Families with annual incomes under $1,000 is more than four times that in the 53,000 income group. Even such diverse conditions as varicose veins, diabetes, lindness, and deafness show disability rates from two to four times higher in the How-income group than in the highest-income group.

Acute conditions also-accidents, pneumonia, and other respiratory diseasesshow considerable excesses in the low-income brackets over the rates for the highest-income level. For example, the home accident rate among the poorest families studied in the National Health Survey was nearly 40 percent higher than in families with incomes of $2,000 and over. Presumably housing conditions among the poorest are responsible for some of the excess.

TUBERCULOSIS AND PNEUMONIA

From the beginning of our modern knowledge of the disease, tuberculosis has been recognized as primarily a disease of the poor. As a cause of death it has been reduced nationally during the present century from first to seventh place; but when we look behind the national average, we find that tuberculosis mortality is much higher in low-income groups. In 1930 it was found that the death rate from tuberculosis among unskilled laborers was seven times that of professional men. In 1943 the tuberculosis death rate among Negroes-who are predominantly in the lowest-income groups-was three and a half times that among whites of all income groups. The National Health Survey also revealed that tuberculosis caused four times as much disability among families with annual incomes under $1,000 as among those with $3,000 or more. Among families on relief, the excess was nearly nine times.

Pneumonia also is an important cause of death; death rates from this cause have been reduced dramatically since 1937, when treatment with sulfa drugs was introduced. However, there probably has been no change in the proportionate rates among various income groups. Earlier studies show that the pneumonia death rate among unskilled workers was three and a half times that among professional people; and that time loss due to pneumonia was 20 percent higher in lowest-income groups than in the upper brackets. Even a 20-percent excess of disability from this cause is significant, since doubtless it reflects the results of poor environment and inability to obtain prompt medical attention.

MATERNAL AND INFANT MORTALITY

Studies extending back as far as 1910 have emphasized the coexistence of high infant mortality with loss income. In 1928, for example, the United States Children's Bureau showed that infants of fathers whose earnings were less than $450 a year died at more than 10 times the rate of those whose fathers earned $1,250 or more.

Studies made in Cleveland, Ohio, from 1920 to 1937 reveal interesting facts. In the last year (1937), the infant mortality rate in the lowest economic groups was 50 percent higher than that in the highest levels. In Denver, Colo., in 1931, 16 in every 100 infants born in families with annual incomes of less than $500 died during the first year of life, as compared with 3 infant deaths per 100 live births among Denver families with incomes of $3,000 or more.

Infant deaths tend to be higher in the low-income States than in the more fortunate areas. In 1940 the six States with the highest infantry mortality rates were New Mexico, Arizona, South Carolina, Louisiana, Texas, and Alabamaall in the lower half of the States ranked according to per capita income.

The deaths of mothers in the child-bearing process also show a relationship with per capita income of States. In 1940 the rate for the country as a whole was 3.8 maternal deaths per 1,000 live births. Of the 15 States with rates above 4.5 per 1,000, were low-income States except Delaware and Nevada.

RECEIPT OF MEDICAL CARE

In the National Health Survey, it was found that the proportion of illnesses without medical care was about twice as high in the low as in the upper income groups. This was true in cities of all sizes, although the proportion of unattended illness was greater among all income groups under $3,000 in the small cities of 25,000 population or less.

A smaller proportion of the cases among poor families received hospital care than among the higher-income groups. Poor patients remained longer in the hospital than did the more fortunate ones. This fact indicates that conditions were allowed to become more critical among the poverty-stricken before medical attention was sought.

Private-duty nursing is almost unknown among the sick poor. Less than 3 percent of the cases were attended by a private nurse, as compared with over 16 percent in families with incomes of $5,000 and over. On the average, the few poor patients who were attended by a nurse received about half as many days of nursing care as did those in the upper income brackets. Families of low income who were not on relief in the survey year received less attention from visting nurses than did families on relief. Only 6 percent of the illnesses among families with income of less than $2,000 received visiting-nurse care, as coti pared with 12 percent among relief families.

This fact reflects the relationship between the adequacy of community provi sions for personal health service more than it indicates the relation of individual income to health. At the time of the survey, relief loads were heavy, and under. staffed services were unable to meet more than their limited statutory obligations, In 1935-36 families with annual incomes of less than $1,000 spent, on the average, less than $50 a year for their sickness costs; that is, 5 percent or less of income. These figures compare with an average annual expenditure of $900 among the richest families, or about 2 percent of income.

INCOME AND HEALTH FACILITIES BY STATES

Studies made during the war show the ratio of physicians to population in the several States, grouped according to per capita income. With few variations the States in the lowest income brackets have the larges populations per active private physician. The average physician in such States as Louisiana, Tennesse Georgia, and Arkansas, served well over 1,000 persons in 1942, before the with drawal of physicians by the armed forces had reached the peak. In North Car olina, New Mexico, South Carolina, Mississippi, and Alabama (also low income States) the ratio was over the critical line of 1 doctor per 1,500 persons. Since 1942, the situation has grown more serious in all these States where the ratio are 1 physician per 2,000 to 3,000 population. Where physicians are concer trated, there also are concentrated dentists, nurses, and general hospital beds The physician-poor States are also poor in other services and facilities essential to health.

Congress has recognized the inequality of health services in the underprivileged areas of the country and with foresight and wisdom, has enacted certain health legislation which reduces partially these inequities of opportunity. In the healt provisions of the Social Security Act (now the Public Health Service Act), the Venereal Disease Control Act of 1938, and legislation on tuberculosis contro Congress has authorized the Public Health Service to weigh grants-in-aid to favor of those States having low income and those having proportionately more severe health problems. In carrying out the intent of Congress, the Publi Health Service has found a close correlation between financial need and extent of health problems among the States. Those States which have received excel** allotments on account of low income have also received excess allotment for their intensified health problems.

From whatever standpoint one considers the health problems of the Nation the conclusion is inescapable that in the creation of a healthy and educated citizenry or in the failure to do so-economic factors are extremely importan if indeed not determining. Improvement in the economic status of the poorer families in this Nation, therefore, contributes also to the health status of the Nation. Higher wages in themselves, however, will not solve the problems of individual and public health. A national policy for a minimum wage is c tributory to health, as also are national policies for healthful housing, for i proved nutrition, for social insurance. But even these do not of themselves constitute a national health program. They must be accompanied by planned advances in the provision of complete medical and health care to all of t people in all parts of the country.

EXHIBIT 6

STATEMENT OF J. W. STUDEBAKER, COMMISSIONER, UNITED STATES OFFICE ⠀ EDUCATION, BEFORE THE SENATE COMMITTEE ON EDUCATION AND LABOR RE S. 13 A BILL PROVIDING FOR REVISION OF THE FAIR LABOR STANDARDS ACT OF 1938

The testimony which I wish to present to the committee today will be direc solely to the general question of the relationship of family income to opportu ties for schooling in the United States. That there is such a relationship has ing

As a

been evident to educators and to many citizens as they have frequently witnessed the withdrawal from school at an early age of the children of the poor. matter of fact, some 1,000,000 young people drop out of school each year. Only about one-half of those enrolled in the fifth grade will remain to be graduated from high school.

Corroborative evidence of this relationship is to be found in numerous studies which have been made of the reasons why the youth leave school. One recent summary of a number of such studies indicates that about one-third of youth who leave school do so from economic necessity (29.27 percent of school-leavers). Reasons classified in the category of economic necessity include such items as: Lack of wearing apparel, services needed at home, lack of transportation, help needed on farm, too far to walk, no money for books and clothing, family needed help financially. Other reasons for school withdrawal include: Reason for leaving:

Negative attitude toward school.

Poor individual health or physical disability.
Unfavorable home conditions___

To go to work (seemingly not under economic pressure).

Scholastic failure___.

Percentage reporting 18. 21

8.04

5. 19

15. 25

Disciplinary trouble__

Marriage____

Miscellaneous

11.29

3.6

5.5

3.6

It seems fairly obvious from this summary (which is typical of results of many studies of the reasons why youth leave school) that low family income resulting in economic pressure ranks high among such reasons.

Closely related to family income as a reason for early school-leaving is the quality of the school itself. There appears to be a reciprocal relationship between per capita income and school support and between school support and quality of educational services. This is brought out in table I which shows by States the 1940 income payments per capita in relation to the 1942 expenditures per person 5 to 20 years of age for school purposes. Although it may be granted that expenditure per pupil is not a perfect measure of the quality of educational services made available, it is at least roughly symptomatic of the quality of educational Opportunity.

Looking at table I we note that the 48 States are arranged in order of per apita income from New York, the highest with $592 per per person 5 to 20 years of age, to Mississippi, with $591 per person 5 to 20 years of age. In the second olumn appears the total current expense for public elementary and secondary ducation in 1942 per person 5 to 20 years of age. It is very clear from this table hat the States whose inhabitants have the greatest per capita income behind ach school-age child spend the most for education. Amounts spent range from 20 per person 5 to 20 years of age among States low on the list in income to over 100 per person in this age range among States at the top of the list. We also now that States at the top of the list have fewer children to educate in proporion to total population and generally have lower tax rates for the support of heir schools, despite the fact that they spend more per pupil. They have a irger percentage of school-age children in school, a higher percentage of adult teracy and fewer men disqualified for service in the armed forces by reason f their educational deficiencies. States which are rich in numbers of children at poor in income, that is without the financial resources to pay for good schools, rovide less adequate levels of expenditure for their schools, and, by and large, re thereby able to achieve less adequate educational results on tax rates which re relatively high as compared with the country as a whole."

One might summarize this income-schooling relationship by saying that, other dings being equal, the "holding power" of the school for its pupils varies directly ith the quality of the school; and the quality of the school varies directly with e expenditure for the support of schools. Financial pressure on pupils from w-income families to leave school when coupled with schools of low quality sults in curtailment of schooling for hosts of American youth.

Dailard, Ralph C., An Estimate of the Cost of Making Grades 9 through 12 of the Berican Common School Effectively Free. Birmingham, Ala.: Birmingham Printing Co., 39, p. 37. *Norton, John K., and Lawler, Eugene S., An Inventory of Public School Expenditures in e United States, a Report of the Cooperative Study of Public School Expenditures. Washgton, D. C.: American Council on Education, 1944, vol. II, p. 316.

Confirmation of the relationship of income to schooling comes from another source. Table II is taken from 1940 census data on income and educational attainment of various occupational groups. It shows that the average wage or salary income varies from $360 for farm laborers to $1,800 for persons in professional and semiprofessional categories of employment. At the same time, the average amount of education of persons in the lowest-paid occupational group mentioned above is 7.4 years, whereas the average amount of schooling of persons in the highest-paid occupational category, professional and semiprofessional workers, is more than twice as much, 15.6 years. Another tabulation made by the United States Bureau of the Census of income in relation to schooling shows that 50 percent of those persons who attended college or went beyond reached or exceeded $5,000 a year in income, whereas only 39 percent of those who attended high school and only 11 percent of those who had 8 years of education or less reached this income level in 1940.3

In summary, then, it may be said that family income is related to school attendance of children both indirectly in the level of financial support of schools as effecting the quality of schooling and the holding-power of schools and directly in the financial pressure on children in low-income families to leave school to contribute to their own support. It should be remembered that so-called free schooling is never entirely free of direct cost to the parents of school children. Not all schools provide textbooks and transportation. Additional drains upon the family income result from fees for materials or the costs of school supplies which children use. There is the expense of suitable school clothing. Again some children living in sparsely settled areas require maintenance while attending school away from home. Indeed, one prewar estimate indicated that it would have cost parents approximately $80,000,000 at that time to meet such expenses of boys and girls, who were then out of school for economic reasons, had they been returned to school.1

It would seem to me therefore that any sound measures which will have the effect of increasing the real income of lower-income families will contribute to the improvement of educational opportunities for the children who are members of these families.

TABLE I.-Income payments per person, ages 5 to 20 years, in relation to 1942 expenditures for school purposes per person, ages 5 to 20 years, by States

TABLE II.-Income and educational attainment of various occupational groups,

Source: U. S. Bureau of Census, Population-comparative occupation statistics for the United States, 1870 to 1940. 1943. P. 181.

EXHIBIT 7

STATEMENT OF T. J. WOOFTER, DIRECTOR OF RESEARCH, FEDERAL SECURITY AGENCY, FOR THE SUBCOMMITTEE ON EDUCATION AND LABOR CONSIDERING S. 1349

I do not appear as an expert in wage economics and, hence, will not attempt to appraise the technical details of the bill under consideration. I will present certain facts as to the composition of wage and salary earning families and their incomes based on recent studies. (Technical definitions of terms are given in an appendix.)

The studies were made to explore the relationships of income levels to family welfare programs. While the Federal Security Agency is not charged with making recommendations as to wage rates or with the administration of wage regulations, it is obvious that the need for asisstance varies with the level and distribution of income. On the other hand, insurance and assistance payments can in no sense be considered as substitutes for adequate and steady earnings. These studies demonstrate the desirability of a higher level of real wages than the scales of 1939, provided certain assumptions are accepted. These assumptions are as follows: First, that the optimum average size family is one large enough to maintain or slightly increase the population; second, that the average wage of a single wage earner should be adequate to support this optimum average size family; and third, that the standard of support should be one which will supply basic needs, both physical and psychological, for health, child care and development, recreation, participation in community organizations, and accumulation of savings for security.

Against these yardsticks it is possible to measure the situation with regard to family income and composition in 1940. Unless otherwise stated, the facts are based on an analysis of nonfarm families whose only income was from wages or salaries. They are from the 1940 census which enumerated income as of 1939 and family composition as of 1940.

If it is agreed that the optimum average size family should be large enough at least to maintain a level population, then we have a fairly approximate mathematical definition of this size. It requires a family of a man and wife who, before the end of the child-bearing period, would have three children. Obviously, two children who reach maturity are required to replace their parents, and more than two births are necessary to offset the deaths in the younger ages and failure on the part of others to have children.

In 1940 the actual number of children in wage or salary families was not sufficient to provide replacement of this group. In man and wife families where the male parent was 35 to 45 years of age, that is to say where most of the children had been born and few had passed the age of 18, the average number of children was just under two. This indicates a deficiency for replacement. A more exact method of determining intrinsic rate of population increase has been worked out by population analysts. It consists of calculating, by actuarial methods, the extent to which daughters replace their mothers. The ratio necessary to replace the population is scaled at 100. In 1940, by this method, the