Report of the Technical Committee on Medical Care
Background- Following the decision made by President Roosevelt during the planning for the Social Security program that he would not propose a medical care program as part of Social Security, the President tried to pursue a federal health-care program by establishing a separate follow-up organization to study this and related issues. This ad-hoc group of federal government experts was known as the Interdepartmental Committee to Coordinate Health and Welfare Activities. It was apparently informally established in August 1935, although a formal Executive Order creating it was promulgated in October 1936. Strictly speaking, the charter of this group was to study existing governmental health and welfare programs and identify ways to better "coordinate" them. Politically speaking, it was the expectation that this new group would be the vehicle to move forward a comprehensive federal health care proposal. This larger ambition was never realized. The group did, however, issue some reports on the topic, which are good sources of information regarding the state of thinking in this era on the issue of a national health program. As part of its work, the Interdepartmental Committee appointed a Technical Committee on Medical Care, which issued a report in February 1938. The report was in two parts. The first part was entitled, "The Need For a National Health Program." (This first part of the report is being reproduced here.) The purpose of this first part of the report was to make the case that there was a need for comprehensive health care reform in America. This part of the report was released to the public immediately. The full report, which contained specific recommendations, was then the subject of a National Health Conference in July 1938. The full report contained five specific recommendations: 1) An expansion of public health and maternal and child health services under existing titles of the Social Security Act. 2) Federal grants-in-aid to the states for the construction of hospitals and for defraying operating costs during the first three years. 3) Federal grants-in-aid to the states toward the costs of a medical care program for medically needy persons. 4) Federal grants-in-aid to the states toward the costs of a general medical care program. 5) Federal action to develop a program of compensation for wage loss due to temporary and permanent disability. At the National Conference, the reception to the report and the specific recommendations was enthusiastic on the part of most attendees, although the representatives of the American Medical Association were opposed to recommendation #4, which was the Committees' proposal that the nation begin the development of a national health care system. Ultimately, the AMA's House of Delegates adopted a resolution in September 1938 accepting all the recommendations, except #4. Expectations were high among the Committee members following the National Conference that President Roosevelt would make this a legislative priority for the Administration, but the President decided to defer action, planning to make the subject an issue in the 1940 elections. Ultimately, the President transmitted the Interdepartmental Committee's report to Congress in his message of January 23, 1939 and Senator Robert Wagner (D-NY) introduced a bill (S-1620) modeled on the Committee's report. However, the President chose not to lend his strong political support to the Wagner bill, and it died in the Senate Finance Committee. Following the demise of the Wagner bill, the Committee continued working into 1940, issuing its last report (on migratory labor) in 1940. Ultimately, the Interdepartmental Committee on Health and Welfare Activities was disbanded without achieving any notable legislative success, although it did contribute to a growing body of knowledge about the issues surrounding health care in the U.S.
Editorial note: page breaks retained from original document to facilitate reference to printed version. (Document transcribed and edited by Naketa Jones)
FOREWORD Pursuant to the following executive order, the Interdepartmental Committee to Coordinate Health and Welfare Activities created a Technical Committee on Medical Care to survey the health and medical care activities of the United States Government, to review in particular the participation of the Government in the health services of the nation and to submit recommendations on Federal participation in a national health program. Executive Order By virtue of and pursuant to the authority vested in me as President of the United States, and in order to provide for the better coordination of the health and welfare activities of the Federal Government, I hereby designate the following as members of the Interdepartmental Committee to Coordinate Health and Welfare Activities:
It shall be the duty of this Committee (1) to continue to sponsor appropriate cooperative working agreements among the various agencies of the Government in the health and welfare field, and to continue the work under agreements already in effect, and (2) to study and make recommendations concerning specific aspects of the health and welfare activities of the Government looking toward a more nearly complete coordination of the activities of the Government in these fields. The Committee will continue to function through the special technical committees it has set up from time to time, and will designate additional committees to deal with new problems. FRANKLIN D. ROOSEVELT The White House, October 27, 1935. The following report on the need for a national health
program has been submitted by the Technical Committee to the Interdepartmental
Committee. The latter Committee has accepted this report, filed it
with the President, and now makes it available for distribution.
THE NEED FOR A NATIONAL HEALTH PROGRAM
I. INTRODUCTORY NOTE The cost of illness and premature death in this country amounts annually to about 10 billion dollars, including in this total the combined costs of health services and medical care, loss of wages through unemployment resulting from disability and the loss of potential future earnings through death. On an average day of the year, there are four million or more persons disabled by illness. Every year 70 million sick persons lose over one billion days from work or customary activities. Such fragmentary but specific estimates are indicative of the economic loss resulting from sickness and premature death, but they give no adequate indication of the incalculable social consequences of ill health. We are not unmindful of the brilliant advances which have been made in scientific knowledge. Nor do we overlook notable improvements in medical, public health, dental and nursing education, or in the progress of research. Nor do we underestimate the contributions of individuals and associations, lay and professional, in raising the standards of professional service. All of these advances are written large on the credit side of the ledger of national progress and they count heavily in the measure of our national resources. But it is not the task of this Committee merely to praise past performances and accomplishments. The Committee is charged with the duty to assess carefully the state of the nation's health, to relate what is being done against what can be done, to search out and define needs which are not being met through current practices, and to outline proposals through which the national health may be improved. Of necessity, therefore, this report deals primarily with the debit rather than with the credit side of the ledger‑not by reason of any intent to give a distorted picture, but to discharge a specified task. Yet this limitation must be kept constantly in mind, lest otherwise the Committee be regarded as taking an unduly pessimistic view. The Committee calls attention to the fact that illness precipitates large costs and enormous economic burdens, and that sickness is among the most important causes of economic and social insecurity. Sickness
2 strikes at the basis of national vitality; the good health of the population is vital to national vigor and well-being. The accomplishments of the past in health conservation are therefore secondary to the needs of the present and of the future. While great advances have already been made, enormous needs still prevail. The amount of preventable sickness and disability which continues, the volume of unattended disease, the rate of premature mortality and the prevalence of avoidable economic burdens created by sickness-costs ,justify grave concern. Do the methods of public health and medical sciences offer no hope of further reducing the national burdens of illness? On the contrary, the Committee finds that the essential lack consists not in inadequate knowledge but in inadequate funds. Indeed, at some points, the resources exceed the need, but they are used to less than capacity while people in need go without service. There are economic barriers between those in need of service and those prepared and equipped to furnish service. The essential inadequacy in respect to health services is not in our capacity to produce but in our capacity to distribute. The greater use of preventive and curative services which modern medicine has made available wait on the purchasing power rather than on the need of community or individual. The effective distribution and utilization of health and medical services requires a national plan for the economic application of our resources in maintaining and improving health.
II. ACCOMPLISHMENTS OF THE HEALTH MOVEMENT The present century has seen the development of the technique of disease prevention, and has seen the technique widely applied by the physician and dentist in private practice, and by a variety of organized voluntary agencies, and by local and State health departments through the aid of general practitioners as well as specialized public health personnel--physicians, public health nurses, bacteriologists, sanitary engineers and others. The achievements of organized effort in the prevention of disease are well known. Yellow fever, which delayed the construction of the Panama Canal until Reed and his associates discovered its method of transmission, has been practically eliminated on this continent. Deaths from typhoid fever and the diarrheal diseases have shown a striking decline following improvements in sanitation of the environment, control of water supplies and pasteurization of milk. Tuberculosis and diphtheria mortality has been greatly reduced through a variety of other procedures. These and numerous other
3 organized preventive efforts have operated hand in hand with concerted efforts directed to improvement of professional education, skill in diagnosis and care of disease, and to ever-broadening scientific knowledge. The progress made in the control of disease is indicated by the downward trend of the death rate, which decreased from 17.6 per 1,000 population in 1900 to 11.5 per 1,000 in 1936, representing a saving of about three-quarters of a million lives in 1936 alone. This saving of life has taken place chiefly in childhood and in the years of early adult life, in which the preventable diseases are most frequent. In the period between 1900 and 1935, 12 years were added to the average expectation of life at birth. However, no significant increase occurred during this period in the average years of life remaining to persons of middle and advanced age. The life expectancy at age 50 for white males in the Original Death Registration States showed, between 1901 and 1929-1931, the almost negligible increase of seven one-hundredths of a year; for white females, the increase was eight-tenths of a year. Lack of improvement in mortality at the older ages is of special moment because our population is "aging"; the proportion of the population which is in the higher age groups is increasing. This results from the combined effects of the declining birth rate, the decrease in childhood and early adult mortality, and the immigration of large numbers of adults in the first part of the present century. Mortality in the higher ages has not, in general, been declining. On the contrary, the death rates from some important diseases of adult life have been increasing. The phenomenon mast be understood in light of the fact that the principal causes of death operating in the advanced years are not, in general, communicable but organic and chronic. Measures designed to control the communicable diseases do not therefore strike directly at mortality in the higher ages, except insofar as they prevent permanent damage from communicable diseases in the earlier years of life. Such chronic diseases as cancer, diabetes, and the diseases of the heart, blood vessels and kidneys, which are associated with the degenerative changes of the aging process, have shown rising death rates. In 1900, the death rate from cancer was 63 per 100,000 population; in 1936 the death rate was 111 per 100,000. This increase to some extent reflects improvements in accuracy of diagnosis and reporting, but there is evidence that at least a substantial part of the increase is real,
4 and the rising cancer death rate warrants concern. In the same period, the death rate from diseases of the heart increased from 132 to 213 per 100,000 and diabetes mortality, from 10 to 24 per 100,000. To some degree, deaths from these diseases can be prevented and deferred, and disability can be reduced, by early diagnosis and competent medical care in these diseases or in diseases which precede them. The great accomplishments of the recent past are harbingers of the future. But the hope for equal or even greater advance in the years ahead can be realized only if the changing nature of health needs is appreciated and only if appropriate adjustment is made in the methods to be used. Anew health program must be something more than merely an expansion of the old. New measures must be used, directed against the new objectives. Fortunately, new methods are not necessarily novel. While the old has been practiced, the new has been subjected to experiment and practical trial. And though a new program must make further provision for still newer experimentation under appropriate conditions, the emphasis may still be laid upon well-founded techniques. No statement of accomplishments in health service would be complete or balanced without reference to the value of research. Medical science can point with justifiable pride to great advances. But this should not obscure needs that remain. At present only little can be done to prevent or cure influenza, common colds or infantile paralysis; the true nature of cancer is not understood and curative measures have value only in the very early stages of the disease; disorders of the mind are still shrouded in obscurity; increasing human toll will be taken by degenerative processes of the heart, arteries and kidneys until medical knowledge is extended beyond its present frontiers; the conditions commonly grouped under the term chronic rheumatism cause an excessive amount of disability, and the loss is not likely to be reduced until these ailments become better understood. Further advance and greater accomplishments in the future require continued research. Any assessment of past progress must, therefore, clearly call attention to the need for adequately supported investigations into the fields where knowledge is still limited and skills are still imperfect. Our study reveals that the principal needs can be most simply presented by casting them into two broad classes: (1) Needs in respect to maternity, infancy and childhood, which fall in a group by themselves though intimately related to (2) needs in respect to health
5
III. THE NEED FOR THE EXPANSION The increasing proportion of persons in the older age periods has been accompanied by a decline in the proportion of children. The conservation of maternal and child life is therefore especially imperative if we are to maintain in the future the proportion of persons in the productive ages necessary to an economically progressive nation. A great opportunity to this end lies in the provision of adequate health services and medical care in maternity, in infancy and in childhood. Today there is a great and unnecessary waste of maternal and infant life; impairment of health is widespread among mothers and children. Physicians, after careful evaluation of causes responsible for the deaths of individual mothers, report that from one-half to two-thirds of maternal deaths are preventable. It has been shown that the death rate of infants in the first month of life can be cut in half. Knowledge of how life and health may be preserved is at hand; adequate demonstration of the practical application of knowledge with favorable results in the saving of lives and conservation of health has been made; the problem lies in finding the ways and means of making good care available to all in need of such care. Maternal and Infant Mortality The health and security of children depend to great extent on the life and health of the mother and on the ability of the family to provide adequate food, shelter, clothing and medical care. Each year, a birth occurs in the households of more than 2,000,000 families in the United States. Each year, more than 75,000 infants are stillborn. Each year, more than 69,000 infants die in the first month of life, 56,000 of these from causes associated with prenatal life or with the process of being born. Each year about 12,500 women die from causes directly connected with pregnancy and childbirth, and approximately 1,500 others who are preg-
6 nant or recently delivered die from such conditions as tuberculosis, chronic nephritis or heart disease. As a result, at least 35,000 children are left motherless, many of them to become dependent on the community, and many of them to become potential delinquents. The maternal mortality rate for the United States is high; in 1336, the rate was 57 per 10,000 live births, more than twice that of Sweden. Rates vary widely in different States, from 40 in Rhode Island and New Jersey to 31 in Arizona and 90 in South Carolina. In individual counties the range is even wider, from no deaths at all for a 5-year period to a rate of more than 200 per 10,000 live births. Daring the 22 years for which records are available, there has been but little decline, with the exception of the last six years during which there has been a slight but significant decrease due to reduction in the deaths from toxemia of pregnancy. This is the cause of maternal death which is most affected by prenatal care; its continued downward trend is dependent on the adequacy of such service. The deaths from causes associated with delivery have shown scarcely any decrease in 22 years. Deaths from hemorrhage have declined slightly; deaths from sepsis, which account for more than 40 percent of all maternal deaths and which are largely preventable by good care before or at the time of delivery, have shown no significant decline. During the 22 years for which records are available, great progress has been made in reducing the death rate of infants during the period between the second and the twelfth month of life. But there has been but slight decline in the death rates of infants under one month of age and no decline in the rate of death on the first day of life. The deaths during the first month of life represent half of all infant deaths during the first year of life. Four-fifths of the deaths under one month are prenatal or natal in origin and, therefore, closely associated with the causes of maternal mortality and morbidity. There are probably 90,000 premature infants born alive each year in the United States. Of these at least two-fifths die in the first month of life, representing half of all deaths which occur in the first month of life. It has been demonstrated that a large proportion of prematurely born infants may be saved by proper care. It is estimated that a considerable proportion could be saved of the
more than 75,000 stillbirths which occur each year. The causes of stillbirth
are those associated with complications of pregnancy and abnormalities
of labor. Reporting of stillbirths is still too incom- 7 plete and the criteria of diagnosis too lacking in uniformity to warrant discussion of trends. It is likely, however, that many more occur than are reported. Though the mortality rate for infants between the second and twelfth
months of life due to the gastro-intestinal and respiratory diseases
has been strikingly reduced for the country as a whole during the past
22 years, there are still areas and groups of the population in which
the death rates from these diseases are as high today as the rates for
the whole country twenty years ago or even higher. The preventive measures
so successfully applied in many urban and some rural areas should be
made available to families in all cities and rural areas. Until 1929
the rural infant mortality rate was lower than the urban rate; in 1929
the urban rate fell below the rural rate, but there are still many cities
with rates far too high. The infant mortality rate for the country as
a whole can be reduced still further. Inadequacy of Maternal and Infant Care A Few salient facts brought out by recent studies will suffice to indicate the inadequacy of present provisions for maternity and infancy:
It is estimated that more than 1,100,000 births occur in families which
are on relief or have total incomes (including home produce on farms)
of less than $1,000 a year. Of these, more than 900,000 occur in rural
areas or cities under 100,000 population and more than 200,000 in cities
of 100,000 population or over. Many hospitals serving rural areas and
small cities report that their maternity facilities are not used to
capacity because of the inability of families to pay for such care. The Special Needs of Childhood In childhood, excluding the first year of life, the probability of
dying is lower than at any subsequent age period in the entire life
span, but the probability of being sick is greater in these than in
the subsequent years of life. In eight large cities canvassed in the
National Health Survey in 1935-1936, white children 5 to 9 years of
age experienced an illness rate (from cases disabling for one week or
longer) which was 19 percent higher than that of persons 65 years of
age and over. Of these disabling illnesses among all children under
15 years of age, about 40 percent were due to acute infectious diseases
such as measles, scarlet fever, whooping cough and diphtheria. In the
period 1934-1936, an annual average of 15,000 children died from these
four 9 causes alone. Many cases can be prevented and many lives can be saved by the application of specific measures for the control of communicable disease, by protection of the milk supply and by adequate health supervision. In addition to more effective provision of services from physicians, this involves provision of services which can be furnished by public health nurses, in the home and in clinics, with medical supervision and consultation. Acute respiratory diseases--influenza, pneumonia, colds, tonsillitis--caused another 40 percent of the disabling illnesses among children under 15 years of are in these eight large cities canvassed in the National Health Survey. The illness rate for this group of causes among children 5 to 9 years of age was twice as high as that of persons 65 years of age and over. Among children of the preschool period (1 to 4 years),pneumonia alone was the cause of 16 percent of these illnesses due to acute respiratory disease. In the period 1930-1934, 18 percent of all deaths among preschool children were due to this cause, a proportion between two and three times as high as that at any subsequent age period. To a great extent the pneumonia occurring in infants and young children, especially that resulting in death, is not the type amenable to known forms of serum treatment. However, illness due to pneumonia in early childhood can be greatly reduced by medical and nursing care of minor respiratory diseases, and deaths may be averted by skilled care when the disease occurs. For older children, prompt and skilled care, early in the disease, typing of the infection, provision of skilled service, and when appropriate, special serum treatment are essential. It is estimated that there are at least six children in every 1,000 who are crippled or seriously handicapped by diseases or conditions such as poliomyelitis, tuberculosis, birth injuries, injuries due to accidents, rheumatic heart disease and congenital deformities amenable to correction, as clubfoot and harelip. Early treatment of children with poliomyelitis is well known to prevent much crippling; prolonged treatment of the child injured at birth will restore many to useful existence; skilled and early treatment of congenital deformities and injuries due to accidents are essential toprevent deformity. In northern parts of the country about 1 percent of all school children
suffer from rheumatic heart disease; in the South the disease is apparently
less frequent. Appropriate treatment of children with rheumatic disease
will restore 60 percent to normal life; 15 percent to a life of restricted
activity. The treatment, however, is long and of- 10 ten requires care in hospital or convalescent home at repeated intervals over a period of several years. In apparently well children, malnutrition and defects of vision, of hearing, of the lymphoid tissues of nose and throat, and of the teeth, are relatively frequent. Many of these defects are remediable, and when they are remedied, the child is saved from further illness or from maladjustments to his environment. In one nation-wide survey in which dental defects were included, it was found that for every 1,000 children entering school there were approximately 1,300 defects that needed dental attention. Inadequate public health and medical services prevent the improvement in child health which may be predicated on the basis of past accomplishments. The nature of the inadequacy is further indicated by the following facts:
Resources for medical care in hospitals, in convalescent homes or in their own homes, for children who suffer from acute illness or from chronic or crippling conditions or are the victims of accidents, are still far from adequate; they are especially inadequate in rural areas and in small cities and towns.
IV. THE NEED FOR MORE
Tuberculosis Each year, 40,000 young adults between the ages of 15 and 45 die from the ravages of tuberculosis. The deaths among these young adults represent about three-fifths of all deaths from this cause. Each year, about 200,000 cases of the disease receive treatment in institutions; approximately 200,000 additional cases receive medical care of varying adequacy, some of which are foci of infection to persons in contact with them. There is adequate evidence to .justify the opinion of experts in this field that tuberculosis deaths can be reduced 50 percent by health supervision of workers in occupations predisposing to the
disease, by detection of incipient cases, and by provision of adequate medical and institutional care in the early stages of the disease. The need for extension of these activities in the control of the disease is further indicated by the following facts:
A large body of evidence testifies that a majority of cases are discovered too late in the course of the disease for effective treatment and far too many reach tuberculosis sanatoria when the disease has advanced too far for a hopeful outcome. The Venereal Diseases The venereal diseases constitute an important health problem with serious implications for many groups of the population. It has been found that approximately 518,000 new patients infected with early syphilis seek treatment each year, and that approximately 1,037,000 are infected with gonorrhea and seek treatment for this disease. Congenital syphilis is an important and preventable cause of infant deaths and loss of fetal life, particularly among Negroes. Some 60,000 cases of congenital syphilis occur annually. The syphilitic involvements of the heart and blood vessels and of the nervous system result in almost 50,000 deaths annually in addition to those assigned specifically to syphilis, 80 percent of which could be prevented by adequate treatment of the infection in its early stages. The increase in chronic nervous diseases is placing a severe burden on our institutional facilities and is creating enormous costs for our State and local governments. At least 10 percent of first admissions to mental disease hospitals are attributable to syphilis in its manifestation as general paralysis. These cases can be eliminated by adequate early treatment of syphilitics. The inadequacy of treatment facilities and practices is indicated by the following facts:
Pneumonia An average of 96,500 deaths from pneumonia occurred annually in the period 1930-1935; as a cause of death, pneumonia is exceeded in importance only by the diseases of the heart, blood vessels, and kidneys and by cancer. Each year, pneumonia disables nearly 600,000 persons. The death rate from this cause is highest among infants and children of the preschool ages, and among persons in late-middle and old age. At least 85 percent, or 500,000, of the pneumonia cases occurring annually are caused by the pneunococcus; anti-pneumococcus serum has been developed for the specific treatment of over one-half of these cases. There are encouraging evidences that in over half of the cases of lobar pneumonia, the case fatality can be reduced by as much as one-half through the skillful use of serum treatment. Pneumonia mortality and disability is excessive among workers exposed to marked changes in temperature, inclement weather, poor ventilation and a dusty atmosphere. Health supervision of the worker and his environment is an effective measure in reducing sickness and deaths due to this cause.
The inadequacy of clinic and nursing supervision of infants and preschool children on a community basis has been noted; such measures are important in the prevention of pneumonia in the ages in which mortality is highest. Present activities in the field of industrial hygiene, in common with other preventive services for adults, are generally inadequate. The status of pneumonia treatment on a community basis is indicated by the following facts:
Malaria The importance of malaria as a regional public health problem is indicated by the fact that 97 percent of the deaths from this cause in 1934 occurred in 14 southern States. In the country as a whole, the average death rate from this cause is relatively low. Great progress has been made in the control of malaria since the discovery of the method of its transmission by the mosquito. In certain southern States, however, malaria still remains a leading cause of death, and it has shown little tendency to decrease in the past decade. The disability resulting from malaria is a serious handicap to workers in the rural areas of the South where the disease is endemic. Effective control measures include education, the detection of malaria carriers, location of the focus of infection and its elimination by drainage, the use of larvicides and the prevention of "man-made" hazards. Application of well-established methods has greatly reduced the malaria problem in areas in which they have been fully developed. The malaria control program in the South has been notably advanced in recent years through drainage projects of the State health departments carried on in cooperation with the Works Progress Administration and the Public Health Service. State health departments in the South have set up new malaria investigation and control units with medical, engineering, entomological and laboratory personnel to carry on epidemio-
logical surveys routine inspection of malarious regions, and public health education--services which will be extended by an adequately staffed county health department. Basic research is needed to discover a means of removing residual malaria parasites in order that recurrent attacks of clinical malaria, and development of the disease among carriers, may be prevented. The best modern methods of treatment of malaria accomplish only the arrest of clinical malaria through removal of the parasites from the peripheral circulation; complete elimination of the parasites is attained only through the development of immunity in the patient. No known therapeutic measures exist for the sterilization of malaria carriers or of cases which have recovered from a clinical attack; present methods of so-called prophylactic treatment of the latter are not effective in preventing subsequent attacks. More effective control of malaria by destruction of the insect carrier will be possible with the development of an effective method of biological attack on the mosquito; research in this field is now in progress under the direction of the United States Public Health Service. Additional needs in this field include the expansion of personnel of county health departments, and an increase in fluids for such specific activities as ditching and control through use of larvicides. The Chronic Diseases of Middle and Old Age The continued aging of the population which is forecast for the near future will contribute to the upward trend of the death rate from the diseases especially severe in middle and old age--heart disease, nephritis, cancer and diabetes. Only a concerted attack on these diseases as recognized problems of public health importance can hope to bring any reduction in the deaths and disability due to these causes. The results of the National Health Survey indicate that chronic disease alone accounts for six of the ten days of incapacity from serious disabling illness experienced by the average person in a year. The long duration of the average case of chronic disease and the specialized requirements for diagnosis and treatment combine to make illness of this type expensive. To persons in low and dependent income groups the assumption of such costs presents a serious burden without such aid from public funds as has been provided for the treatment of the tuberculous and the mentally diseased.
Cancer Control of cancer is one of the most urgent needs in a chronic disease program. Cancer was responsible for 143,000 deaths in 1936 or over 10 percent of all deaths. It is estimated that there are 400,000 living persons suffering from cancer in the United States today. With mortality rates at their present level, it is probable that one person out of every eight who reaches the age of 45 years will ultimately die of cancer. Yet leading authorities have estimated that at least one-sixth of the annual deaths from cancer might be prevented if all cases of the disease received the benefits of modern methods of treatment; an additional number of deaths could be prevented by diagnosis of a larger number of cases in the early stages of the disease. There is, therefore, a three-fold public health need: (1) the establishment of adequate diagnostic centers; (2) the education of the public and of physicians in the supreme importance of early diagnosis and treatment; and (3) the provision of treatment and hospitalization for that large majority of the population who cannot pay for the high costs of these specialized and expensive services. At present, facilities for the diagnosis and treatment of cancer are inadequate and uncoordinated. There is a lack of organized cancer activities with special reference to public health needs. Only six State health departments have assumed responsibility for a coordinated program of cancer control, and local health department activities in this field are generally undeveloped. In addition, there is need for the proper education of medical students in respect to the public health aspects of cancer, and training of specialists in its diagnosis and treatment. Diabetes There were 30,000 deaths in 1936 from diabetes. The number of diabetics in the United States is estimated to be from 400,000 to 500,000. The case fatality from this disease can be greatly reduced and longevity extended by administration of insulin under a regulated regime. Since the introduction of insulin therapy in 1922, death rates from diabetes in persons under 50 years of age have shown a marked decline. A recent analysis of the experience of one of the larger diabetic clinics indicates that the mortality from this cause can be cut for every age, the range of reduction having been from 90 percent or more for young diabetics (under 20) to 37 percent for elderly diabetics (over 60). However, the favorable results of insulin therapy have not oper-
ated to prevent a rise in the death rate from diabetes among persons of all ages, which is chiefly accounted for by the increasing mortality from this cause among women. Diseases of the Heart, Blood Vessels and Kidneys This group of diseases takes an ever-increasing toll of lives. In 1936, deaths from these causes amounted to 581,000: 341,000 from heart diseases, 104,000 from apoplexy, 39,000 from arteriosclerosis and other circulatory diseases, and 107,000 from diseases of the kidneys. While a large proportion of these deaths are the inevitable result of the aging process, much can be done through prevention and treatment to avoid needless cases, to reduce suffering and premature disability and death, and to minimize the economic and emotional distress caused by these diseases. Many of the deaths from these organic diseases are the outcome of earlier infections such as syphilis, acute rheumatic fever, the communicable diseases of childhood, or typhoid fever. It is possible to establish facilities and procedures to arrest infections, and for those cases that result from the process of senescence, there is the problem of providing facilities and care to keep incapacitation and discomfort at a minimum. Arthritis and Rheumatoid Disorders These diseases are rarely responsible for the death of their victims but are responsible for an enormous burden of disability. It is estimated that about one and one-half million persons are disabled annually by arthritis; an additional number amounting to one and three-quarter million are disabled by neuralgia, neuritis and lumbago. Among known means of reducing the disability due to chronic rheumatism are the care and removal of foci of infection such as diseased tonsils and teeth, the treatment of gonorrheal infections, dietary supervision, specialized therapies, and surgery in some of the severe cases of arthritis. It has been stated recently, on good authority, that careful and prolonged treatment resulted in recovery or definite improvement in 90 percent of the cases in several large groups of patients. The hope of coping with the problem lies in a coordinated program of research and in provisions which would make adequate preventive, dental, medical and institutional services available.
Mental Disease and Deficiency An estimated total of half a million persons in this country are in hospitals for mental disease, some 50,000 being on parole. Some 150,000 patients are admitted or readmitted to these institutions annually. The average institutional residence of a patient is three years. Approximately 75,000 persons are in institutions for the feebleminded and epileptic; it is estimated that the number of this mentally deficient group outside of institutions totals some 900,000 persons. In addition, mental illness embraces an unestimated amount of milder forms of the psychoneuroses, a variable proportion of behavior problems now included under the headings of dependency, delinquency and crime, and an additional group representing the outcome of faulty habits and misunderstandings in dealing with environmental relationships. The mentally diseased and defective demand more than twice the volume of hospital and institutional care required by all other diseases combined. All but 2 percent of patients in hospitals for mental diseases enumerated in the Federal census of 1934 were in public institutions; approximately $150,000,000 of public funds--over one-fourth of all governmental expenditures for health and medical services--are expended annually in their operation and maintenance. In addition to the high costs of diagnosis and care, mental disease and deficiency constitute a major source of economic loss due to partial or complete loss of earning capacity. Early treatment of syphilis is effective in the control of general paresis, preventing the extension of this disease to the nervous system. An intensive educational program in accident prevention is required to diminish the increasing frequency of traumatic psychoses resulting from the growth of automotive transportation. The premonitory symptoms of dementia praecox may be detected, and the development of this psychosis prevented, by providing facilities for the psychiatric examination of children. The abnormalities of behavior in childhood may be modified by the special supervision of trained personnel operating in child guidance clinics. Finally, a coordinated program of mental hygiene, carried on in the school, and among adult groups, in particular among parents, offers a means of teaching the basic principles of mental health. The department designed exclusively for the intensive treatment of acute and recoverable cases of mental disease forms an important adjunct to hospital facilities for the mentally ill which should be more
19 widely developed in the interest of the reduction of costs of prolonged hospital residence, and the restoration of many patients to a useful life. Additional trained personnel, as well as increased hospital facilities, are required for the expansion of these centers. Extension of psychiatric teaching facilities in connection with hospitals and medical schools is necessary to provide uniformity in the training of such personnel, and expert consultant service should be maintained for the instruction of institutional physicians in the newer techniques of treatment. Systematic registration of the feebleminded, particularly those below and above school age, is of fundamental importance in planning for their supervision. Institutional care is required for a large proportion of the feebleminded; present facilities are totally inadequate to meet the need. It is necessary that trained personnel be provided for the supervision of feebleminded persons and epileptics on parole from institutions. Finally, the fundamental approach to the problem of mental hygiene demands the development in all State governments, of a department, a division, or a special agency for the effective fulfillment of the needs of the mentally ill of the general population, under medical leadership competent to formulate and coordinate a balanced program. The inadequacy of the present program for the prevention, treatment and supervision of the mentally diseased and deficient is indicated by the following facts:
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Industrial Hazards Industrial hygiene aims to preserve the health of workers. It should therefore involve primarily a program of health conservation and accident and disease prevention. Such a program would necessarily extend beyond prevention of accidents and occupational diseases; it would also include the broad subject of the health of the worker. Some of the problems arise from the nature of the industrial environment itself-namely, the control of poisons, dusts, excessive temperatures and humidities, defective lighting, noise, overcrowding and general plant sanitation. They also involve such factors as hours of works fatigue, communicable diseases in the factory, mental health and personal hygiene. Industrial health is concerned with a large percentage of the population of this country, since according to the last Federal census there were approximately 49 million gainfully occupied persons, of which number nearly 15 million were found in the industrial establishments where a large percentage of our occupational disease and accident hazards occur. The majority of our workers are employed in small plants which are not in a position to furnish adequate industrial health services to their employees. For example, of the more than eight million persons employed in manufacturing plants alone, approximately half are found in factories with less than 250 workers. If these workers are to be given adequate health protection, services will have to be rendered or promoted through some governmental agency. Sufficient occupational mortality data are available to indicate that there exists a greater mortality rate in the industrial population than in the whole group of gainfully employed persons. Excess mortality is especially notable among unskilled workers, among whom the death rate from all causes was 100 percent in excess of the death rate among agricultural workers. Studies of illness in industry made by the U. S. Public Health Service also show high rates of illness among workers. The incidence of such diseases as tuberculosis, pneumonia and degenerative conditions was found to be higher than average in
21 the industrial population. All of these data show a need for a close study of the conditions under which our industrial population lives and works. We must bring public health to the factory as well as to the home. We must accomplish for our adult disease problem what we have achieved in recent years in infant and child hygiene, and industrial groups appear to offer one of the most logical points of approach. That there has been a realization of the need for such a program among public health workers is attested by the fact that today, through the stimulus given by the Social Security Act, there are 22 States and four municipal departments of health which have taken steps to provide industrial health services. However, these units are but in their infancy and will not be in a position to render adequate service to industry and labor unless they have greatly increased financial support and trained personnel. Too much stress cannot be given to the necessity for adequately trained personnel and for adequate funds in order that we may deal with the problems of the health of workers in a manner which will produce substantial improvement and real progress in industrial life with the greatest efficiency and economy. That these objectives are attainable has been demonstrated in the few cases where adequate financial support and qualified personnel were at hand.
V. INCOME AND HEALTH NEEDS In a representative sample of the urban population studied in the National Health Survey, 40 percent of the persons canvassed were found to be members of families with incomes of less than $1,000; 65 percent were in families with incomes under $1,500; and 80 percent in families with incomes of less than $2,000. About one-half of the group with incomes under $1,000 was in receipt of relief at some time during 1935. These figures are fundamental to any consideration of national health because they are basic to any contemplation of capacity to purchase not only food, shelter and clothing, but also medical care. Rich and poor alike have benefited by the progress of public health and the medical sciences. Application of the newer knowledge has reduced to the vanishing point some of the plagues that once killed tens of thousands, and has led to great advances on other fronts where the accomplishments have been significant though partial. However, much of this progress has little significance for a large part of our population--the people who have small means. Community-wide services--so far as they exist--are, of course, available to them. Special services
for the poor and the indigent are at their command. But the services they must buy with funds out of pocket are, in substantial measure, out of their reach when sickness strikes. The advances in national health to which the Committee has directed attention have only limited significance for the poor. It is cause for grave concern, and for action, that the poor of our large cities experience sickness and mortality rates as high today as were the gross rates of 50 years ago. In Massachusetts (where a long series of death records is available) l0 out of every 100 infants born alive in 1880 died during their first year; in that commonwealth today, the average loss is 4 deaths in every 100 infants born alive. Yet as recently as 1931, infants in Denver families with an annual income of less than $500, died at the same rate as average Massachusetts infants in 1880, while among Denver families with incomes of $3,000 or more there were only 3 infant deaths for each 100 live births. In Cleveland, in 1928,infants in the poorer districts died at the rate of 10 per 100 born alive, while infants in the better economic areas had a rate of 5 per 100. In 1930, the tuberculosis death rate for unskilled laborers, in 10 States for which occupational mortality could be computed, was seven times that of professional men. In the general population, the death rate from this cause has been displaced from the leading cause of death to the rank of seventh place and this has been accompanied by a drastic reduction in the gross death rate: But among the industrial workers, among those exposed to special employment hazards, among Negroes and among other special groups, the rates remain much higher than for the population at large. There is danger in the complacent consideration of averages. Death rates tell us of the annual loss of human lives, but we must keep in mind that death rates measure only a fraction of the toll which sickness exacts. For every death that occurs during a year, there are many illnesses. Indeed, if we count only severe disabling illnesses (i.e. those lasting for one week or longer), for each death there are 16 illnesses that mean loss of work for the family bread-winner, absence from school of the school child, or inability of the housewife to go about her normal duties. The association of sickness with low income is illustrated by the following figures taken from a survey made among representative white families in many communities of the United States during the years
1928-1931; the figures relate to wage-earners of both sexes, ages 15 to 64, in the skilled, semi-skilled and unskilled occupations:
In the winter of 1935-1936, the Public Health Service canvassed three-quarters of a million families in 84 urban communities, and obtained information on illness and medical care in relation to family income and relief status. Preliminary results for 2,308,600 persons in 81 of these surveyed communities have brought out some pertinent facts. Disabling illness in the relief population occurred at an annual rate 47 percent higher for acute illness and 87 percent higher for chronic illness than the corresponding rate for families with incomes of $3,000 and over. The annual days of disability per capita in the relief group was found to be three times as great as among upper income families; the non-relief population with an income under $1,000 showed an amount of disability over twice that of the highest income group. One in every 20 family heads in the relief population was unable to work because of chronic disability, as contrasted with only one in 250 heads of families with incomes of $3,000 and over. Children of relief families experienced 30 percent greater loss of time from school and usual activities because of illness than did children in families in moderate and comfortable circumstances. Too often, the final outcome of illness is unemployment and dependency as shown in the following recent reports:
Evidence on the association of sickness and poverty could be enumerated at great length. Perhaps these few citations will suffice. Every substantial study of sickness in the population, whether in urban or in rural communities, serves only to furnish additional proofs. And every careful inquiry, directed to the point, shows clearly that "environmental" factors are at least as certainly responsible as are "genetic" factors. Not the least of the "environmental" factors is economic status. Sickness rates are higher among the poor than among those who are in better economic circumstances. As a corollary, the poor need more health and sickness service than the well-to-do or the wealthy. The poor have much sickness; sickness brings poverty. This circular relation brings anti-social results. The people who are involved in the vicious circle are trapped; they cannot raise themselves out of it by their bootstraps. Only society, which pays a heavy price for this continuing situation, can intervene and bring relief.
VI. INCOME AND THE RECEIPT OF HEALTH SERVICE The purchase of health services is still mainly a matter of private and individual action. Though government (Federal, State and local) spends considerable sums, and though organized groups pay an important share of the nation's bill for sickness, the individual patient still carries the lion's share through out-of-pocket payments. This may be illustrated by the breakdown of the national bill for all kinds of health and medical services, taking 1929 as illustrative of a prosperous pre-depression year, and 1936 as the most recent year for which comprehensive estimates are available:
Although there are some important exceptions, medical care is, in the main, an "economic commodity" which is purchased and paid for directly by the individual who needs it. The fact that this "economic commodity" is chiefly a professional service does not alter the basic fact. It therefore results that the amount of medical care obtained by individuals differs with economic status; the well-to-do obtain more, the poor obtain less. This is so notwithstanding the fact that the poor have more sickness and more disability, and need more (not less) service. There are some notable exceptions to this generalization. In areas where extensive provision has been made for free hospital care for needy persons, the amount of hospital service received (per capita) by the poor is sometimes actually greater than the amount received by any except the very well-to-do. But this is only an exception proving the rule that the amount of medical care received (measured in number of services) varies with the person's ability to pay for it. For example, a survey made during 1928-1931 among representative family groups in 130 communities, scattered among 17 States and the District of Columbia, showed the following volumes of services received during a 12month period:
Although there is more disabling sickness among the people in the low income groups than among those in the higher brackets, the proportion who went through a year of life without professional care was more than three times as high among the poorest as among the wealthiest families. This is summarized in the following figures:
Without laboring the point, a few facts may be cited from the recently completed National Health Survey:
These findings are in accord with the facts revealed in numerous other surveys made in various parts of the country. Each study adds additional evidence that the receipt of medical care depends largely on income and that people of small means or none at all, though having the greatest need for care, receive the least service.
VII. INCOME AND THE ABILITY TO PAY FOR HEALTH SERVICE Although ignorance, indifference and other factors play a part, the main reason why persons in the lower income brackets do not receive proper medical care is that they are unable to pay for it. Surveys of family expenditures show that, by and large, families, tend to spend, on the average, 4 to 5 percent of income for medical care. The proportion of income spent for medical care is fairly constant, whatever the income, up to an annual family income of $5,000, beyond which it tends to decline slightly. A survey showed that in 1928-31, families with
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The present expenditures of families in the lower income brackets may be compared with the cost of adequate medical care. A number of estimates have been made of the per capita or per family cost of furnishing adequate medical care to a representative population group. Such estimates run from a minimum of $100 a year for a family of four, to more than double this amount. Even taking the lower figure, it is apparent that this cost is more than a sizable proportion of families can afford to spend for medical care. An examination of family budgets leads to the conclusion that families with incomes of $1,000 cannot afford to spend as much as $100 a year, on the average, for medical care. The same conclusion probably holds for families with annual incomes of $1,500. Yet, even in 1929, about 12 million families in this country, or more than 42 percent of all, had incomes of less than $1,500. Although reductions in the cost of providing medical care are possible, and although education may induce people to divert a larger portion of income to the purchase of medical care, the fact nevertheless remains that a large proportion of the population--certainly one-third, and perhaps one-half--is too poor to afford the full cost of adequate medical care on any basis. This proportion of the population cannot purchase adequate medical care without depriving themselves of things which, in the long run, are just as necessary for decent healthy living as medical care. The one-third of the population which is ill-nourished, ill-housed, ill-clothed is also badly cared for in sickness and for the same reason: because income is too small. The situation as regards the purchase of medical care, as thus outlined, is somewhat oversimplified by the fact that the analysis runs in terms of averages. In actuality, sickness comes to individual families in average amounts, as it were, only by chance. The individual family's need for medical care is uneven and unpredictable. In one year, little medical service or none whatsoever may be required; in another year, the family may suffer one or more severe illnesses among its members and medical service costing large amounts may be required. One example will suffice. In 1928-31, a sample of urban families with incomes of $1,200 to $2,000 annually, incurred medical costs in a
year's period amounting to approximately $75 each, on the average. However, of 1,000 families, 620 had medical expenses for the year of less than $60 to $300 incurred costs of from $60 to $200, and 90 had expenses running from $200 to over $1,000. Of the 1,000 families, 20 had medical bills ranging from $400 to over $1,000--bills which, if paid, would have absorbed from one-third to one-half or more of the family's entire income. This situation has two results. One is that available income is not well harnassed to the purchase of medical care. The family spends its income from day to day and does not save against the day of serious sickness and large medical bills. As a consequence, many individuals who could pay for their medical care if they made regular provision therefor, either go without care when sickness comes or are forced to ask for charity. A second result of this situation is that families endeavoring to pay their own way are oftentimes confronted in severe illness with medical bills which they can pay only with hardship. The expense of proper medical treatment in certain illnesses has now become an economic hazard like unemployment or death, against which the average family requires protection. The burden of sickness costs is mitigated in some measure by the arrangements whereby fees are adjusted to ability to pay. But the sliding scale operates only in limited ways and more particularly for specialists' than for other services. Though free and part-pay services and facilities have been extensively developed, especially in the large cities; though physicians give generously of their services; though hospitals are extensively equipped to care for the poor without direct charge to the patients and to give service at part pay; and though governments have greatly increased tax support for services furnished to the poor, the fact remains that large costs still fall on small purses. The poor still have fewer of their serious illnesses professionally attended and they purchase less adequate services than the well-to-do. The result is all the more serious because the poor have more sickness and more disability and need more--not less--services. All evidence available to the Committee indicates that the problems raised by sickness costs present two clear-cut needs: (1) For people with incomes, ordinarily self-sustaining in respect to other essentials of living (food, shelter and clothing), health and sickness services must be made more extensively available through measures that will lighten the burdens of sickness costs. This requires appropriate
arrangements to minimize the impact of these costs on individual families through distribution of the costs among groups of people and over periods of time. To what extent the result shall be attained through more extensive use of tax support and to what extent through social insurance, or through a combination of both, is not at issue. Each procedure is applicable to parts of the problem, and each may be more appropriate than the other for particular groups in the population and for particular areas. (2) Larger financial support is needed for services to be furnished to people who are without income, who are unable to obtain necessary care through their own resources. Finally, it may be noted that what has been said regarding the Unequal distribution of the costs of medical care applies also to the loss of wages suffered because of disability or permanent incapacity of the bread-winner. Disability wage-loss amounts, in the aggregate, to something like 2.5 percent of income. But it occurs among families variously in small and in large amounts. Disabling sickness hangs as an ever-present threat over the wage earner. He cannot budget individually against this risk. Provision through social insurance, or through systematic public assistance, or through both devices, is urgently needed to bring security of income against this common risk which threatens people of small and precarious earnings.
VIII. PERSONNEL AND FACILITIES FOR HEALTH SERVICE An effective system of modern health service is impossible without an adequate professional personnel and institutional equipment. This implies a sufficient number of competent persons, effectively trained and experienced, a sufficient number of suitable hospitals, sanatoria and other institutions and an appropriate geographical distribution of both personnel and institutions. All things considered, it is probable that the most acute need in the United States is for more effective distribution, recognizing that this involves fundamental economic considerations. Ineffective distribution and, in certain areas, more or less complete lack of hospital facilities and of medical and public health personnel account in part for excess in mortality and sickness from certain causes. The supply of physicians and private duty nurses, if adequately distributed, appears to be approximately sufficient to meet the current effective demand for service. Public health nursing, however, suffers from an undersupply of personnel. The number of dentists is
determined today by the economic capacity of the public to pay for dental service through current. methods of payment; the number is grossly less than would be required to meet the true need for dental services. Hospital facilities are insufficient to meet the full need for institutional and out-patient care in many areas. Physicians There are 165,000 physicians in the United States today, or a ratio of 128 per 100,000 of the population. These would be approximately sufficient in number to supply the medical needs of the population if they were better distributed in relation to the need for service and if their potential services were being effectively or fully utilized. Young, well-trained men turn to urban centers to begin practice where professional and economic opportunities are greatest because of hospital facilities and higher average income of the people, despite the fact that many of these centers already have an adequate, or more than adequate, number of physicians. Many rural areas, small cities and whole States are undersupplied with physicians. More recognition of the uneven distribution of practitioners will not solve the problem; practice in the underprivileged area must be made attractive from both a professional and economic viewpoint before the young physician can be expected to settle in these areas where his services are most acutely needed. Nurses The supply of private duty nurses is probably sufficient to meet the present needs of the population. However, nurses are not evenly distributed throughout the country; there is a concentration of available nurses in cities, and a limited supply in rural areas. Even more important, large numbers of sick persons are unable to obtain needed nursing services because of inability to pay. There is a definite undersupply of nurses to visit in homes of the low income groups, to give bedside care and health instruction, and to render assistance in clinics. To carry on these important health functions, one nurse to each 2,000 persons, or approximately 65,000 nurses, would be required. At present there are only 18,000 nurses attached to public health agencies that might be utilized for these purposes. In rural areas, the ratio is, on the average, one nurse for every 11,000 persons and in cities, one nurse for every 5,000. In some States, one nurse must (if she can) serve as many as 40,000 persons. Such nurses
are particularly needed for maternal and child care and it is clearly not possible for good prenatal care to be given by nurses if they are required to serve too extensive an area or too large a population. At least three to four times as many field nurses as are now available in rural areas are needed, and at least twice as many in cities, if satisfactory maternal and child health service is to be rendered. A dual problem is here evident: (1) the training of personnel, and (2) the provision of organization and funds for their effective employment. Dentists There are at present about 71,000 dentists in the United States or an average of 58 per 100,000 of the population. Estimates of the needs for adequate dental care for all our population indicate that the number of dentists could be doubled without reaching a figure in excess of the true need. As in the case of physicians and nurses, the number of dentists available is particularly inadequate in rural localities, small cities and other areas where income is low. Because of the enormous accumulated neglect in dental care among adults, such funds as are available for dental care should be directed especially toward preventive and other dentistry among children. Hospitals Each year finds the hospital filling a place of increasing importance in the maintenance of the nation's health. At one time, only the person near death went to a hospital; today, the sick go there to receive care and to be cured; tomorrow, well persons will seek the hospital for the prevention of illness and disability. The technology of modern health service requires increasing use of the clinic and outpatient department. The facilities must be adequate for the care of the bed-patient, the ambulatory sick person, the patient in the early stages of disease and the person in need of preventive care. The increasing importance of the hospital in our national health services is the result of a variety of factors. In urban centers, home care of the sick is increasingly difficult in the crowded dwellings of the majority of the population. In rural areas, physicians can increase their efficiency and effectiveness tremendously if a hospital is available to furnish diagnostic and consultation facilities. Here the hospital serves a larger purpose than the treatment of its in-patients who constitute a small fraction of all the sick; it becomes the center for the health services of the community and influences the quality of care
in the doctor's office and in the patient's home. Furthermore, the pattern of illness is changing as the proportion of older persons in the population increases. The illnesses of adult life--cancer, diabetes, heart and circulatory diseases, kidney diseases--are not subject to the mass methods of environmental control; they require attention to the individual through the services of physician, dentist, nurse, and technician. With the increase in complexity of diagnostic and therapeutic procedures, care can often be given best in a hospital where modern facilities for, diagnosis and treatment which the private physician cannot maintain for himself, are available. Although the hospital facilities of some communities--especially of some large cities--exceed current effective demand for service, existing institutions are grossly inadequate to meet the needs of the population in many parts of the country. Such inadequacies are especially important and severe in rural and in economically underprivileged areas. Enlargement of hospital facilities is needed in many areas where there are some hospitals; construction of new institutions is required in many regions where none have been built. Without such institutions, well-equipped and well-staffed, many of the important services which twentieth century medicine offers to the public are impossible of attainment. Furthermore, there is a growing need for other local facilities equipped to serve as centers for diagnostic and preventive services, where organized health agencies may operate in close correlation with medical and related practitioners. Professional standards of adequacy indicate a need for general hospital facilities in the ratio of 4.6 beds per 1,000 persons, nervous and mental hospital facilities in the ratio of 5.6 beds per 1,000 persons, and tuberculosis hospital facilities in the ratio of 2 beds per annual death from this disease. In this country today, over two-thirds of the States fall below these standards in general hospital facilities, nine-tenths are below the standard for mental hospitals and three-fourths of the States fall below the standard for tuberculosis hospitals. For general hospitals, even a minimum standard of 2 beds per 1,000 persons for areas (mostly rural) which are 50 miles beyond a large hospital center, would require substantial additions to existing facilities. A total of 31,000,000 people now live in areas with less than 2 general hospital beds per 1,000 persons. Nearly 1,300 (42 percent)of the counties in the United States have no registered general hospitals. Being largely rural or sparsely settled, these counties include only 15 percent
of the population.. Nevertheless, this means that there are 18,000,000 persons who are living in counties with no local hospital facilities. Special surveys would be required to determine which of these counties are adequately served by hospitals in adjacent counties and which need additional local facilities. Capital investment in hospital construction diminished from a figure of $200,000,000 annually in the period 1923-1928 to about $50,00,000 in the period of 1932-1936. A large part of the relatively limited construction in the latter period was the result of the P.W.A. program. The stimulation of new construction is imperative because of this resulting accumulated deficit. Today, the United States has about 1,100,000 beds in general, special, mental, and tuberculosis hospitals. According to the minimum professional standards of good care, about 1,500,000 beds will be needed by the end of the next decade. This means a deficiency of about 400,000 beds. Measures to fill this need would include the construction of at least 500 hospitals of 30-60 bed capacity in rural and sparsely settled regions which have inadequate hospital facilities. The amount of chronic disease and the need and economy of adequate care, has been demonstrated by the National Health Survey. Some chronic patients require diagnostic and treatment services equivalent to those of an acute hospital case; others need only skilled nursing or custodial care after their condition has been diagnosed. The large number of beds needed for chronic patients of both types should usually be built in association with general hospitals. In addition, health and diagnostic centers are greatly needed in rural areas where they may serve as centers for the local health department staff; visiting nurse services, maternal and child welfare staff, for basic laboratory and other diagnostic services; for local physicians, for emergency beds, etc. It may be conservatively estimated that about 500 such centers might properly and usefully be built in areas which are without local hospitals but, being adjacent to areas which have hospitals, can have the needs of their people and their physicians met by these centers. SUMMARY The Technical Committee was charged with the duty of assessing the state of the nation's health, of relating what is being done against what can be done, of searching out and defining needs not met through current practices, and of outlining proposals through which the national health may be improved. The combined effort of private practitioners, of public health personnel functioning through organized State and local governmental health agencies, and of professional and lay organizations, has brought about an encouraging reduction in mortality operating chiefly in the period of childhood. The aging of our population gives new importance to accepted procedures in the conservation of maternal and child health, and to new steps designed to maintain the health of persons in the productive years. The increasing proportion of persons in middle and old age focusses attention on the special health needs of the period in which the chronic diseases predominate as causes of disability and death. Certain specific needs developing from a consideration of these broad problems may be briefly summarized:
As a nation, we are doing vastly less to prevent suffering and to conserve health and vitality than we know how to do throw tried and tested methods. The Committee is convinced that current activities are inadequate to assure the population of the United States such health of
body and mind as they can and should have. Sanitary advance owes much to epidemics or threats of their approach, to outbreaks of contagious disease among school children, to floods and other disasters of the past; but we cannot permit the future of health services to continue to rest with the accidents of history. A good beginning has been made in more recent years toward carrying out health activities through well-planned and directed effort, but systematic warfare against disease on a broad front is long overdue. The Committee finds there is need and occasion now for the development of a national health program.
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