Senator DONNELL. Mr. LaGuardia, you would not favor, would you, generally speaking, the right of a public official to determine for you individually whom you shall have as the doctor for yourself or a member of your family? Would you favor that general plan?

Mr. LAGUARDIA. No; but I would favor providing medical service in cases where no medical service would be possible.

Senator DONNELL. But, Mr. LaGuardia, this document here, S.1606, is a Nation-wide plan, and it provides, as I see it, in New York City just as well as in Marysville, Mo., that the Surgeon General may say how many patients a given doctor has, and if you live next door and in an emergency case wanted to consult him, for illness in your family, if he has gone up to the complete limit you cannot get that doctor! Mr. LAGUARDIA. For an immediate emergency?

Senator DONNELL. Under any circumstances.

Mr. LAGUARDIA. Oh, sure.

Senator DONNELL. Just where is the provision in the act authorizing it?

Mr. LAGUARDIA. You say the doctor lives next door?
Senator DONNELL. Yes.

Mr. LAGUARDIA. You have an emergency, and you cannot call on him for this emergency and he will not respond?

Senator DONNELL. I think that shows the absurdity of this provision that limits the number of patients.

Mr. LAGUARDIA. That is all right.

Senator DONNELL. I understand your point, but if you are a person suffering from a disease of quick emergency, or even not of quick emergency, for instance, suppose you have a chronic illness and you would prefer to have the right to pick the doctor of your selection, you would find him unable to serve you because his quota is filled, would you not?

Mr. LAGUARDIA. I think as a practical matter there would be no difficulty in cases of that kind at all. You are just seeing things.

Senator DONNELL. Well, the statute is pretty clear in its language, I think.

Mr. LAGUARDIA. The statute is for the protection of the patient, so that the doctor would not overload himself with too many cases, and that is necessary. We have learned that by experience.

The CHAIRMAN. You do not think there would be any great difficulty in handling a situation of that kind?

Mr. LAGUARDIA. None at all.

The CHAIRMAN. Even though the doctor did have his quota, it would be a simple thing for him to take another case?

Mr. LAGUARDIA. There would always be latitude.

Senator DONNELL. Yet the act does provide, and I am reading:

The Surgeon General may prescribe maximum limits.

Mr. LAGUARDIA. That is for the protection of the patient.
Senator DONNELL. But he does have the power to prescribe these

maximum limits?

Mr. LAGUARDIA. Absolutely. I am strongly for it.

The CHAIRMAN. If there are no other questions I wish to thank you very much for your very fine presentation here this morning. The next witness will be Mr. Fichter.

STATEMENT OF JOSEPH W. FICHTER, CHAIRMAN, JOINT SUBCOMMITTEE ON HEALTH OF THE NATIONAL PLANNING ASSOCIATION

The CHAIRMAN. Mr. Fichter, you are chairman of the Joint Subcommittee on Health of the National Planning Association?

Mr. FICHTER. Yes, sir.

The CHAIRMAN. You are anxious to get through with your testimony this morning so that you may leave the city. Do you have a prepared statement?

Mr. FICHTER. Yes.

The CHAIRMAN. You may proceed.

Mr. FICHTER. Mr. Chairman, and members of the committee, I believe that the statement I have here has been distributed to the members of the committee. If it has not, I shall get you extra copies. I am very happy to be invited to report to you on the findings of the Joint Subcommittee on Health of the National Planning Association. I am master of the Ohio State Grange and chairman of the Committee on Health of the National Grange. Since I am appearing before you as chairman of the National Planning Association Subcommittee, it may be useful to those of you who may not be entirely familiar with National Planning Association's background to have a brief explanation of its approaches to the study of national problems.

THE NATIONAL PLANNING ASSOCIATION

National Planning Association is a nonprofit, nonpolitical organization established in 1934. For the past several years NPA's work has been carried out mainly by four standing committees: three on national policy-the Agriculture, Business, and Labor Committees; and one on international policy, which weights the international implications of the problems under consideration by the Committees on National Policy. I have here a leaflet, which I will be glad to submit to you, which includes the names of NPA's board and committee members.

The joint subcommittee on health-for which I am speaking this morning-was set up by the committees on national policy in 1945, and includes members from each of those committees. Incidentally, I serve regularly as a member of the Agriculture Committee.

The subcommittee is trying to find out the economic effects of a program to provide adequate medical care to the people of the United States. During the past months we have held a number of meetings, have had staff members diligently sifting published and unpublished material, and have consulted many experts in the varied fields of medical care. Our report is not yet complete. The information which I am presenting to you this morning is more or less in the nature of a progress report. We hope soon to submit a complete report to the standing committees which they will wish to endorse. Perhaps after consideration of the facts we have been able to assemble, the committees may feel justified in going further with recommendations on a national health program which would have the joint support of farmers, businessmen, and workers.

In the meantime, in this preliminary report to you I will try to reflect as nearly as possible the views of my associates on the NPA subcommittee and staff. If in the course of our discussion you ask questions about which I seem to hesitate, it is because I want to keep my personal views in the background as much as possible, and bring to the foreground the thinking of the group as a whole-a type of presentation which I believe is NPA's most unusual and useful contribution.

The subcommittee recognizes that the reduction of human misery is the most important reason for trying to improve the health of the people, and that the intrinsic value of the individual human being is such that no justification is needed for helping to save his life. Nevertheless, a program to provide adequate medical care for all the people would have its economic repercussions and we think it useful to try to find out of what sort and how great these would be.

Our subcommittee has completed a preliminary study of two parts of this project. First, we have investigated the cost of a campaign to wipe out tuberculosis and compared this with the costs of going on with this disease year after year, as we do now. Second, we have examined the cost of building enough new hospitals to provide beds for all who need hospital care and the amount of materials and manpower required to build them. I might add that the subcommittee is planning to study other important factors entering into the provision of adequate medical care with a view to discovering their economic effects. Facts developed in our future studies will be included in our final report, which I will be glad to send to all of you if you care to see it when it is published.

TUBERCULOSIS CAMPAIGN

The subcommittee chose to study tuberculosis because it is a costly and communicable disease which we could virtually eliminate by putting into practice the knowledge we now have concerning its treatment and the way it is spread. Much excellent work is being done by private and public groups, whose experience we have been able to draw upon in making this study. However, much still remains to be done if we are to attack the problem on the same scale throughout the country.

Congress itself, the State and local governments, are to be congratulated for providing our best lesson on a national, coordinated, and highly successful program to wipe out tuberculosis-tuberculosis

in cattle.

We have studied this campaign, which began in 1917, and are impressed with the fact that the United States has already succeeded in practically wiping out tuberculosis in cattle. But we think it even more important to do this for human beings.

I'd like to refresh your memories on the campaign to eradicate tuberculosis in cattle. This disease was causing increasing losses to the farmers of this country. The peak loss occurred in 1917 when 40,746 cattle and 76,807 hogs, which were infected by the milk and droppings of cattle, were condemned for tuberculosis under the Federal meat inspection laws. The loss to the livestock industry from this disease was estimated to be $40,000,000 annually at that time. In addition, it was recognized that bovine tuberculosis could cause

tuberculosis in man if he used the milk or other unpasteurized dairy products from infected animals.

Accordingly, in 1917 Congress appropriated $75,000 for tuberculosis eradication in livestock, and in 1918 it provided for paying an indemnity for the tuberculosis cattle slaughtered. In 1935, the Federal, State, and county appropriations totalled 26 million plus, which was the maximum amount for any year. Since then the amount necessary for this work has decreased until now only a small amount is required. In 1917, about 5 percent of the cattle in the country were found to be tuberculosis, and there were varying degrees of tuberculosis in every State. When the infection is reduced to less than one-half of one percent of the cattle population a county is called a modified accredited area, and is considered to be practically free of bovine tuberculosis. By November, 1940 all States as well as Puerto Rico and the Virgin Islands were 100 percent modified accredited.

How was this accomplished? First, a campaign of education to explain how infected animals spread the disease to the uninfected was undertaken by many groups. The Bureau of Animal Industry in the Department of Agriculture, practicing veterinarians, State livestock sanitary officials, members of cattle registry associations, and others, all aided the educational work.

Then, under a cooperative program between the Department of Agriculture, State livestock sanitary officials and livestock owners, all cattle were tested for tuberculosis, and cattle found to react positively to the tuberculin test were slaughtered under the supervision of veterinarians after being given an appraised valuation.

In the case of animals, the difficulty of providing effective treatment, and their relatively short lives made it more economical to slaughter the diseased ones. The owner receives, in addition to the value of that beef which passes inspection, indemnity payments from the Federal and State Governments.

These indemnities averaged $18.75 and $27.50 per head, respectively in 1943. Although the testing was voluntary at first, many States made it compulsory after a large majority requested this.

If recognition of the costs of bovine tuberculosis to the livestock industry caused the undertaking of such a successful campaign to eradicate the disease, it seemed to us at the NPA that it would be worth while first to examine the present costs of the disease in human beings. In presenting figures on these costs you will note that we have called them "approximate" in the summary table which we have labeled exhibit A, and you might want to follow that table in the back as I read. It is the first one. We used the year 1943, as it was the most recent year for which we could obtain some of the information. We found that there were no precise figures available on a number of the points involved, but we had the help of several experts in tuberculosis in estimating the amounts spent, and we believe that these figures present a reasonable picture of the size of the expenditures. However, they are preliminary, and we may revise them in the course of our study.

ANNUAL COSTS OF TUBERCULOSIS

About $104,000,000 was spent in 1943 on the care of those sick in tuberculosis sanatoria. The amount spent for the care of those with tuberculosis at home was about $9,600,000.

What was spent on control measures exclusive of sanatorium care? These include health education; finding the cases; following up and examining people who have been in contact with such cases; and rehabilitation work so that those who have been ill can earn their living with less danger of relapse. About $15,000,000 was spent on these measures. The State, local, and Federal public health departments spent $1,580,000 plus in cooperative work on tuberculosis in the fiscal year 1943-44; the National Tuberculosis Association, which raises all the money it spends on fighting this disease by the sale of Christmas seals, received $12,000,000 plus from this sale at Christmas, 1943. It is estimated that about $1,000,000 is spent on tuberculosis by the health services of civic and welfare associations, private physicians, hospitals, school systems, industry, labor unions, foundations, and by State vocational rehabilitation agencies.

The Veterans' Administration spent about $38,000,000 in the fiscal year 1943 on pensions for veterans whose major disability was tuberculosis. They also spent money on out-patient treatment for tuberculosis, but could not tell us how much since they do not separate their out-patient expenditures by disease.

Probably about $19,000,000 was spent on aid to families where the wage earner was ill for a long period with tuberculosis.

About $1,250,000 was spent in 1943 on medical research on tuberculosis. The United States Public Health Service, including the National Institute of Health, spent about one-third of a million dollars and the groups with whom it cooperates on this problem spent about two-thirds of a million. Other institutions probably spent around a quarter of a million dollars. This money was spent on search for more efficient control techniques, for a chemical or penicillin-like treatment, and for special problems such as vaccination and laboratory investigations.

If we add up all these amounts we find that a total of about $186,850,000 public and private funds was spent on this disease in 1943; and because this was a war year, practically no construction of new hospital beds was undertaken.

Yet this very large sum which is spent on tuberculosis annually takes no account of the personal income lost to families which occurs when wage earners die or are disabled by this disease, nor of the output of goods and services lost to the Nation from this cause. Such losses are especially important in the case of tuberculosis, since this disease tends to strike men and women during the most productive period of their lives-between the ages of 20 and 45. Nearly onehalf of all deaths from tuberculosis in the United States during the period 1939 to 1941 occurred among persons in this age group. From early adulthood to age 35, tuberculosis is the leading cause of death It is one of the first three causes of death from ages 15 to 49. In add:tion, there are great numbers of people at these productive ages whe are disabled from tuberculosis but who do not die. Since the treatment takes months or years, and since there is danger of relapse if th arrested case overexerts himself, tuberculosis is likely to have a permanently depressing effect on the individual's output and his income. What would the adults who died of tuberculosis in 1943 have earned if they had been alive and employed in that year? The number of potential wage earners who died of tuberculosis in the United States in 1943 was 41,631. Average incomes for the population as a whole.