US. of NATIONAL LIBRARY OF EDUCATION U.S. Department o' Health, Education, and Welfare For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C., 20302 - Price $1.25 (Paper cover) U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE As of June 30, 1963 Anthony J. Celebrezze, Secretary Ivan A. Nestingen, Under Secretary OFFICE OF THE SECRETARY Wilbur J. Cohen _ Philip H. Des Marais James M. Quigley _ Lisle C. Carter, Jr _ Robert A. Kevan _ Rufus E. Miles, Jr _ James F. Kelly _ Boisfeuillet Jones- Jim G. Akin _ F. Robert Meier _ Harold R. Levy _ Joseph Ventura _ Alan son W. Willcox _ Chester B. Lund _ Harvey A. Bush _ Frederick H. Schmidt _ James W. Greenwood, Jr_ Dale S. Thompson _ James C. O’Brien _ Dean Snyder _ Assistant Secretary ( for Legislation). Deputy Assistant Secretary. Assistant Secretary. Deputy Assistant Secretary. Deputy Assistant Secretary for International Affairs. Administrative Assistant Secretary. Deputy Administrative Assistant Secretary and Comptroller. Special Assistant to the Secretary ( Health and Medical Affairs). Congressional Liaison Officer. Assistant to the Secretary. Assistant to the Secretary ( for Public Affairs). Assistant to the Secretary. General Counsel. Director of Field Administration. Director of Public Information. Director of Security. Director of Management Policy. Director of General Services. Director of Personnel. Defense Coordinator. SOCIAL SECURITY ADMINISTRATION Robert M. Ball _ Commissioner of Social Security. Victor Christgau _ Executive Director. J. Deane Gannon _ Director , Bureau of Federal Credit Unions. Joseph E. McElvain _ Director, Bureau of Hearings and Appeals. WELFARE ADMINISTRATION Ellen Winston _ Commissioner of Welfare. Joseph H. Meyers _ Deputy Commissioner of Welfare. Donald P. Kent _ Director, Office of Aging. Bernard Russell _ Director, Office of Juvenile Delinquency and Youth Development. John F. Thomas _ Director, Cuban Refugee Program Staff. Katherine B. Oettinger _ Chief, Children’s Bureau. John J. Hurley _ Acting Director, Bureau of Family Services. PUBLIC HEALTH SERVICE Luther L. Terry _ Surgeon General. David E. Price _ Deputy Surgeon General. James V. Lowry _ Chief, Bureau of Medical Services. Charles E. Burbridge _ Superintendent, Freedmen’s Hospital. Robert J. Anderson _ Chief, Bureau of State Services. James A. Shannon _ Director, National Institutes of Health. Forrest E. Linder _ Director, National Center for Health Statistics. Frank B. Rogers _ Director, National Library of Medicine. OFFICE OF EDUCATION Francis Keppel _ Commissioner of Education. Wayne O. Reed _ Deputy Commissioner of Education. FOOD AND DRUG ADMINISTRATION George P. Larrick _ Commissioner of Food and Drugs. John L. Harvey _ Deputy Commissioner of Food and Drugs. VOCATIONAL REHABILITATION ADMINISTRATION Mary E. Switzer _ Commissioner of Vocational Rehabilitation. E. Emory Ferebee _ Deputy Commissioner of Vocational Rehabilita¬ tion. SAINT ELIZABETHS HOSPITAL Dale C. Cameron _ Superintendent. Vacancy _ Assistant Superintendent. FEDERALLY AIDED CORPORATIONS Finis Davis _ Superintendent, American Printing House for the Blind. Leonard M. Elstad _ President, Gallaudet College. James M. Nabrit, Jr _ President, Howard University. REGIONAL DIRECTORS Region I, Boston, Mass. Region II, New York, N.Y. Region III, Charlottesville, Va. Region IV, Atlanta, Ga. Region V, Chicago, III. Region VI, Kansas City, Mo. Region VII, Dallas, Tex. Region VIII, Denver, Colo. Region IX, San Francisco, Calif. iv Lawrence J. Bresnahan. Joseph B. O’Connor _ Edmund W. Baxter _ Richard H. Lyle _ Melville H. Hosch _ James W. Doarn _ James H. Bond _ Albert H. Rosenthal _ Fay W. Hunter _ Letter of Transmittal Department of Health, Education, and Welfare, Washington , D.O. , December 1, 1963. Dear Mr. President: I have the honor to submit herewith the annual report of the Department of Health, Education, and Welfare for the fiscal year ending June 30, 1963. Respectfully, The President, The White House, W ashing ton, D.O. Secretary. VI Contents Page The Secretary's Report . 1 Social Security Administration . 5 Welfare Administration . 47 Public Health Service . 121 Office of Education . 217 Food and Drug Administration . 283 Vocational Rehabilitation Administration . 335 Saint Elizabeths Hospital . 385 American Printing House for the Blind . 405 Gallaudet College . 407 Howard University . 409 A detailed listing of the contents of this report, byl topic headings, will be found on pages 415—427 / Vll The Secretary’s This year marks the 10th anniversary of the creation of the Depart¬ ment of Health, Education, and Welfare. Although only a decade has passed since its establishment, that decade has been one of remarkable social progress. While the Department is the youngest in the Government, its history dates back to the very early days of our Republic — a history marked by a growing concern for the well-being of each individual citizen. As early as 1785, only 4 years after the Articles of Confederation went into effect as the first American constitution, grants of public lands were made to the young States for public schools. Thus, the Nation adopted at its very beginning a policy of providing to all citizens opportunities for individual growth through education. And for the first time in history the now generally accepted worldwide ideal of free public education for masses of people began to sink its first tentative roots in American soil. In 1867 the Office of Education was established “to promote the cause of education” in a nation now deeply committed to education — a nation needing all the intellectual capacities of its people to fulfill new national purposes. Our educational system constantly changes. It must — to meet the requirements of a constantly growing and changing nation and the human aspirations of the American people. Today more than 4^ million young people are in college and more than 47 million are attending elementary and high schools. Their numbers grow — and so do their opportunities. Thousands of talented young people now obtain Federal loans to attend college. And re¬ cently enacted legislation will enable our colleges to expand their facilities to accommodate the increasing flood of young Americans seeking higher education. Nearly $1.2 billion in “bricks and mortar” assistance to colleges, universities, public junior colleges, and technical institutions was authorized for a 3-year period. It was urgently 1 2 Department of Health , Education , and Welfare, 1963 needed legislation, for our Nation needs all the brainpower and skills that can be developed in our people. Now we must move on. We need especially to inject new quality in the schools of city slums and depressed rural areas — for here are children who need the best educational opportunities our society can afford but who generally receive the poorest. As in education, the history of Federal concern for health dates back to the late 18th century, when a hospital for merchant seamen was established by the Fifth Congress. Today the Public Health Service conducts the largest health research operation in the world and, through a myriad of programs, helps to bring health knowledge to benefit all people. It helps to build hospitals, nursing homes, and diagnostic and treatment centers; it conducts mass vaccination and disease control programs. And following recent legislation, com¬ munity projects are beginning to bring health care into the homes of the chronically ill and aged, and the mentally ill and mentally retarded are finally being given new help — and hope. Today our great health concern — along with the ultimate goal of wiping out major killing diseases — is to control environmental health problems arising from our technological growth and rapid industrialization. Other years mark other beginnings, other advances. In 1907 the Bureau of Chemistry in the Department of Agriculture pioneered in providing the nationwide consumer protection now afforded by the Food and Drug Administration. In 1912 the estab¬ lishment of the Children’s Bureau “to prevent babies dying like flies” expressed the Nation’s concern for its children — an assumption of F ederal responsibility that has grown and changed to meet the chang¬ ing needs of children. In 1920 the predecessor of the Vocational Rehabilitation Administration began its work in helping disabled and handicapped men and women attain productive, satisfying lives. Nearly three decades ago the social security system was born of a great forging of sensible economics and humanitarian motives. From both standpoints, this program has proved its worth. To earn a meas¬ ure of individual or family financial security as one earns a living is accepted today as a basic social right of Americans. More than 9 out of 10 people in paid employment and self-employ¬ ment today are covered by the program. Nearly 90 percent of the men and women who reached age 65 in 1963 were eligible for benefits, and 9 out of 10 young children and their mothers could count on monthly payments if the breadwinner of the family died. During the year, benefit payments totaled $15 billion — money that went directly into the economy for food, clothing, shelter, and other basic needs. The Secretary’s Report 3 Our public assistance programs — born along with the social security system in the wake of the Great Depression — now recognize that cash payments, while necessary, are no longer enough to meet the need of a society committed to humanitarian objectives. The 1962 Public Welfare Amendments gave legislative authority not only to new goals of helping people climb out of dependency but also of helping to keep them from becoming dependent. A number of programs are under¬ way providing services leading to employment, strengthening of family life, and improvement in the homes and lives of children who are poor. In 1939 Federal health, education, and welfare agencies were brought together to form the Federal Security Agency in recognition of their close interrelationship in promoting the well-being of the people. Ten years ago, with the establishment of the Department, concerns for health, education, and welfare gained recognition at the highest level of Government. This has been a decade of astonishing change and technological growth, characterized by the continued urbanization and mobility of the American people, and the continued advance of knowledge. Astro¬ nauts circle the globe ; scientists probe the ocean depths. More dra¬ matic changes will come, for the years ahead show promise of being the most exciting and challenging in the long history of civilization. But our social growth has not kept pace with the great scientific advances that are changing the world. This lag we must overcome. We have reached a high plateau in our social development, but higher ground is visible and can be attained. Our goal will be to com¬ plete a variety of tasks that will build what President Johnson en¬ visions as the “Great Society” — a richer life for all Americans. As a result a stronger America will emerge. 4 Department of Health , Education , and Welfare , 1963 Table 1. — Grants to States: Total grants under all Department of Health , Education , and Welfare programs, fiscal year 1963 [On checks-issued basis] States Total i Total. Alabama - Alaska - Arizona - Arkansas - California - Colorado _ Connecticut _ Delaware _ District of Columbia - Florida.. . - Georgia - Hawaii . . Idaho - Illinois _ Indiana - Iowa _ Kansas _ Kentucky . Louisiana _ Maine _ Maryland - Massachusetts. .. Michigan - Minnesota - Mississippi - Missouri - Montana - Nebraska _ Nevada _ New Hampshire. New Jersey . . New Mexico . New York _ North Carolina.. North Dakota _ Ohio . . . Oklahoma . . . Oregon - Pennsylvania _ Rhode Island.... South Carolina- South Dakota _ Tennessee _ Texas _ Utah _ Vermont _ Virginia _ Washington _ West Virginia _ Wisconsin _ Wyoming _ Canal Zone . Guam _ Puerto Rico _ Virgin Islands.... Undistributed _ Foreign _ $3, 629, 835, 300 104,063,541 12,613,841 29,941,432 56, 512, 692 434,939,091 61, 240, 660 38,318, 865 6, 528,038 12,048,522 96,224,188 101,723,341 18, 325, 717 16,376, 133 155,240,389 39, 949, 898 44, 855, 508 43, 950, 536 69, 280, 972 143, 440, 329 22, 269, 819 48, 153, 627 113, 133,963 101,352,960 58, 177, 659 60,325, 152 101,727,252 15,022,185 23,498,999 7,271,477 9, 120, 896 59, 501,709 32,006,247 27^351,490 89,836,182 15,454,074 133, 769, 692 113,948,088 30,201,634 170, 068, 541 16,763,366 45,103,979 17,758, 842 64, 176, 198 205, 222,204 21,660,215 9, 135, 205 58,059, 137 73,986, 884 54,427,845 49, 833,402 5,715,066 42 1,525,870 24,058, 659 957, 503 12, 685,544 Welfare Adminis¬ tration Public Health Service i1 2 Office of Education Vocational Rehabili¬ tation Adminis¬ tration American Printing House for the Blind3 White House Confer¬ ence on Aging $2,802,987,385 $296,246,943 $456,732,980 $73,160,503 $708,000 $-511 86, 818,336 5,509,054 8,405,239 3, 317, 669 13,243 1,947,799 1,164,587 9,418, 122 83,333 19,620,799 2,145,003 7,571,725 598, 103 5,802 45,263,928 4, 928, 711 3,937,214 2,375, 524 7,315 348,086,123 15,167,328 68,076, 629 3, 542, 251 66,760 45, 554, 752 4,147,744 10,250,067 1,280,488 7, 609 29,517,985 2,508,241 5,897,159 379,337 16, 143 3, 267, 937 1,617,707 1,459,262 181, 072 2,060 9, 834,185 1, 579, 807 297,341 334,919 2,270 71, 126, 187 9, 679, 968 12, 880,356 2, 516, 951 20, 726 78, 836, 912 8,068,773 10,822,498 3,977,039 18, 119 6, 505, 425 3,984,261 7,458,520 374,652 2, 859 9,743, 588 2, 624, 145 3,754, 201 253,253 1,135 -189 131,430,731 10,767,436 10,917,647 2,094,180 30,395 29,583,253 4,978,796 4,740,956 631,002 15,891 35, 179, 139 4,576,465 3,964, 884 1,126,864 8, 156 29, 560,467 4, 239, 857 9,430,664 708,323 11,225 58,417, 561 5,442,263 4,367,233 1,045,465 8,450 130,298,592 7,921,219 3, 331, 654 1,877,219 11,645 16, 506,314 1,969,592 3,384, 252 407,559 2, 102 27, 977,739 4, 246,816 14,934,687 978, 199 16, 186 93,583,987 5,408, 196 12, 729, 604 1,384,513 27, 663 81, 695, 296 9,702,332 8, 183, 749 1, 741, 566 30,017 46, 503, 150 6, 183,400 4, 037, 411 1,440, 539 13, 159 47,401,296 7, 881, 140 3, 688, 504 1,347,023 7, 189 88, 127, 775 6,498, 020 5,838,549 1, 250, 926 11,982 6,970,773 2,267, 639 5,467,765 313, 654 2,354 13,476,032 3, 569, 861 5,973,664 474, 860 4, 582 3,417,035 1,061,532 2, 680,718 111,267 925 4,828,960 1,815,443 2, 329, 585 144,638 2,270 41,061,719 5, 605,571 11,210,085 1,596,882 27,452 19, 746, 863 3,667, 805 8, 288,395 298, 265 4,919 242, 532,049 14, 658,297 15,716,334 5,376, 326 68,484 66, 791, 689 11,099, 532 8,732,774 3,189,023 23,164 9,591,469 1, 842, 884 3, 567, 803 450, 657 1,261 107, 606, 095 11,911,724 12,271,773 1,945,333 34,767 93,838,765 5, 546, 126 12, 566, 142 1,991,716 5,339 22, 764, 622 3, 613, 285 3, 126, 658 687, 862 9,207 135, 484, 721 15, 738, 775 12,187,086 6, 607, 300 50,659 11,164,400 1,428,099 3,596, 355 570, 602 3,910 26,087,914 9,327,092 7,800,224 1,880,594 8,155 9,670,312 1,896,061 5, 847, 017 342, 888 2,564 48,461,828 7, 942, 819 5,923,534 1,834, 691 13,326 164,970,157 15, 654,234 21,969,211 2, 600,725 27,999 -122 14, 573,300 2, 238, 549 4, 510,460 334, 543 3,363 7,022,427 1,139,827 688, 816 283, 210 925 24, 887,720 6, 571,519 24,921,044 1,663,089 15,765 56, 225, 718 3, 428, 196 13,412, 226 907, 627 13, 117 46, 154, 766 4,460,289 1,943,995 1,859, 672 9, 123 37,700,251 6, 342, 683 4, 654,052 1,124,771 11, 645 3,401,816 758,526 1,460,615 92,890 1,219 42 238,426 113, 686 1,119,949 53, 809 11,401,085 9,433,481 2,090,533 1,130,397 3,363 -200 527, 217 172,547 212, 496 45,243 12, 685, 544 1 Includes $1,800,995 expended for construction of Indian health facilities prior to fiscal year 1963 and not reported previously. 2 Excludes $252,557 paid to water pollution interstate agencies. 3 Includes permanent annual appropriation of $10,000. Social Security Administration Introduction The Federal social security program — old-age, survivors, and dis¬ ability insurance — now provides protection for practically all working people and their families. More than 9 out of 10 people in paid employment and self-employment are covered or eligible for coverage under the program. Nearly 90 percent of the people reaching age 65 in 1963 were eligible for benefits ; this percentage will rise in the future to 95 percent or more. Nine out of ten young children and their mothers are eligible for monthly benefits if the breadwinner of the family dies- Also, at the beginning of 1963, 52 million people were insured against the loss of income resulting from long-term and severe disability — and this 52 million is increasing by approximately 2 million a year. At the end of June 1963, benefits were being paid to more than 18y2 million people — about 1 out of 10 Americans. The beneficiaries include about 1 4% million older people (retired workers and their aged spouses, and widows, widowers, and parents of deceased work¬ ers) ; about 2y2 million children of retired, deceased, or disabled workers and about % million mothers of those children; and about 800,000 disabled workers under age 65 and their spouses aged 62 or over (chart 1). How the program does its job, as well as what it does, is of great importance. Under social security, the worker earns his future secu¬ rity as he earns his living. A worker’s entitlement to benefits and the amount of benefits he and his family will get are related to his earnings in covered work, on which social security taxes are paid. Basing eligibility on a record of past work and providing variable benefits related to the level of a worker’s earnings adds to and strengthens our general system of economic incentives. Benefits are paid regardless of a beneficiary’s income from savings, pensions, investments, and the like. Consequently, workers are en- 5 6 Department of Health, Education, and Welfare, 1963 WOMEN WORKERS WORKERS RETIRED CHART 1. — YOUNG CHILDREN OF RETIRED AND DECEASED WORKERS 18.6 MILLION BENEFICIARIES couraged to supplement the basic protection afforded by social security with whatever additional protection they can afford to buy. The social security approach to preventing dependency thus largely eliminates any basis for the old fear that making governmental provision for economic security will decrease incentives to work and save. Under social security, the very mechanism for preventing dependency rein¬ forces the individual’s incentives. Since the security he derives under the program grows out of his own work, the person who is covered views his social security benefits as an earned right. He can feel good about taking his benefits, just as he does about accepting wages for the work he does; he has earned the right to both. The concept of an earned right is reinforced by the fact that workers make contributions in the form of social security taxes which are ear¬ marked to help finance the benefits. They make their payments while they are working and receive the benefits when they have stopped, or substantially stopped, working. This financial participation encour¬ ages a responsible attitude among those covered by the program. The contributor knows that the benefits for him and his family are made possible by the payment of social security taxes, and this knowledge gives him a personal interest in the soundness of the program. Both the Congress and the executive branch have been scrupulous in providing for full financing of all program liberalizations. The very nature of the contributory program, with its huge commitments to the future welfare of the aged, the disabled, and the widows and orphans of the Nation, demands this kind of financial responsibility. The social security program is in actuarial balance when expected fu- Social Security Administration 7 ture income from contributions and from interest on the investments of the accumulated trust funds will support the expected disbursements for benefits and administrative expenses. And the program meets this test. The social security program is currently being studied in detail by an advisory council made up of distinguished citizens from outside Government. There is a long tradition, going back to the planning for the original Social Security Act, of seeking the advice and guidance of private citizens in the planning and development of the national social security program. In 1934, President Roosevelt named a 23- member advisory council, representing labor, industry, and the gen¬ eral public, to advise the Committee on Economic Security (a Cabinet committee), which the President had established to study various pro¬ posals and develop recommendations for a social security program. In 1938, shortly after the social security system began operating, a second advisory council was appointed, this time jointly by a Special Senate Committee on Social Security and the Social Security Board, to study the advisability of amending the Social Security Act. Some 10 years later, in September 1947, the Senate Committee on Finance appointed an advisory council to help that committee make a full and complete investigation of the various programs provided for under the Social Security Act. In 1953, a group of 12 consultants from outside Government was appointed by the Secretary of Health, Education, and Welfare to study ways of extending coverage to addi¬ tional workers. Finally, in recognition of the contributions made by past advisory councils and also of the fact that practically all Americans have a financial stake in the social security program, the Congress set a statu¬ tory requirement, in the 1956 amendments to the Social Security Act, for periodic review of the financial soundness of the social security program by advisory councils. The first such council was appointed in the fall of 1957. In his special message relative to the elderly citizens of our Nation, presented on February 21, 1963, President Kennedy stated: As required by the Social Security Act, the Secretary of Health, Education, and Welfare will soon appoint an Advisory Council on Social Security Financing. I am directing him to charge this Council with the obligation to review the status of the social security trust funds in relation to the long-term commitments of the social security program, and to study and report on extensions of pro¬ tection and coverage at all levels of earnings, the adequacy of benefits, the de¬ sirability of improving the present retirement test, and other related aspects of the social security system. The results of the Council’s work should provide a sound basis for continued improvement of the program, keeping it abreast of changes in the economy. 8 Department of Health , Education, and Welfare, 1963 Subsequently, on June 9, 1963, tbe Secretary announced the appoint¬ ment of a 13-member advisory council. The Council convened on June 10, 1963. The Advisory Council appointed this year is the second in the series of councils provided for under the 1956 amendments. The law pro¬ vides for the appointment of subsequent councils in 1966 and every fifth year thereafter. All of these councils are required by law to study and report on the financing of the program. However, the cur¬ rent Advisory Council is, in addition, directed under the amendments of 1960 to study all other aspects of the program. It is, therefore, the first group since the 1947 Advisory Council on Social Security to be charged with making a comprehensive review of the social security program. What the Program Is Doing Beneficiaries and Benefit Amounts During the fiscal year ended June 30, 1963, benefits paid under the old-age, survivors, and disability insurance program totaled $15,015 million — an increase of $1,346 million over the amount paid in the preceding fiscal year. Benefit payments to disabled workers and their dependents were 16 percent higher than in fiscal year 1962 and totaled $1,171 million. Old-age and survivors insurance monthly benefits rose 9 percent to $13,649 million, and lump-sum death payments amounted to $195 million, about $21 million higher than in the previous fiscal year (chart 2). Almost 2.9 million monthly benefits were awarded in fiscal year 1963, 324,000 less than the record number awarded in fiscal year 1962, but more than in any other year. The large number of awards included many (1) old-age benefits awarded to men aged 62-64, (2) wife’s or child’s benefits awarded to dependents of these men, and (3) monthly benefit awards attributable to the liberalized insured-status provisions in the 1960 and 1961 amendments. Old-age (retired- worker) benefits numbered 1,238,000, accounting for two- fifths of the awards. Mother’s benefit awards numbered 102,000, about 4,000 more than the previous record. The 482,000 monthly benefits awarded to disabled workers and their wives, husbands, and children were only 10,000 less than the number awarded in the preceding fiscal year. The 952,000 lump-sum death payments awarded in fiscal year 1963 were 101,000 more than the previous record number in fiscal year 1962. Almost 922,000 deceased workers were represented in the awards. The average lump-sum amount per worker was $211.88. Social Security Administration 9 CHART 2.— BOTH OASDI BENEFIT PAYMENTS AND NUMBER OF BENEFICIARIES HAVE INCREASED RAPIDLY SINCE 1950* □ •50 Annual Payments** Beneficiaries*** FISCAL YEARS *The 1950 amendments made major improvements in the program. **Payments in fiscal year. Includes lump-sum death payments. ***Beneficiaries on the rolls at the end of the fiscal year. The number and amount of monthly benefits in current-payment status increased substantially during fiscal year 1963. The number of monthly benefits went up 1.3 million (8 percent) and the monthly rate of payment rose $98.1 million (9 percent) . At the end of June 1963, 18.6 million beneficiaries were receiving benefits at a monthly rate of $1,226.3 million. A year earlier, monthly benefits totaling $1,128.2 million were going to 17.3 million beneficiaries (chart 2) . At the end of June 1963, about 14.4 million persons aged 62 and over were receiving old-age and survivors insurance monthly benefits — 941,000 more than in June 1962. Old-age (retired- worker) benefits were going to almost 70 percent of the aged group, wife’s or husband’s benefits to 17 percent, widow’s or widower’s benefits to 13 percent, and the remainder — primarily parent’s benefits — to less than one-half of 1 percent. An increase of 278,000 for the 12 months brought the number of mothers and children receiving monthly benefits as depend¬ ents of retired or disabled workers or as survivors to 3.4 million. Dis¬ abled-worker beneficiaries under age 65 numbered 790,000, an increase of 111,000. In June 1963, the average old-age benefit being paid to a retired worker who had no dependents also receiving benefits was $73.00 a month. When the worker and his wife were both receiving benefits, the average family benefit was $128.70. For families composed of a disabled worker, his young wife, and one or more children, the average was $192.80, and for families consisting of a widowed mother and two children the average benefit was $191.60. The average monthly bene- 711-845—64 - 2 10 Department of Health , Education , and Welfare, 1963 fit for an aged widow alone was $66.40 in June. Among beneficiaries on the rolls at the end of J une 1963 whose benefits were based on earn¬ ings after 1950, the average family benefits being paid were $80.30 for a retired worker with no dependents receiving benefits, $136.30 for an aged couple, $200.00 for a disabled worker, his young wife, and one or more children, $212.70 for a widowed mother and two children, and $77.40 for an aged widow alone. At the end of June 1963, about 76 percent of all retired- worker families were receiving benefits based on earnings after 1950. Disability Provisions During the fiscal year, a period of disability was established for about 242,000 workers, almost as many as the record number in fiscal year 1962. About 24,000 disabled persons aged 18 and over who had applied for child’s monthly benefits were found to have a disability that began before they were 18 years of age; the number was about 2,500 smaller than in fiscal year 1962. Since the beginning of the program, almost 1% million persons have been found to meet the disability requirements under the law. The number of disabled workers receiving monthly benefits rose 16 percent in the fiscal year and reached 790,000 at the end of June. Almost 592,000 benefits were being paid to the wives, husbands, and children of these beneficiaries — a 25-percent increase. By the end of June 1963, child’s monthly benefits were being paid at a monthly rate of $7.2 million to 157,000 disabled persons aged 18 and over — dependent sons or daughters of deceased, disabled, or retired insured workers — whose disability began before age 18. About 19,000 women were receiving wife’s or mother’s benefits solely because they were the mothers of disabled persons receiving child’s benefits. A preliminary estimate indicates that at the end of June 1963 about 1 82,000 persons were receiving old-age benefits that had been increased by an average of $8 a month because their earnings records were frozen for periods while they were disabled before reaching retirement age. About 67,000 wives, husbands, and children of retired workers and about 129,000 widows, widowers, children, and parents of workers who had their records frozen before death were also receiving larger monthly benefits because of the freeze. For the same reason, lump¬ sum death payments in fiscal year 1963 based on the earnings records of 31,000 deceased workers were increased by an average of about $25 per worker. Social Security Administration 11 CHART 3. — THE NUMBER AND PROPORTION OF POPULATION AGED 65 AND OVER ELIGIBLE FOR OASDI BENEFITS ARE INCREASING NUMBER (in millions) ♦Figures as of January 1. The Protection Provided At the beginning of calendar year 1963, about 91 million people had worked long enough in covered employment to be insured for benefits under the program. Some 55 million of these people were permanently insured — that is, whether or not they continue to work in covered jobs, they are either already eligible for benefits or will be when they reach retirement age, and their families are protected if they die. The remaining 36 million were insured but must continue in covered work for an additional period to be permanently insured. Nine out of 10 mothers and young children in the Nation can count on receiving monthly survivors insurance benefits if the family bread¬ winner should die. Of the population under age 65, an estimated 80 million were in¬ sured. Some 45 million of them were permanently insured, including about 1.8 million men and 1.1 million women aged 62-64 who were already eligible for old-age benefits but on a reduced basis. About 52 million persons under age 65 had worked long enough and recently enough to be protected in the event of long- term and severe disability. Of the 17.6 million people aged 65 and over in the United States at the beginning of 1963, 79 percent were eligible for benefits under the program (chart 3). Nearly 71 percent were actually receiving 12 Department of Health, Education, and Welfare, 1963 benefits, and almost 9 percent were not receiving benefits because either they or their spouses were receiving substantial income from work. The proportion of aged persons who are eligible is expected to rise to 86 percent by the beginning of 1967. Income and Disbursements Expenditures from the Federal old-age and survivors insurance trust fund during the fiscal year totaled $14,580 million, of which $18,843 million was for benefit payments, $423 million for transfers to the railroad retirement account, and $263 million for administrative expenses, including Treasury Department costs. Total receipts were $13,842 million, including $13,328 million in net contributions and $515 million in interest on investments. Disbursements exceeded re¬ ceipts by $687 million, the amount of the decrease in the trust fund during the year. At the end of June 1963, this fund totaled $18.9 billion. Total assets of the old-age and survivors insurance trust fund, except for $1.3 billion held in cash, were invested in U.S. Government securi¬ ties as required by law; $3.4 billion was invested in public issues (identical to Treasury securities owned by private investors), and $14.2 billion was invested in securities of varying maturities issued solely for purchase by the trust fund. The average interest rate, based on the coupon rate and face amount of all investments of this fund at the end of the fiscal year, was 2.94 percent. Expenditures from the Federal disability insurance trust fund dur¬ ing fiscal year 1963 totaled $1,257 million, of which $1,171 million was for benefit payments, $20 million for transfers to the railroad retire¬ ment account, and $67 million for administrative expenses. Total receipts were $1,144 million, including $1,077 million in net contribu¬ tions and $67 million in net interest on investments. Disbursements exceeded receipts by $113 million, the amount of decrease in the fund during the year. At the end of June 1963, the fund totaled $2,394 million. (Contributions to this fund first became payable in January 1957, and benefit disbursements began in August of that year.) Assets of the disability insurance trust fund consisted of $2,277 million in U.S. Government securities and a cash balance of $116 mil¬ lion. The invested assets consisted of $112 million in public issues and $2,165 million in securities of varying maturities issued solely for purchase by the trust fund. The average interest rate, based on the coupon rate and face amount of all investments of this fund at the end of the fiscal year, was 3.04 percent. Social Security Administration 13 Financing the Program A comprehensive review of the long-range actuarial cost estimates for the old-age, survivors, and disability insurance program has re¬ cently been completed. These new estimates show that, for the system as a whole, the estimated benefit cost is very closely in balance with contribution income. The difficulties involved in making exact predictions of the actuarial status of a program that reaches into the distant future are widely recognized. If different assumptions as to, say, interest, mortality, retirement, disability, or earnings had been used, different results would have been obtained. Accordingly, no one set of estimates should be looked upon as final, in view of the fact that future experi¬ ence may vary from the actuarial assumptions. It is the Department’s policy continually to reexamine the cost estimates of the program in the light of the latest information available. Even though absolute precision in long-range cost estimating is not possible, the intent that the system be actuarially sound can be expressed in law by a contribu¬ tion schedule that, according to the intermediate-cost estimate, results in the system being substantially in balance, and the law has such a contribution schedule. Old-Age and Survivors Insurance Benefits The level cost of old-age and survivors insurance benefits after 1963, on an intermediate basis, assuming interest of 3.50 percent and earn¬ ings at about the levels that prevailed during 1961, is estimated at 8.71 percent of payroll (after adjustments to allow for administrative expenses and interest earnings on the existing trust fund) . The level - contribution rate, equivalent to the graduated rates in the law, is estimated at 8.61 percent of payroll, leaving a small actuarial insuffi¬ ciency of 0.10 percent of payroll. Disability Insurance Benefits The Social Security Amendments of 1956 established a system for financing disability benefits which is separate from the financing of old-age and survivors insurance benefits. The estimated level cost of the disability benefits (adjusted to allow for administrative expenses and interest earnings on the existing trust fund) on an inter¬ mediate basis is 0.64 percent of payroll. Contribution income has been specifically allocated to finance these benefits; this income is equivalent to 0.50 percent of payroll, leaving an actuarial insufficiency of 0.14 percent of payroll. 14 Department of Health , Education , and Welfare , 1963 As indicated above, the new estimates show that the system as a whole will have an income from contributions (based on the schedule now in the law) and from interest earned on investments approxi¬ mately sufficient to meet total expenditures indefinitely into the long- range future. However, the Trustees have recommended an adjust¬ ment of the allocation of the total contribution rate between the two parts of the program to make for a more reasonable subdivision of future income which would in no way affect the overall actuarial balance of tlie system. This Department believes that such an adjust¬ ment should be made. Administering the Program Fiscal year 1963 was a period of continuing progress in the Social Security Administration. Workloads remained at relatively high levels and new peaks were reached in the amount of work needed to maintain the rolls of beneficiaries and to make benefit payments. The policies and procedures governing work operations were restudied and many improvements made. Reorganization of the Social Security Administration A most significant development during this period was the reorga¬ nization of the Social Security Administration, effective January 28, 1963. As a part of this reorganization, the Bureau of Old-Age and Survivors Insurance was abolished and its functions became the pri¬ mary mission of the new Social Security Administration. Included in the new organizational alignment are the Bureau of Hearings and Appeals, the Bureau of Federal Credit Unions, and, from the former Office of the Commissioner of Social Security, the Division of Pro¬ gram Research and the Division of the Actuary, plus the seven divi¬ sions and two staff components formerly in the Bureau of Old-Age and Survivors Insurance. The remaining organizations in the former Social Security Administration were incorporated into the newly created Welfare Administration. The rapid growth of the social security program and the increasingly heavy welfare responsibilities placed on the Department made clear the necessity to have the social security and the welfare programs each under the full time direction of a Commissioner reporting directly to the Secretary. Workloads , Manpower , and Resources A few key workload figures can best illustrate the magnitude of the operating task which the Social Security Administration handled Social Security Administration 15 during the year. About 3 million claims for old-age and survivors insurance benefits were received and processed, as well as almost 700,000 claims for disability insurance benefits from disabled workers and their dependents. New social security account numbers were established for about 6 million individuals, including approximately 3.2 million numbers assigned under the program undertaken by the Internal Revenue Service in cooperation with the Social Security Ad¬ ministration to issue identifying numbers for income tax purposes. Approximately 3.5 million duplicate account number cards were issued during the year to persons who had lost their cards or needed new cards for one reason or another. More than 270 million earnings items were received from employers or the self-employed for posting to the indi¬ vidual social security earnings accounts. Throughout the same period, district offices in all parts of the country handled almost 16 million inquiries about the old-age, sur¬ vivors, and disability insurance program. As the number of bene¬ ficiaries increase, the actions required in maintaining the benefit rolls also increase. In fiscal year 1963, about 9.7 million separate actions were required to maintain the rolls of the more than 18.6 million benefi¬ ciaries receiving old-age, survivors, and disability insurance benefits. Included in these actions were 2.1 million change-of-address notices ; 3.1 million notices canceling benefit checks; 2.5 million changes in benefit amounts due to recomputations or reinstatements; 1.5 million benefit terminations because of death, attainment of age 18, marriage, divorce, etc. ; and 368,000 suspensions of benefits made as a result of beneficiaries returning to work and earning more than the amount permitted by the retirement test. STAFFING AND PRODUCTIVITY To process these very sizable workloads with speed and accuracy required substantial numbers of well-trained employees. At the end of the year, 34,247 employees were engaged in the administration of the old-age, survivors, and disability insurance program. An addi¬ tional 423 employees were engaged in Federal credit union activities. Since 1950, frequent and very substantial amendments to the Social Security Act have greatly increased both the volume and the com¬ plexity of the job to be done. This larger and more complex job was handled by a staff which was increased relatively less than the increase in the workload. F or example, the Administration’s output of work in 1963 was more than four times as much as in 1950, but the staff re¬ quired to handle this work was only a little over three times as large as in 1950. Thus, about 75 employees now perform the same amount of work as 100 did in 1950. 16 Department of Health , Education , and Welfare , 1963 CHART 4.— MANPOWER, WORKLOAD, AND PRODUCTIVITY INDICES— COMPARISON OF MANPOWER WITH WORKLOADS OASDI Function of SSA Fiscal Years 1941-63 3 1941 1945 1950 1955 1960 '62 ’63 PERSONNEL (Man-Years) PERSONNEL INDEX WORKLOAD INDEX PRODUCTIVITY INDEX PERSONNEL INDEX AS A PERCENT OF WORKLOAD INDEX (1) (2) (3) (4) (5) 1941 ACTUAL 9,037.1 100.0 100.0 100.0 100.0 1945 ACTUAL 8,269.3 91.5 121.6 132.9 75.2 1950 ACTUAL 11,136.9 123.2 206.6 167.7 59.6 1955 ACTUAL 16,363.4 181.1 412.0 227.5 44.0 1960 ACTUAL 25,829.3 285.8 620.8 217.2 46.0 1962 ACTUAL 34,740.8 384.4 825.0 214.6 46.6 1963 ACTUAL 34,958.8 386.8 860.5 222.5 45.0 1000 800 700 500 400 200 100 1 All indices are stated in terms of 1941 experience, which is established as a base year of 100. EMPLOYEE DEVELOPMENT For the past several years, the Social Security Administration has been giving special attention to employee development. During fiscal year 1963, a new high was reached both in the number of employees in training and in the number and variety of training courses offered to them. Training was provided for about 20,000 employees during the year. A large proportion attended courses developed and conducted by the Social Security Administration, while a few hundred partici¬ pated in courses conducted by other Government agencies or by non- Government institutions. Some 21 different kinds of employee train¬ ing programs were offered within the Administration, ranging from writing of administrative communications to electronic data proc¬ essing, computer programing, and technical training in claims processing. Social Security Administration 17 Emergency Planning In accordance with the provisions of Executive Order 10346, the Social Security Administration has developed plans for continuing the essential functions of the old-age, survivors, and disability insur¬ ance and the Federal credit union programs in a post- attack period. The plans provide for (1) continued old-age, survivors, and disability benefit payments when possible and resumption of operations follow¬ ing any temporary suspension, and (2) operation of Federal credit unions under applicable regulations which will be issued by the Secre¬ tary of the Treasury for banking institutions. Provision has been made for protecting essential records; lines of succession to key positions have been established ; and instructions for performing essential functions under emergency conditions have been pre-positioned in headquarters and field installations. The Social Security Building at Baltimore has been designated as a shelter area for 42,000 people residing in the community. Emer¬ gency rations and supplies are now being stocked in the building. Administrative Expenses Expenses for administering the old-age, survivors, and disability insurance program amounted to only 2.2 percent of the amount of benefits paid to beneficiaries of the program during the year. Total administrative expenses, on an expenditures basis, amounted to ap¬ proximately $329.1 million. About $49 million of this amount was incurred by the Treasury Department for the collection of social security taxes, the preparation of checks for beneficiaries, and related activities. Administrative expenses for the Federal credit union program in fiscal year 1963 amounted to $4,185,000. This money was obtained from fees collected for services performed by the Bureau of Federal Credit Unions. Improvements in Service and Management Operations Research The Social Security Administration has entered upon a second year of intensive operations research activity, which is a scientific technique of analysis increasingly used by organizations in and out of govern¬ ment, to help them reach decisions on complicated problems. Basic analyses were completed during the first year of work and evaluations of important alternatives to the present patterns of opera- 18 Department of Health, Education, and Welfare, 1963 tion were begun. During the coming period, evaluations will be ex¬ tended and refined with the help of information from experiments and new data collections. This will enable predictions to be made of the value of major systems changes, in terms of such criteria as processing times, quality of work, costs, and various public-service aspects. A professional operations research organization has, under con¬ tract, assisted the Social Security Administration with this work and also is helping it develop for itself a technical operations research capability. EDP-IDP Developments Fiscal year 1963 was a period of development, modification, and improvement in the SSA electronic data-processing and integrated data-processing operations. The telecommunications system was refined to provide for the wire transmission of earnings requests and their direct introduction into the Administration’s computer system. The computer processes the incoming earnings requests at a high rate of speed and prepares the return replies. During the year, the Administration determined that its EDP proc¬ esses would be improved and its costs substantially reduced through the centralization, in Baltimore, of its large-scale computer opera¬ tions. Accordingly, certain payment-center EDP operations were transferred to the Baltimore computer complex, and high-speed mag¬ netic tape terminals were installed in the payment centers and in the central office to facilitate the direct exchange of magnetically recorded information by wire. Thus, beneficiary roll information and payment data are transmitted between the payment centers and the central office by a magnetic tape-to-tape process, computer talking to com¬ puter, as it were. This permits the utilization of available time on large-scale central office computer equipment ( in lieu of medium-scale computers in each of the payment centers) for purposes of maintain¬ ing the beneficiary roils (e.g., monthly updating and benefit certifica¬ tion operations). This relocation of operations (1) reduced costs; (2) enabled increased utilization of the Administration’s EDP techni¬ cal and programing personnel; (3) facilitated systems management through the implementation of uniform methods of training and oper¬ ational controls; and (4) helped to improve operating relationships within the Administration and with the Treasury Department. Also, during the year, the necessary plans were formulated and actions were taken to convert the master beneficiary punchcard file to a magnetic-tape file. In addition, the necessary programs and Social Security Administration 19 procedures were completed to establish a microfilm record in each of the payment centers of the information contained in the master beneficiary magnetic-tape file. This additional microfilm file provides a ready visual reference to related beneficiary information. The Administration’s EDP programing staff developed an advanced programing technique that resulted in overall reduced computer proc¬ essing time and in average savings of over 95 percent in machine setup time. This technique is so unique that the computer manu¬ facturer has published it as information to other computer users. Paying Benefits In payment of benefits during fiscal year 1963, the use of electronic data- processing equipment has permitted the gradual abolishment of 318 payment center positions, amounting to an annual savings of approximately $1,370,000. This has been accomplished by convert¬ ing preparation of the claims award form from a manual operation to the computer, thereby eliminating the need for a separate clerical review; and through conversion of payment center beneficiary roll accounting and control records from a punchcard system to magnetic tape, and the parallel development of EDP capabilities in the regional disbursing offices of the Treasury Department. These changes are be¬ ing accomplished on a gradual basis to permit orderly retraining and reassignment of affected personnel to more critical areas of work. ANNUAL REPORT PROCESSING Computers are also used extensively in the processing of annual reports of earnings filed by beneficiaries. As a result of improvements put into effect during the year, it was possible to process electronically a much larger percentage of the 750,000 annual reports than in the preceding year. Maintaining Earnings Records The establishment of a combined record of suspended and reinstated earnings items on magnetic tape and microfilm has reduced the number of files to be maintained from a total of nine to one. This has resulted in substantial savings in manpower, since all operations concerned with the detection and correction of improperly reported items are now checked to but one file, and is expected to save approximately $280,000 annually. An improvement, implemented prior to 1963 but which accounts for current savings, involves the extent to which the SSA microfilm system has been integrated with its computer operation. Using a cathode ray printer, SSA converts information from magnetic tape directly to microfilm, thus eliminating all the steps of preparing paper lists and then microfilming them. This one printer does the work previously 20 Department of Health , Education, and Welfare, 1963 performed by 5 high-speed electronic printers and 12 cameras. Each year it makes records of about 260 million reports of earnings items, 16 million employer records, 3.5 million social security accounts, and 3 million adjustments to these accounts. The yearly savings resulting from this improvement is more than $500,000. The computer installation has also been used to reduce the cost of processing earnings items suspended because they were reported either without account numbers or with incorrect numbers which could not be identified by checking to our records or under names different from those on our records. In one case, a system, likewise initiated prior to 1963, has eliminated the clerical handling of some 12 million of these items each year. In another instance, a method was worked out to address, by electronic means, 2 million letters sent to employers every year concerning earnings which were reported incorrectly. These two changes combined resulted in an annual savings of about $900,000. MAGNETIC TAPE REPORTING The Social Security Administration maintains over 100 million active accounts and this number continues to grow. While the process of maintaining lifetime earnings records for all persons with earnings covered under the program has been highly automated, using advanced EDP equipment, one major manual operation has remained. This is the task of punching a card, for introduction into the EDP system, for each of the 66 million individual earnings items reported by employers each quarter. Work has been done on ways to eliminate or minimize this last large manual operation. The Social Security Administration has put a plan in effect under which it currently receives about 5 million of the 66 million earnings items each quarter on magnetic tape which go directly into the EDP system, bypassing punchcard operations. These tapes are submitted by 45 large employers and the armed services. This tape reporting saves processing costs amounting to about $12 per thousand earnings reports. The current annual savings from tape reporting is $240,000. The Social Security Administration has also been working with other employers to extend the use of this type of reporting. It is believed that the usage can possibly be doubled in the next few years as employer use of EDP equipment grows. FIELD ORGANIZATION The Social Security Administration’s district offices render service to the public in all parts of the country. They provide information, accept applications for old-age, survivors, and disability insurance benefits, and furnish assistance to all who ask on any social security matter. Social Security Administration 21 During fiscal year 1963, the Social Security Administration opened 12 new district offices which, with the 17 opened in fiscal year 1962, brought the total to 613. The locations for these offices were deter¬ mined on the basis of growing and shifting populations with resulting needs for increased and improved public service. In addition to the full-time district offices, the Social Security Ad¬ ministration maintains 40 resident-station facilities and contact service for over 3,500 additional communities that are visited at regularly scheduled times to accommodate local service needs. The field orga¬ nization is supervised from 11 regional offices which in turn report to the central office in Baltimore. Seven payment centers are located throughout the country to review and approve claims and take other actions affecting beneficiaries’ payments. The field structure of the Social Security Administration is under continuing review to insure the best possible service to the public con¬ sistent with efficient and economical administration. THE “LEADS” PROGRAM In the latter part of fiscal year 1962, the Social Security Administra¬ tion started sending letters to advise aged insured workers, who had not claimed benefits, of their entitlement to these payments. From its implementation in May 1962 through the end of fiscal year 1963, this “leads” program had resulted in approximately 128,000 claims for benefits by retired workers, their dependents, or their survivors. These claims came from persons who were obviously insured, but who had not claimed their benefits. IMPROVEMENTS IN PROCESSING OF DISABILITY CLAIMS At the end of fiscal year 1963, applications for disability insurance benefits were being better handled than at any time since the beginning of the program. Disability workloads were relatively stable, process¬ ing times were at their lowest and still decreasing, and the relationship between trained staff and workloads was generally satisfactory at the various stations. Substantial reductions have been achieved in the time required to process initial disability claims. Where adjudicative action can be taken on the basis of the medical reports from the applicant’s own sources of treatment or examination, disability claims are now com¬ pleted in an average (median) of 2 months after filing. Where special medical or other development is required because the applicant’s sources cannot provide complete information initially, processing time is increased, on the average, by an additional month to a month and a half. 22 Department of Health , Education, and Welfare, 1963 These figures reflect a net reduction of average processing time since 1959 of at least 1 month for each type of case. Further reduction is expected. Significant progress has also been made in reducing the proportion of cases requiring a long time to process. In June 1959, 14 percent of the cases not requiring development of additional evidence by a State agency were completed within 60 days; by June 30, 1963, 53 percent of these cases were processed within 60 days. Another significant index of timeliness of payment is the extent to which applicants receive their benefit award at the earliest time of entitlement under the law. Forty percent of all persons now being awarded disability insurance benefits are receiving their first check at the earliest possible moment that a payment could be made in their case — i.e., there has been no delay resulting in any retroactive pay¬ ments. The proportion of cases in this category has been increasing gradually; in the middle of fiscal year 1963, it was only 25 percent. Possible increases in the ratio are limited by the fact that the majority of claimants wait to file their claims until after 6 or more months of disability, often because they believe they may recover. Average processing times for requests for the reconsideration of disability decisions are also near their lowest points historically, even in the face of continuing emphasis on better documentation of appli¬ cation files. Reconsideration requests are being handled in about 2 y2 months. Concurrently with the gains made in speed of processing, the Social Security Administration has made significant improvements in the quality of case decisions and in service to claimants. Special training was given selected district office personnel ; greater efforts were made to give physicians information about the kinds of medical information needed; disability examiners and claims authorizers working on dis¬ ability claims were placed in the same administrative units under common supervision. Applications for disability insurance benefits require action by more organizational units than other applications, and during fiscal year 1963, a pilot computer-controlled system was placed in operation to make it possible, when the system is in full operation, to locate a disability claim quickly no matter in which office it may be. Hearings and Appeals The elevation of the hearing and appeals organization to Bureau status at the outset of fiscal year 1963 emphasized the importance of the appeals process and its independence from initial adjudication. It also gave increased emphasis to the management needs of this func- Social Security Administration 23 tion. As these needs are met, a marked improvement in the appeals process is being achieved. Throughout fiscal year 1963, dispositions significantly exceeded receipts, reducing the pending load and substantially improving proc¬ essing time- A total of 20,749 requests for hearing were disposed of during fiscal year 1963, an increase of 3,785, or 22 percent, over fiscal year 1962. (See chart 5.) The effect of this was to reduce processing CHART 5.— HEARING REQUESTS: TOTAL RECEIVED, CLEARED, AND PENDING (FISCAL YEAR 1956-63 ACTUAL AND FISCAL YEAR 1964-65 ESTIMATED) Remanded court cases and Appeals Council remands have been included. HEARING REQUESTS TOTAL RECEIVED, CLEARED AND PENDING (FT 1956-1963 ACTUAL AND FT 1964-1965 ESTIMATED) time from the 8 months in the middle of the fiscal year to about 6 months at the close of the year. During the same period, the Appeals Council was disposing of 7,970 requests for review of decisions by hearing examiners, an increase of 2,001 cases, or 33 percent, over the figure for fiscal year 1962. (See chart 6.) The full effects of the improvements which brought about these reductions were just begin¬ ning to be felt at the end of the fiscal year. Thus further decreases in both pending loads and processing times may be anticipated in fiscal year 1964. To get as complete a record as possible in disability cases, steps were taken to (1) obtain the services of vocational consultants as expert witnesses at hearings before hearing examiners, (2) make available as witnesses consultative physicians and private physicians who can 24 Department of Health, Education, and Welfare, 1963 CHART 6.— REVIEWS BEFORE APPEALS COUNCIL: RECEIPTS, DISPOSALS, AND PENDING FISCAL YEARS 1956-65 Remanded court cases have been included. provide expert testimony in the case, and (3) provide for consultative medical services to hearing examiners. The resulting improved docu¬ mentation provides added assurance that claimants will receive fair and impartial hearings. The hearing records and decisions reflect more clearly the claimant’s residual functions and abilities and should minimize requests for remands by the Department when judicial review is sought. To further serve the needs of claimants, steps have been taken to provide each claimant with more complete information regarding his hearing. The notice-of-hearing forms used by hearing examiners have been revised to provide specific information with respect to the conduct of the hearing, what is expected of the claimant, and the issues and facts to be decided. Providing such information to claimants should enable them to come to the hearings better prepared to present their claims. Program Research Activities Realignment of the Social Security Administration’s organization for research, with an enlarged research objective focused on problems associated with' continuing poverty and insecurity in our changing society, was already in progress when the January 1963 reorganiza- Social Security Administration 25 tion took effect. Under the new organizational structure, the research functions were consolidated in a new Division of Research and Sta¬ tistics, which absorbed functions and staff of the Division of Pro¬ gram Research of the Office of the Commissioner and units of the Di¬ vision of Program Analysis of the Bureau of Old-Age and Survivors Insurance. The new organizational base will facilitate realization of the Social Security Administration’s objective of furthering in substantial measure its total research program. Since it was not possible, how¬ ever, to develop all aspects of the program as rapidly as desirable, primary emphasis was placed on formulating an agenda for basic re¬ search and on strengthening the staff and its capability for long-range research. Responsibilities of the organization for research include the following : (1) Research on basic social and economic problems such as poverty, insecurity, and dependence with which the old-age, survivors, and disability insurance program is concerned and on the interrelation¬ ships of social insurance and related programs. (2) Developing statistics that come from the old-age, survivors, and disability insurance program for use in meeting program needs and the needs of other governmental agencies, research organizations, and scholars. (3) Long-range research on changing social and economic needs and new and emerging causes of insecurity, including the general area of the economic security of the American family. As part of its long-range research program, the Division began preparation of a series of research monographs designed to advance theoretical knowledge and its application to social policy. The mono¬ graphs will be the work of professional scholars on the staff of the Division. The first major product of this activity, Slums and Social Insecurity , subtitled “An appraisal of the effectiveness of housing policies in helping to eliminate poverty in the United States,” was published at the close of the fiscal year as Research Report No. 1. Another major study, which examines the incidence and social conse¬ quences of poverty among families with children, was underway. Inauguration of the Research Report series was part of the Social Security Administration’s plan for a strengthened research publica¬ tions program designed to stimulate and facilitate publication of re¬ search findings and significant statistical data. In addition, steps were taken to increase the variety and scope of articles for the monthly Social Security Bulletin. Staff members will also be encouraged to publish in outside professional journals. 711-845—64 - 3 26 Department of Health , Education , and Welfare , 1963 The Quarterly Summary of Earnings , Employment, and Benefit Data and the Handbook of OASDI Statistics were continued as be¬ fore, wdth plans for a future examination of the relation between these publications and the Social Security Bulletin and its Annual Statis¬ tical Supplement. The Social Security Administration’s design for a continuing na¬ tional family economic and social welfare survey program began to take shape. Work moved ahead on the survey of persons 62 years of age and over and on the companion study of mother-child beneficiaries under old-age, survivors, and disability insurance. Among other uses, these surveys will help meet the detailed information needs of the statutory Advisory Council on Social Security in 1964. Other projects that will provide background for the Advisory Coun¬ cil were in various stages of preparation. The projects included development of information and reports on the overlap between work¬ men’s compensation and old-age, survivors, and disability insurance; the relationship between private employee-benefit plans and social security; the effect of the maximum taxable wage base for old-age, survivors, and disability insurance and the impact of the self-em¬ ployment tax; and the characteristics — based on their old-age, survi¬ vors, and disability insurance wage records — of self-employed and household workers, farmers, and retired- worker beneficiaries. At the close of fiscal year 1963, the Social Security Administration had made a cumulative total of 72 awards in the cooperative research and demonstration grants program under Section 1110 of the Social Security Act. The grants, amounting to slightly more than $2 mil¬ lion, went to educational institutions, public agencies, and other non¬ profit organizations for a broad range of research of significance to social security programs and social welfare. Beginning in fiscal year 1964, the Social Security Administration and the Welfare Adminis¬ tration will administer the grants program jointly. A professional historian was added to the research staff toward the end of fiscal year 1963 to inaugurate an historical program for the Social Security Administration. The international activities of the Social Security Administration include responsibility not only for comparative studies of social se¬ curity programs throughout the world, but also for technical liaison with international agencies, and for a program of training of persons from other countries with specialized interest in social security and credit miion activities. International Activities In fiscal year 1963, there was a marked increase in the number of visitors to the Baltimore headquarters of the Social Security Admin- Social Security Administration 27 istration and in the number of countries and areas of the world rep¬ resented by such visitors. During this period, 213 international guests from 53 countries were received. The visitors ranged from high-level officials of government to teenage students. The Federal Credit Union Program The first. Federal credit union charter was issued on October 1, 1934, to a group of people in Texarkana, Texas, who had accumulated a few dollars to launch this cooperative venture. Today, in its 29th year, the Federal credit union program operates in all 50 States, and in the District of Columbia, the Canal Zone, Guam, Puerto Rico, and the Virgin Islands. Resources of the 10,632 Federal credit unions in operation at the end of 1962 totaled $3.4 billion and the 7 million members had accumulated more than $3 billion in savings (shares) in the credit unions. More than 5 million loans were made to the members of Federal credit unions in 1962, aggregating some $3.6 bil¬ lion. Members’ shares averaged $431 at the end of 1962, and loans made during that year averaged $711. Although Federal credit unions were established to make credit available to “people of small means,” few, if any, scientific studies on a broad scale have been made to depict the socioeconomic status of members. The acute need for credit union service to the economi¬ cally disadvantaged and low-income groups has been recognized, and some progress has been made in meeting this need. Currently in process is an inventory of existing credit unions serving predominately low-income groups to determine the most effective means of assistance to groups that may be organized in the future. In conjunction with this study, plans are underway to organize a few pilot Federal credit unions among the Pueblo Indians in New Mexico — in cooperation with the Bureau of Indian Affairs — and several Federal credit unions to serve the residents of low-income housing projects in New York City. Group educational programs and individual counseling in the wise use of credit are conducted in many credit unions, and widespread use of this technique is encouraged in order to help members become more fully awrare that commercial world practices reflect wide varia¬ tions in interest charges and in hidden costs in credit transactions. Research into the difficulties people of small means encounter in obtaining credit, determinations as to wrho are the savers and who are the borrowers in Federal credit unions, and identification of areas not now served by credit unions are examples of research needs that have been largely postponed in favor of data collection for current program needs. As a byproduct of operations, however, the Bureau 28 Department of Health , Education , and Welfare , 1963 collects a great deal of information that is useful for research pur¬ poses, and plans are now underway to utilize this information more effectively. The organization of a Division of Research and Analysis and the recruiting of the necessary personnel to staff this Division will enable greater attention to be directed to research areas previ¬ ously neglected. Close working relations are continuing with the technical assistance staff of the United Nations, the Agency for International Develop¬ ment, and the Organization of American States to develop credit unions and other cooperative organizations throughout the free world. Program Improvements Social security is today a widely applicable and widely accepted program of basic income insurance. It has contributed greatly toward preventing widespread poverty by assuring a continuing income for most of the retired aged, widows and orphans, and the severely dis¬ abled. It could, however, be used much more effectively for this purpose. HOSPITAL INSURANCE FOR THE ELDERLY The American system of retirement protection will be incomplete until it gives the aged basic protection against the financial conse¬ quences of serious illness. In 1935, when the program began, the widely recognized need among people aged 65 and over was for income- loss protection. Social security benefits have provided basic retire¬ ment income to meet that need. But another great need has emerged — the need for protection against the costs of hospital and related care which threaten the financial independence of aged persons despite the cash social security benefits they receive- In 1935, the 7.8 million people aged 65 and over represented 6.1 percent of the total population. By 1963, the aged numbered 17.7 million and represented 9.3 percent of the population. This relative and absolute increase in the aged population reflects a vast improve¬ ment in the Nation’s health resulting from improved medical care and higher standards of living. Since people are living longer, however, more and more of them are exposed to the risk of the diseases that attack the aged. Today’s improved techniques and facilities for pro¬ viding health care are expensive. Hospital charges, for example, are about 5% times what they were in 1935, while the cost of living in general is only about 2% times what it was in that year. These in¬ creased costs fall heavily on the aged, who as a group experience serious illness much more frequently than younger people and who use much more hospital care (chart 7). Social Security Administration 29 CHART 7.— OLD PEOPLE USE MORE HOSPITAL CARE THAN YOUNGER PERSONS DAYS USED PER PERSON PER YEAR Social security benefits go a long way in helping to meet the day-to- day living expenses of aged people but they cannot be expected to meet the high costs an older person faces when he is sent to the hospital. Aged people have, on the average, two or three spells of illness requir¬ ing hospitalization after 65. A couple, on the average, would experi¬ ence five such illnesses. Medical expenses for aged people who are hospitalized in a year are about five times greater than the medical bills of aged persons who are not hospitalized. Hospital costs account for the major portion of the difference. Meeting high health-care CHART 8.— WHEN HOSPITALIZATION BECOMES NECESSARY, MEDICAL COSTS FOR THE AGED RUN HIGH Average Medical Costs of Aged: Hospitalized vs Nonhospitalized AGED COUPLES NON-MARRIED AGED $925 NEITHER HOSPITALIZED NON-HOSPITALIZED HOSPITALIZED Source: 1957 OASI Beneficiary Survey, cost data adjusted to December 1962. 30 Department of Health , Education , and Welfare, 1963 costs is a problem that confronts virtually all aged people — not just the very poor (chart 8) . When there is a risk to which all are subject but which falls un¬ evenly on those exposed, it is only natural for people to turn to insur¬ ance for protection. Unfortunately, the elderly have not been able to protect themselves as adequately through the existing health in¬ surance arrangements as have younger people. Today about one- lialf of the elderly population have no health insurance protection at all and most who have some protection have only a minor part of their health costs covered by insurance. Moreover, those aged persons who have insurance are likely to be persons who are still working, have higher incomes, or are in better health. The biggest obstacle is simply that most older people cannot afford adequate health insurance. One-half of all aged couples, for example, have less than $2,800 in annual income and little in the way of assets other than equity in a home. There are, of course, other factors that put adequate health insurance out of reach of most of the aged. Above-average hospital use by the aged results in high health costs — costs which tend to make health insurance more expensive for the aged than for younger people (chart 9). Also, the aged, unlike working people who can get group coverage, must generally obtain insurance on an individual basis, a form of health insurance that sometimes costs twice as much as group coverage offering the same protection. CHART 9. — PER CAPITA PRIVATE EXPENDITURES FOR HOSPITAL CARE IN GENERAL HOSPITALS — 1961 $106.00 Public assistance programs — both the regular categorical programs and the newer Medical Assistance for the Aged program — have an im¬ portant role in financing individual health needs not otherwise fully taken care of. But assistance provided on the basis of need should be necessary for only a relatively few people. The decision made Social Security Administration 31 28 years ago in the passage of the Social Security Act was to prevent poverty and dependency to the extent possible; not just to relieve poverty after people have lost their savings. Moreover, many States do not have programs of medical assistance for the aged and only a few of those that do fully meet the health needs of the aged. The basic reason for the severe limitations on the medical care available under most medical assistance for the aged programs is that in many States and localities it is very difficult to raise the revenue necessary to support a comprehensive program. The Administration has concluded that the social security mecha¬ nism offers the most practical solution to the problem of insuring the elderly against the cost of expensive illness. Through a program of hospital insurance for the aged under social security, people could protect themselves against the principal component of the cost of serious illness — the cost of hospital and related care. Employees, together with their employers, would make modest contributions dur¬ ing their working lifetimes to provide earned protection against the costs of serious illness in the worker’s old age. The sound and proven method of financing the existing program, the work-related character of social security benefits, the principle of paying benefits as an earned right, the practically universal coverage of the program — all these characteristics are a part of the Administration’s hospital insurance proposal. As in the case of the present social insurance program, the proposed hospital insurance program would provide no more than basic protec¬ tion — in this case, protection against the costs of hospital and related care. And just as with the present program of retirement, survivors, and disability benefits, the individual could build on his basic social insurance protection: to the extent he desired and found possible, he could by his own means obtain protection against the costs of physicians’ services, drugs, and other health needs not covered under the proposed plan. It is not anticipated that the proposed hospital insurance program would completely replace assistance based on need. Public assistance grants for medical care would still be necessary to supplement the proposed basic hospitalization program under social security, just as old-age assistance has supplemented old-age and sur¬ vivors insurance. Thus, the proposal for hospital insurance for the aged under social security would fit into the pattern of existing arrangements. It would work side by side with private insurance, just as retirement benefits, private pension plans, and private insurance have worked together. It would relieve public assistance of a great part of its present burden and thereby permit the States to offer truly meaningful aid to the 32 Department of Health , Education, and Welfare, 1963 few in specially disadvantaged circumstances. It would provide a basic benefit that could easily be supplemented on a private basis. It would carry on the threefold attack against destitution in old age that has been so successful in that area of income maintenance — an attack carried out by social insurance, voluntary insurance, and public assistance — each performing those activities for which it is most appropriately equipped. EXTENSION OF PROGRAM COVERAGE The need to extend social security protection to essentially all of the Nation’s gainfully employed people and their families has been recognized since the program was established. The major strides toward universal coverage have already been taken, and more than 9 out of 10 workers are now building social security protection as they work. But as long as there continue to be areas of employment not covered by social security, some of the many workers who shift from one job to another will see their social security protection di¬ minish or will lose it entirely. The largest area of employment not covered under social security is civilian employment for the Federal Government (chart 10) . More CHART 10. — 9 OUT OF 10 WORKERS ARE COVERED UNDER THE OASDI PROGRAM ♦Includes self-employed physicians and persons earning less than minimum required for coverage. than 2 million Federal civilian jobs are covered only by the civil service retirement system or one of several smaller Federal staff retirement systems. The Federal staff retirement systems are primarily designed to pro¬ vide adequate retirement protection for those who make a career in the F ederal service. As a result, there are many gaps in the protection of Federal civilian employees who spend part of their work lifetimes in the Federal service and part in other work. Employees who die Social Security Administration 33 or become disabled after leaving Federal employment have no protec¬ tion from their period of Federal service; the survivors or the dis¬ abled worker and his dependents may have no protection at all if the worker did not have enough employment after leaving the Federal service to become insured under social security. Employees who die, become disabled, or leave Federal service before completing 5 years of service get no protection based on their Federal employment; even those who have more than 5 years of service may end up without retirement protection because they are allowed to take immediate cash refunds in lieu of deferred annuities. These gaps could be filled through modifications in social security and the Federal staff retire¬ ment programs. Self-employment in the practice of medicine is also excluded from social security coverage — an exclusion affecting about 170,000 physi¬ cians. In general the same reasons that led to coverage of other self- employed professional groups apply also to doctors of medicine. The great majority of other workers who are not covered under Federal law at a particular point in time are found among the part- time household and agricultural workers and part-time self-employed people. During their working lifetimes some of these workers will obtain social security protection based on their coverage under the program during periods of regular employment, from other types of jobs in covered work, or as dependents of covered workers. COVERAGE OF TIPS Much consideration has been given to a proposal that would im¬ prove the social security protection for employees who get part of their earnings in the form of tips. Since employees who work for both wages and tips get social security credit for only the wage part of their pay, protection for them is not based on their full earnings and is less adequate than that of other workers. The need for cover¬ ing tips has been recognized for many years. The Department of Health, Education, and Welfare and the Department of the Treasury have agreed upon and recommended a plan to provide that tips would be considered wages for purposes of the social security program and for income tax withholding. Under the plan, the employee would be required to report to his employer the amount of tips received, and the employer would report the tip income along with the regular wages that he paid to the employee. DISABILITY INSURANCE Most families in the United States are assured of financial help through social security benefits if family income is cut off because of the severe, long-term disablement of the worker. As of June 30, 34 Department of Health , Education, and Welfare , 1963 1963, nearly 1.4 million persons were receiving benefits amounting to about $89 million a month on account of their own disabilities or as dependents of disabled family earners. Under present law, though, the protection a disabled wmrker and his dependents get may hinge on the worker’s awareness of the importance of filing an application with reasonable promptness. At the time the disability program was established, protection was made available to all disabled workers who, at the time of the beginning of their disability, met the insured- status requirements — even though the disability may have begun many years in the past. It was recognized that there would be problems in determining whether a person who had stopped working many years before had actually met the definition of disability at a point in time when he still met the disability insured-status requirements — particu¬ larly, the requirement of 5 years of work out of the 10 years preceding disability. But it was assumed that almost all of the disabled people applying for protection in the future would be those whose disabili¬ ties had begun quite recently, and the legislation therefore provided that after a specified date a long-run provision would take over, under which disabled workers would be required to file applications rela¬ tively promptly in order to protect their rights. After several post¬ ponements, this provision finally became effective with respect to applications filed after June 30, 1962. In the case of applications filed since that date, the 5 years of required earnings must occur in a 10-year period ending no earlier than 18 months before filing appli¬ cation. This means that people who have been out of work for a long time because of a disability but for one reason or another have not filed an application may lose all benefit rights or have their benefit amount significantly reduced. Despite concentrated efforts to inform disabled people of their rights to protection under the program, many, for one reason or another, still do not file applications promptly. Currently, among applications for disability protection during a year, about 50,000 people (disabled workers and their dependents) suffer loss or diminution of protection because the disabled worker failed to apply promptly. Experience in making determinations that a, disability began many years before has shown that the problems that were expected in deter¬ mining that a disability began years ago are not of sufficient magnitude to support the continuation of a provision under which so man}^ people suffer a loss of protection. It therefore seems desirable that the law be changed so that a disabled worker could establish the beginning of his disability as of the date he actually became disabled, even though he may apply for disability benefits much later. Social Security Administration 33 KEEPING BENEFITS AND FINANCING UP TO DATE Keeping benefits and the financial base of the program in line with the general level of the economy is one of the major program needs. Across-the-board benefit increases were enacted in 1950, 1952, 1954, and 1958. Also, in 1950, 1954, and 1958, the maximum amount of annual earnings taxable and creditable toward benefits was increased — from $3,000 to $3,600, to $4,200, and then to $4,800. However, the past legislative actions have been only partially successful in keeping the protection of the program from deteriorating; while benefit amounts have kept up with price increases over the years, they have not kept pace with rising levels of living as reflected in today’s higher earnings levels (chart 11). Benefits may be kept in line with rising levels of living if they are allowed to rise with increases in money wages, since, in general, money wages reflect increases both in prices and productivity. Various ad- CHART 11, — BETWEEN 1940 AND 1961 THE PERCENTAGE INCREASE IN AVERAGE EARNINGS EXCEEDED THE PERCENTAGE INCREASE IN AVERAGE BENEFITS Percentage Increase 36 Department of Health , Education , and Welfare , 1963 justments are needed from time to time. For example, it is necessary to adjust the maximum amount of earnings which is taxable for social security purposes and which is also used for figuring the average monthly earnings on which future benefits depend — the so-called earn¬ ings base. Since it has not been considered appropriate to cover the full earn¬ ings of very high-paid people and to pay correspondingly high bene¬ fits, there has always been a limit on the annual amount of earnings that is taxable and creditable for social security purposes. While the question of where the earnings base should be set has been a contro¬ versial one over the years, and while there have frequently been differ¬ ences of opinion on the timing of increases in the base, congressional committees and other groups who have studied the question generally agree that the earnings base should be raised as earnings levels go up. Although the earnings base has been increased several times over the years, it has not kept pace with changes in earnings levels (chart 12). CHART 12.— THE EARNINGS BASE COVERS THE TOTAL ANNUAL EARNINGS OF A SMALLER PERCENTAGE OF REGULARLY EMPLOYED MEN THAN IN THE PAST EARNINGS BASES I-:-:-:-:-:-:-:! $4,200 W//A $3,600 If the earnings base were not increased, more and more workers as time goes on would have earnings above the creditable amount; eventually the program would become one that pays a flat benefit, un¬ related to actual earnings, to nearly every one who works regularly under the program. Thus, the effectiveness in providing security that comes with a program which pays benefits geared to the amount of earnings loss would be seriously weakened. So, too, would be the in¬ centive values inherent in a wage-related system. Social Security Administration 37 In addition to this fundamental change in the character of the pro¬ gram, if the earnings base were not increased as earnings levels rise, the financial base of the program — the part of the Nation’s payrolls that is subject to tax for its support — would decrease proportionately. When the program started, about 92 percent of covered payrolls was taxed to support the program. This year only 74 percent is being taxed. The cost of keeping benefits reasonably in line with price and wage levels has been met in the past partly through the automatic increase in contribution income that accompanies rising wage levels, partly by increases in the earnings base, and partly from increases in the social security contribution rates. Financing has been required from increases in the contribution rates above what would have been required if the earnings base had been kept in line with increasing wages. In a program that is financed by a tax applied at a constant rate to the covered earnings of all workers under the system — earnings of lower paid workers as well as those of workers earning at or above the maxi¬ mum — it would seem more desirable to meet the cost of increased protection for workers at the higher earnings levels through increasing the amount of earnings on which these workers and their employers contribute rather than through increasing the contribution rates that all workers pay. This is another reason for keeping the wage base up to date. Other changes that affect benefit levels are also necessary from time to time. Additional information on the subject of benefit adequacy will soon be available. A comprehensive study of the income and resources of the aged will be completed in early 1964, and in 1964 the statutory Advisory Council will also report its findings on benefit adequacy. Summary ancl Conclusions Developments during fiscal 1963 emphasized once again social secu¬ rity’s major role in providing most Americans with lifetime protec¬ tion against risks common to all but against which individuals are least able to provide adequate safeguards. That the program has become a growing force in the lives of many of the Nation’s people was highlighted by the fact that the amount paid out in benefits in the single year ending June 30, 1963, exceeded the total amount paid out in the first 15 years of operations — from January 1940 through December 1954. Management improvements continued to be introduced, with pay¬ offs in the form of better service to the public accompanied by econ- 38 Department of Health , Education , and Welfare , 1963 omy of operations. Workloads continued to rise — these were taken in stride without commensurate increase in staffing. The ground¬ work laid in previous years, including the provision of workspace specially designed for operating needs, the stepped up in-service train¬ ing of junior staff members, and the development of more efficient communications, played an important part in the year’s progress and solid achievements. Social Security Administration 39 Table 1. — Old-age , survivors, and disability insurance: JSumber of families and beneficiaries receiving benefits and average monthly benefit in current- payment status, by family group, end of December 1962 and December 1961 [In thousands, except for average benefit] Family classification of beneficiaries Dec. 31, 1962 Dec. 31, 1961 Number of families Number of bene¬ ficiaries Average monthly amount per family Number of families Number of bene¬ ficiaries Average monthly amount per family Total . _ 13,318.3 18, 053. 4 12, 173. 6 16, 494. 8 9, 738. 5 12, 674. 9 8, 924. 8 11,655.2 Worker only _ _ 7, 133. 6 7, 133. 6 $72. 50 6. 470. 2 6, 470. 2 $71. 90 Male - - - - 3, 665. 9 3, 665. 9 81.80 3,335.9 3, 335. 9 81.20 Female - - - - - 3, 467. 7 3, 467. 7 62.60 3, 134. 3 3, 134. 3 62. 00 Worker and aged wife . - 2, 323. 9 4, 647. 8 127. 90 2,213.6 4, 427. 1 126. 60 Worker and young wife 2 3 _ ... 1.1 2.3 113. 20 .9 1.9 108. 50 Worker and aged dependent husband. .. 13.5 27.0 108. 70 13.6 27.2 107. 50 Worker and 1 or more children . . 73.5 167.7 118. 20 62.6 141.2 120. 90 Worker, aged wife, » and 1 or more children _ _ _ _ 27.2 83.7 157. 60 25.2 77.4 159. 20 Worker, voung wife, 2 and 1 or more children _ _ _ 165.7 612.5 148. 80 138.6 509.7 149. 20 Worker, husband, and 1 or more chil¬ dren... - - - - .1 .3 111.60 .1 .4 123.30 Survivor families _ 2, 838. 9 4. 103. 4 2, 630. 7 3, 812. 5 Aged widow _ _ _ _ 1,835.0 1,835.0 65.90 1, 677. 4 1,677.4 64. 90 Aged widow and 1 or more children _ 21.3 43.8 124. 40 17.3 35.4 122. 90 Aged widow and 1 aged dependent parent . . . . . . .4 .7 166. 60 .3 .5 153. 80 Aged dependent widower . . 2.4 2.4 62.20 2.3 2.3 62. 10 Widower and 1 or more children _ .1 .2 113. 20 .1 . 1 91.30 Widowed mother only 3 _ _ ... 2.2 2.2 61.20 1.1 1.1 61.50 Widowed mother and 1 child . . .. 190.5 381.0 137. 30 184.6 369.2 135. 00 Widowed mother and 2 children _ 127.9 383.7 190. 70 120.3 361.0 189. 30 Widowed mother and 3 or more children. 130.7 632. 1 186. 80 121.3 587.5 182. 80 Widowed mother, 1 or more children, and 1 aged dependent parent - ... .3 1.1 210. 70 .4 1.4 231. 00 Widowed mother, divorced wife, and children - - - - 0 0 0 (9 .1 247. 90 Divorced wife and 1 or more children... .5 1.2 180. 90 .4 1.0 170. 10 1 child only _ _ _ _ .. 314.5 314.5 62. 00 302.2 302.2 60. 70 2 children . . . . . 108.5 217.0 126. 40 104.6 209.2 124. 60 3 children _ _ _ _ 43.2 129.5 166. 70 40.8 122.5 160. 10 4 or more children. .. ... ... . ... ... 26.4 121.6 167. 80 23.1 104.8 168. 30 lor more children and 1 aged dependent parent _ _ _ .6 1.5 150. 00 .5 1.1 145. 30 1 aged dependent parent . . 33.2 33.2 69. 10 32.5 32.5 68. 10 2 aged dependent parents.. . . 1.4 2.8 109.60 1.5 3.1 111.00 Disabled-worker families _ 740.9 1, 275. 1 618. 1 1, 027. 1 Worker only . . 542.4 542.4 88. 00 459.3 459. 3 87. 70 Male _ _ 384.2 384.2 92. 10 332.0 332.0 91.50 Female _ _ _ 158.3 158.3 78. 10 127.3 127.3 77. 70 Worker and aged wife 1 _ _ _ 25.3 50.6 137. 10 24.5 48.9 136. 50 Worker and voung wife 2 3 _ ..... (9 (9 143. 70 .1 .1 156.90 Worker and aged dependent husband... .4 .8 125. 00 .3 .6 115. 80 Worker and 1 or more children _ _ 51.4 138.4 156. 70 40.6 106.4 154. 90 Worker, aged wife, i and 1 or more children - - .4 1.2 172. 60 .2 .6 186.60 Worker, young wife, 2 and 1 or more children . . 121.0 541.7 191. 60 93.2 411.2 191. 10 1 Wife aged 65 or over or wife aged 62-64 with no entitled children in her care. 2 Wife under age 65 with 1 or more entitled children in her care. 3 Benefits to children were being withheld, * Less than 50. Table 2. — Old-age, survivors, and disability insurance: Number and amount of monthly benefits in current-payment status at end of June 1963 and amount of benefit payments in fiscal year 1963, by State [In thousands] 40 Department of Health, Education, and Welfare, 1963 Lump-sum death payments $195,330 co 3 f0 2 CM 0 S 03 5 § CO cd ct> r— co co CM CO WO H00OWO CO t''- fiOCOO _J 05(N0) IOOONW Cm"oo"' O ^ CO CM rt< < 03 IO ^ CO 1 O^COVO( HCMC0 03 00 ^ 00 iO O CM O CO O CM CO l 03 00 CM \ cm" ) CO ^ t-H > CM b- vo rH CM 00 03 ^ WVOHOO cm o vd o Tt< co’ io >CO O b- vo CO CO 00 CO OOCOvOCMt ; rti CO* co' co' CM* rt< cm’ COHH^ 0 2 CM o b-"o CO b- 03 b- CM vO 03 00 CM CO VO 00 03 CO COH< CO b- 00 CO < CM 03 CM 03 i I VO b» ’ 03 VO O 03 b» i> vo vo . O CM CM 03 rt !>: t-4 cm’ © © 03 CO 00 - )CMH COHCM^H ) CM CO CM H CM VO N >>40 pi 2 23 NC5VOVOH VO W CO CO H VO CM 00 00 03 CM" 0 03" cm" co" VO CO 03 CO CO CO CM CO H ^ CM 00 cm" O O CM 00 00 b- CM CO ) O CM 03 b- vo CM CM CO CM b^ CM' rH H VO* ‘ 03 VO b- vo CO Tt« CO > CO ^ 1 b^ 03 CM ' * H 03 CM C . O ^ CO CM CO CO CO r-H 03 CM CO VO VO O O VO CO CM 00 CO vd CM GO 'g g«'3 ,2£§ga 43 ^ g "C .S o'® H H •Sl^L 5 C3 3 8* ? c3 c3 'S b a g-gfj, MM aSSWS Social Security Administration 41 islii 883SS 3111! ills! I3S8* SSS83 S -«£«§ Sf-SSS S3S”" asas- eo Hill 302 919 878 537 316 Sisal 006 660 007 961 670 153 973 715 417 15 fllll 1 «-T *• £ *r 3« eocoi-T^T llili ssess 3SSIS Sllll mn Sills 1 mm mm mm mm mm s' SISiS IslII sllsl SiiSS 3SSS3 ISls§ § |g|Bg 2SSS8 SSgRK gS5§8 g'gS'SSf -T i 050 141 153 277 427 103 248 684 351 179 567 159 743 263 902 438 424 455 430 189 053 947 244 201 3 i r-r^r-O^ onV) 33. 00 16. 42 Virginia _ , _ _ 60. 81 67. 96 66. 45 23. 93 Washington _ 84. 58 133. 24 95. 16 67.85 43. 03 West Virginia. _ 47. 09 36. 25 47. 26 47.16 25. 71 Wisconsin _ _ .. _ . .. 100. 82 92. 99 105. 84 44. 32 Wyoming - 85.88 85. 76 82.69 36. 76 * Average payment not computed on base of fewer than 50 recipients. 8 Program in operation but no payments made in June 1963. 116 Department of Health, Education, and Welfare, 1963 Table 3. — Public assistance : Total payments to recipients under Federal-State programs, by State, fiscal year 1963 [In thousands] State Total Old-age assistance Medical assistance for the aged Aid to families with dependent children Aid to the blind Aid to the perma¬ nently and totally disabled Total _ $4,200,499 $2,003,338 $289, 175 $1, 425, 876 $95, 001 $387, 109 Alabama . - - - 105, 434 84, 361 685 12, 462 938 6, 989 3,116 1,262 1,758 95 25, 128 9,919 13, 533 767 909 Arkansas _ - . . 54,904 41, 500 1,311 5,136 1,548 5,409 California _ . ... - - 625, 264 331, 376 59, 295 180, 213 18, 869 35, 511 80, 624 60, 327 15, 094 249 4, 954 Connecticut _ - - - - 51,262 8, 964 11,585 25, 943 413 4,356 3,858 746 2, 487 255 370 District of Columbia - 14, 103 3, 080 75 7. 986 168 2, 795 Florida _ _ - 86, 205 52, 558 20, 414 1,971 11,262 93, 468 57, 629 17, 263 2, 055 16, 520 Guam.. . . ... . -- 220 44 16 133 2 25 Hawaii.. .. _ - - 9, 488 938 1,356 5, 682 96 1,416 Idaho - - 13, 493 4, 761 2, 342 4, 679 112 1,599 Illinois _ _ 244, 817 64, 152 3, 536 141, 037 3,127 32, 965 39, 238 21,394 16, 048 1,743 53 Iowa.. _ _ _ _ 52,311 32, 032 17, 932 1,581 765 Kansas _ 44, 141 26, 720 12, 022 577 4, 822 Kentucky _ .. - 70,930 36.986 901 23, 812 1,882 7, 349 Louisiana . . . 166,451 124, 023 976 26,487 2,690 12, 276 Maine _ 21,618 10, 286 989 7, 710 376 2, 257 Maryland - - 38, 146 8, 018 2, 822 21, 572 347 5,387 Massachusetts- - 165, 734 59,351 46, 284 39, 769 3, 370 16, 959 Michigan _ _ - 133, 386 48, 445 20,379 54, 936 1,768 7, 858 Minnesota _ 81,118 54, 607 22, 930 1,417 2,163 M ississippi _ _ 48, 294 32, 393 8, 620 1,491 5,790 Missouri _ _ 128, 440 82, 239 30, 510 3, 862 11,830 Montana _ 9, 136 4, 855 2,883 265 1,133 Nebraska _ _ _ 19,953 12, 512 4, 639 781 2, 021 Nevada 4, 495 2,623 1,652 221 New Hampshire _ 8, 551 5, 431 175 1,968 312 675 New Jersey 75, 734 20, 583 45, 734 923 8, 493 New Mexico _ _ 24, 833 10,269 11,352 312 2,901 New York _ 419, 744 58, 009 104, 143 205, 911 4, 019 47, 662 North Carolina. _ _ _ 79, 558 29, 088 30. 521 3, 584 16, 365 North Dakota.. - 13, 411 6, 182 2, 259 3,285 78 1, 607 Ohio _ 157, 637 85, 545 52, 930 3, 345 15, 817 Oklahoma _ .. . _ _ 138, 676 92, 665 1, 587 27, 847 2,351 14. 225 Oregon - - 35, 849 15, 620 682 13, 724 421 5. 402 Pennsylvania _ 207, 639 43, 958 16, 843 116,160 16, 108 14, 570 Puerto Rico _ . - ... 16, 869 3,820 698 9, 917 163 2,271 Rhode Island ... . ... 18, 710 6, 099 9,738 113 2, 760 South Carolina - - 29, 028 15, 458 1,409 6, 107 1,146 4,908 South Dakota 12, 338 7, 598 3,768 114 858 Tennessee _ .. 54, 877 27, 716 782 18, 281 1,400 6,698 Texas _ 210, 231 183, 073 17, 564 4,118 5, 477 Utah _ 17, 757 5,018 2, 131 6,829 162 3, 616 Vermont _ 7, 980 5, 240 198 1,731 85 726 Virgin Islands _ 501 219 29 210 6 37 Virginia . . . ----- 27, 691 9, 517 12, 420 880 4, 874 Washington _ .. - 82. 626 46, 813 2,979 21, 516 801 10,517 West Virginia - - 56, 770 9, 013 2, 708 40, 591 504 3,954 Wisconsin 64. 040 35, 647 21. 040 966 6, 387 Wyoming. . 4, 676 2, 657 1,401 53 565 Welfare Administration 117 Table 4. — Public assistance: Aid to families with dependent children., unem¬ ployed-parent segment, recipients and average payment, June 1963, and total payments , by State, fiscal year 1963 State Recipients June 1963 Average payment June 1963 Total pay¬ ments, fiscal year 1963 (in thousands) Total _ _ _ _ _ 300, 552 $28. 89 $108, 856 Arizona . - . . _ _ . _ _ _ _ (>) 12, 097 1,434 (*) 29. 25 2 Connecticut _ _ . . _ _ _ _ 4,324 503 Delaware. .. _ _ _ _ 22.35 Hawaii . . . . . . .. .. . . . . 2,212 28.63 719 Illinois .. - _ _ _ _ 53,818 40.34 27,949 1,278 1,139 27,009 11 Maryland _ _ . . _ __ _ _ . 2,584 28.39 M assachusetts 2,388 78,007 39.41 New York . ... ... _ _ _ _ 30.03 North Carolina. . _ _ _ _ ----- . . . 41 (1 2) 27. 69 Oklahoma.. . - .. .. . _ _ _ _ _ 178 65 Oregon _ ----- - _ _ _ _ . _ _ - _ 3,606 38.53 1,453 Pennsylvania. .. _ .. . _ ------ 72,374 2,978 4,472 21.22 22, 728 Rhode Island . . --------- . .. . _ 33.35 1,086 832 Utah _ _ _ _ _ _ 20. 65 West Virginia _ _ - . . . . . . . - 64,363 26. 10 19, 756 1 Program in operation but no payments made in June 1963. 2 Average payment not computed on fewer than 50 recipients. Table 5. — Public assistance: Aid to families with dependent children receiving foster care, number of children and average payments per child, June 1963, and total payments fiscal year 1963, by State State Total _ Alabama _ Arizona _ California _ Illinois _ Indiana _ Louisiana _ Maryland _ New Mexico _ North Carolina. Oklahoma _ Oregon - Utah _ Virginia - West Virginia.. Wisconsin _ Number of children receiving foster care, June 1963 3, 221 21 144 971 578 64 305 221 68 35 219 184 180 63 9 159 Average payment per child, June 1963 $66. 97 0) 46. 97 80. 49 79.88 37.53 55. 12 65.60 54. 94 (0 40. 47 71. 70 50.31 42. 76 (*) 64.99 Total payments, fiscal year 1963 (in thousands) $1,911 11 33 613 424 18 173 156 38 27 95 116 80 24 1 Average payment not computed on fewer than 50 children. 2 Less than $500. 118 Department of Health, Education, and Welfare, 1963 Table 6.- -Public assistance: Federal grants to States, by program , fiscal year 1963 1 State Total Old-age assistance Medical assistance for the aged Aid to the blind Aid to the permanently and totally disabled Aid to fam¬ ilies with dependent children $2, 671.271.192 $1. 342, 633. 266 $138, 778, 317 $48, 869, 630 $239, 059, 697 $901,930,282 83. 614.170 2, 009. 390 65,876. 819 825, 040 422, 425 749. 924 59, 473 554, 180 5, 732, 180 10, 832, 822 1. 124, 877 10. 308,115 18,891.622 7, 356, 310 673, 017 42, 610.319 31, 986, 766 899, 185 1, 142, 700 4.170,197 4, 411, 471 319, 219. 531 169, 579, 128 25, 950, 927 7, 407, 378 18. 048,458 98, 233. 640 44. 124, 552 30. 395. 404 150, 581 3, 439. 266 10. 139. 301 28. 021,114 6,020.547 6, 840, 880 173, 480 2, 5^9, 598 12, 416, 609 3, 025. 354 588, 958 164, 960 254,397 2, 017, 039 9, 203, 863 1,995.641 100,000 114. 203 1,803, 671 5, 190, 348 68, 187, 785 40, 412, 430 1,441,775 8, 391, 035 17, 942, 545 76, 529, 730 47, 237, 044 1, 606, 939 13, 388. 720 14,297.027 138, 824 29,480 10.389 921 16, 366 81,668 6,141,559 707, 174 803,889 60, 991 618, 034 3,951.471 9, 221,380 3, 431.805 1. 557, 011 81, 973 1,369, 388 2, 781, 203 138, 750, 793 42. 317. 513 1,966,161 1, 686, 300 16, 352, 659 76, 428, 160 27, 718, 304 14,441,037 1,130,702 158, 963 11, 987, 602 33, 448, 462 21, 204, 173 809, 731 537, 316 10, 897, 242 28, 361,389 17,903,380 339, 807 2, 665, 333 7,452, 869 55, 795, 691 28, 756, 895 808,889 1,463, 364 5,551,769 19,214, 774 128,391,600 94.430,414 1, 768, 866 10,255, 573 21,936,747 15, 788, 643 7, 520, 077 472, 042 254, 869 1,495, on 6, 046, 644 26, 140. 147 5, 529, 851 1, 677, 824 236, 610 3, 713, 751 14, 982, 111 90, 982, 966 38, 354, 430 23, 791, 220 1, 332, 407 6, 769, 561 20, 735. 348 79,121,192 31, 028, 546 11, 132, 172 959, 322 3, 612, 861 32, 388, 291 44, 157, 560 30. 040,078 650,258 1, 646, 798 11, 820, 426 42, 068, 711 27, 843. 470 1, 231, 755 5, 144, 522 7. 848.964 93, 781, 252 59, 351, 522 2, 356, 398 8,347. 153 23,726.179 6, 485, 474 3, 473, 611 183, 845 811, 649 2, 016, 369 13, 912, 628 3, 031,354 4, 842,220 8, 636, 659 1, 687, 488 3, 219. 280 423, 041 108, 017 156, 404 1, 270, 155 3, 582, 773 1,235,849 1,098.307 22, 081 346, 148 39, 257. 713 11. 945, 891 578, 488 4, 618, 495 22, 114. 839 18. 770, 157 7, 909, 360 233, 029 2, 045, 607 8. 582. 161 216. 608, 622 38. 427, 380 47, 930,829 2. 135, 488. 21,025, 873 107, 089, 052 63. 986, 207 23, 396. 579 2,905.146 13, 018, 868 24. 665, 614 9,161,927 4. 501, 911 1, 738, 032 61, 623 860, 605 1.999.756 102, 801,854 53, 199, 830 2. 226, 321 9,904,550 37. 471, 153 92. 002. 354 62, 475. 195 1,052,890 1, 083, 546 7, 348, 787 20, 041.936 22, 038, 415 10,320,345 208, 955 2, 946, 676 8, 562, 439 128, 447,981 29, 109, 520 5, 283, 794 3, 123. 380 10, 368, 364 80, 562,923 9. 533, 275 2, 067, 594 358,322 101, 929 1, 398, 053 5, 607, 377 11,377, 463 4,114, 013 78, 381 1,621,469 5. 563, 600 24, 494, 443 12. 982, 732 1, 126, 109 919, 863 4, 044, 853 6. 420. 886 9, 281,411 5, 655, 998 92. 005 672, 513 2,860,895 46, 306, 640 23. 061, 752 803,041 1, 148, 312 5, 543, 297 15, 750, 238 159, 170, 975 136, 842, 873 2,923, 509 4, 257, 698 15, 146, 895 12, 843, 613 3, 621, 372 1, 436. 804 106, 084 2,708,867 4, 970, 486 6, 129, 102 3, 896, 169 194, 352 65, 591 567, 306 1, 405, 684 315, 019 133, 475 21, 384 4,071 22, 554 133, 535 22, 763, 716 7, 875, 563 697, 823 3, 896, 166 10,294, 164 49, 534, 956 28, 869, 412 1, 643, 547 395, 658 6, 344, 637 12,281,702 43, 648. 602 7, 559, 595 734, 118 415, 535 3, 158, 539 31,780,815 36. 057, 552 20, 700, 268 529, 147 3, 194, 921 11,633,216 3, 021, 616 1, 785, 469 34, 572 337, 450 864, 125 Total.... . . Alabama _ _ _ Alaska _ Arizona . . Arkansas _ California _ Colorado _ Connecticut _ Delaware _ District of Columbia Florida _ Georgia _ Guam - Hawaii _ Idaho _ Illinois . . . Indiana - Iowa _ Kansas _ Kentucky . . Louisiana _ Maine _ Maryland _ Massachusetts _ Michigan _ Minnesota _ Mississippi _ Missouri _ Montana _ Nebraska _ Nevada _ New Hampshire . New Jersey _ New Mexico _ New York _ North Carolina _ North Dakota _ Ohio _ Oklahoma _ Oregon _ _ Pennsylvania _ Puerto Rico _ Rhode Island— . South Carolina _ South Dakota _ Tennessee _ Texas _ Utah _ Vermont _ Virgin Islands _ Virginia _ Washington _ West Virginia _ Wisconsin _ Wyoming _ _ i Based on cash advanced for the year; may differ slightly from fiscal year expenditures from Federal funds reported by the States. Welfare Administration 119 Table 7. — Public assistance: Selected fiscal data relating to payments , fiscal year 1963 State Average per capita income, 1962 Expenditures payments fi local fundi 1963 Per inhab¬ itant for assistance rom State and >, fiscal year Per $1,000 of personal income, 1962 Percent of assistance payments from Fed¬ eral funds, fiscal year 1963 Total i _ _ $2, 366 $8.78 $3. 77 60.4 Alabama - - - 1, 567 7. 47 4.74 76.3 Alaska - - - - - . 2,667 4. 86 1.84 61.4 Arizona _ _ _ 2, 097 4. 18 2.07 73.9 Arkansas - - - - ... 1.504 6. 65 4.50 77 5 California . . . . . 2,898 18. 84 6. 75 46.9 Colorado _ -- - - 2, 370 18 25 7. 95 55.4 Connecticut . . . . . . .. 3,089 9. 73 3.23 49.4 Delaware _ _ _ _ _ 3,102 2. 26 .74 72.1 District of Columbia _ 3. 219 7. 00 2.21 60.5 Florida _ _ _ _ -- - 2, 044 3. 65 1. 85 76.0 Georgia - - - 1,759 5.10 2. 93 77.4 Guam . . . . . . . . . (1 2) 1.64 (2) 50.0 Hawaii _ _ _ _ _ _ _ 2,403 5. £9 2. 61 56.1 Idaho - - - - - 1,941 6. 46 3. 40 65.8 Illinois . . . . 2, 844 12.29 4. 30 49.3 Indiana - - - 2, 350 2. 75 1.15 67.4 Iowa - - - - - - 2, 189 7.04 3. 22 62.6 Kansas - - --- --- - 2,188 7.82 3. 59 60.5 Kentucky _ _ _ _ - - 1,712 5. 45 3. 20 76.2 Louisiana _ _ - - - 1,705 12.73 7.64 74.0 Maine... - - - 1,917 6.17 3. 15 72.1 Maryland _ _ _ _ _ .. .. 2, 683 4. 15 1.59 64.3 Massachusetts _ _ _ 2, 769 15. 96 5. 80 50.0 Michigan _ ... _ _ _ 2,416 7. 32 3. 08 55.4 Minnesota . . . . 2, 236 11. 08 4. 96 52.5 M ississippi _ _ _ 1,285 3. 77 2. 99 82.1 Missouri _ _ _ ... 2, 384 8.82 3. 67 70.4 Montana _ _ ... ..... ... .. 2, 207 4. 39 1.98 66 0 Nebraska _ ... .. ... _ _ 2.270 4. 49 1.95 67.1 Nevada _ ... .... _ 3. 278 4. 42 1.52 62.8 New Hampshire _ 2, 206 6.13 2. 76 55.0 New Jersey _ _ _ _ .. 2, 887 6. 06 2. 18 48.2 New Mexico _ _ _ _ 1.824 6. 97 3. 81 71 4 New York.. _ _ _ _ _ 2.930 11 92 4.16 49.4 North Carolina _ _ 1,732 3.84 2. 23 77.0 North Dakota _ _ _ _ ... _ 2. 273 7.66 3. 32 63.9 Ohio _ _ 2. 392 5. 75 2.43 62.8 Oklahoma . . . . 1,905 19. 39 10. 39 65.1 Oregon _ _ _ 2, 333 8. 37 3. 51 57.4 Pennsylvania . . . 2, 363 7.01 2. 98 61.4 Puerto Rico _ _ _ _ (2) 3. 44 (2) 48.8 Rhode Island _ _ _ _ 2, 372 9. 33 4. 01 56.0 South Carolina . . . . . . . 1,545 2 41 1. 59 79.4 South Dakota . . . . . 2, 065 4. 58 2. 27 72.5 Tennessee _ _ _ _ _ . _ 1,702 3. 05 1.82 79.6 Texas _ _ _ _ _ _ 2, 013 5.23 2. 66 74.3 Utah . . . . . . . 2. 084 5. 48 2.69 69.5 Vermont _ _ _ _ 2,005 5. 61 2. 76 72.9 Virgin Islands _ _ _ _ (2) 7.07 (2) 49.2 Virginia _ _ _ _ _ _ 2, 018 1.47 .76 76.9 Washington _ _ 2, 485 12.10 4. 96 55.2 West Virginia _ _ _ 1,810 7. 46 4.11 76.8 Wisconsin _ _ _ 2, 283 7. 53 3. 26 52.4 Wyoming . . . . . 2,164 5. 59 2. 36 60.2 1 Excludes Guam, Puerto Rico, and the Virgin Islands, data on per capita and personal income not available. 2 Data not available. 120 Department of Health , Education , and Welfare , 1963 Table 8. — Maternal and child health and welfare services: Grants for maternal and child health services , services for crippled children, and child welfare services under the Social Security Act, by program and State, fiscal year 1963 1 [In thousands] State Maternal and child health services Crippled children’s services Child wel¬ fare services United States _ _ _ $23, 871. 5 $23, 830. 1 $25. 703. 8 Alabama _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 733.6 650.6 130.4 657.7 166.5 248.7 423.1 1, 569. 8 320.8 267.9 107.9 123.3 654.2 707.7 12.7 166.5 95.0 937.5 624.0 539.0 366.1 633.1 612.6 202.3 384.3 600.6 974.8 523.7 494.1 566.0 157.3 240.6 93.9 103.6 569.0 237.2 1,342.6 895.9 170 5 Alaska.. _ .. __ _ . ._ .... _ _ 119.9 Arizona _ _ . _ . _ _ _ _ _ _ 212.5 Arkansas _ _ _ _ _ _ _ 366.0 372.7 906. 6 1, 378. 4 427.4 Colorado _ _ _ _ _ _ _ _ _ . 286! 3 301.3 127.6 222.2 569.2 779.0 27.3 192.1 201.5 823.2 594.5 489.6 282.0 602.4 585.7 132 4 Connecticut _ _ _ _ _ _ 376. 7 Delaware.. _ .. .. _ _ _ . _ _ _ 130.3 District of Columbia _ _ ... ... _ 284.8 Florida _ _ _ 826.9 Georgia _ _ _ _ _ _ . _ 717.6 Guam _ _ _ _ ... _ _ _ 59. 7 Hawaii _ _ _ 179.3 Idaho _ _ _ _ _ 199.3 711.4 444.8 Iowa... _ . _ 333.3 Kansas _ _ _ 261.8 Kentucky _ .. 536.4 Louisiana _ _ _ _ 504.4 Maine _ _ _ _ 176.7 Maryland .. _ _ _ _ 386.6 434.9 454.1 995.0 663.6 M assachusetts _ 416.4 Michigan _ _ _ _ _ _ _ _ _ 877.3 Minnesota _ _ _ _ _ _ _ 510. 1 Mississippi _ 581. C 546. 7 M issouri _ 516. 7 475.9 189. 5 Montana _ _ _ _ _ _ 147.2 Nebraska _ _ _ 162.3 194. 7 Nevada _ . ... _ _ . ... ... . .. . . 125.0 138.7 New Hampshire.. . . _ _ _ _ _ 89.3 125.6 358.0 New Jersey _ _ _ _ _ _ _ 377.0 New Mexico. _ _ _ _ _ _ _ _ 266.8 235.3 New York _ _ _ _ 1, 119. 1 876.0 936.0 North Carolina _ 977.4 North Dakota _ _ _ _ _ _ _ 140.9 139.5 Ohio _ _ _ _ 915. 1 968.5 1,236.4 420.5 Oklahoma _ .. 364.0 320.5 Oregon . _ - _ _ 195.3 236 2 258.3 1,245.0 589.2 172.5 Penn sylvania _ 1, 122. 6 601. 1 1,233.4 677.5 Puerto Rico _ _ Rhode Island _ _ 223. 1 157.3 South Carolina _ 515. 1 568.9 544.3 South Dakota _ _ _ _ _ _ 88.9 96.0 176.3 Tennessee _ _ _ 711.8 674.4 640.7 Texas _ _ 1,077.7 165. 1 1,338.5 172.6 1, 156. 7 227.4 Utah. _ Vermont... _ _ _ _ 128. 7 125.3 129.6 Virgin Islands _ _ 108.7 108. 1 76.5 Virginia _ 695. C 665.6 634.7 Washington _ _ _ 407.3 346.3 392.4 West Virginia. _ _ _ _ 363.8 381.3 345.2 Wisconsin _ _ 492. 1 501. 1 557. 1 Wyoming _ 123.1 117.0 110.6 i Based on checks-issued basis. Additional payments were made for special project grants to institutions of higher learning and to public or other nonprofit agencies and organizations as follows: Maternal and child health services, $1,016.0; services for crippled children, $897.3; and research and demonstration projects in child welfare, $738.9. Public Health Service Health of the Nation From the point of view of public health, 1963 has been a good year. There were a number of significant achievements in the protection and advancement of the health of the American people. In addition, several developments hold great promise for the future. During the year, President Kennedy discussed vital health issues in four separate messages to the Congress. In his general-health message, Mr. Kennedy emphasized the need for Federal aid in the education of the health professions, for new medical facilities, for a unified and intensified attack on environmental pollution, and for improving the communication of science information. The President also urged bold action programs to develop community facilities for the study and treatment of mental illness and mental retardation, to improve the physical fitness of American youth, and to provide health insurance for the aged under social security. As in other years, many agencies and individuals contributed to the gains in health. These include official agencies — local, State, and Federal — as well as professional organizations, foundations, volun¬ tary agencies, universities, industry, and other institutions. As a result of the President’s recommendations, and of growing public interest in health matters, several significant new programs were enacted into law by the Congress. The Health Professions Educational Assistance Act of 1963 (Public Law 88-129), for ex¬ ample, is a major step toward meeting the Nation’s critical shortage of health manpower. The legislation provides for Federal aid in the construction of teaching facilities for training physicians, dentists, nurses, pharmacists, optometrists, podiatrists, and other profes¬ sional public health personnel. The act also authorizes loans to stu¬ dents of medicine, dentistry, and osteopathy. 711-845—64 9 121 122 Department of Health, Education, and Welfare, 1963 CHART 1. — PUBLIC HEALTH SERVICE, 1963 1/Smparati organlzotional ilotui ilmllor Id iIm Notional Library of Modldno li prapowd ~ under rt>* reorganization plan. groupings would become bureaus under the reorganization plan. Another major health measure enacted by the 88th Congress was the Mental Retardation Facilities and Community Mental Health Cen¬ ters Construction Act of 1968 (Public Law 88-164). The act au¬ thorizes (1) a 4-year program of project grants for the construction of research centers on mental retardation; (2) a 4-year program of project grants for the construction of university-affiliated facilities for the mentally retarded; (3) a 4-year program of grants to the States for the construction of community facilities for the mentally retarded ; (4) a 3-year program of grants to the States for the con¬ struction of community mental health centers ; and (5) a training pro¬ gram for teachers of handicapped children. Two important programs authorized by the 87th Congress came into being by the appropriation of funds in 1963. These programs provide project grants to the States for intensive community vaccina¬ tion against polio, diphtheria, whooping cough and tetanus, and for establishing and operating health service clinics for migratory farm¬ workers and their families. Gains in medical research contributed substantially to the health strides made in 1963. Much of the progress in research stemmed from investigations conducted or supported by the Public Health Service — Public Health Service 123 the largest single source of support for medical research in the country. Among the year’s research developments was the discovery that human viruses can cause cancer in laboratory animals — further evi¬ dence that viruses may be the cause of some forms of cancer in man. Also in the field of virology, a major victory was scored over childhood disease with the development of vaccines against measles. The total research program of the Service was strengthened in 1963 as two new institutes began operations. The National Institute of Child Health and Human Development, authorized in legislation signed October IT, 1962 (Public Law 87-838) , was established January 30, 1963. Its mission is to launch a major research attack on problems of child and maternal health and on the special health problems of children, including mental retardation, and to gather information about the process of human development throughout life. Public Law 87-838 also authorized the establishment of an institute for research and research training in the basic medical and related sciences. Pursuant to this authority, the National Institute of General Medical Sciences was established in 1963, elevating to Institute status the former Division of General Medical Sciences at NIH. In recent years, the administration, the Congress, and many pro¬ fessional groups — both in and out of Government — have expressed concern over the need to improve the communication of scientific in¬ formation developed through biomedical research. Concomitantly there has been a steadily growing public interest in health matters, reflected, for example, in the volume of inquiries being received in the Service. In the central office alone, these inquiries were in excess of 156,000 in 1963, an increase of over 100 percent in the past 10 years. In an effort to achieve wider application of research findings in medical and public health practice, increased emphasis was given in 1963 to the improvement of communications from scientist to scientist and from scientists to the health professions. Activities during the year stemmed, in part, from a PHS-sponsored conference on health com¬ munications in the fall of 1962. Through demonstrations, professional and public education, and technical assistance to the States, the Public Health Service seeks to bring knowledge gained through research into the widest possible use by medical practitioners, health workers, and the general American public. During the year, the Service, among other things, awarded grants to develop new or improved out-of-hospital health services in 68 com¬ munities, ranging from rural counties to large metropolitan areas. 124 Department of Health, Education, and Welfare, 1963 These grants, made under the Community Health Services and Facili¬ ties Act of 1961, are stimulating the development of better techniques for providing home nursing care, dental care for the homebound, rehabilitation and other services needed by the chronically ill and aged. In the area of environmental health, more municipal waste-treat¬ ment facilities were contracted for in fiscal 1963 than in any previous fiscal year, in large part under the aid programs authorized by the Federal Water Pollution Control Act and the accelerated public works program. The Service also provides direct health services for legally specified beneficiaries and for certain Federal agencies; operates a nationwide system of hospitals; and administers the Nation’s foreign quarantine program. Especially noteworthy during the past year was the re¬ cruitment of four surgical teams to aid the civilian population of South Vietnam. Each team includes two surgeons, three nurses, and a medical technician. The 1963 programs of the Public Health Service — in community health, environmental health, medical and hospital services, research and training, health data and information, and international health — are described in detail in subsequent pages. Health Record Latest estimates from the health interview phase of the National Health Survey indicate that T4 million Americans have one or more chronic conditions or impairments. This represents 42 percent of the Nation’s civilian noninstitutional population. Fourteen million of these persons — or 8 percent of the population exclusive of those in resident institutions — are limited in their major activity (the ability to work, keep house, or attend school) because of chronic illness. About 6 million (40 percent) of those limited have had this limitation for 5 years or more. Heart conditions and arthritis or rheumatism were the most frequently named causes of limitation. Acute illness requiring medical attention or resulting in restriction of usual activity for a day or more continues to occur at an annual rate of about two conditions per person. Of the 402 million acute illnesses and injuries included in the recent annual estimate, 231 mil¬ lion (57 percent) were conditions affecting the respiratory system, and 52 million (13 percent) were injuries. About 50.5 million persons were involved in injuries, with 43 percent being injured in home accidents. As for disability, chronic and acute illnesses (including injuries) were responsible during the year for the average person experiencing l*ublic Health Service 125 16.3 days of restricted activity. Of this total, 6.4 days were spent in bed. Employed persons, 17 years of age and older, lost an average of 5.8 days of work, and the average child (6-16 years) was absent from school 5.7 days during the year because of illness. In 1962 there were 1,756,720 registered deaths, giving a rate of 9.5 deaths per 1,000 total population, as compared with rates of 9.3 in 1961 and 9.5 in I960.1 In recent years, the death rate has flucuated in a relatively narrow range, with deaths due directly or indirectly to respiratory conditions largely influencing the exact level of the rate. Over the last 10 years the rate has been 9.5 or 9.6 in years when respi¬ ratory disease was more than usually prevalent ( 1962, 1960, 1958 and the latter part of 1957, and 1953). Other years in this period have had lower rates, but never under the 9.2 rate of 1954, when there were almost no influenza outbreaks. The leveling off of the crude death rate is not confined to the United States. It has been characteristic over recent years of such widely separated countries as England and Wales, Norway, Sweden, Den¬ mark, the Netherlands, Chile, and Japan. Provisional death rates lower than the U.S. rate of 9.5 in 1962 were reported for Canada, the Netherlands, Norway, Australia, New Zealand, and Japan. In 1962, so far as the United States is concerned, in addition to a significant increase in the death rate for influenza and pneumonia there were increases for diseases of the heart (the leading cause of death) and for other diseases of the circulatory system. An unusual feature in 1962 was an increase in the rate for each of the categories of violent deaths — accidents, suicides, and homicides. The last time this occurred was in 1945. Since the age distribution of populations affects the death rate, “age-adjusted death rates” are calculated by weighting the death rate for each age group in a population in proportion to the size of the age group. Using our 1940 population as a base, the age-adjusted death rate for 1962 was 7.5 deaths per 1,000 population, with a corresponding 1961 rate of 7.3 (a record low) and a 1960 rate of 7.6. Thus it is evident that one reason why the country’s crude death rate has been relatively stable over recent years is that the population contains pro¬ portionately more older people than previously. Although 1962 had about 3 percent fewer people aged 55-64 in proportion to the total population than did 1952, it has 5 percent more aged 65-74, and 21 percent more aged 75 years and over. In 1952 the age-adjusted rate was 8.1, so that this rate declined about 6 percent between 1952 and 1962. The rate did not decline 1 All vital data are for calendar years. 126 Department of Health , Education , and Welfare , 1963 CHART 2.— BIRTH RATES BY AGE OF MOTHER: UNITED STATES, 1940-62 (Rates per 1,000 female population In each age group. Trend lines for 1959-60 based on registered live births; trend lines for 1940-59 based on live births adjusted for underreglstrotlon) equally for each of the sex-color groups. The 1962 rate of 5.4 for white females was about 13 percent lower than it had been in 1952; the non white female rate of 8.7 was 16 percent under its 1952 rate; the white male rate of 9.0 had gone down only 4 percent; and the nonwhite male rate of 12.0 had dropped 9 percent. About 1 infant in 40 died within a year of birth in 1962, as compared with 1 in 10 during 1915. But while the infant death rate declined Public Health Service 127 CHART 3. — BIRTH RATES BY LIVE-BIRTH ORDER: UNITED STATES, 1940-62 (Rotes per 1,000 female population aged 15*44 years. Trend lines for 1959*60 based on registered live births; trend lines for 1940*59 based on live births adjusted for underreglstratlon) by 25 percent or more for every 10-year period until 1950, the curve has been going down more slowly in recent years. In 1962 there were 25.3 deaths under 1 year per 1,000 live births, equaling the alltime low for the United States recorded last year, as compared with 26.0 in 1960. For white infants the 1962 rate was 16.9; for nonwhite infants it was 26.1. The maternal death rate, which stood at 317 deaths per 100,000 live births in 1941, reached a low of 35.2 in 1962, as compared with 36.9 in 1961 and 37.1 in 1960. The rate for white mothers in 1962 was 23.8 : for non white mothers, 95.9. In 1962 the expectation of life at birth was 70.0 years, slightly under the 70.2 figure of 1961, again because of the greater incidence of 128 Department of Health , Education , and Welfare , 1963 CHART 4. — DEATH RATES: DEATH-REGISTRATION STATES, 1900-62 1900-1962 (RATES PER 1,000 POPULATION) 20 I 5 10 9 8 7 1900 1910 1920 1930 1940 1950 1962 CHART 5.— AGE-ADJUSTED DEATH RATES: DEATH-REGISTRATION STATES, 1900-62 20 15 10 8 6 1900 1910 1920 1930 1940 1950 1962 (RATES PER 1,000 POPULATION) Public Health Service 129 respiratory disease in 1962. The 1962 expectancies by color and sex were as follows: White males, 67.6 years; white females, 74.4 years; nonwhite males, 61.5 years; nonwhite females, 66.8 years. In recent years the average length of life has been increasing at a faster rate for women than for men, and at a faster rate for the nonwhite population than for the white population. Births , Marriages , and Divorces The 4,167,362 live births registered in 1962 were about 100,000 fewer than the 1961 total of 4,268,326. Since the number of births has not changed greatly during the past 6 years, while the population has continued to grow, the crude birth rate has declined somewhat each year since 1957. The rate was 25.0 in 1950 as compared with 23.3 in 1961 and 22.4 in 1962. The fertility rate, or number of live births per 1,000 women 15^4 years of age, also has declined somewhat each year since 1957. The 121.2 rate for 1957 was higher than any rate since World War I, which indicates that the changes under discussion are going on at a level well above the rates of the middle 1930’s. In 1962 the fertility rate was 112.1 as compared with 117.2 in 1961 and 118.0 in 1960. In 1962, an estimated 1,580,000 marriages were performed, as com¬ pared with 1,547,000 in 1961. The marriage rate remained at 8.5 per 1,000 population, unchanged since 1959. There were an estimated 393,000 divorces in 1960, as compared with 395,000 in 1959. The divorce rate was 2.2 per 1,000 population in 1959, 1960, and 1961. Funds The total funds available to the Public Health Service in fiscal year 1962 amounted to $2,140.2 million. (See table 1, p. 210.) Appro¬ priations and authorizations accounted for about $1,593.2 million of this amount. The balance was made up of repayments for services given to other agencies and of unobligated balances from previous years. Approximately 50 percent of the total funds available was obligated to others, in the form of grants and research contracts to State and local agencies, private institutions, universities, hospitals, and individ¬ uals outside the Federal Government. The remainder was used to support the direct responsibilities of the Public Health Service, such as hospital and medical care for legally designated beneficiaries, for¬ eign and interstate quarantine, and Indian health services. 130 Department of Health , Education , and Welfare , 1963 Office of Personnel Significant progress was made during the year on a major reorga¬ nization to improve the PHS personnel system. Responding to the 1962 recommendations of the Advisory Committee on Public Health Service Personnel Systems, a program has been developed and exten¬ sively implemented to strengthen staff services, improve operations, equitably adjust pay and rank, and generally provide a more efficient, responsive staff. The continuing goals of the Office of Personnel are to better utilize “on board” personnel ; to attract more top-quality individuals at all levels; to further integrate Civil Service and Commissioned Corps personnel systems, to establish closer “top-to-bottom” coordination throughout the Service ; and to acquire and train the manpower essen¬ tial for the ever-broadening PHS responsibilities of the future. Personnel On June 30, 1963, the Public Health Service had a total staff of 34,799, an increase of more than 6 percent over June 30, 1962. (See table 2, page 211.) This number included 4,929 Commissioned Corps Officers, 28,337 full-time and 1,533 part-time Civil Service em¬ ployees. (See table 3, page 213.) Commissioned officers on duty included 2,067 members of the Regular Commissioned Corps, and 2,862 members of the Reserve Corps on Active duty, of which 169 were on temporary training duty . National Center for Health Statistics The National Center for Health Statistics in the past year devoted major attention to improving its publications program. Publications activities were centralized in the Office of the Director. Previous mailing lists maintained in the National Health Survey and the Na¬ tional Vital Statistics Divisions were discontinued and a new consoli¬ dated mailing key was established for the Center. A new publication series was initiated, placing most of the Center’s publications under a single system. Another major development during the year was the establishment of a new training program for statisticians, mathematicians, and social science analysts. The aim of the program is to stimulate the recruit¬ ment of qualified personnel in these professional areas. Under the program, qualified college and university graduates are selected to serve for approximately a year in specially developed training assign¬ ments in the Center’s various program areas. Trainees participate in Public Health Service 131 a series of seminars and are encouraged to further their academic preparation by part-time attendance at local colleges and universities. NATIONAL HEALTH SURVEY DIVISION An historic “first” was scored during the year ; namely, the comple¬ tion of the first cycle of 6,672 health examinations of adult Americans (ages 18 through 79 years). The survey was the first of its kind ever undertaken in the Nation. From the data collected, health offi¬ cials will have information on the prevalence of cardiovascular dis¬ eases, arthritis, diabetes, and dental conditions, and the levels of acuity of hearing and vision in the population. In addition, data on a variety of physical and physiological measure¬ ments will aid health officials and private agencies in making decisions to improve the health of the people. Later in the year, planning and pilot testing of a “second cycle” of health examinations for children (ages 6 through 11 years) were completed for a 3-year program with emphasis on collection of data related to growth and development. Work on the Division’s newest data -collection program, the Health Records Survey, resulted in the collection of data for all types of resi¬ dent institutions and hospitals in the Nation. These data are being tabulated and analyzed in preparation for a report describing facili¬ ties which provide nursing, residential, or personal care. Meanwhile, planning and pretesting were started for a new hospital discharge survey to obtain from hospital discharge records detailed information on the volume, kinds, and characteristics of hospital stays. The National Health Survey Division continued its research and developmental activities, including quality control and surveillance of all operating programs, special research studies in methodology on household interview reports concerning hospital experiences, a special oral glucose tolerance test, a measurement of health expendi¬ tures, and the calibration of testing equipment for visual acuity. The Health Interview Survey produced its 50th report by the end of the year. The year’s output of reports included publication of new information on the volume of X-ray visits and types of accidental injuries. Data was collected to evaluate the reliability of reporting on the volume of medical visits. Another major project was the evaluation and interpretation of data on chronic diseases. NATIONAL VITAL STATISTICS DIVISION The Division continued to reduce the timelag between the receipt of data from the States and its publication. An advance natality report for 1962 was published within 8 months of the end of the data year, and an advance mortality report a month later. At the close of the fiscal year, plans were being carried out to prepare all birth 132 Department of Health , Education , and Welfare , 1963 and death tabulations for 1962 for printing within 12 months of the close of the data year. Extensive tabulations on occupational mortality were completed, drawing upon data from vital records and from 1950 census records. The Division also completed a major part of the tabulations needed for a series of monographs sponsored by the American Public Health Association to synthesize data of concern to public health and demography. A national natality sample survey was inaugurated, based on a sample of births occurring throughout the country. (A similar national mortality sample survey is in its third year of operation.) The new survey will use information contained on birth certificates in order to obtain additional data of interest to public health and demography. The major topic under study for the first year is the exposure of mothers to ionizing radiation during the year before birth of a child. A color film, “Medical Certification of Causes of Death,” was made under the Division’s direction. The film will be shown in hospitals, medical schools, schools of nursing, and health departments to en¬ courage more complete reporting on death certificates. Extensive activities involving study-group meetings and the circu¬ lation and analysis of questionnaires to numerous governmental and nongovernmental agencies and individuals were initiated to carry through revisions of the standard certificates of live birth, death, and fetal death and the standard records of marriage and divorce or annulment. A series of regional institutes was established to train State person¬ nel in new operational techniques. The first series of these institutes was concerned with vital-records management. The institutes feature relatively short conference-seminar sessions and are led by outstanding experts in fields of particular interest. OFFICE OF ELECTRONIC SYSTEMS By the end of the fiscal year, several statistical programs of the National Health Survey and National Vital Statistics Divisions had been transferred from the Remington-Rand UNI VAC computers to the IBM 1401-1410 computer system. The changeover resulted in elimination of the backlog in processing and placed the data programs on a current schedule in the National Vital Statistics Division. The effect on the National Health Survey Division’s programs was to con¬ vert to the more powerful IBM system the data-processing systems and data files which are used in processing health characteristics of sample households to produce estimates and rates for the national population. Public Health Service 133 OFFICE OF HEALTH STATISTICS ANALYSIS The Office continued its study of changes in the general mortality and infant mortality trends in the United States. Contracts were negotiated in several foreign countries for studies to determine the possible factors responsible for changing mortality trends in various parts of the world. Studies of the mortality trend for pneumonia and for selected causes in this Nation and in Chile were completed. A study to develop an index of health is underway. Analysis of multiple causes of death in 1955 is proceeding, and the eighth revision of the international classification of diseases is nearing completion. National Library of Medicine The constantly increasing medical research effort has required the development by the National Library of Medicine of a system which can accommodate the vast amounts of information being generated. This requirement is being met by the Medical Literature Analysis and Retrieval System. MEDLARS, which will become fully opera¬ tional in early 1964, is founded on an understanding of indexing technology derived from the Library’s 80 years of bibliographical experience with the literature of medicine and public health. MED¬ LARS will handle a larger volume of published literature than any existing system. The 250,000 citations it will handle annually repre¬ sent a large proportion of the total scientific literature. MEDLARS comes into being at a time when computer technology and the availability of computers in medical research institutions throughout the United States will permit the multiplication of its search potential by the duplication of searchable tapes. The Library intends to make this new electronic retrieval power available generally to other medical libraries over the next 5 years. The first pilot program to extend the MEDLARS facility to the medical research community is proposed for 1965 and would equip selected medical libraries to search the organized store of information which has been centrally compiled at the Library. The extension of MEDLARS search capabilities, when coupled with photoduplication services to provide physical access to medical literature, will enable libraries to meet modern research requirements for information with unprece¬ dented effectiveness. BOARD OF REGENTS The Board of Regents held two meetings, on November 5, 1962, and on March 29, 1963. New members appointed to the Board were Dr. Henry N. Harkins and Dr. Alfred A. Gellhorn. Items on the agenda 134 Department of Health , Education, and Welfare, 1963 for the Board’s two meetings included the Library’s publications program, budget projections, extramural program plans, the develop¬ ment of the MEDLARS system, and the role of the National Library of Medicine in training and research in the area of science communica¬ tions. SECOND INTERNATIONAL CONGRESS ON MEDICAL LIB RARIAN SHIP The staff of the National Library of Medicine provided major planning and management services for the Second International Con¬ gress on Medical Librarianship, held in Washington, D.C., June 16-22, 1963, under the sponsorship of the Medical Library Association. The purpose of the Congress was to foster the development and improve¬ ment of medical library services throughout the world. More than 1,000 medical librarians from sixty countries attended. PROGRAM STATISTICS In fiscal year 1963 the Library acquired 16,151 books, 67,832 serial pieces, and added 956 new serial titles, increasing its collections to 1,098,006 items. The History of Medicine collection was increased by 300 old and rare items. The staff cataloged 15,273 titles, and 876 pictures and other items were added to the Prints and Photo¬ graphs Collection. There were 205,709 volumes circulated, and 13,418 reference questions answered. Main entries published in the National Library of Medicine Catalog totaled 15,592. The Index Medicus pub¬ lished 139,462 items from 2,244 journal titles. Inter library loans increased to 135,344. Microfilm production amounted to 3,215,649 pages, of which 821,989 were for preservation purposes and 2,333,686 pages for interlibrary loan. Division of Public Health Methods The Division of Public Health Methods conducts studies to identify emerging national health problems and to assess the significances of social, scientific, economic, and educational developments of health services and resources. In these areas, the Division provides advisory and consultative services within the Service, to other governmental agencies, and to national professional and voluntary agencies. HEALTH MANPOWER Three additional sections of the Health Manpower Source Book Series were published during the year : Section 14, “Medical Specialists,” presents basic data on the num¬ bers, distribution, and characteristics of physicians engaged full- or part-time in medical specialties. Information on physicians by type Public Health Service 135 of practice and by type of specialty is shown for selected years be¬ tween 1931 and 1962. For 1961 there are separate sections for each of the 26 specialties with detailed findings on certification, type of prac¬ tice, age, sex, State location, and medical schools from which the specialists graduated. Section 15, “Pharmacists,” gives information on the numbers, loca¬ tion, and characteristics of pharmacists in the United States in 1962. Its appendix presents statistics on undergraduate student enrollments 1958-63, and graduates of U.S. schools of pharmacy from 1932 to 1962. Section 16, “Sanitarians,” compiled in cooperation with the Office of Resource Development, presents basic data on the numbers, loca¬ tions, and characteristics of sanitarians in the United States as of mid-1962. A projection of the number of physicians to 1975, prepared in the Division and published in the American Journal of Public Health , showed that there will be a decline of the physician-population ratio from present levels despite the addition of graduates from the new medical schools now proposed and of foreign- educated physicians. ECONOMIC STUDIES Long-range work on the economic impact of health services was begun, with twin objectives: (a) Identification of those aspects of the topic which should be studied by the Public Health Service or under its auspices, and (Z>) appraisal and further development of method¬ ology for use in such studies by the various levels of government. The most promising aspect of the topic thus far appears to be costs-versus- benefits studies, limited to geographic area or disease entities, or both. As a means of stimulating interest in such research, the Division co¬ operated with the American Public Health Association in planning a panel on economic benefits for the November 1963 meeting of the association in Kansas City. TECHNICAL AND STAFF ASSISTANCE In connection with the Division’s responsibility for the coordina¬ tion, analysis, and review of PHS survey projects, which includes liaison with the Bureau of the Budget on the clearances required by the Federal Reports Act, an informal working agreement was reached with the Bureau of the Budget for waiving clearance on certain classes of forms and for abbreviating procedures on others. The arrange¬ ment is being tested and developed further. The Division has provided staff services for the Surgeon Gen¬ eral’s Committee on Urban Health Affairs, a newly constituted public advisory group under the chairmanship of the Assistant Surgeon Gen¬ eral for Plans; for the Surgeon General’s annual conference with 136 Department of Health , Education , and Welfare , 1963 State and territorial health officers; and for the PHS Committee on Aging. A compilation of PHS laws in effect on December 31, 1962, was prepared for the Committee on Interstate and Foreign Commerce of the House of Representatives. Other activities have included preparation of the Surgeon Gen¬ eral’s quarterly report to the Secretary, a newly assigned respon¬ sibility ; collection within the Public Health Service of the monthly revisions for “HEW Indicators” and the annual revisions for “Trends”; preparation of the PHS portion of the annual edition of the “Handbook on Programs”; participation in a PHS mission to Yugoslavia vis-a-vis projects using Public Law 480 funds; review, in collaboration with the PHS Executive Officer, of internal audit activi¬ ties of PHS and the preparation of a report ; membership on the HEW Waiver Review Board, the National Science Foundation’s Advisory Council on Scientific Manpower, the Task Force on Tax Policy and Educational Expenditures, and the Task Force on Federal Education Programs; assistance to the Pan American Sanitary Bureau in plan¬ ning for a conference on the development of methods for studying the medical education and health manpower requirements of Latin America; technical assistance to the Mayor’s Advisory Committee on the Establishment of a Medical School in Norfolk; and continuing staff services in support of the Assistant Surgeon General for Plans. Office of International Health The Secretary approved a reorganization elevating international health activities to the status of an Office of International Health. During the year, the Office arranged the official U.S. representation at the 16th World Health Assembly in Geneva, Switzerland (May 1963) ; the 31st and 32d sessions of the Executive Board of the World Health Organization, also in Geneva ; the XVI Meeting of the Pan American Sanitary Conference in Minneapolis (August 1962) and the 47th and 48th meetings of the Pan American Health Organization’s Executive Committee in Minneapolis (September 1962) and in Wash¬ ington (April 1963). In addition, the Office was represented at the 13th meeting of the Research Council, South Pacific Commission in Papeete, Tahiti (April 29 to May 3, 1963). The Office, in consultation with the Department of State and other branches of the Service, helped to develop the official U.S. policies on the topics discussed at these international health meetings. The Office also participated in developing the U.S. position on health-related matters which came before the meetings of the Food and Agricultural Public Health Service 137 Organization, the United Nations Children’s Fund, the International Labor Organization, the Social Commission of the United Nations, and the South Pacific Commission. The Office assisted in clearing the appointment of more than 80 U.S. experts to serve as members of WHO expert advisory panels and as short-term consultants to the World Health Organization and the Pan American Health Organization. Seventy of the U.S. experts who are serving as members of WHO panels are Public Health Service officers representing 40 health and medical specialties. The Office arranged to continue the assignment of 46 Public Health Service officers to the Agency for International Development for tech¬ nical assistance and advisory services in 18 countries. Thirty-nine Service officers were detailed to staff the medical organization of the Peace Corps. These officers, principally responsible for the health of Peace Corps volunteers in 84 countries, also supply local health and medical service. The Office provided program guidance to 592 foreign visitors and students from 87 countries, involving more than 150 educational and training centers in the United States. Consultation was given to stu¬ dents and visitors in the United States, and a number of U.S. educa¬ tional institutions were advised on the special needs of foreign students and visitors. The Office made arrangements under a United States-U.S.S.R. agree¬ ment for receiving five Soviet delegations and for sending three U.S. delegations to the U.S.S.R. One joint meeting in cardiovascular dis¬ ease was held in the U.S.S.R. and two joint meetings in cardiovascular disease and rheumatic disease were held in the United States for ex¬ changing views and scientific information in these fields. Five U.S. scientists visited the Soviet Union for periods of four to ten months each, and eight Soviet scientists visited the United States for periods of four months each. Division of Health Mobilization In a national disaster, every community will be faced with the task of meeting the immediate health needs of its civilian population. Sufficient medical supplies and hospital facilities must be available, with predesignated personnel organized and trained to act in an emer¬ gency. By Executive order, PHS is charged with assisting the States and communities in meeting these responsibilities. The value of disaster preparation was demonstrated this year when the Division applied emergency health plans during the removal from 711-845—64 10 138 Department of Health , Education, and Welfare, 1963 the Mississippi River of sunken tanks of deadly chlorine gas that were endangering the citizens of Louisiana and Mississippi. All programs were strengthened during the year by the addition to the Division field staff of 38 new State representatives, augment¬ ing the existing field staff of 9 regional and 7 State representatives. The staff members have been instrumental in furthering emergency health preparedness by arranging training programs; coordinating medical stockpile inspections ; assisting in the development and evalua¬ tion of community plans; and securing the cooperation of medical societies, other allied health groups, and civil organizations. Quality controls and a plan of regular inspections were established to assure readiness of supplies in the emergency medical stockpile, now valued at approximately $200 million. Materials are stored in de¬ pots and allocated to Civil Defense Emergency Hospitals (CDEH’s). A program is underway to provide underground storage locations for bulk stocks because such space offers superior conditions for long¬ term preservation and protection of supplies. In carrying out this program, the Division acquired 250,000 square feet of usable space in a worked-out limestone mine at Wampum, Pa. The 200-bed CDEH’s are now pre-positioned in 1,930 State-pro¬ vided facilities. The Division is currently working to increase their operation capability from 3 or 4 days to 30 days. An additional 750 hospitals are being assembled which will bring the number of pre¬ positioned CDEH’s to 2,680. To familiarize designated staffs with contents and operation of the CDEH, 12 prototype Emergency Train¬ ing Hospital Units were acquired and are being field tested. Physicians, as well as members of allied health professions, must be trained to provide services in a disaster which are not a part of their usual peacetime activities. Research was begun to determine how the present functions of paramedical personnel can be adapted to meet emergency needs. Since immediate medical care will be limited to that available in shelters, the general public also must know how to provide emergency medical care. The Medical Self-Help Training Program allocated almost 30,000 training kits to instructors this year. About 388,000 people have completed formal training, and some 400,000 more have viewed the lessons on television. The ultimate goal is to train one member of every U.S. family. Bureau of Medical Services The Bureau of Medical Services operates hospitals, clinics, health centers, and other health services in this country and abroad, on land and at sea, in major ports and on remote inland reservations. Some Public Health Service 139 14,000 stall members are engaged in these activities that provide direct health care to many people and help to safeguard the Nation’s health. Medical and hospital care is provided for American seamen, mem¬ bers of the Coast Guard and the Coast and Geodetic Survey, and cadets at the Coast Guard and Merchant Marine Academies. Inter¬ national travelers arriving from foreign points are checked against any possibility of contagious disease. American Indians and natives of Alaska are given comprehensive health care. Members and retired members of the Armed Forces and their fam¬ ilies receive care at hospitals and clinics of the Bureau where more convenient than military hospitals; in turn, Public Health Service commissioned officers may receive care in military facilities. A special hospital is devoted to the treatment of leprosy. Treat¬ ment for narcotic addiction is given in two neuropsychiatric hospitals. The Bureau is responsible for medical and hospital care in the Federal prisons and correctional institutions throughout the country. Medical and hospital care for civilian employees of the Govern¬ ment who are injured on duty or become ill from causes related to their work is administered by personnel of the Bureau. Employee health units are operated for a number of Federal departments and agencies. The Bureau is guided by recommendations of the BMS Advisory Committee on Hospitals and Clinics, and the Indian Health Advisory Committee, made up of experts from hospitals and health programs all over the country. Division of Hospitals The mission of the Division of Hospitals — oldest organizational unit in the U.S. Public Health Service — is to provide medical care for American seamen and other beneficiaries designated by the Congress. More than 385,000 persons qualify for care. In addition to seamen, patients include Coast Guardsmen and their dependents; members of the Army, Navy, Marine Corps, and Air Force and their depend¬ ents; commissioned officers of the Public Health Service and the Coast and Geodetic Survey and their dependents; Federal employees in¬ jured in line of duty; any person having leprosy; and any person addicted to narcotic drugs. The Division is the principal source of training in the Public Health Service for physicians, dentists, pharmacists, and other paramedical personnel. Research is conducted in the clinical management of dis¬ ease and health problems. 140 Department of Health , Education , and Welfare , 1963 PATIENT CARE Admissions to the 15 hospitals operated by the Division in fiscal year 1963 totaled 52,346 — an increase of 2.1 percent over 1962. In addition, 1,022 babies were born. The average daily inpatient census declined 2.2 percent to 4,693, but the number of outpatient visits increased 5.8 percent to reach 1,352,506. Uniformed service personnel and dependents accounted for 34 per¬ cent of all admissions and 39 percent of all outpatient visits to Public Health Service hospitals and clinics. Outpatient visits of military personnel and dependents increased by more than 20,000 over the previous year. CARVILLE LEPROSARIUM In April 1963, the PHS hospital for leprosy patients in Carville, La., in cooperation with the American Leprosy Missions, held the fourth annual leprosy seminar, featuring some of the world’s fore¬ most leaders in the field of Hansen’s disease. The hospital in Car¬ ville is an internationally recognized center of knowledge about leprosy and has accomplished much in improving the medical treat¬ ment of patients and also in dispelling the erroneous psychological fears that historically have been attached to this illness. DRUG CONTROL The Division of Hospitals has had for several years a well-developed control program for investigational drugs. In addition, each hos¬ pital has an active pharmacy and therapeutic committee which reviews and advises the staff as to the efficacy and hazards of all therapeutic agents. In cooperation with the Food and Drug Administration, the Division has improved its reporting of adverse reactions to drugs. PROFESSIONAL TRAINING A total of 36 resident physicians completed formal training in the following specialties: Anesthesiology, internal medicine, obstetrics- gynecology, ophthalmology, ophthalmology and otolaryngology, path- ology, psychiatry, radiology, surgery, and urology. Five resident physicians completed training in general practice and two completed training in research methodology. Ninety-nine medical interns com¬ pleted their training in the Division’s hospitals in June 1963. In order to provide trained personnel for Service needs in areas where in-service training is not available, physicians and other health personnel are given opportunities each year to pursue specialized study outside the agency. There were 15 persons attending 10 uni¬ versities in the past year. Public Health Service 141 RESEARCH In the interest of improved patient care, five of the general hospitals now have an established research service with a full complement of professional and technical staff. They are conducting clinical inves¬ tigations of a wide variety of disorders, mainly related to problems of cardiopulmonary physiology. In addition, there is a seven-hospital cooperative research program, under the auspices of the National Institutes of Health, for the study of antihypertensive drugs. Data from the first studies are being analyzed. There are also established cooperative arrangements with the National Cancer Institute for clinical trials of cancer therapeutic agents. In the Boston PIIS Hospital, a 25-bed unit has been estab¬ lished as a part of this program. Plans are underway to set up a similar unit at the Baltimore PHS Hospital. More than 50 scientific papers were written for professional jour¬ nals. One of the most outstanding was “Value of Prolonged Bed Rest in Management of Cardiomegaly,” which originated in the New Orleans PHS Hospital; it was published in the Journal of the Amer¬ ican Medical Association. GOALS Modernization and improvement in the physical structures, and, in some areas, new construction, are needed to enable the PHS hos¬ pitals and outpatient clinics to carry out their mission efficiently. Because of the large number of patients seen at these facilities, and the varieties of disease entities presented, there are exceptional oppor¬ tunities for research. Some of the country’s leading medical schools are thus affiliating with the PHS hospitals in conducting research programs. The Division plans to expand its research program as funds and physical facilities are made available. FEDERAL EMPLOYEE HEALTH PROGRAM The Division conducts a health protection program for Federal employees by operating health units for Federal agencies on a reim¬ bursable basis. At present, there are 38 of these units, which serve 63,000 employees. Each unit is under the professional direction of a physician. Visits to the health units during the year totaled more than one quarter of a million. Mass immunizations against polio, smallpox, tetanus, and influenza, as well as tests for diabetes, glaucoma, and visual acuity, were given at the health units in 1963. The number of immunizations were as follows: influenza, 29,344; poliomyelitis, 7,957; smallpox, 14,671; 142 Department of Health, Education, and Welfare, 1963 tetanus, 10,685 ; diabetes, 10,237 ; glaucoma, 6,913 ; visual acuity, 14,613. Periodic health examinations are given for employees who are 40 years old or older. These examinations totaled 5,209 in 1963. The Division hopes to extend the Federal Employee Health Pro¬ gram to all Federal employees in the coming year and to conduct periodic health examinations for Government employees comparable to those provided in private industry. FREEDMEN’S HOSPITAL In 1963, Freedmen’s Hospital in Washington, D.C., provided care for 15,393 patients. The average daily census was 384. There were 3,564 live births recorded. Outpatient visits to clinics and emergency room totaled 100,917, an increase of 4,290 over 1962. A new 50-bed pavilion was opened in February 1963, representing a most significant and progressive step toward better patient care. The attending and consulting staffs of physicians and dentists totaled 247, with 113 members on the courtesy staff. All training accreditations of the hospital were maintained. Freed¬ men’s Hospital serves as the clinical teaching facility for junior and senior students of Howard University’s College of Medicine. It also offers approved medical, dental, pharmaceutical, and dietetic intern¬ ships; residency training in 14 medical specialties; and residency training in hospital administration. Sixty-two residency appointments were filled during the year; 21 graduates of foreign medical schools were among the residents. There were 19 medical interns, 4 of whom were foreign students; 2 dental interns ; 2 pharmaceutical interns ; 10 dietetic interns ; 5 research fel¬ lows ; and 2 administrative residents. The School of Nursing graduated 25 student nurses, raising the total of the school’s graduates to 1,505. The School of X-Ray Tech¬ nology graduated 4 students and now has 60 graduates. Fifty-five clinical research projects were in progress during the year, and nearly 50 scientific articles by staff members were published. For the fourth consecutive year the hospital participated in the Junior Red Cross volunteer program. The adult volunteer program and the women’s auxiliary provided volunteers throughout the hospital. Division of Foreign Quarantine The Division of Foreign Quarantine guards the Nation against the introduction of disease from abroad. At more than 300 ports of entry in the United States, the Division performs health inspections of international travelers, conveyances, and certain imports. At Public Health Service 143 major consulates in Europe, Canada, Hong Kong, Jamaica, and Mex¬ ico, visa applicants are given medical examinations. Every day 20,000 travelers are cleared through quarantine. Of these, 1,000 are arriving only a few hours or days after leaving countries where such diseases as smallpox, yellow fever, and cholera are present. This number, moreover, is growing — and with it the danger of importing quarantinable diseases into the United States. The trans world jet plane has brought the quarantinable diseases to our doorstep. At no time has the need for constant vigilance been greater. QUARANTINABLE DISEASES IN THE UNITED STATES For the 16th straight year, the United States did not have an outbreak of quarantinable disease known to have been introduced from abroad. In August 1962, a 15-year-old Canadian boy with incubating small¬ pox — but showing no symptoms — on the way from Brazil to Canada was cleared through quarantine at New York. His certificate of vaccination against smallpox had been issued by a Brazilian district department of health and bore the signature of the vaccinating phy¬ sician and a stamp of that department. Later investigation, with the help of Brazilian health authorities, revealed that the boy had not been vaccinated as stated in his certificate. Fortunately, there were no secondary cases of smallpox either in the United States or Canada. This incident, which was widely publicized, alerted the country to the danger of imported disease from abroad. It also stimulated increased response to the longstanding efforts of the Division of Foreign Quarantine to promote current smallpox vaccination for per¬ sons having frequent contact with international travelers and for those who meet and treat the sick. Rodent plague was identified in a dead rat in San Francisco March 12, 1963. A 12-block area of the city was declared infected, and an intensive survey and a cleanup campaign were carried out. There were no human cases, and the area was declared free of infec¬ tion March 29. Rodent plague was also identified in a snowshoe hare caught during a survey made in the Matanuska Valley of Alaska in May 1963. Followup surveys of the area revealed no additional plague-infected animals. QUARANTINABLE DISEASES ABROAD The worldwide smallpox situation grew worse. About 85,000 cases of the disease were reported, compared with 76,000 for the previous year. The disease was present in 50 ports. As the year ended, North America and Australia were the only continents free of smallpox. 144 Department of Health, Education, and Welfare, 1963 Cholera became more widespread in Asia and Oceania. It remained endemic in India and Pakistan, and broke out in Burma, Indonesia, Malaya, the Philippines, Singapore, Hong Kong, West New Guinea, and Taiwan. There was also an unofficial report of a cholera out¬ break in Shanghai, China. J apan reported three imported cases but no secondary spread. Plague remained endemic in Ecuador, Peru, Brazil, Burma, India, the Malagasy Republic, and Viet Nam. In addition, outbreaks were reported in the Congo, Bolivia, Kenya, and Tanganyika. Outbreaks of yellow fever occurred in sections of Bolivia and Peru contiguous to jungle areas where the disease is endemic. Sporadic cases were also reported in Brazil, Colombia, and Venezuela. OTHER COMMUNICABLE DISEASES Typhoid fever was introduced into the United States by 12 trav¬ elers who became ill shortly after returning from Zermatt, Switzer¬ land, which was struck by a typhoid epidemic during the height of the ski season. There were no secondary cases in this country. About 100 cases of the disease were imported into 8 European countries by travelers from Zermatt. INTERNATIONAL TRAFFIC Inspections of aircraft increased 5.8 percent, from 65,000 to 69,000. There was an increase of 14 percent in quarantine inspections of persons arriving by plane, from 2,728,000 to 3,111,000. Inspections of ships dropped from 33,000 to 32,600, and inspections of persons arriving by ship declined from 1,985,000 to 1,960,000. Persons subject to quarantine inspection arriving in the United States by all modes of travel, including many persons making repeated crossings of the Mexican border, totaled 36,000,000. It was necessary to detain 50 travelers in isolation, compared with 65 for the previous year. The number of travelers who were placed under medical surveillance but were allowed to continue to their destinations in the United States decreased from 329,000 to 199,000. Both of these decreases appear to indicate greater compliance by the traveling public with health requirements for entry into the United States. Special arrangements were continued by the Miami Quarantine Station for medical clearance of the large influx of Cuban refugees and escapees. Public Health Service 145 MEDICAL EXAMINATIONS General Program. The number of aliens applying for visas who were examined by medical officers abroad decreased 1.1 percent, from 189,000 to 187,000. Of these, 97 percent were immigrants, refugees, and parolees. About 1,800 applicants, or almost 1 percent, were found to have diseases or conditions excludable under immigration law. Since May 1962, several thousand Chinese refugees have been ad¬ mitted to the United States from Hong Kong under parole provisions of immigration law in accordance with a Presidential directive. In fiscal year 1963, medical officers examined 8,360 such persons in Hong Kong. Of these, 270, or about 3.3 percent, were found to have excludable conditions. Aliens examined on arrival at U.S. ports increased 17.9 percent, from 3,296,000 to 3,887,000. About 3,800 were found to have ex¬ cludable conditions; 23.9 percent of these had been so diagnosed abroad, but were admitted under special provisions of immigration law. Quarantine officials placed under special health controls 1,085 arriv¬ ing aliens with tuberculosis whose entry was authorized under a 1961 amendment to the Immigration and Nationality Act. Migratory Farmworkers In the program of recruiting farmworkers from Mexico, 201,000 men were examined at 3 centers in Mexico. Of these, 2,900 were rejected. At 5 border reception centers in the United States, 203,000 men were examined and 2,350 were rejected. At the reception centers, of 198,000 workers tested for syphilis, 9,000 had positive reactions. The rate of positive reactions decreased slightly from 46 per 1,000 workers to 45 per 1,000. Workers with positive reactions were given intensive antibiotic treatment and were then admitted to the United States. ENTOMOLOGY AND SANITATION PROGRAMS The program for control of the yellow fever-transmitting mosquito, Aedes aegypti , was continued in about 100 international traffic areas within the yellow fever receptive zone of the Southern United States, Puerto Rico, and the Virgin Islands. Wake Island was removed from the yellow fever receptive zone of the United States after surveys showed it to be free of Aedes aegypti. More than 20,000 insects were intercepted on aircraft arriving from foreign countries. Of these, several hundred were mosquitoes, in¬ cluding some species capable of transmitting disease. Spraying with 146 Department of Health , Education, and Welfare, 1963 an authorized insecticidal aerosol at the last port of call before take¬ off for U.S. airports was begun on a number of aircraft. OTHER QUARANTINE ACTIVITIES A cooperative, interagency inspection program, involving the Bureau of Customs, the Immigration and Naturalization Service, the Department of Agriculture, and the Division of F oreign Quarantine, was set up along the Mexican border to increase to almost 100 percent the percentage of border crossers inspected. Health preclearance of aircraft and aircraft passengers destined for the United States was begun in Bermuda. Predeparture inspection by U.S. quarantine officials facilitates entry into this country by eliminating the need for inspection upon arrival. This operation complements preclearance in Bermuda by immigration and customs officials. The Division epidemiologist was a member of the U.S. delegation to a conference on the facilitation of international aviation held in Mexico City. Among the proposals adopted by the conference was one submitted by the Division concerning prompt reporting by radio to health authorities in the country of destination when significant ill¬ ness occurs on an aircraft. The President issued an Executive order, and foreign quarantine regulations were amended to add chickenpox to the list of communica¬ ble diseases for which travelers entering the United States may be detained for observation or kept under surveillance. This change will help insure adequate opportunity for differentiation between chickenpox and smallpox. The Division participated in drafting amendments to the Inter¬ national Sanitary Regulations which were adopted by the 16th World Health Assembly. The amendments improve procedures for pre¬ venting the international spread of disease and facilitate international traffic. A leaflet, “Health Information for Travelers to the U.S. A.,” was published in seven languages : English, French, Italian, Spanish, Japa¬ nese, Portuguese, and German. It is being distributed abroad by the U.S. Travel Service of the Department of Commerce. Health Services for Indians and Alaska Natives The health level of more than 380,000 Indians, Eskimos, and Aleuts living on isolated reservations in the West and in remote villages in Alaska is below that of most other Americans. To raise the health level of these Indians and Alaska Natives, the Division of Indian Public Health Service 147 Health provides them with comprehensive medical, hospital, and dis¬ ease prevention services. The provision of these services is complicated by many factors : low economic status, geographic and cultural isola¬ tion, primitive sanitary conditions, inadequate and often polluted water supply, and cultural traditions that are often in conflict with modern medical practices. Despite these difficulties, the health of the Indian is steadily im¬ proving. Indian birth rates are high, about twice the rate in the gen¬ eral population. Although the infant death rate remains high — almost twice that of other American babies — it has dropped approximately 34 percent since 1954. Life expectancy for Indians is now 62 years, com¬ pared with 70 for the general population; in 1940, it was only 51. Tuberculosis, once the No. 1 cause of death among Indians, is now ninth. MEDIG4L FACILITIES Hospital medical care, maternal and child care, dental care, public health nursing, disease surveillance and control, nutrition and health education are provided through a system of 50 hospitals, 25 health centers, 16 school health centers, and several hundred field stations. The total of hospital beds in Indian hospitals is 3,200. In addition, about 1,000 beds are available in community hospitals under con¬ tract. A total of 87,500 admissions were reported in fiscal year 1963 by Division hospitals and contract facilities, and 1,200,000 outpatient visits were made to Indian health facilities. Since 1957, the Public Health Service has contributed financially to the construction of 15 community hospitals where 110 beds are available for Indians and Alaska Natives. Special health achievements in 1963 included an increase in the number of prenatal, postnatal, and well-baby clinics; more effec¬ tive immunization programs; and an increase in preschool physical examinations. Special clinics were conducted on a contract basis for diagnosis and treatment of trachoma, diabetes, eye and ear conditions, and for serv¬ ices to crippled children. The average daily patient census in Indian health and contract facilities was 2,379 in 1963, an increase from 2,310 in 1962. The num¬ ber of babies born in Indian hospitals in 1963 was 4 percent higher than in 1962 — 9,192 as compared with 8,859. Physicians, accompanied by public health nurses and other health workers, conducted regular clinics in more than 100 Alaskan villages with nearly 13,200 visits reported. 148 Department of Health, Education, and Welfare, 1963 HEALTH EDUCATION Since modern concepts of medicine, such as the germ theory of illness, are unknown to most Indians and Alaska natives, educational activities tailored to meet their unique needs are carried on with both individuals and groups, to bring about a better understanding of the fundamentals of healthful living. Health educators, most of whom are Indians with college train¬ ing in education, anthropology, or sociology, work with all tribal councils and also with health committees, sanitation committees, and mothers’ clubs. They encourage the formation of special groups to cooperate on projects such as rabies control, cleanup programs, weight control, nutrition, tuberculosis studies, and general hygiene. THERAPEUTIC AND PREVENTIVE SERVICES The Division provides both clinical nursing services in hospitals and field clinics and public health nursing in the home. Increases in specialized and advanced training in maternal and child care, re¬ habilitation, and mental health were achievements of the past year. Pharmacy services were provided for patients at the 40 largest health facilities of the Division where 91 percent of inpatients and 76 percent of outpatients who visit Indian hospitals and health centers were treated. A pilot study using automatic data processing in ordering drugs and maintaining drug inventories was started at one hospital. A training program for career development and for keeping abreast of advances in pharmacy was also initiated. The limited knowledge among Indians of the relationship of food to good health and to disease, combined with the small amount and poor quality of much of the food that is available, presents a serious problem. A public health nutritionist was assigned to work with pro¬ fessional staff and community groups in the northern part of Alaska. Training workshops for hospital food-service workers were held in five of the Division’s seven areas. Studies to determine nutritional status were undertaken among specific segments of the Indian population. Social workers, in cooperation with the Bureau of Indian Affairs (Department of the Interior), Indian groups, and State, local, and other health agencies, began a study of the availability of nursing- home resources for aged and chronically ill Indians. MATERNAL AND CHILD CARE Twenty-one percent of all Indian deaths in a year are babies under 1 year of age. Improved methods of dealing with this problem in¬ cluded home followup visits by the public health nurse when mother Public Health Service 149 and child are discharged from the hospital and increased efforts to teach mother and family good health habits and to convince them of the importance of taking the baby to the clinic regularly and of seeking early care when children are sick. The development of an effective measles vaccine and its availability to Indian and Alaska Native children was a landmark of 1963. Accomplishments in maternal and child health can be partially measured by the fact that 96 percent of Indian babies are now born in hospitals, and by the fact that although 43 Indian babies are still dying for every 1,000 live births, this is a drop during the last decade from a rate that was almost 3 times as high. DENTAL SERVICES The dental health program places major emphasis on services to pre¬ school and school children, with close attention to preventive measures. Topical fluoride treatments were given in 1963 to 24,914 persons, an increase of 32 percent over the previous year. Six community water fluoridation units were installed in Indian community systems. Complete clinical care was sought for all Indian children, and dental health education was stressed. Emergency care was given to patients of all ages. Programs in preventive orthodontics and periodontics were begun during the year by two dental consultants to the Division. There was an increase of 8 percent in services over the previous year ; 384,610 services were provided to 103,236 patients, and 52 percent of these patients received complete care. MAJOR ILLNESSES AND MORTALITY RATES Leading causes of death among Indians and Alaska natives have shifted in the last 8 years. Accidents and diseases of aging have displaced tuberculosis and infectious diseases. Tuberculosis, which for many years ranked first as a cause of mortality, is now ninth. In 1956, the peak year of tuberculosis hospitalization, the average daily hospital census of tuberculosis patients was almost 2,400, which constituted about 57 percent of all patients hospitalized. Today it constitutes about 22 percent of the total and accounts for an inpatient census of about 700. This decrease is due largely to the Division’s chemotherapy program, increased outpatient treatment, and im¬ proved case finding and followup. Leading health problems among Indians and Alaska natives today are communicable diseases among children, accidents, mental illness, alcoholism, nutritional deficiencies, dental deficiencies, problems of the aging. Leading causes of death are accidents, heart disease, influenza and pneumonia, diseases of early infancy, malignant neoplasms, diseases 150 Department of Health , Education , and Welfare, 1963 of the cardiovascular system, cirrhosis of the liver, gastroenteric diseases, tuberculosis. ENVIRONMENTAL HEALTH Gross deficiencies in domestic and community water supplies, waste- disposal systems, and other essential sanitation facilities are con¬ tributing factors to the high rate of infectious diseases among Indians and Alaska natives. In 1963, $4 million available for sanitation con¬ struction was allocated to 65 projects on 30 reservations. During the past year, an additional $3 million was allocated under the accel¬ erated public works program for construction of 30 water and sewage projects on 21 reservations. Since 1959 water-supply and waste-dis¬ posal facilities have been authorized for approximately 16,000 Indian and Alaska Native homes in 206 communities. CONSTRUCTION A new 36-bed Indian hospital replacing an old one was completed in 1963 at San Carlos, Ariz., to serve members of the Apache Tribe. A new 25-bed wing added to the PHS Indian Hospital at Red Lake, Minn., serving the Chippewa Tribe, was dedicated in June 1963. Plans were well advanced in 1963 for replacement hospitals at Bar- row, Alaska, and at Fort Yates, N. Dak., and for an 80-bed replace¬ ment hospital at Lawton, Okla. Funds were appropriated by Con¬ gress in 1962 for planning for a 200-bed medical center at Phoenix, Ariz. Modernization plans are nearing completion for the hospital on the Crow Reservation in Montana. Nine field health centers were completed or are under construction at Kayenta and Chinle on the Navajo Reservation, Ariz. ; at Tohatchi Navajo Reservation, N. Mex. ; at Santa Rosa, Papago Reservation, Ariz. ; at Dulce, Jacarilla Apache Reservation, N. Mex. ; at Mescalero, on the Mescalero Apache Reservation, N. Mex. ; at Peach Springs on the Hualapi Reservation, Ariz.; at Fort Hall, on the Shoshone Reser¬ vation, Idaho and at McLaughlin, Standing Rock Cheyenne Reserva¬ tion, S. Dak. Planning is underway for health centers at Toppenish on the Yakima Reservation in Washington; and at Laguna Pueblo in New Mexico. Since transfer of the Indian health program to the Public Health Service, 32 field health stations have been completed, are under con¬ struction, or are in the planning stage. Also, 538 units of permanent housing for personnel have been authorized; 508 units have been completed, 10 are under construction and 20 are to be bid. Public Health Service 151 FUTURE GOALS The future for the Division of Indian Health envisions a closer relationship with Alaska native groups, Indian tribal councils, and health committees; an expanded program of training for auxiliary health workers to permit most efficient use of physicians, dentists, nurses, and other professional staff; establishment of a physician- residency program in preventive medicine, accredited by the Ameri¬ can Medical Association and specialty board, that will provide experience in public health for young physicians and interest them in remaining with the Indian health program; establishment of an Indian health epidemiology training center oriented to diseases and illness that are prevalent among Indians but not commonly found among the general population ; and supervisory management training to increase administrative efficiency. Plans include development of an accident-prevention program, a mental health program to train staff to recognize early symptoms of maladjustment, and a program dealing with problems of the aging. A pilot nursing-home project is underway, designed to improve stand¬ ards of nursing-home care on or near the reservation. Special pro¬ grams are being planned to meet the health problems of children from infancy through preschool years. Medical Services for Federal Agencies The medical services of the U.S. Coast Guard and the Federal Bureau of Prisons are legal responsibilities of the Public Health Serv¬ ice and are operated by Bureau of Medical Services personnel assigned to these agencies. The medical programs of the Bureau of Employees’ Compensation of the Department of Labor and the Maritime Admin¬ istration of the Department of Commerce are also conducted by per¬ sonnel detailed to these agencies. U.S. COAST GUARD, TREASURY DEPARTMENT Ninety-six officers of the Public Health Service were assigned to the Coast Guard in 1963, including 28 physicians, 51 dentists, and 28 nurses. In addition, 50 medical officers and 2 dental officers were on temporary assignments to Coast Guard cutters engaged in the Bering Sea Patrol, Arctic and Antarctic operations, and ocean station duties in the Atlantic and Pacific Oceans. In 1963 an inactive reserve of professional personnel to meet the mobilization needs of the Coast Guard was established within the framework of the Public Health Service. A much-needed aviation medicine program for the Coast Guard was begun, headed by a medi¬ cal officer who completed flight surgeon training in June 1963. A 152 Department of Health, Education, and Welfare, 1963 program for careful psychiatric screening of recruits was initiated to permit earlier detection of neuropsychiatric disabilities and person¬ ality defects. BUREAU OF EMPLOYEES’ COMPENSATION, DEPARTMENT OF LABOR Medical officers of PHS assigned to the Bureau of Employees’ Com¬ pensation are responsible for the medical program under the Federal Employees’ Compensation Act and related acts. They are responsible not only for the rehabilitation of Federal employees who are injured in line of duty but also for identifying and studying special problems in compensation. Increasing numbers of claims based upon exposure to ionizing radia¬ tion are being submitted for evaluation, and a continuing study is being conducted. Studies of drug addiction as it pertains to per¬ sons receiving medical care as a result of a compensable injury were continued, as well as studies of other problems of special importance to compensation. MARITIME ADMINISTRATION, DEPARTMENT OF COMMERCE Health care of 900 cadet midshipmen at the U.S. Merchant Marine Academy, Kings Point, N.Y., was provided by a medical officer, 2 dentists, and supporting staff. During the year, 734 cadets were admitted to the Academy’s Patten Hospital, 7 emergency admissions were made to the North Shore Hos¬ pital, Manhasset, N.Y., and 77 cadets were admitted to the Public Health Service Hospital on Staten Island. Outpatient medical serv¬ ices and treatments given by the Public Health Service physician on duty at the Academy numbered 4,028. There were 4,295 dental visits. The medical officer in charge of the PHS hospital on Staten Island served as professional consultant for the Academy’s health program. BUREAU OF PRISONS, DEPARTMENT OF JUSTICE For the 33d year, the Public Health Service provided medical, psychiatric, psychological, dental, nursing, and related health serv¬ ices for Federal prisoners. The Bureau of Prisons has 24 hospitals and 7 infirmaries in institutions over the country. Fifteen of the hospitals have been fully accredited by the Joint Commission on Accreditation of Hospitals. The full-time staff assigned to the program numbered 278. The staff is augmented by 350 consultants in the various medical special¬ ties. Approximately 900 inmates are assigned to the medical services where they receive training and assist with hospital care. At the end of the year, the total population of the Federal prisons was more than 23,600. The hospitals provided a total of 411,924 Public Health Service 153 hospital relief days. The medical staffs performed 1,162 major oper¬ ations and 6,299 minor operations. The outpatient departments gave 1,141,017 treatments. A total of 29,100 physical examinations were performed. The two institutions for women reported 28 births. Deaths in all institutions totaled 52. Advances in personnel recruitment and development and improve¬ ments in plant and program continued. Additional refinements were made in the diagnosis, treatment, and prevention of physical and mental illness among the prisoners. Psychiatric examinations are required under provisions of the Youth Corrections Act, Adult Sen¬ tencing Act, and Federal Juvenile Delinquency Act. Demand for psychiatric diagnostic and treatment services continued to increase, reflecting the confidence which the Federal courts have in these ob- servation and study provisions. Medical Center for Federal Prisoners The Medical Center for Federal Prisoners in Springfield, Mo., con¬ tinued to operate at near capacity, requiring that all potential trans¬ fers to this hospital be carefully screened to minimize overcrowding. Construction of new office space was begun as part of an extensive plan to modernize and enlarge the clinical services at the Center. The psychiatric staff effected closer liaison with the Federal courts in neighboring districts in the handling of cases committed for observa¬ tion and study under the Mental Competency Act. New Institutions Planning was continued for the new Eastern Psychiatric Institute for Federal Prisoners to be located at Butner, N.C. The new hos¬ pital will provide a full range of facilities for diagnosis, treatment, training, and research. The new Federal Penitentiary at Marion, Ill., began to receive prisoners in the spring of 1963. Part-time medical and dental serv¬ ices were arranged on an interim basis until the hospital is in full operation. Clinical Services A tuberculosis-control program was instituted throughout the Fed¬ eral prisons to insure the early detection of active cases. This pro¬ gram provides for tuberculin testing and X-ray of all newly committed prisoners, with appropriate followup measures. In all institutions, efforts were made to increase the efficiency of outpatient services. At McNeil Island in Washington, special clinics were established for the care of chronic conditions such as heart disease, obesity, and diabetes. The cancer-detection clinic continued its serv- 711-845—64 - 11 154 Department of Health, Education, and Welfare, 1963 ices at Alderson, W. Va., as did the acne clinic at Englewood, Colo. Increasing use of consultants was made throughout the prison system. Arrangements were made to develop closer liaison between the pris¬ on camp programs and neighboring regular penal institutions. For this purpose, the chief medical officer and members of his staff at LaTuna, Tex., made regular visits to the Arizona camps, and arrange¬ ments were made to have medical officers from Tallahassee and At¬ lanta visit the southern camps. A unique psychiatric consultant pro¬ gram at the Tucson camp was continued, as was the program for reg¬ ular visits to Alderson by staff psychiatrists of the Lexington PHS Hospital. At the New York Detention Headquarters, 320 prisoner addicts were treated for withdrawal symptoms. The chief surgeon at Atlanta made regular visits to Tallahassee to perform surgery. Group Counseling At the National Training School for Boys, Washington, D.C., a demonstration counseling project was extended to include all units in the institution. Effective group counseling programs were carried on at Ashland, Ky., Petersburg, Va., Terminal Island, Calif., Chilli- cothe, Ohio, and El Reno, Okla. Hospital Improvements The psychiatric and tuberculosis wards at Atlanta were modernized and renovated, and new beds and furniture were installed in the hos¬ pital. The central dental laboratory was moved from Springfield, Mo., to Lewisburg, Pa., and the dental clinic at Lewisburg was modernized. The hospital at Tallahassee underwent a complete renovation. At Leavenworth, work was begun on installation of acoustic tile and improved lighting. Research Many of the medical staffs continued to assist in selection of prisoner volunteers to participate in medical research. At Atlanta, research projects included studies of malaria, virulent staphylococcus carriers, heart-kidney physiology, and the transmission and treatment of vene¬ real diseases. At Lewisburg, a project to improve the standardiza¬ tion of the glucose tolerance test was completed. A measles vaccine was evaluated at Petersburg. At Danbury, Conn., volunteers par¬ ticipated in studies of the transmission of infectious mononucleosis and in studies of cardiopulmonary physiology at the Public Health Services Hospital on Staten Island, N.Y. Volunteers from several in¬ stitutions took part in the cold virus studies at the Clinical Center, National Institutes of Health. The staff at Lompoc, Calif., made studies of prisoners with asthma. At the National Training School Public Health Service 155 for Boys a study was completed to establish a profile of the Federal juvenile offender. The staff at El Reno completed a study on the use of certain tranquilizers in the treatment of behavior disorders. Participation in Community Affairs Federal prisoners contributed 11,590 pints of blood to community blood banks. A number of the institutional medical staffs cooperated in local polio vaccination programs. A member of the Leavenworth dental staff lectured at the University of Kansas dental school. The chief medical officer at El Reno served as visiting lecturer at the Uni¬ versity of Oklahoma. Members of the psychiatric staff of the Medical Center continued to assist in the Greene County Mental Health Clinic in Springfield. Training At Leavenworth, new courses were established to train inmates in various medical technical specialties. Training in nursing care was extended at the Medical Center and at Alderson. A psychology train¬ ing program at Chillicothe, operated in conjunction with the Veterans Administration and Ohio State University, continued. Additions were made to the inmate training programs at LaTuna and Atlanta. Bureau of State Services The 12 divisions comprising the Bureau of State Services seek to advance the application of health knowledge, translating research re¬ sults into action beneficial to the public health. The Bureau works closely with State and local health agencies and many professional and voluntary groups, strengthening their programs in a variety of ways. To deal more efficiently with today’s major health challenges, the programs of the Bureau have been grouped into two major subdivi¬ sions — the community health group, which seeks to foster the avail¬ ability of comprehensive personal health services; and the environ¬ mental health group, which works toward better protection against hazards of the modern environment. At the close of 1963, all of the divisions of the Bureau had authority to administer research grants. Also during 1963, both parts of the Bureau devoted increased attention to two swiftly emerging prob¬ lems — the public health aspects of pesticides, and health com¬ munications. The Robert A. Taft Sanitary Engineering Center (Cincinnati, Ohio), administered directly by the Bureau, conducts extensive pro- 156 Department of Health , Education , and Welfare , 1963 grams of research and training in environmental health area. The Arctic Health Kesearch Center (Anchorage, Alaska), also under Bu¬ reau administration, conducts studies of special health problems re¬ lated to cold climates. Division of Accident Prevention The first contracts for developing an automobile driving simulation program for traffic accident-prevention research have been awarded by the Division. Among the problems to be explored are driver fatigue, alertness, and emergency behavior on turnpikes. Studies of children less than 6 years old have led to the develop¬ ment of standards for safety harnesses for this age group. The data from this study are being used by university and industrial research groups working to develop these devices. In Charleston, S.C., a Division-supported 2-year public informa¬ tion campaign and a communitywide group discussion program have effected a 20-percent reduction in the incidence of children hospitalized for accidental poisoning. Through the cooperation of the Division and the glass-door indus¬ try, sliding-glass door assemblies, now being widely used in residential construction, are being made with tempered, safety-glass panels. Major new projects begun in fiscal year 1963 include: 1. Development of a safety education program for use in the elemen¬ tary schools in Kentucky. 2. An investigation of the effects on “problem drivers” of mass com¬ munications and group discussion techniques. 3. A pilot project to establish statewide training for ambulance drivers and others in emergency medical service. 4. Promotion, through city and county health departments, of an organized course on gun safety in the home. 5. A study to establish the precise accuracy of a breath-testing in¬ strument that analyzes alcohol content of the blood. Many other projects are in various stages of planning, operation, and reporting, including promotion of mouth-to-mouth resuscitation ; incorporation of accident prevention into the daily routine of local public health nurses and sanitarians ; a research and public education program to reduce accidents involving the use of power lawnmowers, flotation devices, home appliances, and coin-operated d^cleaners ; and evaluation of the comparative value of various communications media in indoctrinating specific advances. Public Health Service 157 Division of Chronic Diseases The Division of Chronic Diseases continued to improve and expand a variety of national control programs against specific chronic diseases and neurological and sensory disorders. To coordinate the planning and direction of common program elements within the Division, two new offices — Care Services and Preventive Services — were established in November 1962. The Grants Program Staff — also established in November 1962 — helped coordinate programs in excess of $37 million. Within this total, State formula grants accounted for $23,500,000, project grants for $10,749,000, contracts for $3,267,000, and cooperative agreements for $100,000. These moneys helped finance a total of 346 projects, as well as 153 traineeships. An active research grants program was initiated with the transfer of 38 grants totaling $1,174,205 from the National Institutes of Health to the Division of Chronic Diseases. During fiscal 1963, gerontology and nursing homes programs were also established within the Division. CANCER CONTROL Cancer is the second-ranking cause of death in the United States, taking more than a quarter of a million lives per year. During a given year about 530,000 cases of cancer will be diagnosed for the first time. Two-thirds of these will be found in persons 60 years of age or over. With optimum application of known measures for control, about 88,000 of the 280,000 annual deaths could be prevented. The Cancer Branch helps train specialists in medical technology, cytotechnology (microscopic cell study), and X-ray. The Branch as¬ sists general practitioners in detection and treatment by developing educational materials for counseling and screening patients. The most promising known techniques for detection and treatment apply to cancers of the cervix, mouth, breast, lung, and skin. Most skin cancers can be seen at an early stage by both the patient and physician. F or this reason cure rates are relatively good. In the other four body sites, however, death rates are distressingly high. The Cancer Con¬ trol Branch, therefore, is directing its major efforts toward improving control of these cancers. Although it is possible to detect cancers of the uterine cervix at a stage when complete cure can be assured in most cases, this malignant lesion still kills 14,000 women each year. Intensive work by the Branch and others, however, is beginning to bring about more general use by physicians of the Papanicolaou (Pap) smear as a routine de¬ tection procedure. 158 Department of Health , Education , and Welfare , 1963 Deaths from lung cancer in the United States have climbed from 4,000 in 1935 to 11,000 in 1945 and 30,000 in 1960. The Surgeon Gen¬ eral has appointed a special committee to compile all available scien¬ tific data on tobacco and health, including the relationship of smok¬ ing and lung cancer. While awaiting the results of this report, the Cancer Control Branch supported a study to determine if cytology can detect early changes in lung tissues which indicate cancer risk. In addition, the Branch has surveyed physicians' attitudes concerning advice to patients about smoking. DIABETES AND ARTHRITIS PROGRAM The diabetes and arthritis program seeks to apply existing knowl¬ edge about metabolic diseases in an effort to reduce their severity on the American people. Diabetes Emphasis has been placed on promoting comprehensive diabetes screening programs throughout the country, developing new and pre¬ cise screening methods, and creating improved educational materials. During 1963, 331,260 people were screened, compared with 182,000 in 1961. Also, the number of positive responses increased by 59 percent. In applied research, final test runs were completed in the Lewisburg Prison study, to determine the validity and reproducibility of the glucose tolerance test for diabetes. A new automated blood-testing method for diabetes detection was developed by Western Reserve University, Cleveland, Ohio, under a project grant. Work was begun on a series of filmstrips for patient education designed to offer the latest information on diet, insulin, oral drugs, urine testing, and care of the feet. Arthritis Educational techniques and applied research have been directed to¬ ward increasing the Nation’s awareness of arthritis as a public health problem. During the year, a study of the prevalence of gout was begun at the program’s research center in Boston. A grant study was approved which will attempt to integrate the physical factors of recreation with the therapeutic needs of the arthritic. Work was be¬ gun on a diet manual for arthritics to combat diet quackery. GERONTOLOGY BRANCH Growing awareness of the need to develop positive action programs to meet the health needs of the aged led to the creation of the Gerontol¬ ogy Branch in November 1962. This is the first operating program in the Public Health Service to be concerned exclusively with health problems of the aged. Public Health Service 159 Intramural and extramural research studies are anticipated in such subject areas as longitudinal studies of aged and aging populations to identify the onset of disease, illness, and disability, and to evaluate existing control, preventive, and care methods; development of suit¬ able measures of functional deterioration in a healthy aging and aged population; and determination of the influence of such variables as physical and mental activity upon fimctional deterioration. Other problem areas requiring research include the effect of housing on health; attitudinal studies of medical and paramedical professions toward the aged ; and the extent of utilization and the basis for non¬ utilization of existing community health facilities by the aged. An educational plan in applied gerontology is now being developed through a project supported by the Branch. When completed, the body of knowledge will be used for the orientation of all the health professions which serve the aged. Responsibility for six community health services projects formerly administered by the health services for long-term illness program was transferred to the Gerontology Branch. HEART DISEASE COINTROL PROGRAM This year over 900,000 Americans will die of cardiovascular dis¬ ease — more than from all other causes combined. It is estimated that from 10 to 12 million persons have some form of cardiovascular disease. However, during the decade of the 1950’s, the combined age- adjusted death rate for the cardiovascular- renal diseases actually declined — from 438 deaths per 100,000 population to 399. Prompt diagnosis and treatment of group A streptococcal infections will prevent rheumatic fever and rheumatic heart disease. The pro¬ gram is assisting States in conducting courses for technicians in the use of the fluorescent antibody diagnostic technique. Eighty health department technicians in all 50 States, 4 territories, 5 cities, and 12 PHS hospitals have received training. Portable heart-sounds recording units suitable for use in detecting children’s heart disease have been developed and are being field tested. The program has recently demonstrated that a computer system can be programed to screen the tapes. Twenty-five stroke-rehabilitation programs have been initiated or are being planned in 19 States. Seminars and workshops held in eight States to teach restorative care to health personnel promise steady expansion of rehabilitation activities. The program is supporting a stroke- prevent ion project in Oregon, featuring a stroke-prevention clinic available to all referred patients with signs of pending stroke. Several more such programs are planned. 160 Department of Health , Education , and Welfare , 1963 The program has demonstrated that electrocardiographic signals can be sent by telephone to a central computer system, electronically analyzed, and the results quickly returned to the physician by phone in a completely automated system. Thus, the routine reading of electrocardiograms — estimated at 35 million annually in this coun¬ try — can be relegated to the computer, freeing the physican for diagnosis and treatment. An intensive-care unit, for patients with acute myocardial infarc¬ tion, has been established in a teaching hospital on a demonstration basis. First results indicate that continuous electronic monitoring and intensive nursing care of patients reduce the mortality rate and shorten the period of hospitalization. The effectiveness of communitywide teaching of external closed- chest cardiac resuscitation is being investigated by the University of Pittsburgh School of Medicine with support from the program. An estimated 250,000 people die yearly from myocardial infarction before reaching a hospital. With effective emergency treatment, some of these lives could be saved. Analysis of the sodium content of drinking water is underway on water samples being collected from 3,000 U.S. cities. The study will provide information about areas of high and low sodium levels in drinking water, which will be of value to physicians in treating con¬ gestive heart failure patients. NEUROLOGICAL AND SENSORY DISEASE SERVICE PROGRAM During its first full year of operation, the neurological and sensory disease service program made grants totaling more than $2.3 million to 36 community service projects and 30 training institutions in 24 States, the District of Columbia, and Puerto Rico. Community Service Projects Community service project grants, amounting to $1.5 million, helped to support four States in surveying their needs and resources for establishing neurological and sensory disease control programs. Sim¬ ilar grants also helped to establish diagnostic and rehabilitative serv¬ ices for patients with speech, hearing, and vision defects; mental retardation ; epilepsy ; and other neurological conditions. Professional Training Grants to institutions for training medical and allied professional personnel amounted to $615,633. Traineeship grants were awarded to 55 nonmedical and physician applicants for training in 19 States and the District of Columbia. Public Health Service 161 Special Studies Field studies to accumulate epidemiological and demographic data on vision and hearing were initiated in several States. Michigan’s Department of Health is making a study to determine if glaucoma tends to run in families. The School of Public Health, University of North Carolina, is doing a “followup” study of positive glaucoma screenees to determine if they later sought professional eye care from ophthalmologists. The effectiveness of a mobile unit for audiometric testing was begun in Boston. The results of the study will determine whether “testmobiles” will be advocated for other areas. “Tonofilm,” a protective latex shield recently developed by the program for use with the Schiotz tonometer as a means of preventing eye infections was distributed to physicians throughout the United States. A na¬ tional communications study, to identify sources of professional and lay neurological and sensory informational materials and to evaluate their effectiveness, was begun. NURSING HOMES AND RELATED FACILITIES BRANCH The mission of this program is to raise the standards of care avail¬ able to over 500,000 patients in the Nation’s 23,000 nursing homes and related facilities. One of the most significant undertakings in 1963 was in cooperation with the District of Columbia Health Department for a prototype project in the full staffing of State or local health agencies with pro¬ fessional personnel needed for consultation with local nursing homes. Another major development in 1963 was a carefully selected series of training activities. The training of personnel who perform inspection services for State and local health agencies was actively promoted during 1963 by regional seminars. With consultation from the Branch, New York City Department of Hospitals is planning ten 16-mm films for training nursing aids in nursing homes, an expansion of a successful television-teaching project in that city. A contract was developed in 1963 with the American Physical Therapy Association for surveying its 10,000 members to determine their present involvement in rehabilitation work in nursing homes and their availability for such professional activity. In accordance with the recommendation of the President’s Council on Aging, the Branch is conducting a nursing-home cost study to determine the economic base of patient care. A basic form to secure uniform cost data from 200 selected nursing homes was developed as a preparatory step to surveying a total of 2,000 establishments. During 1962 and 1963, 11 hospital-nursing home affiliation agree¬ ments were initiated by the Branch, 7 of which have been continued on a self-supporting basis. 162 Department of Health , Education, and Welfare, 1963 Communicable Disease Center The Communicable Disease Center (CDC), Atlanta, Ga., spear¬ heads the Public Health Service’s attack on infectious diseases. CDC, through its assistance and investigative programs, supports and sup¬ plements State health department control activities by providing tech¬ nical competence, manpower, and facilities as required and requested by these agencies. ASSISTANCE TO STATES Epidemic Aid Epidemic aid was extended to 32 States and the District of Colum¬ bia in 66 instances involving a wide variety of diseases. Consultation was also provided to the Department of the Navy. Gastrointestinal disease accounts for 14 of these calls, hepatitis for 8, and poliomyelitis for 6. The most serious epidemic was the Tampa Bay, Fla., outbreak of St. Louis encephalitis. This affected 192 people, mostly above mid¬ dle age, and resulted in 28 deaths in a 4-county area. For the first time since 1949, smallpox virus was introduced into this country. The diagnosis of smallpox in a traveler from South America subsequently led to investigations of eight suspected cases. Immunization Programs Communitywide immunization programs used some 100 million doses of the oral polio vaccines, after all 3 types became available in 1962. Incidence of polio reached an alltime low during the first 6 months of 1963, with only 113 cases reported. This was 50 percent less than for the comparable period of 1962, which had established the previous record low. The vaccination assistance program authorized by Congress in 1962 got underway in May 1963, with an appropriation of $8,600,000 for the first year’s activities. CDC is helping States and communities carry out intensive vaccination programs against polio, diphtheria, whooping cough, and tetanus, especially for all children under 5 years of age. Demonstrations When CDC initiated its communicable disease control demonstra¬ tion program last year, it laid the foundation for a coordinated attack on a community’s actual and potential communicable disease prob¬ lems. In the Huntsville, Ala., project, surveys were made to delineate a health index of the community, identify special local problems, and determine community resources. More than 100 recommendations Public Health Service 163 were made for improving public health in the area. Similar demon¬ strations are now underway in Lebanon, Pa., Oklahoma City, Okla., and Tucson, Ariz. Laboratory Services In an effort to bring public health diagnostic laboratories through¬ out the country up to a uniform standard of excellence, CDC started a Laboratory Consultation and Development Program. Administra¬ tive or technical reviews, or both, wrere conducted in 19 State public health laboratories, 1 foreign country, and in the District of Colum¬ bia. Consultation and assistance were provided 23 States, and nearly 6,000 days of training were given to more than 1,000 students. Training About 8,000 persons from State and local health departments, Federal agencies, academic institutions, industry, and other organiza¬ tions attended more than 300 CDC courses in communicable disease control presented throughout the country and at CDC headquarters. Following the National Conference on “Teaching of Infectious Dis¬ eases in Medical Schools,” sponsored jointly with Emory University and the Association of Medical Colleges, CDC developed a commu¬ nicable disease “teaching aid library” for use by faculties of preven¬ tive medicine in medical schools. A hypothetical community, “Tiller County,” was developed to pro¬ vide essential background materials for superimposed communicable disease problems. The community was used as the basis for a short course in “Public Health Administration — Environmental Aspects,” presented for the first time during 1963. Another innovation was the development and production of instruc¬ tive communications materials (programed instruction) for training public health and allied health workers. PHS Audiovisual Facility In fiscal year 1963, the production of video tape was initiated as a new dimension in biomedical communications from the CDC audio¬ visual facility. The production and distribution of motion pictures is the heart of the audiovisual program of CDC. The film library houses 350 titles, and bookings were made of 30,060 prints for over 55,000 showings. It is estimated that more than 2,200,000 persons viewed the films dur¬ ing the year. Twenty-four new motion pictures and two television productions were completed in 1963. In addition, the graphic and photographic arts program contributed to the production of 16 film- 164 Department of Health, Education, and Welfare, 1963 strips, 33 slid© series, 23 exhibits, 25 publications designs, 150 film¬ strip operations, and more than 114,000 photographs. In support of the audiovisual program, four film guides and catalogs were issued : Film Reference Guide for Medicine and Allied Sciences, Public Health Service Film Catalog , N eurological and Sensory Dis¬ ease Film Guide , and Cancer Film Guide . REPRESENTATIVE DISEASE CONTROL STUDIES Venereal Diseases In 1961, the Surgeon General’s Task Force recommended that the goal of the National Venereal Disease Control Program be the eradi¬ cation of syphilis. This goal is still in the forefront of the control program even though there has been a continuous rise in rates of infection since 1957. In fiscal year 1963, the upward trend continued with a 10. 1-percent rise over the previous year. The 22,105 cases of primary and secondary syphilis reported to health departments was 3 y2 times greater than the 1957 figure. Sixty thousand physicians were visited in 1963 to acquaint them with the National Venereal Disease Control Program and to offer them the diagnostic and epidemiologic services of the health departments. Twelve thousand visits were made to laboratories; 7,700 cases of infectious syphilis were detected as a result of reactor followup activity. Epidemiologic efforts were increased, and at the close of the fiscal year there were 557 field personnel assigned to State and local health departments. Pilot educational projects were carried out in New York, Chicago, and Philadelphia, and research continued into diagnostic, therapeutic, and immunologic aspects of syphilis. New projects were started in the field of behavioral science research to analyze the behavioral aspects of adolescent VD. The World Forum on Syphilis and Other Treponematoses, held in Washington, D.C., was attended by representatives from over 50 countries. Tuberculosis During the fiscal year, 11 new areas with unsually severe tuberculosis problems were given special project grants, bringing the total of such grants to 35. In addition to community projects, two grants went to Pennsylvania and Massachusetts, where the State medical schools sup¬ ported 3-day symposia on “Rational Therapy and Control of Tuber¬ culosis” for physicians. Some 250 physicians in public health and clinical practice attended the symposia. Public Health Service 165 A professional educational facility was established at Denver, Colo., by means of a special project grant to the Colorado State Department of Public Health. Other educational efforts in tuberculosis control included planning and scheduling a series of 28 seminars for annual meetings of State public health associations and academies of general practice. Ten of the seminars were given during fiscal year 1963. Large-scale trials of isoniazid were continued during the year. Studies were also continued for developing a technique to distinguish between tubercle bacillus infections and those of related but less patho¬ genic organisms. Results indicate that an increasing proportion of tuberculin sensitivity seen in the United States is caused by infection with other types of mycobacteria. Influenza The Surgeon General’s Advisory Committee on Influenza scored its second accurate prediction of an impending epidemic. The epidemic began in the South Atlantic States in January 1963 and spread rapidly to almost all parts of the country. Approximately 45,000 excess deaths from all causes could be attributed to this epidemic. More than 40 million doses of influenza vaccine were used from July 1962 to the spring of 1963, with particular emphasis on vaccinating the aged and chronically ill who are particularly vulnerable. Salmonellosis All State health departments joined with CDC, the Food and Drug Administration, and the Department of Agriculture in developing a national surveillance of Salmonella infections. In the spring of 1963, outbreaks of diarrheal disease traced to Salmonella derby infections were reported from 51 hospitals in 13 States, with many infections clearly acquired within the hospitals. Intensive interstate epidemio¬ logical investigation pointed to raw or undercooked eggs as the prob¬ able source of infection. Special laboratory instruction through bench training was inaugurated on the isolation of Salmonella from food products and animal feeds. Leprosy The successful experimental infection of mouse footpads with human Hansen’s disease bacilli at CDC opens new avenues for development of adequate leprosy-control programs. Vector Control Following CDC’s report to the Federal Aviation Agency on results of its 1962 studies on exposure of human volunteers to DDVP vapor, the FAA authorized experimental installation of a DDVP pilot sys- 166 Department of Health , Education , and Welfare , 1963 tern in a commercial aircraft. Initial results have been satisfactory from the standpoint of biological performance, passenger acceptance, and airline personnel approval. There has been no increase of DDT storage in human fat since 1955-56 in this country, according to analysis of fat samples obtained during 1961-62. A slightly larger fraction of the DDT-derived ma¬ terial, DDE, was present, however. For the first time, information was obtained on the concentration of other pesticides in the fat of the general population in this country. Of 30 human-fat samples ana¬ lyzed for chlorinated hydrocarbon insecticides, 24 were found to con¬ tain dieldrin. INTERNATIONAL ACTIVITIES CDC provides technical support and personnel for the health pro¬ grams sponsored by the Agency for International Development (AID), and works with the World Health Organization through rep¬ resentation on expert advisory panels and committees and as a labora¬ tory diagnostic and study center. During 1963 CDC also provided medical service to the Peace Corps in India. The control of insects and other disease-carrying arthropods is an important part of CDC’s international program. This year saw an unprecedented increase in epidemic investigation and consultation in other countries. These activities were undertaken in connection with poliomyelitis in the Marshall Islands, British Guiana, Barbados, and Santo Domingo ; hepatitis in England ; smallpox vaccination in Tonga ; cholera in the Philippines; diphtheria in Jamaica; malaria in Indo¬ nesia ; and rabies in Mexico and Canada. Division of Community Health Services The Division of Community Health Services completed its first full year of operation with expanded activities in all its areas and the addi¬ tion of two new programs : migrant health and research grants in the fields of public health practice and community-based research. The Division sponsored a conference of State directors of local health services and city health officers in Chicago, June 24-25, 1963, on the problems of local health services. In cooperation with the Di¬ vision of Chronic Diseases, the Division also sponsored a conference at Princeton, N.J., for the 31 homemaker service projects supported by PHS contracts, project grants, or formula grants. HEALTH ECONOMICS A Health Economics Series was launched in 1963 with the publica¬ tion of two studies: Medical Care Financing and Utilization, and Public Health Service 167 State Employees’ Health Benefit Programs. Other studies completed during the year were on maternity and infant-care benefits, prepaid drug benefits, and the use of automatic data-processing equipment in the pharmacy. Studies underway at the close of the year included homemaker services in foreign programs and mental health benefits in U.S. voluntary health insurance plans. HEALTH EDUCATION Continuing education of physicians is assuming first-rank impor¬ tance in the application of new scientific knowledge. The health education program is supporting a project conducted by the Empire State Medical, Scientific, and Education Foundation which aims to ascertain the interests of physicians of upstate New York in con¬ tinuing education and to identify the resources available for meeting their educational needs. MEDICAL CARE ADMINISTRATION To obtain needed information on group practice prepayment plans, the Division is supporting a detailed study of the steps involved in establishing a group practice prepayment plan and bringing its services and facilities into operation. Other activities include the development of a program guide on medical-care administration in cooperation with the Program Area Committee on Medical Care Ad¬ ministration of the American Public Health Association. MIGRANT HEALTH The Migrant Health Act, approved September 25, 1962, enables the Public Health Service to assist public and private nonprofit organiza¬ tions in providing family health clinics and other types of services to improve the health of domestic migratory workers and their families. The act authorized the appropriation of $3 million annually for 3 years, beginning in 1963. A supplemental appropriation of $750,000 was made available in May 1963. A total of 36 applications from 20 States were recommended for approval in 1963 and 31 of these were funded with the supplemental appropriation. PUBLIC HEALTH ADMINISTRATION At the request of the Vermont State Health Department, a study of the patterns of rural health and medical services was undertaken. The first phase of the study involved an analysis of the beliefs, atti¬ tudes, and customs associated with health and illness in a typical Vermont town. The second phase, now in progress, involves a study of the relationship of patients, medical personnel, and residents of Vermont towns with the health department. 168 Department of Health , Education, and Welfare, 1963 In cooperation with the Association of Management in Public Health, a detailed listing of information on salaries for 32 selected classes of budgeted positions in State and local health departments employing 30 or more full-time, noninstitutional personnel was completed. RESEARCH GRANTS During the year, 39 research projects supported by grants totaling $1,600,000 were transferred from the National Institutes of Health to the Division of Community Health Services. The research grants program seeks to develop new knowledge regarding the need for health services and the provision, acceptance, and utilization of such services. TRAINING RESOURCES Since its inception in 1957, the public health traineeship program has provided support for academic training to 4,281 individuals. In 1963, 800 trainees were enrolled in schools of their choice with Public Health Service traineeships. In 1963, 83 project grants totaling $1.9 million were awarded to 55 schools of public health, nursing, and engineering for the purpose of enriching their curriculums or otherwise improving instruction in public health schools. Formula grants totaling $1.9 million were awarded to the 12 accredited schools of public health to enable them to increase their enrollment. Division of Dental Public Health and Resources The Division conducts research into the nature and extent of dental diseases and develops effective measures for their assessment and con¬ trol. It assists public and private groups in the planning and opera¬ tion of community health programs at State and local levels and encourages their employment of available disease control measures. It seeks also to stimulate greater use of preventive and remedial measures by individual citizens and conducts sociological studies of attitudes which affect individual and community action in dental health. Finally, the Division works to insure both an adequate supply of dental manpower and the most efficient utilization of available resources. CURBING DENTAL DISEASES Fluoridated water is the most effective dental caries preventive. To stimulate interest in the fluoridation of community water systems, the Division expanded its efforts in public education. It also provided Public Health Service 169 technical assistance to official health agencies and communities initiat¬ ing fluoridation. As of June 30, 1963, nearly 46 million people in 2,460 communities had the health protection afforded by controlled fluoridation. The effectiveness in preventing tooth decay of a fluoride prophylaxis paste used alone and in conjunction with topical fluoride applications is being tested in a project initiated in 1963. Experimentation with home fluoridators and the fluoridation of school water supplies in areas where children would not otherwise have fluoridated water was con¬ tinued, as was investigation of methods of defluoridating water con¬ taining excessive fluorides. Some 250,000 Americans are afflicted with cleft lip or cleft palate. Both epidemiologic information and clues to the cause of this disfigur¬ ing malformation are sought in studies conducted at the Dental Health Center, San Francisco. Analysis of birth records in four States over a 5-year period was completed in 1963, and a similar study covering 30 States initiated. Some findings to date: A positive relationship between race and parental age and occurrence of clefts, and the regular occurrence of a second birth anomaly in babies with facial clefts. Oral cancer attacks 23,000 people annually; with early diagnosis, many of the resulting deaths could be prevented. In a major expan¬ sion of its program to promote the use of oral cytology, the Division initiated seven new training and demonstration projects in 1963. Con¬ ducted in cooperation with health agencies and dental schools, the pro¬ gram teaches dentists the techniques of taking cytological smears of oral lesions. STRENGTHENING PUBLIC PROGRAMS In a continuing series of surveys of official dental health programs, the Division seeks information on staffing, program activities, and financial support which will strengthen its program of technical as¬ sistance to health agencies. The 1963 survey of community health departments shows that only one-third of all Americans have access to full-time local dental health programs. The Ninth Biennial Conference of State and Territorial Dental Di¬ rectors with the Public Health Service and the Children’s Bureau, planned and conducted by the Division, brought State program ad¬ ministrators and Federal officials together for consideration of prob¬ lems of national significance. To aid official health agencies in recruiting personnel, the Division and the U.S. Department of Labor jointly established the Dental Pub- 711-845—64 - 12 170 Department of Health, Education, and Welfare, 1963 lie Health Personnel Service. Maintenance of national rosters of ap¬ plicants and vacancies by the Service simplifies communication between job seekers and agencies with openings for dentists and dental hygienists. EXTENDING DENTAL SERVICES Coverage under dental prepayment plans passed the 1 million mark in 1963. The Division continues to encourage the establishment of new plans through a varied program of informational and technical services. Its analyses of the administration and operation of existing plans form the basis for technical assistance to consumer groups and dental societies organizing prepaid plans. Initiated during the year was an experimental prepayment plan for college students which will serve as a prototype for other plans tailored to the needs of this group. F or handicapped patients — those who are homebound or institution¬ alized and those whose mental or physical conditions necessitate spe¬ cialized treatment procedures — dental care is almost unavailable. In four studies of mentally and physically handicapped children, the Division seeks to determine treatment needs, to develop methods for providing services, and to establish guides for the operation of com¬ munity service programs. A hospital-based program of dental care for handicapped patients of all ages is providing information on this approach to the administration of services. Continuation of a Divi¬ sion-sponsored training program in 12 dental schools gave under¬ graduates technical training and practical experience in the care of handicapped patients. BUILDING DENTAL RESOURCES The growing national dentist shortage underlies the Division’s ef¬ forts to increase both dentist supply and dental productivity. Dele¬ gation of many time-consuming tasks to auxiliary personnel enables dentists to offer improved services for more patients. In 1963, the grants program supporting the training of dental students in the use of chairside assistants was expanded to include 44 dental schools. Anticipating expansion of dental training capacity, the Division published “Dental School Planning,” the first such guide in the dental field. In addition, it offered technical assistance in the planning of educational and research facilities. Data was collected from 11,000 dental and dental hygiene students in the first phase of a comprehen¬ sive study of the costs of dental education. Research in dental educa¬ tion emphasized the use of automated teaching machines and pro¬ gramed instruction. Public Health Service 171 Division of Hospital and Medical Facilities The Division of Hospital and Medical F acilities, in carrying out its many functions in administering the Hill-Burton program, gave spe¬ cial emphasis during the year to developing more refined methods com¬ munities might use in coordinating their health facility planning. While consideration was given the entire spectrum of health facili¬ ties, many of the Division’s activities were focused on finding better methods to cope with the mounting needs of the long-term care pa¬ tient — one of the Nation’s most crucial health problems. Of particular interest to the various agencies and groups around the Nation concerned with the problems of the aged is the national inventory of nursing homes and related facilities conducted under Division auspices. An analysis of the findings of this 1961 survey was completed and will appear in a publication, “Characteristics of Nursing Homes,” prepared by the Division. Another long-term care activity was the compilation of source data concerning nursing homes and related facilities which appeared in the publication “Nursing Homes and Related Facilities — Fact Bool:.” COMMITTEE STUDY PROBLEMS An important part of the Division’s planning activities over the past several years has been its work with special committees charged with the task of evaluating health facility needs in specific areas. During 1963, committees concerned with needs for long-term treatment and care and for rehabilitation facilities published their findings. The committee examining the Nation’s needs in tuberculosis facilities and services was in the final phase of its study at the close of the year. Its report is scheduled for publication in 1964. Two special commit¬ tees which began their studies during the year are looking into present and long-range needs in the fields of nursing education facilities and teaching hospitals. TYPES OF PROJECTS APPROVED During the 1963 fiscal year, a total of 7,074 beds in chronic-disease facilities and skilled nursing homes, which are predominantly for the care of the aged, were approved for Federal aid under the Hill-Burton program. In addition, 16,590 general-hospital beds, 1,560 mental beds, 39 rehabilitation facilities, 77 diagnostic and treatment centers, and 53 public health centers were approved to help meet the health needs of the aged as well as the general population. 172 Department of Health , Education , and Welfare , 1963 APPROPRIATIONS REACH ALLTIME HIGH Appropriations for construction under the Hill-Burton program reached an alltime high of $220 million for fiscal year 1963. A total of $40 million was appropriated for the construction of long-term care facilities (i.e., nursing homes and chronic-disease hospitals), $20 million for diagnostic and treatment centers, and $10 million for re¬ habilitation facilities. In addition, $150 million was made available for hospitals and public health centers. ACCELERATED PUBLIC WORKS PROGRAM The Hill- Burton program also played a role in connection with the allocation of funds to hospitals and related facilities under the accel¬ erated public works program. The Division processed and secured approval for 128 projects to be constructed at a total cost of approxi¬ mately $117,451,800, involving $44,625,000 in APW funds. RESEARCH AND DEMONSTRATION ACTIVITIES Hospital research and demonstration operated on a budget of $4.2 million during the year. Of this total, $1,388,858 went into areawide planning demonstration projects in more than a dozen communities around the Nation. An important byproduct of these demonstrations will be a fuller realization of one of the basic objectives of the Hill- Burton program — the encouragement of local participation in planning. Since the beginning of the research phase of the Hill-Burton pro¬ gram in 1956, funds totaling $18,371,166 have supported 139 projects. Some of the areas of investigation, besides areawide planning, include the development of more effective organizational patterns for provid¬ ing hospital services and improvements in architectural and equipment design. Division of Nursing Several significant developments in 1963 hold out the promise of new directions and greater national and local action for improved nursing. SURGEON GENERAL’S CONSULTANT GROUP ON NURSING The report of the Surgeon General’s Consultant Group on Nursing, issued under the title “Toward Quality in Nursing : Needs and Goals,” showed that by 1970 a minimum of 680,000 professional nurses in practice will be needed, or about 130,000 more than the present supply. As for licensed practical nurses, the 1970 need will be for an estimated 350,000 compared with the present supply of about 225,000. Public Health Service 173 The group, in 20 separate recommendations, urged a greatly ex¬ panded program of Federal aid for student nurses, nursing-school construction and curriculum development, nurse recruitment, advanced nursing education, nursing research and research training, and im¬ proved utilization of nursing personnel. CLOSER ALLIANCE OF NURSING RESEARCH AND PRACTICE Nursing research and nursing practice have been consolidated in a single program as a result of the 1963 transfer of nursing research grants, nurse research fellowships, and nursing research training grants from the National Institutes of Health to the Division. Most nursing research deals directly with patient care, so the new knowl¬ edge yielded by nursing studies lends itself to early application. SECOND NATIONAL TRAINEESHIP EVALUATION CONFERENCE This was the seventh year of the professional nurse traineeship pro¬ gram in which Federal aid goes to schools of nursing and public health for the advanced education of nurse leaders — administrators, super¬ visors, teachers. A national survey of the educational needs and prep¬ aration of nurses was completed along with much other work and planning for the Second National Conference to Evaluate the Pro¬ fessional Nurse Traineeship Program on July 17-19, 1963. ACTION STUDIES FOR MORE EFFICIENT NURSING SERVICE Methods developed and thoroughly tested by the Division help to prevent the waste of nursing skills. F or example, a study method to improve the efficiency of nursing service in the inpatient units of large general hospitals is being applied on a statewide basis in New Jersey. This is the first time that two official State agencies have pooled efforts to carry out these studies over a period of several years and have em¬ ployed a consultant for this work. Already, five other States hope to carry out these statewide studies with Division assistance. The Division is vigorously encouraging use of its method and guide for nursing studies in outpatient units. A workshop this year for 10 hospital outpatient departments and 1 health department in Chicago represents the start of a community wide project to improve outpatient nursing service. NEW, BROAD-GAUGE STUDY METHOD A method for studying patient progress is now being adapted in a Midwestern State research project to measure the effectiveness of nursing service referral by comparing the progress of discharged hos¬ pital patients who receive public health nursing services with those who do not. This method has been enthusiastically received, and 17 174 Department of Health , Education , and Welfare , 1963 preparatory workshops have been conducted this year for regional, State, and local personnel. A six-member advisory committee has been appointed to assist the Division in making plans for extended use of this study method. IMPROVEMENT OF COMMUNITY PUBLIC HEALTH NURSING SERVICES Community health project grant funds are being used to find new ways to develop and extend nursing care of the sick at home programs. This year, the Division had responsibility for 12 new project grants in community public health nursing. Major assistance has been given again this year to State and local health departments in improving the administration and evaluation of public health nursing services. A total of 14 State and local agencies throughout the country were given assistance in use of the Division method to determine the nursing expenditures of small health agencies. KEY STUDIES The prime aim of many Division studies is to obtain better data on nursing resources and needs. Six States are cooperating with the Di¬ vision in the trial of a survey method which is being adapted for state¬ wide reappraisals of nursing resources. The completed study of part- time nurses revealed the increasing growth of this group : at present they contribute about one-fifth of the nursing service in short-term general hospitals. A pretest of the important study of nurse mobility has been completed in a State which is largely dependent on nurse graduates from other States to provide its nursing service. A study of specific programed learning for nurses, patients, and families has been arranged as a cooperative project by the Division’s nursing re¬ search field center at San Francisco and the University of California School of Nursing. GRANTS AND AWARDS The professional nurse traineeship program this year awarded $6,- 354,938 in training grants to a total of 98 schools of nursing and of public health for traineeships to about 2,000 professional nurses. This enabled these nurses to undertake full-time academic study to better prepare themselves for leadership positions in nursing — the admin¬ istration and supervision of nursing services and personnel, and the teaching of nursing. Another $960,327 went for the support of 69 of the very popular short-term intensive training courses in administra¬ tion, supervision, and teaching. The courses were sponsored by a total of 39 nonprofit institutions and agencies for about 4,000 pro¬ fessional nurses. Public Health Service 175 The research grants and fellowships program awarded $1,814,337 for 66 research projects. Of this number 18 were newly approved studies. Awards totaling $275,733 went to 62 nurses for special pre- doctoral research fellowships. Of this number, 25 were new ap¬ pointees. During the year, 73 nurse research fellows were enrolled in 32 universities in 19 States and the District of Columbia, a 10-percent enrollment increase over 1962 and the largest enrollment to date. Five nurse-scientist graduate training grants are currently being supported. Of these, four (totaling $301,532) were awarded this year to basic science departments in universities, to increase the num¬ ber of nurses prepared in the basic sciences for research work. A Nurse Scientist Graduate Training Committee of six members was appointed this year to evaluate applications for nurse research fellow¬ ships and nursing research training. Division of Air Pollution The Division of Air Pollution is authorized (by Public Law 84-159 and its extensions) to conduct a nationwide program with four princi¬ pal features: (1) research, (2) technical assistance to States and com¬ munities, (3) personnel training, and (4) developing and distributing information. RESEARCH During the year, engineering research investigated the amounts, character, and control of automotive emissions ; incineration and other combustion problems; and control procedures. In cooperation with the Weather Bureau, the relationships of meteorological variables to air quality and to the diffusion of pollutants were explored. Supplementing the National Air Sampling Network — which moni¬ tors primarily suspended solids and liquids — the new continuous air¬ monitoring program began operation in eight cities to sample seven different gases. Biomedical research provided further evidence linking air pollut¬ ants to such serious chronic respiratory diseases as emphysema and lung cancer, and to our most common acute respiratory disease, the common cold. TECHNICAL ASSISTANCE The Division’s role in assessing local problems and demonstrating control techniques has grown each year. In 1963, this kind of assist¬ ance ranged from short-term technical studies of limited scope to state¬ wide surveys. Investigations of nationwide importance included the 176 Department of Health, Education, and Welfare, 1963 compilation of emission data on the combustion of oil and coal, and a study of the air-pollution aspects of the iron and steel industry. TRAINING It has been estimated that some 4,000 more control specialists will be needed by 1970. Thus, a major function of the Division is the train¬ ing of personnel from State and local agencies, and from industry. Short technical courses, presented at the Sanitary Engineering Center in Cincinnati, are supplemented by field courses. During 1963, train¬ ing was also provided at a more advanced level through training grants and fellowships at 19 universities. PUBLIC INFORMATION The Division provided during 1963 a record volume of technical and popular pamphlets, reprints of published articles, and responses to requests for information and assistance — from local and nationwide news media, State and local agencies, industry, health and civic orga¬ nizations, and individuals. The Division has also undertaken to pro¬ vide to State and local legislative bodies complete data on what other lawmakers have done and, during 1963, has brought these data up to date. A newly formed sociological and economic section initiated studies on these heretofore neglected phases of air pollution. FUTURE PROSPECTS Two 1963 developments suggest that the Federal air-pollution pro¬ gram may be able to achieve more rapid progress in the near future : The National Conference on Air Pollution, held in Washington, D.C., on December 10-12, was attended by more than 1,400 representa¬ tives of industry, science, education, and government. There was widespread agreement that expanded research should be accompanied by the application of known control measures — now. In February 1963, President Kennedy’s health message to Congress recommended new legislation which would enable the Federal Govern¬ ment to render greater assistance to States and communities in air- pollution control. Specifically, his recommendations called for legis¬ lation which would authorize the Department of Health, Education, and Welfare (1) to engage in a more intensive research program; (2) to provide project grants to State and local agencies for initiating new control programs or improving existing ones; (3) to conduct studies on problems of nationwide or interstate significance ; and (4) to undertake enforcement action, in certain cases of interstate air pol¬ lution, along the general lines of current water pollution control measures. Bills which the Congress was considering at year’s end would substantially carry out the President’s recommendations. Public Health Service 177 Division of Environmental Engineering and Food Protection The Division’s activities include safeguarding the sanitary quality of drinking water, milk, and meals served in food-service locations; controlling environmental dangers such as pollution of individual water systems which arise because of urbanization ; and protecting the public health against environmental health risks encountered aboard common-carrier vehicles in interstate travel or in outdoor recreational areas. The Division also conducts research on problems of food pro¬ tection and environmental engineering. During the year, 48 awards were made for new research projects, bringing the total number of studies supported at the close of fiscal 19G3 to 208. Investigators are located in 76 universities and other research institutions throughout the United States. MILK AND FOOD BRANCH More than 175 seminars and training courses on milk and food sanitation, attended by more than 8,500 individuals, were sponsored, or participated in, by Milk and Food Branch sanitation specialists. Participation by States in the cooperative State-PHS program for the certification of interstate milk shippers increased for the 12th con¬ secutive year. The July 1963 list of milk shippers complying with PHS sanitation compliance ratings contained the names of 935 firms in 44 States and the District of Columbia. The “Food Service Sanitation Ordinance and Code,” which is con¬ tained in the 1962 Food Service Sanitation Manual , is under considera¬ tion for adoption by State and local health authorities as a means for updating their food-protection programs. During 1963, 6 States and 11 local health jurisdictions adopted the Public Health Service rec¬ ommendations. These actions provide increased food-service sanita¬ tion protection for more than 11 million persons. SHELLFISH SANITATION BRANCH Construction of new shellfish sanitation research centers at King¬ ston, R.I., and Dauphin Island, Ala., was nearly completed during fiscal 1963. A major portion of the staff has been recruited for these installations and several research projects are underway. A shellfish sanitation agreement was negotiated between the United States and Japan providing that fresh or frozen oysters and clams exported to the United States by Japan will be produced under sani¬ tary control equal to those used by the States. Evaluations of the shellfish sanitation programs of the 22 shellfish- producing States were virtually completed by June 30, 1963. The 178 Department of Health , Education, and Welfare, 1963 Service continues to endorse pollution-control programs for all coastal States except Alaska and Hawaii. INTERSTATE CARRIER BRANCH A service was established in cooperation with the Division of Acci¬ dent Prevention to provide immediate evaluation of the dangers from toxic materials found in community drinking-water supplies. During the first few months of operation, prompt handling of several requests for assistance from States proved the usefulness of the new emergency service. A publication, “Drinking Water Quality of Selected Interstate Car¬ rier Water Supplies — 1960-61,” was issued, containing data on drinking water in 134 municipalities. SPECIAL ENGINEERING SERVICES BRANCH Plans were developed during the year for a National Conference on Solid Wastes Research, to be held in Chicago late in 1963. Con¬ sulting sanitary engineering services for the National Park Service and other governmental agencies were handled by the Branch, and cooperative work was carried on with the American Public Works Association and other professional organizations. Division of Occupational Health The inventiveness and productivity of American industry continu¬ ously bring about changes in every phase of living. The effects of these changes have been particularly pronounced in the work environ¬ ment where workers are subject to an increasing number of new and complex health stresses. Increased congressional funds made possible a study of chronic chest diseases among bituminous coal miners. The study got under¬ way in West Virginia and will eventually cover the whole Appalach¬ ian region. Another new study is probing more deeply into how health and productivity are affected by work in industries where extreme heat is a problem. Work also continued on what kinds and amounts of noise impair hearing and have a psychological impact. As part of this project, occupational exposures were studied at several international airports. A long-range study of health hazards in uranium mining continued in its 13th year. Close surveillance of a group of over 3,000 miners shows a trend of increasing lung cancer deaths, believed to be due to the radiation exposures in the uranium mines. In toxicology, various projects examined how changes in the body and its functions can signal early progressive injury from toxic Public Health Service 179 substances. Initial studies conducted in the past year are beginning to show promise that increased susceptibility of certain individuals to industrial chemicals may be predicted. A study was completed dealing with the incidence of lung cancer deaths by occupation in the United States. Statistical work was also completed for a similar report on two other causes of death, coronary heart disease and ulcers of the stomach and duodenum. As an extension of its own research activities, the Division sup¬ ported 61 research grants in the field of occupational health in the amount of $1,766,000. A diversified program has been undertaken to stimulate effective community services in occupational health. A study was made, for ex¬ ample, of part-time nursing services provided to industry by visiting nurse agencies. Illustrative of the type of problems generated by a changing tech¬ nology, phosphors and luminescent inks intended for use in a new method of high-speed mail sorting were tested for toxicity by the Division prior to announcement by the Post Office Department of their proposed field trial. The Division provided training for 350 people during the year. Courses range from those covering basic industrial hygiene principles to those that treat highly specialized areas, such as advanced courses in the evaluation and control of heat stress and noise. Division of Radiological Health The Division of Radiological Health increased the scope of its research, environmental surveillance, State assistance, and training programs during the past year. Special emphasis was placed on the development of preventive health measures, in accordance with the recommendations of the National Advisory Committee on Radiation. RESEARCH By the end of fiscal 1963, the Division was funding 74 research grants totaling $1,545,000, in addition to its intramural research. An ion-exchange process for removing radioactive strontium from milk, first tested in a pilot-plant operation, is now being evaluated on a commercial scale by a Missouri dairy cooperative under a PHS- USDA contract. The Division and the Agriculture Department are also cooperating in a project to identify sources of iodine 131 con¬ tamination in milk. Experiments are being conducted at agricultural experiment stations in Minnesota, Utah, and Iowa to determine the relation of herd management and methods of feeding to the iodine 131 content of milk. 180 Department of Health , Education, and Welfare, 1963 Methods for reducing radionuclides in foods other than milk are also being studied. Investigators at the Ohio State University Re¬ search Foundation, under a Division contract, are evaluating the effect of processing methods such as quick freezing, canning, dehydra¬ tion, and cooking on radionuclide content in commercial crops. Along with efforts to develop suitable preventive health measures, other research areas were also expanded. Of major importance are those projects which seek to determine more accurately the genetic and somatic effects of low-level radiation. An example of the work being carried on in this area is a grant study of deciduous (baby) teeth by the Loyola University of the South, New Orleans. About 6,000 teeth are to be collected annually in the gulf -coast area and Puerto Rico and assayed for strontium 90-calcium ratio as an indirect means of monitoring strontium 90 in human bone from fallout. ENVIRONMENTAL SURVEILLANCE Progress was made in the development of the radiation intelligence system. The goal of this system is the establishment of a national network for the assessment of total radiation exposure of the U.S. population. A step in this direction was the first nationwide trial of household interviewing techniques to obtain comprehensive data on individual food consumption. Additional information on total radiation exposure is being sought through a human bone collection program. Bones collected by the DRH in cooperation with selected medical centers are being analyzed for strontium 90 content at the Northeastern Radiological Health Laboratory, Winchester, Mass. As part of the project on measurement of radiation in humans, detailed plans are being developed for a whole-body counting facility for the Division which would serve as a reference standard for whole- body counters throughout the country. Two developments increased the scope of DRH surveillance activity. One was the establishment of a surveillance program in the Americas through an agreement with the Pan American Health Organization. A second was the establishment of a Nuclear Facilities Environmental Analysis Section to advise the States in matters regarding potential radiation effects upon the environment due to proposed nuclear facilities. Still another important action was the initiation of a quality-control program to assure the accuracy of the analytical results of DRH and State radiochemical laboratories. The assurance of valid analytical results is an important function, due to the multitude of radiochemical analyses that are performed by Federal and State laboratories. Public Health Service 181 The Division continued its offsite monitoring activities at the Nevada Test Site and the Pacific Proving Ground. The offsite ac¬ tivity in the Pacific was supported by the establishment on a perma¬ nent basis of a radiochemical laboratory in Hawaii. STATES ASSISTANCE In November 1962 a new formula grant program was estab¬ lished to support State programs in radiological health. An initial appropriation of $1,500,000 was made available for fiscal 1963 on a matching basis. To date, all States and two territories are partici¬ pating. The Division also extended its technical assistance to the States through the appointment of additional consultants to the regional offices and State health agencies. The dental radiological health program continued to receive major emphasis. Inspection programs of dental X-ray equipment have been, or are now being, conducted in 49 States. A survey program for medical radiographic and fluoroscopic units is being developed. An investigation of the use and control of radium and other natu¬ rally occurring radioisotopes was begun. Plans are being laid for providing the States with simple standard methods of radium han¬ dling and control. TRAINING Of major importance was the disbursement of almost $2 million to universities for graduate training in radiation specialties. Thirty schools are now participating, and a total of about 100 specialists have been trained under this program. Pilot projects were also started during the year to provide radiation technician training. During the past year, 1,100 professional personnel from Federal, State, and local health agencies, from colleges and universities, in¬ dustry, and from foreign countries, participated in 51 DRH short courses. Full-time, long-term training in radiological health was provided 25 PHS commissioned officers at selected universities. The Division initiated a technical report series on environmental health and published the first three reports of this series. Division of Water Supply and Pollution Control Government at all levels is setting new records in programs to abate and control water pollution, but the problem remains a pressing issue. Increasing public concern was reflected in the Congress this year. There were significant studies, published reports, and public hearings on water pollution by committees in both the House and Senate. 182 Department of Health , Education , and Welfare , 1963 By 1980, our national water needs will total 600 billion gallons a day, exceeding the available dependable supply, and will double again by the year 2000. The Nation must complete, as rapidly as possible, the engineering works necessary to capture the maximum amount possible ; but, more importantly, it must treat the water in such a way that each gallon is usable at least twice. The Federal water pollution control program is authorized by Public Law 660, enacted in 1956, as amended by Public Law 87-88 in 1961. It places emphasis on Federal- State-local cooperation, with full recognition of States rights and responsibilities, and it is organized to protect and conserve water for all legitimate uses : public water supplies, recreation, industry, agriculture, and fish and wildlife propagation. Essentially the program is one of construction, en¬ forcement, and research, including the training of much-needed manpower. RIVER BASIN STUDIES Program goals call for completion of comprehensive plans for all major U.S. river basins by 1975. Such plans assess the causes of water pollution, develop agreements for desired water uses, outline pollu¬ tion-control measures, and set up timetables for accomplishing them. Comprehensive planning studies were initiated during the year in the Ohio River basin and expanded in basins of the Columbia, Dela¬ ware, Chesapeake Bay- Susquehanna River, and Great Lakes- Illinois River. The intensive phase of the Arkansas-Red Rivers basin plan was completed. In connection with the comprehensive basin studies, field studies of national significance have continued. Of more than usual interest is a study of the effects of pesticides on water quality, and another to determine whether recreational uses affect the quality of water stored in water-supply reservoirs. RESEARCH Intramural research in water supply and pollution control is head¬ quartered at the Sanitary Engineering Center in Cincinnati, where the Division maintains a staff of approximately 140 professional and supporting workers. Research here has been intensified in advanced waste treatment, in synthetic organic chemical contaminants, in streamflow augmentation for waste dilution, and in other areas. The Division is working with the detergent industry to establish standards of biodegradability which industry can use in developing products compatible with water-quality management. Extramural research in fiscal 1963 was supported by 289 Federal grants, totaling $5,173,825. The grants went to 103 universities, Public Health Service 183 agencies, and individuals in 42 States and 3 foreign countries. One such grant was in support of the first international Water Quality Research Conference. Sites have been selected and architectural plans are in progress for six of the seven regional water-pollution research laboratories and two special-purpose national water standards laboratories soon to be built. BASIC DATA The National Water Quality Network, which maintains continuous intelligence on the quality of water in major waterways, added 5 new stations, bringing the total to 126. Eventually, 300 stations will be measuring both natural and manmade contamination. Where feasi- ble, automatic instrumentation — which the PHS is helping to de¬ velop — is being installed for stream monitoring. Regular checks are made on more than 15 parameters, including temperature, synthetic organics, radioactivity, plankton, coliform bacteria, and others. SEWAGE TREATMENT Construction of municipal sewage-treatment works was up 10 per¬ cent over fiscal 1962, again setting a new record. Federal grants of $137 million under both the Water Pollution Control Act and the Accelerated Public Works Act were awarded to 1,105 projects. The local-goverment contribution was $469 million, a ratio of five local dollars to each Federal dollar. In the 7-year history of construction grants, 4,605 projects have received Federal aid in a sewage-treatment building program totaling $2.3 billion. The facilities built will serve 40 million people and im¬ prove the water quality in 45,000 miles of streams. Despite this massive effort, some 3,085 U.S. towns and cities are in need of new or improved sewage-treatment works for populations totaling 17 million. Another 2,746 need both sewage-collection and sewage-treatment systems for 5.8 million people. It will cost $2.2 billion to build the facilities needed by these 5,831 communities, and an annual investment of $750 million through 1970 will be required to eliminate the backlog and keep up with new needs. Grants of $5 million per year to State and interstate agencies stimu¬ lated new activity in the State water pollution control programs. Al¬ locations are based on population, financial need, and extent of the problem, and provide up to two-thirds of a State’s program funds for water-pollution control. Stimulated by the grants, State fund¬ ing has risen from a $4.2 million total in 1956 (before grants) to $10 million in 1963. Per capita expenditures, however, vary from 1 to 24 cents among the 50 States, indicating inadequate water-pollution programs in many. 184 Department of Health , Education , and Welfare , 1963 ENFORCEMENT Two Federal enforcement actions were initiated in fiscal 1963 to abate pollution of interstate waters : one on the Androscoggin River (New Hampshire-Maine) and one on the Escambia River (Alabama- Florida). Additional conference sessions were held in connection with the ongoing enforcement actions involving the Colorado River, North Fork of the Holston River, and Raritan Bay. The three-step Federal enforcement procedure — conference, public hearing, court action — has been initiated in 20 situations in the pro¬ gram’s history. They involve 28 States, the District of Columbia, some 300 municipalities, and a like number of industries. As a result, remedial facilities costing $500 million are in various states of planning, construction, and operation along the 5,500 miles of major water bodies affected. Surveillance is maintained in all these areas to assure that abatement of pollution moves on schedule. INTERAGENCY COORDINATION Some 22,700 points of waste discharge were covered in the Nation’s first inventory of waste treatment at Federal installations, reported to the President in September 1962. About 29 percent of the total wastes volume involved had no treatment. Most of the Federal agen¬ cies have appointed coordinators who are working with HEW in following through on a Presidential directive to control the wastes. Coordination with other Federal water resource development agen¬ cies is an important part of the pollution-control program. Reports are prepared for the Federal construction agencies (Corps of Engi¬ neers and Bureau of Reclamation) on reservoir projects to include water storage for dilution of waste effluents in streamflow below the dams. These studies tie in closely with requirements of the Water Supply Act of 1958, in which the Division determines storage require¬ ments for municipal and industrial water supplies in Federal reservoir planning. About 140 of the two types of water-storage reports have been prepared (43 in fiscal 1963) and 200 others are in progress or scheduled. The nine-member Presidentially appointed Water Pollution Control Advisory Board continued its policy of holding certain of its meetings outside of Washington to provide public forums to assess regional problems and progress in water-pollution control. Meetings in fiscal 1963 were held in St. Louis, Cincinnati, and Honolulu, in addition to one in Washington, D.C. Public Health Service 185 Arctic Health Research Center Significant activities during the year included the establishment of a serology laboratory within the Epidemiology Section ; field trials of measles vaccines among highly susceptible Alaskans; studies of bru¬ cellosis in humans and animals, with clinical observation of the disease in the Center’s experimental herd of reindeer; increased construction of sewage lagoons; isolation of a plague-like organism and recovery of a known insect vector from Alaskan animals ; inauguration of arbo¬ virus investigations; and the discovery of apparent “mild diabetes” cases among Eskimos which may provide valuable leads to the study of diabetes among these people. An International Conference on Medicine and Public Health in the Arctic and Antarctic, sponsored by WHO, was held in Geneva in Sep¬ tember 1962 and attended by 32 participants from 11 countries. It was the first meeting ever held for exploring the special medical needs of polar regions. The National Institutes of Health The growth which has characterized the National Institutes of Health over a period of years was sustained in 1963. NIH funds continued to comprise a significant segment of the total Federal outlay for all research — about 14 percent of an estimated $4.5 billion in 1963. At the end of the fiscal year, its 40-percent contribution to health research money made NIH the largest supporter of biomedical re¬ search in this country. Three major organizational changes — aimed at maximizing the strength and efficiency of NIH research programs — were completed in the past year. The new Institute of Child Health and Human De¬ velopment now brings into a single research focus the continuum of human development from the prenatal stage and birth through old age and death. Raising the Division of General Medical Sciences to insti¬ tute status reflects the growing importance of training and investiga¬ tions in the sciences basic to health. The creation of a new Division of Research Facilities and Resources, by consolidating previously dispersed programs providing ancillary facilities and resources for research, permits assessment of total institutional needs for such resources. Undiminished NIH support of non-Federal medical research con¬ tinued to create complex administrative problems. Major concern centered on defining the terms and conditions of this public-private liaison which must fulfill the obligations of public stewardship as well as meet the exigencies of scientific creativity. The grants program 711-845—64 - 13 186 Department of Health , Education , and Welfare , 1963 was strengthened in a number of ways. Of paramount importance was the issuance of the Research Grants Manual. Other measures in¬ cluded (1) identification of the Division of Research Grants, under NIH, as a single grants manager for the entire Public Health Service; (2) revision of the grant application form and use of electronic aids to obtain more detailed information from the applicant; (3) provision of more uniform information to the advisory councils; (4) establish¬ ment of a formal training program for grants associates and special seminars for staff to provide tightened administration and control of grant programs. In the area of training, NIH continued its efforts to double the medical research manpower pool by 1970. To attain this objective, however, will require a larger annual increment (5,000 scientists) than previously estimated. Major personnel shortages continue in the mental health area, and greatly expanded training is planned for this field. In fulfilling manpower needs, special attention is being given to (1) predoctoral training, (2) postdoctoral training of clinical investi¬ gators, and (3) career awards. 1. Predoctoral training is designed to increase the number of Ph. D.’s and M.D.’s, especially by combining medical and basic science training for research in the biomedical sciences. It seeks especially to discover and develop talent at an earlier age. 2. The postdoctoral program is planned to provide further training to Ph. D’s. The program reflects the belief that competence in clinical research is attainable only by combining the M.D.-Ph. D. training dis¬ ciplines. Special need for this training was evident in neurophysi¬ ology, epidemiology, and molecular genetics. 3. The career award program continues to provide long-term sup¬ port for senior investigators who wish to pursue a research career under stable tenure conditions. Expansion of scientific programs has greatly increased the problems of exchange, storage, and retrieval of biomedical information. The Director of NIH has established within his Office a focal point for scientific and technical communication. Counterparts established in each NIH institute and division, which are coordinated by the Direc¬ tor’s Office, furnish a framework for the scientific communication activity. In addition, the newly established Division of Research Facilities and Resources has been given broad responsibility for under¬ taking support of biomedical communication activities in selected insti¬ tutions throughout the country. Few of the health problems of the American people are unique to this country ; most of our serious health concerns are shared by other Public Health Service 187 nations. Foreign scientific resources (materiel and personnel) — sup¬ plementing our domestic resources — continue to aid NIH in pursuing its medical research objectives. NIH international activities have fallen, for the most part, within three general support types : research projects, research training, and research communication (interchange of information and skill). Under Public Law 480, foreign currencies stemming from the sale of surplus American agricultural products are available for medical re¬ search projects in certain countries. To insure greater selectivity and scientific excellence in awarding grants to foreigners, these steps have been taken : 1. More restrictive criteria have been developed in the selection of foreign projects. 2. Indirect costs have been shifted to recipient institutions. 3. Commitments have been limited, normally, to 3 years and a a maximum of $100,000 in any year. 4. Total foreign grants have been limited to 4 percent of funds available for regular grants. 5. Efforts have been made to increase local participation in medi¬ cal research projects. Foreign-trained scientists and foreign nationals trained in the United States now account for 20 percent of the Ph. D.’s and M.D.’s entering research. Continuation of such a rate will help substantially to attain the 1970 goal of a doubled research manpower pool. The reports that follow on the individual institutes and divisions provide specific examples of research advances and a closer look at NIH performance during 1963. National Cancer Institute The programs of the National Cancer Institute are twofold: (1) Identifying the causes of cancer so that means of prevention can be devised, and (2) developing improved methods of detecting and treating the various forms of malignant disease. In research on the causes of cancer, emphasis is being placed on the role of environmental factors and viruses; in research on treatment, top priority is being given to the quest for new and better drugs. During the year, two task forces organized by the Institute moved ahead rapidly in their separate efforts to increase the effectiveness of treatment for acute leukemia patients and to learn whether viruses cause human cancer. A joint project was launched with the Atomic Energy Commission for wide-ranging studies of the cancer-causing effects of viruses, chemicals, and radiation. The Institute also initi- 188 Department of Health , Education, and Welfare, 1963 ated an effort to facilitate communications among cancer researchers and between these researchers and medical practitioners. Advances came from many areas of the intramural program, notably in virus research, studies of the effects of cancer-causing chemicals, and in work on the techniques of tissue culture — an indispensable tool in cancer research. Animal tumor- virus systems are a rich source of basic knowledge, as well as a testing ground for approaches to the human cancer prob¬ lem. During the year, a rodent leukemia virus, previously isolated by a staff scientist, was found to have an easy-to-identify tadpolelike shape, and a virus that causes wartlike growths known as Milker’s nodules was isolated, more than 150 years after Edward Jenner first suggested its existence. Through the application of expanding knowledge of DNA-RNA- protein relationships, a chemical that causes cancer in animals was shown also to cause changes in the cellular apparatus that synthesizes protein, possibly by interfering with the transfer of information from the genes to protein-production sites. A group that has introduced many innovations in tissue culture technology scored another major gain when, for the first time, animal cells thrived in chemically defined media without undergoing a period of adaptation in media containing blood serum. Also in laboratory work, some success was achieved in purifying protein-nucleic acid complexes by chromatographic techniques pre¬ viously developed by staff scientists. A nationwide survey coordinated by the National Cancer Institute revealed an unusually high frequency of cancer and mongolism among brothers and sisters of children who had leukemia. These and other data suggested a relationship between childhood leukemia and several diseases that are or may be associated with chromosomal defects. On the clinical level, the use of drugs as the initial therapy for choriocarcinoma and related tumors that had not begun spreading enabled several women to forego surgery and thereby to continue bear¬ ing children. As some women previously treated with methotrexate completed 6 years free of cancer, the introduction of a second drug, actinomycin D, raised the rate of apparent complete remissions to 75 percent. In the treatment of childhood acute leukemia, intravenous therapy with methotrexate every fourth day more than doubled the rate of remission achieved with daily oral treatment. An investigation of chronic granulocytic leukemia revealed the pres¬ ence of the abnormal “Philadelphia” chromosome in various cell types other than granulocytes, and showed that cells carrying the anomaly Public Health Service 189 are never completely eliminated, regardless of the extent or duration of drug- induced remissions. From combined immunologic-metabolic studies came gains in the development of techniques for diagnosing the protein disorders asso¬ ciated with multiple myeloma. In research on surgery, a chlorophyll preparation injected into patients was found helpful in locating metastases at operation. GRANT-SUPPORTED RESEARCH A number of significant advances were made during the year by grantees. At Baylor University in Texas, a group of researchers became the first to demonstrate the cancer-causing ability of a human virus. They showed that adenovirus 12, one of a class of viruses known primarily as causes of respiratory infections, induced tumors in hamsters, thus strengthening the theory that viruses cause some forms of cancer in man. In studies at Wistar Institute in Philadelphia, a monkey virus that contaminated some early lots of polio vaccine was shown to cause bizarre changes in human cells kept alive in tissue culture. A virus that causes tumors in chickens was shown to be “defective” by grantees at the University of California in Berkeley. They found that, although the virus produced tumors, new virus particles were not formed in the absence of a second, or helper, virus. From work by grantees at Yale University came a promising find¬ ing in the relatively new but very important search for antiviral chemicals. They found that IUDR, already in use for treatment of a virus-caused eye disease, blocks some of the effects of vaccinia, or cowpox, virus and inhibits tumor induction in hamsters by adeno¬ viruses. A grantee in England extended his historic work on the role of the thymus gland in the development of immune reactivity in animals by showing that it is also essential for recovery of the immune mecha¬ nism in adult animals exposed to X-irradiation. National Institute of Mental Health The National Institute of Mental Health in 1963 began a new pro¬ gram designed to encourage the States to formulate comprehensive community approaches to problems of mental illness. The program was made possible through an appropriation by the Congress of spe¬ cial matching grant-in-aid funds of $4.2 million. Proposals were approved from 53 States and territories regarding use of the funds to plan new community-based facilities and services. The plans will be the basis for implementing the national mental 190 Department of Health, Education, and Welfare, 1963 health program proposed by the President in a special message to the Congress on mental illness and mental retardation in February 1963. GRANT-SUPPORTED ACTIVITIES Because the causes of mental illnesses are still undiscovered, the Institute, through its grant programs, continues to support scientists from an increasingly large number of disciplines to utilize an ever wider range of approaches in investigating the various aspects of mental disorders. Schizophrenia, the major psychosis, continued to dominate the number of research projects supported. More than one- fourth of the Institute grants were made in this area. A significant accomplish¬ ment reported by grantees in 1963 was the development of a bio¬ chemical test which proved valuable as an indicator of an unidentified protein factor in schizophrenics. This protein factor may act as a regulator for complex biochemical mechanisms that control the release of energy in response to stress. The Institute’s Psychopharmacology Service Center completed a nine-hospital collaborative study of drug effectiveness in newly ad¬ mitted acute schizophrenic patients. Drugs involved were three phenothiazine derivatives and a placebo, and the study found all three drugs to be greatly superior to placebo in the treatment of the dis¬ order. Symptoms responded well to the drugs, and social behavior and self-care of the patients improved. Support by the Institute was continued in research and demon¬ stration projects designed to prove the efficacy of short-term, intensive treatment for the mentally ill within the community. These studies have shown that such treatment, although more costly on a per diem basis than treatment in a traditional mental hospital, actually proves more economical because of the shorter terms of hospitalization. Other substantive concerns of the grant programs were juvenile delinquency, alcoholism, aging, drug addiction, abnormal behavioral problems, mental retardation, and child health and development. BASIC AND CLINICAL INTRAMURAL RESEARCH While much of the Institute’s research points to genetic or bio¬ chemical causes for mental disorders, work continues in exploring environmental influences upon mental patients. Researchers, for example, found that artwork produced by the entire family of a schizophrenic patient often suggests a severe, under¬ lying disturbance of thought or perception. Thus, such disturbances — overt in the patient — may be latent or hidden in other family members. Public Health Service 191 A related study indicated that parental styles of thinking and personality functioning may be crucial factors in determining some enduring patterns of behavior in their children, emphasizing the need for further study of links between definable varieties of in¬ dividual mental disorder and family patterns. In addition, NIMH scientists, in their efforts to establish bases for widening investigations into areas of abnormality, conducted a number of projects in normal behavior, including studies of child behavior and adult reaction to stress. In the area of drug addiction, a 5 -year followup study of a group of patients discharged from the Public Health Service Hospital in Lexington, Ky., indicated the need for a systematic program of com¬ munity aftercare or supervision for treated drug addicts in view of the high iate of relapse and antisocial behavior exhibited. More than 90 percent of the group became readdicted, although increased age seemed to tend to reduce the readdiction rate. More than 70 per¬ cent had one or more arrests during the 5-year period. Work progressed on the metabolism of psychoactive drugs at the Institute’s Clinical Neuropharmacology Research Center at St. Eliza¬ beths Hospital, Washington, D.C. TRAINING In recognition of the increasing importance of providing training for personnel in all types of mental health service settings, an in-service training program was initiated in mental hospitals, centering first on grant support for the training of psychiatric aides. Grants were provided for clinical and research training in the basic mental health professions ; relevant research training in the biological and social sciences ; mental health training in schools of public health ; pilot projects in incorporating mental health concepts in the training of lawyers, educators, clergymen, and other groups, and in special areas such as aging, mental retardation, and juvenile delinquency; psychiatric training for general practitioners; integration of the be¬ havioral sciences into medical education; and special projects to support conferences, institutes, workshops, and surveys relevant to mental health training. RESEARCH UTILIZATION The name of the Institute’s Community Services Branch was changed in December 1962 to the Research Utilization Branch, to reflect the increased emphasis upon application of research knowledge by State and local mental health programs in providing improved services. 192 Department of Health , Education, and Welfare, 1963 National Heart Institute Research conducted and supported by the National Heart Institute brought new basic knowledge and clinical weapons for use against cardiovascular disease, the Nation’s foremost cause of death and a major cause of disability. Advances in drug therapy contributed to the year’s progress. A number of antihypertensive drugs appear to owe their blood-pressure¬ lowering ability to their effects on the metabolism of amines, particu¬ larly that of the chemical nerve impulse transmitter, norepinephrine. One of these new drugs is alpha-methyl DOPA, developed by Merck Sharp & Dohme, which strikes at the mechanisms that maintain stores of norepinephrine at sympathetic nerve endings. In long-term clinical studies at the Heart Institute, the drug has performed impressively against hypertension, including the malignant phase of the disease. This powerful agent, with smooth action and mild tranquilizing prop¬ erties, is now on the market for use by physicians. Another blood-pressure-lowering drug found promising in clinical trials at NHI is MO-911, developed by Abbott Laboratories. This potent drug, also recently put on the market, is one of a family of compounds called monoamine oxidase inhibitors because they block the action of that enzyme, which is one largely responsible for inacti¬ vating norepinephrine and some other amines. Heart Institute studies may have solved the puzzle of why slowing the destruction of such a powerful stimulant as norepineprine should lower blood pressure. Findings indicate that certain inhibitors of nonoamine oxidase may block the release of norepinephrine at sympathetic nerve terminals, thereby preventing the transmission of blood-vessel-constricting messages. A further group of enzyme inhibitors under evaluation were those that act on dopamine-beta-oxidase, an enzyme essential to production of norepinephrine and epinephrine. A number of such compounds were found to inhibit catechol amine synthesis in laboratory animals and, although those studied during the year were highly toxic, it is probable that inhibitors will eventually be developed suitable for clinical trial in man. NHI investigators, anticipating the need for assay techniques, devised a simple test for measuring the activity of dopamine-beta-oxidase and the effects of its inhibitors in humans. One of the most important compensatory mechnisms that help the heart to meet excessive circulatory demands imposed by such factors as exercise or stress is provided by the sympathetic nervous system. The release of norepinephrine in the heart by sympathetic nerve dis¬ charges boosts heart output by increasing heart rate and by increasing Public Health Service 193 the vigor and efficiency of heart muscle contraction. Studies carried out at the Heart Institute indicate that the heart may use either of two mechanisms to keep its sympathetic nerve terminals charged with norepinephrine. It can readily take up and store norepinephrine from the circulation. It also has all of the enzymatic machinery needed to make norepinephrine from the amino acid tyrosine. In other studies it was demonstrated that the increased heart output in severe anemia is due not only to stimulation of the heart by the autonomic nervous system but also to a drop in blood viscosity. This lowers the resistance against which the heart must pump and conse¬ quently it can pump more blood without added effort. Among technical advances was a new cardiac catheter, devised by NHI scientists, whose inner diameter expands when radiopaque sub¬ stances, blood, or other fluids are injected. The catheter permits the injection of large fluid volumes under low pressure while eliminating the difficulties and hazards that might attend the passage and posi¬ tioning of large conventional catheters. GRANT-SUPPORTED RESEARCH Although much circumstantial evidence has accumulated indicating that diet and dietary habits may be related to the development and progression of atherosclerosis and its complications, the hypothesis that modification of diet can reduce the incidence of coronary heart disease has not been proved. To confirm or disprove this would re¬ quire a long-term population study involving thousands of partici¬ pants whose diet could be controlled. In order to determine the feasi¬ bility of conducting such an investigation, short-term, small-group cooperative studies were begun during the year by investigators at medical centers in six U.S. cities — Baltimore, Boston, Chicago, Cleve¬ land, Minneapolis, and Oakland, Calif. Research which seeks safe, effective ways of lowering blood choles¬ terol has been stimulated because of the associative evidence linking high cholesterol levels with atherosclerosis. Encouraging results from the dietary approach were obtained by investigators at the Cleveland Clinic Foundation, who placed 25 young married couples for a 10-month period on a diet consisting of a variety of commer¬ cially prepared, fat-modified foods. The altered foods were low in saturated fat, with polyunsaturated oils replacing the deleted fats in many instances. The scientists reported that greatly lowered choles¬ terol levels can be obtained with suitably modified, palatable foods supplied within a balanced diet. Another approach has been to block the manufacture of cholesterol within the body. In animal studies at the Scripps Clinic and Re- 194 Department of Health , Education, and Welfare, 1963 search Foundation, La Jolla, Calif., a liver enzyme, hepatocatalase, was shown to limit cholesterol synthesis without toxic effects or con¬ comitant blocking of other substances needed for normal body metab¬ olism. More extensive investigation will be needed, however, before it can be considered for clinical trials in humans. In studies at Tulane University, it was found that hematocrit read¬ ings, which give the percentage of blood occupied by the blood cells, were consistently higher in heart attack victims than in others of the same ages and similar backgrounds. The scientists concluded that red-cell concentration may significantly influence coronary blood flow. They also reported that reduction of hematocrit by small bleedings was helpful in relief of anginal pain. At the University of Louisville, investigators found measurable quantities of vasculokinase, an enzyme capable of clotting fibrinogen, in the aorta or in its direct branches, including the coronary arteries. Highest concentrations were generally found in those vessels having the greatest number and extent of atherosclerotic lesions. Many complications from use of the heart-lung machine to sustain circulation during heart surgery have been traced to physiologic changes caused by large quantities of blood used to prime the machine. Investigators at Baylor University reported during the year that a 5- percent glucose solution in distilled water can readily substitute for the pooled blood. A technique called synchronized arterial counterpulsation, which appears promising as a means of providing assistance to the heart during the acute stage of heart attacks or during heart failure, was devised by scientists of Peter Bent Brigham Hospital and Harvard University. Their experiments indicate that counterpulsation makes it possible to maintain, or even increase, coronary and systemic blood flow while substantially reducing the workload of the heart. Institute of Arthritis and Metabolic Diseases One of the research goals of this Institute is to find the basic causes of rheumatoid arthritis in order to prevent the disorder and not merely treat its symptoms. With this in mind, the question of the role of autoimmunity in the causation of this form of arthritis is receiving vigorous research attention. During the past year, con¬ tinuing studies yielded essential knowledge of the immunological mechanisms which may be involved in rheumatoid arthritis. Some progress has been made in the further understanding of the “rheuma¬ toid factors” found in the blood of many patients with this disease. It now appears that the rheumatoid factors are large, hitherto un- Public Health Service 195 known antibodies which have been produced by the body as part of its defense mechanism. The rheumatoid factors behave like auto- antibodies in that they react with a certain fraction of the patient’s own gamma globulin, possibly because that gamma globulin has un¬ dergone some alteration that has made it antigenic. The nature of this “alteration,” which could be the aftermath of an infectious proc¬ ess, the result of hereditary factors, or a combination of both, is yet unknown and subject to current investigation. Research concerning possible genetic aspects of rheumatoid arthri¬ tis has resulted in considerable evidence that a hereditary predis¬ position, previously suspected, is not active in this disease. These results were obtained by Institute scientists who conducted a thorough medical survey of two American Indian tribes in two highly distinct climatic and environmental settings, Arizona and Montana. Equally important as the new knowledge gained relating to the basic causes of rheumatoid arthritis are the clinical studies which have resulted in immediate and encouraging treatment for a variety of rheumatic diseases. Continued use and evaluation of amethopterin (methotrexate) for psoriatic arthritis have indicated the effectiveness of this drug, although further investigation of its toxic effects is warranted. A working hypothesis of what may cause marginal bony spurs in another form of arthritis, osteoarthritis, has been reported by Insti¬ tute-supported scientists. This preliminary study has suggested that long-term chemical inflammation caused by cartilage debris may play an important role in formation of bony spurs and other peripheral joint changes. Other significant findings involve osteoporosis, a common bone¬ thinning disease characterized by demineralization, and weakening of the skeleton. A scientist supported by the Institute has successfully used processed cow cortical bone as a substitute for metal pins in re¬ pairing osteoporotic hip fractures. Advancements in basic research on diabetes have been promising. One study this past year has resulted in isolation of a chemically dis¬ tinct, insulinlike factor which is produced by working muscles. F urther studies of this factor may provide answers as to how exercise helps in the suppression of high blood-sugar levels of diabetes. Sig¬ nificant clinical studies in diabetes have centered around improvement of tests to detect the potential, latent diabetic patient before any overt signs of the disease appear. A new oral tolbutamide glucose tolerance test has also been developed, and the simplicity and accuracy of the method warrant its inclusion among diagnostic aids now used in de¬ tecting diabetes. 196 Department of Health , Education, and Welfare, 1963 Institute progress in the field of diabetes also includes a major achievement in scientific communication. Diabetes scientists and electronic documentation specialists supported by the Institute have prepared a bibliography of more than 2,500 recent diabetes-related articles. This bibliography represents the first concrete product of research on an electronic diabetes literature storage and retrieval sys¬ tem which is intended to serve all scientists engaged in diabetes research. Probably one of the most significant developments in clinical medi¬ cine has been the development and perfection of a new, successful technique permitting the repeated and frequent use of artificial kidney machines in patients who have permanently lost their kidney function. Among clinical advances in gastroenterology supported by the Insti¬ tute was the use of a “freezing technique” to heal duodenal ulcers, now undergoing further clinical trials. Other Institute-supported scien¬ tists have found that resistance to peptic ulcers can be established in animals by excision and subsequent reimplantation of their stomachs. This resistance is apparently due to the inability of the transplanted stomachs to secrete more than negligible amounts of pepsin, an enzyme believed necessary to the production of ulcers. A striking general clinical implication of this work is that in the future surgeons may be able to remove an organ, treat it outside of the body, and then return it to its host. Outstanding findings at the basic research level included such dis¬ coveries as the findings by Institute scientists which indicated that the genetic code (carried by the nucleic acids DNA, ENA) may apply to all forms of life, from microscopic organisms to mammals. In a re¬ lated study of great significance to medical genetics, Institute-sup¬ ported scientists reported the first partial synthesis of ENase, an important enzyme which breaks down ENA, genetic messenger mate¬ rial found in all cells. They have also found that the synthesized fragment showed 70 percent of the activity of the natural enzyme, thus supplying long-sought information on the enzyme’s “active site,” that part which holds the key to its function. Institute of Neurological Diseases and Blindness Eesearch programs forged ahead toward discovering cause, pre¬ venting disability, and improving treatment for a wide variety of neurological and sensory disorders which comprise the largest area of permanent disability in the Nation. Public Health Service 197 DISORDERS OF INFANCY AND CHILDHOOD One of every 16 babies born now has some neurological or sensory disorder. New insights into causes of such birth defects during the perinatal period, from conception through the first month of life, are being uncovered by the Institute’s nationwide study of 50,000 pregnant women and their offspring. By June 1963 more than 36,000 of this number had been enrolled by the 15 medical research teams participat¬ ing in the study. Near the end of fiscal year 1963 the Institute reported its first de¬ tailed analysis of voluminous data being gathered in the study. These data are supplying critical information on a wide range of factors bearing on pregnancy outcome. F or example : Blood serum findings from the collaborative perinatal project indi¬ cate that many women who believe themselves to be immune to rubella (German measles) have a hidden susceptibility. At present, gamma globulin injections offer some safeguard to women after exposure in early pregnancy to the rubella virus, which can severely damage the developing fetus. Last year, Institute scientists helped isolate and cultivate the rubella virus. This achievement now makes it possible to test and choose gamma globulin with the highest antibody levels to assure the best possible maternal protection. The next essential step, now underway, is a preventive vaccine to provide immunity for women to German measles during pregnancy. Research findings also suggest that many cases of mental retarda¬ tion may be avoided by revising present standard test levels relied on to determine the need for blood transfusions in newborns with jaundice. PRIMATE RESEARCH IN PUERTO RICO The Institute’s unique primate facility, the Laboratory of Peri¬ natal Physiology in Puerto Rico, also added valuable information on events and circumstances occurring during the perinatal period which affect pregnancy outcome. The Laboratory’s important re¬ search focus on asphyxia, a key factor in damage to the developing brain, is helping to shed light on ways by which injury to the brain caused by lack of oxygen may be lessened. Using intravenous injec¬ tions of glucose and sodium carbonate, certain changes in the blood caused by asphyxia have been minimized and the damage lessened. MULTIPLE SCLEROSIS, MUSCULAR AND NEUROMUSCULAR DISEASES, EPILEPSY A hidden virus infection is suspected as a triggering mechanism for the autoimmune state in multiple sclerosis which robs nerve fibers of their protective covering, myelin. Thus, a target for research is 198 Department of Health , Education , and Welfare , 1963 the detection of chronic and latent virus diseases of the central nervous system. This year the Institute, in collaboration with the Department of Interior’s Patuxent Wildlife Research Center, started a new pro¬ gram to isolate viruses capable of lingering in the nervous system of animals over months or years and slowly leading to progressive neurological damage. From these studies, which will utilize special resources of the Fish and Wildlife Service, may come clues to latent infectious agents that could be causing such human diseases as mul¬ tiple sclerosis, amyotrophic lateral sclerosis (also a demyelinating disorder), chronic epidemic encephalitis (a form of Parkinsonism), Kuru (a mysterious disease among natives of New Guinea), and cer¬ tain forms of epilepsy in childhood. The attack continued on muscular dystrophy (MD) and related conditions involving the progressive destruction of muscle tissue. Institute scientists have identified three never-bef ore- described forms of MD. Recognition of these special forms increases the chances for developing specific therapies. Most persons with epilepsy, one of mankind’s oldest diseases, can now have their seizures controlled. But knowledge of the mecha¬ nisms responsible for seizures is still not fully understood. A clue was found to the mechanism through which accidental injury of the brain or disease may lead to a seizure state. Also, new information was uncovered on the possible genetic origin of petit mal epilepsy in childhood. VISION, HEARING, SPEECH The research fight against blinding eye diseases continued to pro¬ gress. Research produced evidence that the antimalarial drug, chloroquine, may cause retinal degeneration, and that cortisone and its derivatives, in large doses, can cause cataract and glaucoma. A new antibiotic, spiramycin, proved successful in treating certain types of eye inflammations. Diagnosis and control of glaucoma were aided by the finding that intraocular pressure normally varies throughout the day, with the highest pressure usually in the morning. Treat¬ ment of retinal detachment by injection of liquid silicone into the vitreous chamber brought marked improvement in previously untreat- able cases. Surgical measures, electronic techniques, and improved diagnostic tests are helping many people overcome hearing and speech handi¬ caps. But present knowledge must be unified, and more trained manpower is needed, to bring these research benefits to millions of afflicted adults and childen. Of special urgency is the need for Public Health Service 199 trained specialists to detect impairments of speech, hearing, and lan¬ guage development in early childhood, so that remedial treatment can start before more severe problems set in. Also, hundreds of new investigators are required to widen basic discoveries about the mecha¬ nisms of hearing, speech, and language. In view of these critical needs, the Institute stepped up its support of the training of qualified investigators. NERVE REGENERATION A hopeful step was taken toward solving the problem of nerve regeneration, still one of medicine’s deepest challenges. An Insti¬ tute grantee disclosed that it is now possible to transplant nerves more than 5 inches in length in an arm or leg and establish normal function. A nerve bank wTas started and a process of irradiation developed to prevent an autoimmune reaction to the nerve trans¬ plant. These advances should be particularly useful in accident cases. National Institute of Allergy and Infectious Diseases The National Institute of Allergy and Infectious Diseases has as its aim the improvement of health through research into viral, aller¬ gic, parasitic, bacterial, rickettsial, and fungal diseases. This research involves intramural programs, carried out in laboratories at Bethesda and in the field, and extramural programs, conducted through some 2,000 research grants. In addition, a collaborative program, bring¬ ing together resources from the Government, universities, and indus¬ try, provides for the development and production of vaccines and virus reagents. THE INTRAMURAL PROGRAM Research in viral diseases progressed. Extensive studies were con¬ ducted on cancer-causing viruses and the extent to which viruses are involved in neurologic diseases, heart ailments, and other areas of causation and complication. Research in the biochemistry of viral replication was directed at growth-control mechanisms involving the problem of the roles of RNA and DNA. Important studies on viruses were conducted in the field : at the Rocky Mountain Laboratory, on scrapie and other virus infections of animals and on rabies in bats; at the Middle America Research Unit, on the arborviruses and Boliv¬ ian hemorrhagic fever. Institute scientists moved closer to the prevention in man of most of the bronchopneumonia of Mycoplasma pneumoniae , formerly known as “Eaton agent.” Isolation and identification of the organism made 200 Department of Health, Education, and Welfare, 1963 possible the production of a live attenuated vaccine, and work pro¬ gressed on the development of a killed vaccine. To conduct its work in immunology, which holds the key to allergy, the Institute recruited one of the world’s foremost immunologists. Institute parasitologists demonstrated that a new antimalarial drug (CI-501), developed by the pharmaceutical industry, offers protection for 1 year or longer against infection from malarious mosquitoes — a finding that is particularly timely, for there is mounting evidence of widespread malaria-parasite resistance to commonly used antimalarial drugs. Institute scientists also carried on research in simian malaria and in schistosomiasis, a parasitic disease of worldwide importance. Advances were also made in studies of bacterial, rickettsial, and fungal diseases. During the year, the use of immunofluorescent meth¬ ods enabled the growth of the cell wall of the bacterium Streptococcus pyogenes to be observed directly for the first time. A new method of purifying pathogenic rickettsia, which gives a high yield of pure organisms, was developed at the Rocky Mountain Laboratory. Insti¬ tute researchers reported that a case of mycotic endocarditis had been cured by treatment with the antibiotic amphotericin B. THE EXTRAMURAL PROGRAM A 3-day conference on newer respiratory disease viruses was made possible by an Institute grant. The published proceedings of this conference made available a vast amount of information on the viruses associated with respiratory diseases. In other extramural activities in viral diseases, Institute grantees studied the effects of measles vaccine in children with cystic fibrosis and leukemia. The possibility of providing lifetime protection against poliomyelitis through oral vaccination of children was also investigated. In addition, Institute grants made possible the human testing of a new, improved cholera vaccine and the investigation of encephalitis in the Tampa Bay area of Florida. Fundamental research in immunology by Institute grantees con¬ tributed to a better understanding of allergic diseases, and an In¬ stitute grant provided for the continuation of clinical studies in the transplantation of human organs. In research on bacterial diseases, Institute grantees studied bacterial pathogens and antibiotics, and investigated the possible effect of urine acidity on the effectiveness of some of the newly developed antibac¬ terial agents. THE COLLABORATIVE PROGRAM Additional contracts were awarded for the development and clinical evaluation of vaccines against the viral pneumonias and other infec- Public Health Service 201 tions of the upper respiratory tract and for the production and certifi¬ cation of reference reagents for virus research. National Institute of General Medical Sciences In February 1963, the Division of General Medical Sciences was elevated to institute status. Recognition was thus given to the im¬ portant role of research and research training in the basic biomedical sciences and related natural and behavioral sciences in the under¬ standing of fundamental life processes. The programs of the Insti¬ tute are essentially not disease oriented, although the new knowledge gained in these basic sciences provides the foundation on which the main lines of research into specific disease must be based. The more applied research and research training of multicategorical interest are also supported. The operating program of the Institute is carried out by three branches : Research Grants, Research Training Grants, and Research Fellowships. Their activities include program initiation, review, award, and administration of the grant programs. A wide spectrum of research is supported by the new Institute and covers such disciplines as biomathematics, biophysics, biochemistry, genetics, pharmacology, and behavioral sciences as well as certain clinical sciences. Projects interdisciplinary in nature involve the efforts of groups of scientists collaborating in research. Many gains in basic biological knowledge were reported by grantees in the past year. Studies of the thymus gland have disclosed that this organ has an important role in immune reactions vital in rejec¬ tion of grafts, and also appears to inhibit or promote growth by adjusting the balance between two opposing substances which it pro¬ duces simultaneously. In the area of chemistry of life processes, the first total synthesis of an antibiotic of the tetracycline group was achieved by a grantee — an accomplishment which may lead to the development of greatly improved antibiotics. At the molecular level, studies of the nucleic acids are revealing the nature of mutations, DNA-RNA relationships, and the nature and function of the working mechanisms. In the clinical sciences, the use of new instruments and physical and chemical approaches to current problems are making the efforts of physicians more effective. New techniques and instrumentation are a valuable adjunct in unearthing new knowledge in the life sciences. Many Institute- supported studies involve the use of the computer in handling bio- 711-845—64 - 14 202 Department of Health , Education , and Welfare, 1963 medical information, exploring ways and means of using the com¬ puter as an adjunct to the physician in arriving at a diagnosis. Efforts are being made to stimulate research in such areas as bio- mathematics, the behavioral sciences, biomedical engineering, pharma¬ cology, molecular biology, and experimental pathology. The Research Training Grants Branch, through its graduate and undergraduate training grant programs, assists qualified institutions to provide advanced training in the basic medical and health-related sciences in order to increase the numbers of high-caliber investigators for research and academic careers in both the predoctoral and post¬ doctoral categories. The Branch administers the medical student research training pro¬ gram, the experimental research training program, and the graduate research training program. The medical student research training program serves the basic need for early selection of promising medical students interested in research, and encourages their training in natural science disciplines. The experimental research training program supports, in carefully selected liberal arts colleges, a limited number of projects for experi¬ mental research training at the undergraduate level. The graduate research training program supports both disciplinary and multidisciplinary areas of recognized importance to basic biologi¬ cal and medical research and research training. The disciplines re¬ ceiving support include the anatomical, behavioral, and biophysical sciences, anesthesiology, medicinal chemistry and biochemistry, bio¬ medical engineering, biometry, biomathematics, epidemiology, genet¬ ics, microbiology, nutrition, pathology, pharmacology, physiology, toxicology, and selected clinical research areas. The Research Fellowship Branch supports the further training of competent scholars, thereby increasing the supply of qualified in¬ vestigators, and providing stable career opportunities for scientists of superior potential and capability. This Branch administers predoc¬ toral fellowships awarded to qualified persons with a bachelor’s de¬ gree or equivalent training ; postdoctoral fellowships to those with doc¬ toral degrees; and special fellowships for additional advanced or specialized training. This program includes career awards and de¬ velopment awards for investigators of demonstrated accomplishment and capabilities. The Program Analysis Branch, the fourth component of NTGMS, offers advice and analytical information on the scientific program of the Institute. The Branch has made available a three-volume set of lists of active research grants of the Institute. Data-processing meth¬ ods will be extended to the research training and fellowships programs. Public Health Service 203 Later expansion will permit classifying grants so that information on program needs may be made readily available for a variety of uses by the professional staff. National Institute of Dental Research Dental research is broadening and deepening as the horizons of dentistry, once more or less limited to the oral cavity, have extended to encompass an important share of the biomedical scene. Through increasingly profound research in the fundamental life sciences, the dental profession is reaching toward an understanding of disease processes and of the mechanisms through which they are produced. By means of highly sophisticated techniques, including electron and neutron diffraction, electron microscopy, amino acid analysis, germfree animal research, cinefluorograpliy, and chromosome studies, Institute scientists are probing the structure of tissues, the maturation of collagen, and the processes of development of oral tissues. This year the crystallograpliers have found that fluoride renders the crystals of bone larger and more perfect, tending toward greater strength and stability. We have, thus, for the first time acquired some knowledge of the way in which fluoride affects biological mineral. This may be of considerable importance, not only to the teeth of the young, but to the bones of the aged. Institute scientists have in the past identified the bacterial factors which produce tooth decay in animals. This year their research has identified an organism which produces periodontal disease in hamsters ; an L-form of bacteria which produces canker sores in man; and a varied pattern of virus infection which produces herpes simplex. All of the dental schools in the country and many of the universities and hospitals conduct active research under Dental Institute awards. These institutions also have extensive grants for the training of dental research manpower. Studies in tooth transplantation, nutrition, restorative materials, and instrumentation parallel basic investigations in the biology of mineralized tissue, genetics, immunology, metallurgy, and anthro¬ pology. In the past year several multidisciplinary research centers have been established to bring a variety of research skills to bear on the problem of cleft palate. In our population, 90 percent suffer from tooth decay and almost all over the age of 40 have lost teeth as a result of periodontal disease. These facts alone constitute sufficient stimulus to the research which seeks answers to painful and expensive dental problems. 204 Department of Health , Education, and Welfare, 1963 National Institute of Child Health and Human Development During the last 5 months of the fiscal year, the National Institute of Child Health and Human Development reached operational status. It is the first entirely new institute to be established since 1955 as part of the National Institutes of Health. This rapid implementation of authorizing legislation added a new dimension to the potential of NIH by making possible nondisease- oriented research emphasis in several health-related areas. Priorities were assigned by the Institute for research and training to focus on normal physical and intellectual development, including some aspects of prenatal life, obstetrics and infant-mother relationships, the aging process, the continuum of life, special health problems such as mental retardation, the development of behavioral problems, and other processes. Staffing and administrative processing were completed preliminary to beginning support of extramural research and training and to under¬ taking intramural and collaborative research on a variety of problems of pressing professional and public concern. Need for more research was underscored by events during the year, including discovery of the effects of the drug thalidomide in congenital malformations, new at¬ tention to problems of population control, intensified interest in pre¬ maturity and respiratory distress syndrome of the newborn, an out¬ break of “crib deaths” in Philadelphia, and consideration of legislation authorizing new centers for research on mental retardation. Division of Biologies Standards This Division is responsible for the control of all biological products used for the prevention and cure of disease in man. These products — vaccines, antitoxins, therapeutic serums, and human blood and its derivatives — are developed from potentially pathogenic micro-orga¬ nisms. Rigorous control procedures are essential in their preparation to reduce to a minimum the hazards which might occur in processing, and to insure final products of satisfactory potency. Effective administration of these responsibilities requires the de¬ sign and development, within a research context, of adequate and prac¬ tical standards for the production and testing of biologies, careful surveillance of production methods, and the continuous improvement of testing procedures. Much of the Division’s work has been concerned with development of testing methods for exclusion of simian agent, SV-40, from monkey Public Health Service 205 kidney tissue-culture preparations. Chick embryo tissue culture, used for propagation of measles virus, presents a similar challenge, since a number of adventitious viruses are known to be present in fowls, and experience with this type of tissue culture is relatively limited. The development by the Division of a continuous line derived from cercopithecus monkey cells is one approach to testing for adventitious viruses. The cell line, now in its 125th passage, remains sensitive to SV-40, and its susceptibility to other viruses indicates that it can be used to test for a variety of viral agents. The Division recently completed a study in Upper Volta, West Africa, which added materially to knowledge of the use of live, at¬ tenuated measles vaccine. More than 750,000 Volta children, despite their different environment and greater vulnerability to natural measles, responded favorably to live measles vaccine. Broad-based research directed toward improvement of testing pro¬ cedures for control of blood products has continued. These studies include research on freezing, storage at various low temperatures, and thawing and drying of the many elements of whole blood and protein fractions of plasma. Division of Research Facilities and Resources Established in July 1962, the Division of Research Facilities and Resources provides for the first time a focal point at NIH for co¬ ordinating and administering grants of primary institutional signifi¬ cance by bringing together into one unit five programs previously dis¬ persed throughout NIH. The five programs are: Health research facilities, general clinical research centers, general research support, special research resources, and regional primate research centers. A consulting Architectural and Engineering Office was established in the Division to assist institutions with plans for health research facilities and to provide professional review of construction and renovation plans submitted as a part of grant applications. Two out¬ standing awards made by the special research resources program were a contract for the first national enzyme center and a grant for a major, multi-institutional center for computer technology and research in bio¬ medical sciences, also the first of its kind in this country. With the first regional primate research center already operating in Oregon, ground was broken for similar centers in Washington and Wisconsin. General-research support grants, previously limited to schools of medicine, dentistry, osteopathy, and public health, extended eligibility to schools of pharmacy and veterinary medicine, hospitals, and other nonprofit research organizations. The health research facilities pro- 206 Department of Health , Education , and Welfare , 1963 gram provided more than $50 million for 178 projects, mostly new construction, in 40 States. The same law which authorized the estab¬ lishment of the Child Health Institute also extended for 3 years the research facilities construction program of title VII of the PHS Act. General clinical research center awards were made for 11 new centers and support was provided for 48 of these centers where scientists from many disciplines combine research, teaching, and treatment. Division of Research Grants The Division of Research Grants continued to perform its many central functions for the extramural research program of the Public Health Service. These functions included management of the process of technical review by outside consultants of research grant and fel¬ lowship applications ; central business management services for most of the agency’s research grant program ; and a wide variety of process¬ ing, statistical, information, and other services. In response to one of the most serious of the Service’s personnel problems, that of recruitment and training of scientist-administrators for staff positions in institute and division grants branches and for its own staff, the Division organized and launched a grants associate program, offering a year of training divided among PHS institutes and divisions, and including courses in public administration. At the close of the fiscal year, 10 grants associates were in training. The Division experienced a substantial increase in its responsibility for coordination of policies and procedures among the 22 PHS divi¬ sions awarding grants. Its Policy and Procedure Office, established in March of 1962, served as the focus for development and issuance of grant policy and procedure. A major contribution of the Division was the Public Health Service Manual on Research Grants , published in November of 1962. The manual, representing the efforts of a task force, presents in concise form the entire body of grant policy so far developed, and serves as a valuable administrative guide both in grantee institutions and within the Service. A companion volume on training grants was nearing publication at the close of the fiscal year. The Division issued its second annual Research Grants Index , a publication offering quick reference to the scientific subject matter of the Service’s approximately 15,000 active research grants. The 1,450-page volume contains appendixes giving names, addresses, and recent publications of grantees, listing principal and co-investigators alphabetically, and categorizing PHS grants into broad research areas. The index is unique in providing reference to work in progress rather Public Health Service 207 than to research papers whose appearance in journals may be delayed by as much as a year and a half after the work has been completed. To maintain its high standards of scientific review, the Division added a new study section to its Research Grants Review Branch, bringing the total to 46. The study sections, whose primary function is technical review of applications, have also continued to sponsor meetings and seminars for exchange and publication of information on specific health problems. Division of Research Services The Division of Research Services provides facilities, equipment, and a wide variety of scientific and technical services needed by medical investigators and research administrators at NIH. During fiscal 1963, the Division’s computer capacity was doubled, and a team of specialists from the National Bureau of Standards began an intensive study of the optimum long-range computer configuration for NIH. Construction of permanent facilities at the NIH Animal Center was begun in the spring of 1963. Meanwhile, quarantine activities for large animals were carried out at the Center during the past year in existing structures. The Library was recently reorganized as a means of streamlining traditional library functions and of providing the framework for a bibliographical service commensurate with the extensive and pressing needs of NIH investigators. Clinical Center The new four-story surgical wing of the Clinical Center opened this year, with the first heart surgery for the correction of vascular and valvular defects taking place in June, followed by neurosurgery, in¬ cluding brain operations for relief of epilepsy. The new wing serves the Cardiac Surgery Branch of the National Heart Institute and the Surgical Neurology Branch of the National Institute of Neurological Diseases and Blindness. The addition, with its comprehensive sys¬ tems for monitoring and recording physiological data from patients, and with a method for air hygiene that literally washes operating areas in ultrapure air, will not only enable surgeons to provide the most advanced surgical care for Clinical Center patients, but should also serve as a proving ground for innovations of potential value to surgical patients throughout the Nation. Relocation of the Clinical Center blood bank affords some 1,000 square feet of additional space for a more active blood-donor program 208 Department of Health, Education, and Welfare, 1963 and for plasmapheresis procedures for the supportive treatment of children with leukemia. Approximately 4,000 research patients were admitted to the Clinical Center during the fiscal year, and followup visits increased to about 40,000. Table 1. — Statement of appropriations, authorizations, and obligations, fiscal year 1963 [In thousands] Appropriation Funds available for obligation Appropria¬ tions and authoriza¬ tions Net transfers between appro¬ priations Repay¬ ments for Prior year unobli¬ gated services balances Total funds available Total _ Appropriation, PHS. $1, 593, 266 1, 592, 726 Building and facilities _ Accident prevention _ Chronic disease and health of the aged _ Communicable disease activities — Communicable disease activities (1963-64) _ Community health practice and research _ Control of tuberculosis _ Control of venereal diseases - Dental services and resources - Nursing services and resources - Hospital construction activities (1963) _ Hospital construction activities (1963-64) _ _ _ Hospital construction activities 1962-63) - - Air pollution _ Milk, food, interstate, and com¬ munity sanitation - Occupational health - Radiological health - Water supply and water-pollution control - - Grants for waste-treatment works contruction - Hospitals and medical care - Foreign quarantine activities - Foreign quarantine activities (1962- 63) _ Indian health activities - Construction of Indian health facili¬ ties _ ---- General research and services, NIH. National Cancer Institue (1963) - National Cancer Institute (1961-63). Mental health activities - National Heart Institute (1963) - National Heart Institute (1962-63).. National Institute of Dental Re¬ search _ Arthritis and metabolic disease ac¬ tivities — Allergy and infectious disease ac¬ tivities (1963) - Allergy and infectious disease ac¬ tivities (1962-63) - - - Neurology and blindness activities.. Grants for construction of health research facilities _ Scientific activities overseas (special foreign-currency program) - National health statistics - 33, 200 3, 664 22, 936 10, 192 8,700 26, 520 6, 993 8, 000 2,999 8, 437 6, 214 220, 000 11, 065 8, 530 4,121 15, 825 24, 668 90, 000 48,820 5, 910 56, 391 9, 335 159, 703 155, 697 143, 578 147, 374 21, 199 103, 388 66, 137 83, 472 50, 000 2, 800 5, 149 $91, 168 $229, 816 $2, 140, 207 91, 168 229, 494 1, 913, 388 23 62 1,319 +187 275 25 995 641 7,456 367 667 312 35 21, 086 146, 879 22, 649 171 5,765 ’""307 ,000 92 5 8,765 54, 286 3, 687 22, 998 11,511 8,700 26, 724 7, 008 8, 039 2, 999 8,443 6, 214 220, 000 146, 879 11, 074 8, 805 4, 146 16, 820 25,309 112, 649 56, 276 6, 277 171 57, 058 15, 100 160, 015 155, 732 307 143, 676 147, 375 1,000 21,199 103, 477 66, 175 92 83,472 50, 005 11, 565 5, 529 Amounts obligated $1, 653. 814 1, 553, 502 6, 750 3, 661 20, 854 11, 496 244 26, 486 6,979 8, 009 2, 975 8,420 6, 189 65,334 146, 528 11, 041 8, 753 4,122 16, 366 24, 875 93, 349 56, 222 6,256 120 56, 701 7.461 139, 748 132, 799 42 140, 011 120, 342 257 20, 139 95, 603 63,953 78 74, 830 50, 002 3,895 5,520 Public Health Service 209 Table 1. — Statement of appropriations , authorizations , and obligations, fiscal year 1963 — Continued Funds available for obligation Appropriation Appropria¬ tions and authoriza¬ tions Net transfers between appro¬ priations Repay¬ ments for services Prior year unobli¬ gated balances Total funds available Amounts obligated National Library of Medicine - Retired pay of commissioned offi¬ cers _ Emergency health activities _ Salaries and expenses, Office of Sur¬ geon General _ Construction of mental health, neu¬ rology research facility - Bureau of State Services manage¬ ment fund - National Institutes of Health man- agement fund _ Consolidated working fund, HEW, grants for research - General research support grants, NIH _ Consolidated working fund, HEW, PHS _ Consolidated working fund, HEW, PHS _ $3. 335 5,526 7, 000 5, 848 -$187 $13 ”§2" 579 $10,903 Appropriations, special proj¬ ect funds made available by other agencies _ Public works acceleration, executive (transfer to HEW, PHS) (1963- 64) _ Public works acceleration, executive (transfer to HEW, PHS) - - Salaries and expenses, Bureau of Prisons (transfer to HEW, PHS) American Sections, International Commissions, State (transfer to HEW, PHS) _ Salaries and expenses, Office of Emergency Planning (transfer to HEW, PHS) _ Research and development. Office of Emergency Planning (transfer to HEW, PHS) _ Farm labor supply revolving fund, Bureau of Employment Security (transfer to HEW, PHS) _ Inter- American social and economic cooperation program, executive (transfer to HEW) _ Assistance to refugees in the United States, Office of the Commis¬ sioner, Social Security Adminis¬ tration _ _ Administrative expenses, economic assistance, executive (transfer to HEW) _ Development grants economic as¬ sistance, executive (transfer to HEW) _ Development grants economic as¬ sistance, executive (transfer to HEW) _ Supporting assistance, economic assistance, executive (transfer to HEW) _ Alliance for progress development grants economic, executive (trans¬ fer to HEW) _ Alliance for progress development grants economic, executive (trans¬ fer to HEW) _ _ 11, 722 6, 267 39, 923 116 30, 000 1,219 150 150 $3, 348 5, 526 17, 935 6, 240 11, 722 6, 267 39, 923 266 30, 000 1,219 150 225, 957 125, 600 92, 790 2, 580 $3, 334 5,526 15, 584 6, 125 43 6, 224 38, 887 137 30, 000 1,186 46 99, 778 372 92, 714 2. 577 20 350 329 632 472 1,131 1,131 40 39 1,628 1,301 200 174 624 378 70 27 175 143 Does not include $258,000 to be deap propria ted . 210 Department of Health , Education , and Welfare , 1963 Table 1. — Statement of appropriations , authorizations , and obligations , fiscal year 1963 — Continued Funds available for obligation Appropriation Appropria¬ tions and authoriza¬ tions Net transfers between appro¬ priations Repay¬ ments for services Prior year unobli¬ gated balances Total funds available Amounts obligated Military assistance, executive (transfer to HEW) _ $21 $9 Gift funds donated for general and specific. purposes $539. 6 $322. 7 862.3 534.2 Contributions, Indian health facili¬ ties . _ _ 279.8 184.3 464.1 339.7 Public Health Service uncondi¬ tional gift fund . _ _ _ 35.3 40.2 75.5 4.4 Public Health Service conditional gift fund _ _ 49.4 9.6 59.0 31.6 Patients’ benefit fund, Public Health Service hospitals - _ 40.8 15.8 56.6 37.9 Special statistical work, vital sta¬ tistics _ 134.3 72.8 207.1 120.6 Table 2. — PHS total paid employment by bureau and division , as of June 30, 1963 Public Health Service 211 C/D T3 +3 Is! CO ‘O N N rH CO H Pm o •c . Ot3 <3 8> *-< CM CO 05 cd CM co CO —I l|a. infs t> g a o !S85 iOOOOhiO 'COOiOMNNOO^COOOOCl 'C0-^»0 00 00»HIO^ HH ■ODOO^CI ' *0 *0 lO CM GO *0 CD O CM CM ^ CO ^ 00 CO CD CO r-H »H |H CM > 05 0© CM 00 ^ CO *“< C )'^»CC0CX>*-H»O^iO’- )COCO^CON^O» ' 05 ‘O CM 00 05 ^ CO 00 ^ CO CD CO CO *— « »— < t''- CM 1 CO 05 CM 00 O CM CO *— < CD CM 'CO»O»OCX)00CMCD^fcO'" < *-* CO • iHiHiOOONOC^O • O CD 05 CD 00 f-H 05 NO JJ^CM CO O CO GO ^ 05 rHHNCM 3 £ 3-3 a> o Sg pO C3 c3 o ' = "3 o o ,C ’® > c * ® n a h J ! © e.H'o 3 g| gasses > O CL, CJ O ^ ° o o ® OO 0,3 OfL, 5 o o § o o*o o q §,“J2'C PQ a222o3lgg.2.2'3'3© ©5 SQQfiOOOO^rtPQO is o a3 *5§ “ aC5 i'ISSll WKoo § § 2 “p.” § 2 2° * 5o°o°oooo g jo OT J21 53 —c — i o> >§ OQQO Table 2. — PHS total paid employment by bureau and division , as of June 30, 1963 — Continued 212 Department of Health, Education, and Welfare, 1963 Table 3. — PHS total paid employment by bureau , commissioned officers, and civil service, as of June 30, 1963 Public Health Service 213 Table 5. — Payments to States or localities within States for public health services , fiscal year 1963 1 214 Department of Health, Education, and Welfare, 1963 Radio¬ logical health $1, 394 co»o ooio HO ho*— cmcoo5»olo r-ioaor^io HHH CO CO H H ^ CM H CS H H CM ^ CM CM CO H CO HW CO H Public works acceler¬ ation $219 Zf 96 59 Waste treatment works construction $51, 738 inN'fNN TfMOHOl NiHIONN 05 05 05 t- 00 ONOffliO — . <-> _ tn C*5 CO C«5 CM CM OOiClNOO (OHt-NN OlONtDN COiOOO(OH (NHNNN CO 05 £h 5 CD oh^oin n®»u5h c5Tpiptvp CO 00 O Tp CM CM tv O CO CM Cffl 0500TPC005 H 50 tv vp tv ©id-no 05 tv. CO 00 CO OtPhhH OOOOffiffl T-H CO r-H t— 1 CM 1-H 1-H 1— 1 CM 1-H 1— 1 i— 1 Tp T—t Cancer control 00 CO co 0005^^ ^ O CO CO O ^CONHCM CM kO 05 CO COCMI-^IOCO lOiOOCOT^ *Ot^Tt«COt^. CM ^ ^ CO CO CM CM 05 00 CM CM CO CO ^ CO CM *0 05 CM ^ CO 00 CM CO CM 05 CM 00 05 CM Mental health <$6,716 m^hO»o Tt