notified to State departments of health, and evidence for the current year indicates a slight decline. TRAINING GIVEN THROUGH AID OF FEDERAL FUNDS To staff these clinics, doctors, nurses, and other technicians with special training in the treatment and control of these diseases are necessary. During the calendar year 1939 nearly 400 health officers, clinicians, practicing physicians, public health nurses, and laboratory technicians received training through the aid of Federal funds. TASK OF FINDING INFECTED INDIVIDUALS The finding of the infected individuals is a much more difficult task. It requires the services of trained personnel to locate them, and place them under treatment, and also to locate the persons whom they must have exposed to infection, the contacts, in other words. NEED FOR LABORATORIES AND LARGE EDUCATIONAL PROGRAM Laboratories, for example, must be freely available to test the large number of specimens submitted, and a large educational program is necessary, first to bring to the public the seriousness of the disase of syphilis and, second, to keep the doctor alert to the fact that his patient might be infected, when the person has symptoms not ordinarily associated with syphilis. One of the most helpful efforts made to discover venereal disease has been the recent legislation requiring premarital examinations, or for the examination of pregnant women for syphilis. One or more of these laws have been adopted in 25 States. Connecticut, the first State to pass this law in 1935, now reports a 50 percent reduction in the number of cases of congenital syphilis occurring in that State. NUMBER OF BLOOD TESTS OR PHYSICAL EXAMINATIONS GIVEN DURING FIRST 6 MONTHS OF FISCAL YEAR 1940 Further indication as to the extent of case finding work may be gained from the fact that more than 4,600,000 persons received a blood test or physical examination for syphilis during the first 6 months of the present fiscal year. This is an increase of 52 percent over last year, and compares with a total of two and a half million tested in 1936. It will be over 9,000,000 this year. IMPROVEMENT IN QUALITY AND ACCURACY OF TESTS Not only the number of tests has increased, but the quality, the curacy of these tests, has been assured through cooperative work carried out by the Public Health Service, and a distinguished committee of experts-syphilologists and the State departments of health. Now in all but three States one can be assured that the reports of the State laboratory are accurate. In past years a considerable amount of inaccuracy existed before there was a practical system of test control. IMPROVEMENT IN QUALITY OF SERVICE RENDERED BY CLINICS IN REFERENCE TO GONORRHEA Examinations for gonorrhea, as I have indicated, increased by 55 percent between the past 2 years. There is evidence as to the improvement in the quality of service in public clinics. In 1936, only 15 percent of the patients had received minimum effective treatment before they discontinued treatment. Last year in a detailed study among 500 clinics, we find that twice as many patients had received protective therapy before discontinuing treatment. Last year, for example, there were nearly 15 doses on the average of arsenical drugs administered to every new case admitted to clinics compared with only 8 doses administered in 1932. All of this I think means that the best class of work can be done, and that some progress has been made. ALLOTMENTS TO STATES DURING 1940 AND BASIS ON WHICH MADE During the fiscal year 1940, $4,379,250 was allotted to the States under the provisions of the Venereal Disease Control Act. Allocations under the law are made on the following bases. First, basis of population, 24.9 percent. Second, the extent of the venereal disease problem, or the relative prevalence of syphilis in the different States, 37.1 percent. Third, the financial need of the different States, as indicated by the per capita income, 24.9 percent. Senator LODGE. Doctor, I am a little interested in that formula. The money can be obtained on three bases. First, the basis of population. Of course, it is easy to get accurate figures on that. FIGURES ON EXTENT OF VENEREAL-DISEASE PROBLEM Second, the extent of the venereal-disease problem. How extensive are your figures on that now? Dr. PARRAN. Senator Lodge, when the bill was passed, the Public Health Service during the preceding 10 years had procured from every doctor in many States and communities, with a total population of 30,000,000 people, complete reports as to the number of cases of syphilis and gonorrhea which the doctors and hospitals and clinics were treating. So we had a very accurate yardstick, and were able to obtain a reliable figure as to the prevalence of syphilis. DETERMINATION OF FINANCIAL NEED OF STATE Senator LODGE. We come to the third question, the financial need of the State. How do you say that is determined? Dr. PARRAN. Per capita income. Senator LODGE. Not per capita cost of living? Senator LODGE. What is the justification for that? I can see how an industrial State would have a higher per capita income than any other class of State, but there would be really as much if not more poverty there. Dr. PARRAN. I think every student of this problem of weighting grants-in-aid on the basis of financial need of the State realizes that is a very difficult problem. We have consulted widely with various people who have knowledge of this subject, and the consensus was that the method which we are following represented the simplest and perhaps the best single yardstick, although if or when we can find a better yardstick for allotting this part of the money, we certainly shall be glad to have it. Senator LODGE. You admit that is controversial? Senator LODGE. Could you furnish for the record the figures that you have on that factor-the financial need of the State? Dr. PARRAN. I shall be very glad to. Senator LODGE. Thank you. (The information referred to follows:) ALLOCATION OF FUNDS TO STATES It was stipulated in the Venereal Disease Control Act that grants-in-aid to the States should be allocated on the basis of population, extent of the venerealdisease problem, and the financial need of the various States. Since the populations of the various States are available from the Bureau of the Census and the extent of the venereal-disease problem is calculable from widely scattered spot surveys, data for allocation of funds on these bases are readily obtainable. The "financial need" of the various States, however, offered a much more difficult problem. In order to meet this requirement it was necessary to devise a single index which would, to the greatest practical degree, express the ability of the several States to raise revenue. It was also important that such index not only be obtainable from already existing data, but that these data should also be available from year to year in order that this index should reflect current "financial need" as well as long-term changes occurring in the economic structure of the various States. Statisticians of the United States Public Health Service examined all available published data fulfilling these qualifications and as well consulted with other governmental agencies who were collecting unpublished data on this important subject. It was found that the estimates of State income payments more nearly fulfilled the requirements than any other body of data which could be assembled. National income estimates have been made by various nonofficial and governmental agencies since 1921. During this period the techniques for making these estimates and the quantity and quality of data have been steadily improving until at the present moment, competent economists estimate that these data are within 90 percent accurate. The National Income Section of the Bureau of Foreign and Domestic Commerce are now publishing State income payments covering a a period per of years and which are biennially brought up to date. The United States Public Health Service is using the current 5-year averages of these estimates in their index of financial need. It is evident that income payments, if properly calculated, do adequately reflect the financial need of the various States. Items entering into the calculations include: Salaries and wages; relief and work relief payments; entrepreneurial withdrawals; dividends, interest, net rents, and royalties. The volume of direct taxation (income, sales, and other excise taxes) obtainable in any State is directly proportional to the sum of the above items. Land and improvement valuations are also proportional to the amount of rents and other Heome which may be derived from these properties. Likewise, the standard of Iving and variations in price levels are also reflected by the amount of money Benue which accrues to the populations of the several States. The value of income payments as an index of financial need is supported by experience of the governmental agencies who have devoted considerable time and money in an attempt to devise a composite index of the ability of the States te raise revenue from such items as assessed valuations and tax rates, amount of ate indebtedness, amount of Federal income tax payments, volume of retail inde, volume of circulation of publications, number of telephones in use, automobile registrations, etc., and who have found that this composite index is so Cnsely associated with the estimates of State income that the expense involved keeping them current was not justified. EXTENT OF COOPERATION FROM STATES AND LOCAL UNITS Senator MCKELLAR. Doctor, the question I wanted to ask you was this. What is the extent of the cooperation that you are getting from the States, counties, and cities of the country? In other words, I am asking you with respect to financial cooperation. Are they doing their proportionate share of what is necessary to be done? With respect to the question of relief, I think the last relief bill required that the local communities put up something like 25 percent of the money required. I know this is a very interesting question to the various communities, and I should like to know how they are cooperating with you. Dr. PARRAN. That is a very pertinent question. The figure for the amount of Federal funds allotted to the States last year is $4,379,250. The amount appropriated by State, county, and city governments is in excess of $6,000,000. All except two or three States have appropriated more funds than has the Federal Government-sometimes substantially in excess. Senator MCKELLAR. That is very gratifying. Dr. PARRAN. The States have done their part, Mr. Chairman; and it has been extremely gratifying to see the way in which they have come forward. Senator LODGE. That has represented a new and additional activity of government on their part, has it not? Dr. PARRAN. In some instances, it represented what the State or locality was already doing in running a clinic, let us say, for 1 hour a week. Now they run it 2 hours a day for 3 days a week, and necessarily employ additional people. In some instances it does include what they previously were spending. Senator LODGE. But in most cases it represents additional activity, does it not? HOW MONEY WAS SPENT BY STATES Dr. PARRAN. The larger part of it; yes. How was this money spent by the States? How much of it actually is channeled out for the treatment of patients? Approximately 78 percent of the amount was budgeted for treatment and laboratory facilities, for drugs, and for case-finding and case-holding efforts. The remaining 22 percent was budgeted for public and professional education, training of technicians, doctors, nurses, and others to whom I have referred, and for special consultation service from the larger centers to the rural centers, to insure better diagnosis and treatment. AMOUNT FOR ADMINISTRATIVE EXPENSES For the most part the administrative machinery already existed, and this explains the low expenditure for total administrative purposes of approximately 3.75 percent of the total. Senator MCKELLAR. Less Less than 4 percent. ESTABLISHMENT OF TREATMENT FACILITIES Dr. PARRAN. Less than 4 percent. Up to date much of our effort has been to establish treatment facilities staffed with well-trained professional people. We have gone a long way in accomplishing that. In the future, more and more emphasis must be placed on the finding of cases early. The evidence shows that effective work in many places is being done along this line. I am confident that we need not look for or expect any great increase in the number of cases of syphilis reported or brought under treatment in future years, as compared with the number now under treatment. The problem is primarily to get the patients earlier and to hold them longer, through the long process of treatment, some of which is painful. It is inconvenient for patients to leave home and go to a clinic, interfering with work or household duties; but the big effort must be made to continue the patients under treatment. This is an enormous task, and obviously will require considerable expenditure of money and energy. DECLINE IN NUMBER OF SYPHILIS CASES IN WISCONSIN AND I have frequently said, Mr. Chairman, that wherever syphilis is attacked with vigor, and consistently over a peroid of years, there it begins to recede. This disease is barely holding its own in the United States. Senator La Follette has referred to the situation in Wisconsin. Supplementing his information, I can say that the results of tests on pregnant women in that State, which are required, show that the total prevalence is only half as high as the average of other States having similar laws. In Madison, Wis. recently doctors in the University Medical School told me that they have difficulty in finding patients with early syphilis to demonstrate to students. Reference has been made to Massachusetts. The most recent data we have show that there has been a decline in early syphilis in Massachusetts from 35.7 per thousand of population in 1930 to 13.9 in 1939. PROGRESS MADE IN NEW YORK In upstate New York where a venereal disease control campaign has been carried on consistently since the war, the prevalence of syphilis in 1936 was 37.9 per thousand of the population, and in 1939, 17.6 per thousand of the population. Also upstate New York has definitely passed its peak in the total number of cases brought under treatment. PROGRESS MADE IN ALABAMA Moreover, to cite the situation in the black belt of Alabama, in Macon County where 10 years ago syphilis had reached the near saturation point of 38 percent of the Negro population, the rate has been brought down to 18 percent as a result of 6 years of rather sporadic effort, followed by the last 2 years of more intensive effort. NEED FOR CONTINUITY IN PROGRAM Mr. Chairman, I am not content with the progress we have made, but I can say that the program contemplated under the La FolletteBulwinkle Act is well ahead of schedule. The essential point at this time in that the Congress should give to the States some assurance of continuity. We had one experience during the war, working over a period of 2 or 3 years and then having the work terminated; and as a result the States feel a little uncertain as to what the continuing policy |