Mr. TARVER. Including municipalities? Dr. HILLEBOE. Yes. I should clarify my statement by saying that in some of the types of research we work with the State health departments, through local agencies, under the State health department, where we have our people working in those departments. Mr. KEEFE. May I interrupt you right there? Dr. HILLEBOE. Yes. Mr. KEEFE. While a liaison is provided between the municipal hospital and the work you have described, that liaison between the Public Health Service and the private institution is done, is it not, through the State health program? Dr. HILLEBOE. That is right. Mr. KEEFE. And is handled through the public health, the State public health. Dr. HILLEBOE. That is correct. I want to point out also that one of the big things that has happened in the last 3 years on tuberculosis control is that we have been able to reduce the cost of case finding. Up until 1939 it was necessary to take a large-sized film, of about 14 inches wide and 17 inches high, and this covers the entire chest. The actual material and cost of developing that usually was $1 apiece, and by the time you got the interpretation the cost would be up to $5 or $10, so the cost itself was prohibitive, and the number of personnel needed to carry it on was prohibitive. Within the last 4 years, mainly because of the research work that has been done in the Public Health Service, we have developed a new method of case finding. PLAN FOR REDUCING TUBERCULOSIS MORTALITY Mr. TARVER. We had some testimony about that last year, and it was very interesting, but my objective here is to find out just how you expect to project this new program. Dr. HILLEBOE. Very good. On the basis of this smaller film it has made it possible for us to examine thousands and thousands of people, one of the necessary jobs that must be done in that regard. And through this method of approaching the problem of tuberculosis control, we can now examine millions of people where we could only examine in the neighborhood of thousands before. So on the basis of the over-all program, Judge Tarver, we have found that there are four principal things that must be done to have an effective plan in reducing tuberculosis mortality. One, we must have large scale case finding. Second, we must have increased facilities for taking care of and isolating the persons who are discovered to have tuberculosis. Third, there must be some provision made for after care and rehabilitation of those individuals after tuberculosis has been arrested. Fourth, more attention must be given to mobilizing community resources in order to protect the tubercular families against economic distress. Those are the four principal points we have set out as the objective under tuberculosis control. REQUIREMENTS OF STATES FOR PARTICIPATION IN TUBERCULOSIS CONTROL PROGRAM Mr. TARVER. You make the necessary allocations to the various States? Dr. HILLEBOE. Yes, sir. Mr. TARVER. What are the requirements as to the purposes for which the State is using the money? Dr. HILLEBOE. The requirements as to the purpose for which the State is to use the money are as follows: First of all, that the State have a definite plan of tuberculosis control, so that all phases of it are considered, and not limit it to just one particular line in which the State might be interested. Second, there are also certain basic requirements that should be fulfilled: One is to have a full-time tuberculosis control official in the State office, whose responsibility will be to develop a program and to carry it out. In 24 of the 48 States, on January 1 of this year, there were no full-time tuberculosis control officers. And that is one of the objectives in carrying out the program. Another is in finding and pointing out specific ways and means in which clinical facilities should be increased so we can examine the people suspected of having tuberculosis. We must develop nursing services so that nurses can go into the homes and examine contexts of those cases that have tuberculosis. We request State health departments to establish diagnostic clinics so that they can determine whether or not certain people are infectious, whether they can spread tuberculosis. That normally means making facilities available on a broader scale so that there will be no difficulty in making such examinations. Furthermore, we require that standards be set up to make the greatest use possible of the available data or statistics that have been developed in other phases of the health department program. Mr. TARVER. Now suppose that a State organization decides to spend all of the money allocated to that State in meeting the requirements of personnel to which you have made reference, in the conducting of tests and that sort of thing. Is there any way by which any benefit accrues to the indigent persons where they are found to be afflicted with tuberculosis and who have no place to go for treatment, from the use of these funds? Dr. HILLEBOE. Yes, sir. USE OF GRANTS-IN-AID TO STATES FUNDS Mr. TARVER. That is what I am particularly interested in. Is this a study program entirely, or is it to be of some practical benefit, for example, to the person who is found to have active tuberculosis where that person is financially unable to provide for his or her own. treatment? Dr. HILLEBOE. You want to know what is done with the $5,200,000? Mr. TARVER. I would like to hear you tell us what you are going to do for the health of people who have tuberculosis, whether it is all going to be spent on salaries. Dr. HILLEBOE. Very good, sir; I will be glad to answer that question. The $5,200,000 for grants-in-aid, is almost entirely for service in providing the professional skill, the laboratory skill, to search out these people and to develop and to utilize already available community resources for individual patients. If I may follow that through with a particular case: If an examination is conducted in a large industry and individuals are found to be tuberculous by the doctor employed by the State health department, one of the difficult tasks of that doctor is to explain to those individuals that they have tuberculosis and are going to require treatment. He makes provision then for this individual to go to a clinic in the community, and it is out of the $5,200,000 that payment for this physician and for this service is made. And, when the final clinical diagnosis is made the same personnel will arrange, through the community facilities, to hospitalize the individual, to get him into the hospital. Mr. TARVER. Suppose the community has no facilities for hospitalization, what is going to happen to that individual who is found to have active tuberculosis? You have used Federal funds in order to determine his condition; you have provision for that, but suppose there are no hospital facilities available for him and the community has no facilities, so far as hospitalization is concerned. Dr. HILLEBOE. That obtains in many parts of the country. Mr. TARVER. I know that, and that is the reason I am asking the question. Dr. HILLEBOE. In those parts of the country where we find people with active tuberculosis and no hospital beds, we may do two or three different things. First of all we will attempt to get the general hospitals around the county or the city to set up sections in their general hospitals, isolation units, where at least some beds can be used to take care of the patients and get them started on such treatment as pneumothorax. If we have such facilities, in addition to using the general hospitals we will isolate the patients at home until such time as other provision is made. Mr. KEEFE. Who pays the hospital expenses? Dr. HILLEBOE. Usually the municipality pays the hospital. This is accepted as a governmental responsibility. Mr. KEEFE. In the indigent cases, those on relief, they are paid by the local communities? Dr. HILLEBOE. That is correct. I can say that throughout the country about 90 to 95 percent of the tuberculous cases are usually in that class because they have little money to take care of their own treatment. Mr. KEEFE. In my State, Judge Tarver, if that kind of a situation developed I do not know how it is in other States-but I know in my State all that would be necessary would be to have the State doctor certify that the patient has tuberculosis and he goes to the county judge and the county judge would issue an order committing that person to a tuberculosis sanitarium, and that is charged up against the community or the county that maintains the institution, and there is no trouble about it. Mr. TARVER. I am very much interested in this program and I think it is an excellent one but I do not think that you go far enough. For instance, we will pay for the treatment of people who have venereal diseases, do we not? Dr. HILLEBOE. Yes. Mr. TARVER. We treat them for syphillis and for gonorrhea, and you are not permitted and it is not required to apply to local communities for payment of the medical expenses or hospitalization. But where a person has tuberculosis and where he or she happens to live in a community where facilities are not provided, and where there are indigent people afflicted with tuberculosis, it seems to me that your program as far as it affects their condition does not go far enough. I think the program is very likely to prove a very excellent stimulus to public interest throughout the country in dealing with the problem of tuberculosis and the additional features which you have spoken of will be of very great benefit, but it seems to me the program should go a little bit further, and if we are going to take care of syphillis and those who are afflicted with gonorrhea, we ought to make some provision for the treatment of indigent persons who are afflicted with tuberculosis. Mr. KEEFE. We do not take care of those afflicted with syphilis and gonorrhea in the sense that we confine them in institutions unless and until it is demonstrated that they refuse to avail themselves of the clinical treatment in facilities which are set up; then if they refuse to do so they have a process for subjecting them or restricting them to an institution. But the person affiicted with tuberculosis, as I understand, is supposed to go to bed, and I suppose, to go to an institution, and be there for a long period of time. But those affiicted with gonorrhea do not have to have that sort of restriction except in extreme cases. LIMIT ON FUNDS TO BE MADE AVAILABLE FOR THE CONTROL OF TUBERCULOSIS PROGRAM Mr. HARE. Referring to these instruments here for salaries, other obligations, State aid control section salaries, and so forth, this is the first time that request has been made for appropriation for these salaries. Dr. HILLEBOE. Yes, sir. Mr. HARE. Therefore, we have no way of comparing them to know whether you want an increase or a decrease? Dr. HILLEBOE. I believe that is correct. Mr. HARE. Did the act place a limitation on the amounts of money to be made available for this tuberculosis program? Dr. HILLEBOE. The first year 1945 it is limited to $10,000,000, and after that there was no limit placed on it. ALLOCATION OF FUNDS AS BETWEEN THE STATES Mr. TARVER. What is the procedure for the allocation of funds as between the States? Dr. HILLEBOE. The provisions for the allocation of funds, Judge Tarver, are these: You will recall that our law provides for a conference of the State and Territorial health officers in order to determine rules and regulations for allocations to States. We had that meeting just last week, and at the annual conference of the State and Territorial health officers it was recommended at that time to the Surgeon General that funds be allocated on the following basis: 10 percent for population, 10 percent for financial need, and 80 percent for the size of the 71926-45-pt. 221 tuberculosis problem to be determined jointly by the P. H. S. and State health departments. DISTRIBUTION OF GRANTS-IN-AID FUNDS FOR 1946 Mr. TARVER. This table on page 214 of the justifications does not show the distribution of this fund that you are asking for, for the next fiscal year? Dr. HILLEBOE. That is correct. Mr. TARVER. Do you have a table here showing that? Dr. HILLEBOE. I do have, and I will make it available. Mr. TARVER. I will ask that that be placed in the record, Mr. Chairman. Dr. HILLEBOE. May I inform you that we do not have it in this part of it, because this was submitted prior to the meeting of the State and Territorial health officers. Mr. HARE. Insert it in your remarks when you correct them. (The statement referred to is as follows:) Distribution of grants-in-aid requested for fiscal year 1946 on basis of population (10 percent), financial need (10 percent), and extent of problem (80 percent) 1 1 Measured by number of tuberculosis deaths in 1943, 10 percent and evaluation of needs, 70 percent. |