HEALTH MANPOWER ACT OF 1968; HEARINGS BEFORE THE SUBCOMMITTEE ON HEALTH, OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE. UNITED STATES SENATE NINETIETH CONGRESS SECOND SESSION ON S. 3095 TO AMEND THE PUBLIC HEALTH SERVICE ACT TO EXTEND AND IMPROVE THE PROGRAMS RELATING TO THE TRAINING OF NURSING AND OTHER HEALTH PROFESSIONS AND ALLIED HEALTH PROFESSIONS PERSONNEL, THE PROGRAM RELATING TO STUDENT AID FOR SUCH PERSONNEL, AND THE PROGRAM RELATING TO HEALTH RESEARCH FACILITIES, AND FOR OTHER PURPOSES and S. 255 TO AMEND TITLE VII OF THE PUBLIC HEALTH SERVICE ACT TO AUTHORIZE DIRECT STUDENT LOANS TO BE MADE TO CERTAIN STUDENTS STUDYING OUTSIDE THE UNITED STATES ) MARCH 20 AND 21, 1968 Printed for the use of the Committee on Labor and Public Welfare, + JUL 171968 U.S. GOVERNMENT. PNNTING OFFICE 92-079 0 WASHINGTON N IV. OF t ALIF, HEALTH LIBRARY PUBLIC HEALTH COMMITTEE ON LABOR AND PUBLIC WELFARE LISTER HILL, Alabama, Chairman WAYNE MORSE, Oregon RALPH W., YARBOROUGH, Texas JOSEPH 8. CLARK, Pennsylvania JENNINGS RANDOLPH, West Virginia HARRISON A. WILLIAMS, JR., New Jersey CLAIBORNE PELL, Rhode Island EDWARD M. KENNEDY, Massachusetts GAYLORD NELSON, Wisconsin ROBERT F. KENNEDY, New York JACOB K. JAVITS, New York WINSTON L. PROUTY, Vermont PETER H. DOMINICK, Colorado GEORGE MURPHY, California PAUL J. FANNIN, Arizona ROBERT P. GRIFFIN, Michigan STEWART E. MCCLURE, Chief Clerk JoHN 8S. FORSYTHE, General Counsel EUGENE MITTELMAN, Minority Counsel SUBCOMMITTEE ON HEALTH LISTER HILL, Alabama, Chairman RALPH W. YARBOROUGH, Texas JACOB K. JAVITS, New York HARRISON A. WILLIAMS, Jr., New Jersey GEORGE MURPHY, California CLAIBORNE PELL, Rhode Island EDWARD M. KENNEDY, Massachusetts PETER H. DOMINICK, Colorado ROBERT W. BARCLAY, Professional Staff Member Roy H. MILLENSON, Minority Clerk (11) Text of : 8 BOD. ii img es ig who op RE A A ti Section-by-section analysis of - _ _____________________________ Departmental report: Department of Health, Education, and Welfare, ________ CHRONOLOGICAL LIST OF WITNESSES Marca 20, 1968 Javits, Hon. Jacob K., a U.S. Senator from the State of New York________ Lee, Dr. Phillip R., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare; accompanied by Ralph K. Huitt, Assistant Secretary for Legislation; and Dr. Leonard D. Ponpinge Director, Bureau of Health Manpower, Public Health rr TE Timer. 0 Cor. SAL. Se Hubbard, Dr. William H., Jr., past president, Association of American Medical Colleges, Ann Arbor, Mich.; accompanied by Dr. Robert Berson, director, Washington, D. OARS RN ie er Cohelan, Dr. Evelyn, chairman, Committee on Legislation, American Nurses’ Association; accompanied by Miss Helen Connors, director of government relations_____________________________________________ Conley, Miss L. Ann, president, National League for Nursing; accompanied by Dr. Margaret Harty, director, nursing education programs, National League fOr NUTBING.. o.com opie vimimiprvhm FE Ho or pig es Collins, Rev. T. Byron, 8.J., vice president for planning, Georgetown Uni- versity, Washington, D.C___.______________________ o_o ____. Greene, James E., D.V.M., dean, School of Veterinary Medicine, Auburn University, Auburn, Ala.; accompanied by W.T.S. ore: D.V.M,, chair- man, Joint Committee on Education, American Veterinary Medical As- sociation; and Alvin A. Price, D.V.M., dean, College of Veterinary Medicine, Texas A. & M. University. ____________________________ MarcH 21, 1968 McCallum, Dr. Charles A., Jr., dean, University of Alabama School of Dentistry, consultant, Council on Dental Education, and vice president, American Association of Dental Schools; accompanied by Bernard J. Conway, chief legal officer, American Denatal Association; and Benjamin J. Miller III, secretary-treasurer, American Association of Dental Holmes, Reid T., Winston-Salem (N.C.) Council on Government Relations, American Hospital Association; accompanied by Kenneth Williamson, associate director, American Hospital Association, and director, Wash- INZLON, BOIVILE BULB... oes ire soins shld wm hip eo re am i i at oa Sodeman, Dr. William A., Philadelphia, Pa., member, Council on Medical Education, American Medical Association; accompanied by Dr. C. H. William Ruhe, director, Division of Medical Education; and Bernard P. Harrison, director, AMA Legislative Department____________________ Page, Dr. Robert G., associate dean, Division of Biological Sciences, Uni- versity of Chicago, chairman, Committee on Medical Education, Ameri- can Heart Association; accompanied by Dr. Clayton B. Ethridge, Wash- ington, D.C., member, Legislative Advisory Couneil__________________ (III) 386 Page 53 46 43 46 102 112 123 140 141 205 211 220 Iv Bliven, Charles W., executive secretary, American Association of Colleges of Pharmacy; accompanied by Dr. George L. Webster, president, and David 8. Newton, projects director_ _______________________________ Moore, Margaret L., chairman, Committee on Financial Needs for Schools of Physical Therapy, Council of Physical Therapy School Directors, Inc.; director, Division of Physical Therapy; Associate Professor of Physical Therapy, School of Medicine, University of North Carolina, Chapel Hill, NC iin BB nmi gg a sesamin aye Brunyate, Miss Ruth, chairman, legislative committee and past presi- dent, American Occupational Therapy Association _________________ STATEMENTS Allam, Dr. Mark W., dean, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, prepared statement_____________________ American Veterinary Medical Association, prepared statement, submitted by Alvin A. Price, D.V.M., dean, College of Veterinary Medicine, Texas Ai & Ml, UNV OISIUY cc cm em gm mm ig swoon gc pe ye og em i Armistead, W. W., dean, College of Veterinary Medicine, Michigan State University, prepared statement____________________________________ Arnold, Christian K., on behalf of the National Association of State Uni- versities and Land-Grant Colleges, prepared statement_______________ Bliven, Charles W., executive secretary, American Association of Colleges of Pharmacy; accompanied by Dr. George L. Webster, president; and David 8. Newton, projects director ______________________________ Prepared statement. _ o_o ___ aT Booth, Nicholas H., dean, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colo., prepared A OUI OND i mrad ron i ml ot AE A TE Brandly, C. A., dean, College of Veterinary Medicine, University of Illinois, Urbana, Ill., prepared statement _________________________ Brunyate, Miss Ruth, chairman, legislative committee and past president, American Occupational Therapy Association _______________________ Clarkson, Dr. M. R., executive secretary, American Veterinary Medical Association, Jfepated BUILOINCIL. iv oo os cs i gsm sr ero i Cohelan, Dr. Evelyn, chairman, Committee on Legislation, American Nurses’ Association; accompanied by Miss Helen Connors, director of Government relations... coe mm—————— Prepared statement____________________________________________ Cole, Clarence R., D.V.M., Ph. D., regents’ professor of comparative path- ology and dean, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, prepared statement, with attachment. ______________ Collins, Rev. T. Byron, S.J., vice president for planning, Georgetown University, Washington, D.C___________________._ ________________ Conley, Miss L. Ann, president, National League for Nursing; accompa- nied by Dr. Margaret Harty, director, nursing education programs, National League for Nursing __._________________________________ Cornelius, C. E., dean, College of Veterinary Medicine, Kansas State University, Manhattan, prepared statement _______________________ Georgia Veterinary Medical Association, prepared statement, presented by Jesse Derrick, president, Athens, Ga___________________________ Greene, James E., D.V.M., dean, School of Veterinary Medicine, Auburn University, Auburn, Ala.; accompanied by W. T. S. Thorp, D.V.M,, chairman, Joint Committee on Education, American Veterinary Med- ical Association; and Alvin A. Price, D.V.M., dean, College of Veterinary Medicine, Texas A. & M. University. ______________________________ Prepared statement... o.oo Hager, George P., dean, School of Pharmacy, University of North Carolina, hapel Hill, N.C., prepared statement_____________________________ Holmes, Reid T., Winston-Salem (N.C.), Council on Government Rela- tions, American Hospital Association; accompanied by Kenneth William- son, associate director, American Hospital Association, and director, Washington Service Bureau. _____________________________________ Hubbard, Dr. William N., Jr., past president, Association of American Medical Colleges, Ann Arbor, Mich.; accompanied by Dr. Robert Berson, director, Washington, D.C., office. _______________________ Prepared statement. ___________________________ ________ o_o... Javits, Hon. Jacob K., a U.S. Senator from the State of New York______ Page 240 254 261 184 151 171 288 240 247 184 191 261 185 112 116 175 140 123 183 161 141 143 281 211 102 106 Vv Kingrey, Dr. B. W., dean, School of Veterinary Medicine, University of Missouri, Columbia, Mo., prepared statement _____________________ Lee, Dr. Phillip R., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare; fopnmpanicd by Ralph K. Huitt, Assistant Secretary] for Legislation; and Dr. Leonard D. Fen- ninger, Director, Bureau of Health Manpower, Public Health Service__ McCallum, Dr. Charles A., Jr., dean, University of Alabama School of Dentistry, consultant, Council on Dental Education, and vice president, American Association of Dental Schools accompanied by Bernard J. Conway, chief legal officer, American Dental Association; and Benjamin J. Miller III, secretary-treasurer, American Association of DENUIL BOOONE.. .. ey cm goin mm mm mc i 50 McKibben, John S., B.S.,, D.V.M., M.S., professor, Department of Anatomy, College of Veterinary Medicine, Iowa State University, Ames, Towa, Prepared SIALOTNONT. . «uw cum wisp pins simi. mm i ea ioe egos Melby, Dr. Edward C., Jr., and Dr. Robert A. Squire, Johns Hopkins University, School of Medicine, Baltimore, Md., prepared statement____ Moore, Margaret L., chairman, committee on Financial Needs for Schools of Physical Therapy, council of Physical Therapy School Directors, Ine.; director division of physical therapy; associate professor of physical therapy, School of Medicine, University of North Carolina, Chapel HI), WC... comm sn mei se mi mim rain ss coir sos i ST rm ar st Prepared SUALOINIEIE. - «oy rom = im emis mm og sin me cmon sm gp 0 Morse, Dr. Erskine V., dean, School of Veterinary Science and Medicine, Purdue University, Lafayette, Ind., prepared statement______________ Page, Dr. Robert G., associate dean, Division of Biological Sciences, Uni- versity of Chicago, chairman, committee on Medical Education, Ameri- can Heart Association; accompanied by Dr. Clayton B. Ethridge, Wash- ington, D.C., member, Legislative Advisory Ceouneil-________________ Peters, Henry B., O.D., assistant dean, School of Optometry, University of California, Berkeley, Calif., on behalf of the Association of Schools and Colleges of Optometry and the American Optometric Association, Washington, D.C., prepared statement, with attachments____________ Pohlit, Nicholas, executive director, National Association of Sanitarians, Denver, Colo., prepared statement._________________________________ Poppensich George C., dean, New York State Veterinary College, ornell University, Ithaca, N.Y., prepared statement_._______________ Price, Alvin A., D.V.N., dean, College of Veterinary Medicine, Texas A. & M. University: Prepared statement____________________________________________ Supplemental statement _______________________________________ Pritchard, W. R., D.V.M., dean, School of Veterinary Medicine, Uni- versity of California, Davis, Calif., prepared statement. ______________ Schmidt, Mrs. Etta B., executive director, National Federation of Licensed Practical Nurses, prepared statement, with attachments _____________ Sodeman, Dr. William A., Philadelphia, Pa., member, Council on Medical Education, American Medical Association; accompanied by Dr. C. H. William Ruhe, director, Division of Medical Education; and Bernard P. Harrison, director, AMA Legislative Department_________________ Thorp, W.T.S., D.V.M., chairman, Joint Committee on Education, American Veterinary Medical Association, prepared statement _______ Georgia, University of, prepared statement submitted by Fred C. Davison, DECBIAOIL.. «cima vor ss oe so sc se el 0 aur 0 i a is ro Williams, T. S., dean, School of Veterinary Medicine, Tuskegee Institute, Tuskegee, Ala., prepared statement_________________ _______________ ADDITIONAL INFORMATION Articles, publications, ete., entitled: “Accomplishments Under Health Professions Construction Program,” supplied by Dr. Phillip R. Lee, Assistant Secretary for Health and Scientific Affairs, Department of Health, Education and Welfare. _ “Demand-Supply Relationships for Veterinarians, 1960 to 1980,” by J. C. Thompson, Jr., Ph. D., reprinted from the Journal of the American Veterinary Medical Association, October 15, 1967______ “Direct Student Loans to American Medical Students Abroad,” opening statement of Senator Javits, January 12, 1967, on S. 255, from the Congressional Record January 12, 1967________________ “Nursing Education Accreditation—A Service of the National League for RorSiiel. ou prune ummenmemm sms mse ESE re a Page 170 46 205 188 168 254 258 194 236 270 264 195 172 174 164 266 220 146 162 168 73 196 86 136 VI Availability of financial assistance to graduate students in hospital adminis- tration under the MDEA and Higher Education Acts. _______________ Comments of : Department of Health, Education, and Welfare, re direct student loans to American citizens studying at foreign medical schools____ Officials of schools and colleges of optometry re S. 3095, with attach- BOE. 0 ielo is arn sans sms mm RA Ss ww ie Communications to: Committee on Labor and Public Welfare, from J. Robert Brouse, executive vice president, Animal Health Institute, Washington, D.C, March 06; 188... commis mim mpi sili ve msm mors mon mg on Hill, Hon. Lister, a U.S. Senator from the State of Alabama, from: Arnold, Christian K., National Association of State Universities and Land-Grant Colleges, Washington, D.C., March 28, 1968, WELLE TCD CTIYNCIVL,.... o.oo mg 5 mo eg Blasingame, F. J. L., M.D., American Medical Association, Chi- cago, TI, March 27, 1968... ceecpemwmmm mmmmmmmsg m Davison, Fred C., president, University of Georgia, Athens, Ga., March 23, 1968, with attachment__________________________ Entwisle, George, M.D., president, Association of Teachers of Preventive Medicine, March 28, 1968. ___________________._.. Hager, George P., dean, University of North Carolina, Chapel Ho N.C., March 24, 1968, with attachment________________ Mattison, Berwyn F., M.D., executive director, the American Public Health Association, Inc., March 26, 1968_____________ Mickelson, Barbara, president, National Student Nurses Associa- tion, New York, N.Y., March 19; 1968... .cvcvereennumunen Pomerantz, Max M., M.D., president, American Association of Colleges of Podiatric Medicine, Washington, D.C., March 26, Simmons, Willard B., executive secretary, the National Associa- tion of Retail Druggists, Washington, D.C., March 28, 1968__ Stetler, C. Joseph, Pharmaceutical Manufacturers Association, Washington, D.C., March 27, 1968_ _ _ ____________________._ Stevens, Christine, president, Animal Welfare Institute, New York, NX. Moreh 26, LOBB.. .....c...w ois oo sion ods om wn 0 0 mi wes Terry, Luther L., M.D., University of Pennsylvania, Philadelphia, Po, Maroh 258, 1068... oc ti ithe wis ti mom mim me memo ge mim Wellington, Edmund, Jr., executive secretary, American Dental Trade Association, Washington, D.C., April 3, 1968___________ Javits, Hon. Jacob K., a U.S. Senator from the State of New York, from Lewis Thomas, M.D., chairman, Committee on Medical Edu- CObION, MATE 27, 1 BOBS. oo om iin seston em om i im pen Pell, Hon. Claiborne, a U.S. Senator from the State of Rhode Island, from: Kelleher, Margaret C., R.N., State director, Nursing Education, Department of Health, Providence, R.I., March 25, 1968_ _ _ ___ Murphy, Rita M., director, Public Health Nursing, State Depart- ment of Health, Providence, R.I., March 20, 1968_____________ Todd, Dr. Frank A., American Veterinary Medical Association, Washington, D.C., from: Christian, George C., vice president for Academic Affairs, Iowa State University, Ames. _ o_o... Kitchell, R. L., dean, College of Veterinary Medicine, Iowa State UTIVETSILY, ATE. tv otic limon ote mi iio sg cy cmos ron Contracts to encourage full utilization of nursing educational talent under section 868 of the PHS Act, reporton._ ______________________________ Exhibits submitted by Miss 3% Rn Conley, president, National League for Nursing, Detroit, Mich.: I—Role and functions of the National League for Nursing_______._____ II-A—Admissions and graduation for baccalaureate programs in Nursing, September 1 through August 31, 1962-63 through 1966— 07, DY DCOTCHILALION.. ov ie ss rm nr om re on mn mo ok mm em sre II-B—Admissions and graduations for diploma programs in nursing, September 1 through August 31, 1962-63 through 1966-67, by accreditation status. co ce cic mes ea wt Si Page 220 87 271 291 287 226 162 286 279 274 122 275 277 278 276 158 289 290 289 290 171 191 99 129 130 130 VII Exhibits submitted by Miss L. Ann Conley—Continued II-C—Admissions and graduations for associate degree programs in nursing, September 1 through August 31, 1962-63 through 1966-67, by acereditationstatus.. .... ove mm——————— II-D—Admissions, graduations, and enrollments in baccalaureate programs in nursing (registered nurse), by type of program and accreditation status as of January 1968__________________________ III—Educational programs in nursing, 1967—Associate degree, bac- calaureate, diploma, master degree, by States and accreditation SEIU TATS = ccm 150070 st mp oe meee ios i Ge i ee IV—Data on NLN reasonable assurance of accreditation under Nurse Training Act of 1964____ ______________ __________________ V—TFull-time faculty teaching in nursing departments, schools, or pro- grams as of January 3, 1966, by type of program and highest earned CLBABINLIAL. oc oc roe mm mm mm so spe ms gigs i pm VI—Number of candidates and percent failing State board test pool examinations for licensure of registered nurses____________________ VII—NLN accrediting practices and charges for associate degree, baccalaureate and masters, and diploma nursing programs_ _ _ ______ VIII-A—Reasonable assurance of accreditation under the Nurse Training Act of 1964—New nursing programs____________________ VIII-B—Reasonable assurance of accreditation under the Nurse Training Act of 1964—Established nursing programs______________ Report of the National Advisory Commission on Health Manpower, Volume 1, November 1967, excerpt from_____________________________ Response of Dr. Phillip R. Lee, assistant secretary for Health and Secien- tific Affairs, Department of Health, Education, and Welfare, to ques- tions submitted by Senator Jacob K. Javits__________________________ Selected charts and tables: Estimated new obligation authority required for fiscal year 1969-73 under Health Manpower Actof 1968____________________________ Graduates of schools of medicine and osteopathy... ______________ New medical schools opened or planning to open, with assistance of constructionfundsunderHPEA . . . .. eee Number of programs and enrollments by accreditation status and type of program, 1965and 1968_____________________________________ Physicians in relation to population, 1963-67_______________________ Total enrollment in U.S. medical schools, 1962-63 through 1967-68___ _ U.S. medical students, 1965-66_ _ _ _ _______ ______________________ Page 131 131 132 133 133 134 134 135 135 239 88 oR - = A LE. * = oe? $n at EA oo " a " a 1 oe a ' 7 N a cu kd “ I » a : fw ws fend ¥ HEALTH MANPOWER ACT OF 1968 WEDNESDAY, MARCH 20, 1968 U.S. SENATE, SUBCOMMITTEE oN HEALTH OF THE ComMmITTEE ON LABOR AND PuBric WELFARE, Washington, D.C. The subcommittee met, pursuant to notice, at 10:35 a.m., in room 4232, New Senate Office Building, Senator Lister Hill (chairman) presiding. Present : Senators Hill (presiding), Yarborough, and Javits. Committee staff present: Robert W. Barclay, professional staff member ; and Roy H. Millenson, minority clerk. The Crarrman. The subcommittee this morning is meeting to re- ceive testimony on S. 3095, the Health Manpower Act of 1968. This legislation would extend the Health Professions Educational Assistance Act, the Nurse Training Act, the Allied Health Professions Personnel Training Act, the Health Research Facilities Act, and the authorities for traineeships and training grants in public health. The need for expanding our training capacity for health man- power has been well documented since 1951 in studies authored by the Rusk Committee, the Magnuson Commission, the Bayne-Jones Committee, the Bane Committee, and the Jones Committee. Most re- cently the National Advisory Commission on Health Manpower emphasized again the shortages of health manpower that exist in our country today. The legislation that we are considering today will permit further progress in increasing the supply of health man- power. It will also carry out many of the recommendations of the National Advisory Commission on Health Manpower. As we all know, the Chairman of that Commission was Mr. J. Irwin Miller, who serves as chairman of the Cummins Engine Co. in Columbus, Ind. We will also consider S. 255 that would authorize loans to certain health students who are citizens of this country studying outside the United States. Senator Javits. STATEMENT OF HON. JACOB K. JAVITS, A U.S. SENATOR FROM THE STATE OF NEW YORK Senator Javrrs. The hearings we are undertaking this morning on health manpower deal, in effect, with the two principal health prob- lems facing the Nation—delivery of health care and rapidly rising health costs. Our Nation is short 50,000 doctors; 5,000 U.S. communities are without any physician and the number is rising. As to the shortage of nurses, the report of the New York State Joint Legislative Committee on the Problems of Public Health and Medi- (1) 2 care, the Lent report, states that the “single most important health problem in New York State and the Nation is how to increase the number of professional registered nurses.” Health manpower relates directly to the price of medical care. Per- sonnel costs, for example, comprise 70 percent of hospital operating SEonses. And hospital fees are rising twice as fast as the cost of iving. Not only do we have a responsibility to meet growing health man- power demands in the almost 200 health occupations but the Nation also has a responsibility to modernize health care at all levels. This would include, for instance, a reexamination of medical education which has not undergone an extensive revamping for almost two gen- erations. Already progress is being made in this direction as some medical schools are cutting down on the lengthy course of study and redesigning curriculum. We must also apply ourselves to cutting down the wasteful high dropout rate of medical students—running more than 10 percent—who leave in midcourse. And we must sustain our medical schools so that the thousands of qualified young people who are discouraged from undertaking a medical education because of lack of funds or lack of facilities might be able to pursue a medical career. The bill before us goes far to meet these needs. I will, however, be offering amendments so that our goals might better be achieved. First, I will offer as an amendment, S. 255, the bill Senator Yar- borough and I introduced on January 12, 1967, to authorize direct loans to U.S. medical students studying outside the United States. This measure would give to Americans studying medicine and dentistry abroad the same loan program given Americans studying at home. I ask that the explanatory statement I made at the time of the intro- duction of this measure be included in my remarks. The Senate on October 13, 1966, approved the language of this bill as part of the International Education Act but the provision was dropped by the House in conference solely for jurisdictional reasons. Secondly, I intend to propose that S. 3095 be amended so that the student aid programs contained therein conform, where practical, to those contained in higher education legislation. For example, the higher education bill before this committee, S. 3095, provides a 3- percent administrative expense for schools for student aid programs; this bill does not. Third, I shall move to establish a matching program for State scholarship programs for nurses. Some 19 States now have such pro- rams. More should. Present programs should be expanded. New York tate, for instance, is now actively considering a proposal by State Senator Norman Lent to double from 300 to 600 the number of nursing scholarships given by the State. The additional cost will be a maximum of $300,000. Finally, I intend to introduce amendemnts which will look to the encouragement of upward mobility in nursing so that ILPN’s might be helped to advance into the RN field. This would also serve to encourage persons to enter into the LPN field. Mr. Chairman, the bill before us, S. 3095, offers great oppor- tunities for the Congress to met effectively the twin problems of de- livery of health services and health costs, problems which have been— and are continuing to be—thoroughly studied and now demand action. (Text of bills S. 3095 and S. 255 and a departmental report follow :) 90ra CONGRESS 2p SESSION S 3 0 0 5 ° IN THE SENATE OF THE UNITED STATES Marcu 5, 1968 Mr. Hrwy introduced the following bill; which was read twice and referred to the Committee on Labor and Public Welfare A BILL To amend the Public Health Service Act to extend and improve Bw DR the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for such personnel, and the program relating to health research facilities, and for other purposes. Be it enacted by the Senate and House of Representa- tives of the United States of America in Congress assembled, That this Act may be cited as the “Health Manpower Act of 1968”. SEC. 2. As used in the amendments made by this Act, the term “Secretary”, unless the context otherwise requires, means the Secretary of Health, Education, and Welfare. B= Ww Nn [9] 10 11 12 13 14 15 16 17 18 19 20 21 22 2 TITLE I—HEALTH PROFESSIONS TRAINING Parr A—CONSTRUCTION GRANTS EXTENSION OF CONSTRUCTION AUTHORIZATIONS SEC. 101. (a) Section 720 of the Public Health Service Act (42 U.S.C. 293) is amended by inserting after and below clause (3) of the first sentence thereof the following new sentence: “For such grants there are also authorized to be appropriated such sums as may be necessary for the fiscal year ending June 30, 1970, and each of the next three fiscal years.” FEDERAL SHARE Sec. 102. (a) Subsection (a) (1) of section 722 of the Public Health Service Act (42 U.S.C. 293D) is amended by striking out “such amount may not exceed 50 per centum” and inserting in lieu thereof “such amount may not, except where the Secretary determines that unusual circumstances make a larger percentage (which in no case may exceed 663 per centum) necessary in order to effectuate the pur- poses of this part, exceed 50 per centum.” (b) The amendments made by this section shall apply in the case of projects for which grants are made from ap- propriations for fiscal years ending after June 30, 1969. = [5] 10 11 12 13 14 15 16 7 18 19 20 21 22 3 LENGTH AND CITARACTER OF FEDERAL RECOVERY INTEREST IN FACILITIES Sec. 103. (a) (1) Clause (b) of section 723 of the Public Health Service Act (42 U.S.C. 293¢) is amended to read as follows: “(b) the facility shall cease to be used for the teach- ing purposes (and the other purposes permitted under section 722) for which it was constructed, unless the Secretary determines that it is being and will be used for— “(1) any teaching purposes for which a grant was authorized to he made under this part, “(2) research purposes, or research and related purposes, in the sciences related to health (within the meaning of part A), or “(3) medical library purposes (within the meaning of part I of title ITT), or the Secretary determines, in accordance with regula- tions, that there is good cause for releasing the applicant or other owner from the obligation to do so,”. (2) Clause (A) of section 721 (¢) (2) of such Act (42 U.S.C. 293a) is amended to read: “(A) the facility is 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 4 intended to be used for the purposes for which the applica- tion has been made,”. (b) The amendment made by subsection (a) (1) shall apply in the case of facilities for which a grant has been or is in the future made under part B of title VII of the Public Health Service Act. The amendment made by subsection (a) (2) shall apply in the case of assurances given after the date of enactment of this Act under such part B. GRANTS FOR MULTIPURPOSE FACILITIES SEC. 104. (a) Section 722 of the Public Health Service Act (42 U.S.C. 293b) is further amended by adding at the end thereof the following new subsection: “(d) In the case of a project for construction of facilities which are to a substantial extent (as determined in accord- ance with regulations of the Secretary) for teaching pur- poses and for which a grant may be made under this part, but which also are for research purposes, or research and related purposes, in the sciences related to health (within the mean- ing of part A of this title) or for medical library purposes (within the meaning of part I of title III), the project shall, insofar as all such purposes are involved, be regarded as a project for facilities with respect to which a grant may be made under this part.” (b) The amendment made by subsection (a) shall © ow = 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 5 apply in the case of projects for which grants are made under part B of title VII of the Public Health Service Act from appropriations for fiscal years ending after June 30, 1969. GRANTS FOR CONTINUING AND ADVANCED EDUCATION FACILITIES Sec. 105. (a) Paragraph (3) of section 721 (¢) of the Public Health Service Act (42 U.S.C. 293a) is amended by inserting before the semicolon at the end thereof the follow- ing: “ (and, for purposes of this part, expansion or curtail ment of capacity for continuing education shall also be con- sidered expansion and curtailment, respectively, of training capacity) ”. (b) Subsection (d) of section 721 of such Act is amended by inserting (other than a project for facilities for continuing education)” after “an existing school” in para- graph (1) (A) and after “a school” in paragraph (1) (B). (c) Section 724 (4) of such Act is amended by insert- ing before the semicolon at the end thereof: “, and including advanced training related to such training provided by any such school”. (d) The amendments made by this section shall apply in the case of projects for which grants are made under part B of title VII of the Public Health Service Act from appropria- tions for fiscal years ending after June 30, 1969. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 6 PART B—INSTITUTIONAL AND SPECIAL PROJECT GRANTS FOR TRAINING OF HEALTH PROFESSIONS PERSONNEL Sec. 111. (a) Sections 770, 771, and 772 of the Public Health Service Act (42 U.S.C. 295f, 295-1, 295{-2) are amended to read as follows: “AUTHORIZATION FOR APPROPRIATIONS “Sec. 770. (a) There are authorized to be appropriated for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary for institutional grants under section 771 and special project grants under section 772. “(b) The portion of the a so appropriated for each fiscal year which shall be available for grants under each such section shall be determined by the Secretary unless otherwise provided in the Act or Acts appropriating such sums for such year. “INSTITUTIONAL GRANTS Sec. 771. (a) (1) The sums available for grants under this section from appropriations under section 770 for the fiscal year ending June 30, 1970, or any of the next three fiscal years shall be distributed to the schools of medicine, dentistry, osteopathy, optometry, and podiatry with approved applications as follows: Each school shall receive $25,000; and of the remainder— 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 7 “(A) 75 per centum shall be distributed on the basis of— “(i) the relative enrollment of full-time stu- dents for such year, and “(ii) the relative increase in enrollment of such students for such year over the average enroll- ment of such school for the five school years pre- ceding the year for which the application is made; with the amount per full-time student so computed that a school receives twice as much: for each such student in the increase as for other full-time students, and “(B) 25 per centum shall be distributed on the basis of the relative number of graduates for such year. “(2) The sum computed under paragraph (1) for any school which is less than the amount such school received under this section for the fiscal year ending June 30, 1969, shall be increased to that amount, the total of the increases thereby required being derived by proportionately reducing the sums computed under such paragraph (1) for the remain- ing schools, but with such adjustments as may be necessary to prevent the sums computed for any of such remaining schools from being reduced to less than the amount it received for such fiscal year ending June 30, 1969, under this section. 92-079 O - 68 - 2 =>} BH Ww NN © ow J 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 10 8 “(b) (1) The Secretary shall not make a grant under this section to any school unless the application for such grant contains or is supported by reasonable assurances that for the first school year beginning after the fiscal year for which such grant is made and each school year thereafter during which such a grant is made the first-year enrollment of full-time students in such school will exceed the average first-year enrollment of such students in such school for the five school years during the period of July 1, 1963, through June 30, 1968, by at least 24 per centum of such average first-year enrollment, or by five students, whichever is greater. The requirements of this paragraph shall be in addition to the requirements of section 721 (¢) (2) (D) of this Act, where applicable. The Secretary is authorized to waive (in whole or in part) the provisions of this paragraph if he determines, after consultation with the National Ad- visory Council on Health Professions Educational Assistance that the required increase in first-year enrollment of full-time students in a school cannot be accomplished without lowering the quality of training provided therein, or if he determines, after such consultation, that to do so would otherwise be in the public interest and consistent with the purposes of this part. | “(2) Notwithstanding the preceding provisions of this section, no grant under this section to any school for any = Ww nN © ow = 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 11 9 fiscal year may exceed the total of the funds from non- Federal sources expended (excluding expenditures of a nonrecurring nature) by the school during the preceding year for teaching purposes (as determined in accordance with criteria prescribed by the Secretary), except that this paragraph shall not apply in the case of a school which has for such year a particular year-class which it did not have for the preceding year. “(c) (1) For purposes of this part and part F, regula- tions of the Secretary shall include provisions relating to determination of the number of students enrolled in a school, or in a particular year-class in a school, or the number of graduates, as the case may be, on the basis of estimates, or on the basis of the number of students who were enrolled in a school, or in a particular year-class in a school, or were graduates, in an earlier year, as the case may be, or on such basis as he deems appropriate for making such deter- mination, and shall include methods of making such deter- minations when a school or a year-class was not in existence in an earlier year at a school. “(2) For purposes of this part and part F, the term ‘full-time students’ (whether such term is used by itself or in connection with a particular year-class) means students pursuing a full-time course of study leading to a degree of 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 12 10 doctor of medicine, doctor of dentistry, or an equivalent degree, doctor of osteopathy, bachelor of science in pharmacy or doctor of pharmacy, doctor of optometry or an equivalent degree, doctor of veterinary medicine or an equivalent degree, or doctor of podiatry or an equivalent degree. “SPECIAL PROJECT GRANTS “Sec. 772. Grants may be made, from sums available therefor from appropriations under section 770 for the fiscal year ending June 30, 1970, and for each of the next three fiscal years, to assist schools of medicine, dentistry, oste- opathy, pharmacy, optometry, podiatry, and veterinary medi- cine in meeting the cost of special projects to plan, develop, or establish new programs or modifications of existing pro- grams of education in such health professions or to effect significant improvements in curriculums of any such schools or for research in the various fields related to education in such health professions, or to develop training for new levels or types of health professions personnel, or to assist any such schools which are in serious financial straits to meet their costs of operation or which have special need for financial assistance to meet the accreditation requirements, or to assist any such schools to meet the costs of planning experimental teaching facilities or experimental design thereof, or which will otherwise strengthen, improve, or expand programs to train personnel in such health professions or help to increase 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 13 11 the supply of adequately trained personnel in such health professions needed to meet the health needs of the Nation. {(b) (1) Subsection (a) of section 773 of such Act (42 U.S.C. 295-3) is amended by striking out “basic or special grants under section 771 or 772” and inserting in lieu thereof “grants under section 771 or 772”. (2) Subsection (b) (1) of such section is amended by inserting after “or podiatry” the following: “or (in the case of section 772) pharmacy, or veterinary medicine”. (3) Subsection (c¢) of such section is amended by strik- ing out “National Advisory Council on Medical, Dental, Optometric, and Podiatric Education” and inserting in lieu thereof “National Advisory Council on Health Professions Educational Assistance”. (4) Subsection (d) (2) of such section is amended by inserting “(excluding expenditures of a nonrecurring na- ture) after “for such purpose”. (5) Subsection (e) of such section is amended to read as follows: “(e) In determining priority of projects applications for which are filed under section 772, the Secretary shall give consideration to— “(1) the extent to which the project will increase enrollment of full-time students receiving the training for which grants are authorized under this part; — © oo 9 Oo 10 11 12 13 14 15 16 wv 18 19 20 21 22 23 24 14 12 “(2) the relative need of the applicant for financial assistance to maintain or provide for accreditation or to avoid curtailing enrollment or reduction in the quality of training provided ; and “(3) the extent to which the project may result in curriculum improvement or improved methods of training or will help to reduce the period of required training without adversely affecting the quality thereof.” (e) (1) Section 774 (a) of such Act is amended by striking out “or podiatric education” and inserting in lieu thereof “podiatric, pharmaceutical, or veterinary education”. (2) Such section 774 (a) is further amended by strik- ing out “twelve” and inserting in lieu thereof “fourteen”, and by striking out “National Advisory Council on Medical, Dental, Optometric, and Podiatric Education” and insert- ing in lieu thereof “National Advisory Council on Health Professions Educational Assistance”. (3) The heading of section 774 is amended to read: “NATIONAL ADVISORY COUNCIL ON HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE” (d) The amendments made by this section shall apply with respect to appropriations for fiscal years ending after June 30, 1969. (e) Effective only with respect to appropriations for the = Ww nN © Ww 9 Oo Oo 10 11 12 13 14 15 16 17 18 19 20 21 22 23 15 13 fiscal year ending June 30, 1969, section 772 (b) of such Act is amended by inserting before the period at the end thereof “, or (3) to plan for special projects for which grants are authorized under this section as amended by the Health Manpower Act of 1968”. (f) Effective with respect to appropriations for the fiscal year ending June 30, 1968, and the next fiscal year, the third sentence of section 771 (b) of such Act is amended by inserting before the period at the end thereof , or if he de- termines, after such consultation, that to do so would other- wise be in the public interest and consistent with the pur- poses of this part”. ParT C—STUDENT AID STUDENT LOANS Sec. 121. (a) (1) Clauses (2) and (3) of section 740 (b) of the Public Health Service Act (42 U.S.C. 294) are each amended by inserting “‘, except as provided in section 746,” after “fund” the first time it appears therein. (2) Section 740 (b) (4) of such Act is amended by striking out “1969” and inserting in lieu thereof “1973”. (8) Section 741 (¢) of such Act (42 U.S.C. 294a) is amended by adding before the period at the end thereof , or (3) service as a full-time volunteer in the Volunteers in St kx Ww NH [=] © ow = 10 1 13 14 15 16 17 18 20 21 22 23 24 16 14 Service to America program under the Economic Oppor- tunity Act of 1964; and periods (up to five years) of advanced professional training (including residencies) ”. (4) (A) Section 741 of such Act is further amended by adding at the end thereof the following new subsection: “(j) Subject to regulations of the Secretary, a school may assess a charge with respect to a loan made under this part for failure of the borrower to pay all or any part of an installment when it is due and, in the case of a borrower who is entitled to deferment of the loan under subsection (c) or cancellation of part or all of the loan under subsection (f), for any failure to file timely and satisfactory evidence of such entitlement. The amount of any such charge may not exceed $1 for the first month or part of a month by which such installment or evidence is late and $2 for each such month or part of a month thereafter. The school may elect to add the amount of any such charge to the principal amount of the loan as of the first day after the day on which such installment or evidence was due, or to make the amount of the charge payable to the school not later than the due date of the next installment after receipt by the borrower of notice of the assessment of the charge.” (B) Subsection (b) (2) of section 740 of such Act is further amended by striking out “and (D)” and inserting = Ww nN © ww = Oo Oo» 10 11 12 13 14 15 16 Iz 18 19 20 21 22 23 24 17 15 in lieu thereof “ (D) collections pursuant to section 741 (j), and (E)”. (b) (1) The first sentence of subsection (a) of section 742 of such Act (42 U.S.C. 294b) is amended by striking out “and” before “$25,000,000” and by inserting before the period at the end thereof “, and such sums as may be nec- essary for the fiscal year ending June 30, 1970, and each of the next three fiscal years”. (2) The third sentence of such subsection is amended by striking out “1970” and “1969” and inserting in lieu thereof “1974” and “1973”, respectively. (3) The fourth sentence of such subsection is amended by striking out “and” before “(2)” and by inserting before the period at the end thereof “, and (3) for transfers pur- suant to section 746”. (0) Section 743 of such Act (42 U.S.C. 294¢) is amended by striking out “1972” each place it appears therein and inserting in lieu thereof “1976”. . (d) (1) Section 744 (a) (1) of such Act (42 U.S.C. 294d) is amended by inserting “and each of the next five fiscal years” after “1968,” . (2) Section 744 (c) of such Act is amended by striking out “$35,000,000” and inserting in lieu thereof “$45, 000,000”. 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 18 16 (e) Part C of title VII of such Act (42 U.S.C. 294, et seq.) is further amended by adding at the end thereof the following new section: “TRANSFER OF FUNDS TO SCHOLARSHIPS “Sec. 746. Not to exceed 20 per centum of the amount paid to a school from the appropriations for any fiscal year for Federal capital contributions under an agreement under this part, or such larger precentage thereof as the Secretary may approve, may be transferred to the sums available to the school under part F of this title to be used for the same purpose as such sums. In the case of any such transfer, the amount of any funds which the school deposited in its student loan fund pursuant to section 740 (b) (2) (B) may be with- drawn by the school from such fund.” (f) The amendments made by subsection (a) (1), (b) (3), and (e) shall apply with respect to appropriations for fiscal years ending after June 30, 1969. The amendment made by subsection (a) (3) shall apply (1) with respect to all loans made under an agreement under part (C) of title VII of the Public Health Service Act after June 30, 1969, and (2) with respect to loans made thereunder before July 1, 1969, to the extent agreed to by the school which made the loans and the Secretary (but, then, only as to years beginning after June 30, 1969). The amendment made by B= Ww NN 10 11 12 13 14 15 16 17 18 19 20 21 22 23 19 17 subsection (a) (4) shall apply with respect to loans made after June 30, 1969. SCHOLARSHIPS Sec. 122. (a) Subsection (a) of section 780 of the Public Health Service Act (42 U.S.C. 295g) is amended by striking out “or pharmacy” and inserting in lieu thereof “pharmacy, or veterinary medicine”. The heading of such section is amended by striking out “or PHARMACY” and inserting in lieu thereof “PHARMACY, OR VETERINARY MEDI- CINE”. (b) Subsection (b) of such section is amended by in- serting “and each of the next four fiscal years” after “1969,” in the first sentence and by striking out “1970” and “1969” and inserting in lieu thereof “1974” and “1973”, respec- tively, in the second sentence. (e¢) (1) Paragraph (1) of subsection (¢) of such sec- tion is amended by inserting “and each of the next four fiscal years” after “1969” and clause (D) and by striking out “1969” and “1970” in clause (E) and inserting in lieu thereof “1973” and “1974”, respectively. (2) The first sentence of paragraph (2) of such sub- section (c) is amended by striking out “from low-income families who, without such financial assistance could not” and Bow oH © Oo 9 Oo Oo» + 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2% 20 18 inserting in lieu thereof “of exceptional financial need who need such financial assistance to”. (d) Part F of title VII of the Public Health Service Act is further amended by inserting after section 780 the following new section: “TRANSFER TO STUDENT LOAN FUNDS “Sec. 781. Not to exceed 20 per centum of the amount paid to a school from the appropriations for any fiscal year for scholarships under this part, or such larger percentage thereof as the Secretary may approve, may be transferred to the sums available to the school under part C for (and to be regarded as) Federal capital contributions, to be used for the same purpose as such sums.” (e) The amendment made by subsections (a), (b), (¢) (1), and (d) shall apply with respect to appropriations for fiscal years ending June 30, 1969. The amendments made by subsection (c) (2) shall apply with respect to scholarships from appropriations for fiscal years ending after June 30, 1969. | PART D—MISCELLANEOUS STUDY OF SCHOOL AID AND STUDENT AID PROGRAMS Sec. 131. The Secretary shall, in consultation with the Advisory Councils established by sections 725 and 774, pre- pare, and submit to the President and the Congress prior to July L 1972, a report on the administration of parts B, C, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 21 19 E, and F of title VII of the Public Health Service Act, an appraisal of the programs under such parts in the light of their adequacy to meet the long-term needs for health pro- fessionals, and his recommendations as a result thereof. TITLE II—NURSE TRAINING Parr A—CONSTRUCTION GRANTS EXTENSION OF CONSTRUCTION AUTHORIZATION Sec. 201. (a) Section 801 of the Public Health Service Act (42 U.S.C. 296) is amended to read as follows: “Spc. 801. (a) There are authorized to be appropri- ated, for grants to assist in the construction of new facilities for collegiate, associate degree, or diploma schools of nurs- ing, or replacement or rehabilitation of existing facilities for such schools, such sums as may be necessary for the fiscal year ending June 30, 1970, and each of the next three fiscal years. “(b) Sums appropriated pursuant to subsection (a) for a fiscal year shall remain available until expended.” (b) Section 802 (a) of such Act (42 U.S.C. 296a) is amended by striking out “July 1, 1968” and inserting in lieu thereof “July 1, 1972”. LENGTH OF FEDERAL RECOVERY INTEREST Sec. 202. (a) Section 802 (b) (2) of the Public Health Service Act is amended by striking out “twenty” in clause (A) and inserting in lieu thereof “ten”. Gtx Ww NH -3 10 hie | 12 13 14 15 16 17 18 19 20 21 22 23 22 20 (b) Section 804 of such Act (42 U.S.C. 296¢) is amended by striking out “twenty” and inserting in lieu thereof “ten”. FEDERAL SHARE SEC. 203. Section 803 (a) of the Public Health Service Act (42 U.S.C. 296b) is amended by striking out “may not exceed 50 per centum” in clause (B) and inserting in lieu thereof “may not, except where the Secretary determines that unusual circumstances make a larger percentage (which may in no case exceed 66% per centum) necessary in order to effectuate the purposes of this part, exceed 50 per centum”. INCLUSION OF TRUST TERRITORY SEC. 204. Section 843 (a) of the Public Health Service Act (42 U.S.C. 298b) is amended by striking out “or the Virgin Islands” and inserting in lieu thereof “the Virgin Islands, or the Trust Territory of the Pacific Islands”. AMENDMENT OF DEFINITION OF COLLEGIATE SCHOOL OF NURSING SEC. 205. Section 843 (c¢) of the Public Health Service Act is amended by inserting before the period at the end thereof “, and including advanced training related to such program of education”. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 23 21 EFFECTIVE DATE Sec. 206. The amendments made by sections 201, 202, and 205 shall apply with respect to appropriations for fiscal years ending after June 30, 1969, except that (1) section 804 of the Public Health Service Act as amended by this Act shall apply in the case of any projects for which grants have been made or are in the future made under section 803 of such Act; and (2) the amendment made in section 802 (b) (2) of such Act by section 202 (a) of this Act shall apply in the case of any projects for which grants are made under section 803 of the Public Health Service Act after the enactment of this Act. PART B—SPECIAL PROJECT AND INSTITUTIONAL GRANTS T0 SCHOOLS OF NURSING SPECIAL PROJECT AND INSTITUTIONAL GRANTS Sec. 211. Sections 805 and 806 of the Public Health Service Act (42 U.S.C. 296d, 296e) are amended to read as follows: “IMPROVEMENT IN NURSE TRAINING “Sec. 805. From the sums available therefor from appropriations under section 808 for the fiscal year ending June 30, 1970, and each of the next three fiscal years, grants may be made to assist any public or nonprofit private agency, B= Ww 10 ti} 12 13 14 15 16 17 18 19 20 21 22 23 24 25 24 22 organization, or institution to meet the cost of special projects to plan, develop, or establish new programs or modifications of existing programs of nursing education or to effect signifi- cant improvements in curriculums of schools of nursing or for research in the various fields of nursing education, or to assist schools of nursing which are in serious financial straits to meet their costs of operation or to assist schools of nursing which have special need for financial assistance to meet accreditation requirements, or to assist in otherwise strength- ening, improving, or expanding programs of nursing educa- tion, or to assist any such agency, organization, or institution to meet the costs of other special projects which will help to increase the supply of adequately trained nursing personnel needed to meet the health needs of the Nation. “INSTITUTIONAL GRANTS “SEC. 806. (a) The sums available for grants under this section from appropriations under section 808 for the fiscal year ending June 30, 1970, or any of the next three fiscal years shall be distributed to the schools with approved ap- plications as follows: Each school shall receive $15,000; and of the remainder— “(A) 75 per centum shall be distributed on the basis of the relative enrollment of full-time students for such year and the relative increase in enrollment of such students for such year over the average enrollment of 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 23 such school for the five school years preceding the year for which the application is made, with the amount per full-time student so computed that a school receives twice as much for each such student in the increase as for other full-time students, and “(B) 25 per centum shall be distributed on the basis of the relative number of graduates for such year. “(b) (1) For purposes of this part and part D, regula- tions of the Secretary shall include provisions relating to determination of the number of students enrolled in a school, or in a particular year-class in a school, or the number of graduates from a school, as the case may be, on the basis of estimates, or on the basis of the number of students who were enrolled in a school, or in a particular year-class in a school, or were graduates from a school in earlier year, as the case may be, or on such basis as he deems appropri- ate for making such determination, and shall include methods of making such determinations when a school or a year- class was not in existence in an earlier year at a school. “(2) For purposes of this part and part D, the term ‘full-time students’ (whether such term is used by itself or in connection with a particular year-class) means students pursuing a full-time course of study in an accredited program in a school of nursing.” 92-079 O - 68 - 3 © ow J 10 nn 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 24 CONDITIONS OF ELIGIBILITY Sec. 212. Part A of title VIII of the Public Health Service Act is amended by adding at the end thereof the fol- lowing new sections: “APPLICATIONS FOR GRANTS “SEC. 807. (a) The Secretary may from time to time set dates (not earlier than in the fiscal year preceding the year for which a grant is sought) by which applications under section 805 or 806 for any fiscal year must be filed. “(b) The Secretary shall not approve or disapprove any application for a grant under this part except after consultation with the National Advisory Council on Nurse Training. “(c) A grant under section 805 or 806 may be made only if the application therefor— “(1) is from a public or nonprofit private school of nursing, or, in the case of grants under section 805, a public or nonprofit private agency, organization, or institution ; “(2) contains or is supported by assurances satis- factory to the Secretary that the applicant will expend in carrying out its functions as a school of nursing, during the fiscal year for which such grant is sought, an amount of funds (other than funds for construction as determined by the Secretary) from non-Federal 10 11 12 13 14 15 16 17 18 19 20 21 22 23 27 25 sources which are at least as great as the average amount of funds expended by such applicant for such purpose (excluding expenditures of a nonrecurring nature) in the three fiscal years immediately preceding the fiscal year for which such grant is sought; “(3) contains such additional information as the Secretary may require to make the determinations re- quired of him under this part and such assurances as he may find necessary to carry out the purposes of this part; and “(4) provides for such fiscal-control and accounting procedures and reports, and access to the records of the applicant, as the Secretary may require to assure proper disbursement of and accounting for Federal funds paid to the applicant under this part. “AUTHORIZATION FOR APPROPRIATIONS “Sec. 808. (a) There are authorized to be appropriated for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary for improvement grants under section 805 and institutional grants under section 806. “(b) The portion of the sums so appropriated for each fiscal year which shall be available for grants under each such section shall be determined by the Secretary unless otherwise 10 1 12 13 14 15 16 17 18 19 20 21 22 23 28 26 provided in the Act or Acts appropriating such sums for such year.” CONFORMING CHANGE Sec. 213. Clause (2) of section 843 (f) of the Public Health Service Act (42 U.S.C. 298b) is amended to read: “(2) in the case of a school applying for a grant under sec- tion 806 for any fiscal year, prior to the beginning of the first academic year following the normal graduation date of the class which is the entering class for such fiscal year (or is the first such class in such year if there is more than one) ;”. EFFECTIVE DATE Sec. 214. The amendments made by the preceding provisions of this part shall apply with respect to appropria- tions for fiscal years ending after June 30, 1969. PLANNING FOR FISCAL YEAR 1969 Sec. 215. Effective only with respect to appropriations for the fiscal year ending June 30, 1969, section 805 (a) of the Public Health Service Act is amended by inserting at the end thereof the following new sentence: “Appropriations under this section shall also be available for grants for plan- ning special projects for which grants are authorized under this section as amended by the Health Manpower Act of 1968.” 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 27 Parr C—STUDENT AID ADVANCED TRAINING SEC. 221. Section 821 (a) of the Public Health Service Act (42 U.S.C. 297) is amended by striking out “and” be- fore “$12,000,000” and by inserting “and such sums as may be necessary for the next four fiscal years,” after “1969,”. STUDENT LOANS Sec. 222. (a) (1) Clauses (2) and (3) of section 822 (b) of the Public Health Service Act (42 U.S.C. 297a) are each amended by inserting ©, except as provided in sec- tion 829,” after “fund” the first time it appears therein. (2) Section 822 (b) (4) of such Act is amended by striking out “1969” and inserting in lieu thereof “1973”. (b) (1) Section 823 (a) of such Act (42 U.S.C. 297h) is amended by striking out “$1,000” and inserting in lien thereof “$1,500”. (2) Section 823 (b) (2) of such Act is amended by striking “except that” and all that follows down to but not including the semicolon and inserting in lieu thereof “‘exclud- ing from such 10-year period all (A) periods (up to three vears) of (i) active duty performed by the borrower as a member of a uniformed service, (ii) service as a volunteer under the Peace Corps Act, or (iii) service as a full-time 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 30 28 volunteer under the Volunteers in Service to America pro- gram under the Economic Opportunity Act of 1964, and (B) periods (up to five years) during which the borrower is pursuing a full-time course of study at a collegiate school of nursing leading to a baccalaureate degree in nursing or an equivalent degree, or to a graduate degree in nursing, or is otherwise pursuing advanced professional training in nursing”. (3) Section 823 (bh) (3) of such Act is amended by inserting before the semicolon at the end thereof the follow- ing: “, except that such rate shall be 15 per centum for each complete year of service as such a nurse in a public hospital in any area which is determined, in accordance with regula- tions of the Secretary, to be an area with substantial popula- tion which has a substantial shortage of such nurses at such hospitals, and for the purpose of any cancellation at such higher rate, an amount equal to an additional 50 per centum of the total amount of such loans plus interest may be can- celled”. (e) (1) Section 823 of such Act is further amended by adding at the end thereof the following new subsection: “(f) Subject to regulations of the Secretary, a school may assess a charge with respect to a loan from the loan fund established pursuant to an agreement under this part for failure of the borrower to pay all or any part of an install- 10 11 12 14 15 16 17 18 1s 20 21 22 23 25 31 29 ment when it is due and, in the case of a borrower who is entitled to deferment of the loan under subsection (b) (2) or cancellation of part or all of the loan under subsection (b) (3), for any failure to file timely and satisfactory evi- dence of such entitlement. The amount of any such charge may not exceed $1 for the first month or part of a month by which such installment or evidence is late and $2 for each such month or part of a month thereafter. The school may elect to add the amount of any such charge to the principal amount of the loan as of the first day after the day on which such installment or evidence was due, or to make the amount of the charge payable to the school not later than the due date of the next installment after receipt by the borrower of notice of the assessment of the charge.” (2) Subsection (b) (2) of section 822 of such Act is further amended by striking out “and (D)” and inserting in lieu thereof “ (D) collections pursuant to section 823 (f), and (E)”. (d) (1) Section 824 of such Act (42 U.S.C. 297¢) is amended by inserting “such sums as may be necessary for each of the next four fiscal years” after “1969,” the first time it appears therein, by striking out “1970” and inserting in lieu thereof “1974”, and by striking out “1969,” the second time it appears therein and inserting in lien thereof “1973,” 10 11 12 13 14 16 17 18 19 20 21 22 23 24 32 30 (2) The second sentence of such section is amended by inserting before the period at the end thereof ©, and (3) for transfers pursuant to section 829”. (e) The first two sentences of section 825 of such Act (42 U.S.C. 297d) are amended to read as follows: “From the sums appropriated pursuant to section 824 for any fiscal year, the Secretary shall allot to each school an amount which bears the same ratio to the amount so appropriated as the number of persons enrolled on a full-time basis in such school bears to the total number of persons enrolled on a full-time basis in all schools of nursing in all the States. The number of persons enrolled on a full-time basis in schools of nursing for purposes of this section shall he determined by the Secretary for the most recent year for which satis- factory data are available to him.” (f) Section 826 of such Act (42 U.S.C. 297e) is amended by striking out “1972” each place it appears therein and inserting in lieu thereof “1976”. (g) Section 827 (a) (1) of such Act (42 U.S.C. 297f) is amended by inserting “and each of the next five fiscal years’ after “1968,”. (h) Part B of title VIII of such Act (42 U.S.C. 297 et seq.) is further amended by adding at the end thereof the following new section: 10 11 12 13 14 15 16 17 18 190 20 21 22 23 24 33 31 ‘“PRANSFERS TO SCHOLARSHIP PROGRAM “Sec. 829. Not to exceed 20 per centum of the amount paid to a school from the appropriation for any fiscal year for Federal capital contributions under an agreement under this part, or such larger percentage thereof as the Secre- tary may approve, may he transferred to the sums available to the school under part D to be used for the same purpose as such sums. In the case of any such transfer, the amount of any funds which the school deposited in its student loan fund pursuant to section 822 (bh) (2) (B) may be withdrawn by the school from such fund.” (i) The amendments made by subsection (b) (1) and (2) shall apply with respect to all loans made after June 30, 1969, and with respect to loans made from a student loan fund established under an agreement pursuant to section 822, before July 1, 1969, to the extent agreed to by the school which made the loans and the Secretary (but then only for years beginning after June 30, 1968). The amend- ment made by subsection (c¢) shall apply with respect to loans made after June 30, 1969. The amendment made by subsection (h) shall apply with respect to appropriations for fiscal years beginning after June 30, 1969. The amend- ment made by subsection (b) (3) shall apply with respect to service, specified in section 823 (bh) (3) of such Act, per- 10 . a 12 13 14 15 16 17 18 19 20 21 22 23 24 25 34 32 formed during academic years beginning after the enactment of this Act, whether the loan was made before or after such enactment. SCHOLARSHIPS Sec. 223. (a) So much of part D of title VIII of the Public Health Service Act (42 U.S.C. 298c et seq.) as precedes section 868 is amended to read as follows: “PART D—SCHOLARSHIP (GRANTS TO SCHOOLS OF NursiNG “SCHOLARSHIP GRANTS “Sec. 860. (a) The Secretary shall make grants as provided in this part to each public or other nonprofit school of nursing for scholarships to be awarded annually by such school to students thereof. “(b) The amount of the grant under subsection (a) for the fiscal year ending June 30, 1970, and each of the next three fiscal years to each such school shall be equal to $2,000 multiplied by one-tenth of the number of full-time students of such school. For the fiscal year ending June 30, 1974, and for each of the three succeeding fiscal years, the grant under subsection (a) shall be such amount as may be necessary to enable such school to continue making payments under schol- arship awards to students who initially received such awards out of grants made to the school for fiscal years ending prior to July 1, 1973. 10 11 12 13 14 15 16 Yi 18 19 20 21 22 23 24 25 35 33 “(c) (1) Scholarships may be awarded by schools from grants under subsection (a) — “(A) only to individuals who have been accepted by them for enrollment, and individuals enrolled and in good standing, as full-time students, in the case of awards from such grants for the fiscal year ending June 30, 1970, and each of the next three fiscal years; and “(B) only to individuals enrolled and in good stand- ing as full-time students who-initially received scholar- ship awards out of such grants for a fiscal year ending prior to July 1, 1973, in the case of awards from such grants for the fiscal year ending June 30, 1974, and each of the three succeeding fiscal years. “(2) Scholarships from grants under subsection (a) for any school year shall he awarded only to students of ex- ceptional financial need who need such financial assistance to pursue a course of study at the school for such year. Any such scholarship awarded for a school year shall cover such portion of the student’s tuition, fees, books, equipment, and living expenses at the school making the award, but not to exceed $1,500 for any year in the case of any student, as such school may determine the student needs for such year on the basis of his requirements and financial resources. “(d) Grants under subsection (a) shall be made in accordance with regulations prescribed by the Secretary after 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24. 25 36 34 consultation with the National Advisory Council on Nurse Training. “(e) Grants under subsection (a) may be paid in ad- vance or by way of reimbursement, and at such intervals as the Secretary may find necessary; and with appropriate adjustments on account of overpayments or underpayments previously made. “TRANSFERS TO STUDENT LOAN PROGRAM “Sec. 861. (a) Not to exceed 20 per centum of the amount paid to a school from the appropriation for any fiscal year for scholarships under this part, or such larger per- centage thereof as the Secretary may approve for such school for such year, may be transferred to the sums avail- able to the school under this part for (and to be regarded as) Federal capital contributions, to be used for the same purpose as such sums.” (b) The amendment made by subsection (a) shall apply with respect to appropriations for fiscal years ending after June 30, 1969. PART D—MISCELLANEOUS DEFINITION OF ACCREDITATION SEC. 231. So much of section 843 (f) of the Public Health Service Act (42 U.S.C. 298b) as precedes clause i“ (1) is amended Ly inserting ©, or by a State agency,” after J g y gency “a recognized body or bodies” the first time it appears 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 37 35 therein, by inserting “or State agency” after “a recognized body or bodies” the second and third time it appears therein, and by striking out “or a program accredited for the purpose of this Act by the Commissioner of Education,”. Clause (1) of such section 843 (f) amended by striking out “for a project for construction of a new school (which shall include a school that has not had a sufficient period of operation to be eligible for accreditation)” and inserting in lieu thereof “for a construction project”. Such section 843 (f) is further amended by adding at the end thereof the following new sentence: “For the purpose of this paragraph, the Commis- sioner of Education shall publish a list of nationally recog- nized accrediting bodies, and of State agencies, which he determines to be reliable authority as to the quality of train- ing offered.” STUDY OF SCHOOL AID AND STUDENT AID PROGRAMS SEC. 232. The Secretary shall, in consultation with the Advisory Council established by section 841, prepare, and submit to the President and the Congress prior to July 1, 1972, a report on the administration of title VIII of the Public Health Service Act, an appraisal of the programs under such title in the light of their adequacy to meet the long-term needs for nurses, and his recommendations as a result thereof. = Ww ND © oo J Oo Oo 10 11 12 13 14 15 16 17 18 19 20 21 22 23 38 36 TITLE III—ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH TRAINING EXTENSION AND IMPROVEMENT OF ALLIED HEALTH PROFESSIONS PROGRAM Sec. 301. (a) (1) (A) Section 791 (a) (1) of the Public Health Service Act (42 U.S.C. 295h) is amended by striking out “and $13,500,000 for the fiscal year ending June 30, 1969” and inserting in lieu thereof “$13,500,000 for the fiscal year ending June 30, 1969, and such sums as may be necessary for the fiscal year ending June 30, 1970”. (B) Section 791 (b) (1) of such Act is amended by striking out “1968” and inserting in lieu thereof “1969”. (2) (A) Section 792 (a) of such Act (42 U.S.C. 295h-1) is amended by striking out “and $17,000,000 for the fiscal year ending June 30, 1969” and inserting in lieu thereof “$17,000,000 for the fiscal year ending June 30, 1969; and such sums as may be necessary for the fiscal year ending June 30, 1970”. (B) Section 792 (b) (1) of such Act is amended by striking out “1969” and inserting in lieu thereof “1970”. (3) Section 793 (a) of such Act (42 U.S.C. 295h-2) is amended by striking out “and $3,500,000 for the fiscal year ending June 30, 1969” and inserting in lieu thereof 10 11 12 13 14 15 16 17 18 19 20 21 22 23 39 37 “$3,500,000 for the fiscal year ending June 30, 1969; and such sums as may be necessary for the fiscal year ending June 30, 1970”. (4) Section 794 of such Act (42 U.S.C. 295h-3) is amended by striking out “and $3,000,000 for the fiscal year ending June 30, 1969” and inserting in lieu thereof “$3,000,000 for the fiscal year ending June 30, 1969; and such sums as may be necessary for the fiscal year ending June 30, 1970”. (b) Such section 794 is further amended by— (1) striking out “training centers for allied health professions” and inserting in lieu thereof “agencies, in- stitutions, and organizations”; (2) inserting “and methods” after “curriculums”; (3) striking out “new types of”. (c) Part G of title VII of such Act is further amended by adding at the end thereof the following new section: “Sec. 797. Such portion of any appropriation pursuant to sections 791, 792, 793, or 794, for any fiscal year ending after June 30, 1969, as the Secretary may determine, but not exceeding one-half of 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the programs authorized by this part.” 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 40 38 PUBLIC HEALTH TRAINING SEC. 302. (a) Section 309 (a) of the Public Health Service Act (42 U.S.C. 242g) is amended by striking out “and” before “$9,000,000” and by inserting “and such sums as may be necessary for each of the next four fiscal years” after “1969”. (b) (1) Section 306 (a) of the Public Health Service Act (42 U.S.C. 242d) is amended by striking out “and” before “$10,000,000” and by inserting “and such sums as may be necessary for each of the next four fiscal years,” after “the succeeding fiscal year,”. (2) Section 306 (d) of such Act is amended by strik- ing out “$50” and inserting in lien thereof “$100”. TITLE IV—HEALTH RESEARCH FACILITIES EXTENSION OF CONSTRUCTION AUTHORIZATION SEC. 401. (a) Section 704 of the Public Health Service Act (42 U.S.C. 292¢) is amended by striking out “and” after “$50,000,000”; and by inserting “and for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary,” after “$280,000,- 000,”. (b) Section 705 (a) of such Act (42 U.S.C. 293) is amended by striking out “1968” and inserting in lieu thereof “1972”. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 41 39 FEDERAL SHARE Sec. 402. (a) Subsection (a) of section 706 of the Public Health Service Act (42 U.S.C. 292e) is amended by striking out “except that in no event may such amount exceed 50 per centum” and inserting in lieu thereof “but such amount may not, except as provided in paragraph (2), ex- ceed 50 per centum”. (b) Such subsection (a) of section 706 is further amended by inserting “(1)” after “(a)” and adding at the end thereof the following new paragraph: “(2) The maximum amount of any grant shall be 665 per centum instead of the maximum under paragraph (1) in the case of any class or classes of projects which the Sec- retary determines have such special national or regional sig- nificance as to warrant a larger grant than is permitted under paragraph (1); but not more than 25 per centum of the funds appropriated pursuant to section 704 for any fiscal year shall be available for grants in excess of 50 per centum with respect to such class or classes of projects.” ADVISORY COUNCIL COMPENSATION Stc. 403. Section 703 (d) of the Public Health Service Act (42 U.S.C. 292b) is amended by striking out “$50” and inserting in lieu thereof “$100”. 92-079 O - 68 - 4 BW ND 42 40 EFFECTIVE DATE Sec. 404. The amendments made by section 402 shall apply in the case of projects for which grants are made from appropriations for fiscal years ending after June 30, 1969. 43 90ra CONGRESS 1sT Session S 2 5 5 ® IN THE SENATE OF THE UNITED STATES JANUARY 12, 1967 Mr. Javits (for himself and Mr. Yarsorouan) introduced the following bill; which was read twice and referred to the Committee on Labor and Public Welfare A BILL. To amend title VII of the Public Health Service Act to author- ize direct student loans to be made to certain students studying outside the United States. 1 Be 1t enacted by the Senate and House of Representa- 2 tives of the United States of America in Congress assembled, 3 That (a) (1) the heading to part C' of title VII of the Pub- 4 lic Health Service Act is amended by inserting, immediately 5 below “Parr C—S1UDENT LOANS”, the following: “Sus- 6 PART [—LOANS ADMINISTERED BY SCHOOLS”. 7 (2) Sections 740, 741, 742 (bh), 743, 744, and 745 of 8 such Act are each amended by striking out “this part” each © place it appears therein and inserting in lien thereof “this 10 subpart”. I 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 44 2 (b) (1) Section 742 (a) of such Act is amended by in- serting immediately before the last sentence thereof the fol- lowing new sentence: “Of the sums appropriated under this subsection for the fiscal year ending June 30, 1968, or for any fiscal year thereafter, an amount equal to per centum shall be available only for the purpose of making loans under section 746.” (2) The last sentence of section 742 (a) of such Act is amended by striking out “Sums” and inserting in lieu thereof “Except as is otherwise provided by the preceding sentence, sums”, (c) Title VII of the Public Health Service Act is amended by adding after section 745 the following: “SUBPART II—DIRECT LOANS TO STUDENTS IN FOREIGN SCHOOLS “Sec. 746. (a) (1) From the sums made available under section 742 (a), the Secretary is authorized to make direct loans to students who are citizens of the United States and who are pursuing a full-time course of study, at a school of medicine, osteopathy, dentistry, or optometry which is located outside the United States and which is approved by the Secretary of Health, Education, and Welfare, which course of study leads to a degree of doctor of medicine, doctor or dentistry or an equivalent degree, doctor of osteopathy, or doctor of optometry or an equivalent degree. — 45 3 “(2) The Secretary shall not approve any school for purposes of this section unless he determines that such school offers training of a type and quality substantially similar to that offered by similar schools in the United States which are accredited as provided in section 721 (b) (1) (B). “(b) Such loans shall, to the extent feasible, be made on the same terms and conditions as are required with respect to loans made to students under the program established by subpart 1.” 46 DeparTMENT oF HRALTH, EDUCATION, AND WELFARE, March 18, 1968. Hon. Lister Hivy, Chairman, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C. Dear Mr. Cuamrmax : This letter is in response to your request of March 7, 1968, for a report on S. 3095, a bill to amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for such personnel, and the program iy to health research facilities, and for other purposes. This bill embodies the legislative proposals contained in a draft bill submitted by this Department to the Congress on March 4, 1968, to implement the recommendations on the training of health workers contained in the President’s March 4, 1968, message on health. ‘We urge early enactment of this proposed legislation. The Bureau of the Budget advises that enactment of this proposed legislation would be in accord with the program of the President. Sincerely, /S/ WiLsur J. CoHEN, Secretary. The Cramrman. Dr. Lee, we welcome you, sir; as the first witness, Assistant Secretary of the Department of Health, Education, and Welfare for Health and Scientific Affairs. We will be glad to hear from you. STATEMENT OF DR. PHILLIP R. LEE, ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY RALPH K. HUITT, ASSISTANT SECRETARY FOR LEGISLATION; AND DR. LEONARD D. FENNINGER, DIRECTOR, BUREAU OF HEALTH MANPOWER, PUBLIC HEALTH SERVICE Dr. Lee. Thank you, Mr. Chairman. I am accompanied this morning by Mr. Ralph K. Huitt, Assistant Secretary for Legislation, on my right; and Dr. Leonard Fenninger, Director, Bureau of Health Manpower, Public Health Service. We also have available if necessary, Mr. Chairman, members of Dr. Fenninger’s staff to provide appropriate and detailed information if it is needed. The CrarMAN. That will be fine, sir. Dr. Lee. It is a pleasure to testify on behalf of the Health Man- power Act of 1968 introduced by the distinguished chairman of this committee. The people of this country owe you, Mr. Chairman, a great debt of gratitude for your unfailing commitment to improving the Nation’s health, Through your legislative leadership, millions of the sick and disabled in our Nation have available to them the hospitals 47 in which they may find care and the physicians, nurses, and others to serve them. The Health Manpower Act of 1968 will continue and will strengthen five major health programs—the Health Professions Educational As- sistance Act of 1963, the Nurse Training Act of 1964, the Allied Health Professions Personnel Training Act of 1966, and the Health Research Facilities Act of 1956, as well as the Public Health Service Act, au- thority for public health traineeships and project grants to schools of public health for training. These laws have provided the foundation and the framework within which the Federal Government has become a partner with educational institutions to provide the facilities and the faculty for the difficult but essential task of providing large numbers of skilled personnel nec- essary to translate the expectations for health care into reality. Under these laws, new schools have been opened and others have sig- nificantly expanded and updated their training facilities. Schools have been assisted in strengthening their curriculums so that those who are trained are realistically equipped to serve the health needs of the people of this country. Students in the health professions have received loans and other financial assistance enabling them to undertake health careers which they could not otherwise have engaged in. The Health Manpower Act of 1968 would extend all but one of these laws for 4 years (fiscal year 1970 through fiscal year 1973). Since we have had only 1 year of experience under the Allied Health Profes- sions Personnel Training Act, S. 3095 would provide for a 1-year extension of that act in order to gain more experience and evaluate the needs for modification or revision. Mr. Chairman, 4 years is the minimum period of assured continua- tion of this fundamental legislative authority if we are to ask schools to undertake risks attendant upon major expansion of their teaching capacities or significant modifications of curriculums. We, therefore, urge that the extension of these laws be for the full 4-year period au- thorized in the bill. Now, Mr. Chairman, permit me to deal with the general purposes of this legislation. The supply and quality of America’s health professionals is at the very heart of our success in achieving and maintaining the opportunity for good health care for all Americans. The great breakthroughs in medical research will be of little value if patients cannot find doctors or nurses when they are most needed. Our continuously rising pros- perity as a nation will not bring about better health if health services are not there for people to buy. As President Johnson said in his March 4 message to the Congress on health: As a result of the imaginative programs recommended by the Administration and approved by the Congress over the last five years, an additional 100,000 doctors, nurses, dentists, laboratory technicians, and other health workers are being trained this year to meet the health needs of our growing population. More than 850 medical, dental and nursing schools have enlarged their capacity or improved their instruction. 48 This rate of progress is encouraging, but our increasing population and the demand for more and better health care, swell the need for doctors, health professionals, and other medical workers. Yet we lack the capacity to train today those who must serve us tomorrow. Mr. Chairman, today’s and tomorrow’s neads are critical. There are 305,400 physicians in active practice in the United States today—a number which falls far short of meeting the need. We esti- mate that an additional 50,000 physicians are needed today. The Cramrman. An additional 50,000? Dr. Lee. Yes, sir. There are fewer than 100,000 dentists actively practicing today. The supply of dentists in relation to population has been declining for some time. Looking ahead we see a continuing worsening of the sit- uation. There are about 650,000 nurses practicing today, but we still fall short of having enough personnel. And so the story goes, from optometry to osteopathy to podiatry, in all the health and allied health professions. There are too few skilled people to meet the Nation’s requirements. The main purpose of the legislation before you today is to continue, expand, and improve the Federal partnership role in assisting train- ing and educational institutions across the country in meeting these critical needs. In addition, this legislation will offer greater opportuni- ties to the talented youth of limited means. S. 3095 makes some significant improvements in the five legislative acts it amends. In the interest of time, I would like to call particular attention to some major changes made by the present bill and submit to you for the record a more detailed analysis of each of the amend- ments and justifications. The Cratrman. You will have that appear in the record in full? Dr. Ler. Yes, sir. The Criarrman. We will be glad to have it. HEALTH PROFESSIONS TRAINING Dr. Lee. The first major amendment, in title I of the bill, relates to construction grants for health professions training. This amendment is aimed at simplifying and making more efficient the authorities related to the support of construction so that schools planning to construct facilities to serve a variety of functions will not be forced to deal with several authorities and several different review procedures and pri- orities. Under present law, a medical or dental school applies under the health professions educational assistance construction program for funds to construct teaching facilities, but if a school is planning to construct a medical library or a health research facility, the school must make separate application under those respective programs. Each application is separately reviewed and meets separate sets of criteria. Moreover, under the present program, teaching space in a school can be constructed only if the space will be used for teaching programs 49 leading to a degree of doctor of medicine, doctor of dentistry, or other first health professional degree. The amendment we are proposing would allow the inclusion in the construction grant of space for graduate, continuation, or other ad- vanced training activities, as well as training directly related to the first professional degree. Our amendment would also authorize a school to make one applica- tion under the health professions educational assistance construction program if the project is for the construction of facilities which are used to a substantial extent for teaching purposes, but will also be used for health research purposes or medical library purposes. In short, we hope to bring about a more efficient and better coordi- nated support of a teaching facility. This bill would authorize the Secretary of Health, Education, and Welfare to increase the Federal share of construction costs in unusual circumstances. In addition to these proposed changes relating to construction grants, the bill includes several significant revisions with respect to grants to schools for support or improvement of their teaching pro- grams. The law now provides for two classes of grants: basic improvement grants and special improvement grants. The former are ad among the eligible schools on the basis of a statutory formula which now provides $25,000 to each school plus $500 for each full-time stu- dent enrolled. To be eligible for such a grant, the school must have an increase in first-year student enrollment over the highest enrollment in any of the preceding 5 school years—except that the Secretary may waive this requirement if he finds that the facilities of the school are too limited to permit an enrollment expansion without deterioration of quality of training. Special project grants are awarded on the basis of individual project applications, but grants may be made only to schools which have been awarded a basic improvement grant, and there is a specific dollar limitation on the amount of any project grant. In addition there is a combined appropriation authorization covering both basic and special improvement grants, with a specific condition that funds are to be available for project grants only after the re- quirements of the formula grants have been met. Several key amendments to these provisions are proposed in S. 3095. First, the appropriations authorization would be modified so that the availability of project grant funds will not be subordinated to the formula grant requirements. Second, the basis for distributing formula grants would be different. Each school would still receive a basic $25,000, but of the remaining funds appropriated for these grants 75 percent would be distributed on the basis of full-time student enrollments and 25 percent on the basis of the number of graduates. In the distribution of funds for full-time student enrollment, the schools would receive twice the per capita amount for enrollment in excess of the average enrollment dur- ing the 5-year period. In addition, effective with fiscal year 1968, the authority of the Secretary to waive the enrollment expansion requirement would be 50 broadened to apply to cases in which such waiver would be in the public interest and consistent with the purposes of this program. Third, the special project grant provisions would be amended to broaden the purposes for which such grants can be made. New author- ity is proposed, for example, for projects to strengthen the program planning competencies of the schools—including the plannign, devel- opment, or establishment of new programs as well as modifications of existing programs. Projects for planning experimental teaching facilities, including experimental designs, would also be authorized. Special emphasis would of course continue to be given to assisting schools in serious financial straits. Fourth, the proposed amendments would eliminate the dollar ceil- ings on individual projects grants, as well as the provision limiting such grants to Si that are recipients of formula grants. Finally, the eligibility for special project grants would be expanded to include schools of pharmacy and schools of veterinary medicine. We believe these proposed amendments will provide a more flexible basis for institutional assistance and a more realistic approach to incentives for enrollment expansion. We propose to expand the membership of the National Advisory Council, and change its name to National Advisory Council on Health Professions Educational Assistance. There are a number of amendments in the bill which would adjust the health professions student loan program to provide greater in- centives for participation in such programs as VISTA and to en- courage prompt repayment of loans, as well as to increase to $45 mil- lion the total amount of loans which may be made from the revolving fund to student loan funds. We are also asking for greater flexibility in the administration of student assistance programs by the schools by permitting transfer of a percentage of the student capital con- tribution loan funds to the scholarship program and vice versa. NURSE TRAINING Title IT of the bill would extend for four additional years the several authorizations contained in the Nurse Training Act—including grants for the construction of teaching facilities, institutional improvement grants, traineeships for advanced training of professional nurses, and the provision of loans and other forms of financial aid for nursing students. In addition several significant program additions or modifi- cations are proposed. First, the construction grant authorizations would be modified to permit grants of up to 6624 percent, instead of 50 percent under “un- usual circumstances”; to reduce from 20 to 10 years the period during which the facility must be used for the purpose for which the grant was made; and to extend grant eligibility to schools in the Trust Ter- ritory of the Pacific Islands. Second, the present authority for partial reimbursement of diploma schools would be replaced with a broader authority for institutional (formula) grants to all three categories of nursing schools—col- legiate schools, associate degree schools, and diploma schools. Under this proposed formula grant, each school would receive $15,000, and 51 the remaining funds appropriated would then be distributed in the same manner as proposed for the health professions schools—T75 per- cent on the basis of enrollment and 25 percent on the basis of the num- ber of graduates. In the distribution of funds on the basis of enroll- ment, the schools would receive twice the per capita amount for enroll- ment in excess of the average enrollment during the 5-year base period. Third, the present special project grant authorization would be somewhat broadened with respect to the purposes for which grants may be made, and eligibility for these grants would be extended to cover institutions other than nursing schools. The broadened authority would permit grants to be made to institutions or agencies which do not have programs of nurse education but which could plan or develop such programs or could made contributions to the improvement of pro- grams of nurse education, as well as permitting, in this period of transition in nursing education, grants to junior colleges and colleges which are planning and developing arrangements with diploma programs. Fourth, the student aid provisions of the act would be strengthened in several important respects. The present limited authority for “op- portunity grants” for nursing education would be replaced with a broad program of scholarship grants patterned after the scholarship program for students in health professions schools, with a maximum scholarship of $1,500. In addition, the student loan provisions would be amended to increase the maximum loan to individual students from $1,000 to $1,500; to postpone loan repayments during periods of service with VISTA or the Peace Corps, and to liberalize the loan cancellation or “forgiveness” provisions by increasing the annual cancellation rate for service as a professional nurse in publicly owned hospitals in substantially populated, nurse-shortage areas, and by eliminating the present 50-percent limit on the portion of the loan that may be cancelled because of such service. Finally, the accreditation provision would be amended to delete the authority of the Commisisoner of Education directly to accredit the schools and to permit the Commissioner to utilize the services of State agencies, as well as professional accrediting agencies, in evaluating the quality of training offered by nursing schools applying for Federal assistance. ALLIED HEALTH AND PUBLIC HEALTH As mentioned earlier, the allied health professions program is ex- tended by 1 year, with a few clarifying amendments. The program of traineeships for graduate or specialized training in public health and the program of grants to institutions for strengthening or expanding public health training are also extended for four years. HEALTH RESEARCH FACILITIES I want to turn now to Title IV of S. 3095. The health research facilities construction program has played a major role in improving the quality and quantity of the Nation’s health research over the past decade. 52 Since first authorized in 1956, 406 medical schools, universities, graduate schools in the healing arts, and other nonprofit institutions have received $445 million in project funds. These dollars have remodeled or constructed hundreds of labora- tories and research facilities and provided equipment for difficult and increasingly complex research into the causes and cures of disease and the basic elements of life itself. There have been more than 1,100 project awards, involving every State plus the District of Columbia and Puerto Rico. Eight-hundred ninety-three of these projects are completed. Construction has begun on an additional 193. And 58 more are preparing for construction. In many cases, these construction grants have enabled new medical schools to incorporate research facilities into their basic design. In other cases, existing schools and other institutions have been able to expand greatly their research capacity and enhance their train- Ing programs by attracting and utilizing researchers and their find- ings. In all cases, the facilities and equipment have contributed signi- ficantly to the astonishing expansion of our knowledge about disease and disability and what can be done about them. But this is a growing program. So long as the quest for new knowl- edge in the health sciences continues to challenge the country’s best minds there will be a continuing need for expansion of research facilities. So long as technological progress offers new research opportunities and new avenues of exploration, we will need to modernize, expand, and remodel existing research facilities. We are recommending an amendment which would authorize a Federal share of up to 6624 percent for the construction of facilities of special regional or national significance. Not more than 25 percent of the funds appropriated in any fiscal year could be used for this purpose. The Carman. You mean 6624 percent instead of 50-507 Dr. Lee. That is right. The health research facilities construction program expires June 30, 1969. We ask you to extend for another 4 years—until June 30, 1973— so that the momentum gained over the past decade will not be lost. Mr. Chairman, I have given you only a brief description of the most significant proposals in this legislation. Such a statement can hardly convey the urgent need for congressional support of these programs, nor can I, in this limited time, fully describe the impact S. 3095 will have on the educational opportunities for millions of Americans, and the health of all our citizens. I and my associates will be happy to answer your questions and add whatever we can to the committee’s understanding of this bill. I would ask that the section- ly-section analysis be inserted at this point. (The material referred to follows :) 53 TITLE I—HEALTH PROFESSIONS TRAINING Parr A—CoNSTRUCTION GRANTS Section 101.—The program of construction grants would be extended for 4 years (fiscal year 1970 through fiscal year 1973). “Such sums as may be necessary” would be authorized to be appro- priated for each of the 4 years. This program authorizes grants to assist in the construction, ex- pansion, or renovation of schools of medicine, dentistry, osteopathy, optometry, podiatry, pharmacy, veterinary medicine, and public health. Section 102—The Federal share authorized under present law—i.e., a maximum of 6624 percent for new or major expansion, and up to 50 percent for other construction—would be amended to authorize the Secretary to increase the 50-percent maximum Federal share where he determines that “unusual circumstances” make a larger percentage (in no case to exceed 6624 percent) necessary in order to effectuate the purposes of the program. In many established schools producing health professionals there are weaknesses of program, faculty, or facilities which are directly related to financial weakness. These institutions, beset by increasing demands on inadequate and obsolete facilities, have great difficulty in providing the institutional share of matching funds for construc- tion projects and, therefore, have been unable to make use of Federal financial assistance toward rehabilitation of school plant. Financial weakness in health professions schools stems from infla- tionary pressures and inability to secure adequate private or public State and local support. In general, the schools not able to meet the matching requirement are institutions which are privately supported, schools without a tax base for operating and capital funds, or public schools in States with limited matching funds. These institutions are important in the pro- duction of health manpower and deserve support to prevent decline in both quality and capacity of training. Section 103.—This permits facilities constructed for teaching pur- poses (and federally assisted by reason thereof) to be used for teaching purposes, or research purposes, or medical library purposes for which construction grants may be made—thus the provision for Federal re- covery within 10 years of completion for failure to use the facilities for the teaching purposes for which they were constructed would not apply. ih 10}.—The present program has been limited to the construc- tion of teaching facilities in the respective health professions schools. A school planning to construct a facility to include a medical library 54 and/or a health research facility has been required to make separate applications to the medical library construction program and the health research facilities construction program as well as to the health Professions educational assistance construction program. Applications ave been reviewed by three separate councils on three separate sets of criteria. The bill would authorize a school to make one application to and to receive funds under the health professions educational assistance con- struction program if the project is for the construction of facilities which are to a wo oo for teaching purposes but are also for health research purposes or medical library purposes. Section 105.—Under the present program, work area in a medical, dental, or other health professions school can be constructed with pro- From funds only if it 1s space attributable to the teaching program eading to the degree of doctor of medicine, doctor of dentistry, or other first health professional degree. This has proven to be a most un- desirable barrier to sound planning and construction of the school as an entity. The bill would allow the inclusion in the construction project of space for graduate, continuation, and other advanced training activi- ties as well as that attributable specifically to the training of persons in the first health professional degree curriculums. This would allow for sound, coordinated planning and construction of the total school. In the present educational system where advanced and undergrad- uate education arrangements for health professionals are largely in- terdependent, and the inability to support advanced training space has resulted in considerable difficulties for all of our applicant insti- tutions, the institutions have been forced to pay for the entire cost of advanced training space, limit it, or eliminate it from its plan. Parr B—INSTITUTIONAL AND SPECIAL ProJecr Grants To HEALTH Proressions PERSONNEL Section 111 (amends secs. 770-772 of the PHS Act). —Under present law, grants may be made to improve the quality of schools of medicine, dentistry, osteopathy, optometry, and podiatry. Improvement grants are of two kinds: (a) basic grants made on the basis of a formula of $25,000 per school and $500 per enrolled student, (5) special grants made on a project basis. There is a single appropriation authorization for both types of grants. Special improvement grants are awarded from the sums appropriated and not required for making the formula grants. This program became effective in fiscal year 1966. It has provided a source of continuing support for the teaching curriculums of the respec- tive schools. Appropriations were not sufficient to fund the basic im- provement grants under the statutory formula in fiscal years 1966 and 1967. Therefore, no special projects were funded in those years. The bill would authorize a 4-year extension (fiscal year 1970 through fiscal year 1973) of both the institutional (formula) (sec. 771) and Spedia project (sec. 772) grant authorities with significant modifica- 10ns. The 4-year period represents the recommended time to assure these schools of the continued support necessary for sound curriculum devel- 55 opment and stability. In addition, the assurance of 4 years of legisla- tive authority for support of curriculum improvements can do much to encourage these institutions to plan for significant modifications, to recruit and retain faculty necessary for implementation of these modifications, and to risk venture into some of the areas which could contribute most to curriculum improvement. Equally important for the schools which are in serious financial difficulties, the 4-year period of time for the continued, assured support under the formula grants, and the special assistance in meeting their operating costs through the special project grants can be a vital incen- tive to their marshaling of resources to upgrade their programs, or even to remain in existence. The bill would authorize appropriations of such sums as may be necessary for both the improvement grants and the institutional grants. The portion of the moneys appropriated for each fiscal year which would be available for special project improvement grants on the one hand, and formula institutional grants on the other, shall be deter- mined by the Secretary unless otherwise provided in the Appropriation Acts for that year. New section 771 (a) (1).—The formula would be revised as follows: The base grant per institution would remain at $25,000. Of the sums remaining from the available appropriations: (a) 75 percent would be distributed on the basis of (i) the relative enrollment of full-time students, (ii) the relative increase in enroll- ment of such students (over the average enrollment of the school for the 5 preceding school years) with the amount per student computed so that a school receives twice as much for each student in the increase as for other full-time students, and (b) 25 percent would be distributed on the basis of the relative number of graduates. Under present law, the formula for determining the amount of in- stitutional support takes into account only one variable: the number of students enrolled. A school receives $500 for each full-time student. The new formula takes into account two additional factors: («) in- creases in number of students, and (4) the number of graduates. Under the bill, a school would receive twice as much for each stu- dent added to its enrollment in a given year over the average enroll- ment of the school for the 5 preceding years. Consequently, the schools would be assisted to a greater at the new formula than the old. The increased funding for increased enrollment will encourage the schools to enlarge their enrollment while at the same time helping them with the cost of educating the additional students. The new formula would provide that 25 percent of the sums remain- ing from appropriations after the base grant ($25,000 per school) would be distributed on the basis of the relative number of graduates. This would provide a further incentive for the schools to increase and retain their enrollments, since at graduation the student would again be counted. This would also provide an incentive for schools to experiment with shortening the length of the training period without diminishing the quality of training, and to try to develop practical means for accepting students at advanced standing—for example, admitting a first-year student with advanced standing in courses for which he had demon- 56 strated competency. This would assist schools in maintaining a full enrollment and help to counteract the attrition which inevitably occurs. New section 771 (a) (2) —No school could receive less than it receives in fiscal year 1969 as a basic improvement formula grant. New section 771(b) (2).—However, without regard to any other provision relating to the new formula, no school could receive more in any year than it expended from non-Federal sources during the pre- vious year for teaching purposes ( jJsaop that this proviso would not apply in the case of a school which has for such year a particular year- class which it did not have for the preceding year.) New section 771(b) (1).—As in the present law, the bill would re- uire, as a condition for receiving a formula grant, assurances from the school that the school would increase its enrollment by 2Y4 percent or five students (whichever is greater) over the average first-year en- rollment of full-time students of the school over a 5-year period. How- ever, three changes have been made in this provision. (a) The 5-year average period would be changed from July 1, 1960, through July 1, 1965, to the period July 1, 1963, through June 30, 1968. Thus, the 5-year base period against which the expansion of enroll- ment is to be computed would be moved up to July 1, 1963, through June 30, 1968. The effect of this is to advance the fixed period of time against which the computation is made 3 years beyond that provided for in the present law. (5) The expansion would relate to the average first-year enrollment in lieu of the existing law’s highest first-year enrollment. The number of additional students which a school can reasonably be expected to enroll is limited. Since the beginning of the improvement grant program in fiscal year 1966, most schools have already mereased their number of first-year students by at least five. To make the in- crease cumulative, i.e., to require that the school take five more stu- dents in addition to the five which it had so recently taken, would constitute an unreasonable burden: for example, a medical school which enrolled 100 first-year students each year during the period July 1, 1960 through July 1, 1965, made the effort and expanded to 105 students during fiscal year 1968. If the bill were to require the highest enrollment to be used as the base, the cumulative impact would mean a 10-percent increase in enrollment, i.e., an additional five first- year students with the responsibility on the school to assure that places are available for these students in each of their succeeding years— second, third, and fourth, as well as the first, or the equivalent of 20 school places. If the formula were structured so that the school re- ceived approximately the full cost of education for such students, such as required increase might be justifiable. However, it is not reasonable to place such a cumulative requirement of this nature on all schools. The requirement has therefore been changed so that the increases which schools have already made can be averaged over the new 5-year period. This will retain the stimulus for increase without undue, or even unjust, burdens on the schools. Effective in fiscal year 1970, the bill would authorize the Secretary to waive the required first-year enrollment if he determines, after consultation with the Advisory Council, that it cannot be accomplished without lowering the quality and training provided or that a waiver 57 would otherwise be in the public interest and consistent with the purposes of this program. (Sec. 111(f) of the bill would also provide similar waiver authority under present law for fiscal years 1968 and 1969.) (¢) Experience under the expansion of enrollment requirement of the present law has demonstrated that the purposes of the health professions educational assistance program cannot be fully achieved with a rigid and inflexible enforcement of this requirement. Under present law, the Secretary may waive the expansion of enrollment, in whole or in part, if he determines, after consultation with his Ad- visory Council, that such an increase cannot be accomplished because of limitation of physical facilities available to the school without lowering the quality of training. Under present law, a school must have had an approved application for a basic grant to be eligible for a special improvement grant. Therefore, schools which are ineligible for basic improvement grants are also ineligible to receive assistance under the special project authority; thus no Federal assistance is available to them through the improvement grant mechanism. The expansion of enrollment requirement has presented a serious problem to schools which by merely maintaining or cutting back on enrollments could maintain or improve the quality of education pro- vided for students. The dilemma of the school is particularly great when the financial resources of the school are limited. The school has the choice of further reducing the quality of its educational program by taking in more students in an already weak curriculum or going without the funds and undertaking the curriculum improvement en- tirely at its own cost. The bill would authorize the Secretary effective in fiscal year 1968, to waive the expansion of enrollment requirement if he determines, after consultation with the Advisory Council, that the waiver is in the public interest and consistent with the purposes of the law. This amendment would make it possible for the Secretary and the Advisory Council to weigh the many complex factors in the individual situations which the schools are confronting and to deter- mine whether it is in the public interest to grant such a waiver and the degree to which Federal assistance would or would not be warranted in terms of the objectives of the act. New section 772.—Under existing law, special project grants may be made to schools of medicine, dentistry, osteopathy, optometry and podiatry to improve their curricula, to contribute toward the main- tenance of or provide for accreditation, or to contribute toward the maintenance of or provide for specialized functions which the school serves. In order to receive a special improvement grant, a school must have had an approved application for a basic improvement grant. There is a statutory ceiling on the amount of grant to any school: £300,000 for fiscal year 1968 and $400,000 for fiscal year 1969. In addition to the schools presently -eligible to receive special improvement grants, schools of pharmacy and veterinary medicine would be eligible for special project grants under the bill. A school would no? be required to have an approved application for an institutional (formula) grant in order to % eligible for a special project grant. 92-079 O - 68 - 5 58 Effective for fiscal year 1969, the present authority for special im- provement grants would be amended to authorize Sippot of plannin of special projects for which grants could be made under the amende law which would go into effect in fiscal year 1970. The purposes of the special project grants would be— } (1) To plan, develop or establish new programs or modifica- tions of existing programs of education in the respective health professions. . (2) To effect significant improvements in curricula of health professions schools. (3) To conduct research in the various fields related to educa- tion in the respective health professions. (4) To develop training for new levels or types of health professions personnel. (5) To assist any school which is in serious financial straits to meet the costs of operation or to meet accreditation requirements. (6) To plan experimental teaching facilities or experimental design thereof. (7) Or otherwise strengthen, improve, or expand programs to train the personnel in the respective health professions or help to increase the supply of adequately trained personnel in such professions. These are designed to stimulate schools to undertake and carry out projects such as increasing enrollment, improving the quality of educa- tional programs, modernizing and improving the overall approach to health professions education, sazpying out educational research, and training new kinds of intermediate health personnel to extend the resources and skills of highly trained professionals. Further stimulus is given to the development of meaningful projects by the inclusion in the bill of authority, effective in fiscal year 1969, for special improvement grants for planning projects under the new special project authority which becomes effective in fiscal year 1970. New section 773 (e) —In determining the priority of projects under the amended authority, the Secretary Ry be required to give con- sideration to the following: (a) The extent to which the project will increase enrollment. (6) The relative need of the applet for financial assistance to maintain or provide accreditation or to avoid curtailing enroll- ment or reduction in guatisy of training. (¢) The extent to which the project would result in curriculum improvement, improved methods of training or help to reduce the period of required training without adversely affecting the quality thereof. Projects of the magnivide and of the nature envisioned for these grants require careful and time-consuming study. The availability of funds to help meet the costs of preparatory analyses of the needs of the schools and their correction should result in major improvements of the schools. . Section 111(b) (3).—This amendment makes a conforming change in the title of the Advisory Council. Section 111(b) (4).—This amendment excludes nonrecurring ex- penditures from the average non-Federal expenditure of the applicant 59 during the last 3 years when determining how much non-Federal money the applicant must spend to get a grant, n Section 111 (¢) —This amendment would authorize additions to the Advisory Council of members from the fields of pharmaceutical and veterinary medical education; and change the name of the Advisory Council to the National Advisory Council on Health Professions Educational Assistance. The role of the Council is to advise the Secre- tary on regulations and policy with respect to institutional, special project and schalurship grants. The Secretary may not award an insti- tutional grant nor can he grant a waiver of the expansion of enrollment requirement, nor make a special project grant, until he has consulted with the Council. It is important that the Secretary should be author- ized to have the advice of persons who have expert knowledge in the fields of pharmaceutical and veterinary medical education, if schools of veterinary medicine and pharmacy are to be eligible for these grants. Section 111(d).—Provides effective date for the amendments made by section 111. $o. Section 111 (e) —For fiscal year 1969, special improvement grants will be authorized to support planning for special projects for which grants are authorized by the bill beginning in fiscal year 1970. Section 111(f).—For fiscal years 1968 and 1969, the Secretary may waive the condition of eligibility for formula institutional grants that enrollment must increase if he determines it is in the public interest and consistent with the purposes of the program to waive it. Parr C—Hearrin ProressioNns STUDENT AID Section 121. —Under present law, grants may be made to schools of medicine, dentistry, osteopathy, pharmacy, podiatry, or optometry for two types of ae A aid programs: loans and scholarships. Schools of veterinary medicine have also been eligible to receive grants for loans, but not for scholarships. These two programs have provided vital resources for support of students in the respective health professions. The bill would extend the authorization for appropriations of Federal capital contributions to student loan funds for 4 years (fiscal years 1970-73) and extend the authorization for making loans (to en funds) from the revolving fund for 5 years (fiscal years 1969-73). Existing authorization for the Federal capital contribution to student loan funds expires on June 30, 1969, and the authorization which enables the schools to borrow capital from the revolving fund SxPifes on June 30, 1968. he proposed extensions of 4 and 5 years, respectively, for the two methods of capitalization of student Vo funds would provide for coterminous expiration of authority on June 30, 1973. Authority would be extended for three additional years for appropriations for Federal capital contributions to enable students who received a loan for any academic year ending before July 1, 1973, to complete their education. Section 121(a) (3).—Under present law, repayment of a loan must be accomplished within a 10-year period which begins 8 years after 60 a student ceases to pursue a full-time course of study. However, if he is serving as a member of the uniformed services or as a Peace Corps volunteer during the period of repayment, he is entitled to an additional year of postponement for repayments for each full year of such service (but not to exceed 3 years). The bill would include service as a VISTA volunteer as a basis for such postponement. U to 5 years of advanced professional training (including iy would also be a basis for such postponement. This amendment provides (1) an inducement for health professional personnel to serve in the Volunteers in Service to America program similar to the existing provision under section 741(c) of the act which provides for postponement of repayment for borrowers serving in the oo Corps, and (2) for lengthy advanced professional grating required in fields of specialization which might otherwise be deferre because of financial burden. Section 121 (a) (4) (4).—The bill would authorize a school to charge a borrower for failure to pay all or any part of an installment when it is due or, if the borrower 1s entitled to postpone his repayments, or to cancel his repayment, for his failure to file timely evidence of such entitlement ($1 first month ; $2 each month thereafter). The proposed amendment would permit participating schools to place greater emphasis on terms and conditions of repayment. Section 121 (¢) —This would postpone for 4 years through Septem- ber 30, 1976, the date of the capital distribution of the balance of any student loan fund. Section 121(d) (1).—This would extend for 5 years through fiscal year 1973 the authorization of loans to schools. Section 121(d) (2). —This would increase from $35 million to $45 million the total amount of loans which may be made to student loan funds from the revolving fund. Section 121 (e) (new sec. 746) .—The bill would authorize a school to transfer to its scholarship funds up to 20 percent (or a higher percentage with the approval of the Secretary) of the Federal funds Sod to it for its loan fund. (There is a similar provision for transfer rom its scholarship program into its loan fund.) This transfer au- thority will provide a most desirable flexibility to the school in tail- oring its financial assistance programs to meet the needs of its indi- vidual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 121(f).—This provides effective dates for the amendments made by this section. Section 122.—This would extend the health professions scholarship program for 4 years (fiscal year 1970 through fiscal year 1973). It would add veterinary medicine students to the eligible partici- pants. Veterinary medicine makes significant contributions to the field of human medicine, to medical research, and to the maintenance of an abundant and safe food supply. Section 122(d) (new sec. 781). —The bill would authorize a school to transfer to its student loan program up to 20 percent of the amount paid to it for scholarships (or a higher percentage with the approval of the Secretary). (There is a similar provision for transfer from 61 its scholarship program into its loan program.) This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. } } Section 122(c) (2) —*“Students from low-income families who, with- out such financial assistance could not pursue a course of study at the school for such year.” Change to “students of exceptional financial need who need such assistance to pursue a course of study.” This change makes the program comparable in this respect to the higher education scholarship program. Section 131. —The Secretary would be required, in consultation with the Advisory Council to prepare and submit to the President and Congress before July 1, 1972, a report on the administration of parts B, C, E, and F of title VII of the Public Health Service Act. TITLE II—-NURSE TRAINING Parr A—ConstrUCTION GRANTS Under the Nurse Training Act of 1964, Federal grants were au- thorized to assist in the construction, expansion or renovation of di- ploma, associate degree, and collegiate schools of nursing. Section 201—The program would be extended for 4 years (fiscal year 1970 through fiscal year 1973). Such sums as may be necessary would be authorized to be appropri- ated for each of the 4 years. Section 202.—The period that a Federally assisted project would be required to be used as a school of nursing would be reduced from 20 to 10 years. (Failure to comply entitles the United States to recover present value of the Federal share.) Section 203—The Federal share authorized under present law would remain the same. However, a new exception would be added : It would authorize the Secretary to increase the maximum 50 percent Federal share (for construction other than new facilities or major expansion) where he determines that “unusual circumstances” make a larger percentage (in no case to exceed 6624 percent) necessary in order to effectuate the purposes of the program. Section 204.—Adds the Trust Territory of the Pacific Islands to the definition of a State. Section 205.—Under the present program space in a collegiate school of nursing can be constructed only if the space is attributable to the teaching program leading to a degree in nursing. Extension of the program of construction grants was recommended by the Program Review Committee provided for under the nurse train- ing program. Approximately 49,000 new places for first-year students will be needed if schools are to prepare the numbers of nurses needed by 1975. Grants for construction of teaching facilities can help to increase the number of first-year places in three ways: 1. Construction funds to replace and renovate obsolete facilities in order to retain current enrollments. Many nursing education programs occupy makeshift buildings such as barracks, dormitor- les, and basement areas; many are unsafe, poorly ventilated, noisy, 62 and not conducive to learning. These schools can scarcely main- tain their present enrollments much less consider increasing their student body. The contribution which these schools can make to- ward maintaining the nurse manpower supply warrants the same favorable Federal share as new schools or schools which can ex- pand enrollments substantially. 2. Construction funds for existing schools which can undertake major expansion of enrollments. Many well-established schools turn away qualified applicants due to lack of space. Given addi- tional facilities, these schools could expand enrollments without jeopardizing the quality of their teaching programs. 8. Construction funds for new schools in areas where there is a demonstrated potential for recruitment, faculty improvement and community interest but no physical facilities for a new nursing educational program. Schools which do not attract sufficient applicants to fill their spaces do not always provide a reservoir of unused capacity for use by appli- cants red away at other schools which are filled to capacity. This might be the case if undersubseribed and oversubscribed schools were located in the same areas, and were almost equally acceptable as regards accreditation, quality of faculty, adequacy of facilities, and similar criteria which guide applicants in choosing schools. Under the provision of the nurse training program new schools of nursing and those making a major expansion of enrollment are entitled to Federal participation not to exceed 6624 percent of necessary con- struction costs. Schools replacing, renovating, or making minor expan- sion of capacity may receive up to 50 ine participation. The bill would allow the inclusion in the construction project of space for advanced training activities that are not degree-oriented. his would allow for sound, coordinated planning and construction of the school as a whole, taking into consideration the several interrelated teaching mission that the school fulfills. Parr B.—SpEciaL Prosect AND INSTITUTIONAL GRANTS TO SCHOOLS oF NURSING Under the Nurse Training program, special project grants are made to diploma, associate degree and collegiate schools of nursing to assist them in meeting the costs of projects of limited duration to strengthen, improve, and expand their programs to train nurses. Section 212 (new sec. 805). —The program would be extended for 4 years (fiscal year 1970 through fiscal year 1975). The definition of institutions eligible to receive improvement grants would be broadened. Schools of nursing would continue to be eligible, but broadened authority would also permit grants to be made to in- stitutions or agencies which do not have programs of nurse education but which could plan or develop such programs or could contribute to the strengthening and improvement of nursing education. In addition to the general purposes of the project improvement grant authority—i.e., to Siren gilied, Jmprovs, or expand programs of nurse training—the bill would specifically sani ont purposes and would also add new authority to develop, or establish new or modified, programs of nursing education. The specific clarification of purposes 63 gives special emphasis to the assistance of schools which are in serious nancial straits to meet their costs of operation or to meet accreditation requirements. It also emphasizes assistance to projects for the modifi- cation of existing programs, an emphasis which 1s particularly vital at this time of transition in nursing education. Present section 805 (improvement grant) authority would also be amended, effective fiscal year 1969, to include support for planning frei8) projects to be funded under new authority coming into the law in 1970. Content of nursing education must be improved, updated, and ex- panded to prepare students for present-day complexities of Hine ractice and the variety of patient care setting in which they wil function. Curriculum improvement is a continuous process to use new teaching methods to incorporate new knowledge and nursing skills into the student’s educational experience. Man Eo are in such difficult financial straits that they cannot a, the fundamental curricu- lum changes and improvements necessary for quality programs which will meet accreditation standards. Because of increasing specialization and complexity of present-day care, new ways must Re found to train nursing students in shorter periods of time and to train a larger number of students with a short supply of qualified teachers. Improved utilization of qualified faculty members in all types of educational programs for nursing is one ap- proach which is effective for ex lw, the present on. supply. These activities are costly since they require the use of expensive com- munications equipment for large numbers of students. However, these systems can conserve the time required for teaching students and make the most effective use of the short supply of well-qualified teachers. Recent developments in nursing education indicate the need for Federal funds to assist and insure development of the numbers and types of programs needed, and orderly transition from present pat- terns. These rier closing of hospital programs, the pro- liferation of associate degree programs, the enlargement and establish- ment of new baccalaureate and graduate programs, the increasing de- mand for clinical facilities for student experience, and the appropriate interlocking of education for nursing with that for other health pro- fessions—are straining the resources of the institutions and agencies which have responsibility for providing services as well as learning experiences, and of the educational institutions faced with enlarging and adding new programs. New section 806.—Under the Nurse Training Act program, grants are authorized for payments to diploma schools of nursing to defray a portion of the cost of training federally sponsored students. Grants are made on a formula of $250 times the sum of the number of federally sponsored students and the number of students attributable to an in- crease in enrollment. No school could receive more than $100 times its full-time enrollment. An entirely new program of institutional (formula) grants to all three types of schools of nursing would be authorized under this bill. The bill would authorize a new 4-year program, beginning in fiscal year 1970 through fiscal year 1973. New section 806.—The statutory formula provides for: A basic grant to each school of $15,000 and of the remainder: 64 (a) Seventy-five percent of the basis of the relative enrollment of full-time students and the relative increase in enrollment of such students over the average enrollment of the 5 preceding years (with the amount per student computed so that a school would re- ceive twice as much for each student in the increase as for other students), and (6) Twenty-five percent on the basis of the relative numbers of graduates. Institutional support grants would enable all schools to improve student-faculty ratios, attract more highly qualified faculty and strengthen and enrich basic curricula. It would also permit schools to apply new educational methods and innovations to professional nurs- ing education. Costs of the educational institutions have risen rapidly because of increasing costs of supplies, equipment, maintenance. Salaries of academic and nonacademic personnel have accelerated rapidly without commensurate increase of income. Income from tuition and fees has never approximated costs. There has always been a deficit met through other sources. As academic costs have risen, the percentage of the cost paid by tuition has been less and the gap has widened. Income from endowments and gifts has be- come a very limited source of support; Federal funds are also limited. For the public institutions, increase in State appropriations is the only significant source of increased support. Privately supported in- stitutions must look to Federal financing to assist in closing the gap between income and costs. The private institutions particularly are reluctant to increase enrollment in existing programs. Graduate pro- grams (master’s and doctoral level) incur higher deficits than those at the baccalaureate level. This is due to the need for highly specialized faculties, the need to support faculty research as well as Instructional costs, and the desirability of low student-faculty ratio in practicum. Basic support grants would make the vital difference in the decision to open or continue a nursing program. The low faculty student ratio makes a nursing major costly to the school; and there are other costs connected with the clinical practice courses. Broadening the base of the formula grants to include associate degree, baccalaureate degree and graduate programs, and application of a formula which guarantees a basic payment of no less than $15,000 to all schools would permit employment of at least one additional faculty members and supporting services. Basing the remainder of grant on enrollments and graduations would provide a total grant re- lated to size of the programs. These institutional grants would con- tribute directly to high-quality education. These funds could make the difference between an excellent instructional program and a medi- ocre one by making it possible to attract more highly qualified faculty and improve student-faculty ratios. Such grants could make it possible and feasible for the school to allocate a certain proportion of faculty time to research activities and to programs designed to foster faculty growth and development. Basic support grants could place the school in a position to better obtain essential teaching aids to enrich the in- structional program. New section 806 (b) (1).—The Secretary’s regulations shall provide for determination of number of students enrolled in a school or num- ber of graduates. 65 New section 806 (b) (2). — “Full-time students” means students pur- suing a full-time course of study in an accredited program in a school of nursing. Costs for educating nurses, particularly in collegiate and graduate programs, have increased as for all health professions. Schools cannot attract qualified faculties, provide comprehensive and supervised clini- cal practice, and increase enrollments, without financial assistance. It is essential that continuing basic support be provided for all health curricula to maintain the necessary level of quality. Our Consultant Group on Nursing recommended that Federal funds be made available to help schools meet the costs of nursing education. The Program Re- view RT endorsed the principle of basic support grants for schools of nursing, but they took serious exceptions to supporting a single segment oe nursing education. The Committee recommended that basic support grants be given to all types of accredited nursing programs: diploma, associate degree, baccalaureate and graduate degree. Section 212 (new sec. 807 (a) ) —The Secretary may set the date by which applications for improvement or institutional grants must be filed. New section 807 (b) —The Secretary must consult with the National Advisory Council on Nurse Training before acting on any application. New section 807 (¢) —An improvement or institutional grant may be made only: (1) to a public or nonprofit private school of nursing or (in the case of an improvement grant) public or nonprofit private agency, organization, or institution; (2) if recipient assures the Sec- retary that it will expend an amount of non-Federal funds which are at least as great as the average amount of funds expended by applicant in the 3 fiscal years preceding year for which the grant is sought; (8) if applicant provides information and gives assurance that Secre- tary requires; and (4) if applicant provides fiscal control and access to records as Secretary may require. Section 212 (new sec. 808). —The bill would authorize appropria- tions of such sums as may be necessary for both the improvement grants and the tiny grants The portion of the moneys appro- priated for each fiscal year which would be available for special project improvement grants on the one hand, and formula institutional grants on the other, shall be determined by the Secretary unless otherwise provided in the appropriation acts for that year. Section 213.—This makes a conforming change specifying the time that schools with reasonable assurance of accreditation applying for institutional grants under section 806 will become accredited. Section 214.—This provides the effective date for these amendments. Section 215.—With respect to fiscal year 1969, appropriations (un- der old sec. 805(a)) shall be available for planning special projects for which grants are authorized under the amended section beginning with fiscal year 1970. Parr C—SrtupeEnT AD Section 221.—The program of traineeships of professional nurses would be extended for 4 years (fiscal year 1970 through fiscal year 1973). Such sums as may be necessary would be authorized to be appropriated for each of the 4 years. 66 With the incentives to expansions of enrollment and the encourage- ment of the planning and establishment of new programs of nursing education, it is particularly vital to extend the present authority for advanced traineeships for the preparation of teachers in the various fields of nurse training. These advanced traineeships are also a source of support for the training of nurses to serve in administrative or supervisory capacities and to serve in the various professional nursing specialties which have become increasingly important with the ad- vanced technology in medicine. ) Section 222(a) (1).—This would amend the existing Public Health Service Act to make it conform with the new section 829 (transfer of funds to scholarship program). . Section 222 (a) (2) his would extend the deadline for loan appli- cations to 1973. C Section 222(b) (1) —This would revise the maximum limit for loans per academic year from $1,000 to $1,500. Section 222(b) (2). —This would authorize postponement of the 10-year period for repayment of nursing student loans by addin postponement during service (not to exceed 3 years) in the uniforme services, the Peace Corps or VISTA. It would further authorize post- ponement (up to 5 years) for advanced professional training. Section 222(b) (2). —This would authorize up to 100 percent can- cellation of nursing student loans at the rate of 15 percent per year for service as a professional nurse in a public hospital in an area with a substantial population and a substantial shortage of nurses in public hospitals. (Retains 50 percent cancellation at 10 percent per year rate for fulltime service in public or nonprofit institutions or agencies.) Section 222(c).—This would allow a school to charge a borrower for failure to pay all or any part of an installment. en or if a borrower is entitled to postpone repayment or cancel part or all of the loan, he may be similarly charged for failure to file timely evidence of entitlement. The charge may not exceed $1 for the first month, and $2 for each subsequent month. Section 222(d) (1) —This would extend the authorization of appro- priations for payments to student loan funds. Section 222(d) (2). —This would make the existing Public Health Service Act conform to new section 829. ; Section 222(e) —This would change the allotment formula for dis- tribution of funds for Federal Capital contributions to student loan funds. The existing formula allocates the money among the States, 50 pioens on the basis of the relative number of high school graduates, and 50 percent on the relative number of students enrolled in schools of nursing. The new formula would allow for a more equitable dis- tribution of funds among schools of nursing by providing for allotment of the funds among the schools on the basis of the relative school enrollment. Section 222(g) —This would extend the time that the Secretary can Ie loans from the revolving fund for 5 fiscal years to fiscal year 3. Section 222(h).—This would add a new section (sec. 829) to the Public Health Service Act providing for “Transfers to Scholarship Program.” This would authorize the transfer to the school’s scholar- 67 ship program of up to 20 percent {r higher on approval of Secretary) of Federal funds paid to a school for its student loan program. This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 222(i).—Provides effective dates for amendments made by the preceding provisions of section 222, Section 223 —This provides two new sections, section 860 and sec- tion 861. Section 860 replaces the existing educational opportunity grants with a scholarship program patterned generally after the schol- arship provisions for the health professions, Section 860 (a) — This would authorize the Secretary to make grants to public or nonprofit schools of nursing for scholarships, Section 860 (b).— This would authorize scholarship aid for students in all three types of nursing schools: diploma, associate degree, and collegiate. This program would begin in Boca] year 1970 and would go through fiscal year 1973. It would further provide that appropriated funds be allocated among the participating schools on the basis of $2,000 times one-tenth the number of full-time students. Many nursing students come from low-income families who cannot help finance their educations; they will enter a profession where sal- aries are very low, articularly compared with the high remuneration of physicians and dentists, Consequently, proportionately more nurs- mg Snduns will require scholarship support. The increasing costs of education to students are discouraging tal- ented and interested young people from pursuing nursing careers. Availability of scholarship support would relieve financial pressure on students in school and give greater quality of opportunity to those who could not otherwise pursue a nursing career, One-fifth of all nursing students are from families which have less than $5,000 annual income, An additional fifth come from families in the $35,000 to $7,500 income bracket. All of the students in the first category and a substantial number in the second would require finan- cial assistance for their nursing education, Section 860(c) (1). —To be eligible for a scholarship, a student must be enrolled as a full-time student in good standing and must be of exceptional financial need and must need the financial assistance to pursue the course of study. Section 860 (¢) (2) —This would provide that students could not re- ceive more than $1,500 per academic year, The ress scarcity of financial aid, particularly nursing scholar- ships, forces students from low-income families to select on the basis of its cost irrespective of the students’ ability or career goals, The in- creasing costs of eduaction to students will discourage talented and interested youth from pursuing nursing careers unless the amount of a scholarship approximates the cost of the nursing education program, Costs of nursing education vary widely among and within ditterent types of programs—diploma, associate degree and baccalaureate, They can range from minimal in State-supported schools to over $2,000 per year in private institutions. In many nursing programs, tuition alone 1s over $1,000 per year. A maximum scholarship of $1,500 will permit students more realistic planning of their educational programs. 68 Section 860- (d)—This would provide that regulations for nursing student loans be prescribed by the Secretary after consultation with the National Advisory Council on Nurse Training. Section 860 (e)—This would provide that scholarship grants may be made in advance or at such intervals as the Secretary finds neces sary. Section 861—This would authorize up to 20 percent of the amount paid to the school for scholarships (or a higher percentage with the approval of the Secretary) to be transferred to its student loan pro- gram. This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 231—It would delete the authority of the Commissioner of Education directly to accredit programs of nurse education. This sec- tion would take effect on enactment of this act and would add State agencies to the body or bodies which the Commissioner of Education could approve for purposes of accrediting programs of nurse educa- tion. It would require the Commissioner of Education to publish a list of nationally recognized accrediting bodies and State agencies which he determines to be reliable authority as to the quality of training offered. It would authorize the reasonable assurance (of accreditation within a specified period) provision to apply, in the case of a construc- Hon project, to an existing school. (Present law relates solely to new schools.) Section 232—This would direct the National Advisory Council on Nurse Training to submit a report to the President and Congress be- fore July 1, 1972, on the administration of the nurse training pro- gram and recommendations with respect thereto. TITLE III—ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH TRAINING ALLIED HEALTH Stimulated by the advances is medical knowledge, the population ex- plosion, lowered financial barriers to medical care, and an emerging social concept that medical care should be related to medical need, the demand for health manpower is approaching crisis proportions. Less generally recognized than the shortages of physicians and nurses has been the need for a complex of some 85 allied health professions and occupations without which modern medical practice and total health services cannot be delivered. The adequate numbers and quality of education of these professional and technical personnel are critical to maintenance of quality community and personal health services. All allied health occupations present manpower problems to the degree that lack and/or inefficient utilization of such personnel pre- vent, our reaching reasonable objectives for health programs. The allied health professions personnel training program was en- acted in November, 1966. It authorizes grants for the construction of teaching facilities for allied health training centers, grants for train- eeships for advanced training of allied health professions personnel to become teachers, supervisors, administrators or specialists, grants (both formula and special project) to improve the curriculums for 69 training allied health professions personnel, and project grants to de- velop, demonstrate, or evaluate curricula for the training of new types of health technologists. There has been 1 year of experience under the program. Section 301 (a). —This section would extend the allied health pro- fessions program for 1 year (through fiscal year 1970), authorizing such sums as may be necessary. This would make it possible to gain additional experience before proposing a major extension, since there has been only 1 year of experience. Section 301(b) —This would clarify the provisions for projects to develop, demonstrate, or evaluate curricula for the training of new types of health technologists. It would make the following clarifying amendments to those provisions. Section 301(b) (1). —At the present time only training centers for the allied health professions are eligible to apply for project support under this section. The bill would extend the present authority to in- clude agencies, institutions, and organizations. Thus, institutions which do not qualify as training centers, but which have the competency to de- velop, demonstrate, or evaluate curricula, would be eligible to partici- ate. PD Section 301(b) (2). —This would make it clear that among the au- thorized purposes of the projects is the development, demonstration, or evaluation of curricula and methods of training health technolo- gists. This would prevent an unduly restrictive interpretation limited only to curricula. Section 301(b) (3) —This would delete the phrase “new types” as it relates to health technologists. Thus, projects to develop, demon- strate, or evaluate curricula and methods may be directed toward known types of health technologists as well as new types. Section 301(¢).—This would authorize a new section 797 of the Public Health Service Act. This section would authorize the use of up to one-half of 1 percent of the amounts appropriated under the allied health professions training program for any fiscal year beginning with fiscal year 1970 for evaluation of the program. PUBLIC HEALTH TRAINING Project grants for graduate training of schools of public health for professional public health personnel have made a significant contribu- tion to the expansion and improvement of public and community health training throughout the country and in increasing the numbers of trained public health specialists so badly needed in today’s society. It has made possible special innovative programs in schools of public health to provide them with the capacity to become balanced centers of public health training and major public health consultative and investigative resources for the Federal, State, and local governments. Under the present law, the Secretary may make project grants to schools of public health, to other public or nonprofit institutions pro- viding graduate or specialized training in public health, for the pur- pose of strengthening or expanding such public health training. The present law further provides for traineeships for graduate or special- 1zed public health training for physicians, engineers, nurses, and other professional health personnel. 70 Section 302—This section would extend the above described pro- visions for 4 years (through fiscal year 1973). It would also raise the er diem limit for members of the expert advisory committee to $100 rom the current limit of $50 to conform with the statutory authoriza- tion for compensation for members of other health manpower councils. This expert advisory committee, composed of persons FCproseniive of the principal health specialties in the field of public health administra- tion and training, advises the Secretary on both the above programs. TITLE IV—HEALTH RESEARCH FACILITIES Under present law, project grants may be made for the construction of facilities for research, or research and related purposes, in the sciences related to health. Grants may be made to public or nonprofit institutions determined by the Surgeon General to be competent to engage in the type of research for which the facility is to be con- structed. Section 401,—This would extend the program for 4 years through fiscal year 1073, authorizing “such sums as may be necessary.” Section }02~This would allow construction grants of up to 6634 ercent for a class or classes of projects determined by the Secretary to have special national or regional significance. Not more than 25 percent of the moneys appropriated could be made available for these projects. This modifies the existing provision of the law which provides that the Federal share in the construction of health research facilities may not exceed 50 percent. An appropriate analogy to this proposal was the special grant pro- gram to construct research centers investigating mental retardation causes and cures. Mental retardation is clearly a national problem, not restricted to a particular area of the Nation. Program needs pro- jected a limited number of research centers distributed throughout the Nation. Given pressing local health priorities, no single university or medical school could reasonably be expected to take on the task of establishing mental retardation research centers without increased Federal sharing in the cost. A richer sharing was provided by law 3 percent) and the centers were planned, funded, and are now under SOs Tetion: The special construction authority has been allowed to elapse. L'he authority proposed in this section would remove the need for a series of individual, categorical authorities for such construction and allow the Department to respond to situations and problems as they Section 403.—This would raise the maximum per diem for members of the National Advisory Council on Health Research Facilities from $50 to $100 to conform with the statutory compensation for other Public Health Service advisory councils. As indicated earlier in this document, the bill would authorize a school to make an application to the health professions educational assistance construction program if the project is for the construction of facilities which are to a substantial extent for teaching purposes but also for health research purposes or medical library purposes. hu Dr. Lee. Thank you, sir. The Cuamrman. You have brought us a splendid statement. 1 cer- tainly want to thank you for it. Let me ask you this, Doctor, what is your judgment in reference to involving or combining health manpower production with the science programs of NTH ? Dr. Lee. With respect to our reorganization, Senator Hill? The Cuamrman. Well, it would amount to a reorganization. Dr. Lee. Yes. Well, I think there is a very strong case to be made for this, and I personally favor it. The reason is that in our educational institutions there is a very close association between programs of pro- fessional education and biomedical research. These are increasi interwoven, and I think for this reason they should be closely linked at the Federal level. The proposal which we are making here with pospiect to construction of facilities is also consistent with that proposal and with greater flexibility in the educational institutions; we could have a single focal point for the administration of that total program. The CHARMAN. Does the Department have recommendations re- garding authorizations for appropriations that would be required to expand our training capacity for health manpower ? Dr. Lek. Yes, sir; the Department does. We have these here for you, sir. The CratrmAN. Are they broken down ? Dr. Lee. They are broken down in health professions educational as- sistance, by construction grants, institutional support, scholarships, and student loans. Also, there are similar breakdowns under nursing, allied health, public health, and the health research facilities. The Cuamrman, Without objection, we will have this chart appear at this point in the record. (The chart referred to follows:) ESTIMATED NEW OBLIGATION AUTHORITY REQUIRED FOR FISCAL YEAR 1969-73 UNDER HEALTH MANPOWER ACT OF 1968 (S. 3095) [In millions of dollars] New obligation authority Fiscal Year Fiscal your Fiscal year Fiscal year 1971 197 197. 197 A. Health professions Sducational assistance: Construction grants... ___ 170.0 225.0 225.0 225 Institutional support 100.0 150.0 190.0 220 LE 16.0 16.8 17.4 18 Ba Student loans... .....«.covanscrinnavanmunen 35.0 35.0 35.0 35 Construction grants... _________ 25.0 35.0 40.0 50 Institutional support. _ = 30.0 45.0 70.0 100 Traineeships. . 15.0 19.0 23.0 28 Scholarships. 20.0 30.0 33.0 34 5) Student loans. 20.0 21.0 22.0 23 C. Allied health: Construction grants... _____ 10.0 Institutional support = 20.0 Traineeships............. 5.0 New methods grants 4.5 D. Public health: 3 Project grants... an 8.5 2) Trainees ips 10.0 E. Health research facilities—construction grants. 35.0 Note: The projections contained in this table represent departmental predictions and do not represent the administra - tion position on the future program or budget requirements. Personnel requirements will be dependent on program developments and budget factors which at this time cannot be fully predicted. 72 The CrarMAN. What about the construction of health research facilities? on Lee. Yes, sir; those estimates are there in the second page of that. The CrAIRMAN. Second page? Dr. Lee. Yes, sir. The Cuamrman. I see. Dr. Lee. I should add, Senator Hill, that the figures for 1969, of course, are the present requests. The Cramrman. Which are awfully low—terrribly low. In fact, the appropriation requests for research facilities have been slashed for the last 3 years, is that not right? Dr. Leg. Yes, sir. The CramrmaN. This year, $8,400,000. We authorized some 3 years ago an appropriation over a 3-year period of $280 million as I recall. Dr. Lee. I believe that is correct. The Cuamrman. The first year, the budget estimate was for, I think, $15 million and the second year for $35 million, and now this year for $8,400,000, which is far, far under the $280 million needed, is that right? Dr. Lie. Yes, sir. The Caamrman. Let me ask you this question: As introduced, S. 3095 does not provide for veterinary medicine or pharmacy colleges in the case of institutional grants. Would you comment on this exclusion ? I might say I have a telegram here from the dean of the School of Veterinary Medicine, Tuskegee Institute, saying this is a critical need. Understand the hearing on educational bill S. 3095 sponsored by you will come up tomorrow. Strongly urge that bill be amended to include veterinary medicine for institutional grants. This is a critical need to all schools of veterinary medicine. What would be your comment on that? Dr. Lee. This was given very careful consideration, Senator Hill, and, of course, a very strong case can be made. It was our view, in view of the financial situation, that if we asked for institutional support for the pharmacy schools and the veterinary schools, we did not want to reduce the funds that would be available for the existing schools. It was for this reason that we did not propose their inclusion at this time. They have been added, as you know, to the special project grants and to the scholarships where they were not previously included. You will remember that the Veterinary Medical Education Act of 1966 authorized the participants starting in fiscal year 1968, of schools of veterinary medicine in the construction and loan provisions of the Health Professions Educational Assistance Act. Dr. Fenninger has informed me that the first construction grant for a school of veterinary medicine has been funded—is that correct? The CaamrMmaN. Which school is that ? Dr. FENNINGER. Auburn University. The CaatRMAN. You mean Auburn in Alabama? 73 Dr. FEn~NINGER. That is right. Senator Javits. I did not even ask whether it was Auburn, N.Y. The Cratrman. Go ahead, Dr. Lee. Dr. Lee. Two additional construction applications are now under review. Twelve schools of veterinary medicine are participating in the student loan program. That is the only additional comment I wish to make on that, Senator Hill. Thank you. The Cramrman. Could you submit for the record—you might not have it now, but submit for the record a summary of our progress in expanding our training capacity for health manpower. In addition, could you also supply for the record a list that shows the dollar amounts for approved construction applications that cannot be funded at this time? Dr. Lee. Yes, sir, we will submit that for the record. (The material referred to, subsequently supplied by Dr. Lee follows) AccoMPLISHMENTS UNDER HEALTH PROFFESSIONS CONSTRUCTION PROGRAM Since the Health Professions Construction Program was first authorized in 1963, 114 schools have received $365 million for construction of teaching facilities. These dollars have assisted in the construction of 17 new schools, and the expansion, renovation, or remodeling of 97 other schools. HEALTH PROFESSIONS EDUCATIONAL FACILITIES CONSTRUCTION, FISCAL YEAR 1965-MAR. 1, 1968 [Dollar amounts in thousands] Number Total Increase in 1st year Type of construction 0 teaching Federal share 1st-year places schools cost places maintained Toba). occ casnummnunnvnse ws 114 $670,994 $365, 241 3,974 8,655 New schools... 17 188,039 114,000 1,067 ....coovizimnn Existing schools... ___ 97 482,955 251,241 2,907 8,655 Included in the above are— Affilated teaching hospitals... ___ (8) (62,003) (35,054) [1 (= University hospitals. ... «ccccuiucin wren 9) (105,492) (48,420) MB econ 1 These projects are in most cases 2d phases of institutional expansion programs. The 1st-year place increase has been identified with the school. Approximately 4,000 new first year places are attributable to such construc- tion—some are already open and occupied—others will be occupied in later years, as construction progresses. In addition, more than 8,600 first year places have been maintained through renovation and replacement of obsolete facilities. While increases in enrollment are identified, in keeping with the legislative requirements, in terms of first-year students, this number does not reflect either the full effect on the teaching load of the school, or on the value derived from the expansion. As each additional first-year student progresses through the program, the school must add second, third, and fourth year student places. Thus an increase of five first year students means in the fourth year, a total teaching load of 20 students, with the necessary facilities, faculty, and equipment. As to the effect of the increase, it can be most adequately measured in terms of the school’s added production of five graduates a year, or 100 graduates over a 20-year period. These, at an estimated professional life of 40 years—for ex- ample, for a physician or dentist—will give 4,000 professional years of service to the nation, extending well into the next century. 92-079 0—68——6 APPROVED AND FUNDED CONSTRUCTION PROJECTS AS OF FEB. 21, 1968 PL 1965 1st year Federal share student increase MIBHICEL.. oo occ ine cin scammer 540 DBMRAL. ov. ir csmm tt want sendin rh tea Ty 271 pubrie Seah. on ® m Pharm Osteo Veterinary Nursing 1__ BA corns 88,315,718 1 Collegiate schools of nursing. 75 Accomplishments under the Nurse Training Act of 1964 The Nurse Training Act of 1964 authorized matching grants to eligible col- legiate, associate degree and diploma programs for new construction, expansion or renovation of educational facilities for four years, 1966 through 1969. The construction grants awarded to 80 schools of nursing as of February 29, 1968 will enable these programs to accommodate more than 10,000 additional students. Quality of education will be maintained and enhanced as teaching facilities are added, replaced or renovated and, in addition to the increased places, the original enrollment of approximately 14,000 nursing students will benefit. This construction is characterized by a flexibility of plans that promotes effi- cient and economical use of space and specific innovations in design reflecting innovations in curricula. The majority of awards have gone for replacement of obsolete buildings rather than for expansion. Most schools cannot consider increasing enrollment until facilities are improved to accommodate present students. A program of construction of nursing schools is essential both to renovate or replace deteriorated structures, but also to provide generally for expansion of nurse education capacity. It is estimated that the new renovated facilities made possible by the Nurse Training Act will result in 3,141 new first-year places and maintaining another 13,848 places. This total of approximately 17,000 places represents approximately 29 percent of the number of admissions to all nursing schools in 1966-67, Distribution of funds among the students, among the programs, increases in first-year places and student places maintained is shown in the following table : CONSTRUCTION GRANTS AWARDED, COSTS, INCREASE IN 1ST-YEAR PLACES, AND PLACES MAINTAINED, BY TYPE OF PROGRAM, SEPT. 7, 1965, TO FEB. 29, 1968 Number Total Federal Increase in Student Type of program of eligible share 1st-year places schools places maintained TOllasersnsmsnsssmmnsmsansonsans 80 $79,636,000 $45,004,000 3,141 13,848 Baccalaureate and graduate. .........._.._. 28 42,515,000 24,389,000 1,812 7,472 Associate degree 12 5,021, 000 3,249, 000 642 688 Diploma. o.oo. 40 32,101,000 17, 365, 000 687 5,688 1 Portion of total construction costs to which the formula for Federal funds is applied. In addition, 15 other schools have had projects approved but not funded, which will provide another 462 increased first-year places. Of the 80 grants which have been made, 18 were to new schools. Ten of the 13 new schools were associate degree programs, and three were baccalaureate. One new program (master’s) was established in an existing school. Existing schools have received the largest proportion of funds mainly for replacement of obsolete facilities. The largest increases in enrollment will come from the collegiate and associate degree programs. The 28 collegiate schools that have received construction grant awards will produce 1,812 new first-year places, ranging from 5 to 174 per school. Ten of the 12 associate degree programs are new schools. The associate degree programs that have received construction grant awards will produce 642 first- year places. Associate degree programs in nursing are increasing in number and more are becoming accredited. Yet, from the limited experience with construction grants submitted, it appears that the community and junior colleges are requesting less space—and consequently less money—than the two other types of programs. The fact that the associate degree programs are largely supported by tax funds may create some difficulties in their ability to obtain matching funds. The 40 diploma programs that have received construction grant awards will produce 687 new first-year places. Thirty-one of the schools plan to make expan- sion of first-year enrollments, 9 will not increase but will maintain their first- year enrollments and will prevent deterioration in the quality of the instructional program. The Allied Health Professions Personnel Training Act of 1966 (P.L. 89-751), passed by Congress on November 3, 1966, included among other provisions, amendments to Title VIII of the Public Health Service Act relating to nurse 76 training. Those amendments (Javits) allow flexibility in the use of construction funds. For example, if funds appropriated for one category of nursing schools (collegiate schools) are not likely to be used during a given fiscal year, they may be transferred to the other category (associate degree or diploma schools) if there is reason to believe the funds can be used in that category. In June 1967, eight collegiate school applications were funded from the associate degree and diploma category of funds. The Federal share of these applications was $4.9 million. Accomplishments under Public Law 88-129 Construction grant assistance to schools of nursing first became available when baccalaureate programs of nursing education were eligible to apply for construction grant funds with the other disciples under the Health Professions Educational Assistance Act of 1963. Under that authority, grants totaling $8.8 million were made to 16 schools in 13 States. Two grants were made to new schools. The 14 other grants were made to replace existing obsolete facilities and to provide additional facilities to accommodate enrollment increases. Two of these projects involved renovation, and the remaining projects were for new construction. A total of 786 additional first-year student places will be available upon completion of the 16 projects. As of February 29, 1968, we have a backlog of approved, but not funded, Health Professions construction projects totaling $78,806,998. In addition, we have received applications which are now awaiting presentation to Council totaling $166,128,687. APPLICATIONS FOR CONSTRUCTION GRANTS UNDER HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE ACT AS OF FEB. 29, 1968 Number Federal Increase in Discipline of schools share 1st year places Approved but not funded: TIN 11 $60,315,619 153 Dental___... 4 15,719,959 63 Pharmacy. . 2 ,335,414 58 Podiatry. _ 1 1,436, 006 46 TOR vs snmwi simi aid A A SE EEE 18 78,806,998 320 Projects pending presentation to Council: BOI oc ci cus cr sa RR SR SR eR 14 122,761,006 435 DBMAl, «205 50a pinsnss 5 34,105,745 202 Veterinary medicine. I 2 6,342,634 201 PRATIIACY wv mr sem enn mansen man sams sansssns samara swam wanes 1 ,919, 302 49 THB. «civ sn EE TR SR EE RR 22 166,128,687 887 As of February 29, 1968, we have a backlog of approved but unfunded projects for the construction of teaching facilities under the Nurse Training Act totaling $9,484,791. In addition, applications totaling $17,163,784 are pending Council review. APPLICATION FOR CONSTRUCTION GRANTS UNDER NURSE TRAINING ACT AS OF FEB. 29, 1968 Action Number Federal Increase 1st of schools share year places Approved and not funded... ___ 15 $9, 484,791 462 Pending council... _._________ 26 17,163,784 1,067 The backlog of approved but unfunded applications for construction under Title VII-A, HRF, is as follows: As of March 1, 1968, 46 projects totaling $40,734,560. Applications pending April 4-5 Council review : 32 projects totaling $38,806,892. Applications pending later Council review: 39 projects totaling $53,000,000. The Cratrman. Now, S. 3095 would amend the provisions of the Nurse Training Act regarding accreditation for the purposes of the 77 act. The bill proposes that the Commissioner of Education furnish a list of the nationally recognized accrediting bodies and of State agen- cies. What criteria would be used by the Commissioner? Dr. Lee. I would like Dr. Fenninger to address himself to that question, Senator Hill. We are now in the process of developing such criteria. The CrATRMAN. All right, Doctor. Dr. FenninGer. I believe the Commissioner of Education would establish criteria which would be comparable to and compatible with the criteria now in existence with regard to the pattern and quality of educational programs. So, indeed, nurses, who are a national re- source and may move from one region to another, would move with comparable basic education. The Crarrman. What would be comparable basic education ? Dr. FexNinGer. In determining the criteria, there would be criteria for the basic education in nursing in each of the programs which would be comparable to those now established nationally. The criteria and methods of evaluating the respective types of nurs- ing education program would, of course, be appropriate for the spe- cific type of program: Diploma, associate degree, baccalaureate, or higher degree. The criteria would relate to the quality of the nursing education program; specific consideration would be given to: Objectives and purposes of the type of nursing program. Organization and administration of the nursing program. Financial stability of the nursing program. Academic standards and policies. Curriculum and program of instruction. Faculty, preparation, and experience. Academic resources, including teaching materials and library resources. Clinical resources. Physical facilities, including libraries, laboratories, and class- rooms. Methods for evaluating and improving the nursing program. It is assumed that evaluation would be undertaken by qualified indi- viduals representing the type of nursing educational program being evaluated. The Cuarman. Now, let me ask this, Dr. Lee. As proposed by the Department, S. 3095 would extend for only 1 year the Allied Health Professions Personnel Training Act. Do you anticipate recommending major changes in that legislation at a later date ? Dr. Lee. Yes, sir, we have had only 1 year’s experience and we would propose that next year, when we have had further experience, we would come up with a thorough review of the program, careful analysis of the strengths and weaknesses, and recommendations for significant changes in programs. It may work very well and we may need to make no changes, but we believe we have not yet had sufficient experience to recommend either piecemeal changes or major changes in the act. The Cuamrman. I see. You want this year’s time for further thought and study and consideration ? Dr. Ler. Yes, sir, further experience with the administration of the 78 program to see how effective it is in meeting these goals in this major area of manpower need. The Cuamrman. Now, has thought been given to including financial assistance to undergraduate students under the act? Dr. FenNiNGer. Yes, sir; thought has been given to this. The Caamman. In other words, you are considering this in con- nection with the act? Dr. Fennineer. With the general act under this administration. Dr. Lee. There are, Senator Hill, where the students are in ap- Dora educational institutions, funds available through the National efense Education Act programs, but some of these are not in such approved educational institutions, so it is a complex problem at the present time and this is an area that we are—— The Cruamrman. You are thinking through this problem now? Dr. Lee. Yes, sir, and it is a very important problem, The CruarMAN. Any questions, gentlemen ? Senator YArBoroUGH. Yes. Dr. Lee, you quote the statement that there is an additional 100,000 doctors, nurses, dentists, laboratory technicians, and other health workers being trained this year to meet the health needs of our grow- ing population—that is, additional over what was being trained 5 years ago. How many doctors, medical doctors, have been graduated in the last 5 years? If you do not have this data readily available here, gentlemen, I am going to ask you to submit it for the record. If you do have it, I would like to have it now. Two questions. One, how many have been graduated, and how many more have been graduated because of the expansion of medical under this act ? Dr. Lee. We do not have it immediately available, Senator Yar- borough. We may have it as we look through this material. (The information referred to follows :) GRADUATES OF SCHOOLS OF MEDICINE AND OSTEOPATHY Graduates of Graduates of Academic year schools of schools of medicine osteopathy 7,264 362 7,336 354 7,409 395 7,574 360 7,743 405 Senator YarsoroueH. Next, how many medical doctors are we grad- uating each year now? Dr. Lek. The number increased as a result of the legislation. In 1967- 68, there will be approximately 8,400 graduates of medical schools and 430 graduates of schools of osteopathy. Senator Yareoroucr. How many are being graduated today? I am referring to your further statement on page 3 that we need 50,000 additional physicians today, and I want to know how many have grad- uated today, how many are retiring each year now, what kind of in- crease we are getting in graduates over those retiring from medicine or being put out by death or other reasons. How does that relate to the percent of the population ? 79 Dr. Lie. Between academic years 1962-63 and 1966-67, the graduates of schools of medicine have increased from 7,264 to 7,743. During the same period, the number of physicians who have left active practice because of retirement or death has annually ranged somewhere between 2,800 and 4,000. Total enrollment in U.S. medical schools in the 1962-63 academic year was 31,500. In the 1967-68 academic year, it was 34,300, an in- crease of 2,800. By 1972-73, when the full effect of the present legis- lation will be felt, medical school enrollments are expected to increase to 41,900. Total enrollment in U.S. medical schools 1962-63 through 1967-68 Total Academic year : enrollment FOBBOG .... ce ce im i i i rm 5 0 ee se 5 5 31, 491 JOBTBA icin niin som 0 i 50 i 0 i i 32,001 FOBAOB i in cm sion 5 oo 5 i 0 i 32, 428 FOOB =O |... cc cc cm em 25 5m eo ii 5 0 32, 835 FOGBE=BT = tn ccm 0.00. i i ss i 5 oe 58 i 2 SE 33, 449 JOBTADR cc inn ne i i si i 0 8 8 i 34, 314 Source : 1962-63 through 1966-67, J.A.M.A., Nov. 20, 1967, p. 756 ; 1967-68 PHS/BHM. Dr. Lee. The ratio of active physicians (M.D.’s) to population is about 142 per 100,000 population 1m 1967. This ratio has risen from 135 per 100,000 population in 1963. In addition, there are 5.5 osteo- pathic physicians per 100,000 population. PHYSICIANS IN RELATION TO POPULATION, 1963-67 Item 1963 1964 1965 1966 1967 Physicians, M.D.: i I 276,475 284,224 292, 088 300, 375 308, 630 BBHVE. ; . . oo no csi nips $ SEAT ERE === ne ie 261,728 269, 552 277,575 285, 857 294,072 Active physicians per 100,000 population... __ 135 137 170 142 142 Source: Physician statistics from American Medical Association. Population estimates from U.S. Bureau of the Census. OSTEOPATHIC PHYSICIANS IN RELATION TO POPULATION, 1963-67 Item 1963 1964 1965 1956 1967 Number of osteopathic physicians: POH le ran -12,713.0 12,865.0 CC ceeeeen--- 10,772.0 10,909.0 eR Teer IRE 5.6 5.6 8 1 Not available. Senator YarsorougH. As you know, we not only have a terrible shortage of doctors, but the shortage is worsening. I want to know under this act, how many new medical schools have been built and have been opened in America. How many medical schools have ac- tually opened their doors to the students since the passage of this act? Our aim was to get 20 new medical schools by this time from the act. How many have actually opened their doors under this act # Dr. Lee. We will see if we can pull that out for you right now, Senator Yarborough. Senator YarsorouaH. Actually opened their doors, now. Not some- body who has planned that they may open 5 years from now. 80 Dr. Lee. I think we have to recognize that very often from the first planning of the school, it often takes 4 to 5 years to bring that school into operation and another 4 years, of course, for the students to begin to come off the—— Dr. FenNinger. There are seven new schools that have actually admitted students. Senator YarsoroucH. And we contemplated 20. How many more do you expect to open their doors? Dr. FexniNcer. There are three more scheduled to open in 1968-69, and six are presently planning construction to be funded under the act. Senator YarsoroucH. That would be seven opening their doors, three scheduled to open this year, and six more planning construction? Dr. FENNINGER. Yes, six in various stages of planning. New medical schools opened or planning to open, with assistance of construction funds under HPEA Academic year in which the first year year medical school class enrolled Name of school 10 new schools funded : 4 open in new construction : BOBLEBE eee ii University of New Mexico. LOBTBB ......c ce ess i st ie a oi sme University of Arizona; Pennsylvania State University; South Texas Medical School. JOBBBT cece cr et mt mn Rutgers University. 1967-68 ____________ Brown University; University of Hawaii. 3 scheduled to open: 1968-69_______ University of California, San Diego; University of Connecticut; Mt. Sinai Hospital . 1 new school approved but not funded VT so se kh Sa Michigan State University. 5 additional new schools scheduled to open by 1971, which have indicated need for Federal construction funds._ University of California, Davis; Loui- siana State University, Shreveport ; University of Toledo, Ohio (now called Medical College of Ohio at Toledo) ; University of Massachu- setts; State University of New York, Stony Brook. New dental schools opened or planning to open, with assistance of construction funds under HPEA Academic year in which the first year class enrolled Name of school 4 new schools funded : 2 open: TOOL-BY consis mmm im mnie University of California, Los Angeles. 1007-88 .coinmmmtcmmmmmimmm Medical College of South Carolina. 2 scheduled to open : 1968-69 ____________________ University of Connecticut. VICDET cision asians Medical College of Georgia. x additional new schools scheduled to open by 1972, which have indicated need for Federal construction funds Louisiana State University, Univer- sity of Florida, University of Colo- rado. 81 Senator YarsorouaH. What about the other 4? Are there applica- tions for the other 4 to make it 207 Dr. Fenninger. We have no other applications at present but we anticipate letters of intent from other schools. Senator YarsoroueH. Can we push to get the other 4 schools? I went to the ground breaking of one of these medical schools. It has not yet opened its doors. Medical schools are badly needed in my State. I went there at the dedication and said a few words about the need for medical schools. The president-elect of the AMA was there, and he made his old speech about how we had all the medical schools we need. That was the thrust of it. I know you may not want to say this pub- licly, but I know from experience that the AMA has been dragging on this matter, slowing it up. I want you to represent the people here and not the AMA and get us these medical schools. We have this bill Senator Javits and I have introduced, S. 255, to make loans to American students studying in other areas, because 12 percent of our students are studying abroad. Twelve percent of the American students studying medicine are studying in other countries. Is that not correct? Dr. FEnNinger. I am not sure of the exact figure. We can submit it. (The material referred to was subsequently supplied.) In the academic year 1965-66, the latest year for which information is avail- able, there were 2,377 American students in medical schools in other countries. In that year there were 32,402 American students in medical schools in the United States. Thus there were 34,779 Americans enrolled in medical schools, of whom 6.89, were in schools outside of the United States. U.S. MEDICAL STUDENTS, 1965-66 Number Percent TORY ccm rims mit te 5 34,779 100.0 In U.S. medical SEhO0IS 1... couwsanmmsasmmmunumin meme swiss mens 32,402 93.2 In foreign medical schools: TO. coc rE Te Ss ne 2,377 6.8 Canada. eee 2210 6 Other... LLL 22,167 6.2 1 Of the 32,835 total enrolled, 433 were residents of foreign countries. 2 Estimate. Source: Education numbers, Journal of American Medical Association; vol. 198, p. 867, Nov. 21, 1966, and vol. 202, pp. 755-756, Nov. 20, 1967. Canadian schools must be considered separately from other medical schools outside the United States, because there is a single accreditation program for the United States and Canada, and schools in the 2 countries conform to the same standards. Of each year’s estimated 50 American graduates of Canadian schools, approximately 90% become licensed to practice in the U.S. Each year an average of 310 American graduates of medical schools in coun- tries outside of the U.S. and Canada receive initial U.S. licenses to practice (1957-1966 average). It is estimated that of the American citizens who study Hefiome abroad, only 50% return and become licensed to practice in the U.S. Dr. Lek. I think you will find, Senator, now that there will be strong support for this legislation from a very broad base, including the AMA. They will be testifying, of course, before you. Sens ArBorOUGH. How is it they do not build these new medical schools? 82 Dr. Lek. I think you can ask the head of the AMA when he testifies. But it is my belief now that they have changed their joint situation with the Association of American Medical Colleges and have come out now strongly in favor of Federal support for education, for expan- sion, for new schools. They made a strong statement that they did not want it tied exclusively to added enrollment. I think that is appro- priate and recorded in the legislation, because there are some schools that at the present time are not strong enough to add significantly to their enrollment, and we do not want to lower the quality of education. Senator YarsoroucH. Referring to your prepared statement, you say that you support one provision in the bill to encourage prompt repay- ment of loans. Of course, a graduate medical doctor while he is doing his internship and residency is not going to have much chance to repay a loan. Dr. Lee. That fis correct. Senator YareorougH. You do not provide that he has to start the minute he finishes medical school, do you ? Dr. Lee. No, sir. Senator YareoroueH. I think it is impractical to require him to do it while he is doing his internship. Dr. Lee. That tis exactly right. Under present law, a medical student’s loan becomes due 3 years after he fradastes This is to allow for his internship and at least a start on his residency or the time and expense of getting started in a practice. When the loan becomes due he must repay it over a 10-year riod. However, if he is serving in a uniformed service or as a Peace rps volunteer, he can oe ne repayment for each year (up to 3 years) of such service. The bill oad also allow him to postpone repayment of years of service (up to 3 years) as a VISTA volun- teer and years (up to 5 years) for advanced professional training. Senator YarsoroucH. Then you say the accreditation provision which would be amended to delete the authority of the Commissioner of Education directly to accredit the schools. We had quite a dispute about that at the time the nurses education requirements were up. Many colleges wanted to train nurses, but the nurses refused to accredit them ws. they paid the fee in New York. This was a matter of contest among the junior colleges and nurses schools in my State. Will the taking away of this direct authority of the Commissioner to accredit slow up the accreditation of schools for trained nurses? Dr. Lee. No, sir; we think it will speed it up, Senator Yarborough, because it will also permit the Commissioner to approve a State agency to accredit the schools within the State. It would broaden the base of possible accrediting agencies should the presently named bodies—the National League ho ursing orig- J named by the Commissioner for purposes of the Nurse Training Act of 1964, and more recently the regional accrediting bodies for determining reasonable assurance of accreditation—be unable to meet the requests of the schools. Senator YarsoroucH. I see, rather than have it done nationally? Dr. Lee. Rather than have the Federal Government do it. The Commissioner has not exercised that authority to accredit the pro- 83 frm up to this time because of our deep reservations about this ind of Federal involvement in education. We felt it was much better to have the appropriate State agency that meets the standards estab- lished by the CL then be available to accredit these pro- grams within the State. Senator Yarsorouan. Of course, at that time, the registered nurses were concerned that the practical nurses were being confused with registered nurses. We were hopeful of raising the percentage of regis- tered nurses in the country. But the situation has worsened in the intervening years. When I was in my State at Christmas, I heard of a third category serving in hospitals who could not qualify as prac- tical nurses. They were short of registered nurses. They also were short of practical nurses, so they instituted what they call sitters. They just sit in the hospitals and watch the patients because they could not even get practical nurses. I have heard people tell me of the old relative being treated by sitters and protesting they did not want a shot for pain, only to hear, “You will get it anyway.” But these hog ale cannot even get practical help, so this stopgap measure is required. Dr. Lee. One of the problems on that, Senator Yarborough, relates to the licensure problems in the State. We have thousands of well- trained medical corpsmen coming out of the Armed Forces every year. In many States they cannot even be licensed as practical nurses even though they are well trained, skilled, competent, and could fill an enormous need. This is an action that must be taken in every State. There is nothing that the Federal Government can do about State licensure laws. Senator YarsorousH. We run into that over in the Veterans’ Com- mittee with veterans hospitals. A lot of these personnel could be trained as practical nurses, and actually some are far better trained than most practical nurses here at home. Dr. Lee. Veterans hospitals represent one of our greatest resources for training. They are scattered all over the country and they are often in close associations with other educational institutions, junior colleges. So it can be developed and that is an enormous and im- portant source to expand training courses. Senator Yarsorouvci. We know of the number of lives saved by these medical corpsmen in Vietnam, where they treat the wounded before you can get the doctors out there. If we can use the expertise of these medical corpsmen who want to serve when they come out of the service, we can go a long way toward meeting the crisis posed by our nursing shortage. Dr. Lee. Dr. Fenninger has told me there has been significant prog- ress in accreditation of these nursing programs in the last few years, both full accreditation and reasonable assurance. There has been a particularly rapid rate of growth in junior college programs. In January 1965, soon after passage of the Nurse Training Act of 1964, 776, or 67 percent of the 1,158 nursing education programs were accredited or had reasonable assurance of accreditation and were thereby eligible to participate in the provisions of the act. By January 1968, the number of eligible programs had increased to 917, or 72 percent of the total 1,269 programs. These eligible pro- 84 grams enrolled 83 percent of the total students in nursing education programs. The number of programs and enrollments by accreditation status and type of program for both years is shown on the following table. NUMBER OF PROGRAMS AND ENROLLMENTS BY ACCREDITATION STATUS AND TYPE OF PROGRAM, 1965 AND 1968 Programs Enrollments Accreditation status and January 1965 January 1968 January 1965 January 1968 type of programs Number Percent Number Percent Number Percent Number Percent Totals TOA. on snicrimmsisininsse 1,158 100.0 1,269 100.0 129,269 100.0 141,948 100.0 Diploma - 840 100.0 767 100.0 93,089 100.0 84,413 100.0 Associate degree 130 100.0 281 100.0 8,513 100.0 20,936 100.0 Baccalaureate. __......_... 188 100.0 221 100.0 27,667 100.0 36,599 100.0 Eligible for funds under N.T.A. Total cc cine mimi 776 67.0 917 72.3 197,439 175.4 117,550 82.8 DPI: vss ssmmsins 619 13.7 599 78.1 72,970 78.4 71,746 85.0 Associate degree... _...._.____ 16 12,3 136 48.4 365 4.3 11, 884 56.7 Baccalaureate... _...__.__ 141 75.0 182 82.3 24,104 87.1 33,920 92.7 Accredited programs Total... conemanimmunnrs 708 61.1 770 60.7 97,439 75.4 106, 000 74.7 DIPIOMA. pcs cneansassionee 569 67.7 577 75.2 72,970 78.4 70,299 83.3 Associate degree a 5 3.8 42 14.9 365 4.3 4,445 21.2 Baccalaureate... _______ 134 71.3 151 68.3 24,104 87.1 31,256 85.4 Reasonable assurance of accreditation Tolake. cooensaienonns 68 5.9 147 11.6 [O) o 11, 550 8.1 Diploma. ise ouesensvosneses 50 6.0 22 29 (O ) 1,447 1.7 Associate degree... 11 8.5 94 33.5 M [0] 7,439 35.5 Baccalaureate... _ 7 3.7 31 14.0 [0] [QO] 2,664 7.3 1 Enrollments in programs with reasonable assurance of accreditation not available. Senator YarBorouGH. Yes; junior colleges are particularly well suited to train nurses, because they are the cheapest colleges to go to and have the capacity to bring educational opportunity into virtually any community. Students can live at home and get that training with- out having to pay room and board in a dormitory. Yet the whole difficulty on accreditation came primarily on the issue of nursing programs in junior colleges; did they not ? Dr. Lee. This is one of the sources of questioning; yes. Senator YarsoroucH. It is not to break down the standards of nurs- ing that we are trying to get this, but to increase this Nation's capacity to educate more young people to meet the high standards of nursing. Mr. Chairman, I have other questions, but in the interest of time, I will forego them. We have Senator Javits here and we have many other witnesses. Dr. Lee. We will be glad, Senator Yarborough, to take your ques- tions in writing and we will respond to those. Senator Yarsoroueu. Thank you. The CramrmaN. Senator Javits. Senator Javits. The hearings we are undertaking this morning on health manpower deal, in effect, with the two principal health prob- lems facing the Nation—delivery of health care and rapidly rising 85 health costs. That is something we have not talked about here this morning. But Senator Ribicoft’s Subcommittee on Government Opera- tions, of which I am also a member, will be undertaking hearings on that matter next month. The matter of health costs is coming in for enormous attention in the country, because this is the single fastest rising item in the cost of living. And as I am also deeply concerned with economic matters, being a member of the Joint Economic Com- mittee, this has had an enormous impact on my thinking. It is some- thing with which we must deal. The fact is that health costs are rising twice as rapidly as the average cost of living. This is a critical matter to all of us. We have already heard about the shortage of doctors, 50,000, One figure that always has a tremendous impact on me is that 5,000 U.S. communities are without any physician at all, and the number is rising. We have a tremendous problem with the shortage of nurses. It is something to which we have all directed our attention before. For example, the New York State Joint Legislative Committee on the Problems of Health and Medicare, the last report stated that: The single most important health problem in New York State and the Nation is how to increase the number of professional registered nurses. Health manpower relates directly to the price of medical care. Per- sonnel costs, for instance, represent 70 percent of hospital oparaiing expenses and are rising. We are talking now about a $100-a-day hos- pital bed as a maintenance figure in New York. There are 200 health occupations. One thing that I would like to suggest to you, Dr. Lee, and I think it is long overdue, is a reexamina- tion of medical education. It is just taken for granted that a student must go through many, many years of premed, medical school, intern- ship and the specialization, and is really not, theoretically, fit to practice until over 30 years of age. Now, I am sure the Russians are doing better than that. It may be that you need some kind of limited licensure which is different from a complete license to practice any- thing. It is fine with me if a fellow is a great specialist in putting a broken bone together if he does not do anything else, so long as he is turned out in half the time and with half the cost and with half the facilities. The other thing that I urge you to look at is the wasteful high drop- out rate of medical students. More than 10 percent, we understand, leave in midcourse. This is a terrible waste of resources. Then finally, of course, we are still plagued—and Senator Yarborough has certainly been one of our champions in that and I have tried to be—with the thousands of qualified young people who cannot obtain a medical education because of lack of funds or lack of facilities. Now, the fund business is very serious, because medicine uniquely, even more than law—and as you know, I am a lawyer—requires absolutely complete concentration. It is very difficult for a young person to really do justice by a medical course and to try to support himself at the same time, even with such elementary things as waiting on tables. It is very difficult. IT know it as a matter of personal experience. 86 Now, I think there are some amendments needed to this bill, and T would like to submitt those to you if you would be kind enough to read what I have in mind. First, Senator Yarborough has already spoken of our bill, S. 255, for loans for U.S. medical students studying outside of the United States. There is no joy in that. I would rather they studied here, but we are dealing with a fact, not a theory. Therefore, as we are anxious to get our young students to get to be doctors and give themselves a chance, we must go to them, they cannot come to us, which is the practical effect here. I include at the end of these remarks the ex- planatory statement I made at the time of the introduction of S. 255. Second, I think that we should do a little better by administrative expenses for student id progrms. Our higher eduction bill, S. 3098, provides a 3-percent administrative expense for schools for student aid programs. This bill, S. 3095, does not. Third, I would like to see if we can inaugurate a matching program for State scholarship programs for nurses. Now, in my home State, for example, we are going to double these scholarships from 300 to 600; this is the Lent bill. It would be very interesting, it seems to me if we could encourage such State action by having a matching program. I would like to point out that some 19 States have State scholarship programs for nurses. I will submit an amendment on that score to en- courage the States by giving them a scholarship matching incentive, and to encourage other States to inaugurate scholarship programs for nurses, And finally, and Senator Yarborough touched on this quite prop- erly, it would be helpful to upgrade the licensed practical nurse so that she may move into the registered nursing field. Again, there is much too much insularity in these programs. They are compartmental- ized. There is no reason why our Manpower Training Act, at least, should not be used for this, too, to upgrade a skill where we already have a base at the beginning. (Senator Javits’ opening statement of January 12, 1967, on S. 255 follows) [From the Congressional Record, Jan, 12, 1967] DirecT STUDENT LOANS TO AMERICAN MEDICAL STUDENTS ABROAD Mr. Javits. Mr, President, I introduce for myself and Mr. YARBOROUGH, for ap- propriate reference a bill amending title VII of the Public Health Service Act to authorize direct student leans to students studying outside the United States at a school of medicine, osteopathy, dentistry, or optometry approved by the Secre- tary of Health, Education, and Welfare, Under the Health Professions Education Assistance Act, American medical, osteopathic, dental, and optometric students may obtain direct loans from HEW of up to $2,500 annually. My bill would ex- tend this to Americans studying abroad. No additional funding authorization is required. Our Nation is short some 50,000 doctors today. Even with projected expansion of medical schools in the United States, the shortage will still be 50,000 in 1970 due to population increases and increased demand. Some 12 percent of American medical students are now in foreign universities because there are not enough medical schools in this country, A foreign medical education does meet U.S. stand- ards as illustrated by the fact that some 1,600 foreign-educated foreign doctors are “imported” each year and the large number of foreign-educated interns and residents in U.S. hospitals. The GI bills of World War II, the Korean war, and the cold war all extend benefits to eligible veterans studying abroad. Thus, for over a generation the 87 concept of aiding eligible American students attending a foreign school has been well established and operated successfully. It should be pointed out that the authority granted to the Secretary of Health, Education, and Welfare to ap- prove courses of medical study abroad is not intended to establish any new precedent with respect to accreditation of institutions of higher education. This provision is necessary because of the unique nature of study in foreign institu- tions, and it is anticipated that in exercising this authority the Secretary will Sousule with appropriate professional and accrediting groups within the United ates. This bill is identical in language with section 205 of the International Education Act as approved by the Senate on October 13. However, the provision was dropped by the House without prejudice and solely for jurisdictional reasons and hence was not included in the bill as signed into law. As the distinguished chairman of the Senate Subcommittee on Education [Mr. Morse] explained during Senate debate on the conference report on the International Education Act: Section 205 was dropped by the House without prejudice and solely for juris- dictional reasons without reference to the merits of the provision. In the Senate, the Labor and Public Welfare Committee has jurisdiction over both health and education matters. However, the House Committee on Education and Labor exercises no jurisdiction over health. Since section 205 amends a health law and normally comes within the area of responsibility of the House Committee on Interstate and Foreign Commerce, the House Committee on Education and Labor dropped it from the bill. The Vice PresipENT. The bill will be received and appropriately referred. The bill (8. 255) to amend title VII of the Public Heath Service Act to authorize direct student loans to be made to certain students studying outside the United States, introduced by Mr. Javits (for himself and Mr. YARBOROUGH), was received, read twice by its title, and referred to the Committee on Labor and Public Welfare. COMMENTS OF DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, RE DIRECT STUDENT LOANS TO AMERICAN CITIZENS STUDYING AT FOREIGN MEDICAL ScHoOLS . The Department is in sympathy with the Senator's concern for the American citizens who each year go to medical schools outside the United States, many of them because there is not space in an American School. However, there are serious problems inherent in a proposal to authorize direct students loans to be made to these students. The bill introduced by Senator Javits and Senator Yarborough (8. 255), would authorize direct student loans to be made to United States citizen students pursuing a full-time course of study at a school of medicine, dentistry, osteopathy or optometry outside the United States. The bill would require the school to have been approved by the Secretary of HEW. The Secretary could not approve any school unless he determined that it offered training of a type and quality substantially similar to that offered by similar schools in the United States which are accredited. Under the Health Professions Student Loan Program, the individual, accredited, participating schools select the students to receive the loans. The bill would require the Secretary of HEW to make the loans directly to students studying at foreign schools. The proposed amendment would require the Secretary to determine whether schools outside the United States offer training of a type and quality substantially similar to that offered by accredited schools in the United States. Although there are notable exceptions, such as the schools of medicine in Canada which are accredited by the same mechanism used in the United States, the great disparity in quality of medical education provided in schools abroad would require a rigorous evaluation which would be administratively difficult and costly and goes far beyond the past role of the United States Government in matters of international education. The extreme difficulty of the quasi-accrediting role the bill would assign to the Secretary is illustrated by the fact that the Council on Medical Education of the American Medical Association and the Executive Council of the Associa- tion of American Medical Colleges discontinued their practice of publishing a list of foreign medical schools whose graduates they recommend for consideration on the same basis as graduates of the United States and Canadian schools because of their “inability to acquire and maintain a continuing, adequate knowledge of the eductional programs whose graduates come to the United States.” JAMA, Vol. 200, (June 19, 1967). Pp. 1070 ff. 88 As a group, Americans admitted to foreign medical schools have scored significantly lower on the Medical College Admissions Test. Also a significant percentage of the Americans graduating from foreign medical schools, despite repeated attempts, fail to pass the Educational Council for Foreign Medical Graduates Examination. It is estimated that of the American citizens who study medicine abroad (with the exception of Canada), only 509% return and become licensed to practice in the United States. Furthermore, at this particular time, there is the question of United States fiscal policy with respect to the expenditure of American dollars abroad. On the whole, we would not favor the extension of the student loan program to United States students studying abroad. Senator Javits. Now, I have a few questions. Like Senator Yar- borough, I will submit those that you do not have time to answer in writing. I would just like to have, if T may, one or two of them asked, with the Chair's permission. I think it will take no more than 5 or 6 minutes. The Cramrman. Certainly, Senator. (The questions and answers referred to follow :) RESPONSE OF DR. PHILLIP R. LEE, ASSISTANT SECRETARY FOR HEALTH AND SCIEN- TIFIC AFFAIRS, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, TO QUESTIONS SUBMITTED BY SENATOR JAcoB K. JAVITS 1. There are a number of differences between student support programs in the health area and student supports in the higher education category. For example, the scholarship program in S. 3095 provides money to schools on a formula basis; in NDHA, schools receive money on a need basis. Please explain why HEW pre- fers one approach in student support for health as opposed to that contained in higher education legislation. Also, list differences between two categories—an- other example, for instance, comes to mind: NDEA borrowers are given a ninc- month grace period after graduations, nurses receive one year. In seeking to relieve critical health manpower shortages, it is important to maintain single mission-oriented programs of student assistance designed to make aid to students in the health professions occupations fair and equitable and as similar to other Federal student aid programs as possible, given the special nature of education and training in fields of health. Provisions included in these mission-oriented programs provide for (1) assistance to qualified young people to pursue an education in the health fields; (2) improving the distribution of practitioners; and (3) the delay between completion of basic health professional education and entering practice. Comparisons of existing legislation and proposed legislation of the Health Professions Student Loan Program, Nursing Student Loan Program and National Defense Student Loan Program are summarized in Exhibits A, B and C, attached. The principal differences between the Health Manpower student loan programs (Health Professions and Nursing Student Loan Programs) and the National Defense Student Loan Program are : 1. Student interest rate. 2. Reimbursement of institutional expenses. 3. Grace period before loans become repayable. 4. Loan cancellation provisions. 5. Limitation on aggregate amount of student loans. Our comments on these differences follow : 1. Student interest rate—Since the beginning of the National Defense Student Loan Program, the interest rate on loans has been 3%. At the time the Health Professions and Nursing Student Loan Programs were authorized, the interest rate was set in accordance with Federal fiscal policy at 3% or the “going Federal rate,” which ever was the greater. The ‘going Federal rate” has consistently been above 3%. In 1965 and 1966, it was 414%, in 1967, it was 4% 9% and in 1968, it was 434 9%. The Health Manpower Act of 1968 continues the “going Federal rate” factor in the Health Professions and Nursing Student Loan Programs, in accordance with current Federal fiscal policy. 2. Reimbursement of institutional ewpenses.—The present National Defense Student Loan Program allows one-half of actual cost (but not to exceed 19% of 89 the outstanding loans) to be available to the institution for costs of administering the loan program. The Higher Education legislation would authorize 3% of the loans paid out by it during any year, but not to exceed $125,000, to be avail- able to the institution for costs of administrations. Neither the Health Professions Student Loan authority nor the Nursing Student Loan authority has included any provision for costs of administration, nor is such authority included in the Health Manpower legislation. Since assistance grants are made under both the Nurse Training Act and the Health Professions Educational Assistance Act to many of the schools participating in the loan programs, it was thought that the costs of administration need not be included. 3. Grace period before loans become repayable—Under the present National Defense Student Loan Program, a loan becomes repayable nine months after the borrower ceases to carry at least half a normal full-time academic workload. The Higher Education Amendments would make no change in this requirement. Under the Nurse Training Act, loans become repayable one year after the nurse ceases to pursue a full-time course of study in nurse training. Under the Health Pro- fessions Student Loan Program, loans become repayable three years after a student ceases to pursue a full-time course of study leading to his first professional degree, i.e., Doctor of Medicine, Doctor of Dentistry, etc. The three-year period is required for physicians and dentists to allow for internship and residency training, as well as the time and expense of getting established in practice, as for example, the costly investment in equipment that is necessary to dental practice. 4. Loan cancellation provisions.— The National Defense Student Loan Program authorizes cancellation of up to 509% of a student's loan, plus interest, at the rate of 109% a year for each academic year of teaching service. An additional 509% cancellation is authorized at the rate of 159, for each academic year of teaching handicapped children or of teaching in low income areas or in schools eligible under Title IT of P.1. 81-874. Under the current Nursing Student Loan Program, a nurse borrower may can- cel up to 509% of the total amount borrowed, plus interest, at the rate of 109 per vear for each year of full-time employment as a professional nurse in a public or nonprofit institution or agency. This provision is intended to encourage nurses to continue in practice. The Health Manpower Act of 1968 would authorize cancellation of up to 100% of the total amount borrowed, plus interest, at the rate of 159%, for each complete vear of service as a professional nurse in a public hospital in an area having a substantial population and a substantial shortage of nurses in public hospitals. This additional forgiveness is designed to encourage nurses to practice in those public hospitals which have the most acute shortages of professional nurses. It is in these public institutions that a high percentage of vacancies in registered nurse positions persists year after year in spite of active recruitment efforts. The Health Professions Student Loan Program authorizes cancellation of up to 509% of the total loan plus interest at the rate of 109% per year for each year of practice in an area determined by the appropriate State health authority as having a shortage and need for physicians, osteopaths, dentists, or optometrists. Up to 10094 of the total loan plus interest may be cancelled at the rate of 159% per year for each year of practice in an area designated as a rural area charac- terized by low family income. These cancellation provisions are designed to en- courage the borrowers to engage in practice in shortage areas. 5. Limitation on aggregate amount of student loans.—The National Defense Student Ioan Program limits the aggregate amount of loans for an undergradu- ate student to $5,000. (The Higher Education legislation would increase this to $6,000.) The limitation on aggregate amount of loans for a graduate student is now $10,000. (The legislation would increase it to $11,000.) Neither the Health Professions Student Loan Program nor the Nursing Student Loan Program has a specified limitation on aggregate amounts of loans. However, under present law, the maximum loan to any student of nursing in any year is $1,000. (The Health Manpower legislation would increase this to $1,500.) The maximum loan in any year to a student under the Health Professions Student Loan Program is $2,500. No change would be made under the proposed legislation. The cost to the student of health professions education is high and the maximum amount per year presently specified in the statute is a reasonable limitation on the amount of indebtedness for these students at the present levels of costs of education. In addition to the above comments on the student loan programs, we also have the following comments on the scholarship program : 92-079 0—68——T7 90 Allocation of appropriations for Health Professions Scholarship Program.— Health Professions Student Scholarship Program authorized the appropriated funds to be allocated among the participating schools on a basis of a formula of $2,000 times one-tenth the number of full-time students. (Starting in the first year of the program, it was limited to one-tenth of the number of first-year students. An additional class of students is added each year so that in fiscal year 1970, one- tenth of the full-time four-year enrollment would be covered). The sums allocated are used by the schools to assist those students most in need thereof. Schools may, and do, apply for less than the formula amount if they estimate that they cannot utilize the full amount for scholarship purposes. Funds allocated but not used for scholarship purposes because of changing meeds of the student body, lapse under the present authority. The proposed Health Manpower legislation would authorize a school to transfer to its Federal Capital Contribution Loan Fund up to 209% of its scholarship funds (or such higher amount as approved by the Secretary). This transfer authority, together with similar authority for transfer from the loan fund to the scholarship program, would allow the school desirable flexibility in meeting individual student financial needs as between reimbursable and non- reimbursable assistance. This transfer authority also makes it possible for a school to adjust the amounts available for student aid to conform with actual, rather than estimated, needs for scholarship and loan assistance. This method of allocation has proven both effective and inexpensive to ad- minister. EXHIBIT A HEALTH PROFESSIONS STUDENT LOAN PROGRAM Program characteristics Existing legislation Proposed legislation A. Student eligibility: 1 Students of medicine, dentistry, osteop- Same. athy, optometry, pharmacy, podi- atry, and veterinary medicine. LBV). crass rrr ssn s sna mRTe Professional education. ______________ Do. Student status... _______._. Full-time student... .........c....-.- Do. B. Institutional expenses: ~~ Cost of progam administration. . No allowance... _______._.__________ Do. Cost of litigation. _____._________ May be charged to fund. Do. Other collection costs__.____.__. No allowance... Do. C. Charges for late repayment of student None __._...__. wee -- Allowable. Amount may not exceed $1 loans or failure to file timely evi- for the 1st month or part of a dence of entitlement to cancellation month payment is late and $2 for or postponement of payment. each month or part thereafter. D. Minimum monthly 4 RT Same. E. Loan becomes repayable. __________ 3 years from date borrower ceases to Do. pursue a full-time course of study at a health professions school. F Delerment of repayment of student loans for: Uniformed service. .....__.___._ UP 10 B YRS. cc ciscninnnrmnnnemans Do. Peace Corps do Do. Vista. o..oosvissmmensrmsssns Up to 3 years. ~ No. Advanced professiona Itraining No__ -- Up to 5 years. (including residencies). G. Extension of repayment period........ NO...... .cceeaeenesrsmvsornnssoeses Same. H. Interest rate on student loans__.__.__ 3 percent or the going Federal rate, Do. whichever is the greater. 1. Cancellation of student loans: Practice in shortage area__..____ 10 percent per year, up to 50 percent Do. of total loan, plus interest. Practice in rural shortage area 15 percent per year, up to 100 Jersent Do. hefseterized by low family of the total loan, plus interest. ncome. Death of borrower....._________ Do. Permanent and total disability do ws Do. Bankruptcy Do. J. Maximum amount of student loan Academic year $2,500 Do. Limitation on aggregate of loans. No limit Do. K. Loans to schools: Federal loans fo schools for NO.......cccevmesecnsmsivsnanssnnnas Do. matching share. Loans to schools for capitalize VBS. oo cis inin dineran ane asain Do. tion of student loan funds through revolving fund mech- anism. 1 The interest rate since the inception of the program has been as follows: 1965 and 1966, 414 percent; 1967, 414 per- cent; 1968, 43{ percent. 91 EXHIBIT B NURSING STUDENT LOAN PROGRAM Program characteristics Existing legislation Proposed legislation A. Student eligibility : FIle ov evsbnsnnunnsmmnvnane Nursing education___________ Same. Level... ._. Professional education .s Do. Student status__ _ Full-time student... __ i Do. B. Institutional expenses: Cost of program administration__ No allowance. __________ ST, Do. Cost of litigation ______________ May be charged to fund. Do. Other collection costs... _______ No allowance... we Do. C. Charges for late repayment of student None... Allowable. Amount may not exceed loans or failure to file timely evi- $1 for the 1st month or part of a dence of entitlement to cancellation month payment is late and $2 for or postponement of payment. each month or part thereafter. D. Minimum monthly repayments_.__________ do... TTT Ts Same. E. Loan becomes repayable... ____ 1 year from date borrower ceases to Do. pursue a full-time course of study at a nursing school. F. Deferment of repayment of student loans for: Advanced training... _________ Any period during which a borrower is Limit the period to 5 years and pursuing a full-time course of study broaden eligible study to include at a collegiate school of nursing other advanced professional train- leading to a baccalaureate or gradu- ing in nursing. ate degree in nursing. Uniformed service______________ N Up to 3 years. Peace Corps... __ —_ Do. Vista_._______________ i Do. G. Extension of repayment Same. H. Interest rate on student loan________ percent or going Federal rate which- Do. ever is greater.! . Cancellation of student loans: Professional practice in any pub- 10 percent per year, up to 50 percent of Do. lic or nonprofit private institu- total loan plus interest. tion or agency. Professional practice in a public Nome. .___ ._ _ __ _____ ____ _._______ 15 percent per oer, up to 100 percent hospital which has a substan- of the total loan plus interest. tial shortage of nurses and is in an area with substantial popu- lation. Death of borrower._._..________ Total loan, plus interest... _________ Same. Permanent and total disability... _._ 0. cecreseraren sR SE Do. J. Maximum amount of student loans: cademic year. _______________ $1000 oo... $1,500. Limitation on aggregate of loans_. No limit_____________________________ Same. K. Loans to schools: Federal loans to schools_..._____ NO. conciseness Do. Loans to schools for capitaliza- Yes... ___. Do. tion of student loan funds through revolving fund mech- anism. 1 The interest rate since the inception of program has been as follows: 1965 and 1966, 414 percent; 1967, 536 percent; and 1968, 434 percent. EXHIBIT C NATIONAL DEFENSE STUDENT LOAN PROGRAM ! Program characteristics Existing legislation Proposed legislation re ie os SS i Higher education_________.._______._ Same. level ._________ -.. Graduate and undergraduate education. Do. Student status_________________ Full-time or half-time student. ________ Do. B. Institutional expenses: 1 Cost of program administration_. 14 of actual cost up to 1 percent of 39%, of institutional annual expendi- outstanding loans. ture of its allotment plus related non-Federal matching, not to ex- ceed $125,000 in any fiscal year. Cost of litigation________________ May be charged to fund ___.__________ Same. Other collection costs_________________ D0. comm iin mmm mp naam Do. C. Charges for late repayment of student Institution may assess charges as Do. loans. follows: (a) Repayment monthly $1 first month, $2 each month thereafter; (b) repayment bi- monthly or quarterly, $3 and $6 respectively for each period pay- ment is late. Footnote at end of table. 92 EXHIBIT C—Continued Program characteristics Existing legislation Proposed legislation D. Minimum monthly repayments.______ Equal payments, but not less than Do. $15 per month. Do. E. Loan becomes repayable.___________ 9 months after borrower ceases to Do. carry at least 14 normal full-time academic workload. F. Dejerment of repayment of student oans for: Full-time study___._.__________ Yes, when student is carrying at least Do. 14 time workoad. Less than full-time study_______ Yes, institution may defer payment up Do. to 3 years if student is less than 15 time, but is taking course creditable toward a degree. Unites me service (armed serv- Upto3vyears._._.__________________ Do. ices). Peace Corps... 00. con mm Sin sae se SRT Sate Do. es _. do Do. G. Extension of repayment period... ___ Yes. Extended for good cause by Regu- Do. lations of the Commissioner. H. Interest rate on student loans_______ Bpereont. ccvoisuanasnrsunin an ere Do. I. Cancellation of student loans: Teaching service_._____________ (i) up to 50 percent at the rate of 10 Up to 50 percent at the rate of 10 percent of total loan for each aca- percent if combating disadvan- demic year. taged, poverty or unemployment. (ii) up to 100 percent at the rate of 15 Do. percent of total loan for each aca- demic year of teaching handicapped, in low-income areas, and schoo eligible for and under title Il of Public Law Death of borrower______________ Liability cancled_.__.________________ Permanent and total disability_._ Lability canceled. - Bankruptey_______________.____ Lability canceled J. Maximum amount of student loan: Academic year. _._.___________ $1,000 , undergraduate student; $2,500, $1,500, undergraduate student; raduate student. $2,500, graduate student. Limit on aggregate of loans... _. $5,000, undergraduate student; $6,000 undergraduate student; $10. 000, graduate student, $11,000, graduate student. K. Loans to schools: Federal loan to SChODl OF HS YES... .. uo uosmmmmmummmnmmmemuimns Same. matching share. ob Loan to school for capitalization No... ________________. Do. of student loan fund through revolving fund mechanism. 1 No student who is eligible to receive a loan from a fund established under the HPSL program at the institution he is attending may be made a loan under the national defense student loan program. 2. Sec. 806 proposes a $15,000 basic grant to all schools. Why are there no criteria as to size, cost of operation, quality of program, ctc.? Sec. 806 of S. 3095 proposes a formula grant to schools of nursing. Each school would receive a basic grant of $15,000—the minimum amount that would allow a school of nursing to add a faculty member and provide for a few sup- porting costs. From the sums remaining from amounts appropriated after the basic grant had been computed, 75% would be distributed on the basis of rel- ative enrollment and the relative increase in enrollment (with the amount com- puted so that the school would receive twice as much for each student in the increase as for other students) and 259% would be distributed on the basis of the relative numbers of graduates. Thus, the size of the school is specifically taken into consideration in the computation of the formula. Assuming a $50 million appropriation, the following are examples of the formula grants calculated on October 1966 enrollments and 1965-66 graduations: New program with an enrollment of 32 students would receive $21,176. A program with an enrollment of 112 students would receive $49,120. 93 A program with an enrollment of 426 students would receive $125,154. One of the larger schools of nursing, a program with an enrollment of 746 students, would receive $184,427. The bill considers quality in that all the grants are for the improvement of the quality of the educational programs. The bill further considers quality in that only nursing programs that are accredited or have reasonable assurance of accreditation are eligible to receive formula grants. It also carries provisions with respect to the cost of operation. The school would have to provide with its application assurances that the applicant will ex- pend in carrying out its function as a school of nursing, an amount of funds from non-Federal sources which are at least as great as the average amount of funds expended for such purposes (excluding expenditures of a non-recurring nature) in the three fiscal years immediately preceding. This maintenance of effort provision would assure that the Federal assistance provided did not replace non-Federal funds. Costs of operation vary widely among the different schools, even within the same type of program. Moreover, there is lack of comparable cost-of-operation data among the school. It would be extremely difficult to assure that the same criteria were being applied equitably if any specific cost-of-operation criteria were included. 3. What is the advantage of making the incentive grants for enrollments and graduations the same amount? A school could appreciably increase its enroll- ments temporarily but through dropouts would only graduate a small proportion of those enrolled. The institutional grant formula provides for a basic grant to each program of $15,000 and of the remainder 75% on the basis of the relative enrollment of full- time students and the relative increase in enrollment of such students over the average enrollment of the five preceding years (with the amount per student computed so that a school would receive twice as much as each student in the increase as for other students), and 259% on the basis of the relative numbers of graduates. Thus, the formula would provide institutional grants based upon the size of school and increased enrollments and graduations. The amount each school would receive beyond the basic $15,000, the “incentive grant,” would vary according to the size of school. The costs the school incurs for the education of a student begin at the time of her entrance and continue through her graduation. The more heavily the grad- uate factor is weighted, the more the new schools, the schools in transition, and the schools which are increasing their enrollments are penalized. The graduate factor is computed for only one class—the graduating class. It relates to but a fraction of the school, it is delayed to the point at which the student com- pletes the program, and it does not provide an immediate incentive for expansion of enrollments. 4. In Sec. 231 the definition of accreditation has been amended by adding “State agency’. Why is this change necessary? What criteria would be utilized in select- ing a “State agency’? The amendment would add State agencies to the body or bodies which the Commissioner could use as reliable authorities to determine the quality of edu- cation. This would broaden the base of possible accrediting agencies should the presently named bodies—the National League for Nursing originally named by the Commissioner for purposes of the Nurse Training Act of 1964, and more recently the regional accrediting bodies for determining reasonable assurance of accreditation—Dbe unable to meet the requests of the schools. State agencies would use criteria and methods of evaluating the respective types of nursing education program that would be appropriate for the specific type of program : diploma, associate degree, baccalaureate or higher degree. pe The criteria would relate to the quality of nursing education program ; specific consideration would be given to : objectives and purposes of the type of nursing program organization and administration of the nursing program financial stability of the nursing program academic standards and policies curriculum and program of instruction faculty, preparation and experience academic resources, including teaching materials and library resources clinical resources physical facilities, including libraries, laboratories and classrooms methods for evaluating and improving the nursing program It is assumed that evaluation would be undertaken by qualified individuals representing the type of nursing educational program being evaluated. 5. How might the States best be encouraged to foster student and institutional aid programs in the health professions and subprofessions? The best methods of fostering additional investment by the States in the edu- cation of health personnel is to create an awareness of the magnitude of the prob- lem which each State faces in providing adequate health services to its people. This awareness will result as States make realistic assessments of their specific needs, evaluate their resources, and formulate plans to meet these needs. Studies which identify (1) the need for health manpower and (2) the available resources to educate health personnel are a primary factor in encouraging States to foster institutional and student aid programs. Documentation of the magnitude of the need for additional health services personnel within a State serves as the basis for adequate planning of efforts to meet specific health manpower needs including effects of recruitment, support of students and support of new, modified or expanded training programs. The recognition of need, followed by adequate planning to meet that need, points up the necessity for States to allocate addi- tional resources for institutional aid in the health field. For example, among the most significant ways in which States have been en- couraged to support student aid programs and programs of education in the field of nursing have been the planning activities directed toward the assessment of the needs for nurses and the resources for their recruitment and training, and means of improving utilization of nursing personnel. These planning activities have involved the joint efforts of institutions and agencies employing nurses, educators and institutions training nurses, and the nursing profession itself. In some States, support of nursing education—schools and students—has been a direct result of recommendations of a Statewide survey of nursing needs and resurces. Most have indicated need for financial assistance and some study com- mittees or commissions have been instrumental in obtaining State appropriations. In the early 1950's, many State legislatures (Minnesota, Connecticut, Wyoming and South Dakota, for example) provided for direct financial aid both to students and schools of nursing. In Minnesota, the financial aid was in the form of scholar- ships for a two-year period to beginning students of professional and practical nursing. In Mississippi, funds were awarded directly to the University of Missis- sippi nursing education program. Scholarships were also awarded to registered nurses for advanced preparation. Early surveys recognized the need for establish- ment within the State for additional programs of nursing education—associate degree, baccalaureate, graduate or clinical specialties. Current State planning activities for nursing are indicating the importance of State and private as well as Federal support for nursing education. The broad- ened authority for special project grants in Sec. 805, as provided in S. 3095, would assist in many facets of planning and in the development and establishment of new programs of nurse training and modifications of existing programs to which both State and private support could make significant contribution. 6. What recommendations contained in the December 1967 program review report of the Nursc Training Act, published by HEW, have been included in S. 3095? Which recommendations were omitted—and why? The Program Review Committee recommended that the program authorized under the Nurse Training Act of 1964 be continued and suggested certain modifica- 95 tions. Most of these changes and additions have been included in the provisions of S. 3095, the Health Manpower Act of 1968, as shown in following comparative listing. Other recommendations made by the Committee did not require legislative authority. These had to do with administration of certain of the Nurse Training Act provisions, with level of support, and with other PHS-BHM nursing activities, intramural and extramural. PROGRAM REVIEW COMMITTEE RECOMMENDATIONS Assistance Continuation of construction grants for nursing educational facilities under single authorization with increased funds. Increase in maximum Federal share for all projects. Support for construction of continu- ing education facilities. Grants for improvement of nursing education be continued and expanded to cover total costs of projects to public and non-profit private institutions and agencies as well as nursing education programs. Grants to nursing programs to deter- mine long range goals and to facilitate cooperative agreements and orderly transition from one type of nursing education program to another. Grants to assist programs reach high quality standards, i.e., accreditation. Grants to assist in planning, develop- ment and establishment of new or modi- fied programs for nursing education. Additional recommendations for Fed- eral funds emphasized need for specific activities (statewide or regional plan- ning for nursing, recruitment programs, assisting disadvantaged groups to enter nursing, establishing nursing programs in universities and medical centers) all of which could be accomplished under project grant mechanism. Basic support grants for all types of nursing education programs—a fixed sum with additional funds based on en- rollments, and varied according to type of educational program. S. 3095 PROVISIONS to schools Extends program for four years with- out statutory ceiling. Federal share authorized under pres- ent law (maximum 6624 for new or major expansion and up to 509% for other construction) would remain same. However, new exception would au- thorize Secretary to increase the maxi- mum 509% share (not to exceed 662%) in “unusual circumstances.” Would allow inclusion in construc- tion project of space for advanced train- ing activities that are not degree oriented. Extension of project grants with significant modification. Institutions eligible to receive improvement grants would be broadened to include public or nonprofit private agencies, organizations or institutions as well as schools of nursing would add new authority—to plan, develop, or establish new or modify existing programs of nursing educa- tion—to assist schools in financial straits to meet costs of operation or accreditation requirements or to assist in otherwise strengthening, improving or expanding programs of nursing edu- cation. Authorizes new program of institu- tional (formula) grants for all types of nursing education programs. Statu- tory formula provides for basic grant of $15,000 to each school and remainder based on enrollments and graduations. 96 PROGRAM REVIEW COMMITTEE RECOMMENDATIONS Assistance Professional Nurse Traineeship Program be continued and expanded to provide traineeships for diploma and associate degree graduates to obtain baccalaureate preparation prerequisite to advanced training. Nursing Student Loan Program be continued and maximum amount of loan be increased to $2,500 per academic year S. 3095 PROVISIONS to students ixtends traineeships for advanced training of professional nurses for four years without statutory ceiling on ap- propriations. Extends nursing student loan pro- gram, increases maximum loan to any student in any academic year to $1,500. for baccalaureate and graduate stu- dents and $1,500 per academic year for diploma and associate degree students. A scholarship program be established to attract highly qualified high school graduates in need of financial assistance into baccalaureate programs in nursing. Committee recommended continua- tion of the program authorized by the Nurse Training Act for at least five years. 7. What has been the experience in loan forgiveness in accomplishing the goals desired? Health professions student loan program The provision for loan cancellation for borrowers practicing medicine, dentistry, osteopathy, or optometry in designated shortage areas was enacted October 22, 1965. Ten percent of the loan plus accrued interest, up to 50 percent of the total loan, may be canceled for each year of practice in an area determined by the State health authority to be a shortage area. The provision for loan cancellation for borrowers who practice medicine, dentistry, osteopathy or optometry in rural shortage areas characterized by low family income was enacted November 3, 1966. In this case, 15 percent of the total loan plus accrued interest, up to 100 percent of the total loan, may be canceled for each year of practice in a shortage area characterized by low family income. A borrower must have completed a year of employment to claim entitlement to the forgiveness benefit. Inquiries from student borrowers indicate an interest in utilizing the loan cancellation benefit. However, borrowers have not completed their professional studies, internship and residency training; therefore, we are unable, at this time, to report on the effect of these loan cancellation provisions. Nursing student loan program The Nurse Training Act of 1964, enacted on September 4, 1964, includes a pro- vision for cancellation at the rate of 10 percent of the loan and interest per year, up to 50 percent of the total loan, for a borrower who is employed full- time as a professional nurse in a public or nonprofit private institution or agency. The earliest regular graduation dates of borrowers in their freshman year of study at participating institutions during the first year of program operation (FY 65) are rescribed below : (i) collegiate school of nursing, June 1968. (ii) associate degree school of nursing, June 1966. (iii) diploma school of nursing, June 1967. A borrower must have completed a year of employment to claim entitlement to the forgiveness benefit. Since there were few borrowers in associate degree schools of nursing in FY 65, requests for cancellation are not expected until July and August 1968. 8. Health teaching facilities receive 50 percent matching and, as proposed in N. 3095, can under special circumstances receive 6624 percent Federal matching. Why does this differ from matching percentages for teaching facilities admin- istered by the Office of Education under the higher Educaiton Facilities Act and by the National Science Foundation? Authorizes a new program of scholar- ship aid for students of exceptional fi- nancial need in all three types of pro- grams. Bill authorizes support for four years. 97 Health manpower is a shortage area; health care of the people is a national priority. Some schools desperately need higher Federal matching in construction grants in order to maintain student places. 8. 3095 would authorize a Federal share—maximum now set at 6624% for new facilities a major expansion of existing facilities and 509 for others—of up to 6624% for other teaching facilities under “unusual circumstances.” In certain “unusual circumstances” construction and related costs would be so high that it would be impossible for existing schools to undertake construction unless the Federal Government could provide more favorable matching for the entire construction irrespective of expansion, For example: where a school must relocate its entire physical plant as from an inner city area, or as part of a large redevelopment plan to provide more suitable and safer area for both students and faculty, or to be closer to the clinical facilities (because the school of nursing does not build its clinical facilities along with teaching facilities as do the medical schools). where a school is loctaed, and must remain, in an area where real estate (or some other aspect of construction) is excessively high in relation to other construction costs and/or where purchase of land is essential to con- struction of the educational facility—e.g., midtown Manhattan or Chicago. where a school is located in a depressed area where private funds for matching are impossible to raise, and there are heavy demands on public funds and construction plans have to be postponed idenfinitely because of lack of matching funds—e.g., Appalachia. where three or more schools in an area are combining their students and teaching resources for a stronger and more economical operation, an undue burden is placed on thee one school undertaking the construction : a. if two schools were easing operations and the combined enroll- ments would be located in the third school, both new facilities and extensive remodeling and renovation would be required to accommodate the combined programs. Even though this would be major expansion for the continuing existing schools most favorable matching should be given for the entire construction costs. b. if the three schools were to continue in operation and were to jointly use a new facility, each of the programs could undertake major expansion. The school receiving the grant should be treated as a “new school,” and receive the most favorable matching for the entire facility, rather than as an existing school and receive favorable matching only for the construction that was major expansion. where school has never had facility of its own even though it had grad- uated a few classes, e.g., moving from place to place as much as five years in temporary quarters and was still asking for first building. where community need as well as that of individual school was great, e.g., only school producing nurses in area could not increase enrollment but must be maintained. where school has had a year with atypical enrollment during previous five vears, and projected enrollment with new construction would be major expansion except for the atypical year, e.g., one large diploma school picked up the student body of another school which increased operation, thereby, increasing its enrollment in one year by more than twice their usual annual increases; this was much more than facilities and faculty could accommodate and more than school considered when planning con- struction for major expansion. The proposed amendments would make possible favorable matching, up to 6624%, for construction grants to existing schools under such unusual circumstances. 9. Comments on report of “A Study of Federal Student Loan Programs” con- ducted by the College Entrance Examination Board, }75 Riverside Drive, New York, N.Y., 10027. The Secretary, Department of Health, Education, and Welfare authorized the Commissioner of Education to solicit proposals for study of the overall effective- ness of student loan programs administered by the Federal Government, the cost of the study to be jointly supported by the Office of Education and the Public Health Service. 98 A contract supporting this study was awarded to the College Entrance Exami- nation Board, March 13, 1967. The duration of activity of the study covers the period April 1, 1967 to December 31, 1967. Pre-publication drafts of the report dated January 2, 1968, were received by the Department early in January and made available to each of the agencies involved. The final report was received in early February of this year. The report is very detailed, covering all aspects of public policy and administration of the National Defense Student Loan Program, the Health Professions Student Loan Program, the Nursing Student Loan Program, Cuban Refugee Student Loan Assistance Projects, the Guaranteed Loan Program and the National Vocation Student Insurance Act. The report includes several hundred pages of findings and recommendations which merit careful study. A committee made up of representatives of the Office of Education, Public Health Service and the Office of Secretary has been appointed to evaluate the report and to make recommendations concerning any modifications which should be made in existing loan programs. Therefore, we will not be able to provide a response until this committee has completed its review. EFFECT OF BUDGET CUTS Senator Javits. One thing that appalls us, Dr. Lee—and I am saying it at you rather than to you—is that the promise is not realized on the part of the administration. We have had large appropriations, as our chairman pointed out, $200-some odd million. When the fiscal year 1969 budget comes around, it is $8 million. You have appropria- tions, for example, of as little as 10 percent of the amount authorized for construction. Now, I know our troubles. We are all acquainted with that and this is no place to debate the Vietnam war. But the deficiency strikes me as being priorities. There is a completely wrong sense of priorities which are obtaining in our Government. We are doing a little for everybody instead of making, grasping the nettle and making the hard choices. That is what is really missing. Senator Hill, Senator Yarborough, and I are laboring with that in the Appropriations Committee. It is very difficult for the Congress to make the choices because the President can impound the money. So even if we make them, they cannot be final. This is a very, very troublesome thing to us. Now, that leads me to ask you this: Does the law allow an adequate tie-in between what you do and the enormous range of voluntary efforts in the country? Is there any inhibition in law which prevents the Federal Government from matching, not State funds or municipal funds, but private funds? One of the great triumphs of philanthropy, and the Rockefellers were responsible for this very heavily, is the matching idea. We will match everybody else’s dollar or we will put up $3 if others will pay up “$6.98.” Now, examine the law for us, will you, and tell us, especially in the health field, where there is so much money to be gained by philanthropy. Corporations, for example, are contributing about one-fifth or less of their potential based on their earnings. They have a 5-percent allowability. So point out to us where, if anywhere, the law inhibits Federal matching with private and welfare funds coming from private and voluntary organizations, foundations, and private sources. Dr. Lee. We will do that. Just as a general statement, it is my under- standing that there are not really significant deterrents to this, but we will examine it carefully and submit a report to you promptly. 99 Senator Javits. And also, Dr. Lee, give us any ideas you might have on how we could boost that up. Dr. Lie. The private philanthropy ? Yes, sir. Senator Javrrs. Right, when it 1s matched with Federal funds, or perhaps State and Federal. But give us some way, the best way you can think of, for gaining a point of entry into that operation. Dr. Lee. I think you made in your opening statement the most sig- nificant and important point with respect to funds for health profes- sions and the rest of it, and that is unless we find ways of adequately controlling the rapidly rising costs of medical care, we will have diminishing funds available for these purposes on which all medical care depends. So I think you hit the nail on the head. MEDICAL EDUCATION Senator Javrrs. And I hope, too, you will think through and give some attention to this idea of medical education in terms of specializa- tion, in terms of its total length, et cetera. We have so many new techniques, but you still see the treadmill of the 12-year cycle going on to this very day. Dr. Lee. We have specifically in this proposed legislation authorities that will permit schools to make major curriculum reforms, experiment with shortening the curriculum, and also training new types of health professions. I think these are directed to this problem. UTILIZATION OF NURSING EDUCATIONAL TALENT Senator Javits. Now, just two other questions. One, would you give us a report on the Department’s experience under section 868—that is, the encouragement of full utilization of nursing educational talent? This is something which is my particular baby, and I would greatly appreciate a report on it. Dr. Lee. Yes, sir. (The report referred to, subsequently supplied by Dr. Lee follows:) REPORT ON CONTRACTS TO ENCOURAGE FULL UTILIZATION OF NURSING EDUCATIONAL TALENT UNDER SECTION 868 oF THE PHS Act Section 868 authorized contracts not to exceed $100,000 per year for the pur- pose of: 1. identifying qualified youths of exceptional financial need and encour- aging them to complete secondary school and undertake post-secondary educational training in the field of nursing, or 2. publicizing existing forms of financial aid for nursing students, in- cluding aid furnished under this part. Application forms for participation in the Nursing Educational Opportunity Grant Program have included a narrative justification with school plans for identification, motivation, recruitment, admission and counseling of eligible students. These statements have provided information on needs and on present school activities relevant to development of contracts which would help both students and schools. One of the needs that these narratives have pointed to is the necessity of reaching students early in secondary school in order to interest them in nursing as a career and to counsel them in their academic courses. Since many of these students are from socially and economically disadvantaged areas and population groups, they need extensive remedial and tutorial assistance to successfully complete secondary education. This contract authorization enables schools of nursing to undertake the extra work required for identification of potential nursing candidates from minority 100 and disadvantaged groups. It also makes it possible for them to try and to dem- onstrate new and more effective ways of assisting students to overcome the effects of cultural, economic, and educational deprivation. Students for whom nursing might only have been a dream will be able to plan realistically for nurs- ing careers and to become gainfully employed in a profession. Contract funds did not become available until 1968 and only two contracts were possible with the funds for this year, $100,000. The need, interest and potential for this kind of activity is great and schools and community groups are ready and eager to initiate programs when additional funds become available. Schools of nursing have expressed need for assistance in identifying potential nursing candidates from minority and disadvantaged groups and in finding more effective ways to assist these students to meet their cultural, educational, and financial needs. The ODWIN (Open Doors Wider in Nursing) project has been underway in Boston since 1964, starting in a limited way with private funds. The purpose of this organization is to identify young men and women with potenial for nursing but without the financial sources to undertake a program in nursing. Assistance is also provided to schools of nursing to encourage them to become involved in attracting and retaining these students in nursing programs through tutorial assistance. The contract with his group developed under Section 868 will enable the group to add staff so that the activities can be expanded to: 1) reach students at an earlier grade (10th grade rather than the last two years of high school—i.e., grades 11 and 12), and 2) expand opportunities for admitting students to schools of nursing from the Boston area alone to schools throughout the State. The second contract was developed with the ANA-NLN Nursing Careers Com- mittee to design and develop new recruitment methodologies to demonstrate effective ways of motivating boys and girls from disadvantaged backgrounds to enter and complete programs in nursing. Materials will be developed which will be suitable for use by guidance conselors, community resource people and teachers to help them in meeting the needs of potential nursing students. Recruitment methods which prove successful can then be used nationwide for the recruitment of individuals from disadvantaged backgrounds. MEDICAL TECHNOLOGY STUDENTS IN ALLIED HEALTH PROFESSIONS ACT Senator Javits. Now, my final question is this: It has been suggested that financial assistance provisions for medical technology students be included in the Allied Health Professions Act. Does the Depart- ment have a view now, or does it wish to give us one? Dr. Lee. At the present time, with respect to the Allied Health Professions Personnel Training Act and the scholarships, it is our view that we should not make piecemeal changes in the act. We have had a number of different groups who have come to us and asked for this or that change. It has been our view up to this point that we should not make piecemeal changes. Dr. Fenninger has met with a number of the groups. I think there is general support for this notion that we should have this additional year’s experience. We would then come back to lay the whole problem before you, and I am sure that solutions will be found to that. But it is a major problem. It is one that we have looked at. It is one, at least at the present time, our conclusion is we should not go in for piecemeal amendment to the act. Senator Javrrs. My inclination would be to offer an amendment re- quiring you to report within a year in an authoritative way to the Congress. Dr. Lez. That would be fine. Senator Javrrs. That would be all right ? 101 Dr. Lee. Excellent. Senator Javits. Because that kind of thing gives it authority and you have something to pitch it to. Dr. Lee. It keeps our feet to the fire. The Caamrman. That would give you time to study it, too. Dr. Lee. Yes, sir. . Senator YarsorouecH. Mr. Chairman, I have one more question, if I may. The Cramraan. Very well, Senator Yarborough. Senator Yarsoroucn. I will ask this question of Dr. Lee and ask that he have the Department study it and give us an answer when he can. I have had, recently, a man whose business is to sell supplies and equipment to hospitals come to see me about this problem of increasing costs of hospitalization and treatment. He stated that if the hospitals he saw were to be efficiently managed—and he sees many in a certain geographical area—he believes that on the present charges, without any increase, 95 percent of the hospitals in America would be in the black today instead of many losing money. He says a great deal of administration is being done by medical doctors and nurses whose business it is to care for people and who probably would rather be caring for them. He says there have been some hospitals where a registered nurse can give practically no time to treating patients be- cause she is an administrator and must be doing administrative tasks. Doctors and nurses have to pull their time out frequently for admin- istration ; they do not have people who are expert in administration. He told me he thinks the greatest shortage in the medical field today, in medical treatment, is capable administrators. I would like to have the study and comments of the Department on that observa- tion. He said there was absolutely no need to raise the prices of any- thing, that 95 percent of the hospitals of America would be making money if they were properly and efficiently administered by trained administrators. I do not want to use his name, because he is selling equipment to these people: he makes his living this way. But this is his observation. Dr. Lee. Last fall, Secretary Gardner convened a special advisory committee on hospital effectiveness, and we have received a report from that committee which we will submit to you. But we will also address ourselves to this specific question, Senator Yarborough. Senator YarsoroueH. I wish you would. We do not have the time now, but I wish you would study that and see if this is one of our weaknesses in this constantly rising cost situation Senator Javits mentioned. Dr. Lee. In the Public Health training program, in the hospital administration area, there is no question that there is a great deal of interest in this area of improved administration. We could not possibly do the kind of study you request by the time the record is closed, but we will be happy to work with you and your staff on this matter. Senator YarBoroucH. Thank you. Senator Javits. Senator Yarborough, just for your information, Mr. Millenson gives me something you might like to put in the record on what you have just said. It is out of Forbes magazine, the current 102 issue, which apparently has a pretty good piece on medical care. It says: We have found that in the $1,000 hospital bill, $300 of that expense covers non-productive information handling and filing. More important, we found that with all the red tape involved, signatures, counter signatures, 12 different human operations, just to get an x-ray picture, there is one chance in six of a hospital test having some error in it. This is from the current issue of Forbes. The Senator might like even, perhaps, to put in the whole thing. Senator YarBorouaH. I will certainly take a look at it, and I thank the Senator for pointing it out. The Cramrman. Anything you would like to add, Doctor? Dr. Lee. I have no additional comments. The CaamrmaN. Dr. Fenninger? Dr. FENNiNGER. I have nothing, sir. The Caamrman. Mr. Huitt ? Mr. Hurrr. No, sir. The Cumamrman. Thank you very much. You have made fine wit- nesses. Dr. Lee. Thank you. The Cramrman. Now, we hear from Dr. William N. Hubbard, of Ann Arbor, Mich., past president of the Association of American Medical Colleges. STATEMENT OF DR. WILLIAM N. HUBBARD, JR., ANN ARBOR, MICH., PAST PRESIDENT, ASSOCIATION OF AMERICAN MEDICAL COL- LEGES; ACCOMPANIED BY DR. ROBERT BERSON, DIRECTOR, WASHINGTON OFFICE Dr. HusBarp. Mr. Chairman, we appreciate very much the oppor- tunity of being here this morning. If it is agreeable with you, we will Syl a written statement which we hope may find its place in the record. The Caamman. Without objection, we will have that statement ap- pear in full in the record. You may make such additional statements as you wish. Dr. HusBarp. Thank you very much. We will make some comments about this proposed legislation and then we’ll look forward to re- sponding to your questions. We feel that the crucial issues that the bill addresses itself to are three: First is to provide service to meet the expectations of the peo- ple; the second is to provide opportunities for qualified students; and third, hopefully, to control the inflationary effect of increased pur- chasing power In a relatively closed manpower system. The Cramman. That is a very important point you make. Dr. Hussarp. Yes, sir, and we feel that these are the larger and longer term purposes that this bill will work toward. Now, in our view, the only way of achieving these purposes is to support the educational institutions and their present operations and to expand and to create new ones. We would conceive that there is a total array of efforts that are necessary to secure the health of the peo- ple. Research and education is one part of that total array of efforts, 103 and it is that part that we address ourselves to. We would hope that the support of elements of education and research could be of general relationship to the benefit, the product that that education and re- search has for the welfare of the people. We would feel that this legislation needs to recognize different levels of cost of various groups in the health professions—the differ- ence, for instance, between the cost of physician and of dental edu- cation on the one hand, and perhaps nursing and public health on the other. In the long run, we also hope that we can address the total range of efforts of the faculties of the professional schools since, in the last analysis, it is these faculties who are the basic production resource. In title I, we would reiterate what we have presented to you in pre- vious years, sir, and that is that the greatest limitation on major ex- pansion of our capacity to produce more health manpower 1s con- struction. This is the basic element The CrarmaN. Buildings? Dr. Husearp. Buildings; yes, sir. And it remains today the greatest limitation. There are fully approved awards which cannot be funded, and we feel that this, in view of the need for all categories of health- related manpower is greatly to be regretted. Recognizing the very serious problems in the finances of this coun- try, we nevertheless hope that there will be clear recognition of the 4-year lag between the beginning of planning for a building and the completion of the construction. We would recommend further that if possible, immediate effect be given to the administrative improvements in this act which do not require additional funding. The CaamRMAN. Some will require no extra money ? Dr. Hussarp. It would need no extra money, and would bring im- mediate relief in some of the administrative restrictions that we now have. We applaud the recommended administrative changes. We hope that there will not be any unnecessary delay in their implementation. In the institutional grants, we would call attention to a problem that has been created by an incomplete appropriation of the authorized amounts in the face of very long-term commitments that have to be made by the institutions. We feel that we need to rely upon the full faith and credit of the Federal Government in our institutions in as- suming these long-range commitments, and there has been a serious problem of confidence created when the institutions have made the commitments in the authorized appropriations. The Carman. The money has not been forthcoming. Dr. Hussarp. It has not been forthcoming. In the increased eligibility for formula grants in this bill, we ap- plaud this as an essential move. However, as practical operators, we would have to observe that only incremental funding will give validity to this increased eligibility. The “sums as necessary” terminology that appears in the bill we feel states it adequately. The Congress and the public realize it is necessary to fund and to support these programs if this health manpower increase is to be made valid. The Cratrman. You have to have the money to do the job. Dr. Hussar. Yes, sir; we do. 104 In looking at the Federal share in the institutional grants, we recog- nize the need for a ceiling of 50 percent of institutional expenditures. We would propose, however, that a floor might also be considered. We estimate that for physician education—and our best information would lead us to believe that dental education is in the same position—only about 10 percent of the cost of that education is represented in the formula for the Federal share as it now exists. We do not propose that these two are the only branches of the health professions that would be supported, but we feel that in other areas where the present for- mula might provide nearly 50 percent, there needs to be examination of whether the public interest is best served by holding medicine and dentistry down to 10 while other areas are supported at a level of 50. We would suggest then that consideration be given to a floor as well as to a ceiling. ‘We welcome and applaud the changes in the formula that recognize the number of graduates that a school has as well as the number of students that are registered in the first place, since, actually, the public welfare is best served by graduates. The CrairmaN. Doctor, you have one of the best medical schools in the country. How many graduates do you contemplate this year? Dr. HusBarp. We will have approximately 186. We started with a class of 200. The Carman. How many freshmen did you have this year? Dr. Hussarp. We had 206 first-year students this year. The expansion requirement that is a part of the eligibility for the formula grant we endorse in principle, since we agree entirely that the urgency of increased output of manpower is a predominant con- sideration. We are pleased to see the change in the base, and in the average enrollment, approach. We would emphasize the importance of the Secretary’s authority for waiver since, as you well know, sir, we have a number of schools who are in such precarious position that it would not be in the public interest to increase their burden of students at this time. The Caarrman. I think Dr. Berson and I had that brought home to us at a conference we had just this past week. Dr. Berson. Yes; we did. Dr. Hussar. We once more, with some reluctance, but neverthe- less we must, emphasize that there has to be assured funding to meet the problem of increased costs of these expanded enrollments. If there is not, then one has simply guaranteed a decrease in quality. We feel that this set of efforts will importantly maintain our production capacity. As we look at the provision for special project grants, we would hope once more in this instance that the administrative changes that are so admirable and the proposed legislation could be instituted promptly where they do not require additional funding. The CrarmaN. Not delay it, in other words; go ahead with it? Dr. HuBBarp. Yes, sir. We would note as a special problem the difficulties a 2-year medical school looking forward to becoming a 4-year medical school faces, and we would hope, as the legislative intent is expressed, that it will be clear that these problems should be dealt with as a special case. 105 The CrarmaN. How many 2-year medical schools are there? Dr. Berson. Three. Dr. Hueearp. Senator Hill, these special projects are the principal mechanism of achieving the changes that Senator Javits referred to. It is through this kind of funding that one has the capacity for planning and for institution of change which comes in addition to existing program needs. In the student aid, we once more find ourselves in hearty accord with the provisions of this legislation. We feel it is very important to be able to mix loans and scholarships so that they adapt to the needs of the individual student. We recognize that loans to physicians and dentists and others really are simply a deferred cost on the de- livery of health care by those professions, and to the extent that we provide their support through loans, those loans will be paid with interest through charges for their services at a later time. It is the scholarships that make it possible for a realistic debt burden to be taken on by the graduate. And this, we hope, will encourage larger numbers of applicants from the lower economic groups. However, we think this should not be over optimistic, because, actu- ally, that economic selection occurs at the entrance to the college, and as far as medicine and dentistry are concerned, the discriminatory selection has already taken place before we ever have access to the student. In title IT, we would express an opinion at the increased eligibilities that are related to nursing are most important and we lend our full professional support to their inclusion in this increased eligibility. Under title ITT—— The Craamrman. You think that is important ? Dr. Hussarb. I think, sir, it is essential. In title III, relating to the allied health professions and public health, we are particularly pleased to see this part of an omnibus health manpower bill. The Cuoamman. Well, we have to have these allied health professions. Dr. Husearp. The whole array of allied health professions must be supported. It is impossible to meet the needs of the people by dealing separately with physicians, or with dentists, or with any other single group. The Cuatrman. They are a team. Dr. HupBarp. They are a team and they depend on each other. We would hope that as funds are appropriated, there would be— and we are sure there will be—attention given to the relative im- portance of the manpower needs as they are described under the three titles in this bill. Once more, the ceiling as well as the floor for the Federal share Boia seem equitable and indeed necessary to adjust to these relative needs. The health research facilities have already been referred to this morning. We are dismayed at the level of support that is proposed. The CramrMan. You mean the authorizations were good but the recommendations out of the Budget Bureau did not meet the authorizations? 92-079 0—68——8 106 Dr. HusBArp. Yes, sir, and the fully approved applications under this title without funding now represent a loss of potential for im- proved knowledge for the health of the people that is so serious that it must surely be looked at and justified and accepted. We would hope within these health research facilities divisions that once more, im- mediate effect can be given to the administrative changes. We would earnestly hope that if 1t is at all possible, the funding of these facilities be restored. These facilities are basic to our production of knowledge. They are essential for the training of the increased numbers of Fog that we need for our educational programs, and it will be through the knowledge from research that we will finally improve the effectiveness and the efficiency of practice. Senator Hill, we feel that with the proposals that you have in- troduced in Senate Bill 3095, we will find a much more effective use of available funds. We feel that it will secure our basic production capacity for health-related manpower and will put us in a position for adequate program expansion to meet the actual needs of the people when funding does become available. Sir, we thank you again for the privilege of appearing before you and we will be pleased to respond to any questions you may have. (The prepared statement of Dr. Hubbard follows :) PREPARED STATEMENT OF WILLIAM N. HUBBARD, JR., ON BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES INTRODUCTION S. 3095 is a bill that will find a place with other historic legislation that has carried us so far toward our goal of health for the people of the United States. The American people are deeply concerned about health. Responding to this concern from 1946 to 1963 the Federal Government, largely through the Depart- ment of Health, Education and Welfare, joined state and local governments, health and educational institutions, voluntary health agencies, private philan- thropy and industry in meeting two especially-critical needs in the attack on disease : the construction of hospital and other facilities for the care of patients (Hill-Burton program), and the support of medical research (National Institutes of Health). Continuing expenditures by the Government in support of these two programs still represent investments in the health of the nation which pay rich dividends, as has been amply documented. It is imperative that these programs be continued and developed further. Health service facilities and medical research have made possible dramatic progress in the prevention and treatment of disease. By 1961, a block to the effec- tive use of new knowledge and to the pursuit of further knowledge was the increasing shortage of personnel in the health professions, particularly doctors. This block can be removed only by the improvement and expansion of the nation’s system of medical and other health professional education. The Health Professions Educational Assistance Act of 1963, the Nurses Train- ing Act of 1964, the Allied Health Professions Personnel Training Act of 1966, as well as the Health Research Facilities Act and the acts supporting public health professional education have made important contributions toward remov- ing that block. The concept of an omnibus bill as S. 3095 is most suitable in deal- ing with these multiple acts because each of the separate titles supports interdependent efforts that have a common purpose—the achievement of health for the people. This interdependency and common purpose will require ever closer cooperation in planning, in education and in practice by the many branches of the health professions and allied health personnel. Epitomizing this cooperation and interdependence is the modern medical center. In considering needs of medical and other health professional education, it is important to understand the variety, complexity and interrelationships of activi- 107 ties involved in the training of such personnel. This is especially true in relation to the three components of medical education: teaching, research and service. The inseparable nature of these three functions has led to the “medical center” concept as a more realistic characterization of medical education than the too frequently held concept of the medical school, the teaching hospital, the research program, and community health services as activities independent of each other. However, two separate federal support programs—for medical facilities and for medical research—while understandably directed toward specific re- stricted objectives have complicated the conduct of medical education by failing to recognize that research and service are integral functions with teaching. Thus, the need for service facilities and the need for research facilities in a medical education environment has been considered independently by the government, and provision has also been separate for teaching facilities, although teaching is basic to both service and research. The first hard fact to be faced is that there is not enough health manpower to meet the needs of the American people. There are not enough doctors and not enough supporting people. The shortage of physicians is beyond a question the most critical single element in manpower for health service. Although medical schools have increased their capacity to educate physicians and mew schools have increased their capacity to educate physicians and new schools have been created, the increase in the supply is not keeping up with the need. In light of the growing demands for physicians’ services despite the hopeful offsetting factors of increasing his productivity by training as yet undefined categories of assistants, it is clear that more physicians of high quality must be trained as quickly as possible and that the resulting increase in number of physicians will be healthy not only for the nation but for the profession itself. Between now and the middle seventies, we will have approximately 100 medical schools in the United States which can produce the physicians we need. The adequate sup- port of the faculties that are responsible for this medical education is a prime need for the future health of the nation. These 100 institutions must not have their potential limited by an artificial shortage of funds. Artificial because the investment necessary for them to optimise their output is miniscule in compari- son to our country’s wealth and in comparison to the enormous benefit such an expenditure would bring to the health of people. In order to enable the nation’s medical schools both to meet today’s crisis and to atbain the longer-range goal of unrestricted educational opportunity, those re- sponsible for allocation of resources must recognize the magniture of these basks. There are both immediate and long-range steps which should be taken. The immediate steps are : 1. To increase the enrollment of existing medical schools. Considering the time required to create new schools and to provide a student with a medical education, there is no alternative to this step in meeting our present emergency. 2. To foster curricular innovations and other changes in the educational programs which could shorten the time required for a complete medical education. The process of educating a physician embraces the entire edu- cational experience from high school through residency training. In view of the increasing quality of pre-professional education, the growing com- petence of entering medical students, and the increasing amount of clinical experience provided medical students, the duration of internship and re- sidency training should be reassessed. It should be possible to reduce the total length of medical education without sacrificing quality. 3. To meet the need for innovation in educational programs and to en- courage diversity in the character and objectives of medical schools. The development of schools of quality where a primary mission is the preparation of able physicians for clinical practice as economically and rapidly as possible is to be encouraged. Such schools may have less emphasis upon fundamental biologic research than is appropriate for a number of other schools. A longer-range approach to the need for physicians is the development of new medical schools. This approach will not solve our immediate, urgent need for more physicians but it is essential for meeting the national needs of 1980 and beyond. The contribution of such schools to the total capacity of the medical education system is important. The advantages of the organzation of as many such centers of medical education and development through the country as con- sistent with strong programs should be kept in mind. 108 To implement the measures enumerated above will require adequate financial support from governmental and various private sources for: 1. Construction of facilities to expand enrollment of existing schools and to create new schools. 2. Support of the operational costs of medical schools. 3. Stimulation and incentive for educational innovation and improvement. The university is today the typical institutional setting of the interdependent programs of professional education, patient service, and research that form an Academic Medical Center, recognizing that an analogous setting independent of a parent university exists as well. The core of the Academic Medical Center is the faculty and facilities necessary for the education of the M.D. candidate. But other essential roles are simultane- ously served. Basic medical scientists are responsible also for the graduate degree programs and the research training which are the source of tomorrow’s teachers and investigators in these basic health sciences. The research efforts of the basic science faculty create the scholarly environment needed for the kind of education that prepares the student to understand and utilize the scientific advances that will occur during his professional lifetime. These same research efforts produce the knowledge necessary to improve definition and solution of problems vital to human health. The clinical faculty in medicine adds the responsibility for patient care to its obligations for teaching and research. Both the medical school and the hospital phases of the physician's education are shared by the clinical faculty, while they are increasingly sought after for the postgraduate education of the practicing physician. Research and research training programs, both basic and applied, are necessary for these “teacher-physician-scientists” to translate laboratory findings into improved patient care and more effective teaching. Commonly, this same medical faculty shares responsibility for teaching students of dentistry, nursing and pharmacy and allied health workers. The Academic Medical Centers vary widely in their organization for patient service, but all have the obligation to provide exemplary patient care under faculty responsibility. This high level of patient service is necessary to medical education and medical research, but is also an important community resource. Every Academic Medical Center in the United States is in trouble financially and some are in desperate straits. Improved support is needed to sustain the quality of their existing programs, to permit them to enlarge their output of essential medical manpower, and to provide for new programs to enhance the delivery of*health services. BASIC INSTITUTIONAL SUPPORT GRANTS FOR ACADEMIC MEDICAL CENTERS As federal health programs have evolved over the past 20 years, they have dealt separately with education, research and medical care. The institutional in- tegrity of the Academic Medical Center is essential to the attainment of the sepa- rate and collective missions of these programs and so it is necessary that these missions preserve the inseparable interdependence of teaching, research, and patient care within the Academic Medical Center. 1. Basie institutional support grants should be increased and extended to sup- port the full range of educational programs of the Academic Medical Center. 2. Project grants for education or research should allow for overlapping use of these resources within the Academic Medical Center, to the extent that the ful- fillment of the primary purpose allows. 3. Academic Medical Center construction grants should not be restricted to the exclusive use of only one part of the triad of training, research, and service. Com- mon use of an area is inevitable if research and service are part of the teaching environment. 4. A system of accountability which accepts the full range of health-related efforts in the Academic Medical Center should be developed. An accounting con- cept which requires complete separation of teaching, research and clinical serv- ice is not in the best national interest because it decreases the advantages of interaction among these interdependent activities. The medical schools of the United States and their associated Academic Medi- cal Centers require improved support from the Federal Government in order to meet their obligations to the health of the people. The expectations of the people will only be fulfilled through increased output of physicians along with other 109 professional and supporting health workers, through continued support of both basic and applied research, and through enhanced delivery of health care in the community. In each of these functions the medical schools and their associated Academic Medical Centers are an essential national resource. SUMMARY We are told that, after agriculture and manufacturing, health is the largest industry in the nation. The quality of this great system of health care can be no better than the knowledge and skill that serves it. A physician remains at the apex of the team of professional and allied health workers who translate this knowledge and skill into service. It is from the medical schools of the United States and their related Academic Medical Center programs that the knowledge, skill and physician manpower essential to this health-care team will come. By providing these 100 Academic Medical Centers with the resources they need to meet their obligations, the quality and effectiveness of the entire system of health care will be enhanced. Although the total number of dollars involved appears large when isolated, it is very small indeed in comparison with the magnitude of the expenditures for health throughout the nation. It is from a very deep and urgent sense of obligation to meet the health-manpower needs and the needs for improved knowledge and skill that we appear before the Committee to describe the resources that are necessary to meet these public purposes. The real need of the Academic Medical Centers of the United States actually far exceeds the recommendation in the Administration’s health budget. Every university medical center in the United States, both state and private, is in trouble financially and some are in desperate straits. In order to meet their expanded obligations, all must have the space and the stable program support that is essential for their contributions in education, research, and patient service. The Academic Medical Centers of the United States are a vital resource for the health care of the people of the nation and are an important part of the total assets of the nation. State and private agencies do not provide the funds required by all of the programs of the Academic Medical Centers since they have national as well as local purposes. Unless adequate funds from federal sources continue, we cannot fulfill the obligations to the health care of the people that they have every right to expect from us. We therefore urge the committee most strong- ly that every effort be made to assure that the funds appropriated to health- related education, research and service are adequate to meet the needs and ex- pectations of our people. COMMENTS ON 8. 3905 The Association of American Medical Colleges strongly supports the Health Manpower Act of 1968 (8S. 3095). It will extend and significantly improve the Health Professions Educational Assistance Act of 1963, as amended, the Nurses Training Act of 1964, as amended, the Allied Health Professions Personnel Train- ing Act of 1966, project grants for graduate training in public health (Sec. 309 of the Public Health Service Act) and traineeships for professional public health personnel (Sec. 306 of the Public Health Service Act). Each of these have proven to be sound programs. Much has been accomplished toward the production of ad- ditional trained health manpower and the provision of additional educational opportunities in the health fields. But the demands and expectations of society continue to increase, much more needs to be done, and this omnibus bill contains significant improvements and establishes a pattern which we believe to be sound. When these programs can be supported by adequate appropriations, we can make rapid progress toward the provision of educational opportunities for all qualified young Americans in the health fields and an adequate supply of well-trained medical manpower. Health services are delivered to individuals and society by a vast array of trained people and we would emphasize the desirability of supporting all the schools of the health professions. In this broader context, an adequate number of properly qualified physicians is of central importance and we should not lose sight of the level of responsibility each of the types of schools carry for the public welfare. . We think it is very wise to authorize “such sums as may be necessary” for each title of the Act and for Congress each year to decide how much of the available federal resources to allocate to these purposes. We recognize the fact that other 110 national needs restrain the amount than can be invested in these programs at the present time. The Congress and the public undoubtedly realize that the Academic Medical Centers can increase their output of physicians, trained specialists, trained in- vestigators, allied health professionals trained in medical centers, research and service to patients and communities only to the extent they are provided financial support. CONSTRUCTION GRANTS We think it is wise to extend the programs for four years because of the length of time it takes for institutions to develop optimal plans for these complex facilities and to arrange for local matching funds. The provision authorizing a school to make all applications to the Health Professions Education Act construction program for the construction of facilities which are to a substantial extent for teaching purposes but are also for health research purposes or medical library purposes is, in our opinion, sound, indeed almost necessary. Health professional schools typically design and use facilities for these interrelated purposes and, from time to time, reassign rooms or whole sections of buildings among these purposes. We assume that it is intended that clinical facilities justified as essential to the eligible educational programs will continue to be eligible-as they have been in the Health Professions Educational Act and consider this very important. We also think it highly desirable that, as provided in this legislation, the facilities be available for graduate, continuation, and other advanced training activities as well as that attributable specifically to the training of persons in the first professional degree programs. The restrictions which have excluded these necessary functions have constituted undesirable and artificial barriers. We hope Congress will make these amendments effective beginning in Fiscal Year 1969, because they will make it possible to use the funds to be appropriated more effectively. INSTITUTIONAL GRANTS (FORMULA) We believe the formula proposed in the legislation is an appropriate one. It gives credit for all full-time students with twice as much credit for each student in the increase in enrollment as for other full-time students and includes a fac- tor for the number of graduates. These represent desirable improvements, but it seems important to emphasize that even with an improved formula, what can be accomplished will be limited by the amount of funds actually made available. Unfortunately, the funds appropriate for the present legislation have not been sufficient to pay the full amount authorized by the present legislation. The medi- cal schools of this country have responded to the existing legislation and have expanded their enrollments of entering students and have been severely dis- appointed that the Congress did not appropriate as much as its own legislation authorized. The Association of American Medical Colleges has somewhat mixed feelings about the expansion of enrollment as a condition for receiving a formula grant. On the one hand, expansion of enrollment is so clearly desirable that steps in that direction are in the public interest. Relating expansion to the average first- year enrollment for a five-year period is more desirable than relating it to the highest enrollment in a five-year period, as the present legislation requires. We consider it desirable that the Secretary, after consultation with the Advisory Council, have the authority to grant a waiver for this requirement, if that waiver is in the public interest and consistent with the purposes of this part of the legis- lation. On the other hand, the ability of medical schools and other schools in the health professions to respond to the clear intent of Congress and the needs of society by expanding enrollment has been severely restricted by the limitation on funds for this purpose. This legislation authorizes the appropriation of “such sums as may be necessary”. For our joint efforts to meet the needs of the public to be successful, we are convinced that these institutional grants must come to cover a reasonable portion of the educational costs of the institutions. The basic improvement grants of the present legislation would cover approximately 10- percent of the educational cost of medical schools if they had been fully funded. Medical schools do not have the resources with which to meet a large percent of the costs of much larger enrollments. 111 SPECIAL PROJECT GRANTS We believe the proposals in this section of the legislation are entirely sound in concept. The authority to support planning special projects to accomplish the important purposes of this section is expecially important. The eligible schools will be far better able to meet the future needs of society if they can develop competence for orderly and continuing analysis and planning of programs. They will need special funds to initiate and probably to continue this activity. The sound way to achieve expansion of enrollment without sacrifice of quality is for institutions to develop plans, receive support that is tailored to their own needs and have the time to carry out those plans. We also hope Congress will make this section effective in Fiscal Year 1969, because it will make possible more effective use of the funds available. HEALTH PROFESSIONS STUDENT LOANS We believe it is desirable to postpone the mandatory repayment of these loans for up to three years service of VISTA volunteers and up to five years for ad- vanced professional training including residencies, and we think that the au- thority for the institution to transfer to its scholarship fund up to 20-percent of the total funds paid to it for its loan fund is highly desirable. We believe the need for scholarships is relatively greater than that for loan funds, partly be- cause many medical students are already in debt for their college education by the time they enter medical schools and too large a debt burden limits the opportunity a young physician has to enter public service or to serve economically disadvantaged members of society. HEALTH PROFESSIONS STUDENT SCHOLARSHIPS We believe the added flexibility of authorizing the school to transfer up to 20-percent of the amount paid to it for scholarships to its student loan fund is desirable, although we do not believe this authority will be extensively used because in most institutions the need for scholarships far exceeds the supply. We consider the clarifying amendments as quite helpful. We strongly support the purposes of Title INURSE TRAINING and Title III—ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH TRAINING— and would emphasize the very great importance of an adequate supply of well- trained people in these fields and stable and productive educational programs to that end. Colleagues in those professions are more competent to speak to the details of these Titles. TITLE IV-—HEALTH RESEARCH FACILITIES We believe it is desirable to extend this program for four years because of the length of time it takes an institution to plan these facilities and obtain local matching funds. We think it is in the public interest to authorize a federal share of up to 66%-percent of the projects falling within the class or classes determined by the Secretary to have special national or regional significance, but we also approve of the safeguard of providing that no more than 25-percent of the funds appropriated for a fiscal year for this program be available for those projects, In conclusion, the Association of American Medical Colleges fully supports the Health Manpower Act of 1968 (S. 3095) as providing a sound pattern for the support of an expanded educational capacity which can, eventually, provide an educational opportunity for all qualified young Americans in the health fields and an adequate supply of trained health manpower to meet the health needs of society. We urge Congress to act favorably on this legislation and to make the provisions for construction, special project grants, student scholar- ships and loans of Title I and all of Title IV—Health Research Facilities— effective beginning in Fiscal Year 1969. The Cramman. Dr. Berson, is there anything you woud like add? Dr. Berson. Senator Hill, I would like to make three points. The first one is that Senator Yarborough’s questions about the number of graduates and their increases and decreases in relation to the popula- tion deals with the aspects of the supply-demand situation on which the AAMC has done a lot of of arithmetic on for a long time. We have 112 rather recently come to the decision that a far more important focus for national goals would be on educational opportunity in the health professions. This is a very large goal, because at the present time, we are not close to having the educational capacity. But we think that is the appropriate goal so that every qualified young American can have an educational opportunity in the health fields, and if so, we think we will move toward an adequate supply of the profes- sionals. The second point I would like to make is to emphasize some- thing that I know you understand full well, and I hope all the Con- gress and the public understand. That is the urgency of expanding this educational capacity and getting the end product so that we can meet the demand. There is a long lag, from the time you begin to plan expansion or plan a new school until you get the final output. Under very difficult circumstances, of course, decisions have to be made about the allocation of Federal resources. But if resources cannot be allo- cated in adequate amounts to this area, then that day when we can meet the desirable national goals will be further deferred. Finally, I want to emphasize the appreciation, understanding and admiration, that everybody in medical education has, for all you and your committee have done over the years in this field. We think that moving to this omnibus approach for health manpower will take its place as another signal improvement in the legislative approach to these important problems. The Carman. Thank you, Doctor. Is there anything you would like to add, Dr. Hubbard? Dr. Husearp. Nothing more, thank you. The Caamman. And you brought us some very good testimony. We certainly appreciate it very much. If anything else occurs to you, drop us a line and we will be glad to include it in the record. Dr. Hussarp. Thank you. The CrairmaN. Now we hear from the American Nurses Associa- tion, Dr. Evelyn Cohelan, chairman of the Committee on Legislation, Baltimore, Md. You have two medical schools in Maryland, Johns Hopkins Uni- versity and the University of Maryland. STATEMENT OF DR. EVELYN COHELAN, CHAIRMAN, COMMITTEE ON LEGISLATION, AMERICAN NURSES’ ASSOCIATION; ACCOM- PANIED BY MISS HELEN CONNORS, DIRECTOR OF GOVERNMENT RELATIONS Dr. Conrran. That is right, Senator. The Cmamrman. And the University of Maryland Dental School is about the oldest in the country, is it not? Dr. Conrran. I believe it is. The Camara. Their graduates have been very outstanding. Dr. Comeran. Mr. Chairman, I am accompanied today by Miss Helen Connors, who is director of government relations with the American Nurses’ Association. She is down from New York. I would like to have the privilege of referring some questions to her at times, if need be. 113 The Caatrman. That is all right. You are from the big city of New York? Miss CoNNoRs. Yes. Dr. Coneran. I am Dr. Evelyn Cohelan, professor of psychiatric nursing, and head, Department of Psychiatric Nursing, University of Maryland. I might add that I am also chairman of the graduate program in nursing at the University. I am the chairman of the Committee on Legislation of the American Nurses’ Association, the professional organization of 200,000 regis- tered nurses in 54 constituent associations, the District of Columbia, Puerto Rico, the Virgin Islands, and the Canal Zone. The Association’s ultimate purpose is to secure for the people of this country the best possible nursing care. One commitment is to elevate the standards of nursing education to insure nursing practice of high quality. I welcome this opportunity to appear here today on behalf of the American Nurses’ Association to present its views on S. 3095, the Health Manpower Act of 1968. We support assistance to the various schools preparing health personnel in the bill. However, our special concern 1s with title IT, nurse training, which would extend for 4 more years the Nurse Training Act of 1964. We urge the continuation of the construction grant program for 4 more years. Since the program began in fiscal year 1966, 80 schools have received grants. Much of the construction is in the beginning stage but close to 2,700 new first year places will result. Many of the grants were awarded for replacement of obsolete facilities and for minor expansion. These have permitted the maintenance of over 12,- 000 student places that otherwise might have been lost. If I could interject a personal note at this point, Senator. We re- ceived funds to build a new school of nursing building at the Univer- sity of Maryland. To point up the need for new construction, we had 11 offices available for a faculty of something over 70. In my depart- ment, 26 faculty have four offices, which means that faculty have had to see students at home and have had to use broom closets and what- ever was available in the hospitals in which they were located. So, the shortage is extremely severe. The Program Review Committee on the Nurse Training Act noted that many programs are still located in makeshift quarters such as barracks, dormitories and basement areas that are unsafe and poorly ventilated. Until such facilities are replaced, schools cannot expand enrollments. Students are inclined to select attractive schools and fac- ulty choose schools with modern equipment that permits more effective teaching. We support the inclusion in the construction project of space for advanced training activities such as continuing education that is not degree-oriented. Continuing education is a great imperative in this time of rapid change in medical and nursing practice. There isa heavy burden on the individual practitioner to keep current and on the em- ployers of nurses to develop the most economical and effective means of bringing and keeping nursing service personnel up to date. Im- proved utilization of scarce health manpower cannot be accomplished 114 without changes in traditional functions and organizational patterns and change will only occur through new learning. Research and innovation in the delivery of nursing services must be supported and implemented through comprehensive programs of job orientation and inservice education. In addition to increasing the future supply of nurse manpower, equal attention has to be given to improving the knowledge, skills, and abilities of our present nurse manpower pool. We support the continuation of the special project grants to assist schools to strengthen, improve and expand nursing education. One hundred sixteen grants have been awarded to 95 schools with an additional 143 programs sharing in the projects with benefits reach- ing over 33,000 students. . 3095 would expand the present program to permit any public or nonprofit private agency, organization or institution to apply for a grant that would contribute to the strengthening and improve- ment of nursing education. We urge this committee to approve this expansion of the project grant program. The American Nurses’ Association endorses the principle of basic support grants to schools of nursing. It is increasingly difficult for institutions to meet the costs of education since tuition in many insti- tutions provides only a quarter of the cost of the education. We wish to point out that the baccalaureate programs have the higher average enrollment since four or five classes of students are using the facilities simultaneously compared to two and three classes in the associate and diploma programs, respectively. We believe, there- fore, that priority should be given to the baccalaureate programs because of the strain put on the faculty and other institutional resources to support these large enrollments. The professional nurse traineeship program was first established under the Health Amendments Act oF 1956 and provided financial assistance to nurses preparing for positions in teaching, supervision and administration. It was extended in 1959 and again in 1964. Dur- ing the years 1957-66, 16,162 nurses were awarded traineeships. Al- though this program has increased the number of nurses with graduate degress, the need is still great. I would also like to interject a personal comment at this point. The public funds under which I was trained were the ones available under the National Mental Health Act. These funds were available con- siderably before the funds that I am describing here. The CHAIRMAN. Yes, we passed that Dr. Corrran. Well, my personal observation is that I would not be back in nursing today had it not been for those funds. From the years 1950 to 1953, I earned a bachelor’s degree, did a year of field work, and earned a master’s degree. The funds available allowed me to be a full-time student and to allow the children and the house to be taken care of in my absence. The fact that a number of deans of larger schools of nursing today have a background in psychiatric nursing, I think, is attributable to the fact that these wim were made available for that group of nurses very early. So I think you cannot underestimate the importance of the funds that have been made available by Congress. The CaamrMaN. Thank you. 115 Dr. Conrran. The responsibilities of those who serve in positions in teaching, supervision, and administration in nursing and as clinical nursing specialists are such as to require advanced preparation at least at the master’s level. Sound programs of nursing education can- not be developed without, qualified teachers. Quality nursing service cannot be provided for the people of this country unless we have suffi- cient numbers of well-prepared supervisors and administrators. From where I sit as chairman of the graduate nursing program, how we prepare faculty for positions in schools of nursing, this is a matter of great importance. During the summer, we are modifying our mas- ter’s program in order to allow faculty in junior colleges to come for study, because it is difficult for them to leave their positions during the school year. My statement is available, and I think I need not read all of it. The Crairman. We will have it appear in full in the record. Dr. Conrran. Then I shall skip to page 6, line 119. In 1964 when the traineeship program was extended, it provided for expansion to include financial grants for assistance to nurses seeking preparation as clinical specialists. The nurse clinician is a master prac- titioner. She may, for example, be a nurse midwife, a psychiatric nurse, the expert in cardiopulmonary nursing, or in the care of the chronically ill. To become such a practitioner in so broad a field as nursing requires concentrated study at the graduate level in the se- lected area, Once prepared, this nurse uses her specialist’s competence in providing direct care to patients needing expert nursing. She col- laborates with the physician in planning and providing patient care and works with and teaches other nursing personnel during the pro- vision of nursing care and treatment. She may teach in schools of nursing and in programs of continuing education. She conducts and participates in clinical research. Highly qualified expert nurses to prac- tice in specialized areas of nursing are essential to improvement in the quality of care. I might add that there is a tremendous demand from physicians for this kind of prepared practitioner. The salaries for clinical specialists are increasing as further indication of their importance. To pursue a doctoral program in nursing requires a large expendi- ture of money for tuition, books, and suppl ies, and maintenance over at least a 3-year period. Nurses engaged mn doctoral work have been previously employed, hence have loss of income during the 3 years of study. As a typical example: TION LOT 2 ACAAOINIC: FOUTS... sisi somos sm sito fs eos ii gn Si a 5.000 BOOKS GNI SUDDHES TOI 3 NCR ce cc ss es sess so it sm ss i gs vs so el oe seis so apis Living expenses for 3 years (2 academic years and 1 year of work on dis- BOLLATIONY me ms os so sie hs sms sm i i la le i i me 9, 000 OER) ruminal mim as mi i i i a 13, 400 Loss of income for 3 years (minimal) _________________________________ 26, 000 We support the recommendation of the Program Review Commit- tee of the Nurse Training Act that administrative policy regarding duration of support under the traineeship program be ns per- mit completion of program requirements. Section 231 of S. 3095 proposes a change in the definition of accred- itation. The authority of the Commissioner of Education to directly accredit programs of nursing education is deleted, which we approve. 116 However, a State agency would be specifically named as a body the Commissioner could approve for purposes of accrediting nursing pro- grams. We have grave concern about this proposal. The CaaRMAN. And you question this, do you? Dr. Coneran. Yes, we question it. We would ask the question, what State agency, and will the State agency accept established Federal criteria ? The American Nurses’ Association believes that certain safeguards are essential to insure the best use of the Federal funds that S. 3095 would make available. It is most important that only nursing pro- grams accredited by—or having a reasonable assurance of accredita- tion—a recognized national accrediting body be eligible to apply for funds under the act. Evaluation and accreditation of professional programs, made by competent members of the particular profession, gives the best as- surance that the educational program will produce competent prac- titioners and that the public, recipients of the professional services, will be well served. All schools of nursing must have State approval. For over 60 years, nurses have worked for the enactment of nursing practice legislation as the most effective, expedient means of establishing and maintaining at least minimum standards for the preparation of nurses. But legal standards for nursing are minimal and they vary from State to State just as standards for general education vary. Had nurses been satisfied that legal standards were sufficient to insure not only a safe practitioner but a highly competent one, there would have been no movement toward national voluntary accredita- tion. But the need for standards above and beyond those required by law was recognized by the profession itself. The ANA urges, therefore, that you not add the clause “or by a State agency” to the language of the act. I believe there will be further testimony here from the National League for Nursing, and American Nursing Association supports the league accreditation. The CuAIRMAN. Supports its position ? Dr. Conrran. Right. (The prepared statement of Dr. Cohelan follows :) PREPARED STATEMENT OF DR. EVELYN COHELAN, PROFESSOR OF PSYCHIATRIC NURS- ING, AND HEAD, DEPARTMENT OF PSYCHIATRIC NURSING, UNIVERSITY OF MARY- LAND, ON BEHALF OF AMERICAN NURSES’ ASSOCIATION I am Doctor Evelyn Cohelan, Professor of Psychiatric Nursing and Head, Department of Psychiatric Nursing, University of Maryland. I am the Chairman of the Committee on Legislation of the American Nurses’ Association, the profes- sional organization of 200,000 registered nurses in 54 constituent associations, the District of Columbia, Puerto Rico, the Virgin Islands and the Canal Zone. The Association’s ultimate purpose is to secure for the people of this country the best possible nursing care. One commitment is to elevate the standards of nursing education to insure nursing practice of high quality. I welcome this opportunity to appear here today on behalf of the American Nurses’ Association to present its views on S. 3095, the Health Manpower Act of 1968. We support assistance to the various schools preparing health personnel in the bill. However, our special concern is with Title II, Nurse Training, which would extend for four more years the Nurse Training Act of 1964. Title IT of 'S. 3095 would continue the construction grant program for schools of nursing, extend the professional nurse traineeship program and the scholar- 117 ship and loan program for nursing students. Special project grants would be available to public or nonprofit private agencies, organizations or institutions to plan, develop or modify existing programs in nursing education and assist schools of nursing to meet accreditation standards. A new program of institu- tional grants to help all schools meet the cost of nursing education would be authorized. CONSTRUCTION GRANTS We urge the continuation of the construction grant program for four more years. Since the program began in fiscal year 1966, 80 schools have received grants. Much of the construction is in the beginning stage but close to 2,700 new first year places will result. Many of the grants were awarded for replace- ment of obsolete facilities and for minor expansion. These have permitted the maintenance of over 12,000 student places that otherwise might have been lost. The Program Review Committee on the Nurse Training Act noted that many programs are still located in makeshift quarters such as barracks, dormitories and basement areas that are unsafe and poorly ventilated. Until such facilities are replaced schools cannot expand enrollments. Students are inclined to select attractive schools and faculty choose schools with modern equipment that per- mits more effective teaching. We support the inclusion in the construction project of space for advanced training activities such as continuing education that is not degree-oriented. Con- tinuing education is a great imperative in this time of rapid change in medical and nursing practice. There is a heavy burden on the individual practitioner to keep current and on the employers of nurses to develop the most economical and effective means of bringing and keeping nursing service personnel up to date. Improved utilization of scarce health manpower cannot be accomplished with- out changes in traditional functions and organizational patterns and change will only occur through new learning. Research and innovation in the delivery of nursing services must be supported and implemented through comprehensive programs of job orientation and fin- service education. In addition to increasing the future supply of nurse man- power, equal attention has to be given to improving the knowledge, skills, and abilities of our present nurse manpower pool. SPECIAL PROJECT GRANTS We support the continuation of the special project grants to assist schools to strengthen, improve and expand nursing education. One hundred sixteen grants have been awarded to 95 schools with an additional 143 programs sharing in the projects with benefits reaching over 33,000 students. S. 3095 would expand the present program to permit any public or nonprofit private agency, organization or institution to apply for a grant that would con- tribute to the strengthening and improvement of nursing education. We urge this Committee to approve this expansion of the project grant program. INSTITUTIONAL GRANTS The American Nurses’ Association endorses the principle of basic support grants to schools of nursing. It is increasingly difficult for institutions to meet the costs of education since tuition in many institutions provides only a quarter of the cost of the education. We wish to point out that the baccalaureate programs have the higher average enrollment since four or five classes of students are using the facilities simultane- ously compared to two and three classes in the associate and diploma programs, respectively. We believe, therefore, that priority should be given to the bac- calaureate programs because of the strain put on the faculty and other insti- tutional resources to support these large enrollments. TRAINEESHIPS FOR ADVANCED TRAINING OF PROFESSIONAL NURSES The professional nurse traineeship program was first established under the Health Amendments Act of 1956 and provided financial assistance to nurses preparing for positions in teaching, supervision and administration. It was ex- tended in 1959 and again in 1964. During the years 1957-1966, 16,162 nurses were awarded traineeships. Although this program has increased the number of nurses with graduate degrees, the need is still great. 118 The responsibilities of those who serve in positions in teaching, supervision and administration in nursing and as clinical nursing specialists are such as to require advanced preparation at least at the master’s level. Sound programs of nursing education cannot be developed without qualified teachers. Quality nurs- ing service cannot be provided for the people of this country unless we have sufficient numbers of well prepared supervisors and administrators. In all nursing education programs, as in all programs of higher education, the faculty should hold graduate degrees. Therefore, it is startling to con- sider the preparation of those presently teaching in all types of schools of nurs- ing. Only 42.89% of current full-time faculty members in senior and junior colleges, and in hospital schools have graduate degrees. Graduate ~~ Baccalaureate No degree degree degree Collegiate sthools. - «coc. comarca nisms iran ssn sin neva 86.8 2.9 0.3 Junior colleges... ._ 69.7 28.4 1.9 HOS PRAESONOOIS . «iv snes ssssinminmossinmnsmemenssnssermnmmnssnsn 18.8 55.6 25.6 Practical nursing schools... 1,1 44.3 44.6 Obviously, it is impossible for schools to prepare nurses to give the quality of nursing care society needs and expects today when so many who mold future practitioners have only basic nursing preparation. In addition to our concerns about the quality of faculty in schools of nursing, we face the acute problem of shortage of personnel to fill these positions. There are 1,744 vacancies in full-time budgeted faculty positions in all schools prepar- ing nurse practitioners. We urge the extension of the traineeship program so that the preparation of nurse teachers can continue without interruption. The quality of nursing practice is improved or deterred by the organizational framework in which the nurse practitioner functions. Effective nursing service administration and supervision fosters a safe, efficient and therapeutic level of nursing care. Such administration and supervision is dependent upon fa- miliarity with a body of knowledge based on sound principles that can be applied in nursing service situations. To be expert requires the thorough study that is possible only at the graduate level. Basic programs prepare practitioners for beginning positions in nursing and not for administration. At this time, the edu- cational attainment of persons holding positions as supervisors and administra- tors in nursing services has by no means reached the level the profession deems desirable as will be seen from the following data collected for all hospitals and related institutions. Graduate Baccalaureate No degree degree degree Directors.and Assistant DITetlors. ..... ...c...c. coats cutivennsmaninnon 11.9 30.4 51.7 HR a. A PL 2.6 18.7 78.7 If we are to raise the level of education of nurses functioning in the critical areas of supervision and administration and fill the vacancies which still per- sist, it is imperative that the Congress continue the professional nurse trainee- ship program it initiated in 1956. In 1964 when the traineeship program was extended, it provided for expansion to include financial grants for assistance to nurses seeking preparation as clini- cal specialists. The nurse clinician is a master practitioner. She may, for exam- ple, be a nurse midwife, a psychiatric nurse, the expert in cardiopulmonary nursing or in the care of the chronically ill. To become such a practitioner in so broad a field as nursing requires concentrated study at the graduate level in the selected area. Once prepared, this nurse uses her specialist’s competence in providing direct care to patients needing expert nursing. She collaborates with the physician in planning and providing patient care and works and teaches other nursing personnel during the provision of nursing care and treatment. She may teach in schools of nursing and in programs of continuing education. 119 She conducts and participates in clinical research. Highly qualified expert nurses to practice in specialized areas of nursing are essential to improvement in the quality of care. To pursue a doctoral program in nursing requires a large ex- penditure of money for tuition, books and supplies, and maintenance over at least a three-year period. Nurses engaged in doctoral work have been previously employed, hence have loss of income during the three years of study. As a typi- cal example : Tuition for two Academic FORTS cm ee eee eee emer $3, 800 Books and supplies for three years___________________________________ 600 Living expenses for three years (two academic years and one year of WOK OI AISSBIEITIONY oc ces om i mistimiit mtimino n i i ri 9 Si 9, 000 TORE mi rem min me or SR Sm SE SR HS a 13, 400 Loss of income for three years (minimal). ____________________________ 26, 000 We support the recommendation of the Program Review Committee of the Nurse Training Act that administrative policy regarding duration of support under the traineeship program be changed to permit completion of program requirements. DEFINITION OF ACCREDITATIONS Section 231 of S. 3095 proposes a change in the definition of accreditation. The authority of the Commissioner of Education to directly accredit programs of nursing education is deleted, which we approve. However, a state agency would be specifically named as a body the Commissioner could approve for purposes of accrediting nursing programs. We have grave concern about this proposal. The American Nurses’ Association believes that certain safeguards are essen- tial to insure the best use of the federal funds that S. 3095 would make avail- able. It is most important that only nursing programs accredited by—or having a reasonable assurance of accreditation—a recognized national accrediting body be eligible to apply for funds under the Act. Evaluation and accreditation of professional programs, made by competent members of the particular profession, gives the best assurance that the educa- tional program will produce competent practitioners and that the public, recipi- ents of the professional services, will be well served. All schools of nursing must have state approval. For over 60 years, nurses have worked for the enactment of nursing practice legislation as the most effective, expedient means of establishing and maintaining at least minimum standards for the preparation of nurses. But legal standards for nursing are minimal and they vary from state to state just as standards for general education vary. Had nurses been satisfied that legal standards were sufficient to insure not only a safe practitioner but a highly competent one, there would have been no movement toward national voluntary accreditation. But the need for standards above and beyond those required by law was recognized by the profession itself. The ANA urges, therefore, that you not add the clause “or by a state agency” to the language of the Act. I thank the Committee for this opportunity to appear and present the views of the American Nurses’ Association. The CuaIRMAN. Is there anything you would like to add? Miss Connors. I would like to add here that there has been some concern about the strictness of the licensing laws in the States. We consider that the State licensing laws at this point are quite weak. For example, Senator Yarborough, in the State of Texas, a nurse does not really have to be licensed at all to practice. The law is per- missive. If she wants to take the licensing examination to become reg- istered, she may. But she really does not have to. Senator YArrorouGH. She cannot wear that badge without it, can she? Miss Connors. Well, that is a status symbol and, actually, we are far more concerned that she qualify for practice than that she get a title. 120 Senator YarBoroucH. Let me explain what I was referring to. I was not referring to the accreditation laws, to the licensing of individual nurses. I was referring to the accreditation of schools. The problem we had when this bill was first up was that the National Nurses’ Orga- nization would not accredit schools to train nurses. I was never talking about the individual licensing of nurses; I was talking solely about the accreditation of whole educational institutions. The association has re- fused to recognize institutions, colleges, for the training of nurses, or accept that training as a basis upon which to grant licensing of the in- dividual nurses. That was the problem we had some considerable dispute about before. That is why the provision was put in the law for the Secretary of HEW to accredit schools. We did not attempt at that time to go, as I recall, into individual licensing. Better the matter to be left to the States. But the Nurses’ Association and the Medical Association, and many others expressed apprehension or fear that if the Secretary of Health, Education, and Welfare was given authority to accredit the schools for this purpose, then that would be the foot in the door that you hear so much about, this omnipotent Federal power that reaches fingers into the lives of all of us, and that sort of things. We had schools there, we had grants, we had young women wanting to go to these schools. They had registered nurses ready to teach, and the national organization declined. They disputed it. Their position was that it was solely a fee matter. You had to pay a fee that had to be paid before you could be accredited. I do not know if it was that nebulous or not, but I did want it clear that T did not raise this question about the individual licensing of nurses. Miss Connors. The reason I raised it is because you brought up the matter of the medical corpsmen not being able to practice. In the State of Texas, the corpsmen would be able to be employed, because no one who nurses is really required to have a license. Senator YarsoroucH. Well, the hospitals can write their own regu- lations, now. They can just refuse to let them in there. Miss Connors. That 1s right. Senator Yarsorouen. Each hospital writes its own rules and then they do not have to let them in. But, actually, they are letting sitters in. They do not give them status, but they are so short of nurses they can- not even get the so-called practical nurses, whatever status they may have. Miss Connors. I think it is true that Texas has always had an in- sufficient number of nurses. I think you are developing a great many more schools in Texas that have that quality. Senator YarsoroucH. I want to commend your association on seek- ing more nurses and better qualified nurses. I do not seek to break down the standards. We need a greater supply of nurses, and I think that is why the Federal Government has moved in with the money to help build the schools. We need registered nurses. How many registered nurses do you estimate we need to supply the needs of the country ? Miss Connors. Well, according to recent figures, it is estimated that by 1975, 1 million practicing registered nurses will be needed. Senator YareBoroucH. And you have 200,000 now ? 121 Miss Connors. We have 640,000 nurses practicing. Senator YarsoroueH. Is there not an estimate that you need 200,000 more ? Ob, you have 200,000 registered nurses—you mean there are more? Miss Connors. Our membership is 200,000. Senator YarsorouaH. How many are there in all? Miss Connors. Well, there are probably close to a million nurses who hold a license to practice. There are 650,000 practicing, many on a part-time basis, however. Senator YareoroucH. How many are there that could be qualified that belong to your professional organization ? Miss Connors. Any nurse who is licensed may belong to the ANA. Senator YareBorouaH. Are there practical nurses? Miss Connors. No, I mean a registered nurse. Senator Yareorouc. How many registered nurses do you think there are in the country now? Miss Connors. Close to a million. Senator YarsoroucH. I do not mean former registered nurses who are married and no longer working in the profession. Miss Connors. Approximately 650,000 in practice. Senator Yarsoroucr. And you need a million by 19757 Miss Connors. That is an estimate. Senator Yarsorouar. Well, if you do not need a million until 1975, vou would estimate that you have almost enough, do you not ? Because, by 1975, with the increasing affluence of people and medical care already operative, you are going to need a larger number of nurses than you need now. They tell me that you just cannot hire a regis- tered nurse now to work on private cases any more. They are just not there. They are administering hospitals, they are X-ray technicians, or they have special duties that pay much more than your registered nurse gets, Miss Coxyors. IT think the private practitioner of nursing is going out of existence. This has been true, though, for many, many years, the decrease in the number of private practitioners among nurses. Senator Yarsorouen. I know there is a vast shortage in my State of registered nurses who would be paid the registered nurse's fee if people could get them. Have you included that demand for registered nurses in your estimate of 1 million for 1975? Have you estimated for public places and hospitals only, or have you included there any pri- vate practitioners? y Miss Connors. This would include all, but we do have to recognize that the private practice of nursing does not seem to be attracting many young graduates. Senator Yarsorouar. Well, I agree that the young graduate prob- ably would rather go into a hospital, but there is a demand, and 1f the pay is high enough, the nurses would have employment. It is attractive pay. It may not be attractive work, out in private employment, but it 1s attractive pay. What does the registered nurse draw for a certain number of hours? Miss Connors. I do not know. } Senator YareorouGH. It pays better than school work or secretaries, does it not ? . Miss Connors. There are a lot of other problems in relation to pri- rate practice, though. For example, there are no fringe benefits, there 92-079—68——9 122 is no pension, no sick leave, no vacation time. And I think in our so- ciety, people going to work, even nurses who may be committed, look for these kinds of benefits. This is not the case with the private practitioner. Senator YarBorouGH. In other words, it is a harder life. Miss Connors. I think so. Senator YarsoroueH. Mr. Chairman, in the interest of time, I will forgo any further questions. I will read every word of Dr. Cohelan’s statement, however. The Cuamrman. Is there anything you would like to add? Dr. Coneran. I would like to make one statement about the accred- itation procedure. I taught at the University of California before I came to Washington and I have been at the University of Maryland for 10 years. During this period of time, I have had an opportunity to see what it means to have the league responsible for the accredita- tion procedure. They set forth criteria which are used by schools of nursing as guidelines, and consultation is available. What we have embodied in the league in this big city of New York is basically the best brains of the country in terms of nursing education. So it has been a real asset to schools across the country to have avail- able this service. This is based on personal observation. The Cramrman. I might say I have here a telegram from Miss Bar- bara Mickelson, the president of the National Student Nurses Asso- ciation in New York. Do you know her? Dr. Conerax. I donot know her. Miss Connors. I know of her. The office of the Student Nurses Asso- ciation is in New York; she is from South Dakota. I shall put this telegram, without objection, in the record at this point. It strongly supports the passage of the bill, S. 3095. (The telegram referred to above follows :) New York, N.XY., March 19, 1968. For hearing on S. 3095 by Senate Committee on Labor & Public Welfare, March 20, 1968. Senator Lister HiLL, Chairman, Committee on Labor & Public Welfare, Senate Office Building, Washington, D.C.: The National Student Nurses’ Association supports the Health Manpower Act and the extension of current programs relating to the training of nurses and allied health professional personnel. Many of our members are able to continue our nursing education programs because of funds provided by Nurse Training Act and other legislation which we hope will be extended by passage of S. 30953. With critical need for more young people in the health profession, particularly young men and women from the minority groups within American society, this bill will be a needed step in efforts to help the United States keep pace with the needs of present and future. The people of a nation are its greatest re- source and we believe that health is a basic human right which can only be achieved and maintained by constantly improving the education of the profes- sionals who give health care. We urge that all educational programs receiving Federal funds be nationally accredited by national league for nursing and we hope that you will delete from present bill the provision for a state agency to accredit. BARBARA MICKELSON, President, National Student Nurses Association. The Carman. I want to thank you all very much. Now, the National League for Nursing; Miss I.. Ann Conley of Detroit, Mich. X 123 STATEMENT OF MISS L. ANN CONLEY, PRESIDENT, NATIONAL LEAGUE FOR NURSING, DETROIT, MICH.; ACCOMPANIED BY DR. MARGARET HARTY, DIRECTOR, NURSING EDUCATION PRO- GRAMS, NATIONAL LEAGUE FOR NURSING Miss Convey. Sir; I am L. Ann Conley, professor at Wayne State University College of Nursing in Detroit. I am pleased to testify today on S. 3095—Health Manpower Act of 1968—on behalf of the National League for Nursing, which I serve as president. My organization favors the bill. : I have with me a member of the staff of NLN, Dr. Margaret Harty, to my right. She is here to provide additional information as needed. In addition, back here is Col. Inez Haynes, the NLN general director, who is also available, sir; if you wish to get information from her. The National League for Nursing is a nonprofit voluntary organiza- tion founded in 1952 to foster the development and improvement of nursing education and nursing service. Its varied membership— nurses, allied health workers, private citizens, health agencies, and schools of nursing—works together to promote quality nursing care. A fuller description of NLN is appended to this statement for the record as exhibit I. The Cramrman. We will have that appear in the record. Miss Convey. We are directly concerned with the goals set forth in the 1968 act and heartily endorse the intent to guarantee health, safety, and good medical care to all Americans. We support, in particular, title IT of the act, “Nurse Training.” We point specifically to several provisions not included in the Nurse Training Act of 1964. We favor, first, the extension of grants to institutions or agencies to help plan or develop nursing education programs; section 211. We favor, second, the inclusion of all three types of nursing schools—associate degree and baccalaureate in addition to diploma— under the construction grants of section 211. Our only concern here is that the new grant formula not penalize those diploma schools of nursing in which enrollments are decreasing. This is happening in some 3-year schools as well as in those which are shortening their programs and thus have fewer students to count. During the last academic year, however, 72 percent of the gradu- ating nurses were from diploma programs (exhibit IT). The Crramryman. We will have that exhibit appear in the record fol- lowing your remarks. Miss Convey. Thank you. Despite decreasing enrollments, accredited diploma schools will need continuing assistance for some time to come to make their needed con- tribution to the nurse supply. We favor, third, the removal of the statutory ceiling on formula grants, special project improvement grants, section 211; and nurse teacher traineeships, section 221; and the increase in maximum annual loans to students, together with the more liberal provisions for the sancellation of those loans, section 222. My organization must, however, respectfully object to the insertion of the phrase “or by a State agency,” in part D, “Definition of Aceredi- tation,” section 231. We raise our objection for two reasons: 124 First, the specific meaning of “State agency” is unclear and could conceivably refer either to a State board of education, State board of nursing, or other State agency; and Second, standards set by such State agencies as boards of nursing vary widely from State to State; these standards are, in any case, aimed at minimum acceptable achievement rather than at excellence in educational preparation. In raising this objection, Mr. Chairman, I am speaking particularly for the 1,027 schools of nursing included in the membership of the National League for Nursing. I am also strongly endorsing the testi- mony of the American Nurses’ Association in its support of national accreditation as the basis on which nursing education programs should be declared eligible to receive Federal funds under the Health Man- power Act of 1968. These 1,027 schools, representing every constituency in the United States, have joined together voluntarily through the mechanism of the National League for “Nursing to improve nursing education so that patient care services will reflect the best that nursing can offer. In so doing, they conduct a continuing program to improve nursing educa- tion across the country—to help “schools of nursing meet and maintain high standards. The nursing school members of our organization participate in vol- untary accreditation through the league as one means of improving their own education programs and, at the same time, stimulating all schools to similar self-improvement efforts. Their belief in accreditation is not limited to nursing education. They are applying what the former executive director of the National Commission on Accrediting, William K. Selden, has described as a “call for imagination and enlightened initiative in the establishment, and enforcement of academic standards * * *.71 In doing so, nursing schools assume responsibility for self-evalua- tion and voluntarily submit themselves to judgment by their peers. Standards of educational excellence are developed and maintained in this way by most professions which deal with human life and welfare— medicine, dentistry, et cetera, as well as nursing. Voluntary national accreditation, then, Mr. Chairman, is nursing education’s response to its own challenge—to provide the best possible nursing education in this country, aiming ultimately only at high quality in patient care. We feel certain that the infent behind the resent bill is the same. We believe that the purposes of the proposed fain can best be accomplished by making Federal funds avail- able only to those schools which are alread meeting, or show promise of meeting, standards of excellence they, themselves, have determined to be reasonable and universally attaina fe. Before Senator Yarborough leaves the room, may I encourage him by telling him as an aside that 21 of the schools in Texas has met full accreditation and the situation is improving constantly in Texas. Senator YarBoroucH. Pardon me, I am sorry I did not hear that. I have been talking with Dr. Price of Texas A. & M. University. He is to testify here today, but I am afraid I will miss him since those three bells signify that I must go to the floor for a vote. 1 Selden, William K., “Accreditation—The Struggle Over Standards in Higher Educa- tion,” New York, Harper & Row, 1960, p. 92. 125 Miss Conrey. In the State of Texas, strides are being made to im- prove nursing education. Twenty-one of your schools of nursing are fully accredited. Others have not been in the business long enough to meet the qualifications for accreditation. Senator Yarsorouair. There is the nub of the matter. This is where your nurses are wrong. We have fine colleges that want to set up a school of nursing; they have regulations that they have to be accredited to get grants. The nurses have said they have to be in existence for so long before they can get accredited. Miss Contry. They have to have a group of students who have had some education, sir. Senator YArBoroUGH. Suppose we have a college set up, say, we want to start teaching nurses and we want accreditation. These students will not come unless they know they are going to be accredited. You say, you have to be a school in existence so long before you can be accredited. Miss Convey. Dr. Harty, what is the time ? Dr. Harry. The time for reasonable assurance is any time after beginning the program. It can be applied to new programs. Acecredi- tation is following graduation of the first class. Senator YarsorouaH. Of course, there are junior colleges, and junior colleges, but some of the very best in our State have been junior col- leges for 20 years. They have set up schools of nursing, and the nurses said, “No, you have not had schools of nursing long enough, you cannot be accredited.” The students were not willing to go there and invest their money and time for years unless the schools were accredited. Now, you know the past performances of these institutions were such that they do not turn out shoddy work in any line. They are not like some fly-by-night school set up, as some were under the GI bill after World War 11, to teach nothing. We have had many institutions of learning tht have wanted to set up a school of nursing. There ought to be some system to go in and examine the school and, on the reputa- tion of that school, grant accreditation. That is why we put in there that the Secretary of HEW could accredit the nurses. This is an arti- ficial blockage to prevent that. I worked long to get as nurses these young ladies ACCREDIT NURSING SCHOOLS Miss Convey. Sir, I think this has been overcome through the system of reasonable assurance. Senator Yarsoroucn. That was after we had that “hassle” in this Committee. Miss ConrLEY. The term “reasonable assurance” was in the Nursing Training Act of 1964. The League developed reasonable assurance procedures after the Committee’s hearings. Senator Yarsorouci. You did not give reasonable assurance until we said, “We think the Secretary of HEW ought to accredit them.” You ladies did not, of your own, give that. Miss Convey. You are quite right, sir. Senator Yarsorouci. I think you ought to go beyond reasonable assurance. If this school is such, if it is a university or college that has been in existence for so many years, and doing high-level work, you ought to accredit it, because the young ladies indicate that they do not 126 have the money to invest and wait for years, and then have somebody say, “We have too many nurses in the country, you did not pay your fee.” The junior colleges say that the first thing they demand is that we ante up the fee in New York. This sticks in their craw. They feel that they are paying a fee for the accreditation rather than the grade or level of this work. They do not have to pay a fee to get accredited for law school and other things. They think this is purely artificial. This has been a sore spot with a bunch of colleges in my State. We are not trying to lower the standards of nursing; we want higher standards. The complaint of the people is that the standards have been lowered, first, practical nurses, and now sitters. We want good nurses. Miss Convey. That is the aim of my organization—good nurses and good patient care. Senator YarsoroucH. This has been the point of the bill. We au- thorize the money and then the Bureau of the Budget says you can- not spend it, the money is being spent in Vietnam. Miss Convey. I would like to read something to you in terms of the cost of accreditation? Senator Y arsoroucir. Yes, but there are those three bells. Miss Convey. I realize that. Senator Yarsorover. Is it in your statement ? Miss Contry. It is not. I have some additional facts here. Senator Yarsorovcir. Can you submit it ? Miss CoNLey. Yes, I can submit the material for the record. The Crarryman. It will appear in the record. Miss Contry. Fine, and then I can devote the rest of my time to the statement. (The material above referred to, follows :) ACCREDITATION OF NURSING SCHOOLS Questions about the cost of nursing school accreditation often arise. May I set the record straight? Accreditation is offered without fee to NLN member schools; they pay only for travel and maintenance expenses of accreditation visitors. This is similar to the practice of such organizations as the American Association of Medical Colleges and the American Dental Association. An ap- pended exhibit outlines current practices and charges for full accreditation and reasonable assurance for all types of programs. (See Exhibits VII and VIII starting on p. 134). Miss Convey. We said that NLN member schools set standards of excellence that are reasonable and universally attainable. Schools which meet these standards are the schools which qualify for full accreditation or for reasonable assurance of accreditation with- in the framework of the National League for Nursing. These are the schools which have the greatest potential to expand their enrollment and reduce attrition rates. These are the schools which can prepare the types of nurses you would want to care for your families and your- selves. The National League for Nursing is recognized officially as the na- tional accrediting agency for nursing education by the National Com- mission on Accrediting for bachelors and masters degree programs in 127 nursing and as an auxiliary accrediting association at the associate degree level. The U.S. Office of Education and the American Nurses’ Association, the professional organization of registered nurses, officially recognize the National League for Nursing as the national accrediting agency for all nursing education programs. This recognition comes to the league as the administrator and coordinator of nursing education aceredita- tion on behalf of all schools of nursing. Nursing schools—both members and nonmembers of NLN—have rallied to this voluntary system of accreditation. Approximately 60 percent of the 1,269 programs preparing registered nurses now have national accreditation—Ixhibits IT and ITI. Another 12 percent have reasonable assurance of accreditation, assuring their eligibility for Federal funds, and indicating that their standards are such that they will soon be ready to seek full acereditation—Exhibit IV. Further evidence of nursing education’s respect for peer evaluation is that the majority of masters degree programs in nursing make grad- uation from an NLN-accredited baccalaureate program a prerequi- site for acceptance of students. At the last count, of the 271-nurse faculty with doctoral degrees em- ployed by colleges and universities, 222 were in accredited programs— Exhibit V. In hospital-based diploma schools, 1,331 of the 1,571 faculty with master’s degrees were in accredited programs—IExhibit V. This is because the best-qualified faculty usually seek positions in schools whose academic standards and whose student bodies will make the best use of their knowledge and abilities as teachers. In these days of rapid growth in higher education, students are aware that they should seek the best possible education for whatever field they choose. They know that accreditation means high standards. For this reason, accredited programs in nursing find it easier to attract qualified students who will reap the most benefits from their education. Right now, NLN-aceredited programs enroll 75 percent of all the students in schools preparing registered nurses—Exhibit IT, Graduates of nationally accredited nursing programs show better results on their State licensure examinations than those from non- accredited programs. During the past 5 years, the proportion of fail- ures for graduates of nonaccredited programs was approximately twice that for accredited programs—Exhibit VI. The State licensure examination, which is the same across the coun- try, must be passed before a nursing graduate has the legal right to practice as a registered nurse. Nursing schools were quick to respond to the challenge of the Nurse Training Act of 1964, with its provisions that Federal funds should be made available to nationally accredited schools or to schools with reasonable assurance of meeting the criteria for national accreditation. Reasonable assurance is the method by which schools with the poten- tial for developing quality nursing programs can become eligible for funds to help them attain the high standards required for full accreditation. Throuch NLN, schools set in motion new procedures for granting reasonable assurance of acereditation to programs which had not yet 128 sought national accreditation. From the inception of the Nurse Train- ing Act to January 1, 1968, 256 programs out of 314 which sought it were granted reasonable assurance. Of these 256, 104 are now fully accredited by the NLN, and a further 41 have applied for national ac- creditation—Exhibit IV. As an aside, sir; this is a very short period of time. NLN’s reasonable assurance procedures were approved by the Com- missioner of Education before he designated the league as the ac- crediting agency for the purposes of the Nurse Training Act. The Commissioner need not accept the league's recommendations, how- ever; final determination of a school’s eligibility for Federal funds rests with him. We believe the effectiveness of NLN’s reasonable as- surance procedures is attested by the facts that in no instance has the Commissioner questioned the judgment of NLN's review panel and that NLN’s recommendations have always reached the Division of Nursing, U.S. Public Health Service, in time for the Division to take action on a school’s application for funds. This same flexibility guides the league in its reactions to the many factors affecting both education and nursing today. Under a recent arrangement, the National Commission on Accrediting recognized the league “to engage in agreed-to eligibility determination procedures for Federal funding—of associate degree programs—in cooperation with the regional accrediting associations” as well as to grant formal program accreditation to associate degree programs seeking specialized accreditation from NLN. To date, the three programs which have ap- plied have been declared eligible for Federal funds under alternate procedures worked out with the regional accrediting associations. The testimony which I have given here today, Mr. Chairman, is aimed at supporting the belief that only through channeling Federal funds to schools meeting the criteria for national accreditation, as set by their peer group, or to schools manifesting reasonable assurance of achieving such standards, can the basic aim of strengthening nursing education and increasing the numbers of qualified graduates be met. 1 have been speaking not only as president of the National League for Nursing, but as an American citizen—a member of the vast general public in whose hands, ultimately, rests the responsibility for patient care in this great Nation. On behalf of all your constituents, including each individual and agency member of the National League for Nurs- ing, T call upon the Congress to see that funds requested under this Health Manpower Act be expended in a way that will gauarantee quality patient care. This can be achieved best by making national accreditation, or reasonable assurance thereof, the sole requisite for nursing school eligibility for Federal funds under title IT, section 231, of S. 3095. Full data and other exhibits substantiating or enlarging upon points T have made are appended to this report. I respectfully request that they appear in the record. Also attached is a folder entitled, “Nursing Education Accreditation—A Service of the National League for Nursing.” T request that this be printed in the record. The Carman. We will have that appear in the record. (The documents referred to above. follow:) 129 Exuisir I ROLE AND FUNCTIONS OF THE NATIONAL LEAGUE FOR NURSING The National League for Nursing is a membership organization, formed in 1952, to improve nursing service and nursing education through cooperative action by nurses, allied professional persons, other citizens, nursing service agencies, and schools of nursing. It fosters community planning for nursing, the develop- ment of nursing manpower, and high standards of nursing education and nursing service. The League has 23,000 individual members and 1,800 agency members. Its individual members are professional and practical nurses, nursing aides, doctors, hospital administrators, educators, social workers, therapists, and interested citizens. Its agency members are nursing schools and nursing service agencies. Constituent leagues for nursing are organized in most states and localities. NLN activities are governed by an elected board of directors representing vari- ous facets of nursing service and education, consumers of nursing services, and constituent leagues for nursing. NLN’s annual budget of some $3 million comes from membership dues, fees for services and publications, and grants. Nursing programs NLN works to improve organized nursing services in hospitals, public health agencies, nursing homes, and other community agencies. It encourages coordina- tion of public and voluntary community health services and continuing nursing care of patients from hospital to home. It offers consultation, conferences, surveys and studies, and issues publications and reports on a variety of nursing service subjects. NLN nationally accredits community public health nursing services and develops criteria and other tools for hospitals, nursing homes, and other in- stitutions to use in self evaluation. NLN works to improve nursing education programs in universities and colleges which lead to bachelors, masters, and doctoral degrees; hospital diploma pro- grams, junior college associate degree programs, and practical nursing programs. 1t provides consultation, information, and publications; conducts conferences for the improvement of curriculums, faculty preparation, student instruction, and evaluation, Through the League nursing schools develop criteria for self evalua- tion and national recognition. The League is the national accrediting agency for all types of nursing education programs. Testing services NLN conducts the national testing service for nursing. It constructs and processes professional and practical nurse licensing examinations, administers NLN preadmission tests for nursing school candidates, and provides achievement and qualifying tests for nursing students, practicing nurses, and aides. Research NLN annually gathers and publishes statistics on nursing school admissions, enrollments, and graduations ; makes studies of costs, salaries, policies, and prac- tices in public health nursing agencies. It undertakes special studies and demon- stration projects to yield data on such matters as the career patterns of nurses, administrative practices in nursing, community planning for health services, and teaching content and methods. Information NLN is a clearing house for information about trends in nursing, personnel needs, community nursing services, and schools of nursing. It publishes a wide variety of materials about community planning for nursing, nursing education opporutnities for young people, management and teaching, and evaluation of nursing services and nursing education programs. Cooperative activities NLN maintans active liaison with some 60 other national organizations. With the American Nurses’ Association, it cosponsors a mational nurse recruitment program, a film service, and the National Student Nurses’ Association. 130 EXHIBIT NO. I-A ADMISSIONS AND GRADUATIONS FOR BACCALAUREATE PROGRAMS IN NURSING, SEPT. 1 THROUGH AUG. 31, 1962-63 THROUGH 1966-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of Admissions ~~ Graduations Number of Admissions Graduations programs programs 1962-63. . 129 8,192 3,878 54 1,405 603 134 8,828 4,466 54 1,442 593 141 10, 511 4,910 57 1,324 471 147 11,701 5,050 63 1,458 448 151 11,937 5,613 170 2,133 518 1 Includes 31 programs with reasonable assurance. Source: National League for Nursing Research & Development. ENROLLMENTS FOR BACCALAUREATE PROGRAMS IN NURSING ON OCT. 15, 1963-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of programs Enrollments Number of programs Enrollments 129 21,179 54 3,938 134 24,104 54 3,563 141 26,670 57 3,708 147 28,858 63 y 151 31,256 170 5,343 1 Includes 31 programs with reasonable assurance. Source: National League for Nursing Research & Development. EXHIBIT NO. II-B ADMISSIONS AND GRADUATIONS FOR DIPLOMA PROGRAMS IN NURSING, SEPT. 1 THROUGH AUG. 31, 1962-63 THROUGH 1966-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of Admissions Graduations Number of Admissions ~~ Graduations programs programs 1962-63 573 27,834 20, 399 287 8,600 6,039 1963-64 569 29,929 22,309 271 8,007 5,929 1964-65 574 31,067 21,470 247 8, 542 5,325 1965-66 577 31,625 21,514 1220 7,279 4,764 1966-67 577 27,345 23,059 190 5,938 4,393 1 Includes 22 programs with reasonable assurance. Source: National League for Nursing Research & Development. ENROLLMENTS FOR DIPLOMA PROGRAMS IN NURSING ON OCT. 15, 1963-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of programs Enrollments Number of programs Enroliments 573 71, 880 287 21,391 569 72,970 271 20,119 574 74, 825 247 18,935 577 73, 858 1220 16,793 577 70,299 190 14,114 1 Includes 22 programs with reasonable assurance. Source: National League for Nursing Research & Development. 131 EXHIBIT NO. II-C ADMISSIONS AND GRADUATIONS FOR ASSOCIATE DEGREE PROGRAMS IN NURSING, SEPT. 1 THROUGH AUG. 31, 1962-63 THROUGH 1966-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of Admissions Graduations Number of Admissions Graduations programs programs 5 320 154 100 3,170 1,325 5 247 154 125 4,214 1,808 6 337 225 168 5,823 2,285 19 1,258 667 199 7,380 2,682 42 2,731 1,378 1239 8,616 3,276 1 Includes 91 programs with reasonable assurance and 3 programs considered equivalent under the special procedure for eligibility for Federal funds. Source: National League for Nursing Research & Development. ENROLLMENTS FOR ASSOCIATE DEGREE PROGRAMS IN NURSING ON OCT. 15, 1963-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year Number of programs Enrollments Number of programs Enroliments 5 528 100 5,828 5 365 125 8,148 6 595 168 10, 969 19 2,082 199 13, 256 42 , 445 1239 16, 491 UIncludes 91 programs with reasonable assurance and 3 programs considered equivalent under the special procedure for eligibility for Federal funds. Source: National League for Nursing Research & Development. EXHIBIT NO. 11-D ADMISSIONS, GRADUATIONS, AND ENROLLMENTS IN BACCALAUREATE PROGRAMS IN NURSING (REGISTERED NURSE), BY TYPE OF PROGRAM AND ACCREDITATION STATUS AS OF JANUARY 1968 Number of Enrollments, + Admissions, Graduations, Accreditation status programs, Oct. 15, 1967 Sent. 1, 1966— Sept. 1, 1966- Oct. 15, 1967 Aug. 31, 1967 Aug. 31, 1967 Accredited. _ 2... ..c. flue cinanien 151 31,256 11,937 5,613 Reasonable assurance 31 2,664 937 242 Not accredited _____________________ 39 2,679 1,196 276 Total ceo cie ieee 221 36, 599 14,070 6,131 ADMISSIONS, GRADUATIONS, AND ENROLLMENTS IN ASSOCIATED DEGREE PROGRAMS IN NURSING (REGISTERED NURSE), BY TYPE OF PROGRAM AND ACCREDITATION STATUS AS OF JANUARY 1968 Accredited. _____________________ 42 4,445 2,731 1,378 Reasonable assurance 1. _ 94 7,439 3,814 1,172 Not accredited... ________________ 145 9,052 4,802 2,104 Total. ___. ha 281 20,936 11,347 4,654 ADMISSIONS, GRADUATIONS, AND ENROLLMENTS IN DIPLOMA PROGRAMS IN NURSING (REGISTERED NURSE), BY TYPE OF PROGRAM AND ACCREDITATION STATUS AS OF JANUARY 1968 Accredited... __ 577 70,299 27,345 23,059 Reasonable assurance. i 22 1,447 560 487 Not accredited _____________________ 168 12,667 5,378 3,506 Toa sooo ian ennuvessuones 797 84,413 33,283 27,452 1 Includes 3 programs considered equivalent under the special procedure for eligibility for Federal funds. Source: National League for Nursing Research and Development. 132 EXHIBIT 111 EDUCATIONAL PROGRAMS IN NURSING, 1967—ASSOCIATE DEGREE, BACCALAUREATE, DIPLOMA, MASTERS DEGREE, BY STATES AND ACCREDITATION STATUS Associate degree Baccalaureate Diploma Master's degree Total ~~ Number ~~ Total ~~ Number Total ~ Number Total ~~ Number programs accredited programs accredited programs accredited programs accredited State Alabama... _______________ 2 1 2 2 12 11 1 1 Alaska.. 0 0 0 0 0 0 0 0 Arizona 4 1 2 2 2 2 1 0 Arkansas 0 0 2 1 4 4 0 0 California. . 41 6 16 15 16 14 3 3 Colorado... 3 2 3 3 6 6 1 1 Connecticut 1 1 3 2 16 15 1 1 Delaware.....___. i 0 1 1 4 1 0 0 District of Columbia. = 0 0 3 2 3 3 1 1 Florida__.._._______ & 16 0 5 3 4 4 1 1 Georgia. . 6 0 3 2 14 9 2 1 Guam. L 1 0 0 0 0 0 0 0 Hawaii 5 1 1 1 1 1 1 1 1 . 3 0 1 1 1 1 0 0 11 1 9 5 55 41 4 4 11 5 [3 4 2 12 1 1 2 0 2 1 18 17 1 1 - 2 0 2 2 16 14 1 0 Kentucky. 9 1 4 3 10 8 0 0 Louisiana. . 1 1 7 5 7 6 1 0 aine__... 1 0 1 0 4 0 0 Maryland. _ 8 0 3 3 17 14 1 1 Massachusetts. 8 1 6 4 45 38 3 3 Michigan__. 13 1 7 4 20 16 3 2 Minnesota. _ 3 1 8 6 16 15 2 1 Mississippi. 10 0 2 1 5 2 0 0 Missouri. _. 7 1 7 5 18 14 3 2 Montana. _. 1 0 1 1 4 1 1 Nebraska 0 0 3 3 11 10 0 0 Nevada. _____ 1 0 1 1 0 0 0 0 New Hampshire 0 0 2 1 8 3 0 0 New Jersey... 6 1 5 2 33 28 1 1 New Mexico. _ 1 0 1 1 1 1 0 0 New York... 31 9 24 15 83 50 11 iz North Carolina. 8 0 8 3 22 6 3 2 North Dakota. 1 0 3 1 6 0 0 ohig...........- 8 0 7 6 50 42 3 3 Oklahoma. . 2 0 2 2 8 4 0 0 Oregon... 1 0 2 2 3 3 1 0 Pennsylvania. 5 1 11 6 95 71 2 2 Puerto Rico. . 3 1 2 1 8 2 0 0 Rhode Island. 1 0 2 2 5 5 0 0 South Carolin 3 0 2 1 5 1 0 0 South Dakota. 2 0 3 1 6 5 0 0 ? 1 4 3 12 11 1 0 12 1 7 [ 22 13 2 1 2 1 2 2 3 3 1 1 2 1 1 1 2 2 0 0 5 0 5 3 22 10 0 0 s 1 0 0 0 0 0 0 0 Washington__ 7 1 5 4 7 6 1 1 West Virginia. 5 1 3 1 8 4 0 0 Wisconsin... 1 0 8 3 16 16 2 2 WYOMING... cov cnmmiin anime 0 0 1 1 0 0 0 0 FOB ar sn smmmiioss 281 42 221 151 767 577 61 45 Note.—Total program figures as of Oct. 15, 1967, 1,269. Number of accredited schools as of January 1968, 770. Source: National League for Nursing Research and Development. 133 EXHIBIT IV DATA ON NLN REASONABLE ASSURANCE OF ACCREDITATION UNDER NURSE TRAINING ACT OF 1964 [From the beginning of the Nurse Training Act (Public Law 88-581) to Jan. 1, 1968, 314 nursing education programs sought ressandals Sagi tame of accreditation from the National League for Nursing; 256 (82 percent) of these received reason- able assurance Baccalaurete Associate Total and degree Diploma masters Number of programs which applied for reasonable assurance_____ 314 63 146 105 Number of programs granted reasonable assurance # 1256 46 1132 78 Number of programs denied reasonable assurance. _____________ 58 17 14 a Number of programs granted full accreditation following initial receipt of reasonable assurance. ___________________________ 104 17 36 51 Number of programs with reasonable assurance scheduled for accreditation visits in 1968_________________________________ 41 9 5 7 Number of programs denied accreditation after receipt of reason- ADIBASSUIANCE uusiunsnismsisiesssi antes enti 13 1 1 11 , 1} cludes 3 associate degree programs considered equivalent under special procedures for determining eligibility for ederal funds. Source: National League for Nursing Departments of Associate Degree Programs, Baccalaureate and Higher Degree Programs, and Diploma Programs. EXHIBIT NO. V FULL-TIME FACULTY TEACHING IN NURSING DEPARTMENTS, SCHOOLS, OR PROGRAMS AS OF JAN. 3, 1966, BY TYPE OF PROGRAM AND HIGHEST EARNED CREDENTIAL Highest earned credential Type of program by accreditation Doctorate Masters Baccalaureate Associate Diploma Total degree Baccalaureate and higher degree: Accredited ____________ ae 222 2,829 412 0 3 3, 466 Not accredited... ..............__ 37 447 114 0 9 607 TOA cc sons nnmmsnin wasn 259 3,276 526 0 12 4,073 Associate degree: Accredited... cvosdacnsmimarins 0 34 17 0 0 51 Not accredited................... 12 584 240 4 13 853 Hotel ooo simmer meres 12 618 257 4 13 904 Diploma: AOOIOAUBH ooo cnn ems 16 1,331 3,843 32 1,574 6,796 Not accredited..........coonenn... 9 240 880 5 549 1,703 TOA ccs nmamimn inns 25 1,571 4,723 57 2,123 8,499 Allaccredited.. .. ...coomermvmesnsnmns 238 4,194 4,272 32 1,507 10,313 All not accredited... .._____________ 58 1,271 1,234 29 571 , 163 Orang $00). oe sno nosssnscspei 296 5, 465 5, 506 61 2,148 13,476 Source: National League for Nursing Research and Development. 134 EXHIBIT VI NUMBER OF CANDIDATES AND PERCENT FAILING STATE BOARD TEST POOL EXAMINATIONS FOR LICENSURE OF REGISTERED NURSES Accredited Nonaccredited Type of program Number of Percent of Number of Percent of candidates failures candidates failures 1961-62 Baccalaureate... _______ 3,127 4 664 7 Associate degree. - 121 6 772 21 Diploma ccc run inn arse sane 17,875 12 5,313 23 MOU uneasiness snsinssnns 21,123 11 6,749 21 1962-63 Baccalaureate _____________________ 3,325 3 612 11 Associate degree. . 193 4 1,534 15 DIPIOMA. ie simran 20,411 8 6, 504 18 Tolle, ou ng smnmmsmmim mire 23,929 7 8,650 17 1963-64 oo BACRAIAUTBAIE. _. . oss 3,696 6 744 19 Associate degree - 4 10 1,133 25 Diploma... = 20,118 13 5,950 24 Tol canines nom 23,958 12 7,821 24 1964-65 BACCAIAUMAIEL . « cusumunmmmse sma 4,948 6 587 19 Associate degree 2s 219 15 2,807 21 DIPIOMB mown imme mmm wee mmm mmm meme 23,901 11 6, 051 21 Tolalscnssmmnsmnmmrmns 29,068 10 9, 445 21 1965-66 Baccalaureate. co q..omnarennsssnsan= 4,791 7 521 24 Associate degree. _ 5 197 21 3,003 24 DIDIOMIY.. ecm mm mmns imran RES SERS 20,268 13 4,242 21 Total oo 25,256 12 7,766 22 Source: National League for Nursing Evaluation Service. EXHIBIT Vil NLN ACCREDITING PRACTICES AND CHARGES FOR ASSOCIATE DEGREE, BACCALAUREATE AND MASTERS, AND DIPLOMA NURSING PROGRAMS For reasonable assurance of accreditation For full accreditation Characteristics NLN agency Nonmember NLN agency Nonmember members agencies members agencies Length of visit --- 3 days Number of visitors i; i. Drmnrn simme aeS y Gnmw wn A oy Schedule of visits... i re i _ Every 8 years for Every 8 years for as- sociate degree, sociate degree, baccalaureate and baccalaureate and masters programs, masters programs, every 6 years for every 6 years for diploma. diploma. Accreditation charges... $100, plus travel and $100, plus travel and $50 per day per visitor $1,500 fee. per diem expense per diem expense for travel and daily of visitors. of visitors. expenses. This is a prorated charge to Susiize charges for all geographic loca- tions.2 1 May be 2 days for associate degree programs. 2 Annual membership dues (associate degree, $285; baccalaureate and masters, and diploma, $575) support all NLN services, including accreditation. Source: National League for Nursing. 135 Exuisir VIII-A NATIONAL LEAGUE FOR NURSING PROCEDURES REASONABLE ASSURANCE OF ACCREDITATION UNDER THE NURSE TRAINING ACT OF 1964 New Nursing Programs A visit is planned upon receipt of the following material : 1. (a) A statement indicating approval of the educational institution by the appropriate regional accrediting association or evidence that the institution is a candidate for regional accreditation ; or (b) A statement indicating that the hospital controlling a diploma program is accredited by the Joint Commission on Accreditation of Hospitals. 2. A statement indicating approval of the establishment of the new program in nursing by the State Board of Nursing. 3. Acceptance by the institution of current criteria used by the National League for Nursing for accreditation purposes and statements of intention to continue work toward meeting the criteria and seeking accreditation following gradua- tion of the first class. 4. The philosophy and purpose of the nursing program. 5. The commitment of the controlling institution to support a nursing program specifying the extent of committed financial support by the controlling institution. 6. The names and qualifications of the chairman or director and of the faculty already employed. 7. The plan for recruitment and selection of faculty. 8. The length of program and the credential that will be conferred upon suc- cessful completion of the program. 9. The methods to be used in selection and admission of students. 10. The plan of the proposed curriculum. 11. The criteria used in the selection of agencies for clinical experiences for students. 12. The physical facilities (classroom, administrative, housing, if any) cur- rently available and to be provided for the nursing unit by the college. 13. College or school catalog. Exursir VIII-B NATIONAL LEAGUE FOR NURSING PROCEDURES REASONABLE ASSURANCE OF ACCREDITATION UNDER THE NURSE TRAINING ACT OF 1964 Established Nursing Programs A visit is planned upon receipt of the following material : 1. A statement from the administrative officer of the institution indicating acceptance of current criteria used by the National League for Nursing for ac- crediting purposes. 2. A statement from the State Board of Nursing evaluating the nursing program. 3. (a) A statement indicating that the collegiate institution offering the pro- gram is accredited by or is a candidate for accreditation by the appropriate regional accrediting agency ; or (b) A statement indicating that the hospital controlling a diploma program is accredited by the Joint Commission on Accreditation of Hospitals. 4. A statement of intent to continue to work toward meeting the criteria and seeking NLN accreditation within three years or at the termination of a Teach- ing Improvement Grant. 5. A statement of the philosophy and purpose of the institution and of the nursing program, 6. Evidence of the commitment of the institution to support a nursing program that specifies the extent of commited financial support by the university, college, or hospital. 7. Information regarding the qualifications and major responsibilities of the dean or director and of each faculty member. 136 8. The plan for selection, upgrading, promotion, and tenure of faculty. 9. Policies used for selection, admission, promotion, and graduation of students. 10. Current enrollment by class. 11. Number of admissions to program per year for past five years. 12. Number of graduations from program per year for past five years. 13. Curriculum plan. 14. Brief course descriptions. 15. Description of resources and facilities. 16. Methods used to evaluate the program. NURSING EDUCATION ACCREDITATION—A SERVICE OF THE NATIONAL LEAGUE FOR NURSING The National League for Nursing is recognized as the national accrediting agency for nursing education by : The National Commission on Accrediting—for bachelors and masters degree programs in nursing. The United States Commissioner of Education—for all nursing educa- tion programs. The American Nurses’ Association—for all nursing education programs. The National Federation of Licensed Practical Nurses—for practical nurs- ing programs. Accreditation has been called a way of life in American education. So. too, it is in nursing education—accreditation by the National League for Nursing. NLN accredits programs of study in nursing offered by senior colleges and universities, junior and community colleges, hospitals and independent schools, and vocational and other secondary schools, NLN's accreditation services are designed to stimulate schools to improve their nursing programs and to provide a mark of recognition for those which meet certain qualitative criteria. Accreditation as a public service Accreditation is a public service as well as a service to educational institutions offering programs in nursing. One of its purposes is to provide the public with well prepared nurses. It serves as an aid, too, to students, parents, and counselors in evaluating schools and in selecting nursing education programs. It pro- vides a yardstick by which both tax funds and voluntary contributions can be channeled into high quality education. It assures the community that a school has a competent faculty and administration, that its curriculum meets the standards nursing school faculty themselves know are good and attainable, and that the educational experience will be a profitable one for the student. Community groups of many kinds are concerned about nursing education and involved in developing new educational resources for nursing. National accreditation makes guidelines to quality in nursing education available to community planning groups. Accreditation as a service to nursing schools Nursing schools have rallied to national accreditation since the inception of the program in 1948.* The significance of this support is heightened by the fact that national accreditation is voluntary—a school seeks NLN accreditation of its program of study because of the values accreditation holds for the school. National recognition is one of these. Another is the opportunity a nursing school faculty, going through the accreditation process, has to participate in its own evaluation of the school and to plan and execute changes that will improve the program. As a rule, accredited programs in nursing find it easier to attract qualified faculty and students than do non-accredited programs. Their graduates customarily score higher on state board examinations to become licensed to practice as nurses than do the graduates of non-accredited programs. Having *The National Nursing Accrediting Service was established in 1948 to unify the separate acorediting activities of several national organizations concerned with accredita- tion in nursing. When the National League for Nursing was formed in 1952, the National Nursing Accrediting Service became one of the seven national services, committees, and organizations which merged to form the new organization. Nursing accrediting activities were then centered in NLN. 137 national standards to meet often helps a school withstand local pressures to initiate or continue questionable educational practices. Acceptance of accreditation as an instrument for improvement stems from the American tradition to excel, to exceed the minimum expected. State boards of nursing epprove schools of nursing for the preparation of students qualified to take the state licensing examination to practice as nurses. The criteria that must be met for national accreditation are over and above the requirements for legal recognition within a state, and they are established by the schools themselves, Accreditation in nursing education also is geared to the nationwide programs of accrediting in higher education as appropriate. It is specialized accreditation, conducted by nurse educators to evaluate programs of study for the purpose of maintaining educational standards in nursing. Thus accreditation benefits to a school are benefits also to the profession in improving the practice of its mem- bers. The NLN accrediting program NLN accredits all types of nursing education programs—graduate programs for professional nurses at the masters degree level, bachelors and associate de- gree nursing programs in universities, senior, junior and community colleges, diploma programs offered by hospitals and independent schools, and practical nursing programs. For each, accreditation is based on the principle of evaluation by a peer group. The myriad activities involved in evaluation are undertaken by the segment of the NLN membership and staff active and experienced in the type of program under review. Masters and bachelors degree programs are evaluated by faculty members of accredited programs in senior colleges and universities. Faculty members from these programs develop and review the NLN criteria used in evaluation, make accreditation visits to the colleges and universities, and compose the board of review which makes the decision on a school’s accreditation. Whenever possible, NLN visits a college or university for nursing accreditation concurrently with representatives of the regional accrediting associations in higher education who evaluate the institution as a whole. Seventy-one per cent of the baccalaureate programs hold NLN accreditation. Diploma programs are evaluated by faculty members of accredited programs in hospitals and independent schools of nursing. Faculty members of accredited diploma programs develop evaluation criteria, visit schools, and compose the board of review. Sixty-nine per cent of the diploma programs throughout the country are nationally accredited. Associate degree programs in junior and community colleges, as the newest facet of nursing education, are one of the most recent groups to utilize NLN accreditation services. Associate degree programs are growing rapidly through- out the country to meet community needs, and many are yet too new to seek national accreditation. Thus, NLN accreditation of these programs is not yet as well established as for other types of nursing education. The NLN evaluation criteria, however, provide guidelines to quality education in nursing that enable junior and community colleges to establish sound nursing programs. More and more are joining the ranks of accredited programs. As with baccalaureate pro- grams, school visits for NLN accreditation are scheduled, when possible, with visits of representatives of regional accrediting associations evaluating the college as a whole. Practical nursing accreditation was initiated by NLN in 1966 and for the ma- jority of these schools, too, NLN accreditation is a new and largely future goal. Criteria and evaluation procedures have been established, and the first programs approved. In offering national accreditation to practical nursing, NLN recognizes these programs as an integral part of nursing education. Accreditation in action The experiences of a typical nursing school illustrate NLN accreditation meth- ods and the attention to detail, the communications “musts,” and the judgmental faculties exercised throughout the evaluation of a school and its nursing program. First a school applies for accreditation. After doing so it submits a written self-evaluation report substantiating the ways in which it meets the criteria which have been established by and for the type of program it offers. The criteria are published by NLN and are available to all schools. In addition to being a 92-079—68— 10 138 guide for the preparation of the self-evaluation report, they serve as a yardstick by which a school may pace its own improvement efforts and determine its readiness for accreditation. The self study through which a school faculty goes in order to prepare its report often is considered one of the most valuable aspects of accreditation. Teachers and administrators must look searchingly into the philosophy and purposes of the program and the ways in which the program is meeting the nursing needs of the community. They must analyze and report on the orga- nization and administration of the school, the qualifications of faculty, the curric- ulum offerings, policies in effect for students of nursing, the resources and facilities used by the school to educate its students, and the methods by which the school periodically evaluates itself. An accreditation visit then is scheduled at the convenience of the school. At least two persons always visit a school to ensure balanced judgment. Visits may be made by faculty members of the type of program under review, by an NLN staff member, or both. A college or university may also request a visit from a generalist from a regional accrediting association when a joint visit with this group is not possible. The purpose of the accreditating visit is to clarify the material in the self- evaluation report, to elicit additional information that may be needed, and to serve as a communications bridge between the school and the board of review which will evaluate its program. At the conclusion of the visit, usually two to three days, the visitors’ report is read to the faculty and administration of the school so that they may be aware in advance of all data to be reviewed by the board. One further step is taken to assure this. Following the visit, a copy of the visitors’ report is sent to the administrative head of the school and to the dean or director of the nursing program for comments and acceptance before pres- entation to the board of review. The board of review which makes the evaluation is composed of nurse edu- cators from accredited programs of the type under review, selected to represent various types of program control and sections of the country. The board approves a program of NLN accreditation for a specified number of years, and those which are accredited and those which are not are sent a written communication outlining the program's strengths and weaknesses. An accredited school may be asked to submit a subsequent report outlining the progress it has made in meeting recom- mendations of the board. A school may return for evaluation at any meeting of the board of review or appeal a decision of the board. These procedures, and others in the accrediting process, are designed to assure the school’s personnel that every effort is made to judge its program fairly and on the basis of concrete evidence of the way in which it meets the criteria. NLN annually publishes lists of nationally accredited programs in nursing. These appear also in Nursing Outlook, the League's official magazine, and many schools tell their communities, through their newspapers and other media, when they have obtained accreditation. Accreditation costs The cost of League accreditation services is borne partially by the League and partially by the schools. Methods of payment vary with type of program. For in- stance, senior colleges, universities, and hospital and independent schools are entitled to receive accreditation services, along with other NLN services, for the annual dues they pay for membership. Junior and community colleges and practical nursing programs enjoy subsidized membership dues, and pay a per diem fee for travel and expenses of accreditation visitors. Non-member schools pay an over-all fee for accreditation services. NLN’s Board of Directors establishes membership dues and accreditation fees and has voted to move toward uniformity in these for all types of programs. Specific information about accreditation fees and membership dues should be obtained directly from NLN. The NLN school improvement program Accreditation is only one phase of a broad program conducted by NLN to help schools lof nursing meet and maintain high standards. As a membership organi- zation to which both schools of nursing belong as member agencies and nursing 139 school faculty belong as individual members, NLN engages in many school im- provement activities. It offers consultation to schools of nursing to help them with pressing prob- lems. Revision of the curriculum may be one of these. Helping a new school of nursing get underway, assisting in coordination of the facilities of several schools for educating all nursing students in a community, or the use of televi- sion in teaching may be others. Kducational developments are as legion in nurs- ing these days as they are in other fields. Any nursing school, accredited or not, may call on NLN for consultation, advice, and counsel. Through conferences, meetings, and workshops, through studies of educational practices and the publication of research findings and other information materi- als, nursing schools participate in the NLN school improvement program and are aided by it. NLN provides evaluation services for testing applicants to schools of nursing and for use in determining the achievement of students during their school program. League information provides guidance to prospective students. As accreditation is one facet of the NLN school improvement activities, so school improvement is one facet of the total League program. NLN works also to improve nursing services. On the record Although NLN accreditation has widespread acceptance as an instrument of improvement in nursing education, NLN seeks constantly to substantiate the effect of its accreditation efforts, for data such as— NLN accredited programs enroll 759% of all the students in schools pre- paring registered nurses. NLN accredited programs comprise 609 of all the nursing schools in the country. NLN accredited programs attract the best qualified faculty. For instance, of the 254 nurse educators with doctoral degrees employed by colleges and universities, 222 are teaching in accredited programs. In diploma programs 1,331 of the 1,571 faculty with masters degrees are in accredited programs. Accreditation and the future “Revolutionary” often is used to describe what is going on in nursing education. Whether the changes taking place and being projected are revolutionary or evo- lutionary, they are taking place—changes in the systems of control of nursing education, in the assumption of community responsibility for education for a pro- fessional field, in the movement of nursing education into the general pattern of education in the country. Accreditation, as a method of evaluating the particulars of present day nursing school practices, will change as nursing education changes. The essential ingredient of accreditation—decision by a knowledgeable body of peers—and the purpose of accreditation—raising and maintaining high standards in nursing education—however are unchanging and unchangeable. Miss Conrey. I thank you, Mr. Chairman, and the other members of the subcommittee who are here, for this opportunity to appear be- fore you. If I can answer any questions, or supply additional infor- mation, I shall be happy to do so. May I make a further comment, Mr. Chairman ? The Crratrman. Surely. Miss Convey. The NLN is very proud of Alabama. The reason for that is, and I am not sure you are aware of this, that out of your 17 schools of nursing, only two are not fully accredited. Alabama has the distinction of being the first State in the South with an accred- ited junior college program. We think that is pretty good. The Cramman. That is pretty good, isn’t it? Miss Convey. Yes, indeed, sir. The CrarrmaN. Anything you would like to add, Dr. Harty ? Dr. Harry. No, thank you, sir. The Cramrman. I want to thank you very much for the testimony you have given here. It will appear in full in the record. Now, Father Byron Collins, of Georgetown University. 140 STATEMENT OF REV. T. BYRON COLLINS, S.J., VICE PRESIDENT FOR PLANNING, GEORGETOWN UNIVERSITY The Cuamrman, Father, did you know my good friend, Monsignor McGowan ? Father Corrins. Yes; I have met him. The Caairman. He was a wonderful man. Father Corrins. Yes, sir; he was. The Cramrman. He gave us tremendous help in the old days in some of these battles. Father Corrins. Yes; he did. The Cramrman. He was a wonderful man. Father Corrins. My name is Father Collins, Society of Jesus, vice president for planning, Georgetown University. My statement con- cerns S. 3095, title IT, dealing with nurses training under section 805. In the wisdom of the bill is a specific phrase in which I am inter- ested, vitally so. It states: “* * * or to assist schools of nursing which are in serious financial straits to meet their costs of operation.” Georgetown University School of Nursing is in dire financial straits. Our program is one of the approximately 220 baccalaureate degree schools. _ Our school of nursing yearly operating costs far exceed the tuition income. After a conference with representatives of the ANA, T would re- quest consideration of a specific emergency appropriation of a fund for this amount of $1.2 million to be used to allow schools of nurs- ing which are in serious financial straits, to the point of not being able to continue in existence without such help, to use this fund. The next change I would propose is in part D—“Miscellaneous,” section 231, which has been testified in the relationship of the words, “or by a State agency.” The Cramrman. What is your thought about that, Father? Father Corrins. IT would propose that the word “or” in the phrase “or by a State agency” be deleted and substitute the words, “and by a State agency.” The reason for this is to allow the continuing approval of schools by State agencies, but it would also require accreditation by national agencies, which I believe helps the quality of the entire nurs- ing profession. The Cramrman. You would have the whole thing ? Father Corrins. IT would use this as a complement. That is the gist of my statement. The Crairman. We appreciate it very much. Is there anything else you would like to add, Father? Father Corrins. There is this striking thought, to me. I have been vitally concerned in our own school of nursing since 1954. I was priv- ileged to put the building up, get grants and loans for it. In the baccalaureate private schools, the costs have gotten to such a stage that, as in our own case, we are seriously weighing whether we will continue. I was most delighted to see this phrase in the legislation, I believe under the aegis of the Secretary, that funds could be put where a school is considering seriously stopping its school because of financial reasons, and due to the tremendous manpower needs of nurses, that it should be given serious consideration. 141 The Crratrman. As I recall, St. Louis University Dental School had to be closed down for lack of funds. Father Covrrins. Yes, that is correct, Senator. It would seem as though the effort to continue and expand should, in reasonable proc- ess, allow for those who have had a tradition and an ability to con- tinue to serve. The Cramrman. Well, what we need is not fewer schools, but more schools. Right? Father Corrins. That is correct. I wish to thank you, Senator. The Crmairman. Thank you very much, Father. We certainly ap- preciate your testimony. Now, Dr. Greene, dean of the School of Veterinary Medicine at Auburn University, Auburn, Ala. He will be accompanied by Dr. Thorp, chairman of the Joint Com- mittee on Education of the American Veterinary Medical Association, and Dr. Alvin A. Price, here from Texas. Gentleman, we understood you would be here tomorrow, but we are happy to have you proceed today. STATEMENT OF JAMES E. GREENE, D.V.M., DEAN, SCHOOL OF VETERINARY MEDICINE, AUBURN UNIVERSITY, AUBURN, ALA.; ACCOMPANIED BY W. T. S. THORP, D.V.M.,, CHAIRMAN, JOINT COMMITTEE ON EDUCATION, AMERICAN VETERINARY MEDICAL ASSOCIATION; AND ALVIN A. PRICE, D.V.M., DEAN, COLLEGE OF VETERINARY MEDICINE, TEXAS A. & M. UNIVERSITY Dr. Greene. Thank you for the opportunity to be here. We learned last night that we were to be here today and we did our best to comply. The Caatrman. There was some misunderstanding, but do not worry about it, we are glad to have you here. Will you proceed, gentlemen ? Dr. Greene. Speaking as a member of the executive board of the American Veterinary Medical Association, I am presenting a state- ment of the American Veterinary Medical Association. It is the wish of the American Veterinary Medical Association to express strong support for the passage of S. 3095, introduced by Senator Lister Hill, and entitled, Medical Manpower Act of 1968. In expressing our support for the act, however, we urge the com- mittee to amend the bill to include veterinary medical colleges under the provision authorizing institutional grants for the operation of health professions schools. Such an amendment would assure that the act will serve to the fullest possible extent the Nation's growing needs for health services. The numerous responsibilities modern veterinary medicine has assumed in the areas of biomedical research and public health require long-range funding for research, instructional programs, and efficient administration in colleges of veterinary medicine. The colleges of veterinary medicine, in common with the colleges of medicine, den- tistry, osteopathy, optometry, and podiatry, need assistance in the overall admmistration of expanding educational programs. 142 Veterinary medicine is a health profession concerned with the health and welfare of animals and man alike. Not only, are veterinarians actively engaged in diagnosis, treatment, and control of a broad spec- trum of diseases among many species of animals, but they are also key members in the Nation’s medical, public health, research, and military teams. } Veterinarians are responsible for protecting a $41 billion national investment in livestock. They protect the health of the public against some 100 diseases transmissable to man from both farm and companion animals, and they safeguard the wholesomeness of meat and meat products, poultry, and milk and milk products. At U.S. ports of entry they prevent the introduction of animal diseases from foreign coun- tries and enforce health regulations in interstate and intrastate traffic in animals and animal products. At numerous research institutions, both governmental and private, veterinarians contribute to the advances in biomedical and com- parative medical research. They are engaged in the care of experi- mental animals used in medical research and are responsible for the interpretation and application to man of findings obtained from animal research studies. They also participate in the development and testing of biological products for both animals and man. The CHAIRMAN. Inman as well as in animals. Dr. Greene. Right, and in the interest of human health. The CirarrMaN. Surely. Dr. Greene. Veterinarians in the Armed Forces serve as public health officials for troops at home and overseas. They supervise inspec- tion of food prepared and served to troops at home and abroad, and are engaged 1n research studies of bacteriological warfare, effects of excessive radiation and radioactive fallout, effects of space flight on living beings, diet development for astronauts, and space food packaging. The Ciramaran. In other words, they perform a very vital service, correct ? Dr. Greene. Correct. Veterinary medicine is a decidedly consumer-oriented health pro- fession. In 1966, Congress passed the Laboratory Animal Welfare Act—Public Law 89-544; and in 1967, the Wholesome Meat Act— Public Law 90-201. Now, the 90th Congress is considering bills par- taining to the inspection of poultry meat products. The implementation of all of these legislative measures, in their initial stages alone, will require the participation of hundreds of veterinarians, placing additional heavy demands on veterinary medi- cal manpower at a time when there exists already a critical short- age of veterinarians in all fields. The Cramvan. It would impose a much greater burden on the veterinarians than they have had in the past, right? Dr. Greene. We are not prepared to fill the need, Senator. In 1961, the Senate Committee on Government Operations esti- mated that the Nation faces a shortage of 15,000 veterinarians by 1980 when 44,000 veterinarians—or nearly twice the number of today’s veterinarians—will be needed to provide for minimum veterinary man- power needs. In view of mounting population pressure, the increasing 143 need for consumer protection, the accelerated pace of biomedical re- search, and the spectre of food shortage in our time, this estimate must now be considered extremely conservative. The gigantic task of supplying sufficient number of competent veterinarians for the Nation’s growing health needs is the respon- sibility of 18 colleges of veterinary medicine in 17 States. These col- leges are often understaffed, many lack modern teaching and training aids, most are overcrowded, some operate in nearly obsolete facili- ties. Because of all of these inadequacies, they now have to turn away from three to four qualified applicants for each freshman student they admit. Here, again, the things that have been done by this same act have been most helpful in assisting in this situation. The CruatrmaN. How many students will graduate this year? Dr. Greexe. In the United States, we will graduate approximately 960—1,315 were admitted. The CramrmaN. How many will your school graduate this year? Dr. Greene. We will graduate 91. It has been clearly demonstrated that the States are unable to fur- nish the colleges with the support they need. The American Veterinary Medical Association therefore urges passage of the Health Manpower Act of 1968, together with an amendment to include colleges of veteri- nary medicine in the institutional grants provision. Mr. Chairman, thank you very much for this opportunity to testify. If I may, I would request permission to include the documents which have been submitted to counsel previously. The Crratraran. All right, we will be glad to have them, following your remarks, in the record. Dr. Greene. Thank you. I also request permission for these gentlemen, if the time permits, to present concise statements. (The prepared statement of Dr. Greene follows :) PREPARED STATEMENT OF JAMES E. GREENE, D.V.M., DEAN, SCHOOL OF VETERINARY MEDICINE, AUBURN UNIVERSITY, AUBURN, ALA. I am Dr. James E. Greene, dean of the school of veterinary medicine at Auburn University, Alabama, and a member of the Executive Board of the American Veterinary Medical Association. It is the wish of the American Veterinary Medi- cal Association to express strong support for the passage of S-3095 introduced by Senator Lister Hill and entitled “Medical Manpower Act of 1968.” In expressing our support for the Act, however, we urge the Committee to amend the bill to include veterinary medical colleges under the provision authorizing institutional grants for the operation of health professions schools. Such an amendment would assure that the Act will serve to the fullest possible extent the nation’s growing needs for health services. The numerous responsibil- ities modern veterinary medicine has assumed in the areas of biomedical research and public health require long-range funding for research, instructional programs, and efficient administration in colleges of veterinary medicine. The colleges of veterinary medicine, in common with the colleges of medicine, dentistry, osteo- pathy, optometry, and podiatry, need assistance in the over-all administration of expanding educational programs. Veterinary medicine is a health profession concerned with the health and welfare of animals and man alike. Not only are veterinarians actively engaged in diagnosis, treatment, and control of a broad spectrum of diseases among many species of animals, but they are also key members in the nation’s medical, public health, research, and military teams. 144 Veterinarians are responsible for protecting a $41 billion national investment in livestock. They protect the health of the public against some 100 diseases trans- missible to man from both farm and companion animals, and they safeguard the wholesomeness of meat and meat products, poultry, and milk and milk products. At U.S. ports of entry they prevent the introduction of animal diseases from foreign countries and enforce helath regulations in inter-state and intra- state traffic in animals and animal products. At numerous research institutions, both governmental and private, veterinar- ians contribute to the advances in biomedical and comparative medical research. They are engaged in the care of experimental animals used in medical research and are responsible for the interpretation and application to man of findings obtained from animal research studies. They also participate in the develop- ment and testing of biological products for both animals and man. Veterinarians in the Armed Forces serve as public health officials for troops at home and overseas, They supervise inspection of food prepared and served to troops at home and abroad, and are engaged in research studies of bacteriological warfare, effects of excessive radiation and radioactive fallout, effects of space flight on living beings, diet development for astronauts, and space food packaging. Veterinary medicine is a decidedly consumer-oriented health profession. In 1966, Conrgess passed the Laboratory Animal Welfare Act (Public Law 89 544) and in 1967, the Wholesome Meat Act (Public Law 90-201). Now the 90th Congress is considering bills pertaining to the inspection of poultry and poultry meat products. The implementation of all of these legislative measures, in their initial stages alone, will require the participation of hundreds of veterinarians, placing addi- tional heavy demands on veterinary medical manpower at a time when there exists already a critical shortage of veterinarians in all fields. In 1965 the AVMA Joint Committee on Veterinary Education estimated that the nation faces a shortage of 15,000 veterinarians by 1980 when 44,000 veter- inarians—or nearly twice the number of today’s veterinarians—will be needed to provide for minimum veterinary manpower needs. In view of mounting population pressures, the increasing need for consumer protection, the acceler- ated pace of bio-medical research, and the spectre of food shortages in our time, this estimate must now be considered extremely conservative. The gigantic task of supplying sufficient numbers of competent veterinarians for the nation’s growing health needs is the responsibility of 18 colleges of veterinary medicine in 17 states. These colleges are often understaffed, many lack modern teaching and training aids, most are overcrowded, some operate in nearly obsolete facilities. Because of all of these iadequacies, they now have to turn away from three to four qualified applicants for each freshman student they admit. It has been celarly demonstrated that the states are unable to furnish the colleges with the support they need. The American Veterinary Medical Asso- ciation therefore urges passage of the Health Manpower Act of 1968, together with an amendment to include colleges of veterinary medicine in the institu- tional grants provision. The Crarman. Dr. Thorp. Dr. Taorp. Mr. Chairman, I am W. T. S. Thorp, chairman of the Joint Committee on Education of the American Veterinary Medical Association. I am also dean of the College of Veterinary Medicine of the University of Minnesota. I want to take just a few minutes The Caamrman. We will have your prepared statement appear in full in the record. Dr. Traore. Yes. I will simply cite a few examples of the rather direct relationship of veterinary medicine to health and welfare. Since the time of Pasteur, veterinary medical scientists have made significant contributions to the constantly expanding body of knowl- edge that constitutes all medical science. The French veterinarian, Ramon, developed the first effective im- 145 munizing agent against a toxin. Otto Stader, a practicing veterinarian, developed a revolutionary method to reduce fractures in animals. Many American servicemen owe their arms, legs, and jaws to the Stader splint used in World War I1. The oral polio vaccine was backed by 15 years of experience in suc- cessful use of oral vaccine in animals. During the testing of the early Salk vaccine, a veterinary pathologist at NIH was responsible for studying the tissues. We will need many more veterinarians in our medical research institutions. Additional animal legislation would require more. There are many other examples we could give. One other example I would like to use The CrarmaN. Be sure to have them all in your statement, now. Dr. Traore. There is more in here, and the details are included. There are modals of diseases in animals that are similar to those that have occurred in man—Ileukemia, emphysema, lymphoma—they can even reproduce emphysema in horses now, which is a disease apparent in man. The Caairman. A very bad disease, too. Dr. Traore. Yes. I would like to give one example of a peculiar degenerative disease of the brain known as kuru. It was thought to be caused by an infec- tious agent. Dr. Hadlow was working on scrapie in sheep, one of the chronic or slow virus diseases. Dr. Hadlow, a Public Health Service veterinarian now in Montana, observed similar pathology in the tis- sues. He also had shown in his work that the incubation period could be 2 years or more. He worked with NIH chimpanzees, injected with material from cases of kuru, and found that these conditions varied at somewhere around 18 months. I use this as an example of models of disease in animals, also as an example where the veterinarian in his area works on diseases of animals, not only those that are transmissable to man but also those that can be used as models for some of the chronic and serious disease conditions in man such as cancer, heart disease, and nervous disorders. There are many other areas employing veterinarians, many new horizons. I want to say there are many areas of veterinary training which include the same facilities as other branches of science. An example is a new medical school in Davis, Calif., in which the new medical school and new facilities for veterinary medicine are sharing common teaching facilities. I think this was presented to the committee once before. The CrarMAN. Yes; it was. Dr. Traore. As shown in the prepared testimony, veterinary medi- cine is an essential component of the health manpower of this Nation. The schools and colleges of veterinary medicine are a national resource of the education of this health manpower. Dr. Greene has pointed out that 18 schools are providing all the veterinarians. There are many well-qualified, motivated preveterinary students who cannot be accepted, thus depriving a segment of our youth of an educational opportunity and the lack of producing more health manpower. 146 In closing, we appreciate the assistance which the Congress and the administration have provided for construction of teaching facilities and student loans, as well as the inclusion of scholarship grants and special project grants in the present legislation. These will be most helpful in assisting the colleges to expand and meet the increasing demand for veterinarians in health manpower. At this time, we wish to express our support for the proposed Health Manpower Act of 1968. However, the failure of S. 3095 to include veterinary medical institutions in the institutional grants will make it very difficult to improve and strengthen the teaching program and faculty to provide the increased health manpower that is needed. For these reasons, we strongly recommend that S. 3095 be amended to include veterinary medical schools, along with medical schools in other health professions as recipients of institutions grants. Thank you very much, Senator Hill, for letting us appear today. (The prepared statement of Dr. Thorp, follows:) PREPARED STATEMENT oF W. T. S. THORP, D.V.M., CHAIRMAN, JOINT COMMITTEE ON EDUCATION, AMERICAN VETERINARY MEDICAL ASSOCIATION Veterinary Medicine is concerned with the protection and improvement of the health and welfare of our nation. It embraces medical and scientific knowledge essential to the continuing battle against all diseases of both animal and man. The veterinary profession not only safeguards the health of our $50,000,000,000 livestock industry but it shields the human population from scores of animal diseases which may affect man. Eradicating major livestock diseases, many of which are communicable to man, has freed this country from the age-old threats to rural health. This is just one of the major responsibilities of veterinarians. Since the time of Pasteur, veterinary medical scientists have made significant contributions to the constantly expanding body of knowledge that constitutes medical science. Smith, Kilbourne and Curtice, while seeking means to control Texas Fever of cattle, which threatened the industry in the 1800's, proved that an arthropod tick was capable of spreading the disease. This work on Texas Cattle Fever provided the basis for Walter Reed’s work on the transmission of Yellow Fever by mosquitoes. A veterinarian, Dr. Schofield at the Ontario Veterinary College, discovered the chemical “dicoumarol” while investigating sweet clover poisoning in cattle which is important in the control of blood clotting in man. The French veterinarian Ramon, working on ways to protect the French cavalry horses from lockjaw, developed the first effective immunizing agent against a toxin. Successful methods of preventing tetanus, diptheria, and other diseases of man that are induced by toxins resulted from his work. Dr. Karl F. Meyer of the University of California devised means to control botulism in canned foods making a great canning industry possible at a critical time. Dr. William Feldman, formerly of the Mayo Foundation and now with the Veterans Admin- istration, more than any one else, is responsible for emptying the nation’s tuber- culosis sanitariums of patients formerly doomed to something akin to life imprisonment. This veterinarian brought to the human medical community the methods successfully used to control T.B. in cattle and in addition conducted valuable research which led to the successful treatment of tuberculosis in man. Otto Stader, a practicing veterinarian, developed a revolutionary method to reduce fractures in animals. Many American servicemen, particularly World War IT servicement, owe their arms, legs, and jaws to the Stader splint which in its time was an important contribution to fracture repair. The use of oral polio vaccine was backed by fifteen years of experience with the successful use of oral vaccines in animals, These are but a few of the hundreds of examples of the ways veterinary medical research and veterinary medical personnel have benefited the health and welfare of man. There is a kinship of animal and human diseases. We now know of more than 100 diseases of animals that may be transmitted to man, with resulting illness 147 or death such as brucellosis, leptospirosis and rabies. We also know that knowl- edge of human disease has been greatly advanced by producing disease in experi- mental animals. It now appears that there is much to be learned from animal diseases that occur naturally. I want to call your attention to a study made by Dr. D. Carlton Gajdusek of the National Institute of Neurological Diseases and Blindness. There was a peculiar degenerative disease of the brain afflicting tribes in an area of New Guinea. The disease is invariably fatal and is known as Kuru. Several aspects led Dr. Gajdusek and other workers to suspect an infectious agent was implicated ; however, they were unable to prove it. A break came in 1959 from the work of Dr. William Hadlow of the National Institute of Allergy and Infectious Diseases now at the Hamilton Laboratory, who is a veterinarian and who was in England studying Scrapie in Sheep which is one of the chronic or slow virus diseases. Dr. Hadlow made the observation that in viewing tissues under the microscope, there were many similarities between Scrapie and Kuru. Dr. Gajdusek and his colleagues took up this lead. One of the main efforts was to see if a viral agent could be isolated as the cause of Kuru. Work by Dr. Hadlow on Scrapie showed that the incubation period could be two years or more. Based on this information Dr. Gajdusek waited at least five years for the results of inoculating with mate- rial from the brains of New Guinea tribesmen who had died of Kuru. In the program of inoculation the group used several species of chimpanzee, the primate most clearly related to man. Eighteen months after the chimpanzees were inoculated one of the eight chimpanzees began to show neurological apnormalities. During the next three months two more chimpanzees became ill. Examinations of neurological material from the chimpanzees showed that the disease closely resembled human Kuru. Another thread in this story leads back to multiple sclerosis. veterinarians working in the Institute for Research on Animal Diseases in England and veterinarians from the University of Iceland, injected sheep with material from the brains of human patients who had died of multiple sclerosis. Several of the sheep developed a disease similar to the scrapie. It is possible that multiple sclerosis may be an infectious disease with a long incubation period, perhaps twenty years or more. This observation was made by Dr. David Pos- kanzer of the Harvard Medical School. Another example is the study made by Peyton Rous of the Rockefeller Uni- versity who shared the Nobel Prize for Psysiology in Medicine for his work on the sarcoma which appeared in chickens. He succeeded in transplanting the tissue to other chickens and developed the work which has led to extensive studies of viruses as possible causes of cancer of both man and animals. Many of these animals disease models are better suited for studies on the nature of disease and improved methods of treatment than are sick people. Hence, research on these diseases contributes directly to the health of people by increasing our understanding of disease and disease-processes in man. Chronic and degenerative diseases such as cancer, stroke, heart disease and emphysema, have become the chief killers and disablers of the American people. Many of these diseases occur under natural conditions in lower animals, and veterinarians have a unique opportunity to provide and study these models of disease for research. A veterinarian’s education and training requires much the same facilities as the other branches of medicine and the health sciences. There are many examples of the relationship of schools and colleges of medicine to the schools and colleges of veterinary medicine. Although it has been pointed out to this committee previously, I should like to mention the develpoment of a new School of Medicine and the development of new facilities for the School of Veterinary Medicine at the University of California, Davis. Although, these two schools will be maintained as separate academic units they will be closely related physically and functionally, particularly in the common facilities which they will be sharing. It is my understanding that many faculty appointments will be shared by both schools. Their objective is to obtain a maximum productive interaction between these two kinds of medical schools and to provide a setting that will promote cooperative teaching and research ventures. The development of the new Medi- cal School in Michigan State University is very similar to the development at Davis. There are common facilities and particularly in the preclinical depart- ments in which the veterinary students and the medical students will he taught 148 in the same departments. There are other examples of close working relation- ships, although physically not as closely related at the University of Minnesota and many other institutions. One of the best summaries of this whole matter of animal and human disease relative to their public health implications was stated by Dr. LeRoy Burney when he was Surgeon General of the Public Health Service at the 75th anni- versary of the University of Pennsylvania, School of Veterinary Medicine which is, “We meet on ground that has fascinated biologists for years, namely the re- lationship of health and disease in man and animals to environment. Man has made many of his disease problems; he has also improved his health by altering the environment to his advantage and by changing his habits. Public Health and Veterinary Medicine with their modern armamentaria for the protection of human and animal life can work together for further advances in human ecology.” As shown in the preceding testimony, veterinary medicine is an essential com- ponent of the health manpower of this nation and the Schools and Colleges of Veterinary Medicine are a national resource for the education of this health manpower. This national character and the need for strong federal support of veterinary medical education is dramatically emphasized by the fact that at present the taxpayer of only 17 of the 50 states are supporting the 18 Schools which educate all of the veterinary medical students in the United States. We appreciate the assistance which this Congress and the Administration have provided for construction of teaching facilities and student loans as well as the inclusion of scholarship and special project grants in the present legislation. These will be most helpful in assisting the Colleges to expand and meet the demands for an increasing number of veterinarians. At this time we wish to express our support for the proposed Health Manpower Act of 1968. However, the failure of S. 3095 to include veterinary medical institutions in the basic improvement grant will make it very difficult to improve and strengthen the teaching program and faculty to provide the increased health manpower that is needed. For these reasons we strongly recommend that S. 3095 be amended to include veterinary medical schools along with medical schools in other health professions as recipients of basic improvement grants. The Cramrman. I might say to Dr. Greene that I had a telegram this morning from Tuskegee Institute expressing the same position you have. Dr. Greene. I am glad to hear that. The Cramman. Dr. Price, is there anything you would like to add ? Dr. Price. Yes; I am Dr. Alvin A. Price, dean of the College of Veterinary Medicine at Texas A. & M. University. I would like to present a short statement on S. 3095 relative to the contributions of veterinary medicine to food production and consumer protection. The prospect of peace between nations of the world and the prospect of civil tranquillity within our own Nation are closely related to a most powerful freedom—freedom from hunger for all people. Wars and civil strife may be caused by factors other than hunger, but where there is starvation there can be no peace. Two-thirds of the world population lives in food-deficit areas, and 60 percent of these people suffer from malnutrition or diseases aggra- vated by malnutrition. Only 10 countries of the world have food sur- pluses and they contain only 15 percent of the world population. Hunger claims 3 million lives each year, and 50 percent of the popula- tion in many developing countries die before the age of 15 years is reached. The North American’s daily diet includes an average of 66 grams of animal protein. In Africa, only 11 grams are available, and in Asia, the figure is 8 grams a day. The Cratrman. There is quite a difference, is there not ? Dr. Price. Yes: there is. 149 We might ask: Why is America so far ahead of any areas of the world in available animal protein foods? The answer must include the investments which America has made to create a great reservoir of veterinary medical knowledge and manpower. Dr. M. R. Clarkson, executive secretary of the American Veterinary Medical Association, said in a public symposium of the National Re- search Council of the National Academy of Sciences last June: I suggest that the greatest single obstacle to meeting the world’s requirements for food products of animal origin is the crippling and unnecessary drain in- cessantly inflicted upon these resources by major infectious and parasitic animal diseases. The Cramaan. A veterinarian is the man who has to take care of this? Dr. Price. Yes, sir. A statement by the National Academy of Science last year spoke to the essentiality of veterinary medical services when it said: That animal diseases are economically crippling is clearly evident. That they are unnecessary has been amply illustrated wherever the introduction of veteri- nary medical service has led to the control of once rampant animal diseases . . . Faced with the two-pronged task of feeding its own growing population, and rendering aid to those struggling desperately for the basic necessities of life, the United States can no longer afford any delay in opening up to its fullest a source of food unequaled by any other reservoir of life-sustaining substance . . . The National Academy of Science calls upon and urgently requests the Federal Government and the scientific community in every stratum of its endeavors to join hands in establishing, developing, and supporting accelerated national and international programs aimed at the control and eradication of animal diseases. Annual savings resulting from the elimination of bovine piro- plasmosis (Texas fever) from the United States equal the total cost of its eradication. The control of bovine tuberculosis provides a mone- tary savings every 2 years equal to the cost of the control program. Although individually less spectacular, there are a host of more in- sidious, yet debilitating, animal health and parasite problems which collectively are such costly handicaps to efficient, productive, and profitable livestock production that the United States can no longer afford to delay their control. The costs of animal diseases vary from 15 percent of potential ani- mal yield in the developed countries to as high as 50 percent in some of the developing countries. These great losses have been endured for many, many years. The Craamyman. They have not had the veterinarians, right ? Dr. Price. That is correct, sir. These great losses have been endured through the ages, but there is now a new and pressing urgency to limit this unnecessary toll. We have a crucial challenge before us, one which is made sharp by physical states of desperation. The challenge is to raise the level of animal health and productivity in the United States and throughout the world to meet the essential animal protein food needs of an ex- panding population. I have written, in my written statement, five things that must be done to accomplish this. For brevity, I will list only two here. The Cramrman. I think that is important, that quotation you have from the National Academy of Science. Dr. Price. It is very important, yes. 150 The No. 1 point here in doing this job is that research on the diseases of food-producing animals must be increased. There is a developing imbalance of research fund support for diseases of animals related to food production as compared to diseases of animals with direct human health implications. The latter merits support and should be continued and increased. However, if the former is not brought along- Ji man can become the healthiest starving critter the world has mown. 2. Veterinary medical manpower must be increased. At the fastest possible rate which can be accomplished in the most efficient of educa- tional process, it is estimated the United States will have inadequate veterinary medical manpower in 1980, with prospects of even more acute shortages beyond that point. The Cratrman. That means we have to start now. Dr. Price. Yes, sir. We should have started earlier. The Caairman. We should have started about 1950. Dr. Price. Yes, sir; that is so true. The meat markets of this country are, for the most part, well stocked with good, wholesome meat of varieties and standards pleasing to the consumer. The customer can feel safe in his protection against trans- missible diseases through his meat supply. He consumes great amounts of meat, milk, and eggs each year and is confident that his health is protected, and he eats with pleasure and freedom from fear. Contrast this with the open, unrefrigerated, fly- infested and rodent-inhabited meat markets of many countries today where there is no effectively regulated meat and animal products in- spection system. Veterinary medicine plays a central role in consumer protection. As relates to safe and wholesome animal food products this role extends from the healthy herd and flock through £3 processing plants and marketplace to the very hands of the consumer. The American housewife can acquire, prepare, and serve to her family a nutritious, safe, palatable, and wholesome meal because there is surveillance by a guardian created in the due process of law. The system is costly, but in terms of consumer protection, it is one of the best and most productive of the investments Americans make. The veterinary services of the U.S. Armed Forces seeks procurement and delivery of safe and wholesome food supplies to our fighting men around the world. There is no other current system by which this im- portant job can be accomplished. The Wholesome Meat Act of 1967, and a Poultry Inspection Act are programs aimed to secure good food for American people. They, along with the Laboratory Animal Welfare Act, require additional veteri- nary medical manpower. The CaaRMAN. You have to have this personnel. Dr. Price. Yes, sir. The Congress is requested urgently to take the steps necessary to support and strengthen a valuable national resource—veterinary med- icine in the United States of America. The inclusion of veterinary medicine in all of the provisions of S. 3095, including the important institutional grant provision, and the passage of S. 3095 will give greater strength to veterinary medical 151 education and make possible its meeting the challenge it seeks to deliver for all people. ] Thank you sir. I appreciate your having us. ; The Cuamaan. We will have your statement appear in full in the record. (The prepared statement of Dr. Price, referred to, together with the other documents referred to, follow :) PREPARED STATEMENT OF THE AMERICAN VETERINARY MEDICAL ASSOCIATION I. FUTURE REQUIREMENTS FOR VETERINARIANS The American Veterinary Medical Association estimates that there are today approximately 26,000 veterinarians in the United States. This represents a ratio of 13 veterinarians per 100,000 population. However, in 1961 the Senate Commit- tee on Government Operations estimated that to adequately serve the health needs of the United States, 17.5 veterinarians per 100,000 population would be needed by 1980. This would mean 44.100 veterinarians for a population estimated by the U.S. Bureau of the Census to reach 252 million by 1980. Although American colleges of veterinary medicine at present are graduating approximately 1,000 veterinarians per year, in the next 12 years approximately 600 veterinarians per year will be lost to the profession due to death or retire- ment. Consequently, unless student enrollment in veterinary colleges increases substantially, only about 31,000 veterinarians will be available in the United States in 1980—more than 13,000 short of the estimated need. In order to implement the total needed expansion of veterinary education, additional colleges must be established, existing colleges remodeled and expanded, the training of veterinary teachers must be accelerated, new teaching staff must be added and instructional and research programs adequately funded, and addi- tional loan funds and scholarships made available to academically qualified students from lower income families. To earn his Doctor of Veterinary Medicine degree, a student must complete a minimum of 2 years of pre-veterinary college training, and an additional 4 years of professional training in a college of veterinary medicine. The average graduate veterinarian, however, has studied more than 7 years to earn his D.V.M. degree. In the public interest, passage of the Medical Manpower Act of 1968 is urgently needed. Its enactment would enable the veterinary profession to provide : a. Necessary buildings to increase enrollment in existing veterinary medical colleges In 1967 at least 3 qualified applicants were turned away for each one accepted in American veterinary colleges. The limited capacity of our veterinary colleges is especially distressing at a time which is suffering from an acute and growing shortage of veterinarians. Lack of funds for the construction of new buildings and building additions poses the principal obstacle to increasing student enroll- ment at most colleges. b. Stable, long-range funding for research, instructional programs, and efficient administration The heavy emphasis in our society on research and public health exerts a substantial influence on veterinary medical education. It requires additional fac- ulty competent to teach highly specialized subjects ; the acquisition and operation of modern, sophisticated teaching aids; the development and long-range funding of research-oriented instructional programs; the establishment of multiple- service laboratories; multiplication of seminars and self-learning courses of all kinds, and the expansion of personnel to coordinate and administer these programs. c. Establishment of new veterinary colleges There are 18 colleges of veterinary medicine in the United States. Even with expansion, these colleges will be unable to supply all the veterinarians needed 1 Committee Print 9 of the 86th Congress, Second Session, entitled ‘“Health in the Smopieas ond the Pan American Health Organization”, dated May 9, 1960, as printed on page 88. 152 in the years ahead. Moreover, many qualified students from the 33 states lacking a veterinary college find it impossible to obtain a veterinary education. In recent vears, several states have considered establishing new veterinary colleges but have postponed action because of the high cost of construction, maintenance, staffing and operating a college of veterinary medicine. d. Loans and scholarships to veterinary medical students to finance their education A survey of deans of American veterinary colleges reveals that (1) many students are unable to achieve an acceptable level of scholastic performance in their professional studies because of the necessity to work excessively long hours at part-time jobs to support themselves, (2) many students who would prefer to be veterinarians elect other degree programs because of their inability to finance 6 or more years of veterinary education. II. JUSTIFICATION FOR FEDERAL SUPPORT Veterinarians for the 50 United States are supplied by 18 veterinary colleges in 17 states. Consequently, they are national resources in the fullest sense. It is eminently logical, therefore, that federal support be extended to these colleges. Because of the high cost, it is unlikely that each state can support a college of veterinary medicine on its own. Therefore, each veterinary school will con- tinue to enroll students from states having no veterinary college. For the foreseeable future, existing colleges probably could supply the needs of their own 17 states with state funds. But it is unreasonable to expect these states to finance the total expansion of veterinary medical educational facilities that is required nationally to meet the growing need for veterinarians. In some parts of the United States, those states without veterinary medical colleges have entered into agreements with schools in nearby states. However, even where a contract exists, the percentage of applicants admitted from con- tract states is much smaller than that from the state in which the school is located. Obviously, equal educational opportunity does not exist for aspiring veterinary medical students throughout the United States. Passage of the Medical Manpower Act of 1968 would do much toward providing equal educational op- portunity for all students who wish to study veterinary medicine. Modern veterinary medicine has achieved a high level of scientific sophistica- tion and performance. Its contributions to human health and welfare establish veterinary education as a precious national resource which must be supported and promoted in the national interest. III. THE SERVICES OF VETERINARY MEDICINE TO SOCIETY 1. Animal health protection Farm Animals.—Approximately 10,000 veterinarians care for the nation’s farm animals. These practicing veterinarians protect the health of farm animals supplying protein food vital to healthy human nutrition. The demand for pro- tein food is increasing and will continue to increase in order to meet the needs of a rapidly increasing population. The veterinary practitioner also cooperates with state and federal veterinarians in the eradiction or control of major livestock diseases many of which, such as tuberculosis and brucellosis, are communicable to man. Veterinary service and counsel on animal health problems is supplied mainly by the farm animal practitioner. Veterinarians are currently responsible for the health of 108.5 million cattle, 51 million hogs, 24 million sheep, 435 million poultry, and 31 million horses. The combined inventory and production value of the nation’s livestock was 41 billion dollars as of January 1, 1967 (U.S.D.A. estimate). Pets and Recreational Animals.—The veterinarian who concerns himself with the diseases of pets and pleasure animals enhances the emotional well-being of their owners. Moreover, he protects man against diseases transmissible from pet animals, such as rabies, leptospirosis, bacterial diarrhea, ringworm, staphylo- coccosis, and psittacosis. The steadily increasing number of pet animals attests to their popularity and to the pleasure they provide. The maintenance of their health is a vital part of the profession’s contribution to society. 153 2. Government service U.S. Department of Agriculture.—Veterinarians are necessary to carry out many functions of state and federal government agencies in the United States. Veterinarians have been engaged in the eradication of livestock diseases including those communicable to man, since 1884 when the Bureau of Animal Industry became a part of the United States Department of Agriculture. Two diseases of particular public health significance, both of which are targets of a joint eradication effort by U.S.D.A. and the individual states, are tubercu- losis and brucellosis in cattle. Brucellosis in swine is another eradication target, because it is a major source of human brucellosis. Successful elimination of brucellosis in cattle and swine will not only largely remove the major sources of human illness, but will also reduce losses of animals through abortions caused by the disease. Veterinarians working either as members of federal and state government agencies, or as private practitioners, have been responsible for reducing losses to farmers from brucellosis from $90 million in 1947 to $12.5 million in 1967. As a result, reported cases of human brucellosis have dropped by 94 percent since 1947. In 1917, tuberculosis affected 1 out of 20 cattle; the disease affected only 1 in 3,000 in 1967. The death rate for tuberculosis in man in 1917 was 125 per 100,000. In 19635, it was 4.1 per 100,000. Although the reduction of tuberculosis in cattle is not solely responsible for the decline of the disease in man, it has played a major role. The joint efforts of government veterinarians and veterinary practitioners have been responsible for the near elimination of human extra- pulmonary and pulmonary tuberculosis of bovine origin from most of North America. The goal is to eradicate these two diseases completely in animals because until this is accomplished, people will continue to be victims of these diseases through contact with infected animals. Food Hygiene.—Veterinarians direct meat and poultry inspection programs for federal, state and local governments. This country enjoys the highest per capita consumption of meat and poultry in the world; approximately 200 pounds of meat are consumed by the average person each year. In response to the nationwide demand for consumer protection, Congress passed the Wholesome Meat Act in 1967 (Public Law 90-201) and Congress is now considering bills pertaining to inspection of poultry and poultry meat products. The above legislation requires hundreds of veterinarians to implement the new program. Veterinarians participate in food hygiene research and advise and assist in the development and maintenance of recommended ordinances regarding milk sanitation, poultry inspection, and sanitation of food service establishments. Animal diseases are of public health significance because some are transmissible to man through milk, meat, poultry and other animal food products. Food prod- ucts may also serve as vehicles of human infections, namely, typhoid fever, diph- theria, scarlet fever, and streptococcal infections. In fiscal year 1966, 104,988,350 animals were slaughtered under Federal Meat Inspection. Veterinarians direct all slaughtering and administer the over-all meat inspection program, as well as the humane slaughter law, which requires that animals be rendered insensible before slaughter begins. During 1966, over 264,992 animals at slaughter were condemned by veterinarians as unfit for human consumption. In addition, over 9,765,514 animal carcasses were tempo- rarily retained until diseased or affected portions were removed. (Federal Meat Inspection, A Statistical Summary for 1966. United States Department of Ag- riculture, Consumer and Marketing Service, February 1967, pages 2-12.) Department of Health, Education, and Welfare—U.S. Public Health Service.— In 1943 the U.S. Public Health Service organized a veterinary medical program and in 1947 established the veterinary officers’ corps. Members presently occupy key positions in a variety of programs throughout the Service. Veterinarians are today employed by the Service in the fields of milk and food sanitation, lab- oratory animal medicine, comparative pathology and physiology, industrial health, epidemiology, infectious diseases, air pollution, radiological health, can- cer and cardiovascular and kidney disease research. Food and Drug Administration—Veterinarians in the Bureau of Veterinary Medicine of the Food and Drug Administration are concerned with the protection ¥2-679—68———11 154 of human health. They develop scientific methods for detecting worthless or harm- ful drugs and assure that foods, drugs, and cosmetics are wholesome, safe to use, made under sanitary conditions, and truthfully labeled. They deter- mine the safety or danger of additives (such as antibiotics and other growth stimulating drugs) in feed consumed by food-producing animals to insure that meat, milk, or eggs are safe for human consumption. During 1967, the Bureau re- viewed 1,200 new drug applications. The Bureau also processed 7,700 applications for the use of new drugs in the manufacture of medicated feeds. Department of Defense.—Veterinary officers in the Armed Forces work closely with the Medical Corps and other health services wherever prevention of diseases and the promotion of the well being and efficiency of the soldier, sailor and air- man is at stake. In addition to food inspection, veterinary officers help in main- taining surveillance over post or base sanitation, and are called upon to assist in controlling epidemic disease outbreaks where knowledge of the cause, source, prevention, and procedures for disease eradication is essential. The military veterinarian is also an important member of the epidemiological team. Military veterinarians assigned to the Walter Reed Institute of Research and the Armed Forces Institute of Pathology are directly concerned with the identifi- cation, control and eradication of the major animal diseases transmissible to man. In support of these basic objectives, veterinarians are currently engaged in areas such as pathologic examinations, research in nutritional diseases, basic studies in immunopathology, development of new vaccines and improvement of existing ones, studies in the pathogenesis of “standard” and “new” diseases of laboratory animals, and development of better biological systems for viral isolation studies. Aero-space and bio-astronautics research programs using experimental animals are conducted by Air Force biomedical teams. These studies on animals en- compass hyperventilation, anoxia, overpressures, radiation, deceleration, accel- eration, and related hazards, and stresses of space travel. Data derived from these studies are interpreted with a view to man. Some 60 Air Force veterinary officers with post-doctoral training in medical-scientific disciplines such as pathology, laboratory animal medicine, food technology, radiobiology, physiology and toxi- cology, serve as essential members of the biomedical research teams. These highly trained veterinary officers provide the Air Force Medical Services with a research capability and a reservoir of knowledge and skills in widely diversified areas. Military veterinarians have made many contributions to the health and com- fort of civilians. Perhaps the broadest service of the military veterinarian to the health of the public was the establishment and maintenance of minimum stand- ards of sanitation in many thousands of food producing and processing establish- ments throughout the country. Such establishments had to comply with military standards of sanitation in order to qualify for government contracts. As a result, quality control and improved sanitary methods were taught to a large segment of the American food industry. There were approximately 2,200 veterinarians in the military service during World War IL. 3. Institutionl work Teaching—Of the 18 colleges of veterinary medicine in the United States 17 are state institutions relying on state funds as their primary source of financial support. The 18 veterinary colleges employ approximately 1,400 veterinarians on their faculties, and in 1967-68 enrolled 4,623 students. Veterinarians are also employed by universities which do not have veterinary colleges, to teach students enrolled in agricultral and biological science programs, to conduct health- related research involving animals, and to care for university-owned animals. Veterinarians also are being employed in increasing numbers by medical schools in the areas of comparative medicine, pathology, epidemiology, and as laboratory animal specialists. Research.—In the United States, the total annual losses, of livestock and poultry and their products through disease, parasites and insect pests amount to about 2.7 billion dollars (Losses in Agriculture. Agriculture Handbook No. 291, Agricultural Research Service, U.S.D.A., August 1965). The need to increase the effectiveness of animal disease control is urgent not only because animal diseases are economically wasteful, but also because many of these diseases are transmissible to man. In 1965, it was estimated that veterinarians in the animal health industry (pharmaceutical and biological) alone controlled a segment of industry valued at $600 million annually. Veterinarians hold positions of leadership in approxi- 155 mately 310 different companies operating in the chemical and pharmaceutical industries of the United States. Although many veterinarians engaged in research serve the areas of animal health, veterinarians play a vital role in industrial research and development of drugs and other chemicals consumed by man. The greatest recruiting fervor is in the field of toxicology. Veterinary toxicologists are primarily concerned with developing knowledge of the toxic potential of chemical substances, and their fate in the environment, in order to prevent poisoning. Veterinarians serve as directors of toxicology research for many of the major pharmaceutical com- panies developing drugs for human use. Veterinarians have pioneered in toxicologic research concerning space; en- vironmental hazards; pesticides; toxicants in food, air, and water pollution; and chemical warfare agents. Veterinarians’ activities include research in the discovery and development of drugs and other chemicals to be used as food additives in the treatment of human and animal diseases. After a new chemical is synthesized, the veter- inarian is responsible for determining the potential value of the chemical in treatment of disease. Before the chemical can be released for human trial, he must determine, through a long series of testing in many species of animals whether or not the chemical is toxic. Veterinarians in the biologics industry are engaged in discovery and develop- ment of new vaccines, serums, and other biological products of animal origins. Veterinarians have the responsibility not only for determining the value of potential products, but also for assuring both the safety and potency of the products. Federal veterinarians supervise activities in 58 companies licensed to produce biologics for disease prevention and as treatment. 4. Comparative medicine Since the time of Pasteur, veterinary medical scientists have made significant contributions to medical science. Smith and Kilbourne’s recognition that an arthropod could serve as a vector of an infectious disease, Texas fever, was a highly important medical discovery. Jenner's use of cowpox virus to immunize against smallpox, and Ramon’s success in producing an effective immunizing agent against tetanus in horses were medical milestones. Dr. Karl F. Meyer's work on botulism was hailed by medicine and the canning industry as a major accomplishment against this highly fatal food-borne disease. Commonly used fracture splints (Stader) and hip prostheses (Gorman), as well as spinal anes- thesia were first clinically (Benesch) developed by veterinarians in the treatment of animals. Today's widespread use of oral polio vaccines follows a 15 year period during which oral polio vaccine proved effective in animals. Hundreds of similar examples of the contributions of veterinary medicine to medical science could be listed. Current studies in comparative cardiology, cancer, connective tissue diseases, metabolism, hematology, muscle disorders and infectious diseases undoubtedly will yield similar results. Veterinary medicine occupies a particularly advantageous position among the sciences in its opportunity to make contributions to medical science. Nearly every member of the veterinary medical profession, whether he is engaged in private practice, regulatory veterinary medicine, or in research, constantly en- counters disease conditions in animals an understanding of which may contribute to medical science and the welfare of mankind. The profession has an obliga tion to exploit opportunities to study animal diseases to the extent of its resources. Many of the most prevalent and serious human diseases have counterparts in animals. Vital experimental procedures which rule out the use of man may be undertaken jointly by physicians and veterinarians on animals serving as experimental models. In this context, several animal diseases are receiving increased attention. Leukemias and Hodgkins type tumors occur frequently in domestic animals ; they are similar in most respects to their human counterparts. Other forms of cancer common in animals, particularly dogs, provide excellent opportunities for investi- gating these diseases with a view on man. There are respiratory diseases in animals which at present are largely un- explored, and which present distinct similarities to several important human diseases. Pulmonary emphysema of horses and cattle, and certain viral pneu- monias of cattle, sheep, and dogs may be cited as examples. Degenerative nervous disorders similar to multiple sclerosis in man are rep- resented in several animal species. 156 There are several collagen or immunogenic diseases, particularly in dogs, horses, mink and mice, which provide counterparts to such human ailments as rheumatoid arthritis, collagen associated Kidney disease, lupus, and certain forms of anemia. Some of the animal diseases known to be caused by viruses may provide answers to certain human problems. Cardiovascular diseases, particu- larly of older dogs, are common examples of other experimental models. Many more examples may be cited. The broad training offered in veterinary medicine, encompassing several animal species, provides an ideal background for the pursuit of such studies. Full utilization of the unique capabilities of vet- erinarians may well shorten the search for answers to many enigmatic human diseases. Many medical schools and hospitals engage veterinarians as full time faculty members in teaching and research. This permits emphasis on comparative studies to medical students and researchers and promotes collaborative efforts. A pro- gram of this nature is under way at the Johns Hopkins School of Medicine. Five veterinarians on the medical faculty are actively engaged in collaborative re- search in comparative medicine. More positions are open in other institutions but cannot be filled because of the dearth of trained veterinarians. 5. Laboratory animal medicine The expanding establishment of laboratory animal colonies in medical and dental schools, large hospitals, drug companies, feed manufacturing firms and other institutions has created an urgent need for veterinarians trained in laboratory animal medicine, which is closely allied to comparative medicine. Healthy, genetically defined laboratory animals are essential to medical research. What was generally acceptable 20 years ago as a laboratory mouse or rat would have little value today. As research becomes more sophisticated the demand for pedigreed rodents, either with known microbial flora or completely germ free, is rising. Laboratory animals are now used extensively in medical research. Studies on these animals have led to improvements in the health of both human beings and animals. An understanding of naturally occurring diseases of laboratory animals is necessary for the interpretation of results of experimentation. The National Institutes of Health now have a section whose veterinarians devote their efforts to the study of such diseases. There has been a continuing improvement of the health care and humane standards for the use of experimental animals, Veterinarians are ideally qualified to select or control the reproduction of healthy animals for medical research, to insure their well-being and humane treatment during the holding period prior to conducting experiments, and to provide proper post-experimental care. As a result of the passage in 1966 of the Laboratory Animal Welfare Act— which specified “adequate veterinary care” in the facilities covered by the bill— new and heavy demands are being placed on veterinary medicine to fill positions for laboratory animal specialists. 6. Zoonoses Zoonoses are infectious diseases of animals which are transmissible to man. There are over 100 known diseases, according to the World Health Organization, which people can acquire from animals. In the field of zoonoses the veterinarian plays a key role on the epidemiologic team. Rabies, associated with the bites of rabies infected animals, has been known and feared since antiquity. Veterinarians have played a major role in reducing the incidence of rabies in domestic animals, with corresponding reduction in human rabies. In fact, 1967 marks the first year in our history with no recorded deaths from rabies. However, an ominous development in recent years has been the increasing recognition of rabies in wild animals, notably in bats. More than 30,000 persons each year are bitten by suspected rabid animals and are required to take treatment. It will take a concerted effort to insure public protection against this new threat. Horses and man fall common victims to viral sleeping sickness (encephalomye- litis). This mosquito-transmitted infection is carried by apparently healthy wild animals and birds, and therefore is difficult to eradicate. Man and horses acquire the disease as a result of being bitten by infected mosquitoes, but do not spread the disease themselves. A veterinarian, Dr. Karl F. Meyer, of the Uni- versity of California, was the first to recognize virus encephalitis in American horses (1930), and the first to warn of the danger of this disease to man. A veterinarian, Brigadier General Raymond A. Kelser, of the U.S. Army Veterinary 157 Corps, was the first to show that the encephalitis virus is transmitted by mos- quito bites (1933). Salmonellosis, influenza, infectious hepatitis, staphylococcal infections, and internal parasitisms caused by the tapeworms of cattle and swine, are some of the diseases also capable of being transmitted by or from animals to man. Basic to the most effective progress toward suppressing the zoonoses are efforts such as those mounted in 1960 with the establishment of the Illinois Center for Zoonoses Research, a component of the University’s College of Veterinary Medicine. Unique is the multidisciplinary team approach of the Center toward as- certaining the factors that bear on emergency and recession of zoonotic diseases. The recognition that no one profession or scientific discipline, medical or other, has the total competence to solve complex problems of even a few of the zoonoses, a staff composed of veterinarians, physicians, anthropologists, ecologists, clima- tologists, demographers, microbiologists, zoologists and other scientists has ini- tiated already fruitful and promising programs. The World Health Organization’s Advisory Committee has pointed out that one should not overlook the dynamic and changing pattern of microorganisms, their adaptation to the new animal hosts, and their potential and actual trans- fer to human beings as pathogenic organisms. The Committee stated, “The emrerg- ence of new zoonoses or the uncovering of unsuspected human-animal relation- ships in communicable diseases are therefore to be expected.” Recent emphasis has been placed on the transmission of disease from man to animal. In the past it was considered logical to assume that the animal could act as a reservoir of human disease. The reverse possibility, while equally logical, has only recently been given any serious thought. Since it is now rare for man to acquire tuberculosis from cattle, regulatory officials are becoming more acutely aware of the problem of cattle contracting the disease from man. The problem is not only reported in the United States, but also in other countries, including the Netherlands, Great Britain and Israel. 7. The foreign disease threat The concept of “prevention” has enabled veterinarians to protect this country from the importation of diseases that could adversely affect our food supply, eco- nomy and health. Over the past few years many animal diseases and parasites, once relatively confined to small areas, have penetrated the local defense barriers of other coun- tries. South African types of foot and mouth disease virus (SAT-FMD), African horse sickness and African swine fever have spread from endemic areas with dis- astrous results among the domestic animal populations. SAT-FMD was first reported outside of Africa in 1962—spreading to the Middle and Near East and subsequently into Iraq, Israel, Jordan and Syria, Turkey and Iran. Asian Type I FMD was reported in Israel and West Pakistan in 1964. It has since been reported in Russia with serious losses of livestock and now threatens the farm animals of Eastern Europe. The seriousness of this outbreak is emphasized by the lack of an effective protective vaccine for control purposes. African horse sickness spread to the Near and Middle East, subsequently to India, with the result that there has been a devastating reduction in animal transport and power in those countries depending solely on the equine species for such services. African swine fever spread into Portugal, Spain, and France, killing millions of swine. All of these could be brought to the United States to challenge all of our defenses against importation of disease. Lumpy skin disease of cattle, Rift Valley fever (an important viral disease of sheep, cattle and man) and East Coast fever (a highly fatal protozoan disease of cattle) are being reported in areas far beyond those of their origin. Great Britain has just experienced the most severe outbreak of foot-and- mouth disease in its history. According to the Animal Health Division of U.S. D.A., over 2,300 herds (415,800 animals) died or were slaughtered from the beginning of the outbreak to February 1968 in a campaign to eradicate this devastating disease. Diseases and pests continue to travel with man, animals and plants. In our modern world, international commerce in livestock and food products is ever increasing, providing many new opportunities for rapid spread of disease. In- ternational trade and travel continue to increase between areas that were formerly remote and not readily accessible. Man can and does, innocently or illicitly, carry with him items of food and plants that are hosts to disease 158 organisms. There has been a steady and rapid increase of this kind of traffic to the United States. Through inspection of imported animals, poultry, and all animal by-products, veterinarians prevent entry of foreign diseases into the United States. Of the 981,860 animals and 2,950,829 birds presented for import during 1967, 43,961 animals and 9,365 birds were refused entry because they were carrying diseases contagious to man and animals. During the same fiscal year, veterinarians in- spected and certified over 69,000 animals for export to foreign countries. Addi- tionally, more than 15.6 million pounds of meat and meat food products from foreign countries were condemned or refused entry in 1967 (figures supplied by U.S.D.A., Animal Health Division). 8. Radiological health Nuclear energy and its byproducts affect the biosphere in such a manner that their study necessitates a multidisciplinary approach. Because environmental medicine is the major theme of veterinary education, and because the impact of the environment is studied for many species of mammals and birds, veteri- nary medicine is an important discipline in radiological health. The Public Health Service has recognized the important contributions veteri- nary medicine can make to its various program activities, particularly in the area of biomedical research. The Service's Division of Radiological Health employs fourteen veterinarians. In most instances, these veterinarians have had specialized postgraduate training in radiobiology, radiological health, or asso- ciated specialties such as biophysics, radiation pathology, biochemistry, and similar fields. Further recognition of the importance of veterianary medicine is reflected in the radiological health training grant program sponsored by the Radiological Health Division; one of the most successful of these programs has been con- ducted since 1961 by the graduate school of the Veterinary Medical College of Colorado State University. The research projects include studies of the devel- opmental and aging effects of radiation exposure on large colonies of animals. The Atomic Energy Commission also utilizes veterinarians in planning and conducting research. Objects of their studies include the effects of radioactive isotopes on the biological systems of animals, and the movement of radioactive materials in food. Veterinarians on the staff of the U.S. Department of Agriculture conduct similar studies dealing, for example, with the effects of radioactive fallout on agricultural production. These studies include the development of remedial meas- ures that can alter the movements of radioisotopes in the food chain, including food animals, and reduce or eliminate the consumer's intake of radioactive materials. 9. Protection of environment One of the major concerns of health authorities today is the progressive con- tamination of our environment. Air and water pollution and food contamination concern the health community as never before. Veterinarians are aware of the responsibility they have in assuring the safe use of pesticides and food additives. The veterinary profession has contributed to research undertaken to study the movement of environmental contaminants through the food chain to man. More- over, veterinarians are in a position to influence the safe use of animal feed additives and pesticides by their clients and others. By example, in their daily contacts with the owners of animals, and through their employment in govern- mental and regulatory agencies, veterinarians are in the forefront of the battle against environmental contamination. UNIVERSITY OF PENNSYLVANIA, Philadelphia, Pa., March 25, 1968. Hon. Lister HILL, Senate Office Building, Washington, D.C. DEAR SENATOR HILL: My concern over certain provisions of the Health Man- power Act of 1968 prompts me to discuss with you particular aspects of the pro- fession of veterinary medicine and the urgent need for continued and expanded federal support of our nation’s schools of veterinary medicine. 159 The professions of human and veterinary medicine have long shared a common heritage. Although the early history of veterinary medicine was closely related to the cure and treatment of domestic animal diseases, this segment of veterinary science today is only one aspect included within the broad scope of this health discipline. Increasingly, the science of veterinary medicine is serving asa proving ground for the solution of problems related to the transmission, alleviation and treatment of human disease. Veterinarians today are providing answers to basic problems in public and environmental health, human nutrition and reproduction, food production and agricultural economics. Increasingly, practitioner-scientists trained in our nation’s 18 veterinary schools are taking their places beside others in the health professions to assure our citizens a continuity of comprehensive medical services which result in better health and more freedom from disability and morbidity than would be possible without the contribution of veterinary medicine to the total health cosmos of our nation. Today the concept of “One Medicine” is realistically supported by a dynamic collaboration as veterinarians, physicians, dentists and scientists in the allied fields of biomedicine work together to achieve maximal well-being for men and a healthier environment conducive to more productive living. Typical of the kinds of programs undertaken by veterinarians whose professional interest is directed toward studying the animal counterparts of human diseases are two major studies currently in progress at the University of Pennsylvania School of Veterinary Medicine. Dr. David Detweiler is engaged in a study to determine the post-mortem incidence of cardiovascular anomalies in dogs, the clinical evi- dence of heart disease and various parameters of cardiac function in healthy and diseased animals. Such studies have a direct correlation to the various kinds of congenital heart anomalies occurring in man. They also provide valuable infor- mation regarding the pathology, physiology and biochemistry of coronary artery disease and myocardial infarction, leading causes of death among human beings. In another project, a disease almost identical to human leukemia, bovine lympho- sarcoma, is being studied by a team of veterinary investigators under the di- rection of Dr. Robert Marshak. Health scientists have always been faced with the enigma that as certain kinds of diseases are eradicated or brought under control, other more complex diseases and associated problems rapidly assume the newly vacated position of urgent priority for study and solution. In the field of animal diseases, many conditions peculiar to our highly industrialized and technological society are con- ducive to the development of special kinds of problems which merit the serious attention of veterinarians. Such problems include the mass production of live- stock and poultry, concentration of animals in small geographic areas for feeding and economic management, transportation over long distances for marketing and breeding, and the addition of hormones, chemicals, drugs and antibiotics for increased growth and production. The close proximity of animal pets and animals which participate with man in sporting or relaxation activities multiply the opportunity for human infection with disease agents harbored by or transmissible from animal to man. For those interested in scientific research, the specialized kinds of experience which constitute the training of a veterinarian make his knowledge and skill of unique value in the design and execution of experimental animal models ca- pable of determining the projected effect on man of an outer space or subterranean environment. Veterinary scientists have been among the innovators of some of the original research programs designed to quantitate the effects of acceleration and deceleration on human and animal metabolism and problems related to ac- climitization at atmospheric pressures and composition at variance with those normally encountered by man. Many other opportunities for valuable contributions in the field of scientific research parallel these newer challenges in which many of our nation’s veteri- narians are engaged. The production of vaccines and antitoxins to control the spread of both human and animal diseases has traditionally been a field in which veterinarians have worked together with physicians, immunologists, bio- chemists, pharmacologists and scientists from many other basic and clinical disciplines. Many advances in human medicine and surgery, including develop- ing and perfecting open heart surgical techniques, hypothermia, the introduc- tion of improved drugs for anesthesia and splinting techniques for broken bones have been pioneered with the aid of veterinarians. Other essential areas of re- 160 search include the design and management of methods for insect and parasite control. Today about 50% of the nation’s veterinarians work with farmers and agri- cultural specialists to produce quality cattle, swine, sheep and poultry for human consumption. It is conservatively estimated that losses to the livestock industry incurred by the morbidity and mortality caused by animal disease and infection amount to 159% of total production annually. A considerable portion of the price the consumer pays for poultry, eggs, milk, meat and other animal products reflect losses to the farmer due to death and disease of animals he is unable to market. Estimations of the economic losses due to the six major disease problems among cattle, sheep and swine—mastitis, leptospirosis, bloat, hog cholera, erysipelas and brucellosis—range from 300 million to 500 million dollars yearly. Allied to the work of veterinarians in the field of disease eradication and control is the valuable assistance many veterinarians have given to our allies and to the lesser developed nations of the world as they have worked to rebuild or strengthen their livestock industries and improve their national economy. Veterinarians are engaged in a wide variety of programs and activities oriented to provide our citizens with more wholesome and economic nutrition. Some of these include improving the quality of meat products, solving problems related to the sanitary preparation, packaging and storage of food products, the effect of drugs, food additives and insecticide residues on food products and monitoring the food industry to insure that legal safeguards regarding product identification, preparation and quality are respected. Of the 100 diseases known to be transmissible from animal to man, about 30 occur with some degree of frequency in the United States of America. The effec- tive cooperation of veterinarians with other public health professionals has been specifically rsponsible for significant reductions in the incidence of rabies, tuberculosis, brucellosis, parrot fever and other diseases of man. At various re- search stations throughout the United States, veterinarians and other publie health officials are alert to the identification of animal diseases which are not presently found within continental United States. These activities have pre- vented the introduction of the dreaded hoof and mouth disease and rinderpest. Continuing research studies in the control and eradication of such diseases are essential because there is constant danger that such diseases may accidentally be introduced into our country at any time because of the ease and rapidity with which world-wide transportation functions as a disease vector. In order to insure our nation’s supply of manpower to staff these varied and challenging opportunities available today and tomorrow for those whose aptitude, ability and interest lie within the realm of veterinary medicine, our nation’s veterinary colleges need continued and expanding federal support. In order to fulfill their commitment te those eager, capable and deserving to pursue the arduous training necessary to qualify as a graduate veterinarian, our nation’s veterinary colleges urgently need federal funds to expand their teaching faculties. Currently, three qualified candidates are not admitted for every student that is admitted to veterinary school simply because teaching facili- ties are not available. Equally needed is financial support to completely equip and expand laboratories and clinical facilities and classrooms and to provide the means for the continuance of valuable fundamental and applied research. Loan and other plans to ease the financial problems associated with prolonged professional schooling must be made available to students in the basic veterinary science curriculum and to attract graduate students to the basic clinical sci- ences. Those with graduate training are urgently needed as teachers in the biological and physical sciences and to train others as research workers and as public health officials. Today veterinary medicine is so much a part of the health of man that this pro- fession and its future practitioners should receive the same consideration with respect to federal support as medicine and the other health professions. It is es- sential that basic improvement grants be continued and extended to our nation’s veterinary schools so that they can continue in their expanding contribution to our nation’s health. Sincerely yours, LurHER L. TERRY, M.D. 161 PREPARED STATEMENT OF THE GEORGIA VETERINARY MEDICAL ASSOCIATION, PRESENTED BY JESSE DERRICK, PRESIDENT, ATHENS, GA. The Veterinary Profession, while the oldest of the medical professions, is probably the least understood insofar as its importance and contributions to human health and welfare. Most familiar to the average citizen is the professional care provided for the animal population. The care of animal pets in our society is an essential and much appreciated service, but the major contribution to man’s well being has been the high level of professional care provided to the livestock population which serves as a source of food. Within recent years an additional responsi- bility of the veterinary profession has emerged to the forefront—participation in biomedical research programs to study and resolve the health problems of man. Within this sphere of professional activity, the Doctor of Veterinary Medicine assumes two major roles. First, he functions as an independent scientist studying disease processes in animals and providing basic biological data and knowledge which can be extrapolated to man. Each of us is already benefiting as a result of knowledge gained through the use of animals and the future resolution of major health problems such as cancer, heart diseases, mental health, and popula- tion control will, to a significant degree, depend on the availability of well trained scientists in veterinary medicine. Secondly, the increased use of animals as experimental models for biological research has placed a demand on the veterinary profession which far exceeds the ability of veterinary schools to train adequate members in the facilities pres- ently available according to a recent survey of the Institute of Laboratory Ani- mal Resources of the National Academy of Science. There are over 2000 institu- tions and facilities in the United States whose programs require the use of re- search animals. All of these need access to veterinary support by veterinarians specifically trained in the specialty of laboratory animal medicine, and, at the present time there are only 106 who have been certified by this Specialty Board. It is probable that the entire output of veterinarians from all the schools in the United States would be required to meet the existing need for veterinarians in laboratory animal medicine, and this is only one of the specialties in biomedical research dependent on the knowledge and special skills of the veterinary scientist. In addition to vastly increased activities of veterinarians in biomedical re- search, the recent passage of meats and poultry inspection regulations to protect the consumer requires increased number of veterinarians. Further, requirements are compounded by the increased need for animal protein food stuff in the world calls for more veterinarians to control diseases. The World Food Agricultural Organization estimates that a 509, reduction of losses from animal diseases in the developing countries is a realistic goal and that it would result in 259% increase in animal protein produced. This reduction in animal disease losses can come about only by an increased supply of veterinarians educated to conduct biomedical investigations to solve many of the problems resulting in death of animals and likewise in man where the diseases are trans- missible to man. The present occupations of veterinarians in the USA are as follows: 7 percent in large animal practice, 19 percent in small animal practice, 31 percent in mixed practice for a total of 57 percent of the veterinarians in the USA that are com- ducting practice. The remaining 43 percent are engaged in other activities such as teaching, research, consumer regulatory work for the government and industry. The need for veterinarians considerably exceeds the productive capacity of the present educational system. A long range forecast indicates that 40,000 veteri- narians wil be needed by 1980. This figure is 12,000 in access of what our present veterinary colleges can provide. Obviously the additional 12,000 veterinarians can be educated only by enlarging existing schools and building new schools. There are 18 schools of veterinary medicine for the 50 states of the USA and each serves more than the state in which it is located. The School of Veteri- nary Medicine, University of Georgia serves a total of five states : Georgia, South Carolina, North Carolina, Virginia and Maryland. Veterinary schools should be viewed as a national resource instead of a state resource and therefore partly supported by federal dollars in supplement to the appropriation from the state in which the school is located. 162 The demand for entrance into the professional program of the veterinary schools far exceeds the capacity of the existing schools. For example, the follow- ing numbers of eligible preveterinary candidates were interviewed for entry into the School of Veterinary Medicine at the University of Georgia: 1967 (1968)’ MDOT omic min oo ssi si i se spi Be Ss Se a IE Fe 49 (53) SOUT CAOPOII cc iis Sd mimi ie mist mitt Mim pcs iivoitg =e So Sg ie 10 (14) NOLEN CABO ccc msi Bird ef ii et 5 10 (13) NI AN ini emimmsii ee e S ER TE S e 24 (30) IBRERVEIL, ei iin rss sg io mmm no ml ooo on om o pm 28 (46) TOL ce ins misc imo ssi oo i og Sr i121 (156) 1 Tentative. The figures above in parentheses are approximately for 1968 because interviews are now in process and the academic year for determining eligibility is not com- pleted. All of the above candidates have exceeded the average college student grade point and have survived elimination on personal interview examinations conducted within each state. From this total the University of Georgia accepted 64 students for the entering class of 1967; not all of these will be graduated because of the normal attrition-rate. If federal assistance in the form of an institutional grant were available for improving our present educational plant, and if a constructions grant were available for building an addition to the present schools of veterinary medicine, we would have matching state funds to increase the size of our entering class to a minimum of 85 students for an increase of 33 percent. From the above discussion the critical importance of S. 3095 (Health Man Power Act of 1968) in support of veterinary education is obvious for the South- eastern States. This bill would provide vital support for construction grants, student loans, and scholarship grants in the 18 schools of veterinary medicine in these 50 states. It is unfortunate that veterinary schools have not been declared eligible to receive institutional grants under 8. 3095 in view of the direct contribution of veterinarians to biomedical research, public health and consumer protection. The importance of educating veterinarians to protect the health of man is incontravertible. We cannot emphasize too strongly the importance of making schools of veterinary medicine eligible for institutional grants under this Bill. THE UNIVERSITY OF GEORGIA, Athens, Ga., March 23, 1968. Hon. Lister HILL, Chairman, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C. DEAR SENATOR HILL: The University of Georgia has a profound interest in your bill, 8. 3095, entitled: Health Manpower Act of 1968. Therefore, I am at- taching an expression of general and specific opinion on behalf of this University for the consideration of your committee. I sincerely hope your committee will include veterinary schools among those eligible for institutional grants under the provisions of this bill. We deeply appreciate your continuing concern in the health professions and especially your efforts to safeguard the health of the nation by extending the Health Professions Educational Assistance Act. Sincerely yours, Frep C. Davison, President. Enclosure PREPARED STATEMENT OF THE UNIVERSITY OF GEORGIA, SUBMITTED BY Frep C. DAVISON, PRESIDENT The Role of Veterinary Education in Agriculture is of traditional and obvious importance because of the necessity of controlling and eliminating diseases of animals producing food for man. However, an increasing and even greater role for veterinary education is training new graduates to function as an independent group of scientists with a vital and legitimate role in biomedical research and 163 public health programs. The research contribution of veterinary scientists to basic health sciences by use of experimental animals is of tremendous benefit in solving problems afflicting and affecting the health of man. The study of com- parative medicine by veterinary biomedical scientists has provided many solu- tions to disease problems in man. All indications point to the increased use of experimental animals for research to solve problems of aging, cancer, heart disease and other fatal diseases that shorten or debilitate the life of man. In addition to vastly increased activities of veterinarians in biomedical re- search the recent passage of regulations for meat and poultry inspection to protect the consumer requires an increase in the number of veterinarians. The increased human need for animal protein food stuff in the world also calls for more veterinarians to control animal diseases. The World Food and Agricul- tural Organization estimates that a 50 percent reduction of losses from animal diseases in the developing countries is a realistic goal and that it would result in a 25 percent increase in animal protein production. This reduction in animal losses would result principally from an increased supply of veterinarians edu- cated to conduct biomedical investigations to control diseases causing deaths in animals and likewise in man when transmissible. Approximately one-half of the veterinarians in the USA are engaged in prac- tice. The majority of the others are engaged in teaching and research or in sup- porting positions such as laboratory animal medicine. The present occupations of veterinarians in the USA are as follows: 7 percent in large animal practice, 19 percent in small animal practice, and 31 percent in mixed practice for a total of 57 percent of the veterinarains in the USA who are conducting practice. The remaining 43 percent are engaged in teaching, research, consumer regula- tory work for the government, industry and in specialties such as laboratory animal medicine. The latter category is a prominent example of a new activity for which insufficient veterinarians have been educated. The demand for vet- erinarians with special qualifications in laboratory animal medicine to sup- port programs in biomedical research has appeared suddenly and is unfulfilled. A recent survey by the National Academy of Science identified about 2000 bio- medical research laboratories in th USA, which housed experimental animals and needed the services of a veterinarian. At present only 106 veterinarians hold board certification from the American College of Laboratory Animal Medicine. The entire output of veterinarians graduated from all the schools in the US this year would not meet the existing need for veterinarians in lab- oratory animal medicine, which is only one of the many specialties in biomedical research for which veterinarians are in great demand. The need for veterinarians considerably exceeds the productive capacity of the present educational system. A long range forecast indicates that 40.000 veterinarians will be needed by 1980. This figure is 12,000 in access of what our present veterinary colleges can provide during that period of time. Ob- viously the additional 12,000 veterinarians and be educated only by enlarging existing schools and building new schools. There are 18 schools of veterinary medicine for the 50 states in the USA and each serves more than the state in which it is located. The School of Veterinary Medicine, University of Georgia serves a total of five states: Georgia, South Carolina, North Carolina, Virginia and Maryland. Veterinary schools should be viewed as a national resource instead of a state resource and there- fore partly supported by federal dollars in supplement to the appropriation from the state in which the school is located. The demand for entrance into the professional program of the veterinary schools far exceeds the capacity of the existing schools. For example, the fol- lowing numbers of c¢ligible preveterinary candidates were interviewed for entry into the School of Veterinary Medicine at the University of Georgia : 1967 (1968)* BOTY. | nmin rss sian ess si dm as ooh So at 5 49 (53) South Carolina 10 (14) North Carolina 10 (13) WALTER cen sm isis messiness es ost os dct pss i so mi 24 (30) MATTIANM oc iim si ss i ds ep ev 28 (46) TPIT) cco m in o si t 0 121 (156) 1 Tentative. 164 The figures above in parentheses are approximate for 1968 because inter- views are now in process and the academic year for determining eligibility is not completed. All of the above candidates have exceeded the average college stu- dent grade point and have survived elimination on personal interview examina- tions conducted within each state. From this total the University of Georgia ac- cepted 64 students for the entering class of 1967 ; not all of these will be graduated because of the normal attrition-rate. If federal assistance in the form of an institutional grant were available for improving our present educational plant, and if a construction grant were avail- able for building an addition to the present School of Veterinary Medicine, we would have matching state funds to increase the size of our entering class to a minimum of 85 students for an increase of 33 percent. From the above discussion the critical importance of S. 3095 (Health Man Power Act of 1968) in support of veterinary education is obvious for the South- eastern states. This bill will provide vital support for construction grants, student loans, and scholarship grants in the 18 schools of veterinary medicine in these 50 states. It is unfortunate that veterinary schools have not been declared eligible to receive institutional grants under S. 3095 in view of the direct contribution of veterinarians to biomedical research, public health and consumer protection. The importance of educating veterinarians to protect the health of man is in- contravertible, We cannot emphasize too strongly the importance of making schools of veterinary medicine eligible for institutional grants under this bill. PREPARED STATEMENT oF W. R. PrrrcuArp, D.V.M., DEAN, SCHOOL OF VETERINARY MEDICINE, UNIVERSITY OF CALIFORNIA, DAVIS, CALIF. I am Dr. W. R. Pritchard. D. V. M., Dean, School of Veterinary Medicine, Uni- versity of California, Davis. I would like to make a statement about some con- tributions of veterinary medical science to human health and welfare, and com- ment on the critical financial problems facing American colleges and schools of veterinary medicine. I am sure that others will comment on many additional ways veterinarians contribute to human health and welfare. Veterinary medicine has evolved as that branch of medical science responsible for the control of diseases of all spices of animals except man. The D.V.M. applies the principles of biology and medicine to the alleviation of pain, suffering and ill health in animals serving man. He is responsible, too, for the protection of people from those animal diseases that also affect man. Most importantly of all, however, veterinary medicine makes highly significant contributions to the health and welfare of people through research by adding to our knowledge of diseases and disease processes. I shall try to briefly describe some of the unique ways that veterinary medical science contributes to human health. A RICH HISTORY OF RESEARCH ACCOMPLISHMENTS Since the time of Pasteur, veterinary medical scientists have made significant contributions to the body of knowledge that constitutes medical science. I shall cite only a few examples typical of many hundreds made by veterinarians. Smith, Kilbourne and Curtice, seeking means to control Texas fever of cattle, a disease threatening the cattle industry of this nation in the latter 1800s, discovered that arthropods, in the case of Texas fever a tick, are capable of spreading disease. This finding has proven to be one of the most important principles of infectious disease control. It has led to successful control of many important arthropod-borne diseases of people such as malaria, yellow fever, sleep- ing sickness, Chagas’ disease, and numerous encephalitides. A French veterinarian, Ramon, working on ways to protect French cavalry horses from lockjaw, developed the first effective immunization agent against a toxin. Successful methods of preventing tetanus, diphtheria and other diseases in- duced by toxins in people resulted from his work. Karl F. Meyer, D.V.M. of the University of California, devised means to con- trol botulism in canned foods, making the great food canning industry possible at a very critical time in its history. William Feldman, D.V.M., formerly of the Mayo Foundation and now the U.S. Veterans Administration, more than anyone else is responsible for emptying 165 the nation’s tuberculosis sanitariums of patients formerly doomed to something akin to life imprisonment. This veterinarian brought to the human medical com- munity the methods successfully used to control T.B. in cattle and, in addition, led the nation in research which resulted in the successful treatment of this disease. Otto Stader, D.V.M., a practicing veterinarian specializing in pets, developed a revolutionary method of reducing fractures in animals. Many Americans, particularly former World War 1I servicemen, owe their arms, legs, jaws and other bones to the Stader splint, which in its time was an important contribu- tion to fracture repair. The use of oral polio vaccine was backed by nearly 15 years of experience with the successful use of oral vaccines in animals. These are only a few of hundreds of examples of ways the health and welfare of people have benefited by veterinary research. ANIMAL DISEASE MODELS OF DISEASES OF PEOPLE It is becoming apparent that for nearly every disease of people there is a similar or identical disease in some species of animal. The animal may be a dog, cat, mouse, horse, rabbit, turkey, chicken, sheep, cow, deer, primate or even a fish. Many of these animal disease models are far better suited for studies on the nature of a disease and means to prevent or treat it than are sick people. Hence, research on these diseases contributes directly to the health of people by in- creasing our understanding of diseases and disease processes in man. Animal disease models of diseases of people are becoming increasingly im- portant to medical research. Chronic and degenerative diseases such as cancer, stroke, heart disease and emphysema have become the chief killers and disablers of the American people. Unfortunately, there is no adequate way to reproduce many of these diseases in animals for study. On the other hand, many of them occur under natural conditions in lower animals, hence veterinarians have a unique opportunity to provide medical science with models of these diseases for research. A veterinarian’s training and experience with the biology and diseases of these animals make him especially qualified to conduct research on the prin- ciples of disease and disease processes with these models. EXAMPLES OF USEFUL ANIMAL DISEASE MODELS (FROM THE U. C. SCHOOL OF VETERINARY MEDICINE) Veterinarians from the Western United States refer livestock, zoo, wild and fur-bearing animals, laboratory animals and pets with unusual diseases to our School's Veterinary Medical Teaching Hospital for intensive study. Many of these diseases are models of diseases of people, with valuable research potential. Hence, a veterinary school serves as an effective screening mechanism to discover and characterize models of disease in all kinds of animals that might be valuable research tools. Members of the faculty of our School have discovered or made significant con- tributions to the understanding of over 40 animal disease models of important diseases of people. I would like to briefly describe three of them. Emphysema.—Emphysema is a severe, progressively disabling disease of peo- ple. The prevalence rate is high in the United States and is increasing rapidly. In a recent year one of every 14 citizens receiving total disability payments from social security had emphysema. A similar disease also occurs in horses. A team of researchers composed of D.V.M.’s, M.D.’s and other health scientists initiated studies on emphysema in the horse in our School 6 years ago. This team has succeeded in reproducing emphysema in the horse; thus, for the first time, medi-. cal science has been provided with an experimental system in which to study cause, prevention and treatment of emphysema. The group, headed by Dr. Walter Tyler of the School of Veterinary Medicine, now is determining the role of air pollutants and other agents as possible causative factors of emphysema. Their results will be more important to human than to animal health. This important progress was made possible only because a veterinary and. human medical research team together attacked an important human health problem. Leukemia.—Leukemia is one of man’s most feared diseases. How would any of us react to the knowledge that one of our loved ones had this highly fatal 166 disease? How many people know that nearly everything known about the cause, spread and possible means of prevention of leukemia has been learned from studies on leukemia in animals. The most promising research on leukemia in the world today is being conducted on naturally occurring disease in mice, cattle, cats and dogs. We know that leukemia in the mouse is caused by a virus and have obtained excellent leads on how it is spread in cattle. Where would we be in leukemia research today but for these animal disease models? We probably would not have the foggiest notion of the nature of the disease and, indeed, might not have much of an idea about how to find out. If leukemia is ever brought under control, and we are confident that it will be, much will be owed to the animal disease researchers who discovered the models and have conducted research on them. Liver discase in man and sheep.—Exciting progress is being made in under- standing perplexing liver diseases of people as a result of the discovery by veterinarians in sheep of two diseases caused by liver function defects. One of these liver diseases in sheep is identical to Dubin-Johnson syndrome in man. Together they have provided medical science with its best “models” for under- standing liver function in health and disease. Both veterinary and human medical researchers are using these sheep for important research on liver disease in people. FINANCIAL CRISIS IN VETERINARY EDUCATION America’s schools and colleges of veterinary medicine face their most serious financial crisis in the long history of veterinary medical education. Because veterinary medical education must be offered at the graduate level and requires intensive instruction in the basic clinical and medical sciences, as well as a great deal of contact with animals, the cost is very high. Data obtained from the University of California indicate that the cost of veterinary medical edu- cation exceeds that of most medical schools. The reasons are clear. Instruction in veterinary medicine is at the same high academic plane as it is in human medicine. The students have completed, at least in our School, over 4 years of preveterinary medicine in strong schools and colleges. They enter our veterinary medical school with an average of more than a “B” obtained in some of the nation’s top colleges and universities. The course of study is very similar to that in a human medical school, except that all aspects of the program emphasize, in their laboratory and clinical portions, more contact with animals because the animal-—not man—will be the patient of the veterinarian. Consequently, more time must be devoted to animal aspects of laboratory exercises in anatomy, physiology, surgery, obstetrics and similar courses, than in human medical schools. This increases educational costs fantastically because animals used in veterinary medical programs, including those in anatomy, must be purchased and are not donated to veterinary schools as they are to most human medical schools. Adequate clinical instruction requires an abundance of animal patients for study. Unlike human hospitals, many of these patients must be admitted and cared for at a cost less than the real cost of the services rendered to the patient. This is true because the fee that can be charged is limited by economic factors and no medical insurance exists for animals. The cost of care is far greater than in private animal hospitals because they are used for teaching. Consequently, clinical education, by and large, costs a great deal and the activities of the veterinary clinician do not result in earning money for the veterinary medical program, as is the case of many human medical schools. The cost of operating a veterinary medical school amounts to approximately $7500 per professional student per year. The cost of educating an undergraduate student is far less than this. Consequently, legislators and university admin- istrators are sometimes unable to allocate sufficient funds to veterinary medical programs when the demand for educating large numbers of students cannot be adequately met. The problem is accentuated by the fact that since there are only 18 veterinary medical schools in the country, a significant number of students in all schools of veterinary medicine come from out of the state that supports a veterinary medical school. Consequently, legislators are reluctant to spend the required funds to adequately support a veterinary medical program. They reason that because a few states must educate all of the veterinarians for the entire United States, federal funds should be made available to assist in supporting veterinary medical educational programs. Their reasoning is hard to refute. 167 In my opinion, if veterinary medical schools are to meet their commitment to supply badly needed veterinarians for all types of service to society, at least 509% of the total costs of veterinary medical education must come from other than state sources. For our School this would amount to approximately $3,750 per student per year. DEVELOPMENTS IN THE CURRICULUMS OF SCHOOLS OF VETERINARY MEDICINE Schools of veterinary medicine throughout the nation currently are conducting searching examinations of their teaching programs. Teaching and learning in these schools is being scrutinized in greater detail than at any other period in the history of veterinary medical education. Good teaching is acquiring new respectability and, in turn, faculty interest in excellence in teaching has increased a great deal. New curriculums are being developed by most schools of veterinary medicine throughout the nation. Our School adopted a new curriculum in 1966 designed to better prepare graduates to fulfill the needs of the profession as the medical specialist who deals wtih diseases in all species of animals. We have concentrated on providing a fundamental education on the biology and disease of all kinds of animals to make it easier for veterinarians to adapt to the constantly changing nature of the profession. It also will better prepare them for the lifelong learning that is absolutely essential in order to keep up with developments in the profession. Veterinary medical educational programs already firmly established at the graduate level are providing opportunities for the first time for graduates to concentrate in certain disciplines, and hence acquire greater depth of knowledge in certain aspects of veterinary medical science. More responsibility is being placed upon the student in the learning process. More time is being made avail- able for self-learning activities, such as library study, work in instructional resources centers, more clinical study and more thorough work-up of cases, individual research projects and other similar types of self-study programs. A greater proportion of the class time is being devoted to discussions, seminars, workshops and problem-solving exercises rather than to lectures on materials that, in many instances, could be better obtained from textbooks, journals and other sources. One of the most important changes in veterinary medical curriculums is the effort to condition the graduate for lifelong learning. The D.V.M. can hope to obtain little more than an understanding of biology and diseases of animals and an introduction to clinical veterinary medical science while in school. The rest he must learn after graduation. Hence, one of the most important aspects of his education should be the attainment of proficiency in the skills of self-learning, the methods of finding answers, the techniques of problem-solving, and the motivation to continue to grow professionally for the remainder of his life. The incorporation of more self-learning techniques in the veterinary medical curricu- lums should assist in developing habits that will lead to successful lifelong learning. It must be remembered that all of these innovations increase the cost of education. Educational resources Many veterinary medical schools are beginning to incorporate in their teaching programs more of the important advances that have been made in the science and technology of education during the past few years. Programmed learning, new audio-visual techniques, greater use of models, computer-assisted educational programs and other innovations are being used to an ever increasing extent to improve the efficiency and quality of the veterinary medical educational process. Several schools are planning the development of medical education departments. Some are being developed in cooperation with schools of human medicine. It is the avowed intention of the Association of American Veterinary Medical Colleges and the Council on Education of the American Veterinary Medical Association to constantly improve the educational program of the U.S. Schools of veterinary medicine. Symposia and seminars on veterinary medical education are being held throughout the country in ever increasing numbers. This intense interest in the improvement of veterinary medical education is one of the most refreshing developments in veterinary medical schools that has occurred in the last half century. 168 SUMMARY In summary, veterinary medicine has made and will continue to make impor- tant contributions to the advancement of biomedical science. New knowledge about animal biology, diseases and disease processes is being obtained as a result of research being carried out in veterinary medical institutions. Studies on animal diseases that are similar to afflictions of people provide a highly unique mechanism by which important information on the cause, control and treatment of diseases of people can be made. Veterinary medical educational programs are as costly, or more costly, than human medical programs because many more animals are required in the teach- ing program of veterinary medicine and veterinary medical teaching hospitals do not earn incomes proportionate to human medical hospitals. Schools of veter- inary medicine are experiencing considerable difficulty in obtaining adequate state support because only 18 American veterinary schools serve the needs of the entire nation. Many states resent the expenditure of their own funds for educational programs that benefit other states. areat strides are being made in the improvement of veterinary medical edu- cational programs. New approaches to teaching and learning and research on medical education are being developed. The application of the latest advances in educational science is being incorporated into the teaching programs of most veterinary medical schools. STATEMENT OF DR. EpwARD C. MELBY, JR., AND DR. ROBERT A. SQUIRE OF JOHNS HorkINs UNIVERSITY SCHOOL OF MEDICINE, BALTIMORE, MD. This is to affirm support of The Health Manpower Act of 1968 and to urge an amendment which would extend institutional support to include veterinary medi- cine, for the contributions of veterinary medicine to human health in the field of comparative medicine and research are especially vital. It has become apparent that studying the naturally occurring diseases of ani- mals which are counterparts of human disease can make significant contributions to medical knowledge. To mention but a few, studies of the causes and treatment of such human diseases as leukemia, heart disease and inherited disorders, have good equivalents in animals and are being explored by applied and basic methods which could not be utilized on human patients. Veterinarians, because of their backgrounds in Animal Medicine are best equipped to perform many of the investigations. There are currently 10 veterinarians actively engaged in teaching and research in comparative medicine at Johns Hopkins. Five of these persons are in post- doctoral training programs which will prepare them for careers in comparative medicine. Several medical schools have formed departments within their facul- ties to develop similar programs and also to provide the necessary care for experimental animals for this has often been neglected. Medical schools are actively seeking personnel to staff these departments, but unfortunately the other demands of veterinary medicine continue to require virtually all available graduates. To impose limitations on the availability of veterinarians for careers in com- parative medicine will certainly compound the shortages already present, and the needs of the future population will be far greater. In consideration of the above points, we strongly urge the inclusion of veteri- nary medicine for institutional support under the Health Manpower Act. Cer- tainly the contributions of veterinary medicine to human health, both directly and indirectly, equal or exceed those of the other allied professions which are to receive this support. PREPARED STATEMENT OF T. S. WiLriaMms, DEAN, SCHOOL OF VETERINARY MEDICINE, TUSKEGEE INSTITUTE, TUSKEGEE, ALA. Senator Hill, I am pleased to have this opportunity to make this statement before your committee on the Public Health Administration Bill in support of the inclusion of Improvement Grants for Veterinary Medicine. I know that you have long recognized the great urgency for additional support for veterinary medicine. The present critical shortage of veterinary medical man- 169 power and concomitantly the dire need for adequate resources to overconie this shortage are matters of serious concern to the profession and our nation. This urgency is of critical concern to those of us so closely associated with the edu- cation of veterinarians who will be intimately associated with our nation’s total health and welfare. I know, too, that you are fully aware that, like our com- panion field of human medicine, there is no shortage of qualified applicants for the spaces available in our several school of veterinary medicine in this country. It is not likely that the inadequate resources now available for the existing enrollments can be expanded to permit the increase in enrollments needed in the next decade to meet the demands for veterinary services. More alarming is the fact that the present shortage of qualified teachers for our veterinary medical programs would be even more critical in any attempt to expand rapidly to meet the need for sharply increased enrollments. It is unfortunate, in our opinion, that so few of our citizens fully appreciate or recognize the contributions of the veterinary profession to public health. Veterinary medicine as one of the “healing arts” shares equally with others of the medical professions the responsibility for safeguarding the health of the nation’s public. Our first line responsibility is that of safeguarding the health of the nation’s animal population. Apart from this primary function, the present concept of the veterinary profession places the health of every living being fully within the scope of the broad range of our several professional activities. The full economic significance of the contributions of the veterinary profession to our nation’s public health canot be minimized. The veterinary practitioners are our first line of defense against diseases of our vital and ever expanding livestock industry. You know full well the benefits which have accrued as a re- sult of the cooperative efforts of veterinarians in both Federal and State Govern- mental service in the control of livestock diseases which are constant threats, not only to our livestock industry, but to the public health as well. Veterinary medical research singly or, as is often the case, in concert with allied medical scientists has been, and continues to be a significant part of research in prob- lems of human health. In our own reesarch laboratories here at Tuskegee In- stitute our research scientists are now working on problems of significant im- portance to human health. The veterinary colleges, since they are the source of veterinarians, are in a most important position to further these contributions to the eventual solutions of disease problems of animals and man. Our full po- tential is only limited by inadequate resources to do this significant work. All of our veterinary schools are faced with almost insurmountable financial problems as they endeavor to meet the challenges and demands placed on them as sources of the vitally needed veterinary personnel. We are particularly grate- ful for the assistance provided by Congress in the form of the Health Professions Educational Assistant Act which provides for Veterinary Educational Facilities Construction and Student Loans, but strong effort is now needed to provide basic operational fund assistance. Our own position, since we are located at a private institution, is stringently acute. We are being hard-pressed to provide justifica- tion to our administration for the excessive expenditures required to endeavor to keep abreast at the current level. Plainly stated, unless we can find a new source of financial resources we may not be able to continue as a source for veterinary education. The Basic Improvement Grants not now included for veterinary medicine would materially assist us in this financial crisis. Veterinary schools, since there are now only 18 in the country, constitute national resources, not local, state or regional, but vital national resources for needed health professional personnel. As such they merit national support; inclusion of the basic improvement grant would be a step by this Congress in the direction of assuming its rightful obliga- tion to the veterinary profession. Our own school is now trying to operate at a level that is 509, of the median operating cost for the schools in this country. This is truly an impossible situation. We must have assistance if we are to sur- vive. It is interesting to note that in the last data available on comparative oper- ating costs for colleges of veterinary medicine, at least seven of the 18 schools are operating at a level considerably below what would be considered a median operating level. This, gentlemen, indicates a critical financial picture for these vital educational institutions. It has been said that the “half life” of a veterirfary education is quite short; that so much of what we teach and what students learn is obsolete in a very brief 92-079—68——-12 170 period. This means that we must be ever alert to the changing needs for our curriculum. All of the veterinary schools must then constantly engage in the new curriculum development to endeavor to provide the most effective education for our students. Equally we must make a strong effort to provide continuing edu- cation for those already graduated to compensate for the short “half life” of their education. Simply put, then, our veterinary schools have an almost impossible task ahead in the face of inadequate resources of veterinary medical manpower and funds to do the multiplicity of responsibilities that are ours. We urge your favorable consideration of our request to restore to this proposed legislation Basic Improvement Grants for Veterinary Medicine. Tuskegee In- stitute strongly supports this inclusion and urgently needs your assistance. PREPARED STATEMENT OF DR. B. W. KINGREY, DEAN, SCHOOL OF VETERINARY MEDICINE, UNIVERSITY OF Missouri, CoLuMBIia, Mo. 1. One of the major developments during the past few years has been the unexpectedly heavy pressures on the veterinary medical profession to share the responsibilities of public health. This is first apparent on the university campuses where medical school faculty and veterinary medical faculty share the teaching of series of courses concerned with public health. At the University of Missouri there are eight faculty members from the School of Medicine with joint appoint- ment on the veterinary medical faculty. The same number of veterinarians share appointments in the School of Medicine. The arrangement is effective and shares the load with maximum benefit to medical students, veterinary medical students and graduate students. One of the major factors in the current advance of human health students during recent years has been the utilization of the living larger animals as models for the human in research. The pig alone has been utilized for the development of a long list of effective treatments. Each of many animal species have certain features that closely parallel the human. Thus members of the animal kingdom may be selected to form a battery that, in the composite, nearly duplicate the human. In the work utilizing animals to solve human health problems we find the veterinarian and the physician working in collaboration. This is a most re- warding and logical approach. However, the number of veterinarians required for participation in comparative medical research is depleting veterinary medical manpower in the more traditional areas. 2. The School of Veterinary Medicine at the University of Missouri has as the major and unyielding financial problem the lack of funds for facility construc- tion. In the competition for building dollars the sheer increase in student numbers causes the construction of additional classrooms to be highest on priority of con- struction programs. The demand by society for the annual graduation of more veterinarians is well documented. However, during the past 20 years the nation has responded by creating only one new college of veterinary medicine. This places great pressure on existing schools to expand their enrollments. Because veterinary medical facilities are expensive and because of the truly regional and national nature of the veterinary medical institutions it is a serious problem to find adequate funding for the construction of additional buildings to respond to the needs and demands of the nation. Pressure on existing facilities are also exaggerated by the mounting number of veterinarians seeking graduate training as well as the very real need for expansion of instruction through continuing education. On the University of Missouri campus alone the number of doctors of veterinary medicine pursuing advanced degrees increased from four in 1964 to 59 in 1967. Obviously facility construction must appear as an essential response to such responsibilities. 3. At the University of Missouri support through operational funds has been increased rapidly. The existing space has been equipped, staffed and supported to the maximum. Should additional space be made available the mapor opera- tional needs would be for modern teaching devices, suitable support for out- standing faculty and for the support of auxiliary staff. 4. Curriculum developments in the schools of veterinary medicine have been slow in their response to a changed environment. There is now a real need for substantial studies of the veterinarians’ activity and the identification and char- acterization of trends to enable present curriculum to be wisely remodeled. 171 [Telegram] MagrcH 19, 1968. Dr. FRANK A. Topp, American Veterinary Medical Association: It is my understanding that a hearing will be held tomorrow regarding the institutional grant bill (Senate file 3095). I hope that you will have the oppor- tunity to express our interest in this bill before the Labor and Public Welfare Committee of the United States Senate. It is in the best interests of the American people to amend the Public Health Services Act to extend and improve the pro- grams relating to the training of nurses and members of other health profes- sions. Universities must have added Federal support in order to provide quality instruction to perspective members of the health professions. It is vital to the public welfare that an increased number of qualified young people be trained as physicians, Veterinarians, nurses, and as members of other health professions. The Federal aid proposed in this bill will make it possible for the government to help prevent the critical shortage of qualified medical personnel which faces the Nation. GEORGE C. CHRISTIAN, Vice President for Academic Affairs, Towa State University. PREPARED STATEMENT OF W. W. ARMISTEAD, DEAN, COLLEGE OF VETERINARY MEDICINE, MICHIGAN STATE UNIVERSITY PROBLEMS AND PROSPECTS FOR VETERINARY EDUCATION IN THE 1970'S AND 1980'S It is sadly paradoxical that the prospects for adequate future support of veterinary education from state sources should dim at the very time when veter- inary medicine's contributions to human health and welfare are expanding at an unprecedented rate. Since World War II, the veterinary colleges have prospered in an environment of mushrooming university growth. State legislatures, which habitually appropri- ate funds on an enrollment basis, have supported the universities well during this period of postwar expansion. In turn, veterinary colleges have been well treated by their parent universities, even though veterinary enrollments have grown much more slowly than has enrollment of universities at large. Nearly all American veterinary colleges are located at large public universities where most of the college enrollment growth has been absorbed. The growing tendency of these universities to limit enrollment, plus the proliferation of two- vear colleges, now are producing a leveling-off of enrollments on most of the campuses where veterinary colleges are situated. Consequently, there will be less new money available to the universities and to the veterinary colleges than they have become accustomed to during the past 20 years. The veterinary colleges therefore must turn to sources other than the state legislatures for financial support to improve their educational and research pro- grams and facilities. Improvement must include several features: 1. Curriculum revision to modernize the education of veterinarians for many kinds of activities unthought of when present curriculums were designed. 2. Increased and improved research, including more basic research for the benefit of both animals and man. 3. More comprehensive post-DVM education (something legislatures are reluctant to support), to include : a. Formal graduate degree programs b. Residency and specialty training programs (no sources of support exist for these at present) c. Broader, more relevant continuing education programs 4. Expansion and modernization of facilities to accommodate further increases in enrollment and to permit the development of new areas of veterinary interest such as: a. laboratory animal medicine b. Comparative animal disease research c. Clinical specialty training d. Programmed, independent learning laboratories e. Genetic and nutritional disease research f. Modern toxicology 172 It is imperative that veterinary education receive increasing financial support during the next two decades because of the great and growing importance of veterinary medicine to human health and welfare. Because they must serve the 50 United States, the 18 U.S. veterinary colleges are a national resource in the truest sense. Moreover, because of America’s position of political power, wealth, and food productivity, American veterinary colleges also are a powerful asset to a world growing rapidly more crowded and more hungry. PREPARED STATEMENT OF ALVIN A. PrICE, D.V.M., DEAN, COLLEGE OF VETERINARY MEDICINE, TExAS A&M UNIVERSITY THE CONTRIBUTION OF VETERINARY MEDICINE TO FOOD PRODUCTION AND CONSUMER PROTECTION Food production The prospect of peace between nations of the world and the prospect of clvil tranquility within our own nation are closely related to a most powerful free- dom—{freedom from hunger for all people. Wars and civil strife may be caused by factors other than hunger, but where there is starvation there can be no peace. During the past five years, the population of Asia is reported to have risen 129, and in Latin America 17%. Food production in these two vast areas has increased 109, during the same period. The net result is that per capita food production has fallen 3% in Asia and 7% in Latin America. Two-thirds of the world population lives in food deficit areas, and 609% of these people suffer from malnutrition or diseases aggravated by malnutrition. Only 10 countries of the world have food surpluses and they contain only 159% of the world population. Hunger claims 3 million lives each year, and 509% of the population in many developing countries die before the age of 15 years is reached. Plants provide the world with 709% of the available dietary protein and 309 comes from animal sources. While both of these sources are important to human nutritional needs, animal products are superior in protein quality and require less bulk consumption per unit of protein intake. The North American’s daily diet includes an average of 66 grams of animal protein. In Africa only 11 grams are available and in Asia the figure is 8 grams per day. Why is America so far ahead of many areas of the world in available animal protein foods? The answer must include the investments which America has made to create a great reservoir of veterinary medical knowledge and manpower. Dr. M. R. Clarkson, Executive Secretary of the American Veterinary Medical Association, said in a public symposium of the National Research Council of the National Academy of Sciences last June: “On the whole . . . world animal agriculture today presents a vast potential for the production of foods, sufficiently large to satisfy the world’s need for animal proteins of high quality. Without in any way underestimating the economic, ecologic, and logistic factors adversely affecting the utilization of this potential, particularly in the developing countries, I suggest that the greatest single obstacle to meeting the world’s requirements for food products of animal origin is the crippling and unnecessary drain incessantly inflicted upon these resources by major infectious and parasitic animal diseases. Adequate disease control is the first and fundamental ‘must’ in successful meat, milk, and egg production.” A statement by the National Academy of Science last year spoke to the essen- tialty of veterinary medical services when it said : “That animal diseases are economically crippling is clearly evident. That they are unnecessary has been amply illustrated wherever the introduction of veteri- nary medical service has led to the control of once rampant animal diseases. . . . Faced with the two-pronged task of feeding its own growing population, and rendering aid to those struggling desperately for the basic necessities of life, the United States can no longer afford any delay in opening up to its fullest a source of food unequalled by any other reservoir of life-sustaining substance . . . . The National Academy of Science calls upon and urgently requests the Federal gov- ernment and the scientific community in every stratum of its endeavors to join hands in establishing, developing, and supporting accelerated national and inter- national programs aimed at the control and eradication of animal diseases.” 173 Annual savings resulting from the elimination of bovine piroplasmosis (Texas fever) from the United States equal the total cost of its eradication. The control of bovine tuberculosis provides a monetary savings every two years equal to the cost of the control program. Although individually less spectacular, there are a host of more insidious, yet debilitating, animal health and parasite problems which collectively are such costly handicaps to efficient, productive, and profitable livestock production that the United States can no longer afford to delay their control. The costs of animal diseases vary from 159% of potential animal yield in the developed countries to as high as 50% in some of the developing countries. These great losses have been endured through the ages, but there is now a new and pressing urgency to limit this unnecessary toll. The world has now undergone great and unprecedented changes which require more effective disease control if the livestock industry is to thrive and fulfill its potential in the production of food for man. America is the safest place in the world in which to invest in and produce live- stock products. We have a veterinary medical profession in this country which is unexcelled anywhere in all of history. Yet, in the United States alone, we sacri- fice to animal diseases and parasites a staggering 234 billion dollars worth of animal products each year. A United States population of 600 million people is not going to occur overnight some 100 years from now. It will be a progressive increase which has already begun. It is not futuristic and we must begin to face it today. The gap between existing food supplies and essential food requirements is changing, and the change is not for a better fed people. We have a crucial challenge before us, one which is made sharp by physical states of desperation. The challenge is to raise the level of animal health and productivity in the United States and throughout the world to meet the essential animal protein food needs of an expanding population. If the challenge is to be met, if hunger and starvation are to be conquered, then, increased attention must be given to the wastes of our potential food resources. A summary of the President's Science Advisory Committee Report on The World Food Problem, released June 18, 1967, said : “The report warns against the false hope that some ‘panacea’ will appear as an easy answer to worldwide food shortages and decries the publicity accorded to synthesis of food from petroleum, food from algae, and similar processes as raising false hopes and undoubtedly lessening public concern about the serious- ness of the food supply in the developing nations . . .” Five things must be accomplished in meeting the needs for animal health and in reducing the wastes of animal diseases: 1. Research on the diseases of food producing animals must be increased. There is a developing imbalance of research fund support for diseases of animals related to food production as compared to diseases of animals with direct human health implications. The latter merits support and should be continued and increased. However, if the former is not brought alongside, man can become the healthiest starving critter the world has known. 2. Veterinary medical manpower must be increased. At the fastest possible rate which ean be accomplished in the most efficient of educational process, it is esti- mated the United States will have inadequate veterinary medical manpower in 1080 with prospects of even more acute shortages beyond that point. 3. Veterinary medical diagnostic laboratories and an effective and accurate na- tional disease reporting system must be developed and expanded. From such a network can come the data so essential in animal health management. 4. Regulatory authority must be strongly supported and new laws and regula- tions provided as needed to control and or eradicate existing diseases and to prevent the importation of others from which this country is now free. 5. Greater emphasis, across this nation and in foreign countries, must be applied to the problem of ineffective or negative use of currently available animal health “knowhow.” Extending knowledge to the producer and continuing education for the graduate veterinarian must have high priority in the decade immediately ahead. We know how to do more than we do. Consumer protection The meat markets of this country are, for the most part, well stocked with zood, wholesome meat of varieties and standards pleasing to the consumer. The customer can feel safe in his protection against transmissible diseases through 174 his meat supply. He consumes great amounts of meat, milk, and eggs each year and is confident that his health is protected and he eats with pleasure and free- dom from fear. Contrast this with the open, unrefrigerated, fly-infested and rodent-inhabited meat markets of many countries today where there is no effec- tively regulated meat and animal products inspection system. Consumer protection is an unpopular and argued subject in some quarters. Why should the government protect a citizen who does not want this protection? The answer is clear. The majority of our people seek protection from that over which they have no individual control and look to collective protection through legalized governmental processes. The dissenters derive the benefits afforded the majority, and in this great land of ours, have a right to dissent. However, they do not have the right to deny the majority the collective protection it seeks. Veterinary medicine plays a central role in consumer protection. As relates to safe and wholesome animal food products, this role extends from the healthy herd and flock through the processing plants and market place to the very hands of the consumer. The American housewife can acquire, prepare, and serve to her family a nutritious, safe, palatable, and wholesome meal because there is surveillance by a guardian created in the due process of law. The system is costly, but in terms of consumer protection, it is one of the best and most productive of the invest- ments Americans make. The veterinary services of the U.S. armed forces seeks procurement and delivery of safe and wholesome food supplies to our fighting men around the world. There is no other current system by which this important job can be accomplished. The Wholesome Meat Act of 1967, and a Poultry Inspection Act are programs aimed to secure good food for American people. They, along with the Laboratory Animal Welfare Act, require additional veterinary medical manpower. Request The Congress is requested urgently to take steps necessary to support and strengthen a valuable national resource—veterinary medicine in the United States of America. The inclusion of veterinary medicine in all of the provisions of 8. 3095, in- cluding the important institutional grant provision, and the passage of S. 3095 will give greater strength to veterinary medical education and make possible its meeting the challenge it seeks to deliver for all people. SUPPLEMENTAL STATEMENT OF ALVIN A. Price, D.V.M., DEAN, COLLEGE OF VETERINARY MEDICINE, TEXAS A&M UNIVERSITY An important and significant part of the broad area of public health is the environment in which man lives, works, and plays. It is a scientific truth that health and disease are related to the conditions of the habitat in which a living individual resides. When the environment is polluted, contaminated, or otherwise not compatible with the physiological well being of the creatures living within it, the health of its living inhabitants will deteriorate. Therefore, public health is more than medicine. Public health depends upon the continuing surveillance and active programs of many disciplines, one of which is veterinary medicine. The contributions of veterinary medicine to public health have been docu- mented. The eighteen colleges of veterinary medicine in the United States are a national resource in that by far the majority of the veterinarians of the United States who are actively engaged in the practice of the profession were educated in those eighten collges of veterinary medicine. Through 1965, the currently exist- ing colleges of veterinary medicine had graduated over 25,000 veterinarians, more than the total number engaged in the profession in the same year. In addition to the educating of veterinarians, colleges of veterinary medicine are central to research in the area of animal health and disease. Human health, from the consumption of animal product foods to pets in the family household to the condition of wildlife in areas of recreation, is related to animal health. Biomedical research, in its broad application, is dependent upon the use of ani- mals Without veterinary medical care and study, these animals would not be the effective laboratory tools they are today and medical progress would be severely curtailed. 175 Colleges of veterinary medicine supply the trained manpower to maintain protein food producing animals in a high state of health and efficiency for the producer and consumer. America is the safest place in the world in which to invest in and rear livestock because its has a resource of trained veterinary medical manpower. Only 10 nations of the world -have agricultural surpluses and those are de- creasing. Those 10 nations contain only 159% of the world population. By the 1980's those surpluses may not be available to held feed the other 85% of the world population. About 409 of the world’s livestock is in the developed countries and these countries provide 80% of the world’s animal protein foods. If productivity in the underdeveloped countries which have 609% of the world’s livestock could be brought to the efficiency attained in the developed countries, there would be adequate protein foods for all. In the underdeveloped countries, 609 of the people suffer from malnutrition. Three million children die each year from causes related to or aggravated by malnutrition. Adequate animal protein foods are desperately needed to reduce the tide of starvation. Improved animal health can go a long way toward achieving such a goal. Colleges of veterinary medicine throughout the United States lack the necessary facilities and operation capital with which to train the number of veterinarians needed in this country. Salary scales for faculty and staff are less than those ‘required to attract and maintain the personnel with the qualifications essential to the teaching and research programs. Especially critical in some of the colleges is the inability to employ and retain qualified subprofessional personnel. The 18 colleges of veterinary medicine are mostly state supported and the 17 states in which colleges are located cannot carry the full load for the entire nation. More states should build and finance colleges of veterinary medicine. This is not likely to happen without Federal assistance. Basic improvement grants to currently existing colleges of veterinary medicine are sorely needed to make improvements in weaker areas of the total college programs. Strong areas can achieve support more easily than weaker ones. Con- sequently, the strong grow stronger and the weak grow weaker. This does not achieve the total goal of efficiency and effectiveness toward which all colleges wish to move. Two relatively new programs have become the obligations of colleges of veterinary medicine and for which the colleges are not equipped, staffed, and adequately supported. These programs are: (1) the training of auxiliary per- sonnel, and (2) continuing education. Both of these programs are extremely important in the total veterinary medical manpower pool and in the updating of former graduates. Because these programs are not adequately supported and because the colleges cannot default in these great needs, these programs are eroding the already inadequate resources of every veterinary medical college in the country. Formula based and continuing Federal assistance to all colleges of veterinary medicine is desperately needed for achieving the laudable goals of these two programs. The Congress is urged to lend a sympathetic ear and a helping hand in the crisis which is upon the veterinary medical colleges of this great nation. By so doing, veterinary medicine can continue to play the vastly important role in helping to make America stronger and the people of the world a better fed and healthier population that some day the people of all nations may live more comfortably in a more tranquil environment and in peace one with the other. PREPARED STATEMENT OF CLARENCE R. CoLE, D.V.M., PH. D., REGENTS’ PROFESSOR OF COMPARATIVE PATHOLOGY AND DEAN, COLLEGE OF VETERINARY MEDICINE, THE OHIO STATE UNIVERSITY, COLUMBUS THE PROFESSIONAL ROLE OF DOCTORS OF VETERINARY MEDICINE AND NEED FOR FEDERAL SUPPORT OF VETERINARY MEDICAL EDUCATION SUMMARY Veterinary medicine is one of the health professions concerned with the health and well-being of animals and man, the control of diseases transmissible from animals to man, and discovery of new knoweldge in comparative medicine. The broadening role of professional activity pertaining to human health, coupled 176 with a rapidly increasing population and ‘the resulting demand for foods of animal origin, is bringing to emergency proportions the already critical shortage in the nation’s supply of veterinary medical manpower. A large part of veterinarians’ professional activity is directed toward protec- tion of the consuming public. One primary responsibility of veterinarians is the prevention of human illness derived from animal sources. In response to the nationwide demand for consumer protection, Congress in 1967 passed the Whole- some Meat Act (Public Law 90-201) and the 90th Congress will consider at least three bills pertaining to inspection of poultry and poultry meat products. The Laboratory Animal Welfare Act of August 24, 1966 (Public Law 89-544) has placed vast responsibilities upon veterinarians to initiate and execute a nation- wide program for laboratory animal welfare. The above new national programs demand hundreds of veterinarians at a time when there is already a critical shortage of veterinary medical manpower. Studies have indicated the need for doubling the number of veterinarians by 1980 and more than tripling the number of veterinarians in several fields of specialization in veterinary medicine by 1975. The gigantic task for increasing the number of veterinarians is currently the responsibility of the eighteen veterinary medical schools and colleges located in seventeen states of our nation. Veterinary medical colleges have been unable 'to capitalize upon well established new educational techniques because they were denied the educational improvement grants provided to other health professional colleges under Public Law 90-290. Insufficient funds have handicapped educators’ attempts to adopt modern methods of education—such as classroom use of com- puters, closed circuit television, and autodidactic laboratories—to veterinary medical education. Achievement of minimal goals for increased enrollment and maintenance of the quality of professional education requires vast increased fi- nancial support. Experience has clearly demonstrated that adequate funds for development and expansion cannot be provided by the seventeen states which are currently attempting to educate veterinary medical personnel for all fifty states. Facilities and operational support are not adequate even for the number of stu- dents currently enrolled in the veterinary medical colleges in this country. If enrollment is to be increased, it is imperative that veterinary medical col- leges be included in future legislation relating to the following support of educa- tion in the health professions: educational improvement grants, construction of teaching and research facilities, institutional support for innovations in veteri- nary education, and student loans and scholarship grants. THE ROLE OF THE VETERINARIAN IN OUR SOCIETY The activities of all veterinarians contribute to public health. Veterinary medicine is concerned with the health and well-being of animals and man. It is concerned with the control of diseases transmissible from animal to man and with the discovery of new knoweldge in comparative medicine. During the past twenty-five years, activity in comparative medicine and the biomedical sciences has increased at a spectacular rate and has greatly expanded the role of the veterinary medical profession. Public health responsibilities of the veterinarian A large proportion of veterinarians’ professional activity is directed toward protection of the consuming public. The primary objectives of the veterinarian are to prevent human illness derived from animal sources and to protect the health of animals. Veterinarians carry a large responsibility in the field of public health. Many state and municipal codes require at least one veterinarian on the board of health. According to a 1960 report of the Ohio Department of Health, veterinarians have the largest representation of any professional group serving on local health boards. Veterinary medicine provides specific benefits to human health in three major ways: (1) Removal of sources of infection to man through eradication or control of those animal diseases transmissible to man, (2) Development of preventives or treatments that can be adapted for use in man, and (3) Development of food hygiene programs that protect the consumer against food-borne diseases. Removal of sources of infection—More than 100 diseases of animals are trans- missable to man. In 1945, 10,000 cases of rabies were reported in animals, and thousands of people in our nation were treated for this deadly disease.(1) As a result of research and training, the incidence of this disease has dropped more 177 than 50 per cent in the past fifteen years, and 1967 marks the first year in our history with no human deaths from rabies.(2) Veterinarians vaccinate seven million of the nation’s fifty million dog and cat population annually. Research is under way to develop means for elimination of rabies in bats and other wildlife. (1) Many viral diseases of man are transmitted by insects, and the survival of the virus depends upon birds and other animal hosts. Three types of insect- borne virus encephalitis are recognized in the United States. Veterinarians deter- mine the species of animal life that are essential reservoirs of infection and those that form necessary links in the animal-human infection chain. Development of Treatment or Preventives.—Veterinary medicine, formerly oriented to the study of animal diseases for the benefit of animals themselves, since 1940 has been oriented to comparative medicine and the biomedical sci- ences. Advances in veterinary medicine contribute materially to human welfare through the protection of man against certain transmissible diseases, the insur- ing of a stable economy for production of essential food and fiber, and the safe- guarding of the wholesome supply of food products of animal origin. Today, veterinary medicine is faced with tthe additional challenge of providing adequately trained manpower for research where animals serve as biological models for studies of diseases that primarily affect man, and whose solution can only indirectly benefit animals. Food Hygiene.—In response to the nationwide demand for consumer protec- tion, Congress passed the Wholesome Meat Act in 1967 (Public Law 90-201) and Congress will consider at least three bills pertaining to inspection of poultry and poultry meat products. The above legislation requires hundreds of veter- inarians to implement the new program. Veterinarians participate in food hygiene research and advise and assist in the development and maintenance of recom- mended ordinances regarding milk sanitation, poultry inspection, and sanitation of food service establishments. Animal diseases are of public health significance because some are transmissible to man through milk, meat, poultry and other animal food products. Food products may also serve as vehicles of human infec- tions, namely, typhoid fever, diphtheria, scarlet fever and streptococcal infections. The American public takes wholesome food supplies for granted and does not realize that often it is only through the activities of veterinarians that foods of animal origin come from healthy animals and are inspected to insure their safety before reaching the consumer. In fiscal year 1966, 104,988,350 animals were slaughtered under Federal Meat Inspection. Veterinarians direct all slaughtering and administer the over-all meat inspection program, as well as the humane slaughter law, which requires that animals be rendered insensible before slaughter begins. During 1966, over 264,992 animals at slaughter were condemned by veterinarians as unfit for human consumption. In addition, over 9,765,514 animals carcasses were tem- porarily retained until diseased or affected portions were removed. (12) Veterinarians in the Bureau of Veterinary Medicine of the Food and Drug Administration are concerned with the protection of human health. They develop scientific methods for detecting worthless or harmful drugs and assure that foods, drugs, and cosmetics are wholesome, safe to use, made under sanitary conditions, and truthfully labeled. They determine the safety or danger of additives (such as antibiotic and other growth stimulating drugs) in feed consumed by food- producing animals to insure that meat, milk, or eggs are safe for human consump- tion. Unfortunately, the shortage of veterinarians available for food inspection has curtailed the federal, state, and municipal food inspection programs and has sometimes allowed adulterated, unwholesome, mislabeled, and contaminated food to reach the consumer. (4) A wide variety of chemicals are used to protect animals and crops against insects. Many of these chemicals leave a toxic residue which is cumulatively deposited in the animal. When the residue exceeds acceptable levels of safety, the affected product is disposed of in accordance with good food hygiene principles. Protection Against Importation of Foreign Diseases.—The risk of introducing foot-and-mouth disease into the United States grows with increased travel abroad and the prevalence of the disease throughout much of the world. Great Britain is experiencing the most severe outbreak of foot-and-mouth disease in its history. Over 2,300 herds (415,800 animals) died or were slaughtered from the beginning of the outbreak to February 1968 in a campaign to eradicate this devastating disease. (13) 178 Through inspection of imported animals, poultry, and all animal by-products, veterinarians prevent entry of foreign diseases into the United States. Of the 981,860 animals and 2,950,829 birds presented for import during 1967, 43,961 animals and 9,365 birds were refused entry because they were carrying diseases contagious to man and animals. During the same fiscal year, veterinarians in- spected and certified over 69,000 animals for export to foreign countries. (13) More than 15.6 million pounds of meat and meat food products from foreign countries were condemned or refused entry in 1967. (13) Veterinarians in research Three quarters of all veterinary medical prescriptions written today are for drugs that were non-existent twenty-five years ago. Contributions to knowledge in comparative medical sciences since World War II are greater than those made in all previous years of history. The activities of veterinarians holding research or service positions in govern- ment and industry are not as well known ‘to the public as those services rendered by the veterinarians engaged in farm practice or operation of small animal hospitals. Yet one-third of the veterinary profession is engaged in the former category of activity. In 1965, it was estimated that veterinarians in the animal health industry (pharmaceutical and biological) alone controlled a segment of industry valued at $600 million annually. Veterinarians hold positions of leadership in approxi- mately 310 different companies operating in the chemical and pharmaceutical industries of the United States. (3) Although many of these individuals serve the areas of animal health, veteri- narians play a vital role in industrial research and development of drugs and other chemicals consumed by man. The greatest recruiting fervor is in the field of toxicology. Veterinary toxicologists are primarily concerned with de- veloping knowledge of the toxic potential of chemical substances, and their fate in the environment, in order to prevent poisoning. Veterinarians serve as directors of toxicology research for many of the pharmaceutical companies developing drugs for human use, These include companies such as Eli Lilly, Upjohn, Huffman LaRoche, CIBA, Warren-Teed, Pitman-Moore, Wm. S. Merrell, Sandoz and Syntex. Veterinarians have pioneered in toxicologic research concerning space; en- vironmental hazards; pesticides; toxicants in food, air, and water pollution ; and chemical warfare agents. Veterinarians’ activities include research in the discovery and development of drugs and other chemicals to be used as food additives in the treatment of human and animal diseases. After a new chemical is synthesized, the veteri- narian is responsible for determining the potential value of the chemical in treatment of disease. Before the chemical can be released for human trial, he must determine, through a long series of testing in many species of animals whether or not the chemical is toxic. Veterinarians in the biologics industry are engaged in discovery and devel- opment of new vaccines, serums, and other biological products of animal origins. Veterinarians have the responsibility not only for determining the value of potential products, but also for assuring both the safety and potency of the products. Federal veterinarians supervise activities in more than seventy com- panies licensed to produce biologics for disease prevention and as treatment. Study of spontaneous disorders in lower animals provides information more relevant to human disease than does the study of artificially-produced diseases in laboratory animals. A number of spontaneous models for human diseases have been delineated by veterinarians, viz, systemic lupus erythematosus in dogs and mice, porphyra in cows and pigs, atopic diseases in dogs, and balding in primates other than man. Veterinarians are studying animals with naturally occurring diseases (such as diabetes, heart disease, cancer, and blindness) which are identical to their counterparts in man. In December, 1966, a faculty group in the College of Veterinary Medicine at the Ohio State University made an important breakthrough in cancer research. They discovered that leukemia is transmitted through the air and that animals inhaling the virus develop leukemia. Veterinarians in the Army and Air Force Veterinary medical officers of the Armed Forces play a major role in pre- ventive medicine and environmental health by protecting the health of service- men stationed throughout the world. The functions of a military veterinarian are 179 similar to those of the veterinarian in civilian life. His training in the medical sciences enables him to participate in preventive medicine and research activities. The military veterinarian has paralleled his physician counterpart in con- tributing to human health and welfare through his responsibility for inspection of all foods of animal origin consumed by the serviceman. The Department of Defense has assigned world-wide food inspection responsibilities to the military veterinarian. In addition, he has responsibility for disease control through appropriate food handling, inspections of community areas, utilities and waste disposal, and rodent control. Because his training in medical science is parallel to that of the physician, the Doctor of Veterinary Medicine assumes preventive medicine research func- tions in addition to those which are related to foods of amimal origins. Large numbers of veterinarians in the military service are engaged in research. For example, research on the solution of high altitude problems by using animals and vehicles projected into space; acceleration and decelerations; space flights; and space travel. Through animal experimentation, veterinarians determine the effects of radiation upon animals and, by extrapolation, upon man. Other ex- amples are flight and ground feeding research; perservation of foods by radia- tion; research designed to protect against biological warfare; research on diseases transmissible from animals to man; and world-wide laboratory support. (4) Veterinarians in laboratory animal medicine The laboratory animal industry is valued at nearly $500 million. Original research data using animals in space prior to manned flights is an example of the veterinarians’ participation. New ftreatments for disease, new vaccines, and new surgical procedures are first developed by veterinarians on animals to demonstrate their value and safety before such drugs or procedures are used for man. Animals used for biomedical research total 37 million annually. Veterinarians are using millions of animals to study cancer-causing and cancer-inhibiting chemicals, to measure the effects of radioactivity, and to study the reactions of living organisms in space. Laboratory animals constitute a vital resource for medical and other biological research. Animals must be painstakingly cali- brated and standardized as the most sensitive instrument in many health re- search projects. Loss of laboratory animals from disease or malnutrition can have an impact far beyond the cost of the animals’ replacement. It can meet setbacks in scientific efforts in which millions of dollars are invested. One of the growing phases of veterinary service is to provide healthy, uniform laboratory animals, for these represent indispensible elements in biomedical re- search. Veterinary research is concerned with the diseases common to man and animals, and recognizes the usefulness of animals for experimentation in the study of human health problems. Advances in animal health research often open doors to the solution of human disease problems. Generally, research in veterinary medicine makes contributions to human health and well-being as well. The magnitude of the role of veterinarians in laboratory animal medicine is illustrated by the budget and staff of Dr. Zinn, Director of Laboratory Animal Resources at the National Institutes of Health. He has a budget of $3.6 million and a staff of 300 employees. Veterinarians in large animal practice Veterinary research, clinical practice, public health, and regulatory activities in the United States have made possible an abundance of safe, wholesome protein foods. The average per capita consumption of food in the United States exceeds 1500 pounds per year. Over 650 pounds per capita are foods of animal origin. Veterinarians are currently responsible for the health of 108.4 million cattle, 100 million hogs, 30 million sheep, 2.5 million poultry, and 3.1 million horses. (4) Estimates of the value of these animals are: cattle, $12 billion; swine, $1.2 billion ; sheep, $201 million ; and poultry, $480 million. (5) Veterinarians in small animal practice These veterinarians, recognizing the close association between pets and their owners, are constantly striving to eliminate or minimize diseases—such as rabies, psittacosis, and tuberculosis—which might be transmitted to human beings. They provide service to 25 million dogs, 20 million cats, and an estimated 20 million caged birds in the United States. 180 THE INCREASING NEED FOR DOCTORS OF VETERINARY MEDICINE The national demand for veterinarians has increased as the population has increased and as the veterinarian’s role in our society has broadened. The nation’s present total of 24,328 D.V.M.’s cannot fulfill the current responsibilities of the veterinary medical profession. Recent new legislation has placed extensive additional demands upon veteri- narians. Hundreds of veterinarians will be required to carry out the requirements of the 1967 Wholesome Meat Act and the 1966 Laboratory Welfare Act. Several hundred more will be required when bills on poultry inspection, currently before Congress are enacted. As our population increases and creates a demand for a greater food supply, control of animal diseases becomes imperative. Current estimates indicate the need for a 50 per cent national increase in food production by 1975 and a 200 per cent increase by the year 2000. (6) The federal government places a $2.8 billion annual price tag on livestock and poultry losses due to infectious and non-infectious diseases, insects, parasites and nutritional disorders. In addition to this actual loss, more than $245 million was spent in 1959 for pharmaceuticals, biologicals and other treatments for animal use. (8) Industries ultimately affected by loss of livestock through disease include meat packers, tanners and animal fiber producers. The meat packers report an estimated $31 million loss due to condemnation of carcasses in 1960. (9) Nationally, disease causes a loss of $6.73 per head on feed lot cattle going to market. In Ohio alone, the annual loss exceeds $3.5 million. (10) An increasing proportion of doctors of veterinary medicine annually enter biomedical research and service in salaried positions in industry and govern- ment. According to a survey conducted by the American Veterinary Medical Association, 45.4 per cent of all veterinarians who graduate in 1964 entered health activities other than private practice. (In contrast, only 29 per cent of the 1964 newly graduate physicians entered fields of health activities other than patient care.) (14) Many enter professional health-related activities in areas such as (1) public health; (2) laboratory animal medicine; (3) U.S. Army and Air Force; (4) animal disease control agencies; (5) biomedical research in government, universities, and industrial laboratories: (6) meat inspection service; (7) World Health Organization and Food and Agriculture Organization of the United Nations; and (8) The Pure Food and Drug Administration. A list of employers of veterinarians is appended to this report to illustrate the gigantic demands placed upon the scarce supply of veterinarians. (Appendix I). The competition for doctors of veterinary medicine is evidenced by the exten- sive advertising of industrial firms and the federal government in Science magazine and in the professional veterinary medical journals. A shortage of veterinarians has made it impossible for the pharmaceutical and chemical indus- tries to employ adequate numbers to conduct research designed to discover, develop, and test drugs and chemicals for food and cosmetic additives and for treatment and prevention of disease. In the field of toxicology, this shortage has reached emergency proportions. With over 3.000,000 chemicals known, and new ones being synthesized at the rate of 7,000 a year, far more veterinary toxicologists are needed than presently can be trained by the colleges of veterinary medicine. The international tragedy which occurred a few years ago, when many babies were born without hands or feet because pregnant mothers con- sumed thalidomide, could have been averted by animal testing of the compound “thalidomide” prior to human use. The “Community Health Concept” being promoted across the United States further exaggerates the need for veterinarians. The commentary on the urban “rat problem” in a recent issue of Time magazine cited five major diseases of this rodent which are readily transmissible to man. Doctors of Veterinary Medicine have made significant discoveries pertaining to each of those five major diseases. Veterinarians are adaptable professionally and scientifically, and will serve well within the framework of the new “Community Health Concept.” Dr. W. T. 8S. Thorp, a member of the Advisory Council of the Bureau of Health Manpower, U.S. Department of Health, Education, and Welfare has predicted a shortage of 20.000 veterinarians by 1985. He declared that this is occurring at a time when modern medicine in all its categories, including veterinary medicine, requires a greater degree of competence and specialization than ever before. 181 THE NEED FOR FEDERAL SUPPORT OF VETERINARY MEDICAL EDUCATION Citizens who are genuinely concerned with our nation’s total health and welfare, recognize an emerging national emergency created by the extreme shortage of veterinarians. The obvious answer is to expand the colleges of veterinary medicine in a manner which will enable them to accommodate the large numbers of young men and women who apply for admission. Facilities and operational support are not adequate even for the students currently enrolled in the veterinary medical colleges in this country. At one of the oldest and well-established colleges of veterinary medicine, 50 percent of the professional students and a large portion of the faculty are located in temporary space in the university’s garage. That college is awaiting funds to become available for construction of teaching and research facilities. Equipment for instruction is either antiquated or so limited as to handicap the laboratory instruction in many schools. Their faculty and technical personnel are being lost to colleges of medicine, industry and government laboratories in the fierce com- petition for veterinary medical manpower. Bighteen colleges in seventeen states carry the burden of supplying the nation’s veterinarians. Each of these colleges is accredited by the Council on Education of the American Veterinary Medical Association, and their graduates are eligible to take state and national board examinations in veterinary medicine, dentistry and surgery: but the number of veterinarians graduated each year from all colleges totals only about 1,000. Six to eight years of university education is required for the Doctor of Veteri- nary Medicine degree. The courses required are nearly identical to those re- quired for the degree of Doctor of Medicine, except that all species of animals except man are considered. After two to four years of pre-veterinary medical education in the university, students may apply for admission to the College of Veterinary Medicine where an additional four years of professional education is required before the degree of Doctor of Veterinary Medicine is awarded. During the past sixteen years at The Ohio State University, 66 to 77 percent of the well-qualified applicants for admission to the College of Veterinary Medicine could not be accepted because the college has inadequate facilities and faculty to accommodate more students. For the same reasons, during the past sixteen years, 89 percent of the Doctors of Veterinary Medicine were refused admission to the Ph. D. programs in one of the departments. The deficiencies in veterinary manpower are assuming alarming proportions. The number of professional students in the nation’s colleges of veterinary medi- cine must be increased by two- to three-fold if a national emergency is to be avoided. The following is a quotation from a report in the 1961 proceedings of the American Association of Land Grant Colleges and State Universities: The best estimates based on eurrent needs indicate that the number of veterinarians in the country should be tripled by 1980. . . . in order to accomplish this . . . the capacity of all the present veterinary colleges must be doubled and at least five new veterinary colleges established immediately. In response to an overwhelming demand for graduates, most veterinary colleges are now developing means of accommodating more qualified appli- cants by increasing class size, or moving toward year-round teaching programs. (12) Estimates have also indicated that a 300 percent increase in the number of veterinarians in the many specialties in veterinary medicine will be needed by 1975. Achievement of minimal goals for increased enrollment in the Colleges of Veterinary Medicine and maintenance of the quality of professional education requires vastly increased financial support. Experience has clearly demonstrated that adequate funds for development and expansion are not and will not be provided by the states in which the nation’s eighteen veterinary medical colleges are located. Since these colleges must educate veterinarians for the entire nation, federal support of their development and expansion is clearly justified. The efforts of veterinarians to maintain animal health and directly and indirectly to pro- mots human health justify the contention that veterinary education is as de- serving of federal support as any other health profession for which provisions have @wready been made in the Health Professions Educational Assistance Act. 182 Insufficient funds have handicapped educators’ attempts to adapt modern prin- ciples of education—such as classroom use of computers, closed circuit television, and autodidactic or autotutorial laboratories—to veterinary medical education. Veterinary medical colleges have been unable to capitalize upon the well- established new educational techniques because they were denied the educational improvement grants provided to other health professional colleges under Public Law 90-290. Research on veterinary medical education and innovations in cur- riculum have been hampered by the lack of significant financial support. It is imperative that veterinary medical colleges be included in future legislation re- lating to the support of education in the health professions, including: educa- tional improvement grants, construction of teaching and research facilities and institutional support for innovations in veterinary education and research and student loans and scholarship grants. The undeniable potential of the veterinary medical component of the health professions can be reached through continued and expanding support by the U. S. Public Health Service. REFERENCES . National Communicable Disease Center Surveillance, Annual Rabies Sum- mary. U.S. Department of Health, Education and Welfare, 1964. . Veterinary Public Health Notes, No Human Rabies in the United States— 1967. U.S. Department of Health, Education and Welfare, January 1968. . Director of Industrial Veterinarians, 1965. . From the Committee print for the 87th Cong., 1st sess., United States Con- gress Senate Committee on Government Operations. Veterinary Medical Science and Human Health . . .”. August 10, 1961. . Statistical Bulletin No. 389, January 1, 1967. Livestock and Poultry Inventory. United States Department of Agriculture. . Maurer, F. D., United States Livestock Sanitary Association proceedings (70th meeting 1966: Page 214). . New York Times, June 1967. . Drug Trade News, Volume XXXV, Page 16, July 25, 1960. . Information Series, February 1961. Published by Livestock Conservation, Inc., Chicago, Illinois. 10. Unpublished report (The Ohio State University, 1967) by James H. Warner. 11. Report on the proceedings of the 1961 meeting of the American Association of Land Grant Colleges and State Universities, p. 196. 1961. 12. Federal Meat Inspection, A Statistical Summary for 1966. United States Department of Agriculture, Consumer and Marketing Service. Pages 2-12. February 1967. 13. Personal Communication by Paul H. Kramer, U.S. Department of Agriculture, Animal Health Division, February 12, 1968. 14. Directory of the American Medical Association, 1964. wo = LW AH On APPENDIX I—EMPLOYERS OF VETERINARIANS Pharmaceutical and Chemical Industry. Biological Industry. Federal Government : National Institutes of Health. Veterinary Public Health Section of the Communicable Disease Center. Bureau of Veterinary Medicine, U.S. Food and Drug Administration. Animal Inspection and Quarantine Division. Atomic Energy Commission. Veterinary Biologics Control. Animal Disease and Parasite Research Division. Entomology Research Division, Radiological Health Division. U.S. Public Health Service. Oakridge AEC Projects. Collaborative Radiological Health Laboratory. Institute of Laboratory Animal Resources—National Academy of Sci- ences—National Research Council. Air Pollution Research and Control Program. Fish and Wildlife Service, Department of the Interior. Meat Inspection Division. 183 Poultry Division Agricultural Marketing Service. Animal Disease Eradication Division. The Veterinary Corps of the Army and Air Force, Department of Defense. International Cooperation Administration. Foreign Agricultural Service. Foreign Research and Technical Programs Division. TIPood and Agricultural Organization. World Health Organization. National Aeronautics and Space Administration. Pan-American Health Organization. International Office of Epizootics. United Nations Education, Scientific and Cultural Organization. National Animal Disease Laboratory, Ames, Iowa. Plumb Island Animal Disease Laboratory, New York. Animal Disease and Parasite Research, USDA, Beltsville, Maryland. National Medical Audiovisual Center. State and Municipal Governments : Health Departments. Disease Diagnostic Laboratories. Animal Disease Eradication Division. State Meat Inspection. Animal Disease Regulatory Division. Food Hygiene Division. Inspection and Quarantine Division. Veterinarian for Zoo Animals. Universities : Colleges of Veterinary Medicine. Colleges of Medicine. Colleges of Biological Science. Schools of Public Health. PREPARED STATEMENT OF C. KE. CORNELIUS, DEAN, COLLEGE OF VETERINARY MEDICINE, KANSAS STATE UNIVERSITY, MANHATTAN The many contributions of veterinary medicine to human health have become nationally acknowledged as classical discoveries important to understanding human disease. The discovery of numerous nutritional deficiency diseases, the development of advanced surgical techniques including organ transplants, the testing of many new drugs beneficial to man, the discovery of animal models in which to study human disease, and the control of over 150 animal diseases trans- missible to man, are but a few of the important responsibilities of veterinary medicine. It has been said that the greatest contribution of veterinary medicine in the next decade will be what basic information flows to human medicine concern- ing the many animal diseases with counterparts in man. We need to discover new animal models for studying cystic fibrosis, the rejection of organ transplants, multiple sclerosis, emphysema in the over populated city, a variety of leukemias, many types of cancer, and coronary heart disease to mention only a few. Through the use of such animal models, key discoveries can be made in colleges of vet- erinary medicine and in cooperation with leading human medical centers. We must not let this golden opportunity be missed due to insufficient funding of the few colleges of veterinary medicine that exist in the United States today. There is insufficient resources in colleges of veterinary medicine today to stimulate such programs as mentioned above in comparative medicine unless basic improvement grants are made available. This is due to the great expense of medical education and research today. Colleges of veterinary medicine are pres- ently faced with a lack of resources for the training of students in comparative medicine. The serious deficiency of qualified scientists in this field of comparative medicine is appalling. In addition, poor physical facilities in many veterinary medical colleges limits research programs which are directly related to human health. Basic improvement grants to veterinary medical colleges along with the support of improved teaching and research facilities is the only answer that will allow for the training of these new medical scientists. They will be unique to all of medicine. Many veterinary medical colleges in certain smaller states receive state sup- 184 port at only 1.5-2 million dollars per year. They will be unable to develop mean- ingful training and research programs in comparative medicine during the next decade unless institutional grants of $300,000 to $500,000 per year are available from resources outside the state. The injection of many new discoveries on animal diseases from veterinary medicine into human medicine could well be the key to understanding many of our worst crippling diseases in man. I strongly urge that the new programs re- cently initated in developing new veterinary medical manpower for the health sciences as well as increased institutional support be continued ; only by such a program can the colleges of veterinary medicine make a substantial contribution to the health of mankind. PREPARED STATEMENT OF DR. MARK W. ArLrAM, DEAN, SCHOOL OF VETERINARY MEDICINE, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA Veterinary medicine has assumed a role of ever increasing importance in the protection of man’s health by being active on several fronts. The well being of the world population depends on the availability of adequate and wholesome food supplies. Constant surveillance of the health of food producing animals and strict supervision of food products processing is a necessity. The veterinary medical profession must continue its practice of preventive medicine and epide- miological studies in the interests of controlling disease, particularly if the dis- ease is transmissible from animal to man. Community health today depends on cooperatvie action of all disciplines in the health sciences, Added financial support of our undergraduate and graduate educational programs must become available if we are to continue meeting even our minimum obligations. All of us recognize that increasing obligations of any profession go hand in hand with a rising cost in meeting these obligations. It is no longer possible to provide professional medical education at the existing level of support. The spiralling costs of administering a curriculum today will, with- out question, result in an annual increase of $2,000 per student at least. The faculty of the University of Pennsylvania School of Veterinary Medicine has developed a new and imaginative curriculum which would provide the stu- dent with the opportunities for self-learning and independent development. As might be expected, the improved curriculum will call for more faculty and an in- crease in laboratory space. However, the value of the teaching program would be so great to prompt one to say that funds must become available in support of it. We do not have the required financial support at the moment, and a realistic appraisal of the situation also leads us to ask where the funds are coming from. In order to fulfill past, present, and particularly future obligations, veterinary medicine must move ahead, and basic improvement grants constitute one answer to the problem. PREPARED STATEMENT OF NicuHorLAs H. Boorx, DEAN, COLLEGE OF VETERINARY MEDICINE AND BIOMEDICAL SCIENCES, COLORADO STATE UNIVERSITY, FORT Corrins, Coro. Veterinary medicine is now contributing significantly to the total biomedical effort of the nation in many health disciplines, including public health. Un- equivocally, the prevention and control of animal diseases are not only important from a public health standpoint but are necessary if the animal protein and nu- tritional needs of an expanding human population are met. According to Dr. M. R. Clarkson, Executive Secretary of the American Veterinary Medical Asso- ciation, “The greatest single obstacle to meeting the world’s requirements for food products of animal origin is the crippling and unnecessary drain incessantly inflicted upon the world’s food resources by major infectious and parasitic live- stock diseases”. In biomedical research, veterinary medicine is serving importantly in advanc- ing knowledge which is basic to the understanding of animal and human disease processes. The importance of using animal models in studying genetic, metabolic and pathologic conditions similar to those seen in man is an excellent example of veterinary medicine’s contribution to public health. Presently, colleges of vet- erinary medicine in the United States provide intensive instruction in several courses relating to public health. For example, courses on dairy and meat prod- ucts inspection, epizootiology, and zoonoses are offered to veterinary medical 185 students. Consequently, the veterinarian is trained to serve side by side with other members of the health professions within the public health disciplines. Colleges of veterinary medicine are important national resources which deserve considerable financial support from state, federal, and private sources. If su- perior talent is attracted into veterinary public health, fellowship and assistant- ship support is critically needed at the postgraduate level concomitant with im- proved support at the undergraduate level. Furthermore, sufficient financial re- sources are needed in the recruitment of topnotch biomedical instructors and scientists. Although financial support for renovation and construction of facili- ties has been difficult to procure for colleges of veterinary medicine, passage of PL 89-709 by Congress in 1966 is expected to assist immeasurably in replacing obsolescent equipment and facilities as well as to assist in the expansion of present facilities in many of the veterinary medical colleges. Unquestionably, past and current financial support of colleges of veterinary medicine from state and federal sources has been considerably below the level that is necessary to maintain high caliber instructional and research programs. Although the Colo- rado State Legislature has been sympathetic to the annual financial requests of the College of Veterinary Medicine and Biomedical Sciences at Colorado State University, only a small fraction of the requests were granted because public funds were inadequate. The annual loss of food-producing animals from infectious and parasitic dis- eases in the United States is approximately three billion dollars. This figure exceeded all the money appropriated, i.e., 2,618.1 million dollars, for the U.S. Public Health Service and also exceeded the 1,123.2 million dollars appropriated to the National Institutes of Health in fiscal year 1967. The total budgets spent on veterinary medical education and research in 1967 are estimated at less than 30 million dollars for the 18 veterinary medical colleges and represent less than one percent of the annual sum of money lost from animal diseases. It is indeed unfortunate that such a small amount of money is being invested for veterinary medical education and research in the United States. Improvement in human health resulting from control of animal diseases wil more than justify all public expenditures for veterinary medical education, research, and all animal disease control programs ever conducted in the United States. Since it is estimated that twice the number of veterinarians over the present number, i.e., 26,000 is needed by 1980 in North America, greater financial sup- port will be required to overcome the severe manpower shortage. Expansion of present facilities and the development of new colleges of veterinary medicine cannot possibly occur rapidly enough by this time to double the number of veterinarians. Despite this, every effort must be made at the state and federal levels to increase the output of well trained and competent veterinarians to meet the public health and animal health needs of the nation. In moving toward this objective, a realistic balance between education and research must be attempted. Veterinary medical education in our colleges could be greatly improved under a policy that provides comparable support for all its functions, whether it be teach- ing or research. Present policies have made the support of the veterinary medical faculty almost entirely dependent upon publication production and research ac- complishments. The unilateral support of one function over the other develops a lopsided and uncompromising situation in our teaching and research programs. Since it is necessary to be practical and pragmatic in achieving a so-called aca- demic balance of functions, it is urged that support be granted which does not distinguish between the instructional and research activities of veterinary medi- cal colleges. PREPARED STATEMENT OF DR. M. R. CLARKSON, EXECUTIVE SECRETARY, AMERICAN VETERINARY MEDICAL ASSOCIATION THE FUTURE OF VETERINARY MEDICAL EDUCATION Dr. Dixon, members and friends of the Louisiana Veterinary Medical Associa- tion. To talk about the future of veterinary medical education means, of course, to talk about the future of veterinary medicine. Learned discussions about cur- riculum, teaching aids, student selection, and faculty assignment are always fascinating, but they will remain largely irrelevant unless their usefulness is 92-079 0—68——13 186: constantly measured against the question: How will tomorrow’s veterinarian fit into tomorrow’s society? That society is in the making today, and the changes we witness are nothing but the first manifestations of the new socio-economic environment for which we will have to train our students. Veterinary medical practice has already been profoundly affected by these changes; veterinary medical education, on the othere hand, is just beginning to reorient itself structurally and functionally to the incipient realities of the 21st century. The principal changes which, in my opinion, will most significantly influence veterinary medical education are now occurring in the fields of agricultural economics, in housing and urban development, and in bio-medical research. As far as agriculture is concerned, the two most important developments to affect veterinary medicine’s role in this complex and vital sector of our economy are these: First, a marked trend toward huge livestock units managed with all the efficiency and ramifications of the most modern, diversified business enter- prise. Second, the urgent task to provide foods of animal origin for a sharply rising population at home, and to satisfy, whether by direct assistance programs or through the export of knowledge, and protein hunger of the rapidly expanding populations of large underdeveloped areas of the world. The increasing density of herds, coupled with advanced technology in live- stock production and management, has already led to marked changes in the nature of large animal practice. If my interpretation of these changes is correct, a thorough grounding in the principles of epidemiology, refined diagnostic skills, a keen understanding of the art of working with others in a multi-specialty group practice, and a sure footing in agriculture economics have become in- dispensable tools in training today’s veterinary student to meet tomorrow’s agricultural world. As an illustration, the current foot-and-mouth disease epizootic in England may impress us today as an isolated, though tragic occurrence. In the years ahead, epizootics of many dangerous animal diseases could be ever- present threats unless the veterinary medical profession is fully prepared to meet them through both long-range programs of prevention, and immediate con- trol measures. The need to feed our own growing populace and to help feed others will make unprecedented demands on veterinary medicine in terms of manpower, training, and skills. In an article appearing in a recent issue of the Journal of the American Veterinary Medical Association, Dr. J. C. Thompson, Jr., of the Department of Physical Biology at Cornell University, reported that “as the world attempts to solve its food problems, the need for veterinarians will increase tremendously. Without control of diseases and improved survivability there will be little im- provement in food productivity from animals.” To train veterinarians in sufficient numbers to meet world-wide demands for their services is, of course, essential. But something else seems to me significant. The world food situation, growing more serious each year, undoubtedly will give rise within the profession to the need for global exchanges of knowledge, skills, and programs of education, and thereby add to the profession a new world-wide dimension. Its impact on veterinary medicine, already acutely felt by medicine, dentistry, and other health professions, could be considerable. In turning now to urbanization as the second field of consequence to veterinary medical education, I am addressing myself chiefly, although by no means exclu- sively, to the small animal practitioner. Here, again, we come across the words “density” and “exchange of ideas” as key words characterizing the changes which importantly influence both practice and education. Density, because popu- lation growth, crowded living conditions in our cities, and the increasing popu- larity of companion animals all combine to emphasize the interdependence of animal health and human health. One immediate effect of these factors will be that they will bring into sharp focus the public health responsibilities of the small animal practitioner, an aspect of small animal medicine which has not found in the veterinary medical curriculum the consideration it requires. Exchange of ideas, because a sophisticated, prosperous, mundane, and acutely health conscious pet owner will expect for his animal the same kind of superior medical service he takes for granted when it comes to his own health require- ments. Moreover, as the ownership of a pet becomes for many a source of emo- tional stability in a society in which the individual is submerged, we must increasingly turn our attention to the fears and anxieties of the pet owner as well as to the maladies and afflictions of the pet. All of these trends combine to 187 create new points of contact and reference between small animal medicine and other professional disciplines, and contain obvious implications for veterinary medical education. The persistent urging by many of our best educators for a surer footing of the veterinary student in the liberal arts and humanities will be vindicated in the clinics of tomorrow. With these remarks I am already touching on yet another development whose impact on veterinary medicine has been, and will continue to be, enormous: specialization. Unquestionably a boon to the profession, it also causes many of the headaches that plague veterinary medical administrators and educators alike: How can we preserve unity of organization while encouraging diversity of scientific interest and competence? How can we bring the new research find- ings—doubling, as some say, every five to ten years—to those who, although often still young in years, have become professionally obsolete? How should we design the pre-veterinary curriculum, the professional courses, and post-graduate train- ing to achieve, without becoming superficial, a maximum exposure of our students to the scene of contemporary biology and medicine? Top advances in the life sciences are the feat of Dr. Arthur Kornberg of Stan- ford University and Dr. Mehrad Gouliam of the University of Chicago in synthesizing a virus-like substance and thereby creating a primitive form of life; and the human-to-human heart transplants carried out in Cape Town, South Africa, and in California. I am mentioning these two events because they illustrate the breathtaking pace at which we are moving in the domain of bio- medicine. Surely, achievements such as these are of intense interest to veterinar- ians and, therefore, should be in the back of our minds when we talk about the development of tomorrow’s veterinarian. You might say, “But we still have parasites in pets, and scours in calves.” We do, and we probably will for a long time to come. However, it is against this background of an age literally reaching for the stars that we must measure our plans and efforts in veterinary medical education. In the light of the changes briefly summarized it seems, for example, that the requirements for pre-veterinary education should be questioned. The current 2-year pre-professional education may no longer be adequate to give the student an understanding of society, to teach him to think, and to offer him those courses which are prerequisite to his professional courses. Should we, then, restrict the selection of veterinary students to graduates of baccalaureate programs of various kinds? Since veterinary stu- dents today frequently have 4 years of pre-veterinary training, this step, which finds approval among many educators, should not be difficult to accomplish. The purpose of the professional curriculum is to provide the foundation upon which graduates develop the many competencies necessary for the profession to fulfill its role of service to society. The student should be taught the principles of biology and medicine, and acquire at least a basic understanding of the art and science of clinical veterinary medicine. But, the professional course of studies, no matter how sophisticated or diver- sified, today points beyond itself to a lifetime of learning. Post-doctoral education, graduate education in the basic sciences, internships and preceptorships and, perhaps most important of all, programs that bring the latest findings of research and experience to the practitioners, are indispensable parts of the total pro- gramming of veterinary medical education. These thoughts about the future of veterinary medical education may not be uppermost on your minds ag you are about to begin construction of a new college of veterinary medicine on this campus. You might have found it more helpful— and probably more entertaining—had I titled my talk “Seven Mistakes Most Commonly Made By Planners and Builders of Colleges of Veterinary Medicine” or, “How I Built A 15 Million Dollar College With Only 19 Million Dollars.” For a while I indeed intended to address my remarks to the practical issues and problems you are facing in building your school. I could have talked, for example, about the wisdom of allocating sufficient construction funds; the need to recruit an adequate number of qualified faculty members; and about such technical and mechanical things as an audio-visual center; an adequate library ; service labora- tories; integrated study courses; closed-circuit television; the vital need for adequate clinical materials, and even the need to plan for expansion before you have laid the cornerstone to your first building. Yet I felt, for one thing, that there are people available to you who, because of their experience and training, are much more qualified than I to speak to you about these things. Moreover, I was certain that there were very few things, if 188 any, you hadn’t already thoroughly explored at this stage of your development program. Lastly, I didn’t wish to usurp the responsibilities of the AVMA’s Council on Education which, in its “Essentials of An Acceptable Veterinary Medical School,” explicitly states that it will assist schools to meet the requirements for accreditation, and that it will consider evaluation of a newly established school at any stage of its development. There could be no more propitious time for building a new college of veterinary medicine. The urgency of such an undertaking is amply illustrated by three recent legislative measures. The Veterinary Medical Education Act of 1966 marks the first significant national attempt to balance the supply of veterinarians against the nation’s steeply rising demands for their services. It has created a favorable climate for your goals and will provide some of the means essential for their accomplishment. Following on the heels of this piece of legislation, the Laboratory Animal Welfare Act and the Wholesome Meat Act of 1967 have focused national attention on two vital areas, medical research and consumer health protection, in which success or failure depends crucially on the availability of well-trained veterinary medical personnel. Yet for my part, I feel that the grand design, the vision, if you will, of this profession at the age in which it operates will ultimately determine the success or failure of your new college in graduating the type of veterinarian we need and want. More than 200 years have passed since Claude Bourgelat, the French lawyer and riding master, founded the world’s first school specializing in veteri- nary science. The buildings of the small Ecole veterinaire at Lyons may have been, according to our modern standards, primitive, and the textbooks he wrote for his students, and which they had to learn by heart, may be as obsolete today as the methods of diagnosis and treatment he practiced. Yet his understanding of the importance of scientific research, which finally triumphed over the deeply entrenched empirical and often superstitious procedures of the past, and his intuitive grasp of the moral nature of our profession are of timeless validity. There is in the code of ethics he wrote for his students a passage which expresses well what I believe must be the final justification of efforts in training a new generation of veterinarians. “Ever imbued with the principles of honor imparted to them,” he wrote, “the students will never depart from them. They will dis- tinguish between the poor and the rich. They will never set too high a price on the talents which they owe only to the benevolence and the generosity of their country. Finally, they will prove by their conduct that they are all equally con- vinced that wealth exists less in what one possesses than in the good one can do with it.” Thank you. PREPARED STATEMENT OF JOHN S. McKiBBEN, B.S., D.V.M., M.S., PROFESSOR, DE- PARTMENT OF ANATOMY, COLLEGE OF VETERINARY MEDICINE, IOWA STATE UNIVER- SITY, AMES, Iowa VETERINARY EDUCATION Veterinary educators are faced with the critical decision of when and how we should teach the increasing amount of pertinent knowledge demanded by our profession. Expansion in clinical areas has condensed the time devoted in the basic areas. Can we relieve some pressures on the professional curriculum through the preveterinary, graduate, or post-graduate programs? Is our objective to graduate better qualified veterinarians in all areas or should we specialize? Are we still stereotyped by the past? The evolving curriculum Historical trends in our profession (4, 5,19) have influenced some of our pres- ent answers to these questions. The first veterinary school established in Lyons, France, in 1761, emphasized one animal, the horse, and particularly its anatomy. Similar emphasis was noted at the first state supported College of Veterinary Medicine in the United States established in 1879, at the institution now desig- nated Iowa State University. Between 1852 and 1948, some thirty-four, mostly private, veterinary schools were initiated and closed in the United States and Canada. Many occupied livery stables where the emphasis was on learning by doing. Matriculation requirements usually included an elementary or grade school diploma. The course typically consisted of two sessions of four months each. 189 In the first quarter of the twentieth century, three-year programs were gener- ally required in college veterinary curricula. De-emphasis of the horse and co- operation in more complex studies of all domestic animals and factors related to disease commenced. The public image of the veterinarian as a horsedoctor persisted resulting in the lack of financial appropriations for the dying profession. Progress was stymied in all areas of veterinary education. It was emphasized that research and educa- tion must be depended upon to keep the veterinary profession from lagging behind its sister profession (21). Knowledge had increased faster than it was possible to change curricula to meet the newer needs of graduates (10). During the 1930's, few students could afford college. Nevertheless, great strides were undertaken to improve the curricula to prepare the students in various fields of veterinary medicine. Screening students and requiring one year of pre- veterinary training was instituted. By the middle of the twentieth century according to Armistead (2), the cur- ricula of veterinary schools fitted by habit, provincialism and conservatism, were stereotyped patterns which had not changed significantly in fifty years. Curricula were overcrowded as expansion of knowledge increased without provision for increased learning time. This is still our situation today. Objectives and methods In addition to more sophisticated teaching methods, (8, 9) pre-veterinary, graduate, or post-graduate programs should be further developed to present increased knowledge. A longer pre-professional training period has been pro- posed. (13, 14) This apparently is occurring naturally because of the increas- ing competition for admission into a relatively static profession numerically. Since 1949, all veterinary schools in the United States have required two years of pre-veterinary training. In 1965, (22) 860 of 1,388 first-year veterinary stu- dents in the United States had completed more than the required two years of pre-veterinary training. This period has been generally regarded as a time when students broaden their education. It has become, however, a period with little flexibility, with elective courses quite limited. Required courses in mathe- matics, chemistry, physics, and English need to be, but are in all too few instances, adequatedw covered in high school. This allows more time for more broaden- ing electives in the pre-veterinary curriculum. Blocks of time are continually shifting within the framework of the four- year professional curriculum. The efficiency of the traditional four-year curric- ulum has been challenged. (2, 15, 20) The trimester program now in effect since 1963 at the Texas A & M College of Veterinary Medicine provides addi- tional student contact hours and reduces the total investment by students in time and money. (15) Students graduate after nine continuous terms or three years under this system. The Michigan State program includes eleven quarters of eleven weeks each. (2) A three-year program designed for the Towa State Veterinary College (20) has not been instituted. Various methods have been employed to ensure adequate coverage of basic material and still allow clinical experience before graduation. None has been successful in producing veteri- narians proficient in all phases of veterinary medicine upon graduation. In- stead, hopefully, we have provided each student with basic information upon which he can build his proficiency by further study and experience. As our profession matures, the now heterogeneously emphasized facets of the curric- ulum characterizing each veterinary school should mold into a more homogeneous whole. Perhaps then we can eliminate national and state board examinations. The present author agrees with Armistead and Clarkson that specialization in veterinary practice is not only inevitable, but is desirable (3) and is a symptom of growth. (6) Programs designed for further experience and specialization in human medicine (21) are in existence in veterinary medicine. These include preceptorships, post-graduate training, and graduate education. Preceptorships or precepteeships involve undergraduate third and fourth year veterinary students who are sent singly or in pairs for variable periods of time with a practicing veterinarian. The last preceptorship program in the dental profession will be dropped this year and only 20 of the 86 medical schools had preceptorships in 1962. (16) Some feel that this program at the Auburn School of Veterinary Medicine is very beneficial. (7,11) Three months of the senior year is spent with selected practitioners under this program. The present author finds conflict between the need for more time to present material and the premature entrance into practice. 190 Postgraduate training by symposiums, seminars, workshops, and short courses offered by universities, clinics, and veterinary organization offers an excellent though limited means of reaching practitioners. It serves primarily as a re- fresher program or as a means for informing practitioners of new developments or techniques. Not enough practitioners participate unfortunately. Graduate programs include internships, residencies, and degee programs. In- ternships immediately follow graduation from veterinary school and consist of one or two years of supervised practice in medicine with continued instruction in the science and art of medicine. The intern learns by doing and by association with experienced clinicians. (12) Residencies include education and training fol- lowing the internship which provides preparation for the practice of a specialty. Three or more years are generally served. Graduate programs leading to the degrees Master of Science or Doctor of Philosophy are generally preserved for academic or industrial futures rather than to improve ones practice skills and knowledge. The present author agrees with Pritchard (17) that graduate programs are the weakest link in the chain of veterinary medical education today. Compulsory graduate programs are in existence in many foreign countries including India, Germany, Holland, and Scotland. Some indicate that internships should be ‘the responsibility of the licensing authorities in the state where the applicant seeks to practice. (1,18) Graduate programs at universities generally have the advantage of a better staff and facilities; however, instituting internships at universities on a large scale would require the allocation of further funds which probably would not gain priority in the legislatures. Presently, Societies for the Prevention of Cruelty to Animals, several veterinary schools, and scattered group practices provide a limited number of internships in small animal medicine. Far more applicants are turned away than accepted, however. This author would en- courage an expansion of the former and latter programs to better meet the de- mands in this area. Far fewer internships are offered in large animal medicine. This author believes this will change within the next ten years, as the advantages of group practices are more fully appreciated. Specialization within these clinics will ensue and further demands will be made on universities for residency pro- grams. Presently some universities and S.P.C.A. organizations employ residency programs. SUMMARY The veterinary curriculum has changed over the past century in the United States. Eras which concentrated on the health of one animal or group of animals have been expanded to include not only the health of all our domestic animals, but emphasis on public health, laboratory animals, and various research proj- ects. The problems of public image and lack of financial support are still not entirely solved. We have evolved from the status of technician to more deductive and inductive veterinarians. To continue our self improvement specialization seems inevitable. This cannot replace the basic core of material obtained in the professional curriculum, but must be built upon this framework. Greater respon- sibilities must also be assumed by the high schools, thus allowing better utiliza- tion of the prime time in the pre-veterinary curriculum. We are still stereotyped after the past, but with innovation and insight we can convert the influences of the past into assets in the future. REFEREN CES 1. Archibald, James. Internship training in veterinary medicine. Excerpts from Symposium on Veterinary clinical education. June, 1965, at Athens, Georgia. J.A.V.M.A. 147 :436. 1965. 2. Armistead, W. W. A fresh approach to curriculum design. J.A.V.M.A. 144: 1093-1104. 1964. 3. Armistead, W. W. Educating tomorrow’s veterinarians. J.A.V.M.A. 146 :931- 936. 1965. 4. Christensen, G. C. With honor to the past. The Iowa State College Veter- inarian, 83. 1 5. Christensen, G. C. Veterinary medical education a rapid revolution. In J. F. Smithcors, Ed. The American Veterinary Profession. pp. 641-665. Iowa State University Press, Ames, Iowa. 1963. . Clarkson, M. R. The A.V.M.A. looks at specialization. J.A.V.M.A. 146 :492-496. 1965. S 191 7. Few, A. Department of Veterinary Anatomy, College of Veterinary Medicine, Towa State University, Ames, Iowa: Personal Communications. 1966. 8. Getty, R. Possible solutions 'to some educational problems in veterinary medi- cine. Veterinary Medicine/Small Animal Clinician 61 :1036-1037. 1966. 9. Getty, Robert. The multi-media approach to veterinary education. J.A.V.M.A. 150 :74-80, 1967. 10. Hayes, F. M. Education and research in veterinary medicine. J.A.V.M.A. 67 :773-779. 1925. 11. Holloway, C. Department of Anatomy and Histology, School of Veterinary Medicine, Auburn University, Auburn, Alabama. On leave at the Depart- ment of Veterinary Anatomy, College of Veterinary Medicine, Iowa State University, Ames, Iowa: Personal Communications. 1967. 12. Intern’s Manual. Angell Memorial Hospital of the Massachusetts S.P.C.A. 1962. 13. Knisely, W. H. The role of veterinary medicine in M.S.U.’s new institute of biology and medicine, Am. J. Vet. Res. 26:499-502. 1965. 14. McGowan, Blaine. Scientifically oriented preprofessional curriculum. Ex- cerpts from Symposium on preprofessional veterinary education. June 16— 17, 1966. East Lansing, Michigan, J.A.V.M.A. 149 :823-824. 1966. 15. Price, A. A. A trimester program for veterinary medicine. Am. J. Vet. Res. 26 :444-449. 1965. 16. Price, D. A. Interns, Externs, Preceptees. J.A.V.M.A. 141 :728-730. 1962. 17. Pritchard, W. R. A proposal for a change in veterinary education to better meet the needs of a changing profession. J.A.V.M.A. 140:1298-1303. 1962. 18. Railsback, I.. T. The correlation of veterinary medical education with the practice of veterinary medicine. Excerpts from Symposium on veterinary clinical education. June, 1965, at Athens, Georgia. J.A.V.M.A. 147 :434. 1965. 19. Riser, W. H. Your future in veterinary medicine. 1st ed. New York 10, New York. Richard Rosen Press, Inc. 1962. 20. Sis, Raymond. Three-year professional curriculum. Iowa State University Veterinarian 25 :75-78. 1962-63. 21. Stange, C. H. The address of the President. J.A.V.M.A. 65 :689-694. 1924. 22. U.S. and Canadian veterinary student enrollment continues to climb. J.A.V.M.A. 147 :1703-1704. 1965. [Telegram] AMES, Towa. Dr. FRANK A. Topp, American Veterinary Medical Assn., Washington, D.C.: Urge favorable consideration S. 3095. Veterinary medicine like human medi- cine is totally inyolved in environmental health problems/with only 18 veterinary medical colleges, veterinary education is truly a national program. States with veterinary medical colleges train veterinarians for other States. Basic support for medical education should include veterinary medicine to permit admission of more students and particularly more out of State students. R. L. KITCHELL, Dean, College of Veterinary Medicine, Towa State University. PREPARED STATEMENT OF C. A. BRANDLY, DEAN, COLLEGE OF VETERINARY MEDICINE, UNIVERSITY OF ILLINOIS, URBANA, ILL. Statement relating to the contributions to and role of veterinary medicine to the health of man, with comments stressing the urgent need of institutional grants to the nation's colleges of veterinary medicine in order that they may more effectively fulfill their bur- geoning education, research and service obligations.’ 1 This statement deals only and in very brief manner with (1) the serious impact on human health of diseases of animals transmissible to man, i.e., the zoonoses, and hence, veterinary medicine's major accountability for their suppression, and (2) the increasing demand for maximally healthy and disease-free biologically standardized experimental ani- mals that are essential to efficient and successful prosecution of the nation’s extensive bio- logical research program. There will be alluded to an example of new and transcendingly important health research programs to develop means to overcome pollution of our environ- ment with antibiotic and other therapeutic agents or drugs. 192 Man’s health is inextricably interwoven with the environment which he shares with a vast host of other living creatures. Efforts to control the environment to man’t benefit, especially as a means to combat ill health and mortality are age- old exigencies. I. The Threat of the zoonoses to health. The World Health Organization recognizes more than 100 zoonoses. The most serious of these threatening man’s health today, in many developed as well as undeveloped countries of the world, are: 1) Salmonella food poisoning which is increasing in nearly all western countries; 2) bovine tuberculosis, while once causing 209% of human cases of tuberculosis has been reduced by national pro- grams for its eradication from cattle in the most progressive countries to a fraction of 19. Nevertheless, the complete “stamping out” of this insidious malady has proved extremely difficult; and there are still many developing countries where bovine tuberculosis is prevalent. Therefore, a centuries old threat to both human and animal health persists; 3) brucellosis, prevalent uni- versally, spread from its reservoirs in animals to infect an estimated 100,000 people in the Americas alone in 1947. While the bovine type of the infection has been greatly reduced in our land by cattle testing and slaughter of reactor animals, it remains a serious human scourge in most areas of the globe. Brucel- losis constitutes a substantial occupational hazard to farmers and other pro- ducers of swine, goats, sheep and cattle as well as to slaughter house workers and veterinarians; 4) rabies has increased in incidence during the past decade espe- cially among various wild carnivore, e.g.,, skunks, foxes, reservoirs of this horrible disease. Rabid bats are a formidable yet relatively new source of human rabies in the U.S.A. The number of persons treated annually to prevent rabies after being bitten was estimated to be about half a million (W. I. B. Beveridge, 1967—Implications of Animal Health for Man, in Proceedings of CIBA Founda- tion Symposium on the Health of Man: Little, Brown and Co., Boston, Mass.), yet deaths from rabies may be only in the hundreds; 5) leptospirosis resides in a broad range of domestic and wild animals which constitute a world-wide reservoir of human infection, the eradication of which cannot be expected. Nevertheless, development of vaccines and suppression of rodent populations are “footholds” toward better control; 6) infection with Taenia saginata, the com- mon human tapeworm, whose cystic stage in cattle has been reported to have increased substantially in both developed and developing countries of the world. The growing popularity of camping with resultant contamination of cattle pas- tures with human excrement, greater consumption of beef, often rarely cooked, and impaired sewage processing by detergents are apparent explanations for the increased incidence of this disease. The encephalitic diseases, i.e., central nervous disorders, and fevers transmitted from various mammalian and bird reservoirs to man by mosquitoes and other anthropod vectors are demanding greater research and control efforts. To catalog other zoonoses here would be needless. Their pattern must be expected to change, often adversely. New zoonoses may be expected to appear through mutation of infectious agents and because of changes of environment, both natural and enforced. Indeed, the histories of plague, tularemia, yellow fever, malaria are forbidding examples which protend recurring and new serious zoonotic challenges.” ' II. Increasing demands for maximally healthy and discasc-frec laboratory and other cxperimental animals for the nation’s vast health related research pro- grams.® Broad programs in biomedical research have contributed greatly to the well- being of mankind through the discovery of basic knowledge and its application for the diagnosis, management and control of both human and animal disease. 2 Established in 1960 as the first venture of its kind in our country, was the unique inter- and multi-diseiplinary Illinois Center for Zoonoses Research. It is a component of the State's College of Veterinary Medicine. 3 The Institute of Laboratory Animal Medicine, National Research Council, recently esti- joated our nation’s biomedical research program utilized 569 million experimental animals ast year. 193 Veterinary medicine occupies a vital role in biomedical education and research by virtue of the many competencies which the education in various areas by the professional colleges bestow on the Doctor of Veterinary Medicine. Veterinarians are obligated to involvement in many areas, a major one of which is promoting and safeguarding the health of laboratory and other research animals, A broadly based expertise is required for the production and assurance of proper refined use of biologically standardized experimental animals. Comparable competence is essential also for fruitful search among both domestic and wild species of the animal kingdom for those individuals and species with naturally occurring aberrancies and diseases both genetic, e.g., hemophilia, epilepsy, and environ- mental, e.g., atherosclerosis, which may provide models for investigation of comparable human disorders and diseases that have gone unsolved. Stressing the injurious effects of animal disease on human welfare would be misleading and myopic were it not identified and emphasized that great advances of knowledge and progress in concepts of infectious diseases of man have been largely derived from the study of diseases of other animals. The germ theory of disease was first demonstrated by Pasteur and Koch in their work on anthrax of sheep. The basis of artificial immunization with attenuated vaccines arose with Jenner's work with cow pox and Pasteur’s observations on fowl cholera. The “spring board” for suppression of such diseases as African sleeping sickness and yellow fever was the pioneering work of Kilbourne and Smith which demonstrated that so-called Texas fever of cattle was transmitted by ticks. Major advances in e.g., the fixation or immobilization of fractures, open heart surgery, kidney, heart and other organ transplants could not have been possible without the availability of and extensive use of experimental animals. The growing concern about the impact of pollution of the environment on the health of “every useful living being,” especially with more and more crowding of populations, presages a vast augmentation of research toward minimizing or overcoming a number of known dire and probably equally sinister unknown effects of pollution. Of the major pollutants, namely, radioactive substances, fossil fuel residues, human and animal wastes, and thermal radiation from nuclear installations and other sources and of antibiotic and other drug residues have unique potentials for adverse effects. The non-medical, promiscuous use of antibiotics commonly used as additives to animal feeds obviously is creating major health traps. Significantly, the food-poisoning salmonella, as examples of pathogenic bacteria with great zoonotic vigor, have been found to acquire multiple resistance to antibiotics and sulfonamides merely from contact with other resistant bacteria. The practice of adding antibiotics—specifically penicillin and tetracycline—to the feed of poultry and swine has led to the widespread selection of strains of common intestinal bacteria, Escherichia coli, which are resistant. While harmless, these FH. coli strains may transfer their resistance to salmonella strains via episomes during conjugation. Identification of this frightening phenomenon raises new risks to both human and animal health. COMMENTS Our country’s mounting shortage of veterinary medical manpower is rapidly growing more critical. This dilemma is due to both state and national failure to face up to burgeoning needs for veterinary medical education starkly evident in the late 1930’s and which have multiplied at least 7 fold since World War II. Surveys since 1958 by various committees, agencies and individuals of veterinary medicine's current and impending manpower shortages and needs (see citations and calculations in attached “Preparing for an Expanding Role in Medicine,” Veterinary Economics Magazine, August, 1962) led to calculated demands for educating 30,000 to 45,000 more veterinarians by 1975, i.e., doubling or tripling of numbers. A recent published figure is that the nation’s 18 colleges of veterinary medicine were able to increase the number of their graduates by only 59% during the period 1962-1967. The projected needed expansion should have been no less than 3 times this figure. Major expansion and support requirements for veterinary medical education if this increasingly vital health science and profession is to fulfill its increasing 194 obligations * to total human health and welfare were recognized (in part) and underwritten by passage of the 1967 Veterinary Medical Educational Facilities and Student Loan Act. Unmet and required support and needs for this and other health professions are identified in the 1968 Health Manpower Act. To exclude veterinary medical schools from eligibility for institutional grants and other support accorded other health professions schools would be grossly unjust and discriminatory to our nation’s health and welfare. It would signify wanton disregard for our national and individual precepts of humanity as well as our mercenary concern with not only maintaining but improving the “health and welfare of every useful living being.” Several fold the number of fully qualified applicants than can be accepted by the nation’s schools are being turned away each year. Those that qualify should not be denied privileges and benefits that are accorded students of all other health professions except veterinary medicine and pharmacy. Such discriminatory treatment is even less justified in view of the obvious fact that it will prevent the ultimate accrual of important benefits to the individual's and the nation’s health and well being. PREPARED STATEMENT OF DR. ERSKINE V. MORSE, DEAN, SCHOOL OF VETERINARY SCIENCE AND MEDICINE, PURDUE UNIVERSITY, LAFAYETTE, IND. The shortage of veterinarians for practice, health-related activities, academic positions, and biomedical research, has been stressed by the nation’s veterinary educators during the past decade. There are not sufficient veterinary graduates to fill the critical veterinary service needs of the country. There are three to five vocational opportunities for each of Purdue's 1968 graduates. Congressional leg- islation enabling construction of new colleges of veterinary medicine and ex- panded facilities for veterinary education in the existing eighteen colleges will aid in filling the gap. More than physical facilities are needed. Colleges of veteri- nary medicine should be included in the Basic Improvement Grants acts if we are to educate the veterinarians required in the 1970's and 1980's. In addition to producing numbers of veterinarians, the educational and training methodology for the students must not be neglected and should be geared to the changes and needs of the professions of the future. Excellence in teaching can be developed through study and experimentation with new and innovative pedagogical tech- niques. More effective learning or knowledge acquisition in veterinary medicine and better teaching should be possible and a special goal of veterinary medical colleges. Basic Improvement Grants can assist veterinary educational institu- tions in self improvement. Veterinarians should be educated to serve the many needs of international ani- mal agriculture. In the developing countries the shortage of veterinary service is deplorable. Each year animal diseases destroy billions of pounds of the world’s meat, milk and poultry products which starving populations direly need to exist. The field of biomedical engineering requires veterinary assistance, talent, and scientific input. This area relates directly to space age medicine and this coun- try’s commitment to space research. Solutions to common problems in engineering and medicine provide data to military medicine as well. On the horizon one sees developing possible animal and human food sources from the sea. The diseases of marine animals are exceedingly important. Un- fortunately, knowledge is lacking. In addition, the various toxic animals, both large and microscopic, are of significance when one is utilizing their meat and/or products for human food. The importance of cancer stimulating (carcinogenic) drugs, as well as some tragic side effects of new pharmaceutical compounds, is well known to the Amer- ican public. There is a great shortage of veterinary pathologists to work in this research-development area to evaluate and conduct investigations. An ancilliary problem of colleges of veterinary medicine is the dire shortage of individuals who have acquired advanced degrees in the basic sciences and can 4 In the interests of practicality there were defined earlier and briefly only a few of veterinary medical manpower’s many areas vital to human health and welfare where already dire shortages are rapidly worsening. 195 qualify as faculty. Programs to benefit alleviations of this shortage should be devised whereby talented young veterinarians can be encouraged to find inter- esting careers in academia. Supported programs which would encourage and as- sist in developing the talents of the outstanding individuals of a veterinary class should be devised. This may be done through summer research programs while the student is still an undergraduate. Graduate programs should support those aspiring to be the teachers of tomorrow. Colleges of veterinary medicine should take a long, hard look at their teaching methods and their classic, sometimes out- dated and archaic, approaches to teaching veterinary medical subjects. Speciali- zation (laboratory animal medicine, the special research disciplines, etc.) may well be regarded in the senior year to fulfill the envisioned needs of the pro- fession. Funds should be available to finance specialized studies by progressive faculty members at our various veterinary institutions. Curricular “overhauling” appears to be in order! By more effective teaching methods and techniques, it is possible to cut the attrition rate (drop-outs) in the undergraduate veterinary classes. In general, the attrition rate of veterinary students may vary from five to fifteen percent, depending upon the school. It has been suggested that more effec- tual methods of presenting the core curricula may well cut this loss in manpower and save valuable time both of faculty and students. A study of the problem and progressive, imaginative change is indicated and due. Obviously, the salaries of veterinary faculty members should be much higher than they are. In too many cases, institutions cannot compete for the best talents of recent graduates. Basic Improvement Grants could do much to remedy this situation. Ways and means of supporting veterinary researchers and teachers of the future must be found, and as these selected professionals receive their ad- vanced degrees through graduate education, every effort should be made to en- courage them to continue in academia as a life-time career. PREPARED STATEMENT OF GEORGE C. POPPENSIEK, DEAN, NEW YORK STATE VETERINARY COLLEGE, CORNELL UNIVERSITY, ITHACA, N.Y. In 1968 Veterinary Medical Education stands in a situation comparable to that of other belatedly recognized segments of total America: We have come a long way ; but we still have a long way to go. Through a massive effort within the profession and the welcome assistance of certain Senators and Congressmen, we took a step forward in 1966 by being in- cluded nominally under the canopy of the Health Professions eligible for as- sistance. But this recognition has yet to be translated into efficacious support. Meanwhile, other legislation has increased the burden on the nation’s 18 veterinary colleges. The Laboratory Animal Care Bill in 1966, the Wholesome Meat Act of 1967 and the imminent passage of the Poultry Inspection Act of 1968 call for greater availability of doctors of veterinary medicine. And although we hope that military quotas will soon subside, there is a pressing shortage of vet- erinary officers in the Armed Services. When these emerging problems are added to the critical shortages which we documented for Congress in 1966, they create the fantastic need for veterinarians described in the Wall Street Journal on March 12, 1968. The student loans which are now available to veterinary students represent a measure of assistance to those already admitted to the professional colleges. But they are of no consolation to the greater number (we must reject 4 out of 5 appli- cants each year) who would like to enter the profession and alleviate the national crisis. Construction grants and project grants for veterinary colleges—as provided in S. 3095 (the Health Manpower Act of 1968) strike much closer to the center of this emergency. But a weak link remains in the chain of action unless we can gain assistance in establishing additional professorial positions, purchase needed equipment and development new curricula. Hence our wholehearted request for institutional grants which will round out the advance already begun. 196 Reprinted from the Journal of the American Veterinary Medical Association, Vol. 151, No. 8, Oct. 15, 1967, pp. 1033-1040 Demand-Supply Relationships for Veterinarians, 1960 to 1980 J.C. Thompson, Jr., Ph.D. SUMMARY -The demand for veterinarians will increase significantly in the next several decades. If world animal protein needs are met and veterinary services also provided for the increased numbers of nonfood animals (pets, laboratory, and other animals), the world demand for veterinarians could approach 500,000 by 1980—or nearly double the totals projected for that time. With increasing world emphasis on economic development and con- comitant rises in both food and nonfood animal numbers, it is imperative that veterinary output be expanded. THE INCREASING demand for veter- inary services can be expected to continue for the next several decades. Today’s worldwide food and popula- tion problems coupled with those of the future indicate the magnitude of these needs. When these needs are combined with increasing demands for expanded professional coverage into new fields, severe shortages seem imminent. Al- though these shortages have been rec- ognized to some degree, they must be examined in light of the changing role of the veterinarian. The primary role of veterinarians has From the Department of Physical Biology, New York State Veterinary College, Cornell University, Ithaca, N.Y. 14850. been, for many years, associated with food animals. Problems of survivability and improved performance through better health have been the highlights of this type of service. However, with- in the past 20 years, this role has been supplemented with several additional responsibilities. The increased de- mands created by pets and other animals (racing, zoo, and game animals) as our society achieves a higher standard of living are immedi- ately evident. Other areas such as re- search animal production and utiliza- tion as well as actual research program participation have broadened the vet- erinarian’s role. This broadening has occurred without a comparable increase 197 in veterinary output; thereby increas- ing the workload and demand for all veterinarians. Some insight behind these pressures and an indication of future problems is necessary if we are to meet the demands being generated. The Veterinarian and Food Animals Veterinarians, through their atten- tion to food-producing animals, play a vital role in human nutrition. The character of nutrition throughout the world is an excellent indicator of the existing needs and future potential for veterinarians. For example, as a developing or newly emerging nation tries to improve its internal and external structures, one of the pri- mary areas requiring attention is food and nutrition. Improvements in this area must often be accomplished in order to achieve any degree of internal stability, and this usually means in- creased food production. Inasmuch as food from animal protein sources forms an important part of this change, the veterinarian is involved. An analysis of caloric intakes as they relate to protein consumption permits Een : ’ High caloric ard high or minimal protein intake a pid Bm Low caloric and low or minimal protein: intake - an appraisal of the types of food intake in many countries (Fig. 1).° Those areas with low caloric intake and low or minimal protein intake require most improvement. The Far East, Africa, and Central and South America fit into these categories. The distorted nature of the graphic representation (Fig. 1) in- dicates the importance of population weighting in these areas. Similarly, those populations consuming minimal or high protein diets of high caloric content occupy the better fed areas of the world. They are correspondingly small when weighted by population numbers. The part that animal protein plays in protein intake is directly related to the role of the veterinarian, as shown by the animal protein contribution in grams per day for the countries of the world (Fig. 2).5 The distorted nature of graphic representation (Fig. 2) results from population weighting. Most areas of low animal protein intake (less than 15 Gm. per day) are located where there is a serious risk of malnutrition regardless of caloric intake. Such areas as the Far East and Africa have 8 and 11 Gm. of animal protein available per 198 | Kay 100 &e a 30 grams or more daily B 15 - 29 grams daily © < 15 grams daily Fig. 2—Pdpulation weighted total animal protein intake of the world. Total mum ————————tes Animal Protein Intake + r— + + + + 3 100 200 300 LO 500 600 700 800 900 1000 1100 1200 1300 1kod 1500 1600 1700 TE Annual Income (dollar Fig. 3—Effect of income on total protein intake and animal protein contribution. 199 day as compared with recommended levels of 12 and 18 Gm. for proper nutritional balance. These areas are also deficient in total protein intake. Although there is considerable pos- sibility for increasing total protein intake in some areas without changing animal protein intake, the likelihood is small. First, the net utilization potential of other protein sources is often less than animal foods. As a group, animal proteins have higher biological value than vegetable proteins and are utilized more efficiently by man for growth and maintenance. Replacement of animal protein with vegetable protein usually requires supplementation in order to insure adequate nutrition. Second, animal protein is usually the preferred source if income is adequate to assert of this in a typical this preference. Indications preference are shown graph of income and protein intake (Fig. 3).° Small changes in income bring about proportionately larger changes in total protein intake until the $400-income or 70-Gm. intake level is attained. Thereafter, income changes have less effect on total protein intake (e.g., total protein intake levels off). In contrast to this pattern, animal protein intake reflects a constant re- sponse to changes in income. Equal changes in income bring about the same rate of increase in animal protein intake with no apparent leveling off until in- comes are beyond $2,000. Thus, in- creased animal protein intake can be expected as incomes improve, partic- ularly among lower income groups. These data suggest that as the world solves or attempts to solve its food problems, the need for veterinarians will increase tremendously. Actually, 120 + 100 4 ~ g ~ - y 3 2 f % a 2 3 § z ¥ j= 2 34 fe 60 4 EA 8 EZ 8 o = ~ 5 3 or 3 aoe Is — 2 E 10 4 Jerexirs il ad 200 5 i wr B — « g ge, a = Animal Protein Supplies 3S 1 20 L100 2 Fig. 4—Relationship of world population growth and veterinary numbers to animal protein needs and supplies, 1960-1980. 200 the demand for veterinarians will precede the solving of these problem: since it will be veterinarians who make it possible to meet many of these goals. Without control of diseases and improved survivability, there will be little improvement in food productivity from animals. In an attempt to quantify the total demand for veterinarians, world esti- mates of veterinary output have been projected through 1980 (Fig. 4). Com- paring these projections with world population estimates for 1980 and with estimated animal protein needs and supplies gives some indication of future demands on the veterinary profession. Although some improvements are in dicated from 1960 to 1980, the increase in veterinarians only parallels the growth in total population. Thus, the shortage of veterinarians will continue unless output increases significantly. Since changes or improvements in animal protein production are directly related to veterinary services, increases in animal protein output will also fail to follow increased population growth. For example, animal protein needs for 1960 were about 64,000,000 kg. whereas supplies amounted to 21,000,000 kg. (or 33% of needs were met) (Fig. 4).4% This can be contrasted with the problem in 1980 when animal protein needs are estimated at 119,000,000 kg., and availa- ble supplies are estimated as 25,000,000 kg. (or 21% of needs). The higher levels of animal protein for 1980 do incorpo. rate some improvements in overall nutrition, especially among the de- veloping countries. The realization of these improvements depends primarily upon the veterinary and animal hus- bandry professions, since animal pro- tein will form an important part of the effort to reduce the protein gap. If nutritional improvements do not occur, then the expected gap for 1980, under current production rates, would show animal protein needs at 88,000,000 kg. and supplies at 25,000,000 kg. (or 28% of needs). Thus, projected supplies are far shorter than needs in either case. TABLE 1—World Comparison of Animal Protein per Veterinarian, 1960 to 1980 1980 1960 1965 1970 1975 Region (000 kg.) Africa 1,306 947 757 640 560 Asia 204 171 150 136 125 Europe* 27 24 21 19 18 North America* 82 59 48 41 37 Central America 846 1,012 1,139 1,238 1318 South America 444 425 408 393 381 Oceania 453 408 379 357 341 World 138 121 102 92 85 United States (adjusted) ** 142 149 156 158 165 *Nearly half of the veterinarians in these areas may be engaged in nonfood animal practice. Ad- justing for these numbers would require a doubling of figures presented here. **Adjusted to exclude veterinarians in nonfood-orientated practice. Since the veterinarian is so important in animal food supplies, ratios were calculated showing animal protein sup- plies per veterinarian for the major geographic areas of the world (Table 1). This comparison directly relates veter- inarians to food supplies and will show patterns of change over time. It com- pares with the practice of relating livestock units to veterinary numbers. In general, areas with a large number of livestock units per veterinarian cor- respond to those having large quantities of animal protein per veterinarian. Africa and Central and South America have the largest ratios over the entire time span. A level of 200,000 kg. (440,- 000 1b.) per veterinarian would be minimally acceptable for such develop- ing countries (corresponding to about 30,000 livestock units). Such a level would also be appropriate for many developed countries when adjustments are made for: (1) efficiencies due to ‘improved production and transporta- tion methods; (2) the number of vet- erinarians in specialized small animal practice; and (3) the time spent in other nonfood animal functions. In the United States, for example, when these adjustments are made, the ratio ap- proaches 160,000 kg. per veterinarian. Similar adjustments would be expected for other developed countries. Thus, the overall demand for veter- inarians to meet food needs can be 201 estimated by utilizing a guideline of 200,000 kg. of animal protein per veter- inarian. Comparisons can then be made and veterinary needs determined on the basis of changes in animal protein output (Table 2). Although changes in veterinary output are not indicated for Asia, Europe, and North America in order to meet the 200,000 kg. standard, the total increased needs for veter- inarians in other areas ranged from 26,- 640 to 51,165. This represents a 10 to 18% increase in world veterinary output in order to achieve a small measure of improvement in animal protein pro- duction. It would not approach the levels of animal protein production considered necessary for meeting im- proved nutrition requirements. In order to meet these targets, much greater increases in veterinary numbers would be required. More than 500,000 veter- inarians would be required if minimal nutrition requirements were to be met in the world by 1980 (using guidelines of 200,000 kg. animal protein per veter- inarian). The degree to which these improvements are realized may rest heavily upon the veterinary profession. The Veterinarian and Pets Just as economic development pro- vides the answer to food requirements, it also results in a higher standard of living. When higher standards of living are realized and the basic needs are met (food, shelter, and clothing), the remaining income can be used in a more discretionary manner. Such discretion- ary purchases range from durable goods to those of nondurable nature. Included among these purchases are the increased numbers of pets that associate directly with man’s well being. In the United States, the population of dogs and cats has increased from an estimated 38 million in the early 1950's to more than 50 million in the early 1960’s.1%11 Estimates of more than 60 million dogs and cats were reported as early as 1961.!! Using past growth pat- terns to forecast current totals would indicate the possibility of 60 to 65 mil- lion dogs and cats at this time. This could mean more than 75 million dogs and cats in the United States by 1980. Such an increase would require the services of more than 4,000 additional veterinarians by 1980; an amount that matches the total projected veterinary output in the United States during the same period. When these needs are coupled with the increased numbers of other pets, such as 22 million parakeets and canaries, the anticipated deficit in veterinary numbers becomes even greater.? TABLE 2—Projected World Demand for Veterinarians as Related to Changes in Animal Protein Supplies,* 1975 and 1980 1975 1980 Indicated Increase animal Indicated Increase animal Region growth protein 25% growth protein 50%** Africa 14,037 17,543 14,635 21,952 Asiat 51,118 51,118 59,009 59,009 Europet 130,056 130,056 143,360 143,360 North Americat 56,498 56,498 67,947 67,947 Central America 7,545 9,431 8,895 13,342 South America 17,622 21,993 18,245 217,368 Oceania 4,670 5,838 5,095 7,642 World needs 281,546 292,529 317,366 340,620 Normal output 254,906 254,906 289,455 289,455 Increase needed 26,640 37,623 27911 51,165 Percentage increase 10% 15% 10% 0% y *Projection based on standard of 200,000 kg. per veterinarian. **Increases of this magnitude would only meet 329% of animal protein needs. tNo increases over normal growth patterns necessary to meet 200,000 kg. per veterinarian level. 92-079 O - 68 - 14 202 Although the United States cannot serve as the immediate indicator ot world veterinary needs for pets, it does give some insight into the magni- tude of changes that occur under im- proved standards of living. In Great Britain, the problems are similar as evidenced by ratios of dog and cat populations per veterinarian (Great Britain with about 2,200 dogs and cats per veterinarian and the United States with 2,000).'2 As other countries in- crease their developmental pace, pet populations will grow and veterinary needs will become greater. The Veterinarian and Laboratory Animals The importance of biomedical re- search and the advances and improve- ments in this field are often directly related to experiments utilizing vari- ous types of laboratory animals. For the United States, the 1965 totals of 62.5 million animals could easily in- crease to 175 to 200 million by 1980 (Table 3). Similar increases can be TABLE 3—Estimated Laboratory Animal Use in the United States, 1965 to 1980 Type 1965* 1970* 1975** 1980** (millions) Mice 36.8 59.6 82.3 105.0 Rats 15.7 25.3 349 4.6 Hamsters 33 53 73 9.4 Guinea pigs 25 4.1 5.6 72 Dogs 2.0t 33 46 59 Rabbits 1.6 25 34 44 Cats 0.5t 0.8 11 14 Exotic species 0.1 0.2 0.3 0.4 62.5 101.1 Total 139.5 178.3 *See reference 7. **Projected at same rate of increase as 1965 to 1970. tSee reference 1. expected for other animals which are not of sufficient magnitude to be in- cluded in these totals (primates, other rodents, and avian species). In terms of veterinary needs, laboratory animal specialists in the United States totaled 125 in 1958 and approximately 500 in 1965. Continuing this pattern of growth would indicate a need for more than 1,500 veterinarians by 1980. When these requirements are combined with the enlarged biomedical needs of gov- ernment, university, and private in- dustry, the demands created and alter- natives offered present new challenges to the veterinary profession. The total needs for these areas in the United States, using the 5,000 employed in 1960 as a guide, would probably exceed 10,000 at this time and approach 20,000 by 1980.1 Translating the experiences of the United States to the rest of the world provides an indicator of future prob- lem areas as nations grow. The initial emphasis directed toward food-pro- ducing animals can soon be supple- mented by demands from the nonfood segment (pets, laboratory animals, and research). Discussion Increasing veterinary demands through expanded services, new pro- grams, and rising animal numbers form an important part of progress in a developed country. The solution to such problems requires expanded veterinary output from existing facili- ties or the development of new ones. In either case there is a potential solution because the capital and inter- nal stability required for such advances is generally available. Once the need is determined, the interaction of supply and demand can bring about a solution. In the developing countries, the de- mand for veterinarians is an acute and chronic problem. The capability to act or react upon this need is severely hampered by many other demands. The lack of capital and economic stability force many decisions to be postponed or to be confined to short term. Thus, these basic problems may be overlooked or bypassed in favor of ones that seem more pressing. This is the situation facing the shortage of veterinarians in developing countries. The needs are so great and available funds so small that Increased industrial and food production 203 little is accomplished toward easing the shortage of veterinarians. In these countries, the critical shortage of vet- erinary services seems destined to worsen as population and food needs outpace the capabilities of existing and projected facilities. The problem seems to be confined within a circle of constraints: Economic development Better education; improved standard of living Improved industrial capabilities; improved plant, animal development The problem of selecting the entryway that will be most productive in the shortest time is critical. Although worldwide cooperation could solve many of these problems, it is seldom possible under the political uncertainties which persist. It seems most logical for the developed countries to adopt more widespread foreign ex- tension and cooperative programs. In the veterinary profession these pro- grams would significantly improve the future outlook if they were accompa- nied by a significant increase in output of veterinarians. References 1 Editor, New York Times: The Animal Laboratories. New York Times, New York, Nov. 28, 1965. 2 Financial World: Population Growth Spurs Results. Guenther Publishing, New York, Nov., 1966. 3 Food and Agriculture Organization of the United Nations: Animal Health Yearbook. FAO, Rome, Italy, 1960-1965. 4 Food and Agriculture Organization of the United Nations: Production Yearbook. FAO, Rome, Italy, 1960-1965. 5 Food and Agriculture Organization of the United Nations: Protein. No. 5 in series on You Food Problems. FAO, Rome, Italy, 6Food and Agriculture Organization of the United Nations: Third World Food Sur- vey. FFHC Basic Study No. 11. FAO, Rome, Italy, 1963. 7 Institute for Laboratory Animal Re- sources Newsletter: Estimated Laborato: Animal Consumption 1965-1970, 9, 1966) : 10. 8 Joint Committee on Veterinary Educa- tion: Manpower in Veterinary Medicine. American Veterinary Medical Association, Chicago, Ill., 1965. 9 Mattson, Howard W.: Food for the World. International Science and Technology, No. 48, Conover-Mast Publishers, N.Y. (Dec., 1965) : 28-39. 10 Siebel, H.: Veterinary Medicine in the United States. Die Blauen Hefte fiir den Tierarzt, Frankfurt/Hoechst, Germany (1965): 1-9. 11 United States Senate and Its Subcom- mittee on Reorganization and International Organizations: Veterinary Medical Science and Human Health. United States Govern- ment Printing Office, Supt. of Documents, Washington, D.C., 1961. 12Wilkinson, G. T.: Some Conditions of Importance in Cat Practice. Vet. Rec., 75, (Nov., 1963): 1198. (April, 204 The CaaRMAN. I want to thank you. We are delighted you are here today. We appreciate your presence and we certainly thank you for your testimony. It was very fine indeed. The subcommittee will now stand in recess until tomorrow at 10: 30. (Whereupon, at 1:05 p.m., the subcommittee recessed, to reconvene on Thursday, March 21, 1968, at 10: 30 a.m.) HEALTH MANPOWER ACT OF 1968 ‘THURSDAY, MARCH 21, 1968 U.S. SENATE, SuBCOMMITTEE ON HEALTH OF THE ComMmrrTEE ON LiaBor AND PuBrLic WELFARE, Washington, D.C. The subcommittee met, pursuant to notice, at 10: 30 a.m., in room 4232, New Senate Office Building, Senator Lister Hill (chairman) presiding. Present: Senators Hill (presiding), Yarborough, Murphy, and Dominick. Committee staff present: Robert W. Barclay, professional staff member ; and Roy H. Millenson, minority clerk. The Caarman. The subcommittee will kindly come to order. Dr. McCallum, vice president of the American Association of Dental Schools, and consultant to the Council on Dental Education of the American Dental Association, will be our first witness. Will you come up, Doctor? Have a seat, sir. You may proceed now, sir. STATEMENT OF DR. CHARLES A. McCALLUM, JR., DEAN, UNIVER- SITY OF ALABAMA SCHOOL OF DENTISTRY, CONSULTANT, COUN- CIL ON DENTAL EDUCATION, AND VICE PRESIDENT, AMERICAN ASSOCIATION OF DENTAL SCHOOLS; ACCOMPANIED BY BERNARD J. CONWAY, CHIEF LEGAL OFFICER, AMERICAN DENTAL ASSOCI- ATION; AND BENJAMIN F. MILLER III, SECRETARY-TREASURER, AMERICAN ASSOCIATION OF DENTAL SCHOOLS Dr. McCarrum. Mr. Chairman and members of the committee, my name is Dr. Charles A. McCallum, Jr. IT am dean of the University of Alabama School of Dentistry. In addition, I am consultant to the Council on Dental Education of the American Dental Association and vice president of the American Association of Dental Schools. I am appearing today on behalf of these two organizations. With me are Mr. Bernard J. Conway, chief legal officer of the Amer- ican Dental Association, and Mr. Benjamin F. Miller, ITI, secretary- treasurer of the American Association of Dental Schools. We are pleased to have this opportunity to testify on S. 3095, The Health Manpower Act of 1968. As this committee and especially its distinguished chairman well know, the dental profession has been deeply concerned for many years about the problem of providing a supply of well-trained professional (205) 206 and auxiliary dental personnel that would be adequate to the needs of our people. In fact, the organized dental profession was one of the earliest supporters of the Health Professions Educational Assistance Act of 1963, which the chairman authored. The CratRMAN. Your association was one of the strongest and best supporters, correct? Dr. McCarrum. Yes, sir. We have supported, as well, those subsequent measures authored oy the chairman that are now brought together in the four titles of . 3095. There is no question in our mind that each of these programs was necessary at the time of its passage and remains necessary today. We are convinced that they are central to our national effort to extend and improve the health care available to our fellow citizens. We believe that the support furnished by these measures will continue to be re- quired for some years ahead, especially in view of the considerable number of laws passed by Congress in recent years establishing new and widely broadened health care benefits to various groups of people such as the elderly, the categorically needy, the medically indigent and young children from impoverished families. Our paramount purpose, then, in appearing before you today is to make clear our support for S. 3095 and to urge favorable considera- tion of it by this committee. In this brief oral statement, we would like to outline the progress that has been made in recent years, the con- tinuing need for this legislation and, finally, our view of some of the changes S. 3095 would make in the existing programs. CONSTRUCTION Since the inception of the Health Professions Educational Assist- ance Act of 1963, a total of 33 applications involving construction, renovation, or rehabilitation have been received from 29 dental schools. These applications include plans for new dental schools as well as additions to or replacement of existing facilities. As a result of only those construction grants that have been funded, it is our understanding that places for 681 additional first-year stu- dents will be created. An additional 100 places will come into being as a result of six applications that have been approved but are not yet funded. There are four applications awaiting approval which, if re- ceived, will add 200 more places. And finally, 10 schools have given notice of intention to apply for grants by submitting plans that, in total, would provide 272 new first-year places. If all goes well, we can project a 1973 freshman enrollment of some 5,300 individuals as compared with the current figure, 4,198. The Crarrman. That would be definite progress, would it not? Dr. McCarrum. Yes, indeed. It is important to note that these accomplishments and projections are being carried out on the basis of a genuine partnership with the Federal Government. The 33 applications that have been received in- volve a total estimated cost of $216 million, of which some $98 million would come from non-Federal sources. In order to fulfill these projections fully, however, S. 3095 must be approved. The sums authorized under the existing law are not suffi- 207 cient. As of February 1, 1968, approximately $71 million has been distributed by the Federal Government for dental school construction. Applications that are approved but unfunded, deferred or pending will require an additional $47 million, and anticipated applications would call for $59 million more. As of February 1, only some $6 mil- lion was available but not obligated. The CuamrMAN. In other words, that much of the funds appropri- ated had been used ? Dr. McCarrom. That is right. Considering solely those applications that are approved but un- funded, this constitutes a deficit of nearly $15 million. If all applica- tions now pending or anticipated are approved, the deficit would be at least $100 million. Extension of the law is, then, mandatory in our opinion. It is equally essential that the present level of funding for dental schools—$35 million a year—be taken as the minimum amount necessary annually in the foreseeable future. Title I of S. 3095, which relates to construction, would not only extend existing law but would also amend some aspects of it. The bill would, for example, eliminate the provision that prevents the use of Federal funds for construction of teaching facilities for continuing or advanced education. The Caarman. Do you think that is important? Dr. McCarLLum. Very important. Of even greater importance is the provision that would permit a single application for construction of facilities that though substan- tially for teaching purposes also would include research and library facilities. Coty this will eliminate a great deal of administrative confusion and redtape. Indeed, these changes, and perhaps some others in the bill are of such manifest value that we are sorry to see they will not take effect until the end of fiscal 1969. Perhaps the committee would wish to con- sider moving the effective date forward 1 year. A substantive improvement also would be made by the provision that will permit up to 6624 percent Federal support for renovation or re- habilitation if, in the Secretary’s judgment, unusual circumstances exist. In previous years, when testifying on these matters before this committee, we have voiced concern over the possibility that some dental schools might find it necessary to close their doors unless substantial assistance could be obtained. Th CuarmaN. The dental school at the University of St. Louis has closed. Dr. McCarrum. That is right. This concern, we are sorry to say, has now become a reality in the case of one university that, solely for financial reasons, has felt com- pelled to discontinue its dental school. The Caamrman. Did you have in mind the University of St. Louis? Dr. McCarron. The University of St. Louis, yes. Had 2 to 1 matching been available, there 1s some possibility that the university might have felt able to continue. We can presently identify four to six additional existing schools that are actively con- sidering the discontinuance of their dental educational program. This would be a crippling blow to our hopes for progress since, as this com- mittee well knows, the retention of an existing school, its faculty and 208 structure, and student body, is at least as important to the future as is the funding of a completely new school that will require 8 to 10 years before graduating its first practitioner. INSTITUTIONAL GRANTS Viewed as incentive programs for the improvement of dental educa- tion, the basic and special improvement grants of the past 2 years have been remarkably successful. In 1964-65, the operating dental schools spent approximately $51 million on their teaching programs. In 1967- 68, that total had mounted to $77 million, demonstrating clearly that non-Federal expenditures have risen at a rate considerably higher than the amounts distributed by the Federal Government. In fact, cur- rent non-Federal expenditures are some $14 million more than they were in 1964-65, while Federal funds have been increased some $12 million. With the funds available as institutional grants, combined with the non-Federal effort, 45 dental schools have added new courses to the undergraduate curriculum in 28 subject areas, pertinent courses that will significantly improve the services the new dentist can offer his patients. Additionally, 28 schools have reported expenditures of signif- 1cant amounts for such purposes as new educational equipment, new clinical teaching aids, and improved closed-circuit television facilities. The Crairaan. These new aids cost money, too; do they not? Dr. McCarrum. They do. With the funds available from the improvement grants, the Nation's dental schools have been able to recruit 173 full-time equivalent faculty personnel and 92 nonteaching personnel, thus enabling them to better cope with the increasing size of the student body. These are only beginnings, however, and much more must be done. Statistics relative to teaching personnel strikingly document this fact. In the current academic year, there are 148 full-time positions that are vacant. Within the next 5 years, new construction and expansion will create 280 new full-time positions. Within this same 5-year period, some 175 full-time teachers will retire. We are thus facing today, a deficit, in terms of full-time faculty, of more than 600 qualified teachers. The Cuamman. That presents a problem; does it not? Dr. McCaLrLum. Yes. The need for extension and expansion of the institutional grant mechanism, then, lies at the heart of any plan for expanding manpower in dentistry and we support their continued existence. The associations believe that the new formula for allocating the grants is, in general, well-conceived. Because of special circumstances in a few institutions, we regard the waiver provision respecting in- creased enrollment as essential. SPECIAL PROJECT GRANTS Much of the preceding comment regarding institutional grants ap- plies with equal force to the special project grants authorized in the bill. Both approaches will do much to strengthen dental education. The particular value of the special project grants is that they are de- signed to be used to achieve specific improvements or to meet excep- 209 tional problems in health professions education. We are pleased, for reasons expressed earlier, that there is explicit authority to assist schools that are in “serious financial straits,” a description that cur- rently fit several dental schools. SCHOLARSHIP AND LOAN FUNDS We have always shared with this committee the conviction that the opportunity for professional health education should be available to any young man or woman with the talent to pursue it. A lack of per- sonal financial resources should not be a determining factor. The loan and scholarship funds available in the past few years have moved us closer to realization of this goal. The need for these provisions is, if anything, greater than it has been. The cost of dental education to the student has increased as a result of higher tuition fees and living costs. The Cramman. It has gone up like everything else; has it not? Dr. McCarrum. It certainly has. The average tuition cost per year for private schools, in 1963, for example, was $1,100 and today it is $1,476. The average total expense for the 4-year dental education program, exclusive of living costs, was $7,000 in 1963 and is $9,300 today. The Cramman. That is quite an increase; is it not? Dr. McCarrum. Yes. In individual instances, this total can be as high as $15,000. The schools have had no difficulty in identifying students needing the scholarship and loan support being offered. The 1967 Annual Survey of Dental Education Institutions shows that 94 percent of the loan and scholarship funds available, both Federal and nonfederal, were awarded. The small amount not awarded was due, almost entirely, to the existence of a few private scholarships or loans that have highly re- strictive eligibility requirements. The provision in S. 3095 that would permit schools to transfer up to 20 percent of either the loan or scholarship fund from one to the other is, in our view, desirable. The flexibility will permit the indi- vidual school to be that much more responsive to the particular needs of its student body. . The CratrMaN. You can use the money where the greater need is. Dr. McCarrLum. This gives us the opportunity to have greater flexibility. ALLIED HEALTH PROFESSIONS Both associations fully supported passage of the Allied Health Pro- fessions Personnel Training Act of 1966. The program it authorized is barely underway, the value of it and the need for it are abundantly clear and we strongly favor continuation along the lines contemplated by S. 3095. HEALTH RESEARCH FACILITIES The activities authorized under the Health Research Facilities Act are directly and essentially related to the continued expansion of our supply of health practitioners and continued improvement in the education of health students. The final goal, in all instances, is to make the finest possible care readily available to our fellow citizens. If prop- 210 erly funded, the Health Research Facilities law will make an essential contribution and we urge its continuance. Finally, we could not in good conscience conclude this statement without taking note of the fact that this may well be one of the last times our associations will be privileged to testify before this committee under its present chairman. The March issue of the Journal of the American Dental Associa- tion carried an editorial concerning, sir, your decision to retire. The editorial reads, in part: “No one, certainly, can begrudge this great man a slightly lessened pace * * * but he is the patriarch of American health and his imminent retirement makes orphans of us all.” The Cuamrman. That is most gracious and most generous of you, and I deeply appreciate it. Dr. McCarrum. Itis well deserved. The Cmamrman. I deeply appreciate it—from the depths of my heart. Dr. McCarrum. No words are adequate to express to you the grati- tude of American dentistry for what you have done. No words can convey the debt that we, and all Americans, owe you. On behalf of the American Dental Association and the American Association of Dental Schools, may I wish you every blessing in the years ahead. The CaamrMaN. Thank you, sir. Dr. McCarrum. And may I promise—perhaps I should say warn— you that we shall continue to rely as heavily as always on your wise and generous counsel. This concludes our testimony, Mr. Chairman. We are grateful for this opportunity to appear in unequivocal support of S. 3095 and would be glad now to try and answer any questions. he CaatRMAN. Well, again I want to express to you my deepest Fame for your most generous words, my heartfelt thanks. Also, want to express my appreciation for your very fine statemnt. You covered the case so well, you do not leave me any questions to ask. Mr. Conway, is there anything you would like to add ? Mr. Conway. Mr. Chairman, I believe the Association, if it could make a special appeal on S. 3095, it would be to emphasize the need for Federal 2 to 1 matching for the construction program, particularly that which has to do with restoration and renewal of existing facilities. This is a sore need, particularly with the private dental schools, which we wish to maintain. The CaamrMAN. And which are in difficulty ? Mr. Conway. Yes. The Cramrman. Is there anything you would like to add ? Mr. Mirrer. Ido not think so. d ing CuarMaN. Do you agree with me, that he covered the case ully ¢ Mr. Mirier. I believe so. The Cramrman. And you support the statement by Mr. Conway ? Mr. MiLer. Yes. The Caamrman. Thank you very much for appearing and giving us such a fine statement. I deeply appreciate it. Dr. McCarrum. Thank you very much, sir. ps CuaamrMaN. The American Hospital Association—Mr. Reid olmes. 211 STATEMENT OF REID T. HOLMES, WINSTON-SALEM (N.C.) COUNCIL ON GOVERNMENT RELATIONS, AMERICAN HOSPITAL ASSOCIA- TION; ACCOMPANIED BY KENNETH WILLIAMSON, ASSOCIATE DI- RECTOR, AMERICAN HOSPITAL ASSOCIATION, AND DIRECTOR, WASHINGTON SERVICE BUREAU Mr. Homes. Mr. Chairman, I am Reid T. Holmes, administrator of the North Carolina Baptist Hospitals in Winston-Salem. I appear in behalf of the American Hospital Association as a member of its council on Government relations. Accompanying me is Kenneth Williamson, associate director of the association and director of its Washington service bureau. The Cuamrman. He is one of my dearest and best friends. There is one thing he has not done for me that I asked him some time ago. Mr. Houmres. What is that, sir ? The CuairmaN. I want him to grow a new crop up here and tell me how it is done. Of course, in all fairness, I would have to say that your work is at a little lower level, down below that. Mr. Wirrtamson. That is right. When I find the secret, I shall let you know. The Cramrman. All right, be sure you do. Mr. Houmes. S. 3095 is a bill— to amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for such personnel, and the program relating to health research facilities, and for other purposes. We strongly support the purposes of this legislation and highly commend the Congress for its recognition of the essentiality of the Federal Government participating substantially in programs to allevi- ate the severe shortage of health manpower. As the committee is well aware, the Federal Government is sponsoring a number of programs which quarantee health services to various groups of the population. The result is an ever-increasing demand for health-trained personnel. The continued advances in medical care and improved procedures within hospitals depend upon increased numbers of highly skilled personnel for their application to the public. We are ke pleased that S. 3095 proposes bringing together several existing programs. This should result in greater coordination and improved administration overall of the programs. Also, we note that various individual provisions have been brought into conformity which should prove to be beneficial. We cannot stress too strongly the magnitude of the need for greater numbers of highly skilled health personnel and the critical nature of the demand in terms of the overall health of the Nation. We believe the sums proposed for carrying out the programs are modest in rela- tion to the needs and we hope the Congress will recognize this great need and authorize such sums as are found to be necessary to fully fund the programs. 212 Tiros I—Hravura Proressions TRAINING This section proposes to continue the program providing for the construction of needed teaching facilities and provides various forms of assistance to students in several of the health professions. The bill proposes certain changes which should improve the administration of the program and enhance its potential contribution toward meet- ing the very pressing need for greatly increased numbers of physicians, dentists, and others. We fully support this section of the bill and believe it to be a vitally needed program. Trroe IT—Nurse TraiNING PART A—CONSTRUCTION GRANTS As the members of the committee are undoubtedly aware, the Amer- ican Hospital Association and the hospitals of the Nation, have voiced strong support, for the bills, S. 2549 introduced by yourself, Senator Hill, and H.R. 13096 introduced by Congressman Rooney and 56 cosponsors. We believe these bills go far in recognizing the essential role of the diploma schools of nursing and the fact that the nursing needs of the Nation will not be met except by the continued operation of these hospital diploma schools of nursing. They further recognize the serious economic situation confronting these schools. The fact that the diploma schools do not have access to the public funds available for both the collegiate and the junior college schools has been a serious handicap and unless the Congress recognizes the special needs of the diploma schools large numbers of them are likely to discontinue operation. We believe that S. 3095 goes far toward accomplishing this objective. We cannot stress too strongly the significance of this section of the bill in relationship to meeting the health needs of the country. The shortage of nurses is acute and will only be met. through a very sub- stantial Federal program of assistance. The recently published review of the nursing situation by the Department of Health, Education, and Welfare indicated that by 1975 we will have need for 1 million nurses. This indicates that we will have to increase the supply by approx- imately 60,000 nurse graduates a year. The criticalness of the situation facing the Nation will be seen when it is realized during the period 1964-65 there were 34,686 nurse graduates and during the period of 1965-66 there were 35,125 or an increase of less than 500 graduates in nursing. Thus, even with the Nurse Training Act of 1964 in effect we have continued to fall very substantially short of meeting the need. The CuAarMAN. In other words, with our population growing all the time, we have to act and act now. Mr. Houmes. That is correct. Just what does this shortage mean? The needs of the military have grown and these needs require continued and active recruitment of nurses which can only come from the civilian pool. The 1967 published figures indicate that the Federal Government employed 32,793 nurses. The medicare and medicaid programs will increase substantially the health care being provided and various studies reveal that the nursing requirements of aged patients are very much greater than those for 213 younger patients. The Government has assured the 19 million aged of the country the right to access to care not only in hospitals but in extended care facilities and home health services. We are far from meeting the needs for these services and they cannot possibly be pro- vided without key staffing by registered nurses. The Government is commendably raising the quality of care to be provided in nursing homes throughout the Nation and stipulating the basic need for registered nurses in order to qualify these institutions to provide care under the medicaid program. The Cuamrman. Well, we also have all the demands of the Vietnam war. Mr. Houmes. Yes, sir. The CaaATRMAN. And the other military demands. Mr. Houmes. Yes, sir. The CratrmaN. And then you have the medicare and medicaid. Mr. Houmes. And the hospitals themselves. The CuamrmaN. And the hospitals and services we never thought of 10 years ago, right ? Mr. HoLmes. Yes, sir. A great many hospitals report serious shortages affecting their ability to provide care. In some instances whole sections or floors of hospitals are closed because they cannot be staffed. Some insti- tutions are being forced out of the medicare program because they cannot provide the required nursing supervision. The Federal Gov- ernment is investing large sums of money in medical research which when translated into care of patients inevitably means additional essential nursing care. Though the Congress is to be commended for passing the Nurse Training Act of 1964, it is obvious that the very critical nature of the nurse deficit has not yet been fully appreciated. Notwithstanding the benefits of the act, we are not moving forward in any near rela- tionship to the need. The Cuammman. As I have said, this need is increasing tremen- dously each year, is it not? Mr. HoLmes. Yes, sir. The Nurse Training Act and the administration of that act has lent encouragement primarily to baccalaureate and associate degree programs. Unfortunately, there is no possibility whatever of these schools meeting the national shortage of nurses in the foreseeable future. While the situation continues to become more critical, hospital schools which are the major producer of the nurses needed by the Nation—T78 percent of the total last year—are closing. There has been an average of 10 schools closing each year for the past 5 years and at the present time 74 hospital schools are making plans to cease operations. The ever-increasing financial deficits incurred by hospital schools cannot continue to be passed on to patients. The criticism of rising hospital costs is such that the boards of trustees of greater and greater numbers of hospitals operating schools of nursing feel com- pelled to close their schools. It makes very little sense to us to see hospital schools close where they have faculty, buildings, and equip- ment available to produce the needed nurses; and at the same time to see new campus facilities being constructed with an enormous eco- 214 nomic waste. In the overall we feel title II of this bill goes far toward correcting some of the shortcomings of the earlier bill. Though title IT provides the vehicle for the much needed assistance to diploma programs of nursing as well as to the collegiate and junior college programs, the extent to which the bill will correct the growing seriousness of the situation will depend completely upon the adequacy of the funds which the Congress allocates to this section of the bill. Following are comments on special sections of title II: Section 201 amends the present act and gives equal recognition to all schools of nursing. This association strongly endorses each of the three types of schools of nursing and recognizes fully their respective roles. We approve, therefore, the construction assistance which would be provided to all three types of schools. Section 205 amends section 843 (c), makes collegiate schools eligible for construction grants for advanced training facilities. Inasmuch as the Federal program of assistance for advanced training is in no- wise limited to collegiate schools, we recommend this amendment pro- vide for facility construction assistance to all schools participating in advanced training. This could be accomplished by a similar amend- ment to section 843(d) and (e). Section 206 provides that this section of the bill will not become effective until after June 30, 1969. We realize this advanced date is undoubtedly related to budgetary problems. We recommend that if at all possible because of the seriousness of the situation the effective date be June 30, 1968. The Cuarman. June 30, 1969, is a year and a half from now. Mr. Houmes. That is correct, sir. PART B—SPECIAL PROJECTS AND INSTITUTIONAL GRANTS TO SCHOOLS OF NURSING Section 211 amends section 805 of the act. We believe this is an im- portant section of the bill. The provisions have been broadened so as to authorize grants for a wide variety of programs and to include grants to any public and nonprofit private agency which can con- tribute towards improvements in nursing programs and which can encourage the coordination of efforts between programs. Section 806 would also be amended to provide direct assistance to all schools of nursing. Each school would receive a lump sum annual pay- ment of $15,000 and in addition would receive an annual payment based on the relative enrollment of students and graduates. This assist- ance, however, is uncertain as to amount and related to unspecified amounts to be appropriated. We believe that particularly in respect to the diploma schools of nursing it is most essential that they be assured a minimum amount per student. Such a need was recognized in Sena- tor Hill’s bill, S. 2549. As previously pointed out the collegiate and associate degree programs are in the main tied to the public educa- tional system, and therefore, have financial assurances which are not available to the diploma schools. Without such specific assurances we greatly fear we will continue to see a closing of these diploma schools. Therefore, we would urge that this section of the bill be amended so 215 that in addition to the $15,000 lump sum payment to all schools, a per student annual payment of a minimum of $500 be specified for diploma schools of nursing. The CaatrMAN. You must have this minimum, at least. Mr. Homes. Yes. PART C—STUDENT AID Section 823(b) (3) would increase the rate of forgiveness from 10 to 15 percent a year where a nurse following graduation works in prescribed circumstances. However, we believe the language of the bill inadvertently limits the eligible services to a “public” hospital, whereas the basic provision includes public and privately owned nonprofit hospitals. We recommend that the language of the bill be amended to include private nonprofit as well as public hospitals. This section of the bill should serve as a strong incentive to stu- dents; and in relationship to the likely income to be paid a student following graduation, we believe the forgiveness is fully justified. Section 222(e) of the bill would amend section 825 of the Public Health Service Act to provide for the allocation of appropriations among the schools rather than among the States. Further, it provides that the allocations shall be on the basis of the full-time enrollment in the school of nursing rather than on the basis of the number of high school graduates. The amendment provides a much more realistic method for the allocation of funds. Section 222(h) of the bill would add a new section 829 to the bill and would permit the transfer of up to 20 percent of funds from the loan program to the scholarship program. A later provision of the bill also provides for a similar transfer of funds from the scholarship program to the loan program. We believe these provisions will permit desirable flexibility in the program. PART D—SCHOLARSHIP GRANTS TO SCHOOLS OF NURSING Section 223 (a) amends part D of the Public Health Service Act to provide for scholarship grants to schools of nursing. We note that the provisions have been amended so as to pattern the program after the scholarship provisions of the health professions section of the bill. The scholarship program is essential in making possible the enroll- ment of students who are confronted with exceptional financial prob- lems and should prove to offer needed encouragement for such stu- dents to enter the nursing profession. We wholeheartedly endorse this section of the bill. We believe the bill provides substantial improve- ments over the authorization for scholarships in the original act. Section 231 pertains to the definition of accreditation. We believe the language of the bill is ambiguous and we are uncertain as to how the language would apply to each of the three types of schools of nursing. We strongly recommend that the language of this section provide that the Commissioner of Kducation shall be required to recognize approval by the appropriate State authority as meeting the require- ments of accreditation under the act or accreditation by regional authority or by national accrediting bodies. 216 The CaatRMAN. Any one of the three? Mr. Houmes. Yes, sir; there is at present widespread dissatisfaction with the existing requirements for the accreditation of schools of nursing. The above recommendation, we believe, will go far toward alleviating the situation. Trrue IIT—Arviep HEALTH PROFESSIONS AND PusLic Heart TRAINING This part of the bill pertains to a variety of paramedical groups which are highly essential to providing high quality health care in the most effective and efficient manner. The provision includes areas of training pertaining to skills which represent the great advances in medical care. We believe this is a very important part of the bill and we fully endorse this title. Section 301(4) (b) amends section 794 of the Public Health Service Act to eliminate the phrase “training centers for allied health profes- sions” and substitute in lieu thereof the words “agencies, institutions, and organizations.” We believe that this is a considerable improvement over the original act and, further, that this language will permit teach- ing hospitals to participate directly in the program. The Crarman. We must have this allied health program, must we not? Mr. Hormes. Yes, sir. However, this amendment only pertains to the development of new methods. Section 795 of the Public Health Service Act continues to define training centers as a junior college, college, or university. In order that teaching hospitals, which are engaged in the education of large numbers of paramedical health personnel, may be assisted to the extent that they provide training in the programs covered under this title; we recommend that the definition in section 795 be amended so as to read, “in a teaching hospital, junior college, college, or university.” This amendment is urged for the reason that the needs of the Nation are so great it is incumbent upon us to utilize fully all available quali- fied educational programs. In terms of the criticalness of the need it makes very little sense to provide assistance only to certain of these education programs as the act does at present. Section 302 extends the program of traineeships for graduates of specialized training in public health. Graduate degree (master degree) programs in a number of universities prepare professionally trained hospital and medical care administrators. The Congress recently amended the medicare law to require licensing of administrators of nursing homes which gives recognition to the need for professional qualifying administrators of such institutions. At the present time assistance may be granted to students in courses preparing them for administration of health care institutions only if a trainee is enrolled in a school of public health. Students taking the same curriculum but who are enrolled in other schools of the university such as business administration are denied assistance. At the present time there are 16 accredited schools of hospital administration in the United States. Seven of these are in schools of public health. The other nine are in other schools. Therefore, students taking the same curricu- 217 lum in other universities are denied assistance. We strongly recommend that this section of the act be amended so as to provide for assistance to eligible students enrolled in all university courses for the preparation of health care institution administrators. TrrLe IV—HEeavtan ResearcH FACILITIES This title of the bill extends the construction authority for health research facilities. We recommend approval of this part and urge the committee to authorize adequate funds for carrying out its important purposes. Mr. Chairman, we greatly appreciate the opportunity of appearing before the committee and presenting to you the views of the hospitals of the country on these matters which are of critical importance to the operation of nln and all health care institutions and, thus, to the provision of health services. In closing, may I reiterate our great con- cern over the shortage of health care personnel. For this reason we urge the committee to authorize fully adequate funds to carry out the purposes of this greatly needed legislation. I want to reiterate what the dentists said about you personally. Being in the hospital business, you have been a symbol of strength to us ever since I have been in this field. The Cramraan. Well, you are certainly most generous and kind. I want to say I appreciate your helpful support, and that I have received from the American Hospital Association. They have always been up on the battleline fighting the battle, as Ken Williamson knows. I think that is how he lost all his hair. He has always been there, always on the frontline. The bugle never sounded that he was not there, I tell you that. Mr. Homes. That is right, Mr. Chairman. The Cramryaxn. Of course, you know that the act encourages expan- sion of nurses training in colleges, junior colleges, and hospitals. From your experience as a hospital administrator, would you recommend that we give priority to any one type of training for nurses? Mr. HoLmes. Our thought in this whole thing was that the real volume of nurses is coming from the 3-year hospital schools now. We need people, we need nurses. And we need the associate degree people, too, but there is a dangerous trend in the diploma school situation, a trend toward their being closed. In South Carolina, I think they have only about three diploma schools left. The Crratraan. Only three in the whole State of South Carolina? Mr. Horumes. Yes, plus their collegiate schools. This is a serious situation. Mr. WiLniamson. I think, Senator, too, this relates to our interest in quality care. We are interested that the representatives of the nurs- ing organizations stress a program that will guarantee quality patient care. We thought that a statement made by Edwin Rosinski, who is a doctor of education and Deputy Assistant Secretary of Health Man- power in the Department of Health, Education, and Welfare—he made a statement to the National League for Nursing on this subject that we think is very, very interesting and important. He says that quality likewise is often used synonymously with credential, and un- 92-079 0—68——15 218 fortunately, credential can lead to a closed system; within this closed system, ritualistic, prescribed, and often arbitrary standards are set, standards that do not necessarily assure quality but restrict quantity. Then he raised what is really a basic question in our testimony. One can legitimately raise the question whether baccalaureate degree nurses, by virtuously professing their symbol of degree, can provide a better quality of patient care than the graduates of nursing schools or colleges. im he has yet to see quality defined and is at a loss to document quality differences between the functions of various groups of nursing personnel ; graduates of collegiate schools run from good to bad as they do for diploma and hospital schools. As we see it, the function of the hospital school is fundamental in meeting the demands of the patient and they ave closing, and we urge the committee to look particularly at their problems. The Cramrman. To prevent these closings? Mr. Hormes. Yes, sir. The Cratrman. Which will close hospitals —— Mr. Wirriamson. It is a snowball. The Cramrman. Those kinds of things have a way of multiplying, do they not? Mr. Hormes. They do. The Crarman. It is most important to put an end to that, is that right? Mr. HoLmes. Yes, sir. Mr. WiLriamson. The figures indicate that we are not making prog- ress very fast, sir. The needs and the population growth have way outstripped any progress we have made in this field. The win dln We have this tremendous population growth, we have the military needs, we have the war in Vietnam and other military needs in many, many places throughout the world as well as in the United States. You have your medicaid, your medicare. You have a very compelling need, is that right? Mr. WirLiamson. We do. A registered nurse is the key person in developing health care programs for all of these things. The Carman. Senator Dominick? Senator Dominick. Thank you, Mr. Chairman. I am sorry I have not been able to be here before this particular time, but I do have just a couple of questions on this. First of all, on the hospital schools which you say are closing at the rate of about 10 each year. This is on page 6 of your statement. Is this because of the cost of the schools, or is it because of the absence of applications for training, or is it a combination of both ? Mr. HoLmes. Plus the lack of faculty. Senator Dominick. Plus the lack of faculty? Mr. Houmes. Yes, sir. Senator Dominick. So it is not just the cost to the hospitals of the schools that they are trying to run. In other words, it involves a whole series of factors. Mr. Houmes. Yes. Perhaps Mr. Williamson would like to answer that. Mr. WirLiamson. I think, Senator, there are a number of very good schools, well qualified, with full faculty, where the costs are exorbitant 219 and they must be borne by patients. The boards of trustees are under terrific public pressure about hospital costs. Therefore, they are closing schools. So the economics is a major factor in boards of trustees today look- ing at whether they should and can continue their schools of nursing. Senator Dominick. Well, let us assume that we solve the economic factors, do you have enough applicants? Mr. HoLmes. Oh, yes. We can get applicants. Senator Dominick. To become nurses? Mr. Homes. Yes. Senator Dominick. I understood from your previous answer that you felt this was one of the causes of the problem, that you did not have enough applicants for the training. Mr. Horumes. No, we do not have enough training facilities for all of these people. The Caamman. If you had the facilities, you would have the appli- cants, right? Mr. Houmes. Yes, sir. Senator Dominick. You are recommending that assistance be given to hospital administrators. Mr. Wirtiamson. This is what it is, Senator: In order to train pro- fessional people to run health care institutions, hospitals being one of them, this is to provide assistance for them in graduate degree pro- grams to become professionally competent. Senator Dominick. Do they not have the ability to obtain financial assistance under the NDEA, or the Higher Education Act? Mr. Wirniamson. No, as I understand, they do not. They look for assistance under this section of the Public Health Service Act, which it Present will assist some of them, but only those in schools of public ealth. Senator Dominick. There is no restriction in the Higher Education Act which prevents them from getting any kind of assistance there as long as they are going to an accredited college, is there? Mr. Wirriamson. I do not know, frankly, if there is or not. Do you? Mr. Hormes. Is this for master-degree programs? Mr. WirLiamson. Yes. Senator Dominick. This would include a guaranteed student loan or a variety of other programs, would it not? Mr. HorumEs. Yes. The fact 1s that the only one we knew of is the Public Health schools, who are assisted, and the schools of business, like the University of Chicago and others are not. They are not public health schools, they are schools of business administration, yet they have the same course and they get the same degree, a master’s degree. They get a master’s degree in business, and the others get a master’s degree in public health. But their courses are similar. Senator Dominick. I bring this question up because in our present financial crisis that we have, I do not see much point in duplicating programs if we have already a system that can help. Maybe what we need is a dissemination of information. The Cramman. Why not make a survey of the schools and Mr. Wirniamson. We will submit for the record information on whether they do have a program. 220 The Caamman. How about that, Senator, that they survey the schools and get the information? Senator Dominick. I think that would be very helpful. Mr. Houmes. We would be delighted to do that. The Cuamryman. We will have it appear in the record. (The information referred to follows:) AVAILABILITY OF FINANCIAL ASSISTANCE TO GRADUATE STUDENTS IN HOSPITAL ADMINISTRATION UNDER THE NDEA AND HIGHER EDUCATION ACTS In order to determine whether Federal grant funds are available to graduate students in Hospital Administration under the provisions of the National Defense Education Act and Higher Education Act, we directed this question to the Executive Director of the College of Hospital Administrators, the Executive Di- rector of the Association of University Programs in Hospital Administration, and the Bureau of Higher Education, Department of Health, Education and Welfare. We were informed by the representatives of the College of Hospital Adminis- trators and the Association of University Programs in Hospital Administration that to the best of their knowledge, grant assistance to graduate students in hos- pital administration is not available under either of these programs. The Bureau of Higher Education, Department of Health, Education and Wel- fare informs us that while there are a number of loan programs authorized for graduate students under the NDEA or Higher Education Act, neither Act au- thorizes direct grant assistance for such students. The Cramrman. Are there any other questions? Senator Dominick. No, that 1s fine. The Cramrman. Thank you very much, gentlemen. Mr. Houmes. If you retire and want to come to one of those para- medical schools, let me know. The Cuamman. You had better be careful. You may have an applicant. Thank you, sir, very, very much. Now the American Medical Association, Dr. William A. Sodeman of Philadelphia, Pa., member of the Council on Medical Education. STATEMENT OF DR. WILLIAM A. SODEMAN, PHILADELPHIA, PA, MEMBER, COUNCIL ON MEDICAL EDUCATION, AMERICAN MEDI- CAL ASSOCIATION; ACCOMPANIED BY DR. C. H. WILLIAM RUHE, DIRECTOR, DIVISION OF MEDICAL EDUCATION; AND BERNARD P. HARRISON, DIRECTOR, AMA LEGISLATIVE DEPARTMENT Dr. Sopeman. Mr. Chairman, members of the subcommittee, I am William A. Sodeman, a physician and formerly dean of the Jefferson Medical College, in Philadelphia, Pa. I am now scientific director of the life insurance medical research fund, Rosemont, Pa., and also serve as a member of the AMA Council on Medical Education. Seated with me to provide additional information as may be requested are Dr. C. H. William Ruhe, Director of the Division of Medical Education, and Mr. Bernard P. Harrison, Director of the AMA Legislative Department. We are pleased to have this opportunity of presenting the American iy Association’s comments or S. 3095, the Health Manpower Act of 1968. At the outset, Mr. Chairman, I would apprise the subcommittee that our statement on the bill will be limited to a discussion of title I, the 221 amendments pertaining to the Health Professions Educational Assist- ance Act. The Carman. We shall be happy to have you do that. After you have finished that, we would be glad to have any comments you might see fit on the other provisions of the bill. Dr. Sopeman. Fine, sir. While we recognize the merit of the remaining provisions of S. 3095, because of the short period available since the introduction of the bill, we have not been able to complete our study and evaluate these other provisions with the care warranted by their importance to medicine. We shall, however, proceed to do so as diligently as we can and to make known our views to the Congress. We shall proceed to do that, sir, and if you wish, we can send it to you The Crnamrman. We shall be happy to have you do that. Dr. Sopeman. However, our pressing concern for the need for more practicing physicians dictates that we not pass this opportunity of discussing title I, to extend and improve the program for assistance to medical education. In August, 1963, the American Medical Association, in testimony before this subcommittee, urged priority for the increase and improve- ment in the physical facilities available for medical education. We then expressed the belief that there was need for assistance in the con- struction of new medical schools and for expansion and replacement of the facilities of existing medical schools. As a result of that legisla- tion and the ongoing efforts of the American Medical Association and the Association of American Medical Colleges to encourage the devel- opment of new schools and the expansion of existing schools, 17 new medical schools are now officially classed by the Liaison Committee of the two Associations as “in development. ? Further, the number of first year students in all American medical schools has increased from 8,298 in 1960 to 8,964 in 1966 and is expected to increase to 10,200 by 1970. As encouraging as these results may be, the urgent need for more physicians still exists. Recently, this month, on March 5, 1968 a joint statement on health manpower, the American Medical Association and the Association of American Medical Colleges said, “to meet. national expectations for health services, the enrollment of our Nation’s medical schools must be substantially increased.” Both Associations have en- dorsed the policy that all medical schools should now accept as a goal the expansion of their collective enrollments to a level that will permit all qualified applicants to be admitted. The Cramrman. Something you are not able to do today; is that right? Dr. Sobeman. We are not able to do that today, Senator. That is correct. To achieve expanded enrollment, it will be necessary to have in- creased financial support from both Government and private sources for the construction of additional facilities at existing schools and to create new schools. Equally important is increased support for the operational costs of medical schools and for educational improvement and innovation which could shorten the time required for medical education. The bill before the subcommittee provides a means of furnishing the Federal component of the necessary financial resources. 222 Mr. Chairman, we would now like to comment on the provisions of title I of S. 3095. Section 101 extends the program of grants for construction for 4 years and authorizes such sums as may be necessary for appropria- tion in each year. The lack of a statutory ceiling on the authorization for appropriations is justified in these circumstances. As was pointed out in the joint AMA-AAMC statement on Health Manpower, “* * * initiative for development of new schools and expansion of the estab- lished institutions should be locally determined.” It is difficult to pre- dict exactly how many new schools will be initiated and how many existing schools will choose to expand in any given year, but it is important that Federal matching funds for construction be available as the plans of individual schools are developed and the local matching funds are obtained. Delays in Federal funding not only complicate local planning but may greatly increase total costs because of rising costs of construction 54 general inflation. The Cuaamman. Of course, it is much more today than it was 10 years ago, is it not? Dr. SopEman. Yes, sir; and every day it increases. The Cuamman. Every day it goes up, right? Dr. Sopeman. Yes. Another desirable provision of the proposed legislation permits a school to make one application to the health professions educational assistance program rather than separate applications to different agencies for teaching, research and library facilities. Since these are integral portions of any medical school it 1s reasonable to incorporate them in a single application which can be considered as a whole. This should simplify and facilitate the process of obtaining Federal match- ing funds for construction. The bill would also permit space for graduate and continuing medi- cal education and other advanced training to be included in the con- struction project. This is a significant improvement, since graduate and continuing education do be treated as a part of the continuum of medical education in the modern medical center. INSTITUTIONAL AND SPECIAL PROJECT GRANTS The American Medical Association has long favored diverse sources of support for medical schools under circumstances that prevent any extramural source from exercising controlling influence. Recently, the American Medical Association’s Commission on Research recom- mended that there should be increased funds from both public and private sources for the support of educational programs in medical schools, to correct the imbalance between biomedical research and education caused by the heavy, but desirable, Federal support of research. The CuamrMaN. In other words, there ought to be a balance here? Dr. Sopeman. There ought to be a balance, yes, sir. The recommendation further stated that there should be a greatly increased allotment of Federal funds for the operational expenses of medical schools, to be matched by those schools through private or local governmental sources, with every effort—made to keep the Fed- eral contribution on a supplemental basis. 223 S. 3095 would provide general institutional grants on a formula basis and special project grants, which together could provide the necessary level of operational support for medical schools. The pro- sed formula for the institutional grants appears reasonable and contains the desirable provision that no school could receive more in any year than it expended for teaching purposes from non-Federal sources during the previous year. This would insure the important local matching and would keep the Federal contribution on a sup- plemental basis. The bill would require expansion of enrollment as a condition for receiving an institutional grant and the proposed formula provides further incentives for expansion. While this 1s generally desirable in view of the urgent need for more physicians, the American Medical Association feels some concern on conditioning operational support to expansion. There are currently some medical schools in rather severe financial straits. These schools need increased operational support to maintain their present facilities and activities and a requirement that they must increase the student load in order to qualify for such sup- port may serve to defeat the purpose of the program. Accordingly, we stress the importance of retaining the provision which authorizes the Secretary to waive the requirement for expansion if he determines that the increase in enrollment would lower the quality of the training provided. The CuamrMAaN. In other words, it is most important to maintain this quality. Dr. SopEmaN. It is important to maintain this quality within cer- tain schools that are borderline in their support at the present time. Yes, sir. Finally, the enumeration and clarification of the purposes of the special project grants should prove helpful. In addition, we believe that the assigned priorities for project applications will encourage the development of curricular innovations and changes in the educational program to the end that enrollments will be increased and the time re- quired for medical education shortened. These are two important ob- jectives. cited by the recent AMA-AAMC joint statement on Health Manpower. Mr. Chairman, once again let me express my appreciation and that of the American Medical Association for the opportunity of present- ing medicine’s views on this important subject. Today, in every me- dium of communication, health care is a principal topic for discussion. We believe that the extension and improvement of the Health Pro- fessions Educational Assistance Act will serve the interests of our country by encouraging a greater production of physicians. The CrammaN. You brought us a very important statement. Dr. Ruhe, is there anything you would like to add? Dr. Rune. No, thank you. The Caamrman. How about you, Mr. Harrison? Mr. Harrison. No. The Cuamrman. Senator Dominick, do you have any questions? Senator Dominick. Yes, I have a number, Mr. Chairman. Doctor, are your representing the American Medical Association here? Dr. Sobeman. Yes, sir. 224 The CuammaN. Do you have the ratio of doctors to population in the country? Dr. Sopeman. We have those figures, sir. Senator Dominick. Have they changed since 19637 Dr. Sopeman. Yes, they have. They are going up gradually. I be- lieve Dr. Ruhe may have the figures for you if you would like to have them. Senator Dominick. I think it would be helpful to have them just to get the picture in clear context. Dr. Sobeman. Senator, while he is looking for these figures, I might say that the number of doctors relative to the population is important, but this is not only a numbers game. There are many other related factors. We appreciate the importance of the need for more physicians; this is very fundamental. Increasing the number of physicians alone is not our greatest problem. Senator Dominick. But the purpose of this bill is to increase the number of physicians? Dr. Sopeman. This is right, sir, and allied health personnel as well. Senator Dominick. So, in effect, we are talking about the numbers problem. Dr. Sopeman. We are talking about the numbers problem. We are talking about support for the education of physicians which will help in ways other than the numbers problem. Senator Dominick. Do I understand that the AMA is supporting an open-ended authorization for this bill? Dr. Sobeman. Yes, sir. Senator Dominick. Well, I have been working with the AMA on a great number of things since I have been in Congress. I have been delighted to work with them, but I can assure you I am not going to support an open-ended authorization. This is essentially saying that anything that is necessary out of the Federal Treasury, can be put into this particular program. Dr. Sobeman. I do not believe that my statement should be inter- preted in that way, Senator. We are interested in governmental sup- port for as many physicians as we can obtain. It is open ended in that respect. ‘We would not, however, agree to open endedness as far as total sup- port for this program or for any project by the Federal Government. We believe that multiple support for education in the health profes- sions is fundamental and that governmental support must be supple- mental to other types of support. Mr. Harrison. Perhaps I can add something, Senator, if I may. Senator Dominick. Yes. Mr. Harrison. I think our support for an open ended program is in the sense that there be no statutory limitation at this time so that each year—— Senator Dominick. That is what I am objecting to. Mr. Harrison. IT understand ; so that each year the Congress, in its own wisdom, can decide as to the appropriation that may be allotted for this particular program. We recognize, of course, that the Con- gress in each year would determine the amount to be allotted to this program. If there were no statutory limitation as such and if there 225 is a need for another school and another school can get underway, there would be an opportunity to do so without waiting for a later date when the costs may go up. But we realize full well that the Congress will examine the appropriation request each year and make a determi- nation at that time. Senator Dominick. If we are going to go on an open ended authori- zation as such, there is no point in having an authorizing committee, because the same can be argued on any bill. Do you have any figures in mind as to what you feel is needed or planned at the present time? Because I think we have to let the public, at least, and Congress as a whole know what the cost of this will be. Dr. SopEman. In terms of numbers of physicians? Senator Dominick. No, in terms of this particular support for schools, development of new schools and expansion of established institutions. Dr. Sopeman. I believe Dr. Ruhe may have the figures that we have available. He also has the figures you requested on population ratios, Senator Dominick. Senator Dominick. Fine. Dr. Rune. I am sorry to say I do not have them exactly, Senator. We will have to provide these later for you. The approximate ratio is about 153 physicians per 100,000 people, probably slightly larger than that. This has risen from a figure in 1960 of 149 per 100,000. So the figure is going up; the ratio of physicians to population 1s going up. But at the same time the ratio is Increasing, there appears to be an increase in demand for medical care. So that, judged by all expressions which come from physicians and the volume of work they are doing and the demands which are made on their services, the demand for physician services is increasing even though our ratio of physicians to population is higher today than it was a few years ago. With regard to this other question, I think the particular problem here of the developing medical school is one which, in our opinion, justified this statement. The time which is required for the planning and the complexity of the problem of assembling the local matching funds to coincide with the timing of the plan makes it difficult to pre- dict in advance exactly how many schools will be requesting Federal matching funds in any one given year; that is, it is difficult to see this for several years ahead. Some schools over the past few years have encountered a situation in which they have succeeded in assembling their local matching funds and had applied for Federal matching funds but were unable to get them at the time of the application. This posed a number of problems for them in their local area when the funds they had obtained locally for matching were in the form of bonds or in some other form, and, because of rising construction costs and inflation, by the time they were able to get the Federal matching funds, the local funds were then inadequate for doing what they had planned to do. Senator Dominick. That has nothing to do with the authorization process. That has to do with the appropriation process. Dr. Rune. That is correct. Senator Dominick. You would still have yourself in the same bind if you relied on the appropriation process as suggested in the statement. 226 The point I am making is that we have to have some idea, it would seem to me, in exercising our responsibility as committee members, to be able to tell the Appropriations Committee that we think that within these limits, at least, this is about what we are suggesting as a feasible program. We do not have any figures this way at all. So if you can come up with any kind of figures on this, I think it would be helpful, Mr. Chairman. I have always, as you well know, fought the open-ended authorization in every committee I have served on. I would expect to do the same thing again. I would prefer not to do it if we can get a figure. So perhaps we a get some estimate from you of what you think is necessary. Mr. Harrison. Senator, we shall try to do that and provide you with some figures that will assist you in that regard. (The information referred to above follows) AMERICAN MEDICAL ASSOCIATION, Chicago, Ill., March 27, 1968. Hon. LisTER HILL, Chairman, Subcommittee on Health, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C. DeAr SENATOR HILL: During testimony by representatives of the American Medical Association on S. 3095, the Health Manpower Act, Senator Dominick requested that they submit certain information for the record. This letter is in response to his request. With respect to physician-population ratio in 1963 and the present, we submit the following facts. In 1963, there were 276,475 physicians with M.D. degrees. The population at that time was 194,169,000, giving a physician-population ratio of 142.4 per 100,000. As of December 31, 1967, there were 308,630 physicians with M.D. degrees and our population amounted to 203,708,000. This is a ratio of 151.5 per 100,000. The above figures do not include the approximately 13,000 practicing osteo- pathic physicians. With respect to the Association’s opinion as to the amount of federal funds which will be needed over the next four years for the construction of new schools and for the expansion of existing schools, it is our understanding that the Bureau of Health Manpower of the Public Health Service has a backlog of requests for federal matching amounting to $245 million. In addition, the Bureau has received letters of intent from universities which would indicate a need for an additional $670 million. The total, then, for the four-year period for all schools aided under the program would amount to $915 million. Approximately 709%, or $640 million of the above total represents medical school needs. However, since the bill before the Subcommittee authorizes a single appli- cation to include a request for funds for libraries and health research facilities, a 30% increase in the total for medical schools is indicated. Thus, the total funds needed for construction of medical schools over the four-year period would amount to approximately $830 million. This figure includes funds for construc- tion of medical schools and teaching hospitals. With respect to the amount that would be needed to cover operational ex- penses, it is more difficult to arrive at an estimate. One estimate is that it would range between $1 million and $1.5 million per school per year. There are cur- rently ninety-four medical schools in operation. Next year five additional schools will accept students. By 1971, there will be 104 schools accepting students. Senator Dominick’s third question related to the eligibility of medical schools for funds under the Higher Education Facilities Act of 1963, as amended. The Association’s representatives expressed the belief that medical schools were not eligible under that program, but indicated that they would review the matter and advise the Subcommittee. Our review of the Act indicates that medical schools are not eligible. Section 401 (a) (2) (E) of Public Law 88-204 (20 U.S.C. 751(a) (2) (B)) provides that “academic facilities” do not include . . . 227 “* % % any facility used or to be used by a ‘school of medicine’, ‘school of dentistry’, ‘school of osteopathy’, ‘school of pharmacy’, ‘school of optometry’, ‘school of podiatry’, ‘school of nursing’, or ‘school of public health’, as defined in section 724 of the Public Health Service Act.” Let me take this opportunity, in behalf of the American Medical Association, to thank you and the members of the Subcommittee for the courtesies extended to its representatives during the hearings. Sincerely, F. J. L. BLASINGAME, M.D. Dr. SopEman. Senator, we shall give you the best that we can do. Senator Dominick. Thank you. To what extent is the Federal Government now supporting medical research ? Dr. Sobeman. In terms of dollars or percentages, Senator? Senator Dominick. In terms of percentages. Dr. Sopeman. In terms of percentage—I can make a rough guess of my own—between 80 and 90 percent. Since I am concerned with a foundation that supports private research, I know that we are over- whelmed by the Federal Government. Dr. Rusk. I have the figure on this. For the last year for which we have final financial details, the academic year of 1965-66, 82 percent of the sponsored research of medical schools was supported by Federal funds. The Cuarman. But the private foundations have greatly increased their support in the last 10 years, is that true? Dr. Rune. Yes, they have; but the Federal increase has been greater. Dr. Sopeman. They are not keeping up with the Federal increase. The Carman. But they have increased ? Dr. Rune. That is correct. The Federal proportion has gone up. In 1958-59, it was 65 percent. Then in 1965-66, it was 82 percent. The CrairmAN. In spite of the fact that the private foundations have greatly increased their grants. Dr. Rune. That is right. Senator Dominick. Do you find any problems connected with this increase in ratio of Federal fundings? Dr. SopEman. Relative to private funding? Senator Dominick. Just relative to the Be situation. Dr. Sobeman. We have problems relative to the extent to which support of research has gone without a comparable increase in educa- tion support. This does not mean that we are advocating reduction in research support. We would like to have balance, with an increase in educational support. Senator Dominick. Do you find any problems in trying to get pri- vate funding for research because of the predominance of the Federal funding? Dr. Sopeman. I think this is so, Senator. As a matter of fact, there are times, such as the present, when there is a greater tendency for in- vestigators to try to get private funds than Federal funds because of the tightening of the granting mechanism in the Federal Government. Senator Dominick. Have you found any tendency that Federal funding more or less channels your research into formats that the Fed- eral Government would like as opposed to what the researchers them- selves would like? 228 Dr. Sopeman. There is a degree of channeling with Federal money, of course, because the appropriations are for specific categories. This is understandable. There 1s greater flexibility with some private funds than there are with Federal funds. This does not mean that the Federal Government directs an investigator on what to investigate or what to come out with. I would not wish to imply this. But, there is channeling into categories, of course. Dr. Rune. I think we might add here, Senator, that the experience with the federally supported research activities in terms of the degree of Federal control has been reassuring. I think that, largely, there has been certainly no direct control, and while there is a degree of indirect control because of the areas in which the funds have been provided, it has been relatively nonrestrictive on the medical schools. I would say that most of the medical schools feel, in their own experience, that the use of the Federal funds for sponsored research is relatively without direction and without control on the part of the Government. Senator Dominick. Do I gather correctly from your statement that what you are primarily concerned with, however, is the funding of additional facilities for medical schools? Dr. Sopeman. Facilities and operational funds. Senator Dominick. And operational funds? Dr. SopEmaN. It is a combination of both that we need to increase the manpower, the physician manpower. Senator Dominick. Are these schools largely State-supported schools, public schools, or are they private, or what? Dr. SobEman. Again, we have a division of private and public schools, and Dr. Ruhe has in front of him a document with these data in it. Perhaps he can turn to the page and give you the exact figure. Each year, the Council on Medical Education puts these data into one of the medical journals, the AMA Journal, and the data and all the statistics are available in this reprint. We would be happy to transmit one of these, but I assume you already have them. The CaamrmaN. We have them. Dr. Rune. As of the 1966-67 academic year, there were 46 schools which were classified as public medical schools, publicly supported schools, and 43 were regarded as private schools. All of them, of course, received some degree, some measure of public support. It would be a question of the ownership and the primary sponsorship of the schools. There has been approximately a 50-50 division. However, in the case of the new schools coming along, these have been predominantly publicly owned and supported institutions. Of the 17 schools which we classify as being “in development,” I believe there are only two that are private institutions. The rest are all publicly supported. Senator Doainick. Is it not true that the Higher Education Facili- ties Act provides funds for construction of facilities at medical schools as well as undergraduate schools? The Caarman. Not medical schools, I think. Dr. SopemaN. I do not think medical components. Senator Domintek. If a medical school is connected with a univer- sity, is it not eligible to receive funds from that? Dr. Sopeman. For the medical component ? Senator DomiNicK. Yes. 229 Dr. Sopeman. I donot believe so, sir. The Caarman. I donot think so, Senator. Senator Dominick. Thank you, Mr. Chairman. The Cuairman. Jefferson Medical College was the heritage of Samuel D. Gross, was it not? Dr. Sobeman. It still is, sir. May I add a personal world, sir? The Cramrman. Yes, sir. Dr. Sopeman. I want to add a word of personal appreciation to you for all matters of health education. I may be before you again this ses- sion, so this is not a statement in words of final wy to you as the most important leader in health education. But I do want to express, not only for the American Medical Association and for the Jefferson Medical College, of which I am dean emeritus, but for myself, our great admiration and respect to you for your keen insight and fore- sight in health legislation which has been needed. Your stature will ever grow in the future, I know, as we realize more and more your valuable and fundamental contributions. The Cramrmax. Thank you, Doctor. I appreciate that. Particularly do I appreciate it coming from the dean emeritus of Jefferson Medical College, from which my father graduated some years ago. Dr. Sopeman. And I did, too. The Cuamyan. I think he graduated a little bit before your day. Samuel D. Gross was still there in his day. You are most generous and I am deeply grateful to you. Dr. Sopeman. We are deeply grateful to you, Mr. Chairman. Senator Dominick. I want to say for the record that I heartily sec- ond what Dr. Sodeman has said. It is a pleasure to work on the com- mittee with you. The Crarrman. Thank you very much. Senator YarsoroucH. I, too, would like to associate myself with Dr. Sodeman’s sentiments. Dr. Sodeman, I am encouraged by this statement that you make here, that you and the American Medical Association have a pressing concern for the need for more practicing physicians. As I said the day before yesterday, we are denying Americans the opportunity to be treated by people of their own choice. The Journal of the American Medical Association of June 8, 1964, states that of the 9,294 medical school graduates that year who were licensed to practice for the first time in the United States, 1,600, or 17.2 percent, were from foreign medical schools. The Council on Medical Education of the AMA stated that of 10,400 interns in 1966-67 in the United States, 2,800, or 28 percent, were foreign nationals. The same source, the AMA Coun- cil on Medical Education, stated that in the same year, 1966-67, of 32,000 in residence in United States hospitals, 9,500, or 31 percent, were foreign nationals. Dr. Sobeman. Senator, these figures are essentially the same now. You are quoting from a document which Dr. Ruhe developed. He has in front of him the current one. These figures are essentially the same. Senator YaresoroucH. This in itself shows that we are not giving American youth the chance to get a medical education. Since we are an affluent society and able to hire our own physicians, yet we bring in thousands from foreign nations, trained in foreign medical schools. 230 Their pharmacopeia is not the same as ours, is it ? Dr. Sopeman. No, sir; and their standards are somewhat lower. Senator YarsoroucH. The American Medical Association says their standards are lower. As a judge, once I heard a license juror case tried in my court. One of the things pointed out was the difference between methods. I am convinced that our American medicine is superior, our medical teach- ing and treatment is superior. personally think that more American boys and girls ought to have a chance to fill this need that is so great. Rather than opening our doors for thousands and thousands of foreign medical students to come here every year, thus draining off the health manpower of those lands, we must open the doors of our medical schools to a far larger number of our own students. Dr. Sopeman. This is a concern we have, and we feel that we should produce enough physicians for ourselves. Our need for physicians is very great. We should not be dependent upon foreign lands, we should not drain health manpower from other areas over the world that need it themselves. Senator YarBoroucH. In fact, I thing the figures will show that the average medical doctor earns a higher income than members of any other profession. It is difficult to get into it because of the rigid con- trols and the policy of exclusivity that has been practiced for so long. We need doctors for the military service, we need doctors for the Peace Corps. If we can supply our own needs and have more, it will help us greatly in underdeveloped nations. Dr. SobEman. Senator, I am interested in your definition of ex- clusivity. It is a lack of facilities to expand and not a desire on any part to exclude anyone who is capable a able. Senator YarsoroucH. Well, I would hope that we would push this more. We passed a bill that would create 20 new schools. How many of those have actually opened their doors to students? Dr. Sobeman. Five are now taking students, and 12 are in final de- velopment to take students. Dr. Ruhe can tell us for this next year how many will be able to take students. Dr. Rung. There will be five additional in the fall of 1968. Senator YarsoroucH. We passed that bill in 1963, 5 years ago. We have five open. That is one medical school a year. Dr. Rune. It takes a great deal of time to develop a medical school. Senator YarsoroueH. The population of the country is developing rapidly and the financial ability of the people to get medical attention is increasing much faster than the population is. If you look back 10 years, I would say the majority of the people did not have the money or means to get io attention then. Dr. Sopeman. We are increasing the population ratio, but not ade- quately for the demands at the present time. Senator YareorouaH. I noticed there was a statement here in the Washington Post for this month, March 6, quoting Dr. Rouse, pres- ident of the American Medical Association. In response to charges that only the rich can afford to send their sons or daughters to medical schools, Dr. Rouse said that a survey showed that 51 percent of last year’s medical students came from families with an income of $20,000 or less. 231 Well, that would mean that 49 percent came from families with an income of more than $20,000, would it not? Dr. Sopeman. Senator, we have done a study on this. I think Dr. Ruhe was the man who did the study. Would you like to hear some- thing about it from him ? Senator YARBOROUGH. Yes. Is this statement by Dr. Rouse correct ? Dr. Rune. It’s incorrect in the figure of $20,000. This figure should be $10,000. The figure was not for the last year; it was for 1963-64, which was the last year for which we have figures on family incomes. Senator YarsoroueH. Of course, this is a quotation from a news- paper. I do not hold newspapers out as infallible sources. On occasion, I have had a little problem along that line. Dr. Rouse is past president or president of the AMA 7 Dr. Rune. He is president. Senator YarsoroucH. He said 50 percent—— Dr. Ruse. It is 51 percent of the students in the class of 1963-64 who came from families with incomes under $10,000. Senator YarsoroueH. Under $10,000 and not $20,000? Dr. Rune. That is correct. Senator YarBoroucH. What about this year? Dr. Rune. We do not have figures for this year. We do not annually poll the students to determine what their family incomes are. This 1s a result of a study carried out by the Association of American Medical Colleges. Senator YarsoroucH. Five years ago, before the great expansion of the income that has come in the past 5 years, what percentage of the families in America had incomes of over $10,000 a year? Dr. Rune. The figure for the total population is something like 18 percent, Senator. Senator YarsoroucH. Had incomes of over $10,000 a year? Dr. Rune. That is correct. But to compare the incomes of the fami- lies of medical students with the incomes of the total population is somewhat misleading, because medical schools can accept for admis- sion only students who have already gone through college. If you will examine progressively the incomes of families who had children at all, families who have children who go to high school, families who have children who graduate from high school, families who have children who enter college, and families who have children who graduate from college, you will see a steplike projection of income between the 18 percent reported for the total population and the 49 percent reported for the families of medical students in 1963-64. What I am trying to say is there is not the great disproportion which has been reported. After all, the medical schools can accept only stu- dents who apply to medical schools. They cannot apply to medical school unless they first have gone through college. The fact is that students who get to college come from these families in the higher income brackets. This is not the fault of medicine. This is common to all of higher education and to all of the professions. Senator YareoroueH. This is the tragedy of the education in America. Dr. Ruse. I think so. 232 If I may, Senator, I think one of the problems with a statement like this is that it has been somewhat misleading because it implies that if funds were made available to students, the situation would change and we would Senator YarsorouaH. Certainly it would change. Dr. Rune. This has not been the experience with the graduate stu- dents in the natural sciences, where almost full financial support has been available for about 30 years. Starting in the 1930’s and the 1940s, subsidies for graduate students in the natural sciences became quite common. Today, most of the graduate students in the natural sciences receive full support. Yet, if you examine the family income of the stu- dents who are graduate students in the sciences, you will find they are almost identical with those of the medical schools. So it has not really resulted in more students from lower income families entering as stu- dents. I doubt that it would in medicine, although there is no way of being sure. Senator YarsorouaH. Last week I put into the record a statement, including the observation of Lord Clough, who said “Grace is given of - God, but knowledge is bought in the market.” Dr. SopEman. The knowledge would have to be bought at secondary sn and college level, not at the medical school level, to correct the problem. Dr. Rune. I think this is the problem—that large numbers of stu- dents from the low-income families are not coming up through the primary and secondary school systems to get into the higher education schools, first ; and the medical schools cannot tap them. Senator YarBorouGH. I am not speaking of the 20 percent of the people in the poverty bracket under $3,000. I am speaking of the people in the $7,000 income bracket, below $10,000. You catch more schoolteachers, you catch more secretaries, most of the highest paid labor. I do not mean common labor, but the high-paid labor brackets. Dr. Ruse. I think that is correct. We are concerned about this, too, and I think we are disturbed—— Senator YArRBoroUGH. You get mostly white-collar workers. Dr. Rune. I think that is right. It disturbs us to see the implication is a rich man’s profession. I think the fact that the majority of medical students come from families of under $10,000, in view of the fact that the population we get to draw from, I think this is remarkable. All of us know of many, many instances of boys from poor families who study medicine, who are in medical school now. I think the implication that this is a rich man’s profession is erroneous. Senator Dominick. Would the Senator yield ? Senator YarBorouaH. I was not questioning that it is a rich man’s profession, that doctors make money. I was not questioning whether the less affluent young American can get in; I was questioning the fact that we have to fill these places up with foreign nationals from over- seas to get the hospitals staffed. Yes, I yield, Senator. Senator Dominick. Just prior to this time, I was talking about the availability of grants for medical schools outside of this bill. Under title IT of the Higher Education Academic Facilities Act, we have $120 million available for graduate schools existing or new graduate schools 233 for this year, and another $120 million for next year. To the extent that we have these funds, I must say I am not quite sure how many medical schools are taking advantage of this. But at least the gradu- ate schools are included in the Higher Education Academic Fa- cilities Act and are funded to that degree. Dr. SopEman. Did you wish a comment, Senator ? Senator Dominick. I just wanted to put that in the record because we had a discussion on this before, and you indicated you were not, quite sure about it. Dr. SopEman. Our graduate school problems and our professional medical school problems are in a different category, Senator, that would be for baccalaureate, master’s, Ph. D. degrees and so on, but not for the M.D. degree. : 1 Mr. Harrison. I believe they are excluded, Senator. I certainly will check that in the definition. I believe they are excluded from that defi- nition, but I am not quite sure at this moment. Senator Yarsoroun. I believe in the long haul, Doctor, that a young man has to have much more encouragement to go through the M.D. degree than he would for a master’s degree or maybe even a Ph. D. Because of the continuity required for a medical education, it is a fact that they often quit after a bachelor’s degree before they move on to the doctorate, and then the medical education. It requires great application and great diligence and financial support all through that time. After one of our hearings here within the last 3 or 4 years, before the Education Subcommittee, the dean of a great American university, a State-supported one, stopped me out there in the hall and said, I will probably be relieved of my job tomorrow if you quote me on this, but the test of who goes to school today is who has the money, not who has the brains. That is the frank statement of an academic undergraduate dean of one of the great universities in this country. Senator Murpay. Would the Senator yield? Senator YarsorouGgH. Yes, I yield. Senator MurpaY. As an old dropout who has been very interested in education, I know many deans of universities whom 1 would not quote as authorities. This being a personal opinion, I feel T would be on much safer ground to stay with what we have heard as a very fine diagnosis of this situation based on actual facts and figures rather than the presumptive opinion of some man who stopped you in the hall, be he dean or be he not. I would like to say that I am very pleased, of course, with this particular booklet. T have had an interest in these five schools. With this sort of teaching instrumentation, you would be able to do in these five schools what they used to do in 10 schools and do it better and quicker. I have had an abiding interest in this, going back now some 20 years. I was the fellow who instigated the first motion picture made of the heart surgery done in Philadelphia. I became aware of the need when I watched from young students sitting around watching an operation with field glasses from 30, 40, 60, 70 feet away. At the end of World War II, I said, what a shame; you can bring this up to any size you want and you can make the man’s heart as big as that wall, and you can go into the very most minute details; why does not somebody do this? 92-079 0—68——16 234 I prevailed upon one man who was president of a pharmaceutical company. They did some closed circuit things, but that still was not right, because in closed circuit, you are still limited to the actual size of the object. I have been an advocate of the use of teaching aids, teaching appa- ratus and motion pictures. Now, there’s no reason why every medical student in every school—all they have to have is an auditorium and a motion picture projector and a screen to have the advantage of the very finest teachers, the very finest surgeons. I would hope that before I leave this present job of mine, thanks to this committee, we will see this happen around the country. They are just there for somebody to say let us do it. It is so simple that very often, it loses the attention that it might have. But I persisted. I have always had a lot of experience. I have been a subject of many of the new skills. Thanks to the new skills, I can still speak. But these are things that I am so pleased about to be on this committee. Mr. Chairman, I would like to apologize for not being here earlier I had two other committees and an executive committee today. I hope and not being here yesterday to hear the testimony. I can assure the chairman, my absence did not reflect a disinterest, but. a conflict, for you will forgive me. This is a subject that is of great interest to me. Senator YarsoroueH. To respond about the dean, despite the Sen- ator’s unpleasant experience with deans, I will say this was a dean of admissions with a university of, I will say, over 20,000 students, a dean of admissions for years. I personally believe, having heard his testimony and cross examination then, that he knew what he was talking about on the status of students coming to universities. Senator Murrey. If the Senator will yield, we have a most happy experience in one of my cities, Los Angeles, now, where the University of Southern California Medical School made an arrangement with the great Community Hospital out there, and they will have a facility the like of which I do not think exists any place, and it is going to be of great mutual benefit. It will be great for the medical school and great for the community. That Community Hospital, I am told, as a result of medicare, I am told was 60 percent empty. Now that will all be revised. I was pleased to be able to help a little bit. I think it will be very exciting to watch. Thank you, Mr. Chairman. Senator YarBoroueH. Dr. Sodeman, I am encouraged to read the statement that the American Medical Association, the Council on Medical Education, is determined to push this medical education. I appreciate that very much, and I want to appeal to you who represent the Council with the American Medical Association to use its great political power to push medical education so that we can have a higher percentage of American boys and girls going to medical school and filling these jobs, so we will not limit this opportunity to treat our own people to the many thousands we are pulling in every year from foreign countries. Not that T have any prejudice against their coming over here. We need the doctors, and America was built on immigration from other continents. I just hope these boys and girls at home will be afforded every opportunity to pursue medical study. It is going 235 to take a lot of help. Every time we introduce a bill in Congress, somebody says this is a bunch of wild spenders. I hope your Council on Medical Education will give us all the help we can get and help out in the states. It takes the formation of an organization in the state to go in and work with the people at the grass roots to ask for this foundation of medical schools. We want to urge you and request that you push that as fast as you can and help us get this education available for this younger genera- tion of Americans before they lose the chance. Dr. Sopeman. Thank you, sir. Dr. Rune. May I comment on this? I think we have in the record perhaps a little bit of misleading concept on the relation of the num- ber of foreign graduates to ithis question of production by American schools. We are in complete agreement with you on fthat, that we need the opportunity for more Americans to study medicine in medical schools, and the United States should meet its own needs with its own graduates. I think it is a little misleading, however, to believe that the numbers of foreign graduates in our internships and residen- cies are, first of all, either a reflection of the deficiencies in the num- ber of graduates from American schools, or that ‘this number will change markedly when we have more of our own graduates coming out of our own schools. Internships and residencies are educational opportunities. Through educational exchange, the number of foreign students coming here to take advantage of these opportunities has been increasing steadily. The United States has benefited through world medical education. I suspect this is likely to continue whether or not we increase our own graduates from schools. The vacancies from internships or residen- cies or ithe existence of foreign medical students in these positions are not in themselves indications of the relative supply of American physicians. So long as we have superior educational facilities, we can expect that foreign graduates will want to come to this country for advanced training and that they will continue to do so. So the number might increase even though we double the number of our own gradu- uates from our own schools. We might expect that still the numbers of foreign graduates coming for further training will increase. Senator YarsoroueH. I believe the energetic student, the ambi- tious student, the brilliant student will go and seek the best educa- tion he can find in his profession. That was the case of Senator Hill’s father studying under Dr. Lister in London. The CaatrmaN. That is where I got my name. Senator YarsoroucH. We had a situation awhile back where a number of young doctors came and asked for doctor such and such, he is the only person handling internal medicine, the Immigration Service will not allow him to be naturalized, and so on. They appealed to us to put a bill through Congress. He is the only man capable in this field to teach in our hospital, they said. So we know there is uite a pull from American doctors due to the shortage to get those oreign doctors naturalized. The Cuamrman. A lot of them come here, just as in the old days a lot of our doctors went to Edinburgh, to Glasgow, to Paris, to Vien- 236 na, Berlin, places over there, because they thought to go there would give ters the best opportunities for medical education. Is that not true? Dr. Rune. Yes, sir. The CHAIRMAN. At one time, a great many students even went to Vienna. Dr. Rune. They come here now. Dr. Sopeman. We are now the focus of excellence in the world. The CrrairmaN. Are there any other questions? If not, we want to thank you, gentlemen. When you get back to Jefferson Medical College, give them my very, very best, will you, Dr. Sodeman ? Dr. Sopeman. I shall do that this afternoon, sir. Mr. Harrison. For the use of this committee, Senator, this copy of “Medical Education of the United States” will help you. The CrarMaN. Thank you. The American Heart Association: Dr. Ethridge and Dr. Page. STATEMENT OF DR. ROBERT G. PAGE, ASSOCIATE DEAN, DIVISION OF BIOLOGICAL SCIENCES, UNIVERSITY OF CHICAGO, CHAIRMAN, COMMITTEE ON MEDICAL EDUCATION, AMERICAN HEART ASSO- CIATION; AND DR. CLAYTON B. ETHRIDGE, WASHINGTON, D.C. MEMBER, LEGISLATIVE ADVISORY COUNCIL Dr. Page. Mr. Chairman, I am Dr. Robert G. Page, associate dean of ‘the Division of Biological Sciencies of the University of Chicago—— The Crairman. Is that John B. Murphy’s old school? Was he there or at Northwestern ? Dr. Erariee. He was at Northwestern. The Cramrman. And Paul Magnuson was at Northwestern. Dr. Pace. Currently I am chairman of the Committee on Medi- cal Education of the American Heart Association. I speak on behalf of the latter organization, but I must admit that my remarks may well be flavored by my association with the former. Generally speaking, the American Heart Association favors the bill entitled the “Health Manpower Act of 1968.” I would now like to comment, on particular aspects of this bill. We believe that it is essen- tial to increase the number of all health professionals in this country to meet and serve the demands of the public. We are distressed that these appropriations, as we understand it, are to begin in fiscal 1970 instead of fiscal 1969 since the need for funding is now. To enlarge the manpower pool takes time. Often it can be years before the effect of this kind of legislation is apparent. In reading title I, we were happy to note that grants could be made for multipurpose facilities, but unhappy to realize that matching funds are still set at a 1:1 ratio except under unusual circumstances. It is my hope that this will be interpreted liberally or that the Federal contribution might be substantially increased. If it is not, construction of facilities may well be inhibited, thereby preventing an increase in the number of health professions students. 237 We support the institutional grants computed by the formula described on pages 6 and 7 of the bill. T am disturbed by the method of encouraging expansion of enrollment in health schools described on page 8, paragraph (b) (1). This is to me inhibitory. Schools will see here an invitation to make a minimal increase in size, anticipating future legislation which may also invoke the “214 percent or five student rule.” T would prefer to see a basic grant given regardless of mcrease in school size accompanied by an attractive supplementary grant which would be proportional to the increased enrollment. Indeed, such encouragement is already given on page 7, paragraph (A) (ii) of the bill, in which “a school receives twice as much for each student in the increase as for other full-time students.” This approach would allow schools to make substantial increases in class size and thus increase the health student pool in a more efficient way. We encourage the special project grants as described in section 772, page 10, since we believe that stimulation to experiment in the improve- ment of education of health scientists and practitioners should sub- stantially increase the number of individuals attracted to these fields of study. Through such projects the output of health professional may well be accelerated. We have, therefore, no argument with the project priorities listed on pages 11 and 12, paragraphs (b) (5) (e) (1), (b) (5) (€) (2), and (b) (5) (e) (3). e American Heart Association, therefore, supports the concepts set forth in title I of this bill. A few suggestions are made which we believe will enhance the ability to meet the underlying needs which this bill attempts to meet. Our nursing colleagues in the American Heart Association have studied this bill with interest, addressing themselves particularly to title IT. We believe that there is an urgent need to expand the supply of nurses. We are particularly interested in those nurses who specialize in the cardiovascular field. I am sure that all of you are aware of the growing and increasingly complex role being played by nurses in those hospitals which have special care facilities such as cardiac care units. We are particularly pleased with the change in this bill which makes possible grants to all three types of nursing schools; that is, collegiate and associate degree programs as well as diploma schools of nursing. We support the scholarship and loan funds. Again, let me emphasize our unhappiness with the delay in appropriations until fiscal 1970. The need is now. We must plan immediately for the years to come or we will be unable to close the health need to health service gap that is so real to those of us who take care of sick people and sick communities. I shall not comment in detail about title ITT save to say that we are in favor of legislation which will expand the assistance to the allied health professions and to schools of public health. ary ) Title IV is of great importance to the educational institutions in this country which are responsible for teaching health professionals, and creating new knowledge. I again express concern that appropria- tions may be delayed until 1970. There is an immediate need for these facilities so that we can best deal with the health needs and problems of tomorrow. Here I must emphasize that the American Heart Association is most interested in those facilities in which cardiovascular research will be done, but we do not stop there since we easily recognize the many interrelationships which exist in biological research. 238 Finally, the American Heart Association supports this bill. We do hope that funding will start in the next fiscal year rather than waitin until July 1, 1969, since it is our belief that there is an urgent on to start now to meet the demands of today and tomorrow. The Cmarrman. Doctor? Dr. Erarmee. IT am a member of the Legislative Advisory Com- mittee of the American Heart Association, and by way of identification, I am associate dean at the George Washington University School of Medicine and Center, a professor of medicine and a cardiologist. The American Heart Association strongly supports this bill. It recognizes the need for health manpower in many categories, and particularly, of course, the need for physicians and many other types of personnel. I endorse the statement that has just been made as indicative of that support. Thank you. The Cuamman. Are there questions, Senator Yarborough? Senator YaresorougH. No questions, thank you. The CuamrmMan., We thank you very, very much. We certainly appreciate your being here and giving us this splendid testimony. Senator YareoroucH. I think the whole country knows Dr. De- Bakey well. He is a good friend of mine, and I give tribute to the heart specialists for the great advances made in treatment of heart diseases. It is a great chapter in the history of American medicine. Dr. Erarmee. We are pe to have that, Senator. The Cramman. We hope 1f the time comes when he needs a new heart, you will get him one. Dr. Erarmee. We will try to do that. Senator Y arsoroucH. I would like to put a statement in the record at this time in connection with the questioning of Dr. Sodeman from the Report of the National Advisory Commission on Health Man- ower from page 25, starting with paragraph “b. Financial Support or Medical Ktndents.” I would like to put all the rest of that page in the record at this point. It tells about the difficulty of financing a medical education. It says that as a result, 45 percent of medical students come from families in the upper 10 percent of income groups. Existing federal loan programs are not adequate to cover living expenses, and we are concerned that the debts which students will frequently incur through loans they obtain at commercial rates may create a need and desire for financial return in the practicing years that may influence the physicians’ attitudes toward their social responsibilities. I want to say parenthetically there that I think that is illuminative, Mr. Chairman, on the dispute we have going on in the education com- mittee about national defense education loans and the guaranteed bank loans. They recommend that the Federal Government revise and expand present health professions education assistance programs to make available to any medical student loans to cover the full costs of tuition and living expenses during formal professional education. There are three footnotes. Mary Bunting, president of Radcliffe College, says she agrees with this only because free medical education is not available. She wants the loans only until such time as free medical education becomes available. 239 Charles E. Odegaard, a member of the Commission, president of the University of Washington, objects to shifting the full cost of tuition to the student subject to subsequently payment in cash or indentured service as a progressive step in public policy—he objects to that. He says— In a covert way it negates the long-established policy of public responsibility for providing educational opportunities for all according to their talents without reference to their ability to pay. Further, I do not believe that this proposal can really be expected to draw into medicine more students from lower income brackets. That is the statement of the president of the University of Wash- ington. That is my philosophy, also. ; he third statement is from Dr. Dwight L. Wilbur, clinical pro- fessor of medicine at the Stanford University School of Medicine and president-elect of the American Medical Association: I wish to dissent from these recommendations. I believe the principle is not sound and that the recommendations are impractical, unnecessary, will not serve the purposes intended, and will be largely unacceptable to most students. Now, your other college presidents objected to putting the student in debt. The president-elect of the American Medical Association objects to even giving him a chance to borrow money to go. I ask that that full article be printed in the record at the conclusion of Dr. Sodeman’s statement. That is from volume 1, the report of the National Advisory Commission on Health Manpower, dated Novem- ber, 1967. The Cramrman. That will be made part of the record. (The material referred to above follows :) EXCERPT FROM THE REPORT OF THE NATIONAL ADVISORY COMMISSION ON HEALTH MANPOWER, VOLUME I, NOVEMBER 1967 b. Financial Support for Medical Students.—At the present time, tuition charges are set artificially low in order to reduce the financial barrier to medical students, while the remainder of educational costs are obtained from research funds, state appropriations, endowment and private gifts, and income from serv- ices. Even these low tuition rates, when combined with the delay of earning power, make many qualified individuals financially unable to enter the medical profession. As a result, 45 percent of medical students come from families in the upper 10 percent of income groups. Existing Federal loan programs are not ade- quate to cover living expenses, and we are concerned that the debts which stu- dents frequently incur through loans they obtain at commercial rates may create a need and desire for financial return in the practicing years that may influence the physicians’ attitudes toward their social responsibilities. In order to eliminate financial barriers to medical students, we recommend that the Federal Government revise and expand present Health Professions Edu- cation Assistance Programs to make available to any medical student loans to cover the full costs of tuition and living expenses during formal professional education.* *I believe these recommendations are necessary until such time as free medical education becomes available in this country.—Mary Bunting I do not regard the idea of shifting the full cost of tuition to the student subject to subse- quent repayment in cash or indentured service as a progressive step in public policy; in a covert way it negates the long-established policy of public responsibility for providing edu- cational opportunity for all according to their talents without reference to their ability to pay. Further, I do not believe that this proposal can really be expected to draw into medicine more students from lower income brackets.—Charles E. Odegaard I wish to dissent from these recommendations. I believe the principle is not sound and that the recommendations are impractical, unnecessary, will not serve the purposes in- tended, and will be largely unacceptable to most students.—Dwight L. Wilbur 240 The CuamrMAN. Thank you, gentlemen. The American Association of Colleges of Pharmacy : Dr. George L. Webster, president; Mr. Charles W. Bliven, executive secretary; and Mr. David S. Newton, projects director. STATEMENT OF CHARLES W. BLIVEN, EXECUTIVE SECRETARY, AMERICAN ASSOCIATION OF COLLEGES OF PHARMACY; ACCOM- PANIED BY DR. GEORGE L. WEBSTER, PRESIDENT, AND DAVID S. NEWTON, PROJECTS DIRECTOR Mr. Buven. Mr. Chairman, my name is Charles W. Bliven and I am executive secretary of the American Association of Colleges of Pharmacy. On my left is Mr. Newton, who is projects director for the association ; and on my right is Dr. Webster, who is president of our assoclation. Before we begin our statement, Mr. Chairman, I want to say that we in the colleges of pharmacy wish to express our sincere appreciation for your many years of devotion to the people of our country through your service in Congress. We are especially indebted to you for your most significant contribution to the health and welfare of our people through your leadership in major health legislation. Second, we in the pharmacy are most grateful for your understand- ing consideration of the needs of pharmaceutical education and the part our graduates play in the total health care system. The Caamrman. Thank you, sir. I am most grateful to you for those generous words. Mr. Braven. Before assuming this office more than 6 years ago, 1 served for 14 years as dean of a school of pharmacy. a I appear before you in behalf of the membership of the American Association of Colleges of Pharmacy, which consists of 74 schools and colleges of pharmacy. All of them are nationally accredited. Seventy- three of our member schools are located in 44 States and the District of Columbia; the remaining school is located in Puerto Rico. Approx- imately 1,460 teachers are engaged in the instruction of some 14,100 undergraduate and 2,000 graduate students enrolled in our schools. Mr. Chairman, I am not going to present at this time my complete statement. The Cmamman. We will have the complete statement appear in the record. Mr. Buven. I am going to give some highlights, and I would like very much to have Dean Webster make some comments before we conclude. I appear before you in support of titles I and IV of S. 3095, the “Health Manpower Act of 1968.” S. 3095 would extend and broaden the program for the construction of teaching facilities for students in schools of pharmacy and in other health professions. It would extend the student loan and scholarship provisions to give financial aid to needy students in these professions, and authorize special proj- ect grants to all schools of the health professions. In addition, it would provide institutional grants to all such schools except schools of pharmacy and of veterinary medicine. 241 Public Law 88-129, the Health Professions Education Assistance Act of 1963, included schools of pharmacy in the construction program and Public Law 89-290, which amended and extended this legislation, provided scholarships and loans for students of pharmacy. I might add at this point that the scholarships for students of pharmacy came through the efforts of this committee, and we are deeply grateful for this assistance. However, our schools were not included—in fact, we did not ask to be included—in part E of the law which provides basic improve- ment grants and special improvement grants for schools of medicine, dentistry, osteopathy, optometry, and podiatry. But we do wish to express our gratitude for construction funds and for financial assist- ance to our students made possible under these acts. S. 3095 would make schools of pharmacy eligible to apply for special project grants—section 772—but would exclude them from receiving mstitutional grants—section 771. We ask that S. 3095 be so amended as to make schools of pharmacy eligible for institutional grants. MANPOWER Approximately 90 percent of our professional personnel are prac- ticing in the community pharmacies throughout the country. The remaining 10 percent are engaged in the many other areas of the profession. To provide an adequate number of pharmacists for the profession and the allied health fields, our schools and colleges of pharmacy will continue to need financial assistance through the pro- visions of this legislation. In the important area of hospital pharmacy where about 10,000 pharmacists are employed, the demand is greater than the supply. Of the 7,000 hospitals only 2,339, less than one-half, have the services of a full-time pharmacist and only 2,644, or 38 percent, have the serv- ices of a pharmacist on either a full-time or part-time basis. The annual replacement factor for full-time hospital pharmacists is esti- mated to be 12.8 percent or 621 individuals—about 17 percent of the 1967 graduating class. The continually greater demand for pharmaceutical services by our increasing population necessitates an increased output of phar- macists. The annual increase in the number of prescriptions filled in the community and the hospital pharmacists is one factor in this increasing demand for the professional services of pharmacists. In 1967, nearly 1.1 billion prescriptions were filled—about 70 million more than in 1966. In the way of a footnote, Mr. Chairman, I might add that the increase in the number of prescriptions between 1947 and 1967 was 205 percent. We often hear that the average drugstore is not very busy these days in dispensing prescriptions, but corresponding figures show that the average drugstore in 1967 filled 21,000 prescriptions, as compared with 7,000 in 1947, also an increase of 200 percent. This increased number of prescriptions alone, on the average, re- quires the yearly services of about the entire graduating class of 1967. Thus, the annual increase in the number of prescriptions and the failure to graduate a sufficient number of pharmacists to meet our 242 annual manpower replacement needs clearly indicate that all phar- macists—in our hospitals and in our community pharmacies—are having greater and greater demands made of them for professional services. Still another factor to which the attention of all of us should be directed is the increased manpower demands for pharmacists which will result from health legislation such as medicare and medicaid. I might add at this point, Mr. Chairman, that the schools and col- leges of pharmacy are actually conducting training programs so that community pharmacists can serve as consultants to the nursing homes and the extended care facilities. The CuamrmanN. You have so many more of those than you had in the old days. Mr. Briven. That is right. I refer not only to pharmaceutical services as we currently think of them but also the other areas of health service where our graduates can and will be expected to serve. Table C gives information on the average annual number of phar- macists and requirements for replacements— The Carman. We will have that table appear in full in the record. Mr. Buiven. Yes, sir; thank you. It also has new entrants, and the total need for pharmacists in prac- tice in the United States for 5-year periods during 1965-80 in order to maintain the 1965 ratio of 61.2: 100,000 population. For the period 1965-70, an average of 5,900 replacements and new entrants will be needed. This number is 57.6 percent greater than the 3,744 graduates in 1967. To further emphasize our manpower prob- lem, on the basis of the estimated number of graduates in the years ahead, this output of 5,900 may not be reached until 1976 (see table D) at which time our average annual need for graduates will be about 7,400 to maintain the 1965 ratio of practicing pharmacist to popula- tion of 61.2 per 100,000. FACILITIES This emphasizes the need for continued expansion of existing schools and the possible need for new schools. In earlier statements be- fore this committee it was stated : * * * the needs of schools of pharmacy appear to be the replacement or rehabilitation of existing structures and the expansion of some to meet area needs. There does not appear to be a need for the establishment of new schools. Now that we have data on the 5-year program, which was initiated in 1960 and produced the first graduates in 1965, the need for some new schools or at least a more rapid expansion than at present of existing schools appears essential if the pharmacist-to-population ratio is to be maintained at the 1965 level. It should be mentioned that the Fordham University College of Pharmacy, a private institution, will cease to take students into the professional program after 1969. A little later, I shall read part of their statement as they closed the school. Now, in a survey conducted in December 1967, 12 schools of phar- macy reported projects approved and funded during fiscal years 1963 67 with the Federal share amounting to $9.1 million, and a total cost 243 of $26.9 million. Two projects were renovations, the remaining 10 schools reported an increase of 367 first-year places. Six additional schools indicated construction is planned during fiscal years 1968 and 1969 with five schools reporting the total Federal share of $5.1 million. The increase in first-year places is estimated to be 116. During the 3-year period fiscal years 1970-72, 21 schools indicated they plan construction projects. The total estimated Federal share re- ported by 14 schools is $18.2 million, and the estimated total cost of construction given by 18 schools is $40.2 million. The estimated num- ber of new places is 454. Fifteen schools stated they plan construction beyond June 30, 1972. The provision of S. 3095 which would permit schools to submit one application for multipurpose facilities is a most desirable change. With the necessary increase in attention being devoted to continuing educa- tion, and to graduate training, the inclusion of facilities for such pur- poses in the construction program would permit a greater coordination in planning and the development of a more complete and interdigitated program. STUDENT AID As stated previously, we did not seek in 1965 inclusion in the basic improvement grants and the special improvement grants provisions of the legislation. Instead, we sought, and your committee did include students of pharmacy in the loan and scholarship portions of the bill. For this we are grateful, and we believe that it is an important factor in our increasing enrollments in entering classes, i.e., the third year of the 5-year program. In 1966, about 13 percent more students enrolled in the first year of the professional program than in 1965, and last year the increase was almost 6 percent over that for 1966. According to information provided by the Bureau of Health Man- power, scholarship funds in the amount of $1,003,200 were allocated to schools of pharmacy in fiscal year 1967. Of the eligible class of 5,134 students, 1,051 (20.5 percent) of our students received grants. The average grant was for $648 and about 68 percent of the funds allocated were used. In addition to these Federal scholarship funds, our schools used almost 100 percent of the scholarship funds available to them from other sources. A survey conducted in January 1968, by the American Association of Colleges of Pharmacy on the use of scholarship funds allocated for fiscal year 1968 showed the rather similar results: 1. Of the 73 schools receiving funds, 69 reported allocations totaling $1,812,103 ; 2. Grants totaling $1,322,309 were made to 2,104 students for an average loan of $628; 3. About 74 percent of the allocated funds were used as of December 1968, by the schools. With respect to loan funds, the Bureau of Health Manpower re- ported that of 73 eligible schools in fiscal year 1967, 45 received funds— the rest of these schools, Mr. Chairman, chose to remain with the NDEA program in the universities—totaling $1,638,887 and that loans averaging $700 were made to 1,584 students, Thus, 67.7 percent of the funds were used. 244 Again, a survey conducted in January 1968, by the American Asso- ciation of Colleges of Pharmacy revealed that 48 schools received loan funds for fiscal year 1968 totaling $1,887,740; loans totaling $1,416,271 were made to 1,935 students for an average loan of $732; and that 75 percent of the funds had been used as of December 1967. These figures, I believe, indicate the need for student financial assist- ance in schools of pharmacy. We have some figures, Mr. Chairman, on the estimated need for loan funds for fiscal years 1969-72. I had assumed the legislation would be extended for 3 years. Thus our survey did not go beyond 1972. The estimated need for loan funds for fiscal years 1969 through 1972 was ascertained, and for the 45 schools reporting the need is as follows: A060 ccm A ER SR A RR Re $2, 242, 270 | eT Te 2, 489, 395 OT eee em ee te ee eee om 2, 720, 500 ONT missmish ee 2, 952, 460 DORR cisions im ago sl Ga oss so i 10, 404, 625 The provisions of S. 3095 which permit, with the permission of the Secretary, the transfer of up to 20 percent of the money from the scholarship fund to the loan fund and vice versa is a very desirable feature. Too, the change in the definition of those eligible for scholar- ships is most helpful. While only about 10 percent of the deans of pharmacy indicated some change in the basic law was considered desirable, the most frequent comment was in regard to the limitation place on the use of the funds because of the current wording; in fact, two schools failed to make any scholarship grants because of the university’s interpretation of “* * * students of low-income families who without such assistance would be unable to pursue the course of study * * *.” INSTITUTIONAL GRANTS AND SPECIAL PROJECT GRANTS As noted earlier in this statement, the American Association of Colleges of Pharmacy requests that schools of pharmacy be included among the health schools eligible for institutional grants. At the present time, our schools have no broad Federal financial assistance program available. The CratrMaN. You do not have any today, do you ? Mr. Briven. No, sir. Our schools are eligible for support through the general research support program administered by the National Institutes of Health, but the fact is that, while schools of medicine and denistry automatic- ally receive the basic grant of $25,000 annually plus additional funds calculated on research expenditures, schools of pharmacy are required to have grants totaling $100,000 during one year from the Public Health Service in order to be eligible for the basic grant of $25,000. About seven of our 74 schools have qualified for the general research support grants at one time or another, but only four or five have qualified in any one year. One of our needs now is for grants which can be used by the schools to strengthen their total programs, the undergraduate as well as the 245 advanced programs. As in other health profession schools, a graduate program in the pharmaceutical sciences is essential in obtaining and retaining staff, in strengthening the undergraduate program, and in contributing new knowledge in our special area of the health sciences. Mr. Chairman, if I may, I mentioned a moment ago that the Ford- ham University was closing its school of pharmacy, effective in 1972, and will cease taking professional students beginning in the fall of 1969, as I recall. The publicity release, and I will quote one of the factors: To achieve significant results in pharmacy education today would require a major commitment to graduate education in the field. It would involve added faculty, facilities, and student aid, all of which is just beyond the capability of Fordham now, in view of its pressing financial commitments. It is my understanding also that they are going to close out their undergraduate program in education, retaining only the graduate program. They make statements of declining envollment—this may have been true in their particular school, but across the country, our enrollments have been increasing. . In a report made in January 1968, the American Council on Phar- maceutical Education, the accrediting body for shools of pharmacy, made the following statement : While the Council is under . . . rather diffuse pressures shared by others in the accrediting field, it is also under the more immediate pressures of the crisis in higher education as it affects pharmaceutical education. No one can read the newspapers today without being aware of the seriousness of this crisis which is largely a money crisis caused by inadequate funding on the one hand and inflationary pressures on the other. These are difficult problems to understand in pharmaceutical education for there are surface manifestations that all is well. Direct pharmacy budgets are up some 16 percent this year, for example, new buildings for pharmacy were erected during the year and others are under construction—since World War II, 27 new free-standing buildings and 20 shared buildings have been erected for pharmacy—the size of the full-time faculty has inched up to a new record number, the faculty published several hundred research papers and books and were granted 16 U.S. patents during the past academic year. But underneath this rosy facade, there are several evidences of problems growing more acute, Private institutions have raised tuition nearly to the limit of the market place and several have had to be taken over by the State. State legislatures are hard pressed for sources of support almost universally and some States are extremely malnourished. While the past two-year percentage gain in legislative support for higher education in the nation is 44 percent, one State with a college of pharmacy showed only a 6.5 percent gain and another only 12 percent. While the national 8-year gain in legislative support for 1968 over 1960 was 214 percent, one State gained only 73.5 percent. The recent direct pharmacy college budget increases have gone almost entirely into salaries. This means that some faculties do not have adequate supplies, equipment, libraries, and travel funds with which to work effectively. While industrial support for research ap- pears to have increased last year, Federal support for research was diminished by nearly a million dollars. The American Association of Colleges of Pharmacy most recent survey shows that the number of unfilled faculty positions in phar- macy has increased since 1963 from 81 to 124, Seven colleges of pharmacy are looking for new deans currently and there will be other additional retirements next year without doubt. The revolution in the health professions precipitated by Medicare calls for a fresh approach to curriculum planning that has now begun but still has a long way to travel. In addition, I wish to note that only recently—January, 1968—the American Association of State Colleges and Universities and the National Association of State Universities and Land-Grant Colleges 246 in a joint statement commented on education in health-related fields, stating in part: We urge corrective legislation to end this discrimination to major health- related fields, especially as concerns basic and special improvement grants for support of the instructional function at schools of pharmacy and veterinary science. The Carman. This is a statement of what has been ? Mr. Buiven. Yes, sir. This is part of a statement made last year, as I recall. The American Association of Colleges of Pharmacy is in the process of studying program costs in schools of pharmacy. This is one part of a project designed to further delineate the needs of our schools and is considered as an essential first step in strengthening our programs in pharmacy. To date, figures from 18 schools are available, 14 State schools and four non-State schools. The study covers the academic year 1965-1966. The average total expenditure for all schools was $420,657 and the range was from $166,521 to $874,971. Sixteen of the 18 schools operated at a loss; the average was $292,351, and the range was $63,178 to $688,860. The average cost of the undergraduate program per undergraduate student was $1,253 with a range of $631—which seems very low— to $2,294. The average cost per graduate student—13 colleges reporting— was $2,870, with the range from $1,158 to $6,958. Lastly, the cost per undergraduate student on the basis of total expenditures of the 18 schools was $1,970. On the basis of the formula given in S. 3095, it is not possible to determine the funds needed for schools of pharmacy for institutional grants. However, using the formula for the current basic improvement grants provision and the estimated enrollments given in table D, the need would be $9.9 million in fiscal year 1970. Hund on the average estimated enrollment for fiscal years 1970-1973, the need would be about $10.7 million per year for the 4-year period of about $146,000 per school per year. As you are well aware, under S. 3095, schools of pharmacy would not be eligible for participation until fiscal year 1970. Thus, our re- quest for inclusion may be viewed as a request for “legislation for the future ;” it would not affect the 1969 budget. We ask your serious con- sideration of our needs. But please be assured that we in pharmacy are mindful of the many demands of the current period and that pri- orities must be given consideration. However, we are hopeful that the urgencies now with us will have lessened by fiscal year 1970. Certainly, we would be remiss if we failed to acknowledge with ap- preciation the inclusion of our schools in the special project grants provisions of the bill. These will be helpful in view of the several pur- poses for which they can be used but, as stated earlier, our schools ave no source of broad Federal financial assistance such as the insti- tutional grants with which to meet the exigencies which arise and which could not be met immediately by a project grant. Thank you. (The prepared statement of Mr. Bliven, follows:) 247 PREPARED STATEMENT OF CHARLES W. BLIVEN, EXECUTIVE SECRETARY, THE AMERICAN ASSOCIATION OF COLLEGES OF PHARMACY My name is Charles W. Bliven. I am executive secretary of the American Asso- ciation of Colleges of Pharmacy, and I present the statement in this capacity. Be- fore assuming this office more than six years ago, I served for fourteen years as dean of a school of pharmacy. I appear before you in behalf of the membership of the American Association of Colleges of Pharmacy, which consists of 74 schools and colleges of pharmacy. All of them are nationally accredited. Seventy-three of our member schools are located in 44 states and the District of Columbia ; the remaining school is located in Puerto Rico. Approximately 1,460 teachers are engaged in the instruction of some 14,100 undergraduate and 2,000 graduate students enrolled in our schools. The curriculum leading to the undergraduate professional degree has required a minimum of five years since September, 1960. Two of our member schools offer a required six-year curriculum, and at least two others offer this longer program on an optional basis in addition to the minimum program. In the five-year pro- gram at least three years of work in the professional subjects are required in addition to a two-year basic science program. In the six-year curriculum at least four years are mandatory beyond the two years of science. The objective of the American Association of Colleges of Pharmacy is the promotion of education and research within the member institutions. I appear before you in support of Titles I and IV of S. 3095, the “Health Man- power Act of 1968.” 8. 3095 would extend and broaden the program for the con- struction of teaching facilities for students in schools of pharmacy and in other health professions. It would extend the student loan and scholarship provisions to give financial aid to needy students in these professions, and authorize special project grants to all schools of the health professions. In addition it would pro- vide institutional grants to all such schools except schools of pharmacy and of veterinary medicine. Public Law 88-129, the Health Professions Education Assistance Act of 1963 included schools of pharmacy in the construction program and Public Law 89-290, which amended and extended this legislation, provided scholarships and loans for students of pharmacy. However, our schools were not included (in fact we did not ask to be included) in Part E of the law which provides basic improve- ment grants and special improvement grants for schools of medicine, dentistry, osteopathy, optometry, and podiatry. But we do wish to express our gratitude for construction funds and for financial assistance to our students made possible under these Acts. S. 3095 would make schools of pharmacy eligible to apply for special project grants (Section 772) but would exclude them from receiving institutional grants (Section 771). We ask that S. 3095 be so amended as to make schools of pharmacy eligible for institutional grants. Manpower. —Approximately 90 percent of our professional personnel are prac- ticing in the community pharmacies throughout the country. The remaining 10 percent are engaged in the many other areas of the profession: in the pharmacies of our hospitals; in the control, research, or product development laboratories of the manufacturing plants; as medical service representatives to the physicians; in our educational programs; in government; and in the Armed Forces. The schools of pharmacy are making every effort to respond to the demands for per- sonnel from all of these public health areas. The educational program in pharmacy provides our graduates with an excellent background in the basic sciences as well as in the professional courses. For this reason allied health fields are utilizing an increasing number of our graduates. To provide an adequate number of pharma- cists for the profession and the allied health fields, our schools and colleges of pharmacy will continue to need financial assistance through the provisions of this legislation. In the important area of hospital pharmacy where about 10,000 pharmacists are employed, the demand is greater than the supply. Of the 7,000 hospitals only 2,339, less than one-half, have the services of a full-time pharmacist and only 2,644 (38%) have the services of a pharmacist on either a full-time or part-time basis. The annual replacement factor for full-time hospital pharmacists is esti- mated to be 12.8 percent or 621 individuals—about 17 percent of the 1967 grad- uating class. 248 The continually greater demand for pharmaceutical services by our increasing population necessitates an increased output of pharmacists. The annual increase in the number of prescriptions filled in the community and the hospital pharmacies is one factor in this increasing demand for the professional services of pharma- cists. In 1967 nearly 1.1 billion prescriptions were filled—about 70 million more than in 1966. This increased number of prescriptions alone, on the average, re- quires the yearly services of about the entire graduating class of 1967. Thus, the annual increase in the number of prescriptions and the failure to graduate a sufficient number of pharmacists to meet our annual manpower replacement needs clearly indicate that all pharmacists—in our hospitals and in our com- munity pharmacies—are having greater and greater demands made of them for professional services. Still another factor to which the attention of all of us should be directed is the increased manpower demands for pharmacists which will result from health legis- lation such as Medicare and Medicaid. I refer not only to pharmaceutical services as we currently think of them but also the other areas of health service where our graduates can and will be expected to serve. Our member colleges have the responsibility of graduating an adequate number of pharmacists at both the undergraduate and graduate levels to meet not only the replacement needs of the profession (currently 4,300 undergraduates annually on a replacement rate of 3.5 percent per year) but also the demands of our rapidly-expanding area of the health sciences. A rather constant pharmacist-to- population ratio of 67/100,000 existed from at least 1920 until about 1960; this included all licensed pharmacists not merely those in practice. Information compiled by the U.S. Public Health Service ! shows that as of 1962 there were 123,057 licensed pharmacists, excluding Puerto Rico, residing in the state of registry. But this number included retired pharmacists, those who may have been seeking positions, and those who were employed outside of the profes- sion. In relation to population there were 66.2 licensed pharmacists per 100,000 population. However, the number of licensed pharmacists in practice in the United States as of January 1, 1962, according to the same report numbered 117,377 which on the basis of a population of 188 million provided a pharmacist to population ratio of 62.4 per 100,000. As of January 1, 1965, the number of resident pharmacists in practice was 118,284 or 61.2 per 100,000 and as of January 1, 1967, the number was 122,421 or 61.6 per 100,000. Table C gives information on the average annual number of pharmacists and requirements for replacements, new entrants, and the total need for pharmacists in practice in the U.S. for five year periods during 1965-1980 in order to main- tain the 1965 ratio of 61.2:100,000 population. For the period 1965-1970, an average of 5,900 replacements and new entrants will be needed. This number is 57.6 percent greater than the 3,744 graduates in 1967. To further emphasize our manpower problem, on the basis of the estimated number of graduates in the years ahead, this output of 5,900 may not be reached until 1976 (see Table D) at which time our average annual need for graduates will be about 7,400 to maintain the 1965 of practicing pharmacist to population ratio of 61.2 per 100,000. Facilities.—This emphasizes the need for continued expansion of existing schools and the possible need for new schools. In earlier statements before this committee it was stated: “—the needs of schools of pharmacy appear to be the replacement or rehabilitation of existing structures and the expansion of some to meet area needs. There does not appear to be a need for the establish- ment of new schools.” Now that we have data on the five-year program, which was initiated in 1960 and produced the first graduates in 1965, the need for some new schools or at least a more rapid expansion, than at present of existing schools appears essential if the pharmacist to population ratio is to be maintained at the 1965 level. It should be mentioned that the Fordham University College of Pharmacy, a private institution, will cease to take students into the professional program after 1969. In a survey conducted in December, 1967, 12 schools of pharmacy reported projects approved and funded during FY 1963-1967 with the federal share 1 Peterson, P. Q. and Pennel, M. Y. : Health Manpower Source Book 15, Pharmacists, PHS Publication No. 263, Section 15, p. 3, U.S. Government Printing Office, Washington, D.C. 249 amounting to 9.1 million (total cost of 26.9 million). T'wo projects were renova- tions, the remaining ten schools reported an increase of 367 first-year places. Six additional schools indicated construction is planned during FY 1968 and 1969 with five schools reporting the total federal share at 5.1 million. The increase in first year places is estimated to be 116. During the three year period FY 1970-1972, 21 schools indicated they plan construction projects. The total estimated federal share reported by 14 schools is $18.2 million and the estimated total cost of construction given by 18 schools is $40.2 million. The estimated number of new places is 454. Fifteen schools stated they plan construction beyond June 30, 1972. The provision of S. 3095 which would permit schools to submit one application for multipurpose facilities is a most desirable change. With the necessary increase in attention being devoted to continuing education, and to graduate training, the inclusion of facilities for such purposes in the construction program would per- mit a greater coordination in planning and the development of a more complete and interdigitated program. Student aid.—As stated previously we did not seek in 1965 inclusion in the basic improvement grants and the special improvement grants provisions of the legislation. Instead we sought and your Committee did include students of pharmacy in the loan and scholarship portions of the bill. For this we are grate- ful, and we believe that it is an important factor in our increasing enrollments in entering classes, i.e., the third year of the five-year program. In 1966 about 13 per cent more students enrolled in the first year of the professional program than in 1965, and last year the increase was almost 6 per cent over that for 1966. According to information provided by the Bureau of Health Manpower, schol- arship funds in the amount of $1,003,200 were allocated to schools of pharmacy in FY 1967. Of the eligible class of 5,134 students, 1,051 (20.5 per cent) of our students received grants. The average grant was for $648 and about 68 per cent of the funds allocated were used. In addition to these federal scholarship funds, our schools used almost 100 per cent of the scholarship funds available to them from other sources. A survey conducted in January, 1968, by the American Association of Col- leges of Pharmacy on the use of scholarship funds allocated for FY 1968 showed the rather similar results: (1) Of the 73 schools receiving funds 69 reported allocations totaling $1,812,103; (2) Grants totaling $1,322,309 were made to 2,104 students for an average loan of $628; (3) About T4 per cent of the allocated funds were used as of December, 1968 by the schools. With respect to loan funds, the Bureau of Health Manpower reported that of 73 eligible schools in FY 1967 45 received funds totaling $1,638,887 and that loans averaging $700 were made to 1,584 students. Thus 67.7 per cent of the funds were used. Again, a survey conducted in January, 1968, by the American Association of Colleges of Pharmacy revealed that 48 schools received loan funds for FY 1968 totaling $1,887,740; loans totaling $1,416,271 were made to 1,935 students for an average loan of $732; and that 75 per cent of the funds had been used as of December, 1967. These figures, I believe, indicate the need for student financial assistance in schools of pharmacy. The estimated need for loan funds for FY 1969 through 1972 was ascertained, and for the 45 schools reporting the need is as follows: HOB. rumors msi oes oS nm tod Sp RE 3 rm $2, 242, 270 TOTO im citi sin io of i Te ee 2, 489, 395 TOT, oes isons mes i et no is Se om se ep en 2, 720, 500 1972 _.. am oi A Ep te So ee ee 2, 952, 460 TTOEAL cee eee em em mm 10, 404, 625 The provisions of S. 3095 which permit, with the permission of the Secretary, the transfer of up to 20 per cent of the money from the scholarship fund to the loan fund and vice versa is a very desirable feature. Too, the change in the 92-079—68——17 250 definition of those eligible for scholarships is most helpful. While only about 10: per cent of the deans of pharmacy indicated some change in the basic law was considered desirable, the most frequent comment was in regard to the limitation place on the use of the funds because of the current wording ; in fact, two schools failed to make any scholarship grants because of the university's interpretation of ‘“—students of low income families who without such assistance would be unable to pursue the course of study—.” Institutional Grants and Special Project Grants. As noted earlier in this state- ment, the American Association of Colleges of Pharmacy requests that schools of pharmacy be included among the health schools eligible for institutional grants. At the present time our schools have no broad Federal financial assistance program available. Our schools are eligible for support through the general re- search support program administered by the National Institutes of Health, but the fact is that, while schools of medicine and dentistry automatically receive the basic grant of $25,000 annually plus additional funds calculated on research expenditures, schools of pharmacy are required to have grants totaling $100,000 during one year from the Public Health Service in order to be eligible for the basic grant of $25,000. About seven of our 74 schools have qualified for the gen- eral research support grants at one time or another, but only four or five have qualified in any one year. One of our needs now is for grants which can be used by the schools to strengthen their total programs, the undergraduate as well as the advanced pro- grams. As in other health profession schools, a graduate program in the pharma- ceutical sciences is essential in obtaining and retaining staff, in strengthening the undergraduate program, and in contributing new knowledge in our special area of the health sciences. In a report made in January, 1968, the American Council on Pharamecutical Education, the accrediting body for schools of pharmacy, made the following statement : “While the Council is under . . . rather diffuse pressures shared by others in the accrediting field, it is also under the more immediate pressures of the crisis in higher education as it affects pharmaceutical education. No one can read the newspapers today without being aware of the seriousness of this crisis which is largely a money crisis caused by inadequate funding on the one hand and inflationary pressures on the other. “These are difficult problems to understand in pharmaceutical education for there are surface manifestations that all is well. Direct pharamcy budgets are up some 16 per cent this year, for example, new buildings for pharmacy were erected during the year and others are under constructon (since World War II, 27 new free-standing buildings and 20 shared buildings have been erected for pharmacy), the size of the full-time faculty has inched up to a new record number, the faculty published several hundred research papers and books and were granted 16 U.S. patents during the past acadmeic year. But underneath this rosy facade, there are several evidences of problems growing more acute. “Private institutions have raised tuition nearly to the limit of the market place and several have had to be taken over by the state. State legislatures are hard pressed for sources of support almost universally and some states are ex- tremely malnourished. While the past two-year percentage gain in legislative support, for higher education in the nation is 44 per cent, one state with a college: of pharmacy showed only a 6.5 per cent gain and another only 12 per cent. While the national 8-year gain in legislative support for 1968 over 1960 was 214 per cent, one state gained only 73.5 per cent. The recent direct pharmacy college budget increases have gone almost entirely into salaries. This means that some faculties do not have adequate supplies, equipment, libraries and travel funds with which to work effectively. While industrial support for research appears to have increased last year, Federal support for research was diminished by nearly a million dollars. The American Association of Colleges of Pharmacy most recent survey shows that the number of unfilled faculty positions in pharmacy has: increased since 1963 from 81 to 124. Seven colleges of pharmacy are looking for new deans currently and there will be other additional retirements next year without doubt. The revolution in the health professions precipitated by medicare calls for a fresh approach to curriculum planning that has now begun but still has a long way to travel. In addition I wish to note that only recently (January 1968) the American Association of State Colleges and Universities and the National Association of 251 State Universities and Land-Grant Colleges in a joint statement commented on education in health-related fields stating in part: “We urge corrective legislation to end this discrimination to major health-related fields, especially as concerns basic and special improvement grants for support of the instructional function at schools of pharmacy and veterinary science.” The American Association of Colleges of Pharmacy is in the process of study- ing program costs in schools of pharmacy. This is one part of a project designed to further delineate the needs of our schools and is considered as an essential first step in strengthening our programs in pharmacy. To date figures from 18 schools are available, 14 state schools and four non-state schools. The study covers the academic year 1965-1966. The average total expenditure for all schools was $420,657 and the range was from $166,521 to $874,971. Sixteen of the 18 schools operated at a loss, the aver- age was $292,351, and the range was $63,178 to $688,860. The average cost of the undergraduate program per undergraduate student was $1,253 with a range of $631 which seems very low to $2,294. The average cost per graduate student (13 colleges reporting) was $2,870 with the range from $1,158 to $6,958. Lastly, the cost per undergraduate student en the basis of total expenditures of the 18 schools was $1,970. On the basis of the formula given in S. 3095, it is not possible to determine the funds needed for schools of pharmacy for institutional grants. However, using the formula for the current basic improvement grants provisions and the esti- mated enrollments given in Table D, the need would be $9.9 million in FY 1970. Based on the average estimated enrollment for FY 1970-1973, the need would be about $10.7 million per year for the four-year period or about $146,000 per school per year. As you are well aware, under 8S. 3095, schools of pharmacy would not be eligible for participation until FY 1970. Thus, our request for inclusion may be viewed as a request for “legislation for the future ;” is would not affect the 1969 hudget. We ask your serious consideration of our needs. But please be assured that we in pharmacy are mindful of the many demands of the current period and that priorities must be given consideration. However, we are hopeful that the urgen- cies now with us will have lessened by FY 1970. Certainly, we would be remiss if we failed to acknowledge with appreciation the inclusion of our schools in the special project grants provisions of the bill. These will be helpful in view of the several purposes for which they can be used but, as stated earlier, our schools have no source of broad Federal financial assistance such as the institutional grants with which to meet the exigencies which arise and which could not be met immediately by a project grant, TABLE A.—UNDERGRADUATE ENROLLMENT IN CONTINENTAL U.S. SCHOOLS OF PHARMACY, 1964-67 Year Last year 2d from 3d from Total last year last year 1964-65 8,957 3,977 4,427 11,961 1965-66. 3,770 3,990 4,583 12,343 1966-67... 3,871 4,024 5 1713 13,068 1967-68____ 4,085 4,476 5, 561 14,122 Table B.—Graduates From Undergraduate Curriculums of Continental U.S. Schools of Pharmacy, 1958-67 Year: Graduates | Year—Continued Graduates BOTS. crmmmmmdrrm— 3, 683 4,163 1959 __ 3, 686 12 194 1960 __ 3,497 3, 360 196] cee 3, 438 3, 659 1962. imma 3, 699 3, 744 1 The small number of graduates in 1964 was the result of the transition from the four- to the five-year program in 1960 by those schools not already on the longer program. 252 TABLE C.—AVERAGE ANNUAL NUMBER OF PHARMACISTS, AND REQUIREMENTS FOR REPLACEMENTS, NEW EN- TRANTS, AND TOTAL NEED FOR PHARMACISTS IN THE UNITED STATES FOR 5-YEAR PERIODS, 1965-80 ! Average annual Requirements Period number of pharmacists 2 Replacements? New entrants Total AIBBETY.. ensigns mains SiH ES GE SG 120, 000 4,200 1,700 5,900 1970-75.. -..- 128,700 4,500 1, 800 6,300 1975780... cc cncmnsn smn EE RE SR SERS 138,700 4,800 2,600 7,400 1 Puerto Rico is not included. 2 Based on Bureau of Census population projection of February 1967, series B, on the population increase as being linear, and on 1965 pharmacist-to-population ratio of 61.2:100,000. 3 Calculated at 3.5 percent of number of pharmacists. TABLE D.—ENROLLMENT BY CLASSES IN SCHOOLS OF PHARMACY FOR 1967-68 AND ESTIMATED ENROLLMENTS AND NUMBER OF GRADUATES FOR YEARS 1968-69 TO 1975-76 Estimated total Estimated Year 3d last year! 2d last year? Last year 3 enrollment ¢ number of graduates 5, 561 , 476 4,085 14,122 3,936 , 900 4, 960 , 337 15,197 , 168 6, 260 5,263 4, 806 16, 329 4,619 6, 642 5,584 5,100 17,326 4,901 7,000 5,925 5 411 18,336 5,200 7,080 6, 244 5,741 19, 065 7,160 6,315 6, 050 19, 525 5,814 7,240 6, 387 6,119 19, 746 5, 880 7,320 6, 458 6,189 19, 967 5,984 1 Enrollment increase based on 6.1 percent, the average increase for years 1963-67. 2 Enrollment decrease from preceding class based on 10.8 percent, the average decrease for years 1962-66. 3 Enrollment decrease from preceding class based on 3.1 percent, the average decrease for years 1962-65. 4 Attrition rate from last year based on 3.9 percent, the average rate for years 1962-64. § Actual enrollment. i . 8 Assumes construction will continue beyond fiscal year 1972 at same average rate and new places will be available at same average rate per year as for the period fiscal years 1964-69 (483 places +6 years=80 places per year). Mr. Briven. On title IV, I failed to include a statement there, but as was discussed yesterday, the proposed appropriation of $8 million, I think $8,400,000-plus of funds held over from last year, for a total of approximately $20 million, seems highly inadequate in the face of a backlog of at least twice that size. We have been fortunate in our schools being included, but a survey made, I think in 1964, with 59 of our schools reporting, shows that for the 10-year period ending June 1974, funds in excess of $20 million, based on total cost of construction, would be necessary for new research facilities. The Cramrman. You will need that much ? Mr. Briven. That is what I expect would be needed for the decade from 1964 through 1974. Mr. Chairman, I appreciate the privilege of appearing before you again. I have enjoyed this through the years. The Cuamman. We are always happy to have you, sir. You always bring us some very helpful information. Dr. Webster, is there anything you want to add ? Dr. Weester. Mr. Chairman, my name is George I. Webster, and 1 am dean of the College of Pharmacy of the University of Illinois in Chicago and president of the American Association of Colleges of Pharmacy. I appear on behalf of my colleagues in pharmaceutical 253 education to express our appreciation for the inclusion of colleges of pharmacy in section 772 of S. 3095 and to describe some of the trends in pharmaceutical education which could benefits the whole program, on the delivery of health care, if our colleges were to be included in section 771. Many conferences over the last 2 to 3 years have emphasized the shortage of health personnel. Physicians and nurses have pointed to the need for others to do some of the tasks which they have tradition- ally done. There is need for someone to counsel patients on the use of drugs, both the use of prescribed drugs or over-the-counter drugs for which no prescription is necessary; someone to keep records of the patients’ use of drugs so that needless duplication or reenforcement of drugs may not take place. There is need for someone to counsel with physicians regarding the choice of dosage forms and availability of these choices among the dosage forms. These counseling functions need undergirding by some experience with patient care at first hand, to enable pharmacists to join with the health care community in furnishing comprehensive care to all. This will require affiliation of the colleges of pharmacy with hospitals offer- ing comprehensive care, with extended care facilities, with geriatric care hospitals, with community health centers, and regional medical program centers. All of these are designed to give better health care. We need, also, to add research on better ways of delivering such health care. Such education requires additional manpower and sub- stantial sums of money. In my own institution, we have made a beginning through pilot programs in orienting students toward patient care by assigning a highly qualified pharmacist to a large medical ward where he has released scarce nurse power from the necessitous pharmaceutical practice to her equally necessitous duties at the bedside. This pharmacist has also served as an adviser on medication to the house staff and as a tutorial preceptor to a selected class of senior stu- dents in our college. We wish to extend this patient-centered education to all of our students but are handicapped by the necessity to develop and fund the training of an adequate number of tutorial preceptors. In addition, the colleges of pharmacy must make it possible for the practitioner who graduated recently, or not so recently, to acquire the new attitudes and techniques, placing an increased emphasis on con- tinuing education. All of these additional requirements need funds for achievement. Hitherto, only construction grants and project grants to the National Institutes of Health for research in medicinal chemistry, in pharma- cology, and for economic problems were available. Our colleges are appreciative of these many grants and suggest that one of the import- ant objectives of the Congress; that is, to provide high-quality medica- tion to all participants in the health provisions of the Social Security Act can be brought forward with some support to colleges of phar- macy and scientists who can and desire to investigate the relative effectiveness of dosage forms prepared under different formulas by different manufactures. Some vestigations in this area of research which we call biopharmaceutics is going on, but much more could be 254 done with more funds. At present, the projects supported by the NIH do not include this type of research. Participation by colleges of pharmacy in the institutional grant sections of the amendment would enable colleges to engage in this type of research. Many of the heralded advances in our treatment of disease have resulted from the invention and development of new drugs and dosage forms. Tt would be much appreciated if the Congress would include our colleges of pharmacy in the institutional grant section of S. 3095. The Cramrman. That is the important thing, is it not? Dr. Wesster. Yes, sir. May T express for myself and on behalf of my colleagues, our thanks for being permitted to make these remarks before this distinguished Chairman, whose interest and encouragement have advanced the health care of our Nation immeasurably. The Cuamaman. We appreciate your being here and appreciate this very helpful, informative testimony which you have given us. Is there anything you would like to add, Mr. Newton ? Mr. Newton. No: I think not, Mr. Chairman. The Cramrman. Thank you for being here, gentlemen, and giving this very fine testimony. We deeply appreciate it. Now, Miss Margaret I. Moore, director of the Division of Physical Therapy at the University of North Carolina. STATEMENT OF MARGARET L. MOORE, CHAIRMAN, COMMITTEE ON FINANCIAL NEEDS FOR SCHOOLS OF PHYSICAL THERAPY, COUN- CIL OF PHYSICAL THERAPY SCHOOL DIRECTORS, INC. ; DIRECTOR, DIVISION OF PHYSICAL THERAPY; ASSOCIATE PROFESSOR OF PHYSICAL THERAPY, SCHOOL OF MEDICINE, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL, N.C. Miss Moore. Good morning, sir. The CuamMaN. Good morning, young lady. Miss Moore. You have my statement, Senator Hill, and I see no reason for reading it word for word. Therefore, I am just going to speak from some notes, which I think would be more helpful. The Cmamman. We will have your statement in the record. You just highlight it or emphasize it, as you wish. Miss Moore. The last time, I was last on this hearing. This time, I think somebody is following me. The Caamman. That is right, you have moved up today. You can blame this gentleman for that. Miss Moore. He got me here, though. We are improving. I am a physical therapy school director, but I also represent the Council of Physical Therapy School Directors, which have 51 schools currently. This is an increase since I appeared before you in 1966, and also, since 1966, our enrollment has expanded and 1s maximum for the capacity of our schools. We have some new ones and others have increased enrollment and will continue to try to do so. I thought maybe I would react to some of the comments made by the other gentlemen related to medical education, since everybody on 255 this committee has physical therapy schools in his State except the Senator from Rhode Island. We do have the foreign training situation in our own field as we do in all fields. Under the new Immigration Act, more and more are coming, People are recruiting from abroad because they simply cannot get enough physical therapists from this country. This 1s tragic, when I had an admissions committee on Tuesday and I had to turn down twice as many as I could accept. The CramyMan. Did they not meet your requirements? Miss Moore. Yes; they met my requirements, but I did not have chairs to put them in. They are qualified ; they had great motivation; they were eager. Every school im the Southeast is filled, and most every school in the United States is filled. You say we need 8,000 a year; we are graduating this year a little over a thousand. We had about 1,100 graduates last year. It will climb this year, but we are a long way from the 8,000 we need, and we are a long way from the numbers of qualified, motivated, eager men and women who want to come into this program. Certainly, our demands are no less than they were and, in fact, increased. It is a tragedy and almost a national disgrace, the lack of physical therapists to help the number of mentally retarded that we have. We have not begun to scratch the surface of home care, extended care facilities, and the like. We recognize that under the new proposals, very little has been recommended to be changed now. We can appreciate some of this, but reluctantly, from our understanding. We think there are inadequacies under the current law and we would like to see some changes made in the way the law is being administered, as well as the amendments which we would like to see. If the changes are as we interpret them, it does mean that our non- academic certificate programs, which take the post-bachelor of arts students, will be included—This means the very important schools like Mayo Clinic and the Children’s Hospital in Los Angeles that have not been approved and funded under this. We wonder about the clause on evaluation and the funds appro- priated. What is the real intent and purpose of it, and we wonder if 1t is not best done by outside professional groups, rather than the Government. In area of construction, it has been identified time and again that this is a major need—space. It is a primary one. All school directors have identified it as a primary need for schools. We again understand the Federal budget situation and the tightness of funds, but it is tragic that this is a first and primary need, and yet this is the area where absolutely no moneys are going. The Cramrman. None is going there now? Miss Moore. No, sir. It was a small allocation this year, and I do not know how they distributed, but the first year it was completely eliminated and I do not know if any is recommended in the next budget. This meant no expansion for a lot of us, including my school and vours in Alabama. It means new schools are being developed in very fragmentary situations, with the dilution of faculty, with the dilution 256 of programs, so that good schools cannot expand and a lot of good new ones are having a hard time. In relation to the Higher Education Act, I believe that those funds are categorical and The CHAIRMAN. They are. Miss Moore. We tried this several years ago as far as physical therapy is concerned and were turned down as being entirely out of the higher education facilities program. The CuamrMAN. You could not get in? Miss Moore. We could hardly get the door open. This includes fellowships and scholarships. You well know that when buildings are built on campus, it is the guy who has the money to match who gets in on them, and those of us who do not have any money The CHAIRMAN. You do not get any. Miss Moore. We do not get in. We are in a trailer right now, courtesy of the Children’s Bureau, for part of our program. There are two things in the current act which we think need calling attention of the Congress to, and perhaps those who will be responsible for rewriting it. We are keenly aware of your leaving and your leader- ship. We do not know who will be sitting in your chair next year, but we are also aware that whatever is presented to the next Congress will probably be written between the time you adjourn and the new Con- gress comes. So perhaps these remarks are appropriate at this time. ‘We would hope some of them would be acted on by this Congress, but if they are not, we hope they are favorably received by the next Congress. The Cuamrman. They are most appropriate, I would say. Miss Moore. Of course, the money is too little and too thin. The law just grew like Topsy and by the time all the junior colleges were in, we had a tremendous number of people, with 19 disciplines funded. We got 41 percent of entitlement, which was gratefully received, but as far as we are concerned, I cannot do very much with $6,200. We had a real ball with that. The more people who are in this act, the less coverage there is unless the funding can be increased and, again, how likely is that? We are concerned with money that went to what we call feeder pro- grams. These are colleges and universities that have pre-physical- therapy curriculums in them and from which the students then transfer or apply to schools of physical therapy for admission. Nine of the schools received money last year and we feel that money would have gone more appropriately to the fully accredited programs. If every feeder program receives money based on a head count of students in this country, you will have 1,200 schools asking for money for undergraduate students, particularly at the sophomore and junior level. It will be further diluted or else the appropriation requests will be in the millions, higher than you can even imagine at the moment. We think the demands of the allied health programs are so diverse that each one needs looking at differently. Maybe this is appropriate to medical technology, but it does not seem appropriate to us in physical therapy. The use and distribution of funds that were awarded are also a little appalling to us. One-third of the campuses that received money 257 in the interest of physical therapy either made that money inaccessible to the physical therapy educational director or very hard to get to. In some situations, the money was used for items that are not even included in the law—completely outside the law. In other institutions the money was used by the so-called coordinator or dean for projects which could only be remotely associated. These were people who had struggled to increase enrollment, they earned a per-capita or a per-unit cost because they were there, and then they did not have access to the money that was there. This is pretty rough. We do not believe that was the intention of this com- mittee and the Congress in allocating those funds. We think the amendments are needed. The CrHaRMAN. You want to make that clearer in this act? Miss Moore. Well, if it cannot be controlled by guidelines, then I would hope that Congress could tighten up the law. If the distribution of money to the feeder programs cannot be made better by guidelines, I would hope Congress would tighten up the law in that regard, also. I speak for school directors, who have taken a very firm stand on both of those topics. One of the funny things about the law is that you can get funding for basic support or basic programs, but those who want to develop graduate programs cannot get any assistance for this, although the law does give you traineeship money for these people who want to go to graduate school. Many of us want and need to develop masters programs in order to get the faculty for the new programs and for the programs which are developing in the community colleges. We feel that newly organizing schools that have some reasonable assurance of success or accreditation should receive some funds. LSU is one. It is in the organizational stage. The Cramrman. It is just beginning. Miss Moore. It is a fine university, has reasonable assurance of suc- cess, but they are not eligible for any support. Concerning the loans with cancellation clauses, it is a great omission for all of the allied health people. It makes our recruiting a little lopsided when special education, physical education, nursing, medicine, dentistry, all have loans with cancellation clauses and we have nothing here. Our students can borrow from the national defense educational program, but they have to pay every nickel back, whereas if they chose another allied health program or one remotely connected with mental retardation, they can be forgiven portions of it. The scholarship funds under Vocational Rehabilitation Administra- tion of Social Rehabilitation Services are inadequate. They just do not go around nearly as far as they should, and we would hope the same scholarship opportunities would be built into this law that are cur- rently in it for nursing and other areas. One of the needs that we see that we also know nursing enjoys is part-time support for graduate study. You either have to go full time or take the full cost of this, and it is discouraging for people working off deficiencies in order to enroll full time. We hope there would be some consideration of that. We do feel that the areas of the current law either should be tight- ened by administrative guidelines or, if they are not, it should be looked at for other changes in the law. 258 We have real concern and I say this most advisedly and I hope well— we have too much concern, perhaps, but real concern that there will be to much authority and power put in the hands of one or two people for the expenditure of funds coming to one campus or to one institu- tion. If our experience with the distribution of funds under the allied health law is a good example, we wonder how the distribution of funds is going to come under a broader law. We sincerely believe that the professions should have access to their own funds and they should grow and develop as they have the talent and the ability and the public need indicates. It is one thing to coordi- nate programs on a university campus; it is another to control them. Certainly, the funding is a way of doing either one or both. We could hope that some of these will receive the attention of this Congress. We certainly hope that your recommendations will be con- sidered by your colleagues and by others in Congress. I would be glad to answer any questions that I could. (The prepared statement of Miss Moore follows :) PREPARED STATEMENT OF MARGARET L. MOORE, CHAIRMAN OF THE COMMITTEE ON FINANCIAL NEEDS FOR SCHOOLS OF PHYSICAL THERAPY OF THE COUNCIL OF PHYS- ICAL THERAPY SCHOOL DIRECTORS, INC., AND DIRECTOR OF THE DIVISION OF PHYSICAL THERAPY, AND ASSOCIATE PROFESSOR OF PHYSICAL THERAPY, SCHOOL oF MEDICINE, UNIVERSITY OF NORTH CAROLINA, CmareL Hiun, N.C. Thank you again for the opportunity of representing the educational adminis- trators in the schools of physical therapy in this country. Since I appeared last in October of 66, additional schools have been activated, enrollment in the schools has increased in volume, and hopefully, the schools have maintained or im- proved in quality. The original intent of the Allied Health Professions Person- nel Training Act of 1966, which became Public Law 87-751, was for the purpose of increasing the numbers and the quality of professional health workers, and in our instance, physical therapists, in order to meet the needs of the public for health care. In the United States there are currently forty-six (46) curriculums in physical therapy actively educating young people on the college and university campuses, and soon there will be fifty-one (51). Several others are in the planning stage. These institutions are accredited by the American Medical Association in collaboration with the American Physical Therapy Association; all but two (2) are in institutions with regional educational accreditation; these are in excel- lent hospitals with national reputations. The Council of Physical Therapy School Directors represents the educational administrators of these institutions. All are members of the American Physical Therapy Association, which is the national professional membership association of the qualified physical therapists in this country. As I comment today on the Health Manpower Act of 1968, Senate Bill 3095, and especially Title III, Section 301, dealing with allied health professions, it should be reiterated that the lack of physical therapists in centers for the men- tally retarded and hospitals for the mentally ill borders on a national disgrace. Hospitals both large and small in rural areas and in metropolitan areas, con- tinue to clamor for personnel which is simply unavailable. Public health pro- grams, home care programs, extended care facilities, are begging for physical therapists. Rehabilitation centers and children's centers for birth defects, de- velopmental evaluation problems, orthopedically and the neurologically handi- capped, are all continuing to seek staff which is in acute short supply. As we read the proposed amendments to the Allied Health Professions Act included in the Health Manpower Act of 1968, few changes have been recom- mended. Since this section of the law has been in effect only one and a half years, perhaps it is the wish of Congress to wait another year before making major adjustments in the law. If so, that can be understood with some reluct- ance. Some changes have been recommended however, and deserve analysis. If it is the intent of the authors of this bill to include certificate programs for post- baccalaureate degree students enrolled in several hospital-based program, then 259 several of our physical therapy educational administrators will be pleased, since they have been excluded under the current law. If the clause on funds for eval- uation purposes means that the government will be evaluating curriculums instead of evaluation being carried on by professional agencies and educational organizations outside of government, then a question should be asked as to “the proper role of government” in this situation. THE CURRENT LAW Comment should be made on the current law as it has been functioning. First and foremost, the construction money is still so inadequate that the well docu- mented first and primary need of the schools is not being touched. This year we have the largest enrollment in the history of our schools and there is absolutely no room to expand in most of them, unless funds are available for renovation, remodeling, or construction of new facilities. To continue to encourage new schools to be organized will drain the precious supply of quality faculty and will be more costly than if funds would be devoted to expansion of existing qual- ity educational programs in our universities. It is a well-known fact, that in the everyday on-campus competition for space, the discipline which has the money for space is the one that gets it, and in most instances, this is medicine, dentistry, nursing, and other disciplines where more liberal construction money has been made available. Those of us without construction funds are simply left out when new buildings are constructed and space is allocated for other purposes. We do have growth in our schools, but it is slow and tortuous in relation to the public need for increased manpower. This growth need deserves Congress’ attention even in face of the fiscal problems which this government faces today. Second, the basic improvement grants last year gave our schools forty-one (41) per cent of their entitlement, which was helpful and gratefully appreciated by most of us, but this is a very low per capita allocation. Funds are spread too thin to really bring an impact on increasing enrollment and improving the quality of the educational opportunities available. It could be stated that funds are simply insufficient to adequately cover the nineteen (19) disciplines currently approved for funding under the law and covered in the guidelines. In regard to the thin distribution of funds, two main issues should be recog- nized. First, monies were awarded to some finstitutions last year which do not have curriculums that are accredited by professional groups although they are in universities and colleges with regional educational accreditation. We firmly believe accreditation by both groups is necessary. These are the so-called “feeder programs” where pre-physical therapy curriculums exist and students then trans- fer to accredited schools of physical therapy for the final portion of their profes- sional education. Nine (9) such colleges and universities received funds last year for students enrolled in programs of this type. If all colleges and univer- sities in this country that had pre-physical therapy curriculums applied for funding, over twelve hundred (1200) additional institutions would soon be clam- oring for the few dollars that are available for funding. These ‘feeder pro- grams” in most instances are not institutional components of schools of physical therapy and are not officially, by contract or otherwise, affiliated with a school of physical therapy. We realize that a different situation may exist in Medical Technology, but again the disciplines are different and their academic designs are different and should be viewed that way. It is the view of the members of the Council that to continue to support the “feeder program” is poor utilization of available funds and is not only questionable from an academic point of view, but also questionable as to the use of public money for these purposes. The enroll- ment in the “feeder programs” can be very high since screening of candidates for admission into schools of physical therapy has not yet taken place, and a per capita allocation to all of these schools would soon mount into the millions. The second area of concern is the use to which funds have been made once they have been awarded to a university. It is a sad fact that one-third (14) of the educational administrators in schools of physical therapy who had earned grant awards had limited or no access to the money once it came to the univer- sity. We sincerely believe that the current law is being too liberally interpreted and that 'the intent of Congress is being violated by this practice. This very loose utilization of money, which has been earned by physical therapy educa- tional program, to strengthen and improve the professional and technical com- ponents of the educational programs to which the grant is made, is being violated in too many instances and should be the concern of members of this committee. 260 (This is not restricted to Physical Therapy but involves awards to other allied health disciplines.) Funds have been utilized for personnel on programs only remotely concerned with the education of physical therapists and other groups earning funds for the university. In several instances funds have been utilized for programs absolutely omitted and prohibited under terms of the law, and for disciplines not identified in the guidelines of the nineteen (19) professional programs. AMENDMENT NEEDED The Council of Physical Therapy School Directors is still disappointed and continues to make a plea that other provisions need to be included in the allied health portion of any Health Manpower Act. (1) Project grant authority is needed to develop graduate degree offerings on campuses where basic educational programs at the baccalaureate level already exist. Such provision is now prohibited under the law, although some graduate traineeship money is available for graduate study. There are no funds available for development of the graduate curriculum into which these graduate trainees could enroll. (2) Project grant authority is needed for the support of newly forming schools in universities where there is a reasonable assurance that an accredited and qual- ity type curriculum will materialize. Under the terms of the current law a school has to be in operation with a stated number of students before it is eligible for support, and many new curriculums are having difliculty getting started without additional support. (3) We sincerely regret that no undergraduate loans with cancellation clauses are included for any of the allied health professions, in a manner comparable to that currently enjoyed by nursing, recreation, physical education, social work, special education, medicine, dentistry, and a host of others. This puts us at a distinct disadvantage in recruitment and puts an extra burden and hardship on the professional student in physical therapy, if not in other allied health professions. (4) No scholarship funds are available other than the few coming from Voca- tional Rehabilitation Administration of Social Rehabilitation Services. This is in sharp contrast to the scholarships which are available and are recommended to be increased for medicine, dentistry, nursing, veterinary medicine, and others. This also puts us at a distinet disadvantage in recruitment. (5) There is no support for part-time study for graduate education through which current faculty and supervisors could upgrade their knowledge and skills for teaching, supervision, and administration which is so badly needed not only for professional personnel, but for the teaching and supervision of the ever increasing number of supportive personnel in physical therapy and in the other allied health professions. (6) If the current law is too weak to control awards to non-accredited feeder curriculums, it should be strengthened. If the current law is too weak to control the distribution of funds once awarded to an institution, it should be strength- ened. The intent of Congress is being circumvented and funds are diluted and enrollment is being affected in a negative way by the use of funds other than what was originally intnded by Congress. Members of the Council question too much authority being invested in a single pair of hands on a campus or in a university if institutional awards are being considered. Programs should have their entitlement and be free to develop and grow as determined by the professions themselves and by demands of the public, and not by edicts passed along by those in other professions. Each profession has so much work which needs to be done in the public interest that it is improper, foolish, and shortsighted to put more and more authority, power and money in the hands of one discipline. Coordination among groups is one thing; control by one over several is entirely different, unwise and dangerous. The original intent of the law was good, but revision is needed if enrollment is to increase in proportion to need, and if faculty and supervisors as well as staff- level physical therapists are to be available to serve the mentally retarded, the mentally ill, the stroke patient, the victim of an automobile accident, or the home-bound elderly with arthritis. We appreciate the dilemma which faces Con- gress this year on expenditures, but we seriously request your consideration in further amendments to this law and in strengthening the current law. 261 The Cramrymax. There is a very real need for many of these changes; is that not true? ; Miss Moore. I think so, sir. We are grateful for the intent of Con- gress, but we believe that the law as it is being administered does not satisfy the intent that you wrote. We do believe there will have to be changes in the law in order to carry out the intent which you, in all sincerity, wanted carried out. That is not only an increase in numbers, it is an increase in quality. One without the other would be suicide. The Craatrymax. We certainly want to thank you. Miss Moore. Well, we appreciate your interest. The Crairman. Off the record. (Whereupon, there was a short discussion off the record.) The Cratrmax. Thank you very much, Miss Moore. The American Occupational Therapy Association, Miss Ruth Brun- yate, chairman of the legislative committee. STATEMENT OF MISS RUTH BRUNYATE, CHAIRMAN, LEGISLATIVE COMMITTEE, AND PAST PRESIDENT, AMERICAN OCCUPATIONAL THERAPY ASSOCIATION Miss Bruxvyare. Thank you, Mr. Chairman, for the privilege of appearing before you today to present testimony on S. 3095, the Health Manpower Act of 1968. I am Ruth Brunyate, chairman of the legislative committee and immediate past president, American Occupational Therapy Associa- tion, and I am testifying today as the representative of that associa- tion. I also am chief of the division of occupational therapy in the Maryland State Department of Health. The association endorses the aims and most of the provisions of S. 3095. We are pleased that the administration has taken action this year to propose such legislation, and we are deeply grateful to you, Senator Hill, for your prompt action in scheduling hearings and moving ahead on this important legislation. The American Occupational Therapy Association also takes this occasion to express to you personally, Senator Hill, its profound ad- miration for the distinguished career which you have achieved for goss in the whole broad field of health services for the American people. The Cuairman. Thank you very much. I appreciate that deeply. Miss BruxyaTe. We are convinced that your long list of accom- plishments will be a towering monument to your outstanding career, long after the 90th er ati entered the books of history. Mr. Chairman, we are happy to see that in considering S." 3095 the committee has an opportunity to look at this kind of grouping of health and related programs at one time. As you know so well, most of these programs were considered and enacted as separate pieces of legis- lation. However, through S. 3095, the committee now has an oppor- tunity to look at the whole health manpower situation in relation to physicians, nurses, therapists, and a variety of related health person- nel—and do it in relation to the construction, teaching, and traineeship programs that we count on so heavily to produce more and better trained health personnel. 262 The American Occupational Therapy Association is a national pro- fessional organization of about 9,500 members, who work daily with physicians, nurses, other therapists, and health professionals in caring for the sick, the injured, and the disabled. They provide treatment pro- cedures that range from preventive, to curative, to restorative. They work in hospitals, and out of hospitals, having about 4,000 in hospitals at the moment and just under 6,000 in out-of-hospital services. ~ We feel you should know there have been some changes in our profes- sion in recent years. They are now calling on us to serve in in-hospital settings, out-of-hospital settings, in programs like Headstart, and this sort of thing, which makes a shift in delivery and demands on our manpower. Occupational therapists work in rehabilitation centers, clinics, and other settings where the skills of the professional therapist can minimize suffering, restore function, and help the patient adjust to new and constructive patterns of living. As one of the oldest of the allied health groups—we are Now com- pleting the observance of our 50th anniversary—we find that pro- fessional practice is undergoing some very substantial changes. You will recall, Mr. Chairman, that the Commission on Health Manpower urged the professional groups to take the initiative in finding new ways to meet manpower needs and to do this in a wa which would improve patient care. In occupational therapy we too this task seriously. For one thing, we were one of the first, and perhaps we are the first, group to develop and carry out programs to increase the supply and use of subprofessional therapists, and in so doing, have brought retired therapists back to practice even in part-time positions in the supervision of the subprofessionals. But, again, as we bring people back, as we produce the technical level of persons in order to assure quality of therapy, we must produce the professional for supervision. The Crramraan. Surely ; you have to have them. Miss Brunyare. We have to. We have been equally concerned with finding improved ways of delivering services. One result is that occupational therapists are in- creasingly used in home care programs, nursing home programs, and other arrangements outside the usual institutional pattern of care. This has advantages and disadvantages: it usually means that patients are getting care who never received it before, particularly among elderly patients. It means, too, that the cost of care ordinarily is less than in a typical hospital situation. But I think we should also note that this tends to increase the health manpower problem in occupational therapy and no doubt in other groups. These much-needed, extra-hospital care programs, despite their obvious desirability, are not the most efficient use of professional manpower. Mr. Chairman, let me ask your attention now to title IIT of the bill, which proposes to extend the present authorities for assistance in the allied health professions. We are pleased that the administration and the Congress propose to act this year, rather than wait until next year when there authorities are presently scheduled to expire on June 30, 1969. However, we are keenly disappointed that the bill proposes to extend these authorizations for only 1 additional year. 263 Perhaps there are reasons why this extremely short extension is in order. If there are such reasons, they have not been explained to us. Elsewhere in the bill, expiring authorities are being extended for much longer periods of time. In Tact, in the same title ITI, the public health training provisions would be extended for an additional 4 vears beyond 1969. Thus, we find it quite disappointing to face the prospect that a year or two from now, all of us who are concerned with teaching programs designed to encourage and assist young people to make careers in these important fields will be back where we are today. Wo will face the same worrisome question that inhibits greater ex- pansion today—mnamely : does the Federal Government intend to enter mto a program of financial assistance for a reasonable period of time? The universities and teaching institutions on whom we must all rely are equally in the dark regarding the Federal Government’s inten- tions. Many of them feel, as we do, that the authorizations in law should extend at least as far ahead as the duration of the professional train- ing required. So that our professions, our faculties, our students, will know what their commitments are. The CrarMaN. How long a period would you suggest ? Miss Brunvyare. For our full professional span of education, which would be roughly 5 years. We wish to suggest that the Committee consider extending the period of authorizations at least through the fiscal year 1972. Along with this, we hope the Committee will authorize the appropriations of such sums as may be necessary for the fiscal years 1970 through 1972. On the subject of appropriations, IT would like to record the associa- tion's feeling that the funding of these programs in support of train- ing more personnel in the allied health fields needs to be sharply in- creased. The Division of Allied Health Manpower in the Public Health Service has made a good beginning in a short period of time with limited resources. They should be given the funds now to begin mount- ing programs which are at least reasonably close to what is needed to cope with the shortages of personnel. I am aware, Senator Hill, of your personal efforts in this direction and we are all quite grateful for them. Again, Mr. Chairman, let me express the pleasure of the American Occupational Therapy Association in being permitted to appear before vou and your Committee today. I assure you that you will have our cooperation on this bill and on all other constructive steps which will lead to improved health services for the American people. The Crairaran. We want to thank you and express our appreciation to you for your appearance here today. And for the very helpful, in- formative testimony which you have given us. Miss Brunvare. We thank you, and we would say that our only additional comment would be in support of much of the content of the physical theraphy report. I did not repeat in my report our common concern with theirs, particulary in part-time scholarships in our facilities. The CrarrmaN. Thank you very much. I am submitting for the record a statement prepared by Mr. Nicholas Pohlit, who serves as managing editor of the Journal of Environmen- 264 tal Health. He is also the executive director of the National Associa- tion of Samitarians. (The prepared statement referred to, and all prepared statements and other pertinent material subsequently supplied for the record follows) PREPARED STATEMENT OF NICHOLAS POHLIT, EXECUTIVE DIRECTOR, NATIONAL ASSO- CIATION OF SANITARIANS, DENVER, COLO. Mr. Chairman and members of the Committee, I want to thank you for the opportunity to review certain critical aspects of S. 3095, the Health Manpower Act of 1968. As you know, this is a culmination of several Congressional efforts to improve the future course of public health training and the health manpower situation of the nation. But let me say, that without certain revisions this Bill will do neither of these. When the Allied Health Professions Training Act (H.R. 3196) was first in- troduced in the House, the sanitarian, or environmental health category was excluded from the Bill, and it was only after much testimony and the realiza- tion by the Senate that 29,000 MORE sanitarians would be needed by 1970 that the Senate amended the bill to include the sanitarian and schools with environ- mental health curricula were included among those eligible to receive aid. Since the amendment, the Public Health Service, in implementing the Bill, has again and again ignored the sanitarian in training opportunities. In S. 3095, the Health Manpower Act of 1968, still no clear provision is made for the sanitarian and, as past experience has shown, without this provision clearly stated IN THE BILL, the sanitarian and environmental health person- nel will again be ignored when the Bill is further implemented. This is not just a problem for the sanitarian, either; the total environmental health field is suffering from lack of training opportunities. For one thing, en- vironmental health lacks the leadership it needs; its leadership has been scat- tered out to various federal agencies such as the Food and Drug Administration, Housing and Urban Development, the Agriculture Department and the Depart- ment of Interior. The federal government, in other words, has been taking the top environmental health persons, but has seen no need to replenish our field. It has seemed to forget that training is THE KEY to successful environmental health programs. When we realize how much money has already been spent by the federal government for water, air pollution, and solid waste, for example, we must wonder why none of this money was available for training of environ- mentalists, for without this training and personnel, our programs will get nowhere, The National Association of Sanitarians has taken what leadership role it could afford to take up to now. It has helped develop curricula in environmental health for thirty-five undergraduate schools and we have been finalizing plans for accreditation for such curricula. But now we are at a standstill, simply because we have no more money to do what the federal government should be doing in the first place—aiding students and schools in environmental health with undergraduate programs. It is not enough, either, for the nation to continue to recruit needed environmental health personnel from colleges with majors in special courses such as microbiology, chemistry, and botany. This is not the answer; we must have undergraduate schools in environmental health with environmental health curricula and requiring courses in all the environmental health subjects, not just a few isolated subjects. If we are to have these schools of undergraduate training in environmental health, we need the money for adequate facilities, for faculty, for recruiting students. In recruitment alone we need brochures, filmstrips and other ma- terials for high school students and junior college students. Most of them do not even know about the opportunities in environmental health. The underprivileged is another group unaware of the opportunities in environ- mental health. Our Association has worked closely with Dr. Paul Cornely of Howard University in trying to educate Negroes, particularly in environmental health, but that university is not getting the federal support it needs and, as Dr. Cornely and our Association know, recent legislation in environmental health will fail without the Negro and other underprivileged persons taking an active part in those programs. The Model Cities Act is a good example of this. 265 If we do not educate the underprivileged for important leadership roles in this Act, we will defeat the entire purpose of the Act. It is absolutely necessary that this Committee require those implementing this Bill to understand the importance of the environmentalist and that financial assistance be given ito undergraduate schools of environmental health and their students. The sanitarians make up the largest health profession next to the nursing profession. It is well understood that the key to the success of all health departments IS the environmental health person, after all, ninety per cent (90%) of the nation’s local health departments environmental health sections are manned by sanitarians or environmental health personnel. It is through the cooperation of the nursing profession and the sanitarians that local health departments survive and are successful because they are the ones who find the community problems, who inspect, who advise, who educate the public in the need for cooperation in health matters. Environmental health personnel are involved in the TOTAL health of man, not just the medical, nursing or engineering aspect, but ALL of these and all the other health phases in the environment. They protect man’s health through control of such environmental factors as food, milk, air, water, radiation, metro- politan planning, accident prevention, pesticides control, hospital sanitation, com- municable disease control, insect and rodent control, safe housing, industrial hy- giene, sewage and waste disposal, ete. and in all of these it is essential that the environmentalist has the necessary educational background to recognize the multiplicity of the problem ; that is, the engineering problems involved in sewage problems which also bring in problems of bacteriology, epidemiology, metropolitan planning, urban renewal, chemistry, entomology, microbiology, and administration. More than any other professional, the environmentalist’s back ground must be varied and complete—it must take in ALL phases of environ- mental health. The Third National Conference on Public Health Training recognized this. The Senate recognized it when it amended the first Bill to include the sanitarians. We ask that this Committee recognize it and require those implementing the Bill to recognize it. We ask this Committee to clearly state the need in an amendment and to give the environmentalists the training they need and require. An example of the need for undergraduate training in environmental health is seen in the sanitarian’s duty in meat and poultry inspection. In this work he sees the need for the same close and continual check in meat inspection that is required in other food areas. He sees the interrelated problems of waste disposal, water pollution, air-borne and food-borne bacteria and the possibilities of con- tamination at ANY point from pre-processing, processing, storage, distribution, labeling, preparation for sale and in the store. This is just one example of how the public health inspector’s, the environmentalist’s, educational background must be complete and varied—at the undergraduate level. Instead of helping the environmentalists, the federal government is making them extinct. The 14,000 sanitarians in the nation today are not newcomers. Many have been in the field for years and the field is not being replenished the way it should. Those implementing S3095, the Health Professions Act, are not seeing to it that the environmental health profession is being resupplied. The environ- mentalists need the opportunity for undergraduate education just as much as the other health professions, if not moreso, because those other professions, the nurses, the physicians and the dental hygienists, for example, have been looked after for years. The sanitarian has only been ignored. There is no phase of public health or environmental health where the sanitarian is not needed. Many sanitarians lead or assist in administrative positions of health departments. Many are on state boards of health and their backgrounds are well respected there. The sanitarian has always been associated with the interpretation and enforcement of city, state, federal, or other laws regarding sanitary and healthful standards. Now besides his historical inspectional duties, the sanitarian is expected to understand all the current environmental health problems, the care, use and interpretation of measuring devices and control proce- dures in these areas and even in the new area of space flight sanitation. Also, he must act as educator of the public and convince the public to do its part. You know the minimum educational requirement for a professional sanitarian is a B.S. degree, with specific training in such fields as sanitary science, dairy science, food technology, entomology, or other specialities directly concerned with man’s environment. For the requirements of his work, it is not enough for the 92-079—68——18 - 266 nation to recruit environmentalists from programs of microbiology or other spe- cial subject curricula; there must be undergraduate schools of environmental health established. Today there are not enough training opportunities for sani- tarians. Many employment opportunities, in fact, are just left open because there is not the adequately trained and educated persons to manage them. The employment opportunities for the professional sanitarian are improving all the time, especially with the latest health legislation being passed and current concern about air and water pollution, model cities, radiological health, and comprehensive health planning. Professional sanitarians are continually needed by local, county, state and municipal health departments and persons with ad- vanced degrees have excellent career opportunities with the U.S. Public Health Service and the Food and Drug Administration. The Public Health Service re- cently added the sanitarian category to its residency programs (although there are only two available now), and the Army has followed the Navy in adding the sanitarian officer category to its Military Occupational Specialty description. Sanitarians are needed in private industry, hospitals and similar institutions, food establishments, by equipment manufacturers, insect and vermin control industries, chemical specialty manufacturers, professional trade organizations, colleges and universities, in research programs, in the World Health Organization and in the Peace Corps. But all these employment opportunities require education in environmental health with courses in engineering, chemistry, bacteriology, sanitary science, epidemiology, mathematics, physics, botany, entomology, microbiology, bacte- riology, administration, and environmental science and the undergraduate edu- cational opportunities must be there. The schools must have the required facilities, faculty and students. It should be no news that the entire health outlook must take in all the health professions, and that those professions must cooperate in order to provide what Congress has declared our national purpose, “promoting and assuring the highest level of health attainable for every person, in an environment which contributes positively to individual and family living.” Surely training for such a national purpose must start with environmental health, where the total health picture can be evaluated and solutions made with the total environment in mind. If this Committee fails to include the undergraduate environmental health schools in this Bill, the entire purpose of all these Congressional efforts and our national purpose itself will have been overlooked. PREPARED STATEMENT OF MRS. ErrA B. ScHMIDT, EXECUTIVE DIRECTOR, NATIONAL FEDERATION OF LLICENSED PRACTICAL NURSES Mr. Chairman and Members of the Subcommittee on Health, my name is Etta B. Schmidt. I am Executive Director of the National Federation of Licensed Practical Nurses (NFLPN). The National Federation of Licensed Practical Nurses (NFLPN) is the na- tional association of licensed practical nurses. The association has 40 constituent state associations with individual members in each of the remaining states. Its current membership is approximately 29,000. NFLPN was organized in 1949. Its primary purpose is to foster high standards of nursing practice through sound practical nurse training programs and through upgading of the LPN practitioner to the end that the people of this country will have the best possible nursing care. By way of personal background, I am a Licensed Practical Nurse (LPN). I received my license to practice in Illinois in 1953. I obtained my Master in Educa- tion degree in 1960 from Colorado State University with a major in Administra- tion and Supervision of Vocational Education. For three years I served on the Advisory Committee for Health Occupations Education of the U.S. Office of Education. ‘We appreciate this opportunity to present our views to the Committee on the proposed amendment No. 666 to the Health Manpower Act of 1968 (S. 3095). In the course of my service with the Licensed Practical Nurse Association of Illinois (1950-60) and my responsibilities with the national group going back to 4957, T have had the opportunity to observe the rapid increase in the demand for the services of the LPN and the general acceptance of her service as an integral part of caring for the sick and disabled in this country. Also, I am 267 particularly aware of the skilled services of the Licensed Practical Nurse (LPN) which have been made possible by Federal funds authorized by the 1956 amend- ments (P.L. 84-911) to the Vocational Education Act of 1946 (George-Barden Act) and specifically extended in Sections 10 and 11 of the Vocational Education Act of 1963 (P.L. 88-210). Thus it is with enthusiasm that we endorse and support proposed Amendment No. 666 to the Health Manpower Act of 1968 (8. 3095). In particular we refer to: 1. Provision for inclusion of Licensed Practical Nurses (LPN) in the nursing student loan program (42 U.S.C. 297(a)) which will provide a visible and viable mechanism for the encouragement of upward mobility from the bedside nursing ranks of LPN’s who would aspire to further their education and become Registered Nurses. 2. The amendments dealing with “STUDY OF NURSING PROGRAMS.” In a similar vein, such a program was thoughtfully articulated in a March 31, 1967, report of the New York State Joint Legislative Committee on the Problems of Public Health and Medicare entitled “Public Health and Public Responsibility—The Task Before Us” (Legislative Document, 1967, no. 40). RECOMMENDATION No. 13 “A program to enrich the training and education of licensed practical nurses which would ultimately enable them to qualify for professional nursing licenses “This Committee will support a program to enrich the training and education of Licensed Practical Nurses that will enable them to qualify for a Professional Nursing License while actively engaged in hospital work. It is estimated by Federal sources that 80 percent of the direct nursing care to patients is now given by Licensed Practical Nurses and Nurse's Aides. Testimony at our hearing indicated that there is very little upward mobility from the ranks of the nom- professional nursing staff into the professional nursing staff. “The lack of vertical mobility discourages many girls from entering the pro- fession. Young girls may not desire to commit themselves to two or three year programs, but prefer to try one year programs leading to a license as a practical nurse, if the year of training and the clinical experience which follows could ultimately lead to promotion to a license as a registered nurse. It would seem that the formal training and the clinical experience should be credited against the training required to become a RN and the current system of requiring a LPN to start all over again in the educational process before she can become a RN is unnecessary and unsound. “Again, the Department of Education can exercise its influence in this area and develop the programs above.” A successful program for the further training of Licensed Practical Nurses to become Registered Nurses has been conducted for a number of years in New York City at the Hospital For Joint Diseases. It is a 16 month program for Licensed Practical Nurses to train to become Registered Nurses. This demon- stration project is under the direction of Justine Hannan, R.N. Thirty years ago the practical nurse was an untrained auxiliary worker. She had no legal status. Her function was debatable. Today she is recognized as a skilled practitioner and an essential component in the health services. Every state provides a legal definition in the Nurse Practice Act. In California and Texas the legal title is Licensed Vocational Nurse. In 1965 there were 338,000 licenses issued. It is estimated 250,000 are actively engaged in nursing. The LPN remains on the job longer than any other member of the nursing team. She is the Bedside Nurse of today. Her role has been defined as a nurse prepared to give direct patient care under supervision of a registered nurse, physician or dentist. The LPN is prepared to work independently in nursing situations relatively free of scientific complexities. She can assist the RN and the MD in giving bedside patient care in more complex nursing stuations. The skilled supportive service of the LPN enables the registered nurse and the physician to further extend their services in meeting the health needs of the people. The LPN is employed in every kind of health facility. Major areas of employ- ment are private and government hospitals, extended care facilities, nursing homes, doctor’s offices, public health service, the military and private duty in the home and hospital. In the past 25 years the demand for the service of the LPN 268 has far exceeded the supply in spite of the rapid growth in numbers. The hospital is the employer of the greatest number of LPN's. A 1967 report of the Bureau of Health Manpower of the United States Public Health Service states “The annual output of practical nurses should be increased from the present 25,000 to not less than 40,000.” In 1966 a health Manpower survey was conducted by the United States Public Health Service and the American Hospital Association. The Report, Manpower Resources in Hospitals— 1966, (See Table 1) indicated urgent current needs for 41,400 LPN’s in the hospitals reporting. The Report estimates a total of 245,000 LPN’s needed by 1975 in these hospitals alone. Similar needs exist in Extended Care Facilities where it is reported a shortage of 9400 LPN’s in 1966 (See Table 2). The American Medical Association’s policy making House of Delegates, at its 1967 biannual session in Atlantic City adopted a statement reaffirming its continued support of all nursing education programs. The statement is Resolved, that the American Medical Association reaffirms its support of all forms of nursing education including baccalaureate, diploma, associate, and practical nurse education programs. . . (italics added) Practical Nursing was first recognized by the Federal Government as a com- ponent of Vocational Education through the Public Health Amendments Act of 1956. The Vocational Education Act of 1963 gave additional impetus by identifying funds for practical nursing education in Sec. 11(a) of P.L. 88-210. The avail- ability of these funds was instrumental in bringing about the rapid growth and development of practical nursing programs. In 1960 the programs had increased to 693 and they graduated 16,635. (See Table 3). Today there are 1150 programs in operation graduating more than 27,000 annually. The need is still not met. The practical nursing curricula includes instruction in basic concepts in the biological and behavioral sciences and direct bedside nursing care of patients of all age groups. Every practical nursing program is approved by the State Department of Nursing and we encourage accreditation by the National League For Nursing. Every program gives basic instruction and clinical practice in at least four basic areas; medical nursing, surgical nursing, nursing of children and care of the mother and the newborn infant. Many schools are adding a fifth area; care of the emotionally disturbed patient. An increasing number of affiliations with nursing homes provides for clinical practice in the care of the geriatric patient. By 1970, it is estimated that there will be 20 million of our citizens age 65 or over. A large portion of these persons will have chronic or disabling illness requiring medical and nursing service. It is known that 909, of all patients are not acutely ill, but rather chronically ill or psychiatric patients. The practical nursing programs prepare a bedside practitioner that is particularly well quali- fied to administer nursing care to these people. These facts alone identify the real need for continuation and expansion of practical nursing training programs. As never before we need assurance that funds will be available for training of practical nurses. Therefore, we feel it is in the public interest to oppose the elimination of the practical nurse category of vocational education which is proposed by Section 215 of H.R. 15066. Practical mursing is a dignified vocation available to qualified candidates from all economic levels of our society and with a variety of academic bhack- grounds, ranging from two years of high school to college degrees. It attracts the high school drop out, the high school graduate as well as the mature person who wishes to be trained in nursing skill so greatly needed in every community. The practical nurse training programs accept both male and female students in the age range from 17 to 55 years. It is one of the few status vocations to which the culturally disadvantaged have ready access and reasonable possibility of attainment in minimum time. CONCLUSION We respectfully urge this Committee to incorporate into S. 3095 the provisions of proposed Amendment No. 666. In view of the critical shortage of nursing help, both Registered Nurses and Licensed Practical Nurses, we feel that the demonstrated success of the explora- tory program described earlier is an additional avenue of opportunity which can encourage the upward mobility for many young girls whose horizons may expand once they have achieved the first step in becoming an LPN. Going on to become an RN is the next logical step. 269 This situation is particularly appropriate for the young person of a culturally disadvantaged background whose first step may have been only to become an LPN. Financial support in taking the second step toward becoming an RN would be evidence of Society's support and encouragement of this motivation. BIBLIOGRAPHY Facts About Nursing, 1967, Chapter IV, Section B. Bureau of Health Manpower Public Health Service, U. S. Department of Health, Education, and Welfare. Health Manpower Perspective: 1967, Washington, D.C. U.S. Government Printing Office, 1967. Bureau of Health Manpower and Public Health Service, U.S. Department of Health, Education, and Welfare and the American Hospital Association. Manpower Resources in Hospitals—1966. Chicago, American Hospital Association. TABLE 1.—NURSING PERSONNEL NEEDS IN HOSPITALS, 1966 AND 1975 Additional needed Percent Estimated total Category of personnel Staff, 1966 to give optimum additional needed in 1975 care, 1966 Nurse (BN)... coc msnumin sn osmnnmmumnnmms ss 361,000 79, 500 22 563, 800 Licensed practical nurse. 150, 600 41, 400 27 245, 800 Surgical technician__________________________ 17, 600 3,900 22 27, 500 Aide, orderly (except in psychiatric hospitals). _ 374,400 51,300 14 544,900 Aide, orderly in psychiatric hospitals. .___..___ 117, 600 18, 500 16 174, 200 Source: Health Manpower Perspective, 1967, p. 12. TABLE 2.—NURSING PERSONNEL NEEDS IN EXTENDED CARE FACILITIES, 1966 Additional needed Category of personnel Present staff to give optimum Percent additional care NUISE, BN-....c owen mmm min wie dm 31,000 6,000 19 Licensed practical nurse. 33,600 9, 400 28 Aide; orderly, aHEntaDE. ... «co vnin anna ran 177, 400 10,700 6 Source: Health Manpower Perspective: 1967, p. 13. NATIONAL FEDERATION OF LICENSED PRACTICAL NURSES, INC., NEW YORK, N.Y. The information below is taken from Facts About Nursing, 1967, Chapter IV. The Research and Statistics Unit of the National League For Nursing reports 1150 practical nursing programs in operation in March, 1968. TABLE 3.—ADMISSIONS, ENROLLMENTS, AND GRADUATIONS FROM 1960 TO 1966 Admissions Enrollments Graduations 24,955 23,817 16, 635 26,660 25,910 18, 106 30, 585 29,417 19, 621 34,131 33,128 22,761 36, 489 33,877 24,331 38,755 36,729 25,688 In 1966, 126 schools opened and 40 closed. As of October 15, 1966 there were 1.081 programs in 1,043 schools. Between 1960 and 1966 these programs have increased. 1960-61 oem 693 1961-62 _______ 739 TOG cn ssermimimonios oe simi i soos ii ee 851 1963-64 913 TOOEDD corm orem sommes ss i oo RF ER 0 sm et 984 TOOT B0 os mtmsore mmr mmo ae secs i SE re ir 1, 081 270 The following is a list of practical nursing programs and administrative con- trol for 1963-66 : 1963 1964 1965 1966 Closed in 1966 Total programs._...._.______ 810 948 1,011 1,081 40 Trade, technical, or vocational Sdn 452 488 526 571 19 University, college, or junior ¢ university, BEB College... cr coe ech wi —————————— 105 128 149 164 3 Hosp... cu ssisrune spans nmangmanes 192 250 241 237 16 Government agency other than hospital... 5 3 7 YY mmm Other independent agency... _______. 9 10 10 11 RE Secondary SCHOO ...n. cv eee ccna amma 47 72 78 85 2 PREPARED STATEMENT oF HENRY B. PETERS, O.D., ASSISTANT DEAN, SCHOOL OF OPTOMETRY, UNIVERSITY OF CALIFORNIA, BERKELEY, CALIF., ON BEHALF OF THE ASSOCIATION OF SCHOOLS AND COLLEGES OF OPTOMETRY AND THE AMERICAN OPTOMETRIC ASSOCIATION, WASHINGTON, D.C. Mr. Chairman and Members of the Committee, I am Henry B. Peters, 0.D., Assistant Dean, School of Optometry, University of California at Berkeley. Last June, I was elected President of the Association of Schools and Colleges of Optometry whose members are the country’s ten optometric teaching facilities. I also serve as a member of the American Optometric Association’s Committee on Public Health and Optometric Care. A copy of my resume is attached for your information. The Association of Schools and Colleges of Optometry and the American Optometric Association both appreciate this opportunity to express support of S. 3095, the Health Manpower Act of 1968. Although there are a few points which we feel may warrant further consideration before passage, there is no question about the importance of continuing the programs with which the bill deals. We in optometry have seen some direct results of the Health Professions Educational Assistance Act and subsequent amendments. A timely example is the new optometry building at Indiana University to be dedicated in April. That building will house the Division of Optometry and also provide additional facili- ties for graduate school programs in Physiological Optics. On June 30, 1967, the College of Optometry at Pacific University, Forest Grove, Oregon, dedicated its expanded facilities made possible in part by a $300,000 grant under P.L. 88-129. Other projects in progress include facilities at Illinois College of Optometry in Chicago and Southern College of Optometry in Memphis, Tennessee. The remaining six colleges of optometry have also taken steps to improve or expand their facilities or teaching programs. Grants and loans made available through existing legislation have increased both the quality of optometric teaching facilities and the number of students the schools are able to train. Continuing Federal support is essential to assure the availability of optometry school graduates in sufficient number to provide vision care services to our 200-million citizens. We are concerned particularly about the new formula which requires a 2149; or five-student increase of first-year students to qualify for a grant. Such a requirement for expanded enrollment could well lead a school already experienc- ing financial problems to close its doors entirely. As the law is designed to increase the number of health care practitioners, we would urge the Committee to review this formula because it could, in application, curtail a school’s ability to train future practitioners. The increase of manpower might be accomplished more efficiently and economically by new or additional schools rather than by arbitrary expansion of our present ten schools. In view of the differences in capabilities of the schools to accommodate such increases, this could be a trouble- some provision. Specifically, the amendment to Section 723 of the Public Health Service Act is an important one as it extends the use of facilities to research, medical or health library purposes, in addition to teaching. Research constitutes an essential 271 adjunct to training of health care practitioners. Adequate library facilities pro- vide reference data to support research activities. This bill will also expand the scope of existing laws to include other disciplines important to the general health of the public; this is commendable. We would, however, urge that any funding formula contained in this bill be carefully reviewed to assure that programs begun under existing law in no way be curtailed. We hope Congress in its wisdom will more promptly to provide funds suffi- cient to accelerate the health care training programs and to assure the neces- sary increases in funds required to administer such programs. Deans of the various optometry schools were solicited for comments on S. 3095 shortly after its introduction. Responses from some of the schools are attached to this statement for your information. Statements from other optometry schools may be submitted separately. The Association of Schools and Colleges of Optometry and the American Optometric Association are pleased to have had this opportunity to support this legislation, which will assure that health care professions will be able to con- tinue the record of achievements made possible by the original legislation being improved upon by S. 3095. Riisumit or HENRY B. PETERS, M.A., O0.D., F.A.A.O. Title: Associate Professor of Optometry, Assistant Dean and Director of Clinics, School of Optometry, University of California Place and Date of Birth: Oakland, California, 1916 Education: A.B., University of California, 1938, Optometry M.A., University of Nebraska, 1939, Educational-Psychology Professional and/or Business Experience : President, Association of Schools and Colleges of Optometry, 1967-68. Vision Consultant, Contra Costa County, California, School Dept. Vision Consultant, Lawrence Radiation Laboratory (AEC), Livermore. Vision Consultant, Kaiser Aluminum and Chemical Company. Research Fellow, American Research Council of Optometry, 1938-39. Lecturer, Los Angeles College of Optometry, 1939-40. Lecturer, Claremont College, Claremont Reading Conference, 1940. Fellow, American Academy of Optometry, and former Chairman of Section on Public Health and Occupational Optometry. Fellow, Distinguished Service Foundation of Optometry. Fellow, American Association for the Advancement of Science. Member of the Faculty, University of California, School of Optometry, since 1946. Vice-President, Children’s Vision Center of East Bay. Member, Committee on Public Health and Optometric Care, American Optometric Association, 1963-64, 1967-68. Educational Director, PHS-AOA Training Seminar on Optometry in Public Health, February 1967. Special field of interest is vision screening and its application in schools and industry. Author and co-author of many articles on optical problems and vision, vision screening in schools, industry, and transportation. Member, Ad Hoc Program and Review Council, California Medical As- sistance Program. Activities: Member, Sigma Xi and Phi Beta Kappa. “Optometrist of the Year,” California, 1959. Personal History : Lt., U.S. Naval Reserve, 1942-46. CoMMENTS BY OFFICIALS OF SCHOOLS AND COLLEGES OF OPTOMETRY REGARDING S. 3095 Illinois College of Optometry (Private), Chicago, Ill, “Would like to go on record in support of this bill”. (Dr. Alfred A. Rosenbloom, Dean). Indiana University, Division of Optometry (State), Bloomington, Ind., “While 272 there is built into the bill some provisions to increase enrollments over the present figures, the legislators should consider the possibility of providing for an increase in the number of colleges of optometry rather than merely expanding present facilities.” (Dr. Henry W. Hofstetter, Director). Los Angeles College of Optometry (Private), Los Angeles, Calif., (See copy of 3/21/68 letter attached.) Massachusetts College of Optometry (Private), Boston, Mass., (See copy of 3/21/68 letter attached.) Ohio State University, School of Optometry (State), Columbus, Ohio, “We are in favor of the legislation, but do not favor the bonus or double payment for schools which increase their enrollment levels above those of prior years.” (Dr. Fred W. Hebbard, Director). Pennsylvania College of Optometry (Private), Philadelphia, Pa., (See tele- gram of 3/21/68 and letter of 3/21/68 attached.) Los ANGELES COLLEGE OF OPTOMETRY, Los Angeles, Calif., March 21, 1968. Dr. W. Jupp CHAPMAN, Chairman, Committee on Legislation AOA, 205 South Monroe Street, P.O. Box 367, Tallahassee, Fla. DEAR DR. CHAPMAN : Thank you for supplying the comments and copy of S. 3095 to this college and our opportunity to comment is appreciated. In reply to your telegram 'of March 20th, I have wired the Washington Office a summary of our attitude about this proposed legislation as follows: “Opinion of of this college S. 3095 represents great improvement over previous requirements of Public Health Service Act, particularly in provisions for Library and Research facilities and method of payment of institutional improvement grants. Favorable action recommended. Letter follows.” As all of you must be aware, the availability of Federal Grants for construction, basic and special improvement grants, scholarships to students, loan funds, ‘and the like have represented major improvements to all schools of optometry. The American Optometric Association and its hard-working committees and staff are to be complemented on the work they have done to make all of this possible. In our opinion the new proposed legislation ‘as is outlined in S. 3095, represents another major improvement in the wording of the Public Service Act. As pre- viously stated in our telegram we are particularly pleased with the attempt to in- clude research and library facilities in the provisions of the act. For most colleges of optometry this can be a very welcome and convenient change for by the very nature of their specialization optometry schools require the immediate availability of these facilities within their buildings. Additionally, we are in favor of the proposed change in the method of distri- bution of funds to the various professions. We believe it is as important to consider the number of graduates as it is to consider the entering class. To the suspicious mind this might appear as an incentive to graduate students who are not as fullv qualified as they might be but I believe that era in this profession, as in the others, has long since passed and each school is concerned with graduat- ing a candidate for the profession with the highest qualifications that it is pos- sible to give him. As is the intent of the bill, this consideration for the number of graduates may very well be the incentive to improve the counseling and exer- cise the concern that some young men seem to require. We do have some concern about the requirements for eligibility as it will require a slight increase in enrollment for the entering class at this college. This is a problem which must be resolved between the Council on Education which establishes the ceilings and the individual colleges or the Association of Schools and Colleges collectively. For most schools this problem will be resolved when new construction has taken place and expanded facilities are available. In general we believe the proposed changes for the Public Health Service Act are to the advantage of education in the Health Professions and we strongly recommend the hearing committee act favorably towards its passage. Sincerely, CHARLES A. ABEL, 0.D., Dean. 273 Los ANGELES, CALIF., March 21, 1968. AMERICAN OPTOMETRIC ASSN., 1026 17th St. NW., Wash., D.C. Opinion of this college, S. 3095 represents great improvement over previous requirements of Public Health Service Act, particularly in provisions for library at research facilities and method of payment of institutional improvement grants. Favorable action recommended letter follows. C. ABEL, Dean. PHILADELPHIA, PA., March 21, 1968. Dr. W. Jupp CHAPMAN, American Optometric Assoc. 1026 17th St. NW., Wash., D.C. If the quality of professional eye care to the public is to continue and improve it is imperative that 8. 3095 be implemented as soon as possible. Without addi- tional assistance as provided in this bill it will be difficult if not impossible to attract highly competent faculty to train the practitioners of the future. No college, public or private, can afford the increasing cost of competing with private practice for faculty without Federal subsidy the future of quality health care here in the United States and our leadership role in world health is at stake for the sake of future generations this bill must be passed. STANLEY S. WILLING, E.D.D., Dean, Pennsylvania College of Optometry. PENNSYLVANIA COLLEGE OF OPTOMETRY, Philadelphia, Pa., March 21, 1968. Dr. W. Jupp CHAPMAN, American Optometric Association, 1026 17th Street, N.W., Suite 205, Washington, D.C. DEAR Dr. CHAPMAN : 8. 3095 is an important bill, but the most important area is the pool of funds relative to Basic Improvement and Special Projects Grants (pages 6 and 7). Should this area be so funded that there would be less than $1,500 per sutdent, the bill will be not worthy of its function. This year’s operating budget here at P.C.O. breaks down to a cost of $2,735 per student. Our projections indicate a direct teaching cost of $3,375 within two years. If one realizes that our tuition is $1,200 per annum, you will be painfully aware that a vast chasm exists between cost of education and school income. Tuition has risen to its maximum here in Pennsylvania. Competitive health care professions teaching institutions charge from $400 to $1,200 per annum as tuition. It should, therefore, be obvious that tuition is no the answer to the need for additional funds. We in optometry have not as yet developed our capabiilty for private fund raising. This is true of most of the health care professions teaching institutions. This facet of fund accumulation is too far in the future for effective use, State assistance is still in its early stages. Here in Pennsylvania, it amounts to approximately 89 of our operating budget. It is, therefore, imperative that the Federal Government become more involved in the funding of all of the health professions teaching institutions. As the professions become more affluent, it becomes more difficult to recruit new teaching personnel and retain old personnel. The rewards of private practice must be matched by the schools if competent faculty are to be used in teaching. The schools cannot do so without massive new funding. There must be a “crash” program for the training of new teachers. A ten-year program is a must. Graduate optometrists must be enticed into post-graduate studies to prepare themselves for teaching. This will take fellowships of approxi- mately $7,500-$10,000 per annum each for four-year periods. This to the end of new M.A’s and Ph.D’s beyond the O.D. degree. Senate Bill S. 3095 is a most commendable piece of legislation. The keys to its efficacy will be the amount of funding and the complexity of the regulations set forth by H.E.W. No institution in the health care field can afford the personnel to spend full time preparing proposals to H.E.W. The work is overwhelming and if this is 274 required, it will subvert the philosophy of the Congress. Simple regulations and reporting procedures are the concomitant of a successful program. Thank you for the opportunity of getting this off my chest. If I may be of further assistance, please feel free to avail yourself of my time. Cordially, STANLEY S. WiLLing, Ed. D., Dean. THE MASSACHUSETTS COLLEGE OF OPTOMETRY, Boston, Mass., March 21, 1968. Mr. RicHARD W. AVERILL, Director, American Optometric Association, 1026 17th Street, NW., Washington, D.C. DEAR MR. AveriLL: I would like to say as Dean of The Massachusetts College of Optometry, I am heartily in favor of supporting the following legislation: Bill No. S3095—“Health Manpower Act of 1968”. Please have this endorsement included in the Appendix. Sincerely, HymAN R. KaMENS, O.D., Dean. THE AMERICAN PUBLIC HEALTH ASSOCIATION, INC. March 26, 1968. Hon. Lister HILL, Chairman, Senate Committee on Labor and Public Welfare, New Senate Office Building, Washington, D.C. Dear MR. CHAIRMAN : It is my purpose to apprise you of the views of the Amer- ican Public Health Association pertaining to legislation currently under consid- eration by your Committee relative to the continuation of programs intended to assist in the development of health manpower, S. 3095. As I need not remind you or your Committee, the APHA has been a supporter of each of the programs contained in this legislative proposal. I would, however, like to comment on them individually and point out to you what, in the view of our Association, would be improvements to the basic legislation. Without question, the authorization for the Health Professions Educational Assistance Act should be continued. The thrust of that initial authorization has not as yet been felt because of the time lag required in realizing the benefits that were envisaged. It takes a considerable period of time to realize an addition in the end product of a physician, dentist and similar training program and this is no wise should deter commitment of the nation to increase the numbers of these trained health professionals. Our Association is of the opinion, however, that within this authority provision should be made to include colleges of veterinary medicine as institutions eligible to receive the basic improvement grants. As you are well aware, the contributions of doctors of veterinary medicine to the improve- ment of human health are well documented and there is a demonstrated need to increase the capabilities of these institutions to train even more individuals in the art and science of veterinary medicine. We would recommend, therefore, that the basic improvement grants be made available to colleges of veterinary medicine. It appears to our Association that there is a clear justification for continuing the priority for training nurses. The shortage of qualified nurses remains a serious problem in implementing not only the health programs which have been authorized recently by the Congress but in delivering the health care needed throughout this country no matter what the jurisdictional responsibility may be. We do, therefore, wish to recommend strongly that authority for nurse training be continued. The third title under this Act relates to the training of allied health profes- sions. We certainly urge the continuation of this authority and must, in all con- science, point out that in our view the program has not been given a real chance to prove its value because of the extremely anemic financing through appropria- tions to carry out its purposes. I realize that there may be, in the view of some, overriding reasons for withholding or for not requesting construction funds. None- theless, we must point out that unless and until persons trained and skilled to assume the responsibility for the various parts of the medical care spectrum are available, the already over worked physicians, dentists and nurses will continue 275 to be unable to cope with the monumental demands for health care. We do strongly support the continuation of the authority for the training of allied health professionals, but we would urge that an advisory council be established to assist the Public Health Service in the administration of this Act. Most certainly the grant authority proposed to be extended by your bill, S. 3095, to continue authority for project grants to train public health personnel in schools of public health, departments of preventive medicine in medical schools, schools of nursing, schools of engineering and others appropriate to this purpose should be extended. We are not privy to the Administration’s views as to the amounts of funds necessary to implement these programs and very little can be learned from the language “and such sums as may be necessary for each of the next four fiscal years”. There is every reason and opportunity for persons to disagree as to what is “necessary”, but we would urge that these authorizations be at least equal to and preferably in excess of the authorizations contained in the present Act. It is our hope that affirmative action on this legislation will be forthcoming and our further hope that the Congress, in its wisdom, will see fit to incorporate in this legislation the suggested changes contained in this letter. I would appre- ciate your making this communication part of the record of the hearings. Sincerely yours, BERWYN F. MATTIson, M.D. Eaxecutive Director. AMERICAN ASSOCIATION OF COLLEGES OF PODIATRIC MEDICINE, Washington, D.C., March 26, 1968. Hon. LisTER HILL, Chairman, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C. DEAR SENATOR HiLL: The American Association of Colleges of Podiatric Medi- cine and the American Podiatry Association jointly support S. 3095 known as the ‘Health Manpower Act of 1968.” The Association of Colleges is a voluntary, not-for-profit, corporation. The five member colleges of podiatry are accredited by the American Podiatry Associa- tion’s Council on Education, the agency recognized for this purpose by the Com- missioner of Education, U.S. Department of Health, Education and Welfare. The colleges are all private, independent, non-profit institutions. The minimal educa- tional program is four years of podiatry college after two years of undergraduate work. As many as one third of the graduates of this six-year training period also complete an additional year of internship in various hospitals and colleges of podiatry. Podiatrists are licensed by examining boards in every state to treat the foot by medical and surgical means. As this Committee well knows, the podiatry profession has been deeply con- cerned for many years about the problem of providing a supply of well educated professionals that would be adequate to meet the needs of our people. As a direct result of the provisions of the Health Professions Educational Assistance Act the five accredited colleges of podiatry have been able to increase first-year student enrollment from 167 four years ago to 311 this year, an increase of 86.29, during this period. Of significance also is the increased level of pre-podiatry education. The Nation's requirements for podiatrists continues to increase each year. The Congress last session included podiatrists’ services for Medicare beneficiaries. Also, the Medicaid programs in the various states utilize podiatrists as part of their health services. The facilities and resources of the colleges of podiatry are cooperating fully with these community health programs. In other areas an in- creasing number of podiatrists are being sought for positions on community public health teams. The various branches of the armed services have doubled the spaces for podiatrists during the past two years and further expansion is pro- jected. Despite the increasing number of well qualified graduates, we are only beginning to catch up with the critical shortage of podiatrists needed to care for the foot health of this country. The U.S. Department of Labor in Report No. 323, June 1967, “Health Man- power 1966-75—A Study of Requirements and Supply,” clearly points out the need for increased numbers of podiatrists. “To meet projected needs, the average annual number of graduates of podiatry colleges must be increased substantially 276 above current levels between 1966 and 1975. Some increases in facilities are expected as a result of funds provided by the Health Professions Educational Assistance Act of 1963. However, a great deal of additional action is necessary to increase the capacity of the schools.” All five colleges of podiatry are planning for construction of new facilities and major renovation to existing facilities, with one college having been approved for matching construction funds under the present act. Additionally, projects and plans are being considered for the opening of one or more new colleges within the next four to six years. Both Associations are pleased to take this opportunity to express their strong support for S. 3095 entitled “Health Manpower Act of 1968.” This bill if enacted by the Congress will have a positive and substantial impact upon the future podiatric health of the American public by making it possible to increase the number of doctors of podiatry, by providing continued assistance for improve- ments in the teaching programs of podiatry colleges, and by providing loans and scholarships for young scholars who otherwise will not be able to consider a career in podiatry. It is our opinion that S. 3095 provides needed funds to meet the most critical problems facing the health professions today. On behalf of the American Association of Colleges of Podiatric Medicine and the American Podiatry Association it is respectfully requested that this state- ment on S. 3095 be considered by your Committee and included in the record of these hearings. Respectfully yours, Max M. POMERANTZ, M.D., President. ANIMAL WELFARE INSTITUTE, New York, N.Y., March 26, 1968. Senator Lister HILL, Chairman, Labor and Public Welfare Committee, Senate Oflice Building, Washington, D.C. DEAR SENATOR HILL: On behalf of the Animal Welfare Institute, I wish to re- quest your Committee to include the 18 schools of veterinary medicine in the section of your bill, S. 3095, on Institutional Grants. So far as human welfare is concerned, the contributions of veterinary medicine rank second only to medicine specifically directed towards human beings. The early veterinarians in this country were, in fact, M.D.’s, not D.V.M.’s; and for a time it was considered wise for veterinarians to take an M.D. as well as a D.V.M.—demonstrating that there is, in fact, only one medicine though the immediate subject of its ministrations may vary as to species. The advancement of medicine, for which you and your Committee have worked so long and hard, should not be hampered by cutting off its veterinary medi- cal aspect. Animal experimentation is meaningful to the degree that the animal is medically understood. Clearly veterinary medical training is most directed toward such an understanding. Animal experimentation has grown immensely as a result of the actions of your Committee; and though the numbers of veterinarians employed by labora- tories has not kept pace with the need, it has grown substantially in large in- stitutions. When we began inspecting laboratory animal rooms in 1951, a veteri- narian was a rarity. Now veterinarians are being given so many administrative tasks in big institutions that some of them lack the time to see the animals as should be done and as is required under the provisions of the Laboratory Animal Welfare Act, P.L. 89-544. Humanitarians are deeply grateful to you for your sup- port of this law. Under the Laboratory Animal Welfare Act, which is still in process of being fully implemented, much more veterinary advice will be required (1) by smaller scientific institutions which have gotten along in the past without veterinary con- sultation, and (2) by animal dealers, most of whom never even thought of con- sulting a veterinarian no matter how sick an animal might be or how its disease was spreading to others. As you know, P.L. 89-544 specifies that research animals shall receive “ade- quate veterinary care.” This provision is expressed in the regulations as follows: “Programs of disease control and prevention, euthanasia, and adequate veteri- 277 nary care shall be established and maintained under the supervision and as- sistance of a doctor of veterinary medicine.” To carry out the will of Congress in preventing the needless suffering and death caused by sale and use of diseased animals of research purposes, provision needs to be made for the graduation of increased, and, in all probability, increasing numbers of veterinarians. Thus, we urge, on behalf of humanitarians throughout the country who demonstrated their interest in such great numbers in passage of the Laboratory Animal Wel- fare Act, that you amend S. 3095 to include schools of veterinary medicine in the provisions for insitutional grants. In addition to the specific need for veterinarians to provide adequate veterinary care for research animals, as directed by the Congress in P.L. 89-544, we believe broad considerations of human and animal welfare also require that schools of veterinary medicine should be given the support they need. Veterinarians are the chief guardians of our plentiful and wholesome food supply. They are largely responsible for the health of our livestock, which does not suffer from many of the scourges, such as foot and mouth disease, which decimate the herds of less for- tunate countries. The veterinarians of the United States Department of Agricul- ture played a major part in eradicating this scourge in our two neighboring coun- tries, Mexico and Canada. Both humans and animals, not to mention the economy, benefit enormously from their achievements; and the fact that these are taken for granted and rarely mentioned in the press makes them more, not less, worthy of attention by the federal government so that the basic support of veterinary education keeps pace with support provided to other medical programs. Both humans and animals benefits, too, from the work of veterinary public health ; both benefit from the expert care provided to pets and to other animals in distress through injury or illness. The humanitarian aspect of veterinary medi- cine is important. Our country prides itself on humane attitudes. There are few adjectives more bitterly resented than the word “cruel.” Thus, at the broadest as well as at the most specific levels, there are powerful reasons to give the support to the nation’s schools of veterinary medicine which S. 3095 gives not only to schools of medicine but to schools of dentistry, osteopathy, optometry, and podiatry. I would appreciate having this letter made part of the record of the hearings. Sincerely, CHRISTINE STEVENS, President. THE NATIONAL ASSOCIATION OF RETAIL DRUGGISTS, Washington, D.C., March 28, 1968. Hon. LisTeER HILL, Chairman, Health Subcommittee of the Senate, Committee on Labor and Public Welfare, Washington, D.C. DEAR SENATOR HILL: The purpose of this letter for the printed record of S. 3095 hearings is to apprise you and other members of the important Health Subcom- mittee of the U.S. Senate Committee on Labor and Public Welfare regarding the views of the National Association of Retail Druggists on 8. 3095, the “Health Manpower Act of 1968.” The National Association of Retail Druggists, with the largest national mem- bership of retail pharmacy owners in the country, has historically been vitally concerned with all aspects of pharmacy education. Our concern is emphasized by the fact that 90 per cent of the nations pharmacists are employed in retail drug stores. NARD represents over 40,000 independent retail pharmacies com- prising about 90 per cent of such stores. More than 75,000 licensed pharmacists are engaged in the practice of pharmacy in our member stores. We support continuation and the proposed extension of the program for the construction of teaching facilities for students in schools of pharmacy. We support extension of the student loan and scholarship provisions for needy pharmacy students and authorization of special grants to pharmacy schools. In 1965 the NARD took a similar position which received favorable considera- tion by members of your distinguished committee. We are concerned that S. 3095 does not provide institutional grants for pharmacy schools for we believe that an inclusion of pharmacy schools deserves 278 reconsideration as such inclusion would probably enhance greatly the diversified: health care training programs in the college of pharmacy and would materially benefit the public. From our vantage point, the NARD believes retail pharmacy is an essential link in the expanding Health and Medical Care programs. The drug distribution system in America through retail pharmacies is superior to ail other approaches and is the one in most demand by the public. The retail pharmacy in ‘the com- munities is indispensable and irreplaceable. We are confident that institutional grants for pharmacy schools are necessary to attract and secure appropriate teaching personnel and to pharmacy college services on a basis that is adequate to meet the future managerial and professional challenges of retail pharmacy. It is our recommendation that consideration be given to amending S. 3095 so that pharmacy schools might be eligible for appropriate institutional grants. In the interest of high caliber pharmacy education for a greater number of pharmacy students to meet the critical shortage of pharmacy manpower, the National Association of Retail Druggists appreciates this opportunity to express its views on 8. 3095. We recognize S. 3095 as health legislation of major interest: to the public and to the pharmacy profession we proudly represent. Sincerely yours, WiLLArD B. SiMMoNSs, Executive Secretary. PHARMACEUTICAL MANUFACTURERS ASSOCIATION, Washington, D.C., March 27, 1968. Hon. Lister HILL, Chairman, Senate Committee on Labor and Public Welfare, Washington, D.C. Dear MR. CHAIRMAN : This letter is submitted on behalf of the Pharmaceutical Manufacturers Association concerning S. 3095, a bill entitled “The Health Man- power Act of 1968.” Among other things, this bill, if enacted, would extend and improve the existing construction program for teaching facilities for stu- dents in the schools of medicine, pharmacy, and other health professions; it would also broaden the student loan and scholarship program to provide financial assistance to needy students in these professions. The PMA is a national trade association representing 136 firms which manu- facture approximately 95 percent of the nation’s supply of prescription drugs. We respectfully call to the Committee's attention the historical fact that there. has been no important development in the field of effective drug therapy for more than a quarter century where members of PMA have not played a sig- nificant role either in the discovery of the therapeutic agent or in defining its utility and making it readily available to the professions of medicine and pharmacy. The PMA is vitally interested in this legislation because of the effect it has on the health of this nation and upon the people who are providing our medical and health services. Graduates of our medical and allied health schools are meeting the demands of Federal and state governments, of the armed services, of education, of research, of community services, and of industry. The pharma- ceutical manufacturing industry employs many physicians, pharmacists, and others and our concern, therefore, is that the nation have an adequate supply of such personnel. The PMA believes that the extension and improvement of the construction program for teaching facilities which was initiated in the 88th Congress by the enactment of the Health Professions Educational Assistance Act is in the best interests of the nation because it makes possible the education and training of a greater number of physicians and pharmacists. If our country is to be able to meet the demands for services now being made on its health professions, the enrollment in our medical, pharmacy and other health schools must be in- creased. To achieve this expanded enrollment through construction of additional facilities at existing schools, as well as through the creation of new schools, we feel that it is necessary to have increased financial support from both the Government and private sectors. In addition the PMA supports the program of providing student loans and scholarships to students in the health schools. We also support the liberalization 279 of this program by which financial aid is provided to needy students in these professions. We would urge, however, that such student aid should not be ex- tended beyond providing assistance to qualified applicants. In other words, the program should not, in any fashion, dilute the quality of medical or pharmacy education. We believe it is important to note that private funds are now to a very considerable extent supporting student loan and scholarship programs and thereby relieving financial difficulties among students in medicine and pharmacy. We would hope that in the administration of its program the Government would make every effort to avoid competition between these programs, which could have the unhappy effect of drying up the incentive for private financial assistance. The PMA. has not expressed an opinion in relation to those provisions of S. 3095 relating to special project grants and institutional grants. We have not had ample opportunity to study the programs which would be established by these pro- visions and therefore feel that we should not comment upon them. In light of the foregoing comments, we respectfully urge Congress to enact the provisions of 8. 3095 relating to the construction program and student aid. It would be appreciated if you would make this letter a part of the printed record of your Committee's hearings on S. 3093, 90th Congress. Respectfully submitted, C. JOSEPH STETLER. THE UNIVERSITY OF NORTH CAROLINA, Chapel Hill, N.C., March 2}, 1968. Hon. LisTER HILL, U.S. Senate, Washington D.C. DEAR SENATOR HILL: As a pharmaceutical educator, I am very grateful to vou for the provisions in the Health Manpower Act of 1968 (S. 3095) that you have introduced. I am writing this letter as a statement that I earnestly hope will be included in the hearings on 8. 3095 before the Subcommittee on Health of the Committee on Labor and Public Welfare. I respectfully request that the benefits of the institutional (formula) grants be made available to schools of pharmacy that submit applications that merit approval, as well as to schools of medicine, dentistry, osteopathy, optometry and podiatry. The consortium of health professionals for delivery higher quality medical care and community health services in greater quantity to more people is a “chain that is as strong as its weakest link”. The pharmacists we are educating today must be strong links in that chain. The pharmacist’s role in an efficient and effective team effort has changed greatly and has become far more impor- tant than ever before as a greater variety and number of more potent drugs— potentially more hazardous and (because of higher specificity) more precisely applicable in treatment of disease—have become available during recent years. “What the pharmacists knows” about those drugs has become equally—perhaps more—important in comparison to “what the pharmacist does” in procuring, pre- paring and dispensing those drugs in accordance with his more traditional and visible role. I discussed the functions of the modern pharmacist that are based on his intellectual skills as well as those based on his manipulative skills in a rather comprehensive statement prepared for the Panel on Education and Supply of Health Manpower (National Advisory Commission on Health Manpower Re- sources). I am enclosing that part of the statement pertinent to the pharmacist’s true role. It includes the following summary : “In summary, as a result of what the pharmacist knows, the pharmacist assists the physician in medical care by helping him to minimize medication errors, by serving as a communications center for drug information, by com- municating toxicological information to the public and to other health pro- fessionals and by cooperating in poison control programs, by his ‘follow-up to see that patients are in fact carrying out the doctor’s orders’, by dealing with the high risk families in his community ‘to insure physician attention at appropriate times’, by cooperating in the ‘wellness care’ of his patrons, and in many other ways. As a further result of what he knows and has a unique and frequent opportunity to communicate, the pharmacist plays a very important position on the health team by serving as a triage in directing appropriate members of the large self-medicating public to a physician while their ailments 280 are still minor and before they are prostrate with a major illness, by reducing the hazard attendant in self-medication often with a variety of drugs (irration- ally selected, often incompatible and toxic especially when consumed simultan- eously), by imposing prudent restraints upon the promiscuous use of drugs and instituting steps that will forestall or correct their abuse, and in many other ways contributing to ‘wellness care’ of the people of his community.” I am also enclosing an excerpt from “Medicine, Money and Manpower—The Challenge to Professional Education” by Ward Darley and A. R. Somers [New England Journal of Medicine, 276, No. 25, pp 1420-1421 (1967) 1. The implications of the pharmacist’s true role with respect to the mission of schools of pharmacy are very clear. The faculty they recruit and retain, the facilities they develop for the complex and interdisciplinary curriculum they offer their students, the teaching, research and service programs they maintain, expand, improve and initiate (now especially when considerable innovation is is urgently needed).—all of these require the type of support provided by the institutional (formula) grants of Sec. 771 of S. 3095. At the School of Pharmacy of the University of North Carolina, we are edu- cating a far greater number of pharmacists, pharmaceutical scientists and pharmaceutical technologists than ever before in the School’s 72-year history. The enclosed summary of the “School of Pharmacy Enrollments” show that the present undergraduate student body represents a 57.6% increase over the average yearly enrollment of the past ten years. The number of graduate students has increased 66.7%. The rate of enrollment increase has exceeded the rate of in- crease in support by the State and other agencies. The institutional (formula) grant is urgently needed to help the School to handle the many contingencies related to increased enrollments. The increasing and changing requirements for modern pharmaceutical services have made necessary extensive changes in existing programs and the initiation of new, urgently-needed programs. For example, to impart to our students a clinical orientation—to make them fully aware of their relationships with physicians and others who prescribe drugs for specific purposes to patients who take drugs for specific needs, we have introduced training in “clinical pharmacy” and have re-oriented the teaching in all of our professional courses. (In the past, pharmacists have been somewhat unilaterally oriented toward drugs as physical entities rather than as tools with which the physician brings about desirable effects in patients.) As a further example, because of the large, rapidly growing and highly dynamic body of information that must be applied at the clinical level for safe and effective use of drugs with proper control against their abuse, (1) we are enhancing greatly our continuing education activities (expanding our traditional programs and initiating new and different programs; (2) we are planning and implementing a program for training drug information specialists; (3) we have initiated a very signficant program in a new pharma- ceutical science—biopharmaceutics; ete. The changing programs of the School and, particularly, the initiation of new programs that are innovative and urgently- needed, require the type of support that would be provided through the institu- tional (formula) grant provisions of S. 3095. I earnestly hope that the Subcommitte will agree that schools of pharmacy must be enabled to keep pace with other health professional schools, and will realize that schools of pharmacy now have a pressing need for institutional grants equal to or greater than that of the other health professional schools. Schools of pharmacy have been able to move forward up to this time in spite of the handicap of ineligibility for institutional grants of the formula type at a time when other health professional schools (with which many schools of pharmacy are affiliated in university-based health science education centers) enjoyed the benefits of such grants. With the institutional grant of the formula type, schools of pharmacy will be able to approach the level of excellence that is urgently required in the education of today’s pharmacists, pharmaceutical scientist and pharmaceutical technologist. I earnestly hope that the Subcommittee on Health will take the action re- quired to make schools of pharmacy eligible for institutional (formula) grants and I shall be most grateful for any effort you will make in this regard. Very sincerely yours, GEo. P. HAGER, Dean. 281 PREPARED STATEMENT OF GEORGE P. HAGER, DEAN, SCHOOL OF PHARMACY, THE UNIVERSITY OF NORTH CAROLINA THE SUPPLY AND EDUCATION OF PHARMACY MANPOWER The Need and Demand for Pharmacy Manpower There is an obvious need (and demand) for the traditional services of the pharmacist—a need that is based primarily on his manipulative skills and one that has much visibility and is universally recognized. There is also a more subtle demand (and need) for other services of the pharmacist—a demand that is based on his intellectual skills, The latter is a demand that has always existed but which now, in an age of modern drug therapy, has engendered a need that has become critical, in every way justifying a clear definition and recognition of the pharmacist’s true role in medical care and community health. This demand, and the urgent needs upon which it is based, now places the pharmacist in a new perspective as a member of increasing importance on the health team. Perhaps the need and demand for pharmacy manpower can be more clearly understood if presented first in terms of what the pharmacist does (the exer- cise of his manipulative skills) and then in terms of what the pharmacist knows (the exercise of his intellectual skills). What the pharmacist does.—Statutory requirements and the regulations of the boards appointed to control the practice of pharmacy in all of the states define the role of the pharmacist in procurement, storage, compounding, control and dispensing of drugs. These assign to the pharmacist responsibilities that cannot properly be demanded of others and authority that properly is withheld from others. Dispensing prescribed medication is, perhaps, the most obvious professional service of the pharmacist in community and hospital practice. Although prescrip- tion compounding and dispensing are by no means the exclusive—nor even the most important—professional service of the pharmacist ; these funcitons do epito- mize the popular concept of what the pharmacist does. During the past twenty years, 1947 to present, the number of prescriptions dispensed yearly has almost tripled. In 1947, 371 million prescriptions were dispensed, and, in 1965, the num- ber increased to 965 million (1). In 1966, the number of prescriptions exceeded 1 billion (1a). The capacity of existing pharmacy manpower to compound and dis- pense prescribed medications has not increased commensurately. Although the number of lincensed pharmacies has remained fairly constant during this 20 year period, the number of pharmacists probably has declined (vide infra), It is true that there has been a considerable increase in the proportion of “prefabri- cated” medications dispensed by the pharmacist. It must be emphasized, however, that many of the operations involved in dispensing require the same amount of time regardless of the “prefabricated” or “extemporaneously compounded” na- ture of the medication, e.g., interpretation of the physician's prescription order, preparation of the label, maintainance of the pharmacist’s records (making in- creasing demands on the pharmacist’s time), ete. The leveling effect of these functions that are common to all dispensing (in view of the great increase in the number of prescriptions) has more than offset any advantage resulting from an increase in the proportion of “prefabricated” drug products with respect to pharmacy manpower. Furthermore, the integrity of the medical profession and the growing need for physicians to individualize the drug therapy prescribed in accordance with the individual patient's peculiar needs requires that phar- macists maintain their expertise and their resources for compounding prescrip- tions extemporaneously. [In fact, today the pharmacist’s expertise in compounding has become particularly important as he deals with the frequently complex— often very subtle—problems arising when one or frequently a number of drugs (drug additives) are combined extemporaneously with “prefabricated” paren- teral products.] What the pharmacist does is a very important segment of medical care and community health in an age of wonder drugs—two-edged swords for prevention, treatment, mitigation, and cure of disease, and, at the same time potent and po- tentially hazardous—specific and, therefore, having very precise indications and many contraindications. Medical care and community health programs, now greatly expanding and approaching their real potential for the good of society, are placed in serious jeopardy and pharamcists are placed in a defensive position unjustifiably by short-sighted individuals who propagate the notion that a pharmacist merely “counts and pours” and cam, therefore, be ignored as an 92-079—68——19 282 essential member of the health team or replaced, wholly or in part, by untrained or inadequately trained and supervised personnel. Such attitudes reflect an ulte- rior desire to pursue a course of expediency or to spare a relatively small fraction of medical care budgets. Especially where life and human misery are concerned, it is not profitable, much less moral, to be, in this way, “penny-wise and pound- foolish”. Whoever is ignorant of the importance of what the pharmacist does will, if he is also prudent in matters of medical care and public health, seek to become informed about the true role of the pharmacist and, by this and any other means, to diabuse his own prejudices however justified he may think them to have been in the past. The pharmacy profession, as all other health professions, has kept pace with the tremendous changes in medical care (especially the grow- ing and changing drug armamentarium) and the pharmacist, as well as the public he serves, deserves a completely fair judgment according to present, and especially anticipated future, situations. The profession is justly proud of what the pharmacist has done in the past in regard to expert compounding, responsible dispensing, and prudent control of drugs (particularly those drugs that lend themselves to abuse). What he now does and what he will and should do in the future constitute a challenge clearly recognized by the profession. The profession is fully prepared to accept the re- sponsibility of this challenge. In doing this, the profession is simply perpetu- ating its long-standing traditional mission in the modern setting of medical care and community health. What the pharmacist knows.—Today, more than ever before, what the pharma- cist knows and communicates—his intellectual skills and the exercise thereof— have become sine qua non for proper medical care and community health, Un- fortunately, this—the most important—virtue of the pharmacist, is not readily apparent to the public nor, indeed, to the casual professional observer. By the latter it is often taken for granted. On the other hand, the testimony of respon- sible individuals and agencies reveals a growing awareness of the need and demand for the pharmacist’s intellectual skills. Among those who perceive most clearly the true role of the pharmacist are the many physicians who work closely with pharmacists in ministering to the needs of their patients. The National Advisory Committee on the Selection of Physicians, Dentists and Allied Specialists (Selective Service System) consists mainly of physicians and dentists chosen by the President for their awareness of the health manpower needs of both the armed forces and the civilian economy. This Committee adopted the following resolution in March, 1966: “The National Advisory Committee recommends that pharmacists be placed on the list of critical occupations as an urgent measure related (1) to a rapidly developing shortage of qualified manpower (especially in younger pharmacists who have more modern training) and (2) to the rapidly increasing need for qualified pharmacists, especially as regards their intellectual and communication skillg, in modern medical care and community health. The pending new programs (Medicare, ete.) involving pharmacists as well as other professionals make this action more urgently needed.” This is no question that the dialogue between the physician and the pharma- cist is an important feature of medical care. The modern pharmacist is expert in his knowledge of drugs and the physician seeks his advice more frequently as the drug information bank rapidly grows and changes. The pharmacist is a very important link in the drug information communica- tion chain. He receives information from many sources (vide infra) and dis- seminates it to a variety of users with greatest convenience and accessibility to them and in accordance with their need to be immediately informed. James I. Goddard, Commissioner of Food and Drugs, commented on this point in an ad- dress to the Clinical Midyear Meeting of the American Society of Hospital Pharmacists on November 30, 1966 : “While the practice of medicine may keep the physician so busy that he has trouble absorbing all that’s new about drug developments, the reverse is true for the pharmacist. He no longer is buried in the pharmacy compounding prescrip- tions . . . If the pharmacist is not compounding as much, he is most certainly dispensing more. In addition, his record-keeping is more extensive and the body of drug literature directed specifically to his attention is growing continually. Those who operate Drug Information Centers are already in the middle of the drug information explosion and know very well the real volume of knowledge coming your way from a variety of sources, industry, government, professional associations and publishers.” 283 Certainly physicians are a very important user group thus served by the phar- macist and their patients’ care depends on the knowledge of the physician as it is complemented by that of the pharmacist. There is, however, another important public whose care depends almost solely on the knowledge of the pharmacist— the self-medicating public with which the pharmacist is in intimate and frequent contact. For this public, the pharmacist is the first, frequently the sole, line of defense against ignorance and, indeed, misinformation that predispose to drug abuse and otherwise threaten the health and the lives of the members of the large self-medicating public. Patients who are receiving proper medical care from physicians in conjunction with the other members of the health team including pharmacists are the top of an iceberg relative to the many other persons who, possibly, should be receiving such care. The efforts of the latter to self-medicate, especially while their symp- toms are mild and at a time when they would present minor medical care prob- lems, have the effect, in many instances, of depriving them of the many benefits of medical progress and modern drug therapy. Such persons urgently need proper communications about drugs. [The pharmacist’s communication often places a proper constraint on the effects of otherwise poorly restrained advertising] For many people in the self-medicating public, the pharmacist alone among the members of the health team is both qualified and has the opportunity to com- municate to them information that can spare their suffering and even save their lives. Many persons in the large self-medicating public first consult their physician as a result of the pharmacist’s intercession. For them, the pharmacist exercises a very important triage function and he has the special qualifications and a unique opportunity to do so. The following resolution grew out of a conference on “Public Health in the Curricula of Colleges of Pharmacy” held in Washing- ton, February 28 to March 3, 1965. It was adopted by the American Association of Colleges of Pharmacy at its annual meeting, March 28-30, 1965. “Whereas, the community pharmacist and the hospital pharmacist are now qualified to play a much more important and active role in medical care and public health as a result of the great improvements in pharmaceutical educa- tion, including continuing education, and the adoption of a five-year curriculum in 1960, and, “Whereas, the community pharmacist, especially, and also the hospital phar- macist have unique opportunities to provide professional health services which are now urgently needed and far exceed those of the pharmacist in his traditional role, and, “Whereas, the modern pharmacist’s special qualifications and his peculiar opportunity to satisfy health needs (which without his services would be unmet or inadequately satisfied) are not being fully exploited in the interest of medical care and public health, therefore, “Be it resolved, that the modern role of the pharmacist should be clearly de- fined for the benefit of other professions and of the agencies which are concerned with medical care and public health, and, “Be it further resolved, that such definition be followed by every effort to secure proper recognition of the pharmacist’s role and his involvement in medical care and public health in a way that is truly commensurate with the modern pharmacist’s special qualifications and his peculiar opportunity to render the pro- fessional pharmaceutical services now urgently needed.” The public’s need for what the pharmacist knows and communicates was stated as follows by Dr. Luther Terry while he was Surgeon General of the United States Public Health Service : “The pharmacist today continues to serve as a major source of health informa- tion to the public. Young mothers consult the pharmacist on medication for everything from diaper rash to colic, and older persons anxiously seek guidance from their pharmacist. It is he who directs them to their physician when the complaints so indicate; it is he who warns against self- and automedication in many instances. “Because of this public trust, the pharmacist holds a unique position in the education of the public concerning matters of health. In their respective roles as teachers, the pharmacist and the physician stand side by side today as they have in past centuries for the common good of those they serve. Therefore, we welcome and need the cooperation of the pharmacist in this task of providing for a healthier America.” 284 The pharmacist, as indicated in Dr. Terry's statement, plays a particularly important role with regard to high risk segments of the public. That this role is important is borne out in a statement by Dr. James I. Dennis: © “We propose the development of pilot studies to identify effective programs in which physicians will necessarily place a great deal of reliance on a supporting team of assistants in the allied health science fields. It is possible that the proper utilization of such personnel could free as much as 50 percent of a doctor’s pro- fessional time, and this would in effect be the equivalent of doubling the number of available physicians. Any successful effort in this direction must recognize the need to preserve the physician’s position as ‘captain’ of the health team. A properly organized health service team can lead to both ‘happier’ physicians and better medical care, e.g, a member of the ‘team’ may follow up to see that patients are in fact carrying out the doctor’s orders, and high risk families can be identified and systematically reviewed to insure physician attention at appropriate times, hence, provide preventive ‘wellness care’, and the like. There are many other examples that could be cited.” The pharmacist is an ideally qualified and ideally located individual to assist the physician as suggested by Dr. Dennis. The pharmacist has always played this “position on the team”. In view of the overall health manpower needs and in view of the pharmacist’s traditional and well-established relations with his patrons who are (or who, through the pharmacist’s intercession, often become) the physician’s patients, the pharmacist’s role by virtue of what he knows is very important and should now be clearly recognized, fully utilized, and com- pletely committed in medical care and community health activities. In summary, as a result of what the pharmacist knows, the pharmacist assists the physician in medical care by helping him to minimize medication errors,’ by serving as a communications center for drug information, by communicating tox- icological information to the public and to other health professionals and by cooperating in poison control programs, by his “follow up to see that patients are in fact carrying out the doctor’s orders, by dealing with the high risk families in his community “to insure physician attention at appropriate times”, by cooper- ating in the “wellness care” of his patrons, and in many other ways. As a fur- ther result of what he knows and has a unique and frequent opportunity to com- municate, the pharmacist plays a very important position on the health team by serving as a triage in directing appropriate members of the large self-medicat- ing public to a physician while their ailments are still minor and before they are prostrate with a major illness, by reducing the hazard attendant in self-medi- cation often with a variety of drugs (irrationally selected, often incompatible and toxic especially when consumed simultaneously), by imposing prudent re- straints upon the promiscuous use of drugs and instituting steps that will fore- stall or correct their abuse, and in many other ways contributing to “wellness care” of the people of his community. ScHooL OF PHARMACY ENROLLMENTS The 1967-1968 enrollments—undergraduate students and graduate students— of the School of Pharmacy are the highest in the 72-year history of the School. The EPA positions in the School’s budget have by no means increased com- mensurately with the increase in enrollment. With only 13.33 full-time positions at the rank of assistant professor or higher, the School is now seriously understaffed. Yearly enrollments ! Undergraduate Graduate students students 33-34 0 44-45 0 81-82 0 94-95 20 141-142 1-2 219-220 11-12 276-277 12-13 435 20 1 For the 10-year periods, the average enrollment per year is given. 2] graduate student enrolled in each of the last 3 years of the decennium. 285 As the above figures show, the undergraduate student enrollment of the School of Pharmacy in 1967-1968 (435 students) corresponds to an increase of 57.69 over the average yearly enrollment of the preceding ten years; and the graduate student enrollment (20), to an increase of 66.79%. (The latter figure does not include three postdoctoral research associates, compared to one in preceding years). The projected enrollments for the next three years are as follows : Yearly enrollments t Undergraduate Graduate students students 1 490 (367) 25 (25) 524 X 30 1970-71. 534 35 1 The school’s budget for 1968-69 is based on the figure in parentheses. This is believed to be an underestimate and was the figure used in determining the school’s budget for 1967-68. PHARMACISTS As a rule, the pharmacist has not been considered a professional in the main- stream of person-to-person patient care. His principal task has been to count or measure a prescribed brand of precompounded pills, capsules, liquids or powders, to prepare the proper labels and to keep appropriae records. Occasionally, he is consulted by physicians regarding dosage or the appropriateness of a given product. Depending upon the locale of this operation, particularly if the pharma- cist is an entrepreneur operating a corner or a chain-owned drugstore, he is frequently consulted by members of the general public about nonprescription and propietary remedies or about where to seek professional medical attention. There has been an increase in the trend for professionally trained pharmacists to seek full-time employment in hospital pharmacies or in prescription pharmacies in professional buildings, or in close association with organized clinical groups. However, the prescription department of the corner or chain drugstore that offers an endless array of nonprescription and even nonmedical items is still a major outlet patronized by physician-directed patients. With prescription drugs increasing in their effectiveness and, unless properly used, becoming increasingly dangerous, it is time for the pharmacist to become a more important member of the medical-care team. He should be used for what he knows as much as, if not more, than for what he does—indeed, under his supervision, many of the things the pharmacist does now could be done by other, less skilled assistants. This would free the trained pharmacist to play a truly significant part in patient care. He should be prepared to participate in the evaluation and distribu- tion of drugs in the clinical setting. Ie should be active on the clinical floors of the hopsital interpreting chart orders for medication; when necessary, preparing medications for the nursing staff; and providing consultative services to both physicians and nurses. Such desirable developments would be both hastened and facilitated if the medical staff would take the initiative in encouraging them. ven without such encouragement, however, there are signs that we are moving in this direction. For example, Medicare's requirements that every participating hospital must have a pharmacy under the direction of a registered pharmacist or a drug room under competent supervision, as well as a pharmacy committee composed of physicians and pharmacists, have already helped to raise the pharmacist’s status and to bring him into closer contact with the medical staff. The much debated and controversial issue of whether to require use of generic names for purchase of drugs under public programs could also, by debunking some of the mystique surrounding certain trade names, help ‘to enhance the status of the pharmacist—if he understands and takes advantage of the opportunity offered him. Even the present limited Medicare requirement that drugs dispensed in hospitals to Medicare beneficiaries must be included on one of the recognized national professional formularies, or approved by the hospital's pharmacy com- mittee, calls for increased judgment and responsibility on the part of the pharma- 286 cist. “The pharmacist, with the advice and guidance of the pharmacy committee, is responsible for specifications as to quality, quantity, and source or supply of all drugs.” The future of the pharmacist—if imaginatively approached—could be exciting indeed. As computer services become more common and less expensive it would probably be possible, within a few years, for the pharmacist to supply the phy- sician with a print-out of every patient's medication, with a flagging of questions of incompatibility, possible toxicity, excessive of alternative costs, improper use and so forth. Furthermore, since many patients go to more than 1 physician and to more than 1 pharmacy, a central “clearing house” where all medication in- formation could be “poled,” and a print-out given to every physician involved, would be of great value. These print-outs would be a part of every patient's record and when a hospital record is involved, a matter of review by an appro- priate staff committee. The pharmacist, diluting his talents running the nonmedical aspects of a drug- store, would rapidly lose status as a professional. Programs of continuing educa- tion for pharmacists now in practice would quickly grow in importance. Restruc- turing of the curriculums in schools of pharmacy would be greatly accelerated. Questions of increasing the input of new blood into these curriculums on the one extreme, and of extending them into graduate areas on the other, would become matters of immediate concern. There were, in 1965, about 118,000 active licensed pharmacists. Some 88 per- cent of these practiced in community drugstores. Hospital pharmacies account for about 4700, although the American Society of Hospital Pharmacies estimates that, if those practicing part-time in hospitals are included, the figure may rise to 10,000. Others are engaged in manufacturing and wholesaling, teaching, gov- ernment and so forth. Seventy-five colleges of pharmacy—2 less than in 1959—offered degrees, and 3360 pharmacists graduated in 1964-65, compared to 3686 in 1959. As of March 1, 1967, the Educational Facilities Branch of the Division of Physician Man- power, United States Public Health Service, reported the possibility of 389 new first-year places; more will probably be authorized over the next few months. Although the number of pharmacists continues to increase in absolute figures, the rate in proportion to population has dropped from 67.0 per 100,000 in 1950 to 61.6 in 1965. Spokesmen for the pharmacists say that if the full potential of the profession is to be achieved, and a constant pharmacist-population ratio main- tained, by 1970, 7200 a year should be graduating. It is difficult to appraise the validity of this figure. This is one of the few areas in the medical-care economy in which manufacturing and distribution efficency has clearly had a significant impact. There is no perceptible shortage of drugs. The need for more pharmacists is clearly related to an upgraded and more profes- sionalized role of the type suggested above. The pharmacist’'s future—quanita- tively as well as qualitatively—may depend on this willingness and initiative in assuming these larger challenges and responsibilities and on his willingness and ability to become a meaningful member of the comprehensive medical-care team. ASSOCIATION OF TEACHERS OF PREVENTIVE MEDICINE, March 28, 1968. Senator Lister HILL, Chairman, Senate Committee on Labor and Public Welfare, New Senate Office Building, Washington, D.C. Dear SENATOR HILL: I would like to indicate to you the concern which the Association of Teachers of Preventive Medicine and also the departments of preventive medicine have for increasing support of the activities of these departments. To many people, preventive medicine is a vague title but these departments are working primarily in the area of community health. Departments of pre- ventive medicine and their faculty are concerned with the consideration and solution of problems of groups of people, or communities. Their interest encom- passes such areas as consideration of causes of current epidemic chronic diseases, the delivery of health services, the quality of care, the adequacy of manpower and the organization of health services. You will note that the concern of departments of preventive medicine is similar to that of schools of public health, 287 but there are a number of differences. First, there are over 80 departments of preventive medicine compared with a dozen or so schools of public health. The departments of preventive medicine are primarily involved with the education of the future practicing physicians, and the learning of these students about com- munity health. Furthermore, the medical school departments of preventive medicine are involved in care programs and the delivery of services to patients, participating in this work with other clinical departments of the medical school. But departments of preventive medicine are also different from schools of public health in that these departments have less prestige and, on the average, very little support, either from the federal government or from their own medical school deans. Although it is beginning to change at this time, the faculty of medical schools, and their deans, have been largely focusing their attention on specialty training, research, and care of individual patients, with little concern for and participation in community medical care and studies of community health problems. This posture does account, to a large extent, for the presence of many weak departments of preventive medicine in this country. It was our hope that the medical school block grants (General Research Support Grant and Health Professions Educational Assistance Act) would be of assistance to the departments of preventive medicine but these sources of funds have, by and large, been used for purposes other than strengthening departments of Preventive Medicine. Although the faculty members of departments of pre- ventive medicine will continue their attempts to influence their own deans to allocate more funds to departmental activities, these departments and the Asso- ciation of Teachers of Preventive Medicine are looking for other ways of obtain- ing financial support. You are well aware of the various federal programs that have impact on community medicine and now medical schools and certain medical faculty mem- bers are becoming involved in comprehensive health planning, Regional Medical Programs, Neighborhood Health Centers and so forth. For participation in a number of these activities the school is turning to departments of preventive medicine for some assistance and these weak, understaffed departments are frequently unable to respond to the degree that they would wish. Furthermore, these programs may not have funds that are of direct assistance to these depart- ments of preventive medicine. We are then in a situation where now there are increasing opportunities for and demands on the departments of preventive medicine and because of their traditionally weak position in the medical faculty hierarchy, they cannot respond appropriately. Our Association has considered attempting to influence federal legislation so that specific categorical support would be given to departments of preventive medicine of the kind that is now made available to other clinical departments. However, we do recognize that the trend nationally is towards increasing the block grants to medical schools for allocation within the schools and decreasing the amount and number of categorical departmental support programs. Nevertheless, I do hope, that you and your committee members would consider seriously the needs of these departments of Preventive Medicine and the opportunities that they could capitalize on if further support were made available. The education and service programs in comprehensive health require strong departments, and some way needs to be found for enhanced financial sup- port of them. Sincerely yours, GEORGE ENTWISLE, M.D., President. NATIONAL ASSOCIATION OF STATE UNIVERSITIES AND LAND-GRANT COLLEGES, Washington, D.C., March 28, 1968. Hon. Lister HILL, Chairman, Senate Committee on Labor and Public Welfare, New Senate O flice Building, Washington, D.C. DEAR SENATOR HILL: The National Association of State Universities and Land- Grant Colleges is, and has been, vitally concerned with legislation relative to the support of research and education in health and health-related fields. Over the vears, we have been extremely appreciative of the leadership given in this area by the Senate Committee on Labor and Public Welfare and by your chairmanship 288 of that Committee. You and the Committee you chair have given the United States legislation that has served not only to provide this country with pro- grams that have resulted in the world’s healthiest citizenry but also to provide models for Federal legislation in other but related areas. S. 3095 provides still another opportunity for the type of statesmanship that has characterized the work of your Committee. As indicated in the attached statement, this Association strongly endorses the provisions of this bill, but would like to suggest modifications that, we feel, are urgently needed. We would hope that this statement could be read into the record of your hearings on the bill and made a subject of consideration by the Committee during its delibera- tions. The suggestions contained in the statement were adopted by the Association as official Associational policy during its annual meeting this last November, Sincerely yours, CHRISTIAN K. ARNOLD. PREPARED STATEMENT OF CHRISTIAN K. ARNOLD ON BEHALF OF THE NATIONAL ASSOCIATION OF STATE UNIVERSITIES AND LAND-GRANT COLLEGES The National Association of State Universities and Land-Grant Colleges repre- sents 99 major state universities and land-grant institutions located in all 50 states and Puerto Rico. Its members enroll nearly 30 per cent of all students in the nation. They award 44 per cent of all medical and dental degrees in the nation and 50.9 per cent of those in other health professions. In addition, they contain all but one of the nation’s schools of veterinary science. In the future, these institutions will inevitably produce an even greater share of the nation’s badly needed health manpower, as much of the expansion of medical education is taking place in state and land-grant institutions. At its annual meeting in November 1967, our Association, meeting jointly with the American Association of State Colleges and Universities, commended the 90th Congress “for its recognition of the need for substantial programs of sup- port for education, extension activities, and library services in health-related fields through the enactment of the Health Professions Educational Assistance Act, the Regional Medical Programs Act, and significant expansions of existing legislation.” We are pleased that the Congress has continued to demonstrate its interest in these fields by its consideration of the Health Manpower Act of 1968. We par- ticularly commend and endorse the provision of this Act which makes direct operational support available to schools of nursing. The needs of the schools of nursing are such that in its 1968 statement of policy positions concerning recoms- mendations for national action affecting higher education, the Association urged that this kind of support be extended to these schools. The Association is also pleased to note that 8. 3095 contains provisions for extending the eligibility for special improvement grants to schools of pharmacy and veterinary science. This too was a matter of concern at our most recent annual meeting. Our member institutions, however, would like to see the committee carry this extension one step further. They are also anxious to see schools of pharmacy and veterinary science eligible for institutional, basic improvement grants. In the words of our 1968 policy statement, “We note with concern that eligibility for assistance for the schools of pharmacy and veterinary science is limited to construction aid. We urge corrective legislation to end this discrimination to major health-related fields, especially as concerns eligibility for basic and special improvement grants for support of the instructional function at schools of pharmacy and veterinary science.” The extension of basic improvements grants that we are advocating has already been put before this committee by its distinguished chairman, Mr. Hill. In a bill Senator Hill introduced last April (8S. 1645), which was referred to this Com- mittee, he proposed amending the Public Health Service Act in order to authorize improvement grants for schools of veterinary medicine. We hope the committee will pick up this idea from Senator Hill's bil] and then carry it further to also include pharmacy. In conclusion, we support and commend the general objectives of 8. 3095 and hope that the modification we are suggesting can be incorporated into this legislation. 289 AMERICAN DENTAL TRADE ASSOCIATION, Washington, D.C., April 3, 1968. Hon. Lister HILL, Chairman, Committee on Labor and Public Welfare, U.S. Senate, Washington, D.C. DEAR SENATOR HILL: The American Dental Trade Association welcomes this opportunity to comment on 8. 3095, the “Health Manpower Act of 1968.” Our Association, whose members are the manufacturers and suppliers of dental supplies and equipment, is vitally interested in legislative programs which pro- vide financial support for the training of members of the health professions, especially the dental profession. The Health Manpower Act of 1968 is an imaginative step toward providing the trained professional personnel who will be required to meet the future health needs of our country. As an example of the magnitude of the potential future shortage of dentists, the U.S. Public Health Service states that 30,800 more dentists will be needed in 1975 than will be available. It is clear, therefore, that legislation such as S. 3095, with its balanced approach of providing funds to construct training facilities, as well as to provide student aid for those pursuing professional training, serves the public interest. With appreciation to you and to the members of your Committee for allowing the American Dental Trade Association to present its views on The Health Man- power Act of 1968, IT am, Cordially, EpMUND WELLINGTON, Jr. Executive Secretary. STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS, DEPARTMENT OF HEALTII, Providence, March 25, 1968. HoN. SENATOR CLAIBORNE PELL, New Senate Office Building, Washington, D.C. Dear SENATOR PELL: IT am writing you in relation to the Health Manpower Act of 1968 and, specifically, about Title IT, which refers to Federal funds for nursing education. It is my understanding that Title IT permits the Commissioner of Education to name state boards of nursing as the accrediting body for schools of nursing to be eligible for Federal funds. As you probably know, under the former nurse train- ing act the Commissioner of Education named the National League For Nursing as the accrediting agency. In my current position as Executive Secretary of the Rhode Island Board of Nursing, I am greatly concerned about this change and hope you will oppose it. The standards of the various boards of nursing in this country are entirely too variable to name them as the accrediting agency, and in some instances are about minimal. I am proud to say that six of the seven schools of nursing preparing registered nurses in Rhode Island are accredited by the National League For Nursing. The only school not so approved is our newest one, namely : the associate degree nurs- ing program being offered by the Rhode Island Junior College. This course has not been in existence long enough to apply for full accreditation by the National League For Nursing but plans to do so directly after the graduation of its first class of nursing students in June of 1968. My colleagues in nursing education in Rhode Island and I cherish accreditation by the National League For Nursing because it indicates to young people entering the field that such schools offer quality education in nursing. May I add that for many years I was privileged to be a member of the Na- tional League For Nursing’s Board of Review for hospital schools of nursing. This is the board which acts on the eligibility for accreditation of such schools of nursing. In this capacity, I witnessed first hand the tremendous improvements made in schools of nursing throughout the country because of the help received from the National League For Nursing. In this respect may I say I am not hesitant to add that I believe the accreditation program of the National League 290 For Nursing has done more to improve the quality of schools of nursing in this country than any other movement. I, also, understand that Title IT of the Health Manpower Act of 1968 reduces the amount of construction aid for diploma schools of nursing. This I think is most unfortunate, in light of the fact that, even during the current transition of nursing education from hospitals to institutions of higher learning, the bulk of the registered nurses are still being prepared in hospital schools. I am quite sure for some years to come this will be so. I appreciate your consideration of this communication, and I know you will do all you can to remedy what I believe are two very serious flaws in Title II. With kindest personal regards. Very truly yours, MARGARET C. KELLEHER, R.N., State Director Nursing Education. ProvipeNCE, R.1., March 20, 1968. Hon. SENATOR CLAIRBORNE PELL, New Senate Building, Washington, D.C.: As a member of the Program Review Committee for the Nurse Training Act of 1964, I write you to express grave concern about a major change in S. 3095 quote “Health Manpower Act of 1968” end on quote. It is specifically in reference to title 2 since you are a vital member of the committee introducing this bill, I urgently petition your valuable and timely assistance. To give the critical re- sponsibility to the Commissioner of Education to name more than one body to accredit schools of nursing, at this time, could be disastrous, presently, the National League for Nursing, which maintains high goals and standards, has been his choice and it has been a most satisfactory one. The change would per- mit individual State accrediting bodies, with varying levels of standards and requirements to do the accrediting. In too many instances, State requirements are below the standards of the National League for Nursing. We are fully cogni- zant of your interest in maintaining and improving the quality of nursing care rendered to all patients in our State as well as on a National level and it is with this assurity that we know you will give careful deliberation to this point. Simi- larly, we are concerned for the diploma schools which, in most instances, will not be phased out for some time. Therefore, it is urgent that additional financial assistance be made available to maintain these schools at this time at their high level of performance. The quantity and quality of manpower and nursing care are our true concerns, Senator Pell, in your committee’s well constructed piece of legislation. We are confident that we have approached you in the past so again we come knowing that your interests and dedication will alleviate our fears and find you endeavoring to provide the optimum in nursing care and nursing education. We are appreciative of this opportunity to contact you. Respectfully yours, Rita M. MURPHY, Director of Public Health Nursing, R.I. Department of Health. COMMITTEE ON MEDICAL EDUCATION, March 27, 1968. Hon. JAcoB K. JAVITS, U.S. Senate Washington, D.C. DEAR SENATOR JAVITS : As Chairman of the Committee on Medical Education, I appreciate the opportunity offered by your letter of March 21, 1968 to comment on 8S. 3095. Having reviewed the proposed legislation, I believe that it strengthens the Federal commitment to enable medical schools to participate more fully in the national mission of ensuring quality health care in the United States. The report of the Committee on Medical Education attests to the readiness of the medical schools to contribute to the health revolution taking place in the nation today. 14 DAY US® LIL v 5 The schools’ capacities, however, are not commensurate with their willingness. S. 3095 could contribute significantly to enhancing these capacities. I welcome the emphasis in 8. 3095 on the educational function of medical schools, the key emphasis of the Committee on Medical Education. Specifically, the proposed institutional and special project grant programs authorize support for medical education which would assist in fulfilling two major goals: 1) edu- cating more doctors and allied health personnel and 2) developing curricula more responsive to the vast increases in biomedical knowledge and the increased de- mands for research and programs in health care. Increased flexibility in student assistance and construction grants are vital aspects of these two programs. S. 3095s strengthening of medical schools is important not only for the edu- cation of doctors, but also because the schools must continue to play their proper and leading role in biomedical research. They must have the sound institutional base visualized in S. 3095, as well as increased direct support for research which is demanded by national growth and national needs. The schools as institutions, must also be strengthened in order to enable them to contribute to community service. The regional medical programs and OEO’s neighborhood health programs are two examples of activities in which the schools could pioneer and develop new patterns in medicine if their institutional base was made reliable. S. 3095 authorizes an increased and coherent Federal commitment to the educational function of medical schools. This is clearly essential if the medical schools are to continue their traditional functions and innovate with new patterns of curricula and health care. It is only fair to point out, however, that the Federal commitment to be authorized in S. 3095 must be complemented by appro- priations which provide the substantial direct Federal support indispensible for implementing this commitment. These comments are, of necessity, brief and general statements. I and other members of the Committee would welcome the opportunity to discuss with you in greater detail our report and its relation to medical legislation. Sincerely yours, Lewis Tuomas, M.D., Chairman. ANIMAL HEALTH INSTITUTE, Washington, D.C., March 26, 1968. COMMITTEE ON LABOR AND PUBLIC WELFARE, U.S. Senate, Washington, D.C. GENTLEMEN : On behalf of the members of the Animal Health Institute, I urge the Committee to take prompt and favorable action on S. 3095, introduced by Senator Hill in this session of the 90th Congress, which would extend and improve educational programs for health professions personnel. The Animal Health Institute represents over 60 manufacturers of animal health and nutrition products. Its member companies produce 90 percent of the veterinary pharmaceuticals, biologicals, and feed additives in the United States. Industrial veterinarians employed by these companies perform much of the critical research and development work for the products which have so signifi- cantly diminished incidence of livestock diseases and improved the abundance and qualify of America’s meat, milk, and eggs. The shortage of veterinarians, however, is becoming critical ; and the Animal Health Institute is interested in furthering expanded education opportunities in the veterinary field. We believe the provisions of 8. 3095 will accomplish this purpose. J. ROBERT BROUSE, Executive Vice President. Tue Ciamman. The subcommittee now stands in adjournment. (Whereupon, at 1:25 p.m., the subcommittee adjourned subject to the call of the Chair.) : O ™ AS 5% %! (028509933