ple, the Title XIX program will purchase health services for many indigent rural people. However, if the program is to reach the people for whom it is designed, there must be intensive health education, counseling, referral, trans portation and follow-up services which might be offered by the Public Health Service.

In some States not yet covered by Title XIX but possessing acute rural health needs, the Public Health Service could with extended authority and additional funds provide comprehensive health care in areas meeting carefully designed criteria of need. The kinds of services which could be developed would include some or all of the following: Mass screening, follow-up diagnosis, referral treatment and continuing patient supervision. The kinds of physical facilities which could be used include existing hospitals and health centers. For some purposes schools and churches could be used, and for some, stores and other resources could be converted. Mobile units would be effective-some to bring the patients to the service, others to take the depending service to the patient.

The Public Health Service will work to develop integrated rural-urban ho pitals, medical care and academic affiliation. Such relationships will both strengthen the services of the rural hospital and tend to reduce the professional isolation and academic frustrations of the rural medical staff. This will improve the chances of securing or retaining personnel in such areas. With the consultation and interchange of specialized personnel and services, such as medical record, pathology, radiology, dietary, physical therapy, etc. from the urban medical center, the vital links in comprehensive health care can be provided within the economic capabilities of rural facilities. This association will be to the advantage of urban teaching hospitals in that it will reduce their nonemergency patient backlog (more extensive services being offered in rural facilities) and will result in a broader selection of teaching material.

The Public Health Service has the administrative responsibility for the multicounty demonstration health projects funded by Section 202 of the Appalachian Act. Additional Regional Commissions are currently being planned for New England, the Coastal Plains, the Ozarks, the Four Corners area of the Southwest and the Upper Great Lakes. The Public Health Service will likely be given the administrative responsibility for the health services approved by those Commis sions. This will provide additional links for coordinating rural-urban hospital and other health relationships.

Each Regional Office will have professional staff knowledgeable of rural health problems and available to offer consultation to health and health related agencies, organizations or groups. Assignment of Public Health Service staff to a State Public Health Agency or to a local multi-county area will be made when considered desirable and when requested by the State. These assignees will promote rural health activities and coordinate services.

We visualize that a comprehensive problem solving approach will be taken which involves health service as a component part of a larger program to meet the social, cultural, and economic needs. It is only by such a comprehensive approach to the total problems of an individual that sound long-term solutions can be secured.

Mr. GOODLING. In line with what Mr. Montgomery said as to the matter of local responsibility, I can tell you what we do in our community. I happen to be a director in a small rural bank. I can think of at least four or five doctors who were doing intern work in the hospitals and we went after them to come into that particular community. While we did not give them any money, we made it possible for them to get the money to start. I can assure you that every last one of them did well, and did real well. In fact, they did so well that they decided that they would like to go to the city.

Mr. RESNICK. That is the problem.

Mr. GOODLING. But we do get them by giving them an incentive. Mr. NICHOLS. In my area they have put out these signs "Doctor, please come and be with us-house and lot, clinic available and no rent." And they do come. They get their feet on the ground and in 2 or 3 years they are gone.

Mr. GOODLING. We repeat the process. We do not put out any signs. We go right to the hospitals where we know there are interns. We ind out which is the good intern. And then we contact him personally and try to get him to come in to our community. We have been successful in doing that. As I say, they do not always stay but we always have medical service.

Mr. RESNICK. I would like to suggest to you that that is fine but if you need 1,500 interns and you are only graduating 750, somebody is going to do without medical help. We have one small community and all of the medical help we need. It is a resort area-people like to be there. Here we are in fine shape-however, 40 miles away there is no help at all. They just do not want to go there. The problem is not who can use the best effort to grab these people but the question is how do we get enough people to go through school so that a poor community in a remote area can have the help. This is the problem.

Mr. MONTGOMERY. We have a law in our State-I do not think that it is original with us-where we pay for the education of a medical student if he will sign an agreement with the State of Mississippi that after he completes his medical education he will serve in a small community for 3 years. It has worked fairly well. Some have paid the money back and have gone to other places. It has worked fairly well in trying to get doctors into the rural areas.

Mr. RESNICK. Again I agree. There are all sorts of steps which can and should be taken, but the root of the problem is that we are not training enough doctors.

Mr. NICHOLS. That is right.

Mr. RESNICK. We are not training enough doctors per thousand population. It is fair to say that the cities are satisfied first, and then whatever is left over spills out into your rural area, so that the rural areas have been shortchanged. Unless you take positive steps to get doctors out to the rural areas, you will not have any medical service out there. It is as simple as that.

I want to thank you for your very fine testimony. We certainly will appreciate the figures that you will supply on the counties and the other medical outlook in the rural areas.

Mr. CARTER. Thank you.

Mr. RESNICK. Thank you again.

Our next witness is Dr. Lowell H. Watts, director of the extension services, Colorado State University, chairman of the ECOP and he is accompanied by Dr. G. W. Schneider, associate director of cooperative extension service, University of Kentucky and chairman of the ECOP subcommittee on community and resource development and Dr. W. M. Bost, director of cooperative extension service, Mississippi State University and a member of ECOP.

Mr. MONTGOMERY. Before we start the testimony, I would like especially to state that Dr. Bost is from my home State and I am glad to see him come here to testify before the subcommittee. He is a distinguished Mississippian. He has done much in the extension department work in our State.

Mr. RESNICK. We are very proud to have him present here today. Mr. Bost. It is a pleasure to be here.

STATEMENT OF LOWELL H. WATTS, DIRECTOR FOR EXTENSION AND UNIVERSITY SERVICES, AND DIRECTOR OF COOPERATIVE EXTENSION SERVICE, COLORADO STATE UNIVERSITY, AND CHAIRMAN OF ECOP; ACCOMPANIED BY F. W. SCHNEIDER, ASSOCIATE DIRECTOR OF COOPERATIVE EXTENSION SERVICE, UNIVERSITY OF KENTUCKY, AND CHAIRMAN, ECOP SUBCOMMITTEE ON COMMUNITY AND RESOURCE DEVELOPMENT; AND W. M. BOST, DIRECTOR OF COOPERATIVE EXTENSION SERVICE, MISSISSIPPI STATE UNIVERSITY, AND A MEMBER OF ECOP

Mr. WATTS. Mr. Chairman and members of the subcommittee, we appreciate the opportunity to present testimony before your subcommittee. We do request that our prepared statement be made a part of the record.

We would like to address our comments this morning to some of the problems you have under discussion, but perhaps with a little different

context.

As you know, the cooperative extension service was authorized in 1914 under the provisions of the Smith-Lever Act. The growth of cooperative extension educational programs across the country has resulted in the gradual development of a unique educational system which focuses upon the use of new technology and information to solve everyday problems of people at the local level. I think that you have serious local problems. The involvement of our extension agents and our staff specialists has brought the extension program into an extremely close relationship to the people whom we serve.

Functioning as an educational arm of the Department of Agriculture and as a grassroots problem solving extension of our land-grant universities, we share with this committee a concern for the welfare of rural America. Our close and continuing contact with people in their local environment has also brought to our attention certain types of problems and concerns which we feel are of relevance to your committee in its review of Federal assistance in the development process.

Extension's early activities might best be described as that part of an educational process aimed at promoting and encouraging change in individuals. The sum total of these changes has made and is continuing to make possible the highly efficient commercial agriculture which provides the American consumer with the world's best food supply at less than 20 percent of disposable income.

Unfortunately, the past concentration on agricultural production largely ignored the more complicated interrelationships of individuals and families with their communities and ignored almost entirely community interrelationships within the broad economic and social framework of the Nation.

As we look at the role of cooperative extension today we recognize that in addition to individual learning, the processes of planning and development also require the stimulation of group decisionmaking as basic to development. Said another way, the initial purpose of extension is to enhance individual decisionmaking and the second purpose is to enhance group decisionmaking. This is really the second purpose that we are addressing our comments to this morning.

- Development in a nation such as ours requires recognition of the ommunity as a fundamental unit involved in structural change. tructural changes affecting the community will not take place until nd unless there is sufficient understanding, information, and motivaion by decisionmakers to make such changes both possible and palatble at the community level.

Let me speak for just a moment on the needs for rural development. think this has been brought out by other witnesses who have appeared before the subcommittee previously. Rural communities lag behind the rest of the Nation in many aspects vital to the social and conomic development of our country. Chief among these these are indequate education, family income, job training, employment opportunities, health, housing, and community institutions and facilities that make for a viable society.

You have just been discussing this in terms of medical facilities specifically.

Moreover, rural areas do not have the organizations, agencies, and professional personnel common to large metropolitan areas which provide leadership and technical assistance for coordinated development of all aspects of their community. The large metropolitan areas have planning commissions and planning authorities and many subdivisions of government to carry out specific programs of transportation, urban renewal, housing, health, water and sewer development, job training and similar aspects of human, natural, and economic development. These planning commissions and governmental subdivisions usually have full-time technical staffs which make studies, forecast needs, and prepare proposals for use of Government grant and loan programs. Consequently, largely I think because of the fact that the urban areas get the lion's share of Government assistance.

The fact that half of this Nation's poverty exists in rural areas but that a majority of funds now go to metropolitan areas illustrates this impact.

Mr. RESNICK. If I could interrupt right at that point. We have a variation of figures on this subject. We are talking in terms of onehalf of the people. In other words, the poor, I believe, is 20 percent of the Nation's total-there are 40 million poor and 20 million live in the rural areas, whereas the other 20 million live in our cities, so that, on a percentage basis, more poor reside in rural areas.

Mr. WATTS. If you take it in terms of percentages, I would agree;

yes.

Mr. RESNICK. In other words, in absolute figures one-half is in rural America and on a percentage basis this is probably up around 70 percent.

Mr. WATTS. Yes.

Mr. RESNICK. That is a very interesting point. I will go into that later. I just wanted to understand whether we were talking in percentages or in absolute figures.

Mr. WATTS. Those who live in rural areas are often viewed as ultraconservative and as slow in adopting to new ideas. The very fact that our agricultural industry has moved forward rapidly during the past two decades indicates that this is not necessarily true. Rural Americans will change and will innovate providing they have a full understand

ing and appreciation of the reason for change and are convinced the changes can be beneficial for them.

If we review the history of agricultural development we recall the early difficult days of the county agent whose first job was to win the friendship and confidence of the farmer whom he sought to serve Only after this confidence was achieved was the agent able to provide the innovative stimulation which resulted in progress in agricultural production techniques.

As we turn to the present day, it would appear that some parallels can be drawn. The types of problems faced in rural America are many and they are highly complex. They involve communities, regions, and trade areas which often transcend not only county but State lines.

The concern regarding local problems is relatively high. The factors that are forcing changes upon rural America are much less well understood. Local residents should not be expected to apply corrective innovations until the agencies assisting them win confidence and trust. The rapid evolution of many different programs in a short span of time has, however, tended to confuse the smalltown resident and has resulted in suspicion of intent and outright opposition in some cases. Testimony already presented to this committee has indicated some disenchantment at the local level with many Federal development programs.

Secretary Freeman in appearing before this committee on June 6 acknowledged that, “* * * some local communities are prejudiced against Federal assistance." He then emphasized the serious efforts being made within the executive branch of Government to coordinate development programs and to develop model applications to cut down on duplication of effort and complexity of filing for Federal assistance. I would like to address some comments to the proliferation of Government programs. The proliferation of Government assistance programs and the lack of technical assistance for dealing with them in a meaningful manner has caused confusion and frustration in rural areas. The latest Catalog of Federal Assistance Programs, published by the Office of Economic Opportunity on June 1, 1967, lists 459 different "domestic programs to assist the American people in furthering their social and economic progress."

With such a vast array of programs and the complicated and variable procedures and requirements for obtaining assistance under them, with insufficient leadership and a lack of technical help, it is no wonder that rural communities not only lag behind but also suffer untold frustration in trying to take advantage of these programs. In my own State of Colorado, one of the few successful rural community proposals has been the direct result of one individual who was willing to work almost full time in studying various programs and in seeking guidance in proposal development. This individual has suggested that programs provide staff assistance to rural communities to assist local leadership in understanding required procedures and proposal requirements.

It has been suggested that more programs should be provided for help at the local area level to compensate for this lack of professional help that is available in the cities.

Mr. RESNICK. If I may interrupt you there. Do you not think that is a function of the State?