health measure that should be enacted. We would hope, however, that this is the last time that the Congress finds it necessary to come to the rescue of a categorical program for communicable disease control and vaccination assistance at the eleventh hour.

This last sentiment requires some explanation. The American Public Health Association has been a consistent supporter of the concept of comprehensive health planning and of block grants to states for programs of public health importance. Our support for this concept was manifest at the time of the enactment of Public Law 89-749 in 1966 and remains strong. If I may recall some history, the theory in 1966 was that the enactment of block grant authority under section 314(d) of the Public Health Service Act would obviate the need for continued categorical funding-a major factor contributing to the fragmentation and discontinuity of health service programs in the United States. In theory, state health agencies would be able to program block grant funds under 314(d) for programs of import to the states such as communicable disease control and venereal disease control and to exercise some degree of autonomy in deciding the relative emphasis to be placed on various public health programs. In practice, the inadequate appropriations requested by successive administrations and granted by the Congress for the implementation of Section 314(d) have doomed the block grant concept to relative inadequacy without an adequate trial. It quickly became obvious that in the face of an unwillingness to commit adequate funds for block grants to state health agencies, categorical funding would have to be continued if we were not to lose ground in several basic areas of public health programming. If the spirit of Public Law 89-749 had been followed, there would be no need for this narrow categorical legislation today.

Further, as the Congress hears arguments pro and con on the issues of national health insurance and health maintenance organizations, the need and the appropriateness of these types of categorical programs again comes into question. Hopefully, between now and the time that these programs again come up for renewal, the national concern for a more rational high quality health care delivery system which includes prevention of disease as an integral part of every individuals' right to health, will have found expression in a comprehensive and coordinated program for the financing and delivery of health services. Under such circumstances, and with due attention to the importance of prevention in a national health program, these types of categorical grants should become truly redundant and of historical interest only.

In addition to these general comments on the relationship of communicable disease control activities to the overall health services delivery system, we would like to offer a few specific ideas for the Committee's consideration. First, we would like to lend our whole-hearted support to that portion of S. 3442 that deals with public education in the area of communicable disease. This new emphasis on public education is welcome indeed. Our Association is convinced that the development of a sense of personal responsibility for health on the part of every citizen is an essential prerequisite to really improving health indicies and health services in this country. The individual needs not only to know the facts about prevention of disease but also to put them into practice. There are many opportunities in the communicable disease field and other aspects of personal health for individual decision making to promote and enhance individual health. One only needs to point to examples like automotive seatbelts, cigarette smoking, and inappropriate eating habits as areas of individual decision with implications for individual health. At the time of the President's Health Message in 1971, when the concept of a National Health Education Foundation was introduced, we supported the idea but questioned whether such an effort would be successful without the infusion of Federal funds for development and dissemination of educational materials. This provision of S. 3442 would make it possible for Federal funds to be invested in public education on communicable disease. We feel that this committee-which reviews most health legislation-should consider the incorporation of similar language into other categorical programs until such time as an overall national effort in health education is designed, structured, and funded.

In the case of S. 3187, the effectiveness of the well-stated preamble and the adequate authorizations is materially weakened by a return, in Section 318(c)(2), to a hopefully archaic form-a disease-specific state plan requirement in order to qualify for Federal formula grant funding. One of the important thrusts of the comprehensive health planning legislation in 1966 was to unify state health planning in a single state agency and to consolidate the various categorical plans into a single state plan for health services. Each state has strived to develop a state health planning process under the impetus of Section 314(a) of the Public Health Service Act. This effort to eliminate the chaos of many different state planning requirements under different Federal funding authorities has borne important fruit. We would strongly urge that, if S. 3187 is enacted, the requirements for a separate state plan be stricken and the state required to cover the venereal disease program planning as an integral part of the overall planning processes already conducted

under the provisions of Sections 314(a) and 314(d) of the Public Health Service Act. The effect, we believe, would be to achieve what the Congress desires and the nation needs-targeted funding of venereal disease control-without a regressive return of categorical state health planning.

We have appreciated this opportunity to appear before the Committee and present our views on these important legislative proposals. We will be happy to answer any questions you might have.

Senator DOMINICK. Our next witness is Dr. Bruce Webster, Cornell University School of Medicine and president, American Social Health Association, together with Dr. John Hume, dean, School of Public Health, Johns Hopkins University, on behalf of the American Social Health Association.

STATEMENT OF BRUCE WEBSTER, M.D., CORNELL UNIVERSITY SCHOOL OF MEDICINE, AND JOHN HUME, M.D., SCHOOL OF PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, ON BEHALF OF THE AMERICAN SOCIAL HEALTH ASSOCIATION

Dr. WEBSTER. Somewhere in the Commission report someone pointed out that the curve of VD rates in the United States is an inverse ratio to Federal funding. As Dr. Duval has already mentioned gonorrhea is epidemic, that there are probably 21⁄2 million cases, and that syphillis is rising.

This is in spite of the fact that we know the organisms that cause these diseases and we have a means of treating them. The concept of a national commission arose in 1969 when the American Medical Association, the American Social Health Association and various other groups got together in Chicago and discussed the alarming increase in rates.

The commission was established in February 1971, by the assistant Secretary of Health, Education, and Welfare. Represented on this commission is the American Medical, the American Osteopathic, the American Public Health Associations, the American Social Health Association, and most of the other groups concerned in the management of venereal diseases.

We have drawn heavily on the National Institute of Health, the Center for Disease Control and the National Institute of Mental Health, as well as a great many private consultants.

We concerned ourselves first with the problem of research, the scarcity of research in the problems of venereal disease. If a fraction of the effort of research that went into polio had gone into these diseases, we would be further ahead.

We don't have a really adequate test for the diagnosis of gonorrhea. A great deal more research can be done in the matter of prophylaxis. Dr. John Cutler is working on this, but this research is very inadequately funded. There is need for further research in the behavioral sciences, so that we know more about the high risk groups.

All of this necessitates funding for greater extramural research. We need to interest the immunologists throughout the country. The commission has recommended $6.5 million for 1973, escalating to over $19 million in 1976. It has been suggested that we might do research into the present control methods. Are they the best methods? These should be evaluated. The commission concerned itself with education. There is a great scarcity of professional manpower in the venereal disease field. Recently this country was visited by experts from the World Health Organization. They have issued a report which is in the process of being liberated at the present time. This report substantiates this finding.

On the basis of these findings of the National Commission it is suggested that teaching grants be made available to medical schools and

schools of public health in an effort to bring back the teaching of these diseases into the curriculum of the schools.

It has been suggested that the clinics be brought back into the university and community hospitals.

The Commission made recommendations in regard to strengthening venereal disease education in schools. We made recommendations with regard to public education. It has been felt strongly that an all out campaign in public education is necessary. It must be direct, it must reach the high risk groups, and they must be told plainly what the problems are, and where to go. Other countries have done excellent jobs in this regard.

The Commission has recommended that we urgently need earmarked funds for both research and professional and public education. Because of the liability of these funds to be lost in State capitals, it is urged that they be earmarked. The problem of increased grants to States has been discussed earlier. It is felt that the public clinics need strengthening, as Dr. Sencer has pointed out.

They need better qualified professional manpower, better diagnostic facilities for the practicing physicians, since the practicing physicians are the keynote of this disease control program. Lastly, the Commission recommended that an on-going commission composed of representatives of governmental and private medicine be appointed to advise the Secretary of HEW on appropriate research and control measures designed to reduce the incidence of venereal diseases.

Dr. Hume will discuss the problem of funding as recommended by the Commission.

Dr. HUME. Mr. Chairman, the Commission did look very carefully not only to the elements of the program which Dr. Webster has outlined, but did try to come up with reasonable estimates of the amount of money that could be effectively used, and at the same time would be adequate to mount a successful attack on the venereal diseases, a program covering project grants to States and operating funds for the Federal establishment, public and professional education and venereal disease research.

Interestingly enough, the total figures that we arrived at are well within the limits of the bill that is proposed by Senator Javits and yourself and others. On the other hand, there is a slightly different distribution. You have received a copy of the Commission report to be, hopefully, entered as part of our testimony. In that, you find we have an escalating request starting out in fiscal year 1973 with a total of $46 million, but rising to $68 million by fiscal year 1971.

The distribution as I mentioned is somewhat different. We put more stress on research and professional education funds than has been the case in the bills that are currently up for consideration, because we feel it is here that the long-term solution of the problem lies. We are fearful that if we continue to put all of our funds into the operating programs, we will continue to go through the cycles of mounting extensive and effective campaigns which bring the diseases under relative control to the point that public apathy sets in, appropriations fall off and the VD control apparatus is pretty much ruined, to be followed once again with an increase in the rates.

I don't want to go into great detail. I think that we do have the materials before you for the record, and unless you have further questions on these figures, I will stop here.