funding of the medical school with the choice of the career made by one of its graduates. As a medical school dean, there is no way I can control what the man does after he leaves my premises. I can only assume that you did not intend that.

Senator KENNEDY. Well, just on this thought, I talked to the Minister of Health in Fiji yesterday, and he told me that out there they guarantee the cost of the complete education of young people and after they graduate they have to go wherever the Minister of Health assigns them for a period of time. And if they get the full cost of their education subsidized they have to work in the particular area of need in terms of the national interest.

There are a lot of problems suggested by this approach. One is that you are going to encourage the lesser advantaged to be sort of the indentured servants of the health system. This would be the argument I would make against it. I would say, well, you are just going to take the poor people that can't afford it and send them out to rural America.

But, you know, there has been the suggestion that we ought to require anybody that goes to medical school to go wherever the Secretary of Health assigns them for a year. Maybe we are going to have to do that, too. But again, that is down the road. But how else do we do it?

Dr. DUVAL. Well, if I may go back, Senator, in effect, the Emergency Health Personnel Act, does in fact offer that opportunity.

Senator KENNEDY. Would you like to see some increased funding in that area?

Dr. DUVAL. Yes, sir. I would like to see us try that first, and if this does provide an instrument through which we can show that this may have opened up further, we want to look at it again. I would like to see this tried first. I would not like to see the system turned upside down to accomplish what they have accomplished in Fiji. If sick, I would like to be sick here.

Senator KENNEDY. They have a good system there.

Okay; let me ask you again your views about the importance of including the consumer in the health system generally. Do you think that is important? Do you think we should try through legislation to insure that the consumer has an important role?

Dr. DUVAL. Senator Kennedy, my answer at this time to that question would be that I would also appreciate having the opportunity to answer that question as it impacted on each of the specifications to which you were going to address it, but in general I am on the record as saying that I think there should be heavy consumer participation in the decisionmaking levels with assistance in making the decisions, but not at the providing level.

Senator KENNEDY. For example, in your neighborhood health center in Arizona, are they part of the Board?

Dr. DUVAL. Very heavily. They are the Board. In fact, they have the power of hiring and firing in our instance.

Senator KENNEDY. Are they the contracting agent?

Dr. DUVAL. No. The University of Arizona is the contracting agent. We actually own the premises occupied by the county, in the model cities area, in this instance, Tucson.

Senator KENNEDY. But the Board itself would be able to control the hiring and firing?

Dr. DUVAL. Yes.

Senator KENNEDY. Did that work satisfactorily?
Dr. DUVAL. So far it is working very well.

Senator KENNEDY. Do you find that that the consumer brings a viewpoint which is useful and helpful to the health professionals, regarding what that community needs and how they want to handle it? Dr. DUVAL. Yes.

Senator KENNEDY. I want to thank you very much, Doctor.
The CHAIRMAN. Senator Randolph.

Senator RANDOLPH. Mr. Chairman, I shall be very brief in questioning Dr. DuVal.

Doctor, there are two major measures pending in the Subcommittee on Health of the Labor and Public Welfare Committee that attempt to cope with the crisis in the research and treatment of cancer. Senate 34 was introduced with the cosponsorship of many Senators, but the major author of that measure is Senator Kennedy, Chairman of our Subcommittee on Health. Senate 1828, which was proposed by the administration, is the second major bill. There may be in process a third measure which would in some degree be a compromise approach.

If you will permit me, and I shall be very brief, I want to give two illustrations of the impact of cancer, of which I have received personal knowledge in the last week.

A few days ago, as I journeyed from Washington to Charleston, W. Va., on the plane were Mary and Elbert Cox, whom I know very well, and who live in Logan, W. Va. Mr. Cox came forward and asked me to go towards the rear of the plane and talk with his wife. They were a sad couple on this occasion, and told me why.

Their son, Joe Byron Cox, had died that afternoon in Baltimore in a hospital, in a clinic, which is affiliated with the National Institutes of Health. He had died from cancer, a young man 16 years of age. I shall not attempt, of course, to give a correct definition of the form of cancer with which he had been afflicted, which brought about his death at that age. It is known as African virus.

Now, I want you, if you would, to tell the members of the committee what we may expect in the way of a deepening of the cancer crisis among young people in the United States of America and what you might feel would be the all-out frontal attack upon this scourge. Would you do that?

Dr. DUVAL. Senator Randolph, I do not have actuarial figures with which to back up this statement I am about to make, but it could be provided for the record, if necessary. I do not believe that the incidence of cancer of the African virus sort, or for most of the other forms afflicting children are on the increase per one thousand population.

As we have more young people, we do have more cancer. With regard to an all-out frontal attack, as you know, the administration and many members of this committee are deeply concerned at this time that this should take a very high national priority, and it is our intention to give it just that type of priority in the program that we are now espousing.

Senator RANDOLPH. I thank you, Dr. DuVal, because I think it is important, as you undertake your duties, that we have from you this statement in a sense of reaffirmation of that which has been given to us before by the administration officials. Within the Congress itself, I was red by these friends of mine, the Coxes, to do everything I could, see, to bring about what is encompassed in these two bills or some approach. They didn't know, naturally, of our pending legisla

tion. Even in their sadness, they were commendatory of the doctors and the nurses who in their healing efforts had compassion and understanding for this boy of 16. They were just saying that they didn't want to see another boy of that age afflicted with cancer.

After I arrived in Charleston that evening, I was asked to go by the home of a friend who had had a surgical operation just 3 weeks before. This man is the former executive director of the cancer society of Kanawha County, Charleston, W. Va. He was a commander in the Navy. Lewis Nichols is his name. He had checks and rechecks. There was something wrong but the doctors were not able to identify it as cancer, until after continuing tests were made, and cancer seemed to be determined by analysis all at once. Apparently nothing had shown up over a period of weeks as he deteriorated, but then it was diagnosed as cancer, and he had his leg amputed at the hip, and as he said, "What happens from here out, I don't know." He is 52 years of

age.

I only give this example of an adult and earlier, the youth, to indicate that we seem not yet to have been able to bring together the forces of research and of study and of creative thinking, and I am not critical, which are necessary to do this job. Am I correct about that, sir? Dr. DUVAL. You are, Senator. Your story is very touching, and I share your sympathy, and I am confident that the entire medical profession would agree with you that our best is still not quite good enough.

Senator RANDOLPH. I thank you, Dr. DuVal, and since I am dealing in names today and cases that I know about personally, I was struck once again as we dedicated a hospital in Fairmont, W. Va., a structure built with Appalachian funds, Hill-Burton money, a loan from HEW, and $100,300 of funds which people had given voluntarily in a community that can't always give that kind of money, but the hospital of 200 beds has been constructed, and we needed it very, very much; but on that occasion, as I visited two cancer patients prior to the ceremony, there was occasion for one of them to remind me that Senator Matthew Neely of West Virginia, who is now dead, who served for many years in this body, had in 1927 or 1928, they said, and I haven't checked itI remember his crusade efforts to give $5 million to anyone or any group that would find some answers to cancer. He died of cancer while serving in the Senate of the United States.

These three illustrations are only indicative of the long search, the constant effort, and now the hope for realization, I trust, is a little shorter down the path than we thought. Is this correct, or is it a long way off?

Dr. DUVAL. Obviously, that is a big question, Senator. I join you in hoping that the day would be just around the corner. Every day of agony for the number of persons in this country who have this disease is a day that most of us would like to wipe out in our memories, and I would like to get there just as fast as you.

Senator RANDOLPH. Thank you, Mr. Chairman, I shall support the nomination, and hope we may act promptly and the Senate can concur. The CHAIRMAN. Senator Pell.

Senator PELL. Thank you, Mr. Chairman.

I have heard many fine reports about Dr. DuVal, and have looked forward to supporting and voting for his confirmation. There are a couple of questions that I would like to ask. As I understand it, in your

new responsibility, you will have general charge of the Federal medical programs in HEW, and among these you will have the responsibility for the implemention of two studies that are presently called for under enacted law.

One of them is the cost-study comparison of the different health programs that were offered in the last Congress, and the other is a system study of alernative health care plans. This is supposed to be given to us in September of this year. Are you familiar with either of these studies as yet?

Dr. DUVAL. I know only of their authority in law, Senator Pell. I am not personally knowledgable about their current status.

Senator PELL. I am disappointed as the author of that amendment by the fact that the first study which was due to us a couple of months ago has still not been completed. It is essential that we have those cost figures so that Congress may have it at their fingertips in order to make a decision as to what new medical system it should support. We hope that when you get in your new post, you will do what you can to press ahead in that area.

With regard to the various medical distribution plans before us now, I was wondering if you had had a chance to compare the Kennedy general bill, the administration bill, my own S. 703, or any of the others?

Dr. DUVAL. I know only most generally the substance of the proposals, Senator Pell, and I would be glad to supply such information that you may choose to ask of me, knowing that I have a limited knowledge of the content of the three approaches.

Senator PELL. While I support Senator Kennedy's bill and would like to see us get there, I also am the principal sponsor of the minimum health care bill of my own. This bill is somewhat the same approach that the administration has adopted. And I would also hope we would take a long look at the elements in my bill that have not yet become part of the administration's bill.

Under a more general subject, I have been struck by the fact that while doctors, I think, are much maligned, they are selfless and a fine group of men who are driven in their profession by a desire to serve. Nevertheless, I am somewhat concerned about the fact that today the main financial welfare of the doctor is in his patient being sick. If his patient is well, he gets nothing. It seems to me that the idea should be to try to transfer the emphasis so that the financial benefit to the doctor will accrue most when the patient is well rather than when he is sick. This is what I am striving for.

I am wondering if you feel that we can change this approach in any way so that the real economics incentive for the doctors' work will be to keep people well rather than to treat them while they are sick?

Dr. DUVAL. I think all of us within the profession, as well as the consumer groups, have to refocus our attention on preventive medicine. I believe this is one of the most important thrusts that we can undertake in the next several years.

Senator PELL. Thank you very much.

The CHAIRMAN. Senator Kennedy would like to submit some questions in writing this afternoon, if he could, Doctor. He says there aren't many, and they are relatively brief. We would like to consider this nomination at the next executive meeting. So it would be helpful if

you could get the questions today and have the answers to us as soon as possible.

I don't have anything further. I indicated to you in our earlier discussion, my concern over the administration's practice of impounding funds appropriated for a variety of programs, including health programs, and I would be hopeful that you could be an advocate for the release of impounded funds and also an advocate for more vigorous implementation of some of the health programs which are of particular legislative concern, including the research activities under the Occupational Health and Safety Act.

This has been a good hour for all of us. We appreciate the opportunity to hear you.

Dr. DUVAL. Thank you, Mr. Chairman.

The CHAIRMAN. Thank you, Dr. DuVal.

(Information subsequentially supplied for the record follows:)

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE,

Senator EDWARD M. KENNEDY,
New Senate Office Building,

Washington, D.C.

OFFICE OF THE SECRETARY, Washington, D.C., June 11, 1971.

DEAR SENATOR KENNEDY: Enclosed are the responses to the questions asked by Senator Kennedy of Dr. DuVal during the Senate hearing held on June 10, 1971.

If there is any additional information you would like, we would be pleased to provide it.

Sincerely yours,

Enclosure.

JOHN S. ZAPP, D.D.S., Deputy Assistant Secretary for Health Manpower.

Q. 1. The President's Health Message emphasizes the necessity of improving the "supply side" before instituting a broad-based national health plan. What actions would you take as Assistant Secretary to achieve that and how long would it take?

A. The Department is already in the process of increasing the "supply side," both through legislative proposals submitted to the Congress and its commitment to ongoing health manpower programs. The objective of the Administration is to substantially increase the numbers of graduating physicians, dentists and other primary providers through higher dollar level support to the institutions and to support new innovative patterns of health education which show promise for educating these personnel in shorter periods of time. At the same time we will be supporting programs leading to increased numbers, we also will be stressing higher utilization of all persons employed and trained for health occupations. Of course, all of these programs will be addressing themselves to the problems of distribution both geographically and among the specialities. As to the length of time, there will be a continual and substantial increase throughout the decade.

Q. 2. Some have said that HEW is so big, so complex that it cannot be managed. Would you describe the extent to which you see this as a problem, as well as what can be done to improve upon it?

A. I would not necessarily say that the size of the Department acts as a deterrent to its efficient management. I believe it is more a matter of grouping related activities within a functionally related Department and then the application of the proper management techniques to achieve desired objectives. It is also a matter of working with the legislative branch of the Government to develop the necessary statutory interrelationship between programs in related fields. I intend to direct my efforts in this area.

Q. 3. The health functions of HEW have been organized and reorganized over the past four or five years. Do you envision the necessity for any reorganization of the health functions of HEW? If so, what would they be?

A. One never looks forward to reorganization, however, as priorities and legislative and National patterns change, so must the organizations which admin