERT M. SHANNON, VICE PRESIDENT, THE STUDENT AMERICAN MEDICAL ASSOCIATION

Dr. SHANNON. Mr. Chairman, it is a great pleasure to be here before your committee.

I am Robert M. Shannon, a fourth-year medical student at the University of Maryland Medical School. I am appearing before you today in my capacity as vice president of the Student American Medical

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Association, which represents more than 24,000 medical students, and 36,000 interns and residents.

For many years, the concept of the National Health Service Corps has received wide support from young professionals in medicine. Each year since 1965, the national conventions of the Student American Medical Association have seen the passage of major resolutions supporting the establishment of such a corps. The thrust of the discussion has centered on the need for direct intervention to improve the delivery of health care in the povertystricken areas of our country.

The health care crisis presently occurring in this country has many facets, among which are:

1. The quantity and quality of health care.

2. The deficit of physicians, other health professionals, and allied health personnel.

3. The present maldistribution of these groups.

At present, problems seen in the quantity and quality of delivered health care do not revolve around the patient's opportunity for heart transplant. Rather, at issue is the minimum level of health care available to all citizens.

Many geographic health crisis areas, areas of unacceptable minimum care levels, have been defined throughout our country. Estimates of the number of Americans affected vary from the Urban Coalition's figure of 42 million (proposal for a civilian assistance program, prepared by the Urban Coalition, August 12, 1969, p. 3) to the approximately 30 million noted by Under Secretary for Health and Scientific Affairs, Dr. Roger O. Egeberg.

The shortage of physicians and other health professionals has been well documented in the past. The Department of Health, Education. and Welfare in 1967 pointed out that by 1975 a minimum of 40,000 more physicians than the present output of U.S. medical schools and the immigration of foreign medical doctors could provide would be necessary to maintain a "minimum essential (ratio of physicians to population) to protect the health of the people of the United States."

This statement was followed by the inauguration of the physician augmentation program, which was created to assist medical and osteopathic schools to increase their total enrollments by some 4,000 students during the next 4 years. Although the response by medical schools has been vigorous, the expectations of this program have not yet been reached.

This shortage of physicians compounds the health care crisis, particularly in the economically deprived areas of the country. These areas lack many of the attractive features of our more affluent suburban areas, where good hospitals, diagnostic facilities, referral systems, and a highly-desirable social environment exist.

Congress has, in recent years, created dozens of Federal programs to support development of delivery, encourage training of health manpower, construct facilities, and stimulate health planning. Yet, not one of these Federal programs provides for essential staffing without which health services for the deprived millions is an expression not only of numbers, but also of distribution and deployment of health

manpower.

A progressive decline in the number of physicians per 100,000 population is evident as one moves further away from our cities. (See appendix I.)

However, maldistribution exists also within our large urban centers, where the highest physician to population ratios in the country exist. Therefore, essential staffing becomes the sine qua non of health care delivery to the poor.

Today's medical students are well aware of the aforementioned. The recognition can be found in their writings, literature, programs, actions, and call for change in medical education.

I would offer the following as testimony of student support and commitment to the National Health Service Corps concept:

1. Massive overapplication has occurred for positions in SAMA projects in Appalachia, Indian health, migrant health, and other related areas.

2. Overapplication (in order of five to 10 per position) for the 700 presently available positions in the Commissioned Corps.

3. A recent survey conducted by SAMA which identified 1,500 U.S. medical students who desire to participate in a corps-type program in poverty areas.

4. At the 1970 SAMA convention, over 90 percent of the delegates, representing 92 U.S. medical schools, voiced their support by resolution supporting the concept of a National Health Service Corps.

As concerns the actual proposal, it is highly commendable that an overlap of service is provided between outgoing and incoming personnel. This in essence provides a very real continuity not previously found in Federal programs.

However, in light of:

1. So great a need;

2. The necessity for flexibility to establish facilities in areas not presently served by the Public Health Service; and

3. The fact that the needs of presently ongoing direct-care programs under other Government agencies are great enough to absorb several times the proposed membership of the new corps (see appendix II); The Student American Medical Association strongly urges the initial funding level be $10 million during the first year, with successive increases for each of the next 3 years of $5 million per year. Mr. Chairman, the enactment of the National Health Service Corps Act of 1970 will provide the opportunity for young health professionals to serve their country where its needs are greatest.

Thank you for the opportunity to testify before you today. (Appendixes I and II referred to follow :)