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It is appropriate that this should be a Federal concern for one finds that the failure of one State to give adequate preparation for parenthood in many instances creates a burden that falls upon another State, especially with many of the larger cities situated near boundaries and with modern facilities of transportation.

For the very same reason, page 3, line 22, it is important that a program of this sort cover the whole State since the effects of poor initiation into life cannot be localized within the State either. The effects of such a poor start, of course, frequently fall on the private resources of parents and the children later in life, but they also so frequently, especially as aggravated mental conditions, become a public charge that public funds looking toward their prevention are appropriate.

Page 4, line 15, I would feel that the provision is not quite strong enough in its use of the word “may." It is inconceivable to me that a program can be adequate if it is not presented to the people as a joint effort of the involved departments of service. By using the term “may” a health department may construct a program that definitely influences the school or the welfare department without taking these departments into account, and such a program is bound to be less effective. It would seem to me that some sort of requirement should exist that the State present a program that at least is harmonious within its own framework. Furthermore, many of the most important mental health activities that could be presented for Federal support under this bill would properly originate in a State department of education, correction, welfare, or mental health, and so it is not so much a matter of getting the sanction of another department for a program submitted by a department as it is to get a department of health to channel through a program that originates elsewhere in the State organization.

Page 6, lines 2 and 3, this principle is supported in the wise provision on page 7, line 3, for cooperation between the involved agencies, public or private, within the State.

I shall now pass on to title II. Some of the principles that I have stressed with respect to title I apply to subsequent titles, so I will not repeat them.

Page 11, line 8, there is a distinct mental hygiene interest in the training of personnel for State and local crippled children's services. It has frequently been said by cripples themselves that their problem is more above the shoulders than below. This, however, is not a recognized element in preparation for professional services in this field, and I would like to go on record as indicating its importance at this point.

Under title III there are very clear mental hygiene potentialities, lines 5 to 10. For the training of personnel the same need obtains as in the case of crippled children, although schools of social work have been very cognizant of this need. The need for the mental hygiene significance of the hazards facing children without parental care and supervision is implied in the early part of this statement, and dependency, neglect, and delinquency are all a part of this picture.

The development of programs and measures under this title, therefore, are very closely related to the activities under title I and should not be far sep arated from them in actual operation. It is for that reason that since these two would properly be carried out by different State departments that the two should be closely coordinated.

Those who are interested in mental hygiene are also interested in page 26, lines 15 to 17, since the performance of child-welfare services as described here involve clinical activities and in the regulations should require some minimum standards of personnel to carry through such activities if they are to be performed adequately.

Page 27 , lines 1 to 3, reference is made to a field which is very much in need of critical exploration. Institutions have been utilized on the false assumption, which I think no one actually believes, that they are substitutes for honies. More recently considerable research has been done on the value of the institution when it is recognized for what it is, both as to its limitations and to its positive possibilities, and if under this bill we can begin to turn institutions to positive value and at the same time recognize their limitations we would have made many steps ahead. The general principle is that whether a child is placed in an institution, foster home or given day care, this step should be taken with clear appreciation of how it may contribute to his growth and development.

In view of the need for care and thorough studies in this respect the provision of Section 402, page 28, lines 13 to 16, are especially important. Sincerely yours,

GEO. S. STEVENSON, Medical Director.

EXHIBIT 26

BETHLEHEM, PA., June 24, 1946. Hon. CLAUDE PEPPER,

The United States Senate, Washington, D. C. DEAR SENATOR PEPPER: To establish for the record my right to speak in the interests of health legislation, I offer the following:

For many years I was chairman of the committe on economics of the American Dental Association, during which time I organized and supervised many surveys and studies having to do with the general lack of dental facilities and the great inequalities that existed in the use of such services in this country.

When the American Dental Association established the national health program committee to represent the association in conversations with governmental agencies, I was appointed to this group.

I was a member of the sponsoring group and one of the essayists that organized the course on dental health economics at the School of Public Health, the University of Michigan, Ann Arbor, Mich., in June 1944.

I am a member of the subcommittee on medical care of the American Public Health Association, of the American School Health Association, the Association of Public Health Dentists (associate), dental consultant to the United States Public Health Service (district No. 1). I served as consultant to the United States Public Health Service and the Social Security Board in a study made in 1945 and I was a member of a group called as consultants by the Children's Bureau in the same year. I am a member of the health advisory council of the Chamber of Commerce of the United States.

In my own State I have been president of all organized dental associations from the Pennsylvania State Dental Association down to my local society. LOcally I am chief of the dental department of St. Lukes Hospital, dental consultant to the public-school district, the Cecil Sayre Day Nursery, and the Children's Home of Bethlehem and Allentown, Pa. I have been chairman of the health division of the Council of Social Agencies and am a board member of the Visiting Nurses' Association.

In all of these connections I have been afforded an opportunity to see how utterly impossible it is for local groups with their own resources, or even when assisted by the State, to make substantial or progressive improvements in the condition of the teeth and supporting tissues in the mouths of our children.

I favor Senate bill 1318 which you and your colleagues have introduced, because it makes provision for the care of mothers, as well as their children. It requires that States desiring to benefit from the program must have established on a State-wide basis services and facilities to meet the maternity-care needs of mothers, as well as having child-welfare services available when needed. I feel that this provision is most important if minority groups and others that are not amply represented are to be benefited.

It has been said that the education of a child should begin with it's grandparents. It can, as well, be said that the health of a child must begin with it's parents. The health of the mother does have a great influence upon the first teeth of the child and the condition of the first teeth will have much to do with the general condition of the permanent teeth as well as influencing the proper positioning of these teeth in the dental arch.

In my opinion, to provide in this bill that the pregnant woman may secure appropriate health service and that her child may secure dental care, would give added encouragement to all of us, and the funds that would be made available would make it possible for State health departments to enlarge their activities and to the forty-odd State dental directors it would grant the opportunity for enlarging their service programs, or to include in a program that has been limited to education and examinations, an operative type of service.

Another thing that I like about your bill, Senator Pepper, is the fact that as the demands of the people for a greater health security are expressed in the adoption of legislation, this bill can become a part of any plan for a greater coverage. I want to wish you and the other sponsors success in your endeavors. Yours truly,

R. M. WALLS, D. D, S.

EXHIBIT 27

Our dental conditions are so deplorable that dental programs throughout the United States must be intensified.

However, three precautions should be taken in planning dental programs:

First, they should be conducted throughout the United States--a fact that necessitates Federal funds.

Second, dental-care programs for children seem to be the most effective approach to the dental problem.

Third, if Federal funds are to be provided for a care program for children they should include earmarked funds for dental care. Unfortunately there are many health administrators who do not utilize general funds for dental programs. The failure of health administrators to consider dental needs has been one of the most discouraging obstacles facing dental directors in the various States.

This statement is a brief but urgent plea for your committee to provide earmarked Federal funds for dental-care programs for children.

J. M. WISAN, D. D. S.,
Chief, Division of Dental Health,
New Jersey State Department of Health.

EXHIBIT 28

THE MURRY AND LEONIE GUGGENHEIM DENTAL CLINIC,

New York 21, N. Y., June 21, 1946. Hon. CLAUDE PEPPER,

United States Senate, Washington, D. C. MY DEAR SENATOR PEPPER: I am happy to respond to your invitation to present my views on the proposed Maternal and Child Welfare Act (S. 1318).

A year ago I wrote to you in support of the so-called dental bills, S. 190 and S. 1099, and still believe that in their broad aspects they are good bills. However, I have come to feel that, even as regards the dental problem of our children, a broader approach is needed. That is, I believe provisions for dental care of children should he integrated into a general health program since dental problems are for the most part related fundamentally to questions of general body metabolism and health.

Proposals for giving health care to children in the past have not usually specifically mentioned dental care. It was, therefore, gratifying to see that in S. 1318 there is recognized the fact that children do need dental care and need this as something related to their general health care. Some of the provisions in S. 1099 which are desirable are not mentioned in S. 1318 (specialized training of personnel, demonstration programs, and health education). Also there is no provision for research, as in S. 190. At the same time I would support S. 1318 because its base is essentially broader and it would apparently be possible to develop these desirable features by amendment. I would urge that consideration be given to such additions to the bill.

I was pleased to see in your speech, presented when the bill was introduced, that utilization of a chain of hospital and health-center facilities was envisioned in the wroking out of the program. However, the bill, as you said, does not provide for construction of such facilites. The passage of coordinate legislation such as S. 191 is therefore essential to the ultimate accomplishment of the objects of S. 1318.

I was pleased to note in your speech, referred to above, that a very substantial proportion of the total money to be spent would probably be allocated to dentistry. It is desirable that such money be definitely earmarked for dentistry, even if at the start the proportion were less. The point is that in the minds of State medical administrators who would have control of the funds, medical needs might seem so urgent that dentistry might receive only a token budget annually. This idea was advanced by Dr. Gruebbel, of the American Dental Association, when he spoke on S. 1318 before your committee on June 6 this year.

In the absence of an earmarked fund, which might well prove inadequate, I would suggest a specific statement as to the dental services to be provided and the age group to which those services would be available. While I agree with Dr. Gruebbel on that and several other points he made, I do not endorse his criticism that the bill is faulty in not refering specifically to dentistry in certain passages. I am sure that the intent to include dental services with other health services is adequately expressed. Nor am I fearful with regard to how dentists will be paid for their services.

While endorsing the bill in regard to the services to be given I question how far the grant-in-aid principle will carry in terms of the total need. It is stated in the bill that the services will be available to all mothers and children who elect to participate. However, the grant-in-aid in the health field is usually looked upon as a charitable device. The question then is whether, through rejection of charity by some or by restriction by administrators, services will perhaps fail to reach all who should receive them. This situation is complicated, too, by the fact that part of the money will be allocated on a matching basis and even though this is only one-tenth of the total the amount to be allocated will depend on what the State is willing or able to allot for the purpose.

This brings me to the point of questioning whether it would not be better to have a system supported in large part by involuntary contributions from those who are to receive the benefits. This would do away with the thought and implications of charity and would assure the distribution of services to those who contribute regardless of variation in State actions.

There is no doubt that health care of mothers and children should be expanded as provided in this bill. But just as I think dental care should be included in the brcad health program for mothers and children so also I think that maternal and child care should be a part of a broad health program that would include our entire population. If we cannot have the latter then by all means the care proposed in S. 1318 should be provided. Yours sincerely,

JOHN OPPIE MCCALL, D, D, S.

EXHIBIT 29

NATIONAL ORGANIZATION FOR PUBLIC HEALTH NURSING, INC.,

New York 19, N. Y., June 20, 1946. HON. CLAUDE PEPPER,

United States Senate, Washington 25, D. C. MY DEAR SENATOR PEPPER : In reply to your telegram of June 18, we are glad to send you three copies of the statement of the National Organization for Public Health Nursing on the Maternal and Child Welfare Act of 1945, S. 1318. Sincerely yours,

Ruth HOULTON, General Director,

STATEMENT FILED AT HEARINGS OF MATERNAL AND CHILD WELFARE ACT (S. 1318)

ence,

The National Organization for Public Health Nursing is a membership agency comprising 9,268 public health nurses, 356 public health nursing agencies, 973 nonnurse citizens, and 22 State branches. It acts as a medium through which public health nurses and other interested citizens express opinions and provide information on public health nursing as assembled from their collective experi

Public health nurses have actively manifested their concern for the improvement and expansion of preventive and curative health services for the entire population. This interest was formalized by resolutions passed at the biennial convention of the NOPHN in 1944 which state that

1. Means should be found to bring medical and public health services within the reach of every citizen.

2. In addition to voluntary effort, governmental assistance is necessary for attaining adequate provision of health services.

3. To carry on public health nursing functions in connection with expanded programs of public health and medical care 40,000 additional public health nurses will be needed.

4. Pressing need of public health-nursing personnel requires added facilities for recruitment, training, and postgraduate education.

The NOPHN, while it does not lobby for specific legislation, is much concerned with all programs affecting the health and welfare of our population. That public health nurses are alert to the needs of mothers and children is evidenced by the proportionate amount of nursing activities devoted to their care. Data collected by the NOPHN from a representative sample of agencies show that in nonofficial agencies 13.6 percent of all public health nursing visits were made to maternity cases, 20.1 percent to infants and preschool children, and 0.3 percent to the school-age child. In the official agencies 8.6 percent of total nursing visits were made to maternity cases, 29.9 percent to infants and preschool children, and 11 percent to the school-age child. Approximately one-third of all home visits made by public health nurses are to mothers and children.

We would call to your attention exhibits I and II which show a comparison of the United States census maternal and infant mortality rates with distribution of public health nurses. They reveal that in the areas where the need is greatest the amount of nursing service is lowest. This in itself suggests the need for more public health nurses.

Foremost authorities in the public health field have accepted a ratio of 1 public health nurse to 2,000 population as meeting the basic needs of a community including care of the sick in the home. As of today two States only--New Hampshire and Connecticut-approximate this standard. More than 65.7 percent of our cities, with a population of 10,000 to 25,000, have no organized community resources for public health nursing care of the sick in the home. Approximately one-third of all the counties have no public health nurses giving maternity and child-health service.

To provide basic service to every county in the 48 States will necessitate an increase of approximately 40,000 well-qualified public-health nurses. pare these nurses and to better equip those already in the field, additional training facilities, instructors, and field supervisors are essential. Perhaps the best method of expediting this program would be through intensified training of approximately 300 able and experienced nurses, who in turn would serve in a teaching and consultant capacity to training centers and health agencies in the special fields of maternal, pediatric, and orthopedic nursing.

To conserve this Nation's most precious resource—a strong citizenry-necessitates comprehensive action at its source, the protection of the mother and infant of today.

Through the 16,200,000 visits made each year to the homes of our people, pubjic-health inurses are in a strategic position to know tragedies that often occur because of lack of medical care. Attached are some unedited case stories received from widespread communities, which demonstrate the need for, the value to, and the right of every mother and child to complete health and medical service of good quality.

To pre

Exhibit I.-Ratio of public health nurses to population, 1940

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! Including industrial nurses, but excluding nurses on staffs serving more than 1 State. Territories not included. Count made by U. S. Public Health Service as of Jan. 1, 1940.

State showing most favorable ratio of population to public health nurses is Connecticut, in which State this ratio is 2,466.4.

State showing least favorable ratio of population to public health nurses is Oklahoma, in which State this ratio is 16,453.8.

State showing median ratio of population to public health nurses is Washington in which State this ratio 7,144.8.

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