The Office of Economic Opportunity now will approve Federal funding for family planning services under its community action programs if the community wishes to undertake that activity. This program is just getting underway, so there is no way yet to know how many communities will place an emphasis on family planning.

The Department of Health, Education, and Welfare is the appropriate Federal agency to carry forward all three elements of research, training and service which must be achieved if we are to illuminate the nature of population changes, to provide new and better methods of controlling fertility and investigate the social and psychological aspects of family planning.

For example, its National Institute of Child Health and Human Development supports basic research in reproductive biology which will lead to better understanding of those factors leading to the creation and development of healthy, new individuals. It is currently spending about $500,000 a year to support research directly related to population problems.

Most recently, it awarded a grant to Princeton University to survey birth control practices. This study will provide a base for other studies of the influence of birth control practices on the health of women and children. While earlier fertility studies were conducted in 1955 and 1960, the results of the 1955 survey could vary considerably from the current study since oral contraceptives only entered the market in 1960. One of the most interesting aspects of the study is that it should give us reliable national data on the size of the family desired by parents.

The Children's Bureau, as a part of its program related research, is undertaking research and demonstration grants on various phases of family planning. To get at the complexities surrounding the question of motivation for family planning, the Bureau has awarded a grant to the Community and Family Study Center in Chicago to find answers to these two basic questions:

1. Why do some low-income families totally reject family planning or accept it only on a limited or temporary basis?

2. How do prevailing community attitudes and the individual's own psychology work to promote or impede the adoption of birth control measures?

Another grant now underway with the support of Bureau funds has gone to the Hudson Institute in New York, to project what U.S. birth rates might be in 1975 as a basis for developing alternative planning requirements for future maternal and child health services throughout the country.

Still a third grant has gone to the Tulane University School of Medicine, New Orleans, to continue its study of fertility and attitudes relevant to fertility and family planning among a group of 1,000 mothers living in the New Orleans metropolitan area.

President Johnson has pointed out that "In all sectors of health care, the need for trained personnel continues to outstrip the supply."

In the field of training to meet the Nation's health needs, many parts of the Department are supporting grants, institutes, fellowships, and other means of augmenting our supply of trained personnel.

The Children's Bureau has long recognized that there must be a steady and continuing process of upgrading the professional skills of the medical, paramedical and social work personnel offering services in the three grants programs it administers. In the maternal and child health and crippled children's programs, for examples, practically all the States are using some of their Federal funds to provide special training opportunities to physicians, nurses, nutritionists, medical social workers, and other professional personnel.

As you know, maternal and child health programs in schools of public health now have family planning in their programs but much more concentration on this aspect of public health is needed in many teaching hospitals.

The Children's Bureau is supporting training programs specifically geared to the roles which various disciplines must play in the most effective planning and carrying forward of family planning programs. It also is interested in the work which the Ford Foundation is financing to establish a university center for population planning in Michigan which includes public health, sociological, obstetric, and gynecological components.

In October, we plan to offer a 4-week course to about a dozen American registered professional nurses to study family planning at the Graduate School of Nursing of the New York Medical College.

This course, to be given concurrently with the training program for nurses from other countries which is sponsored by the Agency for International Develop

ment and the Children's Bureau, will enable both groups of nurses to participate in classroom and clinical experience, including study of the use of specific contraceptive devices.

In a few State maternal and child health programs, inservice training is going forward to supply a pool of physicians able to give consultation on up-todate methods of application of contraceptive techniques from the medical points of view. One of the paramount uses of this pool of technicians is as consultants to counties who want to upgrade their programs. In a very efficient way, this method gives all physicians in a given community the opportunity to take advantage of the most advanced medical knowledge in this area. If this form of inservice training were extended on a national basis, the potential benefit could be immeasurable.

The Children's Bureau is in a key position in the Department of Health, Education, and Welfare in its involvement in helping to support service programs of family planning. Our basic concern has been, and always will be, to improve the social and physical health of mothers and children throughout the country. Our obligation under the Social Security Act is to assist the States in promoting these health services.

A marked change in attitudes toward family planning and an improvement from the findings of research about various methods that can be offered in very recent years has made it possible for States, many of which already provided such services as an integral part of their maternal and child health programs, to expand these activities and for other States to initiate family planning programs.

This expansion would not have been possible without the unstinting efforts of voluntary organizations interested in family planning in giving demonstrations, which have always maintained high standards, a valid scientific approach, and excellent interpretation, about the true meaning of family planning as a part of responsible parenthood.

Research foundations have poured millions into studies focused on family planning and pharmaceutical firms have made an immense contribution by developing resource material and inservice training teaching tools which not only enrich the individual efforts to inform parents about spacing their children but can be used by professional personnel as valuable tools in both public and voluntary programs of family planning.

It is against this background that public health has truly become involved in family programs as the numbers of families seeking this service and vast urban and rural areas to be covered outstripped available voluntary efforts. Moreover, the conviction has grown that education and instruction in effective family planning should be an essential component of both the health and welfare agencies responsible for the payment of health services for the dependent families. For it is the families of the poor who too long have suffered spiritual dejection and demoralization after bearing successive babies without hope of these children being able to achieve their full potential or breaking the cycle of poverty. Federal matching funds are available for medical services connected with family planning under the public assistance titles of the Social Security Act. Such services may include inpatient and outpatient hospital services, physicians' services, clinical services, prescriptions for drugs and devices, and other preventative and rehabilitative services associated with a comprehensive program for family planning.

Further impetus for expanded activities came with the enactment, in 1963, of maternal and child health amendments which authorize a new project program of maternity care for women in low-income families. These projects were intended primarily to give the States a chance for intensified attention to reducing the incidence of mental retardation caused by premature births and complications associated with child bearing, especially among concentrations of economically, educationally and socially deprived low-income groups.

The method is to increase the number of prenatal clinics in neighborhoods where they will be more accessible to pregnant women, and to provide hospital care of good quality for women with complications of pregnancy. The amendments also called for an expansion of services to attend to any health complications of infants cared for under this program.

Most of the States and localities which have chosen to take advantage of the maternity and infant care program have included family planning as a part of

their comprehensive care efforts. During fiscal year 1965, 27 States spent some $1,835,000 for family planning services in relation to maternal health programs. From State plans submitted to the Bureau for the current fiscal year, it is apparent that in some States they are planning to double the amounts they are spending for family planning services in their comprehensive programs of maternity and infant care. Project directors report a great deal of enthusiasm on the part of the staff concerned in these projects, and have particularly noted the high quality of trained obstetrical personnel who are relating their knowledge and skills, for the first time, to community problems as being necessarily schematic in the proper execution of their role in a planned approach to maternal health.

The Children's Bureau has just added a staff member to obtain further factual information about family planning services provided by State and local health departments. Hopefully, her findings will enrich future program planning in this field. Additionally, beginning with the current fiscal year, we are asking the States to give us basic information about the numbers of persons receiving family planning services which will indicate the scope of the program and where additional new approaches may be needed in some areas if it appears that these programs are not now meeting the needs of all persons requesting service. Our experience so far in the maternity and infant care programs gives us hopeful indications that the institution of family planning services more than doubles attendance at post partum clinics and, in some programs at least, seems to have a favorable influence in attracting women to prenatal clinics early, as word gets around that the services are available.

One graphic example of this has been the experience at Augusta, Ga., where in a rural area, between 85 and 90 percent of the women served in a maternity and infant care program return for the critical postpartum examination, and 90 percent of those who do return ask for family planning advice.

We are aware that we are still at the beginning of a learning experience; but early evidence indicates we will come to know much more about the physical aspects of family planning; the usefulness of the devices themselves; peoples' attitudes toward their use; the continuity of interest in this subject.

It should be quite clear, too, that our definition of family planning is not limited to the spacing of children but also includes a concept of service to those couples who seek to correct their infertility in order to have a family.

As a part of this definition, it is a goal-but certainly not a reality-to have services available in communities, not just as a part of the post partum clinic service, but as a part of regular maternal services which women could use at other times than during the maternity cycle. There is a beginning in this direction but only a beginning.

Most importantly, we need to know how to communicate with families so that they internally accept family planning as a part of their family pattern. I would like to emphasize, too, that when we speak of family planning, we are talking about both parents-the base of family life. Our efforts will be both futile and misdirected if we fail to involve the husband and father in family planning. To the extent that this is possible, it now is being done in the maternal care programs but greater progress needs to be made in this direction.

I can think of no more concrete example of the need for the involvement of both parents than a letter which came to the Children's Bureau a few years ago written by a mountaineer. It read, in part, as follows: "Dear Sir: I am writing to ask your advice. I want some personal advice and not just some little papers or pamphlets." He went on to say that when his wife had given birth to their first and second children she had gotten up in a day or two and begun helping him in the fields. Then he related what happened to her in each successive pregnancy-her third, fourth, and fifth; her sixth ended in a miscarriage. By the end of the first page she had had nine pregnancies. In her 10th, she had a convulsion, then followed her 11th, 12th, and 13th. And now she was pregnant for the 14th time. She didn't want to do anything except lay around all the time. He didn't know whether she was getting lazy or not. He had heard when women had grown children they liked to sit down and let their children wait on them. The letter ended with the question, "Can it be that my faithful wife don't want to help me anymore?"

We are forced to recognize that men who father children with the very best of intentions of giving them adequate care can be overwhelmed at the economic burden which each successive child brings to the end that family adequacy

flounders and the burdens under which the family struggles finally make the family itself a casualty. Even if they take "moonlight" jobs, many of these men cannot make ends meet. In administering the companion obligation for child welfare services which is an integral part of the Children's Bureau total approach to maternal and child welfare, this situation continues to exist. Despite the principle so long advanced in child welfare that no child shall be separated from his family for economic reasons only, often wind up in public institutions, seriously dislocated from the society of which they must some day be a part. Daily, social welfare workers are confronted with situations in families where they are forced to search for palliatives rather than solutions to real problems. For example, as a society we must take far more forceful steps than we have, if we are to reduce the growing problem of babies abandoned in our great cities by mothers who do not have the means to care for them. For example, in the first 9 months of 1964 in New York City alone there were 443 well babies left in hospitals by mothers who simply walked out because they had no way of caring for their new babies.

When emergency placement measures are undertaken to clear the hospital beds they occupy so that others can be served, these young infants too frequently spend their growing years in so-called temporary shelters.

The enormous impact of this problem is reflected in our child welfare services program in many ways. In a recent year, 36 percent of all children receiving services by public child welfare agencies were neglected by their parents. The second largest group in the caseload-17 percent-needed care because of illness, desertion, or other loss of their parents.

In both Children's Bureau maternal and child welfare programs we are acutely aware that among the most vulnerable women are the young unmarried mothers. We have a special obligation to see to it that they get every special help they need, for we have proof that their children are frequently more susceptible to physical impairments, as well as the indisputable social implications which attend these fatherless home situations.

All these factors point for more attention to the crucial period surrounding the conception, birth, and aftercare of the infant. The seriousness of this problem is vividly pointed up by Dr. Allan C. Barnes, obstetrician in chief at Johns Hopkins University in Baltimore: "In hospital practice the removal of a brain tumor calls for a surgeon with two assistants, a scrub nurse and two circulating nurses, an anesthetist, and an assistant. The patient's prognosis is about 18 months and the hospital investment is tremendous. The birth of a new baby at 4 a.m. more often is attended by one physician, no scrub nurse, one circulating nurse, and inadequate or haphazard anesthesia coverage. The combined predictable lifespan of the two patients is over a hundred years, but the hospital investment is minimal."

If the baby is born into a low-income family, he may stay in the hospital 48 hours or less and the unique opportunity to discover congenital malformations and recognize high-risk infants during the first days of life may be lost.

There is a discernible gap between what we expect of each new generation and what we have been doing to help meet rising expectation It is an exciting prospect to think of the opportunities that now lie before us to remove or ameliorate those health and welfare barriers which now make the future so bleak for many children.

Healthy mothers and babies are a paramount part of our national concern for the future well-being of all our citizens. We are, of course, greatly concerned that we now rank 10th among leading nations of the world in reducing the infant mortality rate. President Johnson has called for a drastic reduction in this rate by the end of this decade.

Could it be mere coincidence that in all but one of the nine nations which now rank ahead of us in reducing infant mortality, the birth rate is lower than that of the United States? Sweden, which reports the lowest infant mortality rate, had a birth rate per 1,000 population in 1961 of 13.9 compared with 23.7 for the United States. Only New Zealand, which ranks directly ahead of us in the standings, had a higher birth rate-27.1.

Many of us here are working together at a new rapid pace as dimensions of our problem become clearer in reaching the goal of providing better health for the mothers and children of this Nation. If family planning is a useful tool in achieving this goal, then it should be available on a universal basis as a right to parents, without coercion, but with a genuine and sympathetic attention to the needs of each human being.

EXHIBIT 211

"NEW HORIZONS"

(By Mrs. Katherine Brownell Oettinger, Chief of the Children's Bureau, Welfare Administration, Department of Health, Education, and Welfare)

(An address made before the Institute on Health Education, sponsored by the Davidson County Anti-Tuberculosis Association, Peabody College, Nashville, Tenn., July 12, 1965)

I was talking recently with a young businessman from a Southern State who flies his own plane to cover a vast southern territory.

He was telling me about some of his more exciting trips, and then added: "The toughest part of it all, though, is flying at night in complete darkness. For then you have no horizon to guide you."

How true this is in the whole history of civilization. Without horizons, we do not advance. With horizons, we can push forward endlessly to new

goals, new visions.

And so tonight, I would like to talk with you about some of the new horizons that can guide us; horizons which offer not just promise, but challenge; not just steady forward progress in our work, but a chance to take giant strides, where now we are only marching.

The climate has never been more auspicious for rapid progress in the fields of health and welfare.

This year, in H.R. 6675, more familiarly known as the medicare bill, which has passed the House of Representatives and is now awaiting Senate action, we are witnessing the most significant health legislation since the Social Security Act was passed 30 years ago.

When this legislation is enacted, it, together with the 1963 amendments to the Social Security Act, will provide us with the opportunity to move with assurance to close the gaps in the Nation's health services for mothers and children. Communities can develop comprehensive, well-organized programs of preventive health services and medical care for mothers and children of a high quality. The best medical resources in our communities will have a new reason to plan together to meet the problems of providing good medical care for mothers and children. Medical schools and teaching hospitals will have an un-. precedented opportunity to practice and teach medicine with a greater understanding of the patient's life outside of the hospital. There will be a better distribution of patients among the available resources of the community and the growing trend toward hospital ghettoes will be halted.

All of these goals, of course, cannot be accomplished overnight. They will be speeded as we improve the quality and quantity of communications and cooperation between community services-health, welfare, education, housingto achieve maximum results from each innovation, each new concept, each scientific development.

Let us examine some of the challenges that lie before us.

At long last, and through concerted efforts on many fronts, the wall of both silence and neglect has finally been broken in the field of mental retardation.

First came the voices of the parents, then in the last half of the 1950 decade, an active Federal program under Children's Bureau auspices to establish mental retardation clinics through State maternal and child health programs. The Child Development Clinic at the University of Tennessee College of Medicine was one of the early mental retardation clinics supported by the Children's Bureau when it was established in 1957.

The number of these clinics has continued to grow until there are now nearly 100 which are receiving Children's Bureau support and a substantial number which have been established through State initiative alone.

The next great step forward in our concern came with President Kennedy's vigorous leadership in establishing a panel to discuss all aspects of the problem and to come up with every possible solution.

Out of his concern emerged the 1963 Maternal and Child Health and Mental Retardation Planning Amendments, whose main focus was on the prevention

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