Mr. COHEN. Most everything that this committee has done in the last several years and will be doing this year all goes to that approach. Vocational education and the other legislation that you pass make it possible for more people to be trained and to support themselves. The higher education bill that you passed enables the colleges and universities to train more people to meet these training needs that Miss Switzer mentioned. And passage of the Elementary and Secondary Education Act will make it possible for more boys and girls to go on to college and be trained and to contribute to this work, so that all of these things that you are doing are a part of a circle of activity that will make more boys and girls and men and women in this country self-supporting. I think that is the objective of all of the legislation. I think it is most commendable, too.

The CHAIRMAN. Again we thank you, Secretary Cohen and Miss Switzer.

We will now hear from our next witness, Dr. William A. Spencer. Dr. Spencer is a constituent of Senator Yarborough's and I am going to ask Senator Yarborough to present him.

Senator YARBOROUGH. Thank you for this kindness.

It is a great pleasure to have one of my constituents here who is one of the outstanding persons and authorities in his field in this country; that is, in the vocational rehabilitation field.

Dr. Spencer is chairman of the Department of Rehabilitation of Baylor University of Houston, Tex. I know that the chairman knows of the great Texas Medical Center which contains within itself Baylor University College of Medicine, which is a private school; the Texas Institute for Rehabilitation & Research, the Houston Speech and Hearing Center; the University of Texas; M.D. Anderson Hospital & Tumor Institute; the Graduate School of Biomedical Sciences; the University of Texas Dental School, a State university; the Texas Women's University College of Nursing, also a branch of a State university; the Houston State Psychiatric Institute, under a State hospital board; the Methodist Hospital, a Baylor affiliate and the M. DeBakey surgical program and the Brown & Fundren Cardiovascular Research Institute; the Texas Children's Hospital; St. Luke's Episcopal Hospital; Hermann Hospital, all private hospitals which are also contained within the Texas Medical Center, Inc., the coordinating body. These are all the great medical center complex. We are extremely proud of this in our State. Every facet of our society is represented in that great medical complex. And it functions extremely well.

It is a pleasure for me to present Dr. Spencer to you.

The CHAIRMAN. We are very happy to have you here. I do know about the medical complex, Senator Yarborough, in Houston. I know of you and other doctors there, Dr. Spencer. I know something of the work that you are doing. We are certainly very happy to have you here this morning. We will be glad to hear from you now.

STATEMENT OF DR. WILLIAM A. SPENCER, PRESIDENT, ASSOCIATION OF REHABILITATION CENTERS; CHAIRMAN, DEPARTMENT OF REHABILITATION, COLLEGE OF MEDICINE, BAYLOR UNIVERSITY, HOUSTON, TEX.

Dr. SPENCER. Mr. Chairman and Senator Yarborough, these remarks put me at a considerable disadvantage to appeal to you for that which obviously appeals, so strongly as this does to me, the opportunity to rehabilitate a greater number of disabled American citizens. I am reminded of a comment that one of my colleagues made of a famous Franciscan monk of the 14th century, who said that it is vain to do with more that which can be done with fewer. This already applies to testimony. Yet this comment really applies to a characteristic of both legislative and administrative efforts which encompass rehabilitation. This has been a program that has been modestly approached; which has been prudently developed; and which is now at the threshold of need for very great implementation. This is the key factor that we must keep in our minds. The program has grown with such wisdom and guidance and such effective legislation that you must take my remarks from the viewpoint of the physician and as a representative of the National Association of Rehabilitation Centers interpreting them from the point of view of the disabled person.

I am here to support this bill fully and I appreciate this opportunity to do it.

We all embrace the tremendous importance of making it possible for disabled people to do really what I am firmly convinced they want to do and; that is, to live their lives as responsible and useful persons.

I am going to enter into a kind of dialog with you and depart from written testimony, much as I would discuss this problem with a group of medical students, because this is how I can familiarly com

municate.

The CHAIRMAN. We will put your prepared statement in full into the record at the conclusion of your remarks. You may treat it in any way that you see fit.

Dr. SPENCER. I think that if I were talking to a group of students, the first thing that I would try to identify for them is what the problem is that this legislation seeks to redress.

Certainly disability is a hidden catastrophe that lay people and physicians alike are unaware of largely. It is only the concern of the person who is so incapacitated and reduced in his ability to participate in living activities because of disease or injury or impairment or some inconvient mental factor which medicine recently has come to recognize; and the thing that concerns the patient most is not the name or the diagnosis of what he has, but what can be done for him, so that he can get back into the mainstream of life.

It is a curious thing, therefore, that rehabilitation offers this new approach-really the new future of medicine and that rehabilitation; that is, vocational rehabilitation has given such leadership in getting this attitude and understanding established.

In talking to students, I would try to separate what are facts and what are opinions. The facts are that there is a serious national problem with disability. It is a problem, because not all of the people

who need the services that can be given can receive them for financial reasons; for reasons of lack of resources; and for reasons of lack of accessibility to the resources. This legislation attempts to get at this problem. How to do this is a matter of opinion, and I am not going to try to analyze the "hows" before experts like yourselves who know how to translate such needs into effective legislation.

What rehabilitation accomplishes, I think, is a matter of some concern to both the student and professional and lay people and is not generally recognized. It is possible through the advances of research and the application of research knowledge of recent decades, much of which has been supported by the Vocational Rehabilitation Administration-it is possible to minimize and to reverse many disabling consequences of diseases and injuries and defects.

This may seem like a minor accomplishment, because much of our attention in the world today is given to the cure of diseases, which is terribly important, but this is only one side of the coin. There are those who, as they grow older, will have conditions that are noncurable there are people that medicine with its lifesaving early care allow to live who have severe continuing impairments who must have an opportunity to be useful and to have a satisfying existence.

We are attempting, as it were, to close the circle or to complete the picture the great efforts that we have had for the prevention of disease through basic research and things of that sort, much of which has emanated from this committee by means of enabling legislation and we are here now trying to close the circle and make it possible for those who have conditions that cannot be eliminated to still be able to live in a normal and satisfactory manner.

So, really, the reestablishment of the capacity for daily living activities is a kind of reentry, like getting back to the earth from space, that is attended by serious problems of the same sort-our people here on earth who are disabled. This is what we are attempting to do. The promotion of social and emotional adjustments in the development of vocational educational potentials is our doorway, because as Miss Switzer said, we recognize that a healthy person is a person who is occupied. Man does not live by bread alone. Medical care alone is insufficient. All of these things interact and are necessary in rehabilitation. The key thing that this legislation attempts is to try to look for the first time at how to avoid fragmenting the total care of the group of people who cannot be cared for at present-people who because of the severity of their problems cannot be helped twothirds of the way-you either help them all the way or you cannot help them at all.

What this bill promises practically is an opportunity for the provision of services to a needy group not now being served.

Secondly, I think it is an initiation of a much broader framework for a program that will effectively combine community, State, and Federal financing of rehabilitation programs. This has been a hallmark of the efforts of vocational rehabilitation, as Senator Hill knows, the matching of private and public funds. We think this partnership epitomized in the matching is also epitomized in the work, and this will extend this concept.

As a matter of fact, only one major amendment which we would suggest concerns this principle of matching. Private Federal matching should extend into the domain of service on a reasonable basis for

those severe problems like stroke, spinal cord injuries, mental retardation, where it is likely that only regional resources are going to be available for these people because we cannot have these resources available in every hamlet of 5,000 and over. This creates, as you

know, many difficult technical problems of financing and matching, but I am sure that these can be worked out.

We have had some testimony on how this might be done. Another point is that this program-this legislation-provides for more effective and efficient utilization of existing resources.

I would like to comment that presently in 200-member rehabilitation facilities which make up out association of rehabilitation centers and in the additional centers we have in the entire Nation, which a study was conducted under a grant sponsored in part by the Vocational Rehabilitation Administration. We found that the severely disabled group were but a small part of the people whom these centers served and that the State agencies were purchasing a very small part of the total services rendered. This is not criticism of the agency. This is criticism of the restrictions of the original legislation which said a physician had to predict in advance that a person was going to work as a condition for acceptance for services.

In a recent study conducted for OASI and VRA, we found that 25 out of every 100 people accepted in the study receiving benefits could go back to work.

The CHAIRMAN. Could go back to work?

Dr. SPENCER. With total and permanent disability. This was research study. And this study convinced us of two things: First, that we did not predict who was in this situation before we started. We had to have a trial test of rehabilitation. Secondly, we found that many of these people had not had access to essential medical, surgical, and other restorative services. Many of them had no desire to go to work, because they were hurting, and until you stop hurting, you do not think about work.

By the same token, we found that these people were unable to work only because they needed continuing medical help and continuing maintenance. Then they could work and we found that they got better medically.

So what I am saying is that all of this is interrelated. And what we are now looking at is a way to aline research and care needs for disabled people which will focus all of our country's resources, I think, into a much more effective plan.

Senator YARBOROUGH. If I may interrupt, your footnote No. 2 states that 3 million persons are disabled in this country. And if you restored only 25 percent of them, 750,000 were restored, it would be worth far more than we have to pay out for the program.

Dr. SPENCER. A doctor probably should be reluctant to predict. We know that nearly 200,000 were rehabilitated last year. We do not have, as I say in the testimony, an accurate estimate of those who will need and benefit by services. We know how many people are chronically ill and disabled, roughly. The National Health Survey provides these statistics. We do not know how many will need this benefit. This is one of the primary reasons for this information and data pool because by exchanging the data and, therefore, information into a common resource like this information pool proposes in the legislation we hope to derive really sound knowledge upon which to base future plans. I am not begging the question of making a predic

tion, because I do not really think we have enough information yet to make the prediction. I can tell you from our own experience with severely disabled people that certainly in the adult group better than a fourth of them are able to have some kind of gainful employmentsuch as a mother can resume her home activities and the like.

Senator YARBOROUGH. I was not trying to pin you down to a certain percentage. But I did say that if only 25 percent could be rehabilitated, just as a minimum, it would be worth far more than we have ever envisioned.

Dr. SPENCER. Of course it would. This is the extent of this problem. This is why I think we had better be exercised about it when we look at it. These people are hidden in rooms by themselves. You do not see them en masse. If they were all lined up before us, we would be staggered by the significance of it but this is something that each little family absorbs and is destroyed by it. That is, their resources, their capabilities of continued living. We cannot solve all of these problems, obviously, and this is only a beginning, but it is a bellwether of the type of legislation I think will attack all of the realistic problems, the vocation, the independent living aspect, the replacement of other members of the family for work, and accomplishing independence from custodial care institutions and public welfare.

It is so worthwhile because the work focuses particularly on the facilities and the opportunities for special employment which have been so long neglected and this is going to force us to look at this problem even more fully and with more opportunity for success than we have had before.

I think that this whole effort is adding life and breath to a self-help method of assistance which is so characteristic of our great Nation.

I have tried to detail in the testimony for you the particular provisions and what they mean from the point of view of the national association which I am concerned with and from my own personal point of view. I would only like to comment on certain additional points which I think might be added. And one is that rehabilitation centers add a primary resource for availability of a team of people who can do this sophisticated evaluation which needs to be done with these severely disabled groups. In some way this evaluation concept which was employed by the VRA in the OASI studies validates the opinion that you need the experience of multiple professional groups.

Secondly, I think that we should support the proposal for a continuing advisory planning function in each State in respect to facilities, both rehabilitation facilities as well as workshop facilities.

Now, I think that it would be helpful if there would be a State rehabilitation facility advisory council to advise and consult with the State agency. There is precedent for this type of advisory council. Miss Switzer, I believe, discussed some aspects of this. This, I think, needs to be strengthened.

I mention that we should go beyond the opportunity of contributing matching funds from city and county to include private sources. I realize that this is a difficult area, but certainly our research grants have shown we can match private and public funds. Our Hill-Burton program construction shows the workability of this.

I think in the limited areas of service where cost studies need to be made and value studies need to be accomplished with these greatly