Mr. POND. I would like with the committee's approval to include some summary health manpower figures that I think will be of inter est to members of the committee.

Source: Estimates by Public Health Service, Division of Public Health Methods, April 1963.

Mr. POND. Briefly, about 2.2 million people are currently working in the health professions or in ancillary fields of providing health services for the American people.

We know a good deal about the dentists, about nurses, about the physicians, and about the public health workers, but we have a great deal to learn about other kinds of professional personnel which are of concern to all of us in providing the public health services.

One of the major problems in the Public Health Service is to move ahead on the careful analysis of the total manpower needs for health services in the United States, and this we can do.

With respect to the manpower problems at the present, Dr. Shannon, Dr. Anderson, and Dr. Christensen have all discussed some of the training activities of the Public Health Service. These activities provide for assistance to students, for graduate work, and for professional training. They also provide funds for the stimulation of better training programs in universities and professional schools. They provide for research fellowships to train people who are needed to carry on the research efforts of the Nation.

In my statement, Mr. Chairman, I also discuss the three major construction grant programs in which the Public Health Service is currently engaged: the Hill-Burton program which has been discussed somewhat by Dr. Christensen, the program for construction of waste treatment plants which Dr. Anderson mentioned the other day, and the health research facilities construction of the National Institutes of Health.

In addition to these programs, we do have a smaller one which is highly significant, nonetheless, for the construction of sanitary facilities on Indian reservations, a program which this committee started down its path some years ago.

In summary, Mr. Chairman, the principal points that I would like to make are that without an adequate source of skilled manpower and without the essential facilities for them to work in, and for the protection of the environment, we cannot expect to maintain the progress that this country has made in the last several years.

This committee has already considered what I think is a most important piece of health legislation, H.R. 12. This is going to be a real milestone when it is enacted. It will make it possible to do a better job of providing the basic manpower that we need in the health sciences.

Thank you very much, Mr. Chairman.

Mr. ROBERTS. Mr. Pond, just one or two questions.

I think sometimes that the general public lacks understanding as to what we are trying to do in the Indian health program. I, personally, visited some of the areas that are being affected by this new program, and I would like for you to tell briefly what was the problem, why they lacked certain sanitary facilities, and what part the governing bodies of the Indian tribes played and are playing in the parts of the States and Federal role of the Federal Government in trying to do something about the situation.

Mr. POND. Basically, Mr. Chairman, when the Indian health program was transferred to the Public Health Service in 1955, the health conditions on Indian reservations and among the American Indian and Alaska native populations were abominable. They lacked essential sanitary facilities; they had very inadequate health services: they had very limited immunizing activities of the type most health departments and most private physicians provide for the people elsewhere in the United States.

The Service has been able, with the help of Congress, to mount a very substantial program for the construction of decent health service facilities, hospitals, clinics, and other facilities for the care of the Indian population. It has made very real progress in the development of decent sanitary facilities on Indian reservations so that the Indian population can be protected against the enteric diseases which were ravaging the tribes and still do in some areas.

The basic effort of the Service can be summarized in this way: We have attempted to provide decent health facilities and adequate health services to the Indian people. We have attempted to develop a decent sanitary environment for the Indian people and we have carried on, I think. a very effective job of trying to teach the Indian people how to live in a healthful fashion. This has been done cooperatively with tribal representatives and tribes themselves, and has elicited, I think,

real support from the Indian people as well as from the Service itself.

We have some data here which I think might be interesting to the committee. For example, in 1954, in the Indian population of the United States, there was a death rate of 54 per hundred thousand from tuberculosis; in 1961, this has dropped to 21.

Mr. ROBERTS. Would you give that figure again, please?

Mr. POND. It was 54 in 1954, 54 per hundred thousand population; and it dropped to 21 in 1961.

Among the Alaskan natives the death rate from tuberculosis in 1954 was 236 per hundred thousand. This has dropped to 37 per hundred thousand.

Mr. ROBERTS. What about the infant mortality? Have we made any improvement in that?

Mr. POND. We have, sir.

For Indian babies, the death rate per thousand live births in 1954 was about 65; in 1961 it had dropped to about 43. For the rest of the population, as a comparison, the infant death rate for the United States as a whole was about 27 in 1954 and it dropped only to about 25 in 1961. It is a very dramatic drop among the Indians.

Mr. ROBERTS. Dollarwise, what are we spending on that program? Mr. POND. This year, we are spending around $56 million on the basic program, and the construction program is around $9 million. Mr. ROBERTS. Is most of that money, as far as the Federal Government is concerned, in the form of technical assistance?

Mr. POND. In part. The greater part is for the provision of direct services, or services provided under contract.

Mr. ROBERTS. How much of the money is being supplied by the tribes themselves, and by the States affected?

Mr. POND. I will have to supply that information for the record, sir.

Mr. ROBERTS. Without objection.

(The material referred to follows:)

THE INDIAN SANITATION FACILITIES CONSTRUCTION PROGRAM

Public Law 86-121, commonly referred to as the Indian Sanitation Facilities Construction Act, was approved July 31, 1959. This law authorizes the Surgeon General of the Public Health Service to work with the Indians and Alaska natives in construction of sanitation facalities for their homes and communities. Projects initiated under this authority involve modernization, construction and extension of community and individual water supply, waste disposal and drainage facilities.

Projects are undertaken only with the full knowledge, understanding, and participation of the beneficiary groups. Indian participation is obtained in project planning, in project execution and in assumption of responsibility for operation and maintenance of completed facilities.

The program began in fiscal year 1960. Through fiscal year 1963, a total of 168 construction projects and 66 emergency projects and engineering investigations at an estimated Federal cost of $9,750,000 have been programed. It is estimated than an additional $65 million will be necessary to meet the remaining known needs. Construction progress as of February 28, 1963, can be summarized as follows:

Construction projects authorized_.

Public Health Service-tribal agreements executed_.

Projects essentially completed_.

Projects under construction_.

Agreements to be negotiated.

168

147

68

49

21

Upon completion, Indian homes served by the foregoing projects will number more than 13,000.

During fiscal year 1963, an additional $3 million for 29 Indian sanitation facilities construction projects was made available under the public works acceleration program. Public Health Service-tribal agreements have been exe cuted for 25 of these projects, and work is progressing rapidly toward initiation of construction activity.

In addition to the foregoing budgeted activities, the Division of Indian Health provides the engineering and technical supervision to the Navajo tribal shallow well and spring development program. During fiscal years 1960, 1961, and 1962, approximately 887 projects financed by the tribe were constructed. It is anticipated that an additional 300 projects will be constructed in fiscal year 1963. Each project represents a watering point which serves 5 to 15 Navajo homes.

In the conduct of this program to date, increasing understanding by the Indian people of the advantages of adequate sanitation facilities has been demonstrated. Substantial contributions of labor, money, and materials have been made by the Indians to construction projects. The extent of Indian contributions to date is equivalent in value to approximately one-third of the total construction effort.

This cooperative construction activity between the tribes and the Public Health Service requires (1) frequent consultation regarding design, supervision of construction and tribal participation in the project, (2) development of operational and maintenance organizations within the Indian groups for continued operation and care of completed facilities, and (3) instruction of Indian people in maintenance, repair, and protection of sanitary facilities. The staff necessary to satisfactorily perform these duties when implementing a million dollars in construction is 10 field positions. These include engineers, construction supervisors, sanitarian aids, draftsmen, clerical and staff assistants.

Dr. TERRY. Mr. Chairman, I have the figures here for your information.

In relation to the Indian health program for 1963, there is a total of $55,834,000 with an additional $9,335,000 for construction.

Mr. ROBERTS. Now, what form does the Federal construction take, Dr. Terry?

Dr. TERRY. Federal construction takes several forms.

First, it takes the form of the construction of hospitals jointly used by Indians and non-Indians, including assistance to communities for the construction of hospitals, outpatient clinics, and that sort of facility.

In addition to that, there are funds for construction of sanitation facilities, sewage disposal plants, water supply systems, even individual wells or wells for communities. Those are the two general

areas.

Mr. ROBERTS. Do you see any trends in this programing? I mean by that, do you see any situation of a need for an increase or do you think that we are moving along very well within what we know and what we can do with the money that we have?

Dr. TERRY. As one looks back over our program since 1955 when this was given mainly as the responsibility of the Public Health Service, we have had gradual increases each year by the Congress, Mr. Chairman. One cannot move into this sort of program on a crash basis and suddenly change from the existing high death rate conditions to a situation comparable to the rest of the American people. Consequently, what we have seen over these 7 years is a gradual buildup in terms of the number of personnel we have been able to put into the program, the establishment of facilities, the training and education of the American Indian, and the Alaska native to use those facilities.