The CHAIRMAN. Well, we want to thank you, Mr. Secretary, for your very excellent testimony here this morning. Thank you, too, Dr. Stewart, for your testimony. I appreciate it very, very much, I sure do. Mr. COHEN. It is always a pleasure, Senator, to testify before your committee and, as I said, all these pieces of health legislation that have been passed are really a testimonial to the great vision that you and your committee have shown in this area. We appreciate it very much.

The CHAIRMAN. Well, we appreciate your kind words. We realize we have just got to keep moving forward. The battle goes on.

Mr. COHEN. Yes, sir.

The CHAIRMAN. Is that right?
Mr. COHEN. Yes, sir.

(Discussion off the record.)

The CHAIRMAN. Thank you, gentlemen, very much. You have presented some very fine testimony and we appreciate it very much.

Now, Dr. Venable, president of the Association of State and Territorial Health Officers and director of the Georgia Department of Public Health.

Doctor, we are happy to have you here, sir, and we will be glad now to have you proceed in your own way, sir.

STATEMENT OF JOHN H. VENABLE, M.D., DIRECTOR, GEORGIA DEPARTMENT OF PUBLIC HEALTH, IN BEHALF OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS

Dr. VENABLE. Thank you, Senator.

I have prepared a statement which is in the hands of your staff but which I will not read if it can become a part of the record.

The CHAIRMAN. We will have it appear in full in the record and then you proceed as you see fit.

Dr. VENABLE. Thank you, sir.

First, I would like to say what an honor it is to appear before you and this committee, the source of so much constructive and forwardlooking health legislation over the last decade or more.

The CHAIRMAN. Well, I assure you we are honored to have you here, sir.

Dr. VENABLE. Thank you, sir.

I think when the history books have been written that perhaps the legislation under consideration this morning will be seen as the most important legislation that has come along in a long time.

I speak primarily to the sections 314(a) and 314(d) which are the primary interests of State health officers whom I represent.

The comprehensive planning under 314(a) providing an umbrella for total comprehensive coordinated State health planning of all aspects but not doing it all, the umbrella for coordination, whether this be with regional medical programs or whether it be with environmental health, whether it be with facilities planning or any other particular aspect, these all need to come together into a comprehensive whole if the States are to do their job.

I think having had the opportunity categorically to break programs down to learn about the operation of specialized programs, has been very beneficial in the past. Now under 314 (d) we have the opportunity

of putting this back together again into a comprehensive whole relating the parts and the manner in which the States' problems are justified, and we are thrilled at the opportunities that were discussed by Secretary Cohen and Dr. Stewart and yourself as to the partnership aspects of health in Federal, State, and local aspects.

I would certainly agree with the Secretary, as you yourself, Senator, know, from your knowledge of the Southeast, that local health departments are the real important sites of delivery of health services wherever this is possible, and as we have found in your State and mine, it can be done very effectively in this manner provided State health departments support these community activities.

The CHAIRMAN. That is right.

Dr. VENABLE. The ASTHO and I personally, are very much supportive of this legislation, and I want to express our appreciation to you for your personal interest in it as we move ahead in the health field.

(The prepared statement of Dr. Venable follows:)

PREPARED STATEMENT OF JOHN H. VENABLE, M.D., DIRECTOR, GEORGIA DEPARTMENT OF PUBLIC HEALTH, IN BEHALF OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS

Mr. Chairman and Members of the Committee: I appear before you today as President of the Association of State and Territorial Health Officers to present our Association's views on S. 1131 and H.R. 6418, the bill to extend the authority of Public Law 89-749. The burden of my statement to you today will deal with the extension of that law.

Our Association believes that by the action which this Committee and the Congress took last year in the enactment of Public Law 89-749 that you are convinced of the necessity for (a) the careful planning of health services which need to be provided to the people of this Nation, and (b) the need for flexibility in the grant arrangement between Federal, State, and local jurisdictions whereby the States and localities will have necessary freedom of action to expend these grants in a manner which will be most responsive to the health needs of their own particular State or locality. We look now to the extension of this authority for the next three years; and it is my purpose today to discuss with you in specific detail the level of health needs that exists throughout the nation and the level of Federal support necessary if these health needs are to be met.

Our Association pointed out last year that the relatively small increase of but $6.5 million each for the formula and project grants contained in P.L. 89-749 would not enable us to make any significant impact on some health problems. It was and it remains our view that the role of full partner on the part of the Federal Government did not seem to be accomplished when there was such a meager increase in the appropriation. It was the recommendation of the ASTHO at that time that $100 million be authorized for the formula grants to States and an additional $75 million be authorized for the project grant authority, a total of $175 million rather than the $125 million which was authorized for health services in P.L. 89-749.

Since enactment of this law, we set about to make an assessment in each state of the total health needs. We asked each State Health Officer to list these needs by priority. to report the amount of financial support available from State and local sources for the programs at the present time, and to program over the next five years the level of increased activities possible, taking into account available health manpower and anticipated increases in financing from State and local sources. We asked them to report the level of Federal support that would be needed to carry on these programs at an optimum level. We asked further that each State report on three specific health programs, family planning, cervical cancer, and dental health, in order to provide a nationwide measurement of the problem level of these three health programs. This meant that in each instance we have received from each State a priority evaluation of health programs which could be funded through Section 314(d), PHS Act, the formula

grants, consisting of not less than six areas and not more than nine. This survey, while in no way precise revealed that we were overly conservative in our request of last year. The survey indicated that health programs are needed and that we are in a position to implement remedial programs at a level requiring $400 million Federal support. This is over and above State and local support which exceeds the Federal contribution.

If the Committee will excuse me, I would like to refer to our own program in Georgia. For family planning programs, we have a potential caseload presently of approximately 210,000. Family planning services could be provided for 21,000 people with the expenditure of $196,000. We have State and local funding at the level of $146,000. We would need, therefore, $50,000 additional Federal support for this activity. In five years' time, when the caseload has increased to approximately 223,000, we can reach 70 percent of the objective or 156,000 with the expenditure of $1,380,000. It can easily be seen that there needs to be a great increase in the level of support from the Federal Government for this very necessary activity.

In respect to cervical cancer control, approximately 30 percent of women in Georgia are screened by private physicians. We have established a limited program, which has been budgeted and is being implemented for approximately 25,000 patients, four percent of the total population with incomes under $3,000. The cost of this program presently is $56,000 for supplies and cytology readings. We could expand this program in 1968 to a level of $72,000 and 1969 to a level in excess of $1 million. While the level of support from the State and local sources could be increased it could not be of the magnitude necessary to implement the program which could and should be carried on.

In this respect to dental health, of the approximately 1.7 million children in Georgia under 18 years of age, 1.3 million have experienced dental caries, which affect over 8 million teeth. Less than 35 percent have been treated, leaving almost 51⁄2 million untreated teeth. Thirty percent of this population lives in areas not served by public water supplies, and 40 percent lives in communities where public water suppiles still are non-fluoridated. We have a further problem with the shortage of dental manpower and its uneven distribution. In rural areas and areas of economic need our people have the least availability to dental care. The ratio of dentists to the population of Georgia is approximately one to every 3,750 compared to one for every 1,750 for the United States as a whole. Our dental caries rates in the non-white population are approximately 20 percent less than in the white, but 94 percent of the non-white dental needs are untreated compared to 58 percent of the white. To correct this problem, we would like to fluoridate each year 100 of the 1,000 municipal systems and 85 of the 425 schools with individual water systems. To accomplish this, our level of expenditure in 1968 would total $742,000 of which $120,000 would come from State and local sources, requiring a balance of $662,000 from the Federal grant.

Another priority in Georgia is the establishment of an aftercare program for State mental hospital patients. Approximately 10,000 patients each year are released through furlough or direct discharge from State mental hospitals. Each hospital operates an outpatient clinic, but many patients live great distances from the hospital, some up to 200 miles. At present, the pattern of offering assistance to patients released from mental hospitals is through county health departments. We are making some progress in establishing clinics in county health departments staffed by a physician who reviews the progress of former patients and who changes and renews prescriptions as needed. Drugs are made available to the medically indigent. At the present time, twelve of our county health departments operate such clinics, although most are not yet able to handle the volume of patients returning. The level of expenditure and the number of patients seen for the present fiscal year is approximately 750 patients with a drug expenditure approximating $50,000 and expenditure for personnel approximating $26,000. Of the 10,000 patients returning to the communities in 1967 from State hospitals, 5,500 are known to be without aftercare services other than minimal access by visitation of public health nurses, 3,750 can be seen at the outpatient department of the State hospital, and 750 can be seen in the present twelve aftercare clinics of county health departments. We plan and need to increase to a total of 45 the community care clinics. This number, serving a population of not more than 100,000, would make statewide coverage possible. We also need to increase the range of services provided from the present emphasis primarily upon the supervision of medication to the total range of care necessary. This would require the services of a physician, preferably a psychiatrist, a mental

health professional, a social worker or a nurse fulltime, public health nurse time equivalent to two fulltime nurses, and a secretary. The level of this program presently is $169,000, all from State and local sources. If in 1968 an additional $400,000 could be realized from Federal sources, this could be increased, together with the state and local funding, to a level of $600,000.

Another of our serious public health problems is that of controlling tuberculosis. We have approximately one million persons in our State who harbour the tubercle bacilli in their bodies. Approximately 3.4 percent of the 1,269 newly active cases reported for Georgia in 1965 could be attributed to endogenous (internal) reinfections or breakdowns within this group. We have a program in Georgia which attempts to follow cases of active tuberculosis who are not hos pitalized to see that they are under medical supervision and are taking the drugs and other necessary precautions. We continue surveillance of inactive cases for five years to guard against reinfection. We also have prompt examination of contacts of active cases, medical examination and surveillance of suspects, identification and periodic examination of persons at greatest risk, and specific efforts to prevent children from becoming exposed to tuberculosis. The level of our support at the present time for fiscal year 1967 for this program is $1.7 million, of which $1.1 million is from State and local source with a Federal share of $560,000. In our projected increase in the level of activity in tuberculosis control, at no point would the Federal contribution be greater than one-third of the total expenditure on this problem.

I believe these examples provide to you an idea of the specificity with which we have gone about our task of evaluating the health needs of our State, and the pricing out of the costs of the services which are needed to bring about bettered health conditions. Please understand that in each of these instances we are dealing with the application of known medical knowledge in making available to the people the fruits of research and experience which have been forthcoming over the years. Not to apply our knowledge and skill is, in our estimation, a dereliction of duty and responsibility.

We, in Georgia, may by extrapolation illustrate the national need. We have carefully priced out nine high priority programs and find that a realistic cost to meet these needs by 1971 is in the neighborhood of $20 million. Assuming that only one-third of this is a fair Federal partnership share this would amount to $6 million and, as Georgia's usual share of a national grant is approximately 22 percent of the total amount, the Federal appropriation should be in excess of $250 million for only nine programs. But these nine are only part of the fifty-odd health programs for which my Department is responsible.

We urge upon you very seriously the consideration of increasing the level of appropriations authorized by Public Law 89-749 and contemplated under the bill presently before you to a level consistent with the health needs of the people of this Nation. It is our recommendation that Public Law 89-749 be amended so that the authorization for grants to provide health services, both for formula and for project, be increased from the present $125 million to at least $200 million for 1968, and that for 1969 $300 million be authorized; for 1970 $400 million be authorized; and for 1971 $500 million be authorized.

S. 1131 and H.R. 6418 also propose licensing of clinical laboratories which engage in interstate commerce. Although our Association has not had an opportunity to act upon this proposal, I feel confident that our constituent members, in great majority if not unanimously, support this proposal. I would like to suggest two points which may need clarification. The first would make it clear that the Secretary would accept as meeting the letter of law, state laws or regulations relating to clinical laboratory procedures which are equal to or more stringent than those promulgated by the Secretary. Second, that the Secretary, via grants and contracts, provide financial assistance to official health agencies who are responsible for monitoring and consulting with these laboratories to the end that the health of our people can be safeguarded.

The CHAIRMAN. Well, we deeply appreciate your presence here this morning and your very fine, strong statement.

Tell me this, Doctor, have you appointed your planning agency in Georgia yet?

Dr. VENABLE. No, sir.

Our plan is in the Public Health Service now and we expect it out in the next couple of weeks. As soon as it is approved we will appoint our committee.

The CHAIRMAN. You will then make the appointment of your committee?

Well, we want to thank you again for being here.

If you have any further thoughts or suggestions of any kind, don't hesitate on letting us hear from you.

Dr. VENABLE. I appreciate the opportunity.

The CHAIRMAN. Now, the College of American Pathologists, Dr. Ernest Simard, and Mr. Oliver Neibel and the Honorable Kenneth A. Roberts, of Alabama.

All right, Doctor, we are delighted to have you, and Mr. Roberts and Mr. Neibel, here with us, and we will be glad to have you proceed in

your own way.

STATEMENT OF DR. ERNEST SIMARD, PRESIDENT, COLLEGE OF AMERICAN PATHOLOGISTS, ACCOMPANIED BY KENNETH A. ROBERTS, OF WASHINGTON, D.C., LEGISLATIVE COUNSEL; AND OLIVER J. NEIBEL, JR., EXECUTIVE DIRECTOR AND GENERAL COUNSEL

Dr. SIMARD. May I ask, Senator, if you prefer us to read this statement in detail, if that is the procedure you have followed this morning? The CHAIRMAN. We haven't followed it up to date, but we will be glad to have you proceed in any way you think is most effective or that you care to follow.

Dr. SIMARD. I will proceed to read the statement in detail.

The CHAIRMAN. All right.

Dr. SIMARD I am Dr. Ernest A. Simard of Salinas, Calif., president of the College of American Pathologists.

The CHAIRMAN. I see when you went to school out there you stayed there, right?

Dr. SIMARD. Yes.

The CHAIRMAN. What is your native State, sir?

Dr. SIMARD. California.

The CHAIRMAN. California. All right.

Dr. SIMARD. We moved to Alabama for a while.

Mr. ROBERTS. He came from a good start.

The CHAIRMAN. You have a good Alabamian here with you.

Dr. SIMARD. Yes, sir.

As you know, with me are Mr. Roberts, the legislative counsel of the college, and Mr. Oliver Neibel our deputy director and general counsel of the college.

The College of American Pathologists is a professional society of doctors of medicine representing approximately 5,000 physicians who practice the medical specialty of pathology in hospitals, both private and governmental, medical schools, clinics, and research institutions as well as in private offices throughout the country. I appear before you today representing these physicians and presenting their views on that portion of H.R. 6418 which seeks to provide for the Federal licensing of some clinical laboratories. It is our considered opinion that the bill, as passed by the House of Representatives, is fair and equitable. We shall limit our testimony before this committee to comments on section 5 of the legislation now before you for consideration.