Dr. BAGNALL. Very much so.

Senator FERGUSON. Is that one of the reasons why it gets to the bottom rather than to the top?

Dr. BAGNALL. Social workers are much more active. It is a fulltime job with them, and with the medical men it is a part-time job, and a good many of them don't have time to devote the time and energy to the analysis and meeting of these problems.

Senator FERGUSON. Could that be remedied by getting some medical men in there who made a full-time job of it?

Dr. BAGNALL. I am very sure it could.

Senator FERGUSON. You think, though, that the mere consolidation of them interferes and permits one or the other to become more active, to dominate the other?

Dr. BAGNALL. I think the important thing is that, inherently, the social worker is in a career job which develops and evolves these plans more effectively, and I am sure perfectly sincerely. I think they want to do the job well, but my observation has been that the practice of medicine is so specialized a field that they do not give adequate consideration or they do not try hard enough to get the point of view of the doctors, and it is necessary in any plan where health is concerned that they do have the point of view of the doctors, and that they have cooperation.

I remember, for instance, within a few months the medical research head of one of the largest insurance companies told me that he was in serious difficulty because the doctors in a large city were hot after his local administrator there, and they had come to a point where blood was flowing and they wanted to make a national issue of it. He asked my advice, and I looked into the situation a little-this is a city of 100,000 people, and they had about 29,000 insured there he asked my advice, and I looked into the situation an found that he had not in the beginning made any attempt to get together with the doctors so that there would be a mutual understanding and correlation of the program. I told him I though the best thing to do was to go out there and talk with the doctors and be pretty humble about it, because he realized then that he had made a mistake. Well, to make a long story short, after he got through with it he told me that he never again would go into a community of that size without first contacting representatives of organized medicine in the community and getting understandings, so that all of these things could have been eliminated in advance.

Senator FERGUSON. Then your experience in Massachusetts brings you to these conclusions that you are now giving us, that in your opinion you should have a separate and distinct branch for medicine? Dr. BAGNALL. That is right.

Senator FERGUSON. And that the Federal Government should undertake it as a unit. Is it a big enough job, in your opinion, to be a Cabinet office?

Dr. BAGNALL. I think ultimately, yes. Perhaps with the set-up as Senator Taft has it in S. 545 as an agency, I think that would do temporarily.

While I think of it, it seems to me important that we should not rush in now and set the mold on this thing too soon. We are a little bit disturbed in Massachusetts about the fact that these bills have come in first instead of Senate 545.

Senator FERGUSON. And you think if you should set the mold to have the social services take over the Cabinet position, medicine might never get anywhere?

Dr. BAGNALL. I am afraid that is true. Those are the indications from past experience. I could elaborate on that a little bit, perhaps. In England, with the old health bill which they adopted first under Lloyd George, it took about 10 years before the administrators gave adequate consideration-it was a matter of trial and error, mainly error-it took about 10 years before they gave adequate consideration to the health part of the program. I think the doctors perhaps lacked in statesmanship and consideration. There was some fault on their side, but after about 10 years the administrators looked to organized medicine to settle these problems for them.

I think the tendency is too frequently for the administrators of these plans, whether they are social security or welfare people, not to give adequate consideration to the point of view of medicine. They are, perhaps, troubled by the tempermental traits of the doctors. They are individualists, and the doctors sometimes question the good faith of the social-security people. I do not for the most part. I think that for the most part they mean to do well, but they do not see the thing adequately from our point of view. We live with the people and we live pretty close to the grass roots on this thing, and we know what the troubles are, and it is quite a while before those troubles are ironed out so that they get to proper settlement.

In the old Veterans' Bureau program I think the position of the medical service there was probably principally responsible for the failures. Now, the new plan, General Hawley as a medical man has a pretty large range of responsibility and power in developing that plan, and he has developed it with organized medicine, and it seems to me he has done it rather well.

In Massachusetts we have the oldest department of public health in the country. It was established as a department of public health, but for a while it was considered desirable, as a matter of administrative efficiency, to change it to a combination of welfare and health. After a trial it was found that that did not work well at all, so they went back to the department of public health and a department of public welfare.

Senator FERGUSON. And they are now distinct departments?

Dr. BAGNALL. Yes. Of course, practically every commissioner of health is a physician. The health department, I think, on that account needs to work with the doctors, and works with the doctors much more effectively than welfare departments do.

I think S. 545 is a good structure from which to evolve a new set-up for medicine. Certainly something is going to be developed, and Senate 545 seems to us by all odds the best structure yet to start from, and it seems to me that if these bills now could wait until the studies that are a part of Senate bill 545 can be completed-for instance, a 6 months' study provided for of the United States Public Health Service, with a report at the end of 6 months-there will be more facts available after some experience with a plan of that sort, so that the future would be more secure for an adequate representation of the several departments in the set-up.

Senator FERGUSON. Then you indicate that this is not a matter that should be rushed, just to get a new cabinet position, but should have very careful study?

Dr. BAGNALL. I feel very strongly about that.

Senator FERGUSON. Are there any questions? Do you have anything further, Doctor?

Dr. BAGNALL. No, Senator; thank you.

Senator FERGUSON. Is Dr. Gourley, of the American Osteopathic Association, here? I believe you are general counsel for the association.

Mr. GOURLEY. That is right. I am not a doctor.

Senator FERGUSON. You may proceed with your statement.

STATEMENT OF L. L. GOURLEY, COUNSEL, AMERICAN OSTEOPATHIC ASSOCIATION, WASHINGTON, D. C.

Mr. GOURLEY. The American Osteopathic Association appreciates the invitation and privilege extended by this committee to advise with you on the provisions of Senate bills S. 140 and S. 712, which establish an executive department of health, education, and security. I am the legal counsel for the department of public relations of the association and I am appearing here as the deputy of the chairman of that department, Dr. Chester D. Swope. The statement that I am about to make has the approval of that department.

The

The American Osteopathic Association comprises some 9,000 out of a total of approximately 11,000 licensed and practicing osteopathic physicians. The policies of the association are determined by a house of delegates selected on a representative basis by divisional societies which in most instances are coterminus with State boundaries. house of delegates meets annually, and the interim governing body is a board of trustees consisting of 15 members elected by the house. The department of public relations is the instrument of the board of trustees which is charged with cooperation with Congress and the Federal departments. Neither the house of delegates nor the board of trustees has convened since these bills have been introduced. The attitude of the department of public relations here expressed is derived from the general policies of the association.

The motivation of both these bills S. 140 and S. 712 is worthy of commendation and we have amendments which we offer, we believe, in the public interest.

We direct attention first to S. 140, section 2 (a). We would strike the third, fourth, and fifth sentences, all of which have to do with prescribing the qualifications of the Under Secretaries of Health, Education, and Security. We think the President should be able to choose the best man for each job.

Senator FERGUSON. You think he should be a layman?

Mr. GOURLEY He might be a layman.

Senator FERGUSON. Would it be advantageous to have him a layman?

Mr. GOURLEY. I can see where a layman might very well be the best man for the post.

Senator FERGUSON. You prefer a layman, then, to an M. D.? Is that correct?

Mr. GOURLEY. I think that would be so.

Senator FERGUSON. Well, do you think that is generally true in the United States, that in health matters it would be well to keep the doctors out and put the laymen in as directors?

Mr. GOURLEY. Well, I cover that as I go along here, but I may say that it is not our impression that the creation of a Department of Health in the Federal Government means that the Federal Government is going to take over the practice of medicine in the States, or that it is going to furnish medical services generally in the States, to the point of necessitating a physician administrator.

Senator FERGUSON. In order to supervise this properly, doesn't a man have to know more about health than the average layman knows, the great mass of laymen? Isn't this a specialized job, whether it be an osteopath or M. D.? I am not distinguishing between an M. D. and an osteopath, but doesn't he have to have some special, distinct training in the field of health?

Mr. GOURLEY. Yes; I mention here, though, that in the 1940 census there were over a million persons engaged in health work. About 160,000 of them were doctors of medicine. Other physicians, doctors of public health

Senator FERGUSON. How many doctors of public health have we in the United States?

Mr. GOURLEY. There is no break-down on that.

Senator FERGUSON. Isn't this the trouble with the Census Bureau ratings: They ask a person what his occupation is, and he tells them he is in the health field, and they put that down?

Mr. GOURLEY. No; I think they break it down a little better than that.

Senator FERGUSON. What do they do? What is this million doing in health, if only 160,000 are doctors of medicine?

Mr. GOURLEY. Doctors of osteopathy, dentists, sanitary engineers; I could give you a partial break-down of it, I suppose, if you want it. Senator FERGUSON. I would like to have it for the record. I think it is important to have that.

Mr. GOURLEY. Doctors of medicine, 165,629; dentists, 70,601; nurses, 371,066; practical nurses and midwives, 109,287; pharmacists, 83,167. Senator FERGUSON. Pharmacists have a very distinct field, do they not?

Mr. GOURLEY. Yes, they do, and it is an important field in health. Osteopathic physicians, 6,067. Our 1940 directory listed some

9,700.

Senator FERGUSON. How would they serve in the health field, just practicing their profession?

Mr. GOURLEY. Osteopathic physicians? They would be active to the same extent as doctors of medicine.

Senator FERGUSON. In what way other than practicing their profession?

Mr. GOURLEY. Well, a number of them serve as school physicians, as town, city, and county health officers.

Senator FERGUSON. What I am trying to get at is this census rating. Mr. GOURLEY. The census rating here is an occupation.

Senator FERGUSON. Yes, an occupation rather than carrying on health work in the communities. How is that classified as health work rather than a profession?

Mr. GOURLEY. I am not sure that I get the drift of your question, Senator. They are all engaged in rendering health work throughout the country. Each one has his own place.

Senator FERGUSON. As a distinct profession?

Mr. GOURLEY. Yes.

Senator FERGUSON. Not necessarily in the public-health field as representing the State or the community or the United States?

Mr. GOURLEY. Not necessarily so. That is right-any more than, as I say, the doctor of medicine is in the category you are describing. Senator FERGUSON. Yes, a professional man.

Mr. GOURLEY. That is right. Do you want any more of this? Senator FERGUSON. Is it in the form of a paper, a pamphlet or something?

Mr. GOURLEY. Census bulletin, series P-14, No. 13, 1940 census. Chiropractors, 10,809; healers and medical services, 20,575; and others. Senator FERGUSON. Now proceed with your statement, Mr. Gourley. Mr. GOURLEY. We think the President should be able to choose the best man for each job. Inasmuch as he is responsible for the actions of each of them, it should be presumed that he will exercise the greatest care in their selection. That fact, together with the additional safeguard of the required advice and consent of the Senate as to the caliber and capacity of the appointees should be sufficient.

We are especially concerned with the requirements of S. 140 for appointment of an Under Secretary of Health. These requirements have no parallel in any of the other departments. The first requirement is that he be a doctor of medicine. We object to that requirement on these grounds.

The Department of Commerce Bulletin of the 1940 census indicates that there were a total of 1,058,995 persons in medical and health work at that time. We see no necessity for restricting eligibility to

one group.

As we see it, the principal activities of the Division of Health would be public health and preventive medicine, and the administration of grants-in-aid in the health fields. A physician whether he be a doctor of medicine or doctor of osteopathy is trained primarily to treat the sick and injured. A preliminary report on the teaching of preventive medicine and public health by the American Association of Medical Colleges which appeared in the March 1942 issue of the Journal of the American Medical Association stated in part as follows [reading]:

There is as much variation in the number of hours assigned to the teaching of this subject as there is in the content. A few schools provide no instruction at all in preventive medicine and public health, as such, while a few others provide more than 200 hours. The median number of clock hours is 82. Compared to the total number of hours available in the whole medical school curriculum, this represents 1.9 percent as against 4 percent advocated by the American Medical Association and the Association of American Medical Colleges. Premedical schools appear to have reached this recommended goal.

The best known schools of public health are located at the University of Michigan and Yale University, neither of which requires a degree of doctor of medicine.

Senator FERGUSON. But much of their teaching is in the medical school, is it not?

Mr. GOURLEY. I believe so.