Special Message to the Congress on Improving the Nation's Health.

To the Congress of the United States:

Health, as Emerson said, is the "first wealth." This Nation has built an impressive health record. Life expectancy has been increased by more than 20 years since 1900; infant mortality rates have been dramatically reduced; many communicable diseases have been practically eliminated. We have developed or are close to developing the means for controlling many others. The intensive medical research effort begun shortly after World War II is now showing dramatic results. The array of modern drugs, appliances, and techniques available to prevent and cure disease is impressive in scope and in quality.

But each improvement raises our horizons; each success enables us to concentrate more on the remaining dangers, and on new challenges and threats to health. Some of these new challenges result from our changing environment, some from new habits and activities. More people than ever before are in those vulnerable age groups--the very young and the very old--which need the greatest amount of health services. More people are living in huge metropolitan and industrial complexes, where they face a host of new problems in achieving safety even in the common environmental elements of food, water, land, and air. The hazards of modern living also raise new problems of psychological stability.

In addition to the long-neglected problems of mental illness and mental retardation on which I made recommendations earlier this week, other areas affecting our Nation's health also require serious and sustained attention:

--There is a shortage of professional health personnel. We must take prompt and vigorous action not only to increase the numbers of trained personnel but to perfect better means for making the most effective use of the health manpower now available.

--Health facilities must be improved and modernized. More of them need to be geared to the problems of older and long-term patients.

--Health care is not adequately available to our older citizens. Costs to aged individuals too often are prohibitively high, and we have not yet been effectively able to bring modern health services to many of them.

--Threats to the physical well-being of our families from the contamination of food, air and water, and from hazardous drugs and cosmetics, must be dealt with more promptly and more effectively.

--Health protection and care must be made more widely available to our children, particularly those whose parents cannot afford proper care and those who are suffering from crippling diseases.

In each of these key areas, this Nation has an obligation to strengthen its resources and services. The alternative is a weaker people and Nation, a waste of manpower and funds, and a denial to millions of people of a full and equal opportunity to life, liberty and the pursuit of happiness. The Federal Government has stimulated much of the recent progress in medical research, without any interference with scientific, academic or individual liberty. Our task now is to be equally decisive in putting this knowledge into practice. Financial provision for the recommendations made in this Message was included in the 1964 Budget which I transmitted to the Congress last month.

I. PROFESSIONAL HEALTH PERSONNEL

Perhaps the most threatening breach in our health defenses is the shortage of trained health manpower. Our health can be no better than the knowledge and skills of the physicians, dentists, nurses and others to whom we entrust it. It is essential that we always have a sufficient supply of such talent, drawn from the best and most gifted men and women in the land.

But the harsh fact of the matter is that we are already hard hit by a critical shortage in our supply of professional health personnel, with the situation threatening to become even more critical in the years immediately ahead. Our hospitals report substantial numbers of unfilled positions for nurses and other health workers. In some cases, entire wings or floors have been closed for lack of trained personnel. In others--particularly mental hospitals, where thousands of patients languish in needless confinement and suffering due to a lack of doctors and nurses--the unavailability of sufficient personnel is a reluctantly accepted fact.

A. Medical and Dental Education

The shortage of physicians and dentists is particularly serious. Our medical and dental schools do not graduate enough students to keep pace with our growth in population. There are 137 physicians and 56 dentists for every 100,000 American people in the country today. And merely to maintain even this ratio will require, over the next ten years, a 50 percent increase in the number of graduates from our medical schools and a 100 percent increase in the number of dental graduates.

In an effort to meet present needs, we now license more than 1,500 graduates of foreign medical schools each year to practice in this country--approximately one-fifth of the annual additions to our medical profession. In addition, one-quarter of the interns and residents in our hospitals are foreign medical graduates. Yet many internships and residencies remain vacant due to lack of manpower. More and more physicians are devoting their time to teaching, to research, to advanced preparation in a specialty; and while this trend represents progress, it also decreases the proportionate supply of physicians available to treat our families. In 1950, there were 1,300 people in the United States for each family physician. The present outlook--unless steps are taken now to increase the supply of physicians--is for more than 2,000 people per family physician by 1970.

Therefore, I again urgently recommend enactment of legislation authorizing (1) Federal matching grants for the construction of new, and the expansion or rehabilitation of existing, teaching facilities for the medical, dental, and other health professions; and (2) Federal financial assistance for students of medicine, dentistry, and osteopathy.

B. Nurses' Education

There were 550,000 professional nurses and 225,000 practical nurses in active practice in 1962. This number is far too small to meet the needs for high quality nursing care. Too many hospitals have been required to rely on inadequately trained orderlies and attendants. At my request, a distinguished group of citizens, serving as consultants to the Surgeon General, has studied the scope and solutions of this problem. They concluded that a feasible and essential goal for 1970 is to increase the number of professional nurses in practice to some 680,000 and the number of practical nurses to 350,000. This requires a 25 percent increase in the supply of nursing personnel and, therefore, a major expansion in both collegiate and hospital programs of nursing education. The number of nurses graduating from collegiate courses would have to double from 4,000 in 1960 to at least 8,000 in 1970. This expansion would require the equivalent of more than 30 to 35 new collegiate nursing schools. Graduates from hospital schools would have to increase from 25,000 to 40,000 by 1970, and junior colleges would have to be graduating 5,000 by that year.

Nursing schools are unable to bear the tremendous financial burden for an expanded effort of this size. Despite diligent effort, nursing has had little success in commanding sufficient local support for the development of its educational facilities and programs. Federal assistance in the expansion of our capacity to train nurses will be necessary.

To meet these goals, and generally to improve the quality of nursing services, the consultant group recommended that the Federal Government: (1) provide financial assistance to expand teaching facilities for nurses' training; (2) provide financial assistance to students of nursing, many of whom cannot afford an education beyond high school; (3) initiate new and improved programs for the support of graduate nursing education, to provide more teachers of nursing; and (4) initiate new programs and expand current programs of research which are directed toward improved utilization of nursing personnel.

I shall transmit to the Congress for action legislation now being prepared on the basis of this report.

II. HEALTH FACILITIES A.

Aid for Construction of Hospitals and Nursing Homes

The Hill-Burton program of Federal aid for the construction of health facilities has been in operation for more than 16 years. Its success can best be measured by the network of modern and efficient hospitals which have been built throughout the country, particularly in smaller towns and rural areas. But the gains have been more than quantitative. The program has had a marked effect in raising State licensing standards, and in improving the design, maintenance and operation of health facilities in every State. It has helped attract vitally needed physicians and other health specialists to rural areas. And, through development of more effective State plans, it has encouraged the first step toward the establishment of more coordinated systems of hospital and other facilities to provide more efficient and economical health care.

A year ago I asked the Secretary of Health, Education, and Welfare to review this program and to make recommendations for its future. This review has now been completed. It points out the necessity for continuing the program to meet new and changing medical facility needs.

Significant progress has been made in reducing the deficit of general hospital beds throughout the country, especially in rural areas. Nevertheless, shortage areas remain and their needs should be met. Indeed, rapid population growth alone requires a constantly expanding hospital system. I recommend, therefore, that the Hill-Burton program, which is due to expire June 30, 1964, be extended for five years.

A particularly acute problem is that of the older hospitals faced with physical deterioration and functional obsolescence. Many hospitals are growing obsolete at such an alarming rate as to hamper the quality of care. State Hill-Burton agencies have reported that there are 75,000 beds in general hospitals that have serious structural or fire hazards. Almost half of all the hospitals in the Nation need some form of modernization.

A 1960 study, based on reports made by State hospital agencies, revealed that it would cost $2.8 billion to modernize or replace antiquated general hospitals, without even adding to the number of beds. This estimate is more than three times the present annual level of construction expenditures for all health facilities. Because of the priority it gives to projects which increase the total number of beds, particularly in rural areas, the Hill-Burton Act as presently constituted cannot meet this vast need for modernization and replacement.

In response to this critical national need, I am recommending modification of the Hill-Burton Act to authorize a new program of financial assistance for modernizing or replacing hospitals and other health facilities.

Although some progress has been made in meeting the backlog of need for chronic disease hospitals and nursing homes, it is estimated that less than one-third of this need has been met and that an additional 500,000 beds for long-term patients are required to meet today's demand.

The outlook for the future is even more serious. In 1960, there were nearly 18 million people aged 65 or over. By 1980, this group will exceed 24 million. As the number of older people increases and as the economic barriers to care in these facilities are eased, the demand for long-term care facilities will soar. The need for high quality nursing homes will be especially great. For these reasons, I recommend amendment of the Hill-Burton Act to increase the appropriation authorization for nursing homes from $20 million to $50 million annually.

B. Mental Health and Mental Retardation Facilities

My proposals for a National Mental Health Program and a National Program To Combat Mental Retardation, including proposals to assist in the construction of community mental health centers and mental retardation facilities, have been set forth in an earlier message on these subjects. I wish to underline here again the urgency of the Nation's need for long-postponed solutions to a long-neglected problem, and to urge once more their prompt enactment by the Congress.

C. Health Facility Planning Grants

As health facilities become more numerous and complex, there is a greater need for more coordinated planning, particularly in our metropolitan areas. This is necessary to insure against the use of public and private resources to construct facilities which are not needed, are poorly located, create unnecessary duplication, or create further imbalances among the kinds of services provided. Proper planning will not only make for more efficient use of the large sums of capital expended for health facility construction, but may also help materially to control the ever increasing cost of hospital care. Therefore, I recommend legislation to authorize planning grants to public and nonprofit organizations, including State agencies, to assist in developing comprehensive area-wide plans for the construction and operation of all types of health facilities.

D. Encouragement of Group Practice

Concern over the shortage of professional personnel and the shortage of health facilities makes clear the desirability of encouraging those efforts which seek to make the most effective use of both. Experience has demonstrated that both patients and professional personnel benefit from group practice facilities--where general practitioners and specialists are able to combine their diverse professional skills and use common facilities and personnel to furnish comprehensive medical and dental care. Group practice of medicine and dentistry promises to improve the quality of medical and dental care, while making possible significant economies for both patient and practitioner. Unfortunately, the difficulty of obtaining financing on reasonable terms to construct and equip such facilities is too often a major obstacle in their development.

In order to encourage this trend, particularly in our smaller communities and under the sponsorship of cooperative or other nonprofit organizations, I recommend legislation to authorize a five-year program of Federal mortgage insurance and loans to help finance the cost of constructing and equipping group practice medical and dental facilities.

III. COMMUNITY HEALTH PROTECTION

Substantial advances have been made during the past year in protecting the American people against contamination of food, air and water, and the hazards associated with drugs. In 1962, as a result of legislation passed by the 87th Congress, our communities with Federal financial aid, spent $600 million to build needed waste treatment facilities, the largest total in our history. Our national program of protection against undue exposure to radiation was strengthened through broadened surveillance, expansion of research, increased training of manpower, and aid to the States in developing their own programs of radiation protection and control. Better protection for the consumer was assured by the enactment of the Kefauver-Harris drug control amendments, which set higher standards of safety, honesty and efficacy in the manufacture and sale of prescription drugs and new drugs of all kinds. Additional action by the Department of Health, Education, and Welfare to improve controls over the clinical testing of new drugs will add to our safeguards against the possibility of health catastrophes during the development of new remedies.

But much remains to be done.

We need to broaden our surveillance and control of pollution in the air we breathe, the water we drink and the food we eat. We need to intensify our research effort in this area, to define the precise damages done to our health by various contaminants, and to develop more effective and economical means of controlling or eliminating them. We need to step up our training of scientific manpower in the many disciplines related to the maintenance of a healthy environment. We need to continue our support and stimulation of vigorous control programs in States and communities.

In addition, there is clear and urgent need for new legislative authority in three specific areas of health protection.

A. Food, Drugs, Devices and Cosmetics

Legislation is needed to strengthen the Food, Drug and Cosmetic Act in its task of protecting the health of the consumer. The Food and Drug Administration--which lacks authority to require the adequate safety testing of cosmetics before they are placed on the market--has ample evidence of the harm which is caused by harmful cosmetic products. Other problems are presented by untested dangerous or worthless therapeutic or diagnostic devices. Of particular danger to children are the 300,000 ordinary household items containing poisonous or dangerous substances without proper labeling and warning. Food, drugs and cosmetics were not included in the Federal Hazardous Substances Labeling Act of 1960.

We cannot afford to withhold from the Food and Drug Administration the full authority required to provide the maximum protection to our families. I recommend the enactment of new legislation to:

(a) Extend and clarify inspection authority to determine whether food, over-the-counter drugs, cosmetics, and therapeutic or diagnostic devices are being manufactured and marketed in accordance with the law; and to provide authority similar to that of most other regulatory agencies for the production of evidence in hearings;

(b) Require cosmetics to be tested and proved safe before they are marketed;

(c) Require manufacturers of therapeutic devices to maintain controls which assure the reliability of their products, and require proof of both safety and effectiveness before such devices are put on the market; and

(d) Extend existing requirements for label warnings to include hazardous household articles, where necessary.

Further delay in the enactment of this authority can only 'prolong and aggravate these unnecessary hazards to health.

B. Air Pollution Control

Reports by leading scientists in the past year have stressed that there is overwhelming evidence linking air pollution to the aggravation of heart conditions and to increases in susceptibility to chronic respiratory diseases, particularly among older people.

Economic damage from air pollution amounts to as much as $11 billion every year in the United States. Agricultural losses alone total $500 million a year. Crops are stunted or destroyed, livestock become ill, meat and milk production are reduced. In some 6,000 communities various amounts of smoke, smog, grime or fumes reduce property values and--as dramatically shown in England last year--endanger life itself. Hospitals, department stores, office buildings and hotels are all affected. Some cities suffer damages of up to $100 million a year. One of our larger cities has a daily average of 25,000 tons of air-borne pollutants. My own home city of Boston experienced in 1960 a "black rain" of smoke, soot, oil or a mixture of all three.

In the light of the known damage caused by polluted air, both to our health and to our economy, it is imperative that greater emphasis be given to the control of air pollution by communities, States, and the Federal Government. We are currently spending 10 cents per capita a year in fighting a problem which cost an estimated $65 per capita annually in economic losses alone. I therefore recommend legislation authorizing the Public Health Service of the Department of Health, Education, and Welfare:

(a) To engage in a more intensive research program permitting full investigation of the causes, effects and control of air pollution;

(b) To provide financial stimulation to States and local air pollution control agencies through project grants which will help them to initiate or improve their control programs;

(c) To conduct studies on air pollution problems of interstate or nationwide significance; and

(d) To take action to abate interstate air pollution along the general lines of the existing water pollution control enforcement measures.

C. Environmental Health

The long-range assault of multiple environmental contamination's on human health are cumulative and interrelated. It is of great importance, therefore, that our efforts to learn about and control health hazards be unified and mutually supporting. The President's Science Advisory Committee, in cooperation with the Federal Council for Science and Technology, has undertaken a major review of the Government's activities with respect to the use of chemicals in the environment. Special attention is being given to the control of pesticides. Nearly 180 million pounds of pesticides valued at more than $1 billion are used in the United States every year. If this review reveals need for additional authority, necessary recommendations will be made to the Congress.

I am renewing my recommendation of last year that authority be granted to the Surgeon General of the Public Health Service, with the approval of the Secretary of Health, Education, and Welfare, to bring environmental health functions together in one Bureau. I also ask that the Congress approve the funds requested in my 1964 budget for initial steps to establish a central facility in the Washington area which can serve as a focal point for related research, training and technical assistance in environmental health.

IV. HEALTH RESEARCH

This Nation has made impressive strides in its search for knowledge to combat disease and, as a result of a deliberate national effort, a bold and far-reaching program is moving well. The Federal Government is now providing the financial support for nearly two-thirds of the $ 1-5 billion in public and private expenditures for medical and health-related research in this country. But this effort is unending--new breakthroughs lie ahead--major problems are unsolved. This country must invest in a further expansion of essential and high quality research and related activities. I have, therefore, recommended appropriations in the 1964 budget of 1980 million for support of the National Institutes of Health, an increase of $50 million in authorizations and $113 million in expenditures over the current year.

The budget also provides funds for the work of the Institute of Child Health and Human Development and the Institute of General Medical Sciences. These new Institutes, which were authorized by the 87th Congress, will provide a needed focus for more intensive research efforts in these areas. One of the greatest threats to maintaining the high quality health research now being achieved through the activities of the National Institutes of Health is the continued loss of its outstanding scientists as the result of pay scales which are not generally competitive. The Federal Salary Reform Act approved last October carries forward the Administration's plan to provide Federal salary rates that are comparable with national private industry salary rates for the same work levels. However, the final stage of that salary reform plan, which will be effective next January, provides salary rates that are still too low, particularly in the upper levels, when measured by the compensation provided outside of Government. It is important that the Congress take appropriate action to correct this disparity.

Last year I pointed out that the accumulation of knowledge through research is of little use unless communicated in useful form to those who need to use it--to other scientists, educators, practitioners, administrators and the public. There is now wide recognition that improved scientific communication is an urgent goal--and action is being taken. With the assistance of information developed by Congressional studies, I have asked the Department of Health, Education, and Welfare to take the lead in developing new methods and systems of utilizing and making effectively available more health research results and information. Should additional legislation be required, it will be transmitted promptly to the Congress.

V. OTHER ESSENTIAL HEALTH EFFORTS

A. Health Insurance For Our Older Citizens

In a subsequent message to the Congress concerned solely with the needs of older people, I will again outline my recommendations for a long overdue measure to fill a crucial gap in our social insurance protection-health insurance under Social Security. This measure should also be at the top of the Congressional agenda on "health."

It is a tragic irony that medical science has kept millions of retired men and women alive to face illnesses they cannot afford-that the very drugs and methods which have done so much to prolong their lives and ease their pain are too expensive for the majority of older citizens. Many can face one siege of serious illness, with the help of savings and families. But a second wipes them out-and the average person can expect two or three hospital bouts after age 65. Needless suffering in silence, financial catastrophe, public or private charity--these are not acceptable alternatives in the richest country on earth. Social Security Health Insurance must be enacted this year. Details will be contained in a forthcoming message.

B. Improving Maternal and Child Health

In my Special Message on Mental Health and Mental Retardation, I recommended several new measures designed to improve the health of mothers and children. The relationship between improving maternal and child health and preventing mental retardation is clear. But equally clear is the fact that the need for better health services for mothers and children is steadily increasing in general, due to the growing child population, the rising costs of medical care, and changes in the practice of medicine and public health. I take this opportunity, therefore, to stress again the urgency of those provisions.

C. Vocational Rehabilitation

As we expand and improve health services, we make it possible for larger numbers of people to recover from the damaging effects of serious illness and injury, and to return to active and useful lives. Vocational rehabilitation programs, both private and public, are playing a key role in helping to convert these gains in curative medicine into gains in productive living. Work--often the mere hope of returning to work--provides a powerful incentive for large numbers of seriously disabled people as they travel the difficult road to recovery and rehabilitation. For these reasons, I recommend that funds for the State-Federal program of vocational rehabilitation be increased to permit 126,500 handicapped individuals to be successfully returned to employment, a 25 percent increase over this year. I am also recommending legislation to strengthen and improve the vocational rehabilitation program, including Federal assistance in constructing rehabilitation facilities and workshops, additional aid to help States increase the number of persons rehabilitated, and special pro, visions to increase the rehabilitation of the mentally retarded.

D. Community Health Services

Last year the Congress passed the Vaccination Assistance Act and the Migrant Health Act, both of which were designed to meet important national health problems. The Vaccination Assistance Act looks toward the eradication of poliomyelitis, diphtheria, whooping cough and tetanus through the mass immunization of children at the earliest possible stage, under community-sponsored programs. We can and should eliminate these four deadly diseases. The Migrant Health Act authorizes grants to improve the deplorable health conditions of migrant workers.

I am submitting supplemental appropriation requests to the Congress to provide funds in this fiscal year to enable both the Vaccination Assistance and Migrant Health programs to get under way at the earliest possible date.

These programs, coupled with progress now being made under the Community Health Services and Facilities Act of 1961, are directed toward the long-range goal of comprehensive community health services, available to people in their own communities, when and where they need them. To permit the more effective prosecution of programs to improve health services at the community level, I am again renewing my recommendation of last year that authority be granted to bring all community health activities of the Public Health Service together in one Bureau.

E. International Health

We must continue our collaborative efforts with other nations in the global struggle against disease. Over the past few years the United States has rapidly expanded its international medical research activities and support. We have also been instrumental in encouraging research under the aegis of the World Health Organization. These efforts are consistent with and in furtherance of our goals of world peace and betterment, and it is important that they be continued.

A problem of particular significance in the Western Hemisphere is that of yellow fever. Many countries of the Americas have conducted campaigns to eradicate the mosquito which carries yellow fever, but the problem of reinfestation has become a serious one, particularly in the Caribbean area. We have pledged our participation in a program to eradicate this disease-carrying mosquito from the United States, and the 1964 budget provides funds to initiate such efforts. This will bring this country into conformity with the long-established policy of the Pan American Health Organization to eliminate the threat of yellow fever in this Hemisphere.

CONCLUSION

Good health for all our people is a continuing goal. In a democratic society where every human life is precious, we can aspire to no less. Healthy people build a stronger nation, and make a maximum contribution to its growth and development.

This national need calls for a national effort--an effort which involves individuals and families, States and communities, professional and voluntary groups, in every part of the country. The role of the Federal Government, although a substantial one, is essentially supportive and stimulatory. The task is one which all of us share--to improve our own health, and that of generations to come.

JOHN F. KENNEDY