T-W Medical Facilities Available in Rural Areas of the State Report of the Virginia Advisory Legislative Council to The Governor and The General Assembly of Virginia Senate Document No. 6 Commonwealth of Virginia Division of Purchase and Printing 1945 Medical Facilities Available in Rural Areas of the State Report of the Virginia, Advisory Legislative Council u» to The Governor and The General Assembly of Virginia Senate Document No, 6 Commonwealth of Virginia Division of Purchase and Printing 1945 MEMBERS OF THE COUNCIL Edward L. Breeden, Jr., Chairman Edward O. McCue, Jr., Vice-Chairman Willis E. Cohoon Charles R. Fenwick Garland Gray E. Glenn Jordan E. Blackburn Moore John B. Spiers Robert C. Vaden Cassius M. Chichester, Secretary John B. Boatwright, Jr., Recording Secretary Medical Facilities Available in Rural Areas of the State A Report of the Virginia Advisory Legislative Council To: Honorable Colgate W. Darden, Jr., Governor, of Virginia and The General Assembly of Virginia Richmond, Virginia, November 12, 1945 Introduction I The following resolution was passed by the General Assembly of Vir- ginia in February, 1944: SENATE JOINT RESOLUTION NO. 16 Whereas, the medical facilities available in the rural areas is a matter of increasing concern to the State, now, therefore, Be it resolved by the Senate of Virginia, the House of Delegates concurring, That the Virginia Advisory Legislative Council is authorized and directed to make an investigation and study of the medical facilities available to the rural population of Virginia. In its work the Council shall avail itself of the assistance of the Depart- ment of Health, and of any other Federal, State or local agency concerned with this problem. The Council shall submit to the Gov- ernor and the General Assembly at least thirty days prior to the next regular session of the General Assembly a report of its findings and recommendations, together with any proposed legislation necessary to carry its recommendations into effect. Interim reports may be made upon request of the Governor or whenever the Council deem such a report advisable. The Council requested Charles R. Fenwick, House of Delegates, Ar- lington County, to serve as chairman of a committee to make the initial study and report. The following were appointed to serve with the chair- man: FI. B. Mulholland, M. D., Assistant Dean, University of Virginia Medical School and President, Medical Society of Virginia, University; President W. T. Sanger, Medical College of Vrginia, Rchmond; Philip S. Smith, M. D., Johnston Memorial Clinic, Vice-President, Medical Society of Virginia, Abingdon; W. E. Garnett, Ph. D., Rural Sociologist, 6 Senate Document No. 6 Virginia Agricultural Experiment Station, Virginia Polytechnic Institute, Blacksburg; J. M. Emmett, M. D., Chief Surgeon, Chesapeake and Ohio Railway Company, Clifton Forge; M. M. Long, patron of the resolution and Senator 17th Senatorial District, St. Paul; W. J. Sturgis, M. D., Presi- dent, Northampton-Accomac Memorial Hospital, Nassawadox, and I. C. Riggin, M. D., State Health Commissioner, Richmond. The Committee organized by electing Dr. Riggin Vice-Chairman. Cassius M. Chichester and John B. Boatwright, Jr., were appointed Secre- tary and Recording Secretary, respectively, to the Committee. Through the courtesy of Dr. John R. Hutcheson, Acting President, V. P. I., and Dr. A. W. Drinkard, Jr., Director, Virginia Agricultural Ex- periment Station, Dr. W. E. Garnett, Director of the Experiment Station’s Rural Health and Medical Care Study, was released to the Committee for two months, to aid in correlating the great amount of material which the Committee had in hand. Nine meetings of the Committee and three public hearings were held. Great interest was evidenced throughout the State in the matters being studied. While there did not appear to be any hysteria the practically unanimous opinion was that if the State does not act to encourage doctors to settle in rural areas, to extend the coverage and program of health de- partments, to make hospitalization more readily available to the rural population, and to give increased aid in furnishing hospital, dental and medical care to the medically needy, the situation will become extremely critical. The statement presented at the Roanoke hearing by a representa- tive of the Federation of Home Demonstration Clubs, an organization of over 25,000 rural women, is typical (Appendix I). The members of the Committee studied the programs of several Fed- eral agencies, the programs of other states and countries and the plans which are being advocated on every hand. Much data was accumulated and analyzed. At the inception of the study, the Committee decided that many problems were common to the rural and the urban population of the State. While the number of urban doctors in proportion to the popula- tion is large as compared with the number for the rural population, evi- dence of the effects of the decrease in the number of doctors is also ap- parent in the cities. A program which will provide more medical and dental facilities and care for the rural population must also make provision for those dwelling in and around cities. The extension of State aid for the medically needy must be made equally applicable to city and country people. In short, if a person is sick he needs medical attention whether he lives in the city or on a farm. If he is unable to pay for it, he should be assisted to obtain the needed care by public aid. The Committee recognized that needed improvements in the State’s system of medical care such as are required to insure the benefits of modern medical science to all the people will take a number of years and that only a beginning can be made at this time. The Committee realized that an adequate system of medical care will involve material increases in the expenditure of public funds. The term “medical care” is used in the broad sense to cover the services of physicians, dentists, nurses, hospitals, and public health agencies. Medical Facilities Available in Rural Areas of the State 7 The Committee consulted with many experts in the field, studied the experience of hospital and medical care plans and analyzed the ma- terial before it and reported to the Council which, after careful considera- tion, makes the following recommendations: II Summary of Basic Recommendations for Immediate Action The Council recognizes that it will take a number of years to fully develop the measures needed for insuring adequate medical facilities and care for all the people. 1. Expansion of public health services to include complete coverage of the State, by local public health departments, closer relationship of pre- ventive and curative medicine, periodic examination of all school children and teachers by doctors and increased public health service responsibility for the correction of the defects revealed by such examinations are needed. (Since it is understood that the implementation of these recommendations is being dealt with in another report, this phase of the subject will not be considered here.) 2. An expanded correlated hospital and health center system to cover the State should be provided. As a beginning in the development of such a system, it is recommended that (a) .an appropriation of $20,- 000.00 be made for a hospital and health center survey; (b) provision be made for building six health centers at a cost of approximately $60,- 000.00 each with the State providing up to 75% of the cost. The cost of operation of these centers would be divided between the State and lo- calities. 3. Development of methods of furthering the financing of essential medical care for everyone is needed. The Council recommends (a) that public funds in the amount of $803,332.00, or 30c per capita of the 1940 population, be provided for extending hospital and medical care to the medically needy, the State and localities to contribute equally to this fund, the distribution of the appropriation is the subject matter study being conducted by a commission and this subject is left to the report of that commission; (b) prepayment plans for hospital, surgical and medical care should be fostered and encouraged in every way possible by all public agencies. Since reliable actuarial figures on insurance for medical and dental care insurance other than hospital, surgical and physicians care within hospitals, is lacking for rural people, and since such insurance is of great public importance, it is recommended that further study be given this matter. 4. To help to increase the supply of rural doctors, it is recommended that an appropriation of $25,000.00 a year be made to each of the two State Medical Schools for creating loan funds for medical students, to be accompanied by a pledge of stipulated service in rural areas. 5. It is recommended that hospitals and nursing homes be licensed by the State Department of Health. 6. The sum of $9,500 should be appropriated to the State Board of 8 Senate Document No. 6 Health to provide a consultant on hospital location and planning, with necessary office assistance and travel allowance. 7. The State should create a revolving hospital and health center construction and equipment loan fund of not less than $2,000,000 nor more than $5,000,000; that this fund be derived either from the general fund of the State or from funds to be invested by the State; that from this fund loans be made for the construction and equipment of local hos- pitals and health centers not to exceed 45% of the total cost of construc- tion and equipment; not including the site used for the hospital or health center, and not to exceed a total of $125,000 as a loan on any individual project; that this revolving fund be administered by a board composed of the State Commissioner of Health, State Treasurer, State Commissioner of Public Welfare, Superintendent of Public Instruction, Director of the State Planning Board, and the Governor, ex-officio; that loans be made only on projects previously approved with the cooperation of the State hospital consultant under conditions of amortization and other require- ments that may be laid down by the board provided for above; that the interests rate currently be 2%; that loans be made only to local hospital or health center boards that are self-perpetuating, are duly incorporated, have recognized local standing, and have on them at least one representa- tive of the local government, such as chairman of the board of super- visors, or the treasurer of the county or city; and that there be vested in the board making local hospital and health center loans, full authority to protect the State in the discharge of its duties. 8. It is recommended that the whole problem of medical facilities and care and the promotion of needed measures in this field be studied further by a commission; such a study would be conducted in coopera- tion with but be more inclusive than the study recommended to be made under item No. 2 above. The Medical Care Situation in Rural Virginia Ill The recommendations designed to improve medical care are justi- fied by many conditions and trends, especially as they affect rural people. This phase of the problem has been set forth in some detail in The Health and Medical Care Situation in Rural Virginia, Va. Agr. Exp. Sta. Bul- letin 363, and Rural Medical Care on the March, V. P. I. Bulletin Vol. XXXVIII, No. 4, which are available on request. Doctor Shortage and Maldistribution In hearings on Wartime Health and Education conducted by a Congressional Committee, it was reported that 33.9 per cent of Virginia counties with 25.8 percent of the State’s population had over 3,000 people per active physician on January 1, 1944, as compared to 15 per- cent of the counties with 7.5 percent of the population in 1940. “The standard of adequacy usually used by the American Medical Association and the U. S. Public Health Service is 1500 people per physician, whereas anything beyond 3,000 people per physician is usually considered Medical Facilities Available in Rural Areas of the State critical.”1 In 1944, according to the same report, the following counties had no active physician:2 County Population Cumberland 7,505 King George 5,431 King William 7,855 Mathews 7,149 Middlesex 6,673 Powhatan 5.671 In the light of such standards, the following figures are significant: Virginia Counties with 5,000 to 10,000 population per active physician, 1940 and 1944 County Ratio of Population to active physician 1940 Chesterfield 6,237 Greene 5,218 King and Queen 6.954 Richmond 6,634 1944 Bland 6,047 Brunswick 6,159 Fairfax 5.897 Floyd 5,313 Halifax 5,207 King and Queen 5.939 Mecklenburg 5,736 Princess Anne 6,473 Stafford 8,739 York 5,284 Virginia Counties with over 10,000 population per active physician, 1944 Ratio of Population County • to active physician Carroll 21,552 Franklin 21,624 In the past three years, over 800 or more than one-third3 of the 2,187 physicians said to have been in active practice in Virginia in 1941,4 have 1Hearings on Wartime Health and Education pursuant S. Res. 74, page 2121. 2Ibid. page 2122 (Varying conditions such as nearness to doctors in another county, or in a nearby city, or accessibility to a hospital, must be taken into ac- count when judging physician population ratios). 3Files of Dr. H. H. Trout, Jefferson Hospital, Roanoke, Chairman Va. Physicians Procurement and Assignment Committee. 4Estimates of Dr. George M. Lawson, University of Virginia Medical School; based on 1942 A. M. A. Directory. 10 Senate Document No. 6 been taken by the armed forces or have died, many succumbing to the strain of overwork. Before the physician losses of the war period there was for the State as a whole, one active physician to approximately 1,225 people. This would have been a good ratio if the doctors were well dis- tributed. However, according to a table compiled by the State Depart- ment of Health in May, 1941, there was then-a ratio of one doctor in general practice to approximately one thousand people in the cities, as compared to a ratio of approximately one to 2,000 people in rural areas (the term “rural” as used in these Health Department ratios, included places up to 10,000 population). This is a situation not peculiar to Vir- ginia. The figures for the few counties represented in the following Table are typical of trends in regard to physicians in rural areas. Furthermore, in 1941, 32 percent of the rural doctors were over 60 years of age, as com- pared to 23 per cent of the urban doctors.1 For further information as to Virginia’s rank in medical care see Appendix Table 1. Table—Comparative changes in the number of physicians and persons per physician in Charlottesville city and nearby counties during the 57-year period, 1886-1943 Place Physicians Persons per physician 1886 1943 Percent change 1886-1943 1886 1943 Percent change 1886-1943 Gain Loss Gain Loss Charlottesville city .... . 15 41 173 0 373 473 27 0 Charlottesville city and Albemarle county combined . 48 48 0 0 791 917 16 0 Albemarle county . .33 7 0 79 812 3,522 334 0 Buckingham county .. . 17 4 0 76 846 3,349 296 0 Fluvanna county . 14 4 0 71 679 1,772 161 0 Greene county . 12 1 0 92 468 5,218 1,015 0 Louisa county . 16 4 0 75 1,062 3,416 222 0 Madison county . 16 5 0 69 639 1,693 165 0 Nelson county . 25 6 0 76. 613 2,707 342 0 Orange county . 21 6 0 71 610 2,108 246 0 Total . 169 78 — — — — 0 Average . — — 54 694 1,548 123 0 Source: Compilations of Dr. George M. Lawson, University of Virginia Medical School and the U. S. Census of Population for 1890 and 1940. (NOTE: Charlottesville physicians serve adjacent areas in Albemarle county; also the University Hospital established since 1886. In 1945, there were only 6 actively practising physi- cians in Albemarle, 2 in Buckingham, 3 in Fluvanna, 1 in Greene, 4 in Louisa, 2 in Madison, 8 in Nelson and 4 in Orange.) x1942 Medical Directory Medical Facilities Available in Rural Areas of the State 11 The Virginia dentist situation is as critical as that for physicians. On the basis of a report of the Virginia Dental Association in February, 1944, for the State as a whole, there were 3,760 persons per dentist—urban 2,085, rural, 6,691. These ratios, like those for physicians, varied markedly in different regions of the State. The Inadequacy of Rural Medical and Dental Care In the last half century, medical and dental science have made rapid progress. However rural people are receiving less benefit from this progress than the urban population. Some of the evidences of inadequate medical and dental care for the rural population are: 1. Results of the Selective Service Medical Examinations.—The Selective Service medical examinations of Virgnia men who were called between July, 1942 and January, 1944, show a rejecton rate of 42.1 per cent for the white, and 50.3 per cent for the Negro, or a combined rejection rate of 45.6 per cent, including rejections on the grounds of mental and emo- tional instability and illiteracy.1 This was 6.4 per cent above the national average. Forty-two states made a better showing than Virginia. The per- centage of rejection for rural boys was higher than for the urban boys. A report on 1,138 youths who had been reared in North Carolina orphanages show only 16 rejected, or a rate of 1.4 per cent. Incomplete reports from Virginia orphanages give practically the same picture as North Carolina. The better showing of the orphanage youth is attributed to better medical care—regular medical examination and correction of defects with properly balanced diets and regular habits. With 734 defects per 1,000 men, Virginia was among the three states with the highest rate of total defects in the 20-odd points covered by the medical exami- nations of World War I. It was among the six highest for 13 types of defects.2 Apparently Virginia did not take the lessons of the medical examinations of the first World War seriously. 2. Physical Inspection of School Children.—Testimony before a Con- gressional committee shows a high correlation between physical defects found among school youth and Selective Service rejections. Therefore, the results of physical inspections of Virginia School children by the teachers are of interest. In 1941-42, approximately 23 per cent of the white rural youth had a five-point rating, that is, met the standard set for teeth, vision, hearing, throat, and weight, as compared to 35 per cent of the city youth.3 A wide variation between the percentage of children with physical de- fects and the percentage with defects corrected is found among the counties (Appendix, Table 2). The information given in Table 2 clearly shows the need for an expanded school health program, including periodic examinations of the school children by a physician, and a definite respons- JData from office of Virginia Director of Selective Service. Scientific Monthly, Vol. 10, 1920, page 135. based on 1941-42 report of the State Department of Education. 12 Senate Document No. 6 ibility on the part of the local health department for correction of the de- fects found. 3. Maternity Care.—The service rendered in maternal cases is another index of the adequacy of medical facilities. In 1941, there were 42,330 maternity cases in rural Virginia. Among these births, only three out of four had the attention of a physician. Only one mother in four had hospital care at the time of birth. Among these rural births, approximately 12% in the white race occurred without the attendance of a physician, and a little more than 66% among the Negro. Hospital care was received by one in three of the white births and by one in fifteen of the Negro. On the other hand, in the cities, approximately only one in 100 of the white mothers, and one in three of the Negro mothers, were without medical attendance at birth. A litle over three out of four of the urban white births, and nearly one in three of the Negro births, occurred in hospitals. A wide variation in medical care of maternal cases is seen among the counties, (Appendix, Table 3) 4 Since August, 1943, when Federal allotments were first made for the medical care of wives of soldiers in the four lowest pay grades, there has been a decided increase in the number of maternity cases receving medical and hospital care. 4. Medical Examinations of Virginia F.S.A. Clients.—Still further evi- dence of the need of more adequate rural medical care is indicated by the results of physicians’ examinations of Farm Security Administration clients. Medical examinaton of each member of 84 families consisting of 330 individuals, all in one county, shows an average of approximately 3/2 defects or conditions per family needing attention. Records of 6,315 clients of the Farm Security Administration in 1937 show 43 per cent as being unable to get needed medical care without payment being guaranteed by someone, and nine per cent claimed not to have had hospital care when needed. Forty-two per cent of the mothers, or 1,392, were said to be in need of medical attention at the time of the report. 5. Reports of Competent Observers.-—Dr. Louis S. Reed, of the U. S. Public Health Service, in a study of the medical care situation in six Virginia counties and two cities, says: “A sizable proportion of Virginia’s population fails to receive ade- quate medical care, and a large proportion is unable to pay for needed medical services, at least under prevailing methods of payment. In many areas little free service is available. Therefore, many go without needed care. The situation is more serious in rural than in urban areas because the rural population, by and large, has lower incomes. Less free service is available in rural areas, and many rural areas lack the facilities—the physicians and hospitals—necessary for provision of care. “In all places surveyed, virtually all groups interviewed stressed Special report of the Farm Security Administration. Medical Facilities Available in Rural Areas of the State 13 the seriousness of the situation with regard to hospital care; that people of low income often do not have or cannot raise the money to pay for hospital care when the need arises; that the hospitals either refuse free care or can accept only a limited number of such cases; that public funds to pay for such care are generally either non-existent or inadequate; and that consequently many are unable to obtain urgently needed care. “It was also stressed that even people in moderate financial cir- cumstances often find it difficult to pay a large hospital bill. Physicians in all the areas surveyed stated that substantial portions of their patients cannot pay for hospital care, and that they frequently are unable to obtain care for such patients. “From interviews with those in a position to observe, it appears that in the rural areas, at least, a sybstantial part of the population have accommodated themselves to meagre medical attention. They are not used to consulting a physician except in emergencies. Having never experienced adequate medical care, they do not miss what they have never had. In many of the rural areas, not only the quantity, but also the quality of service is deficient.”1 To Dr. Reed’s observations as to the inadequacy of rural medical care may be added the testimony obtained in the 1941 Virginia Rural Health and Medical Care Survey. This survey included interviews with hospital directors, public health and welfare workers, rural physicians, and hundreds of rural families. Consequences of Inadequate Medical Care The greatest penalty of inadequate medical care is paid in the suf- fering and untimely deaths caused by preventible illness. In many cases suffering includes a large amount of chronic illness involving, to a greater or lesser extent, economic loss and various social complications. Much of the poverty affecting Virginia’s rural population can be traced to illness which, in turn, is based to some extent upon inadequate medical care. 1. Loss of time.—Records kept by 984 Virginia rural families in 1941 show 29 per cent as having had members sick in bed 15 or more days, and 25 per cent with members incapacitated to some extent for 15 or more days, but not in bed. National studies indicate an average loss of seven days per year per employee.2 Approximately 140,000 Virginia people are sick each day, involving loss of time estimated at $30,000,000 per year.3 At least one-fifth of this sickness is believed to be preventable. Adequate medical care will cost a lot, but its lack costs even more. 2. Untimely deaths.—While advances in medicine and treatment of diseases have resulted in a progressive reduction in death rates as a whole, ffleed, Louis S., Medical Needs in Virginia, unpublished report of the U. S. Public Health Service. 2Falk, I. G., American Journal of Public Health, Vol. 34, No. 12, December 1944, 3Senate Committee on Health and Education, Interim Kept., January 1945, p. 5. 14 Senate Document No. 6 the rates for some diseases are still unnecessarily high. The death rate in many rural areas is higher than the urban.1 In 1941, the rural death rate for children under one year of age, per 1,000 live births, was 60, or hive points higher than the urban rate. In 1941, 31 states had a lower infant death rate than'Virginia. The infant death rate, in Virginia, is highest in the areas where doctors are fewest and farm incomes lowest. 3. Chronic i//nm.—Approximately one-half of 2,400 widely distributed rural families covered in the Virginia Rural Health and Medical Care Survey, 1941, reported one or more members with chronic ailments of some type. Chronic ailments, which greatly lessen work efficiency, were reported much more frequently among the poorer white and Negro families than among families with good incomes. Those with cash in- comes of $500 or less reported about one-third smaller average annual expenditures for medical care than those with incomes of more than $500. Interviews with doctors, superintendents of hospitals and directors of clinics, indicate that many of the chronic ailments of poor people can be traced to the lack of adequate medical care when needed. A num- ber of national studies give approximately the same picture—the lower income groups paying less for medical care in the face of a greater need with a larger proportion of chronic illness. The Cost of Medical Care in Relation to Farm Income According to the June, 1943, issue of Current Business, a publica- tion of the U. S. Department of Commerce, the average 1939 net cash farm income of Virginia farm operators was $463; in normal times, the average annual income of approximately 50,000 families, who live on farm wages, was even less. In 1939, three farm operators in eight had some additional earnings from non-farm work. In 1940, the gross farm income of the Virginia farm population was approximately $180 per capita as compared to an income of approximately $640 per capita of the non-farm population. Gross farm income includes home produced supplies to the average value of $252 per farm in 1939 and the expense of farm operation. In 1939, approximately one Virginia farm operator in three had a gross farm income of less than $600. Average farm incomes, as well as returns from non-farm work, have increased greatly since 1939, but the cost of living and farm operation have also increased. It is estimated that “The low output Virginia farm operators in 1945, numbered around 65,000 and have annual cash sales, at 1945 prices, averaging around $700, or about double the 1939 average of approximately $350.” Prices of everything purchased by such families are also much higher than in 1939. For a complete picture of the low- income rural population, about 50,000 farm wage laborer families and a large number of non-farm rural families, must be added to the low output farm operators. Appendix Table 4 11941-42 report of the State Department of Health. Medical Facilities Available in Rural Areas of the State 15 In 1941, reports of approximately 2,400 Virginia rural families give an average expenditure of $60 per year per family for all types of medical care. This is closely in line with several nationwide studies. About one-sixth of these families had medical care bills of more than $100 per year, while nine-tenths of the families had some expense for medical care during the year. For the country as a whole approximately one person in 10 is re- ported as having hospital treatment each year; one-half of the hospital admissions are for surgery. Available figures indicate that the farm people of Virginia are below the national average in both the use of hospital facilities and hospital expenditures. Distances from a doctor or hospital adds to the cost and difficulty of rural people getting adequate medical care. In 1941, reports of 894 rural Virginia families show that 52 per cent live more than five miles from a doctor, and 21 per cent live ten miles or more; 47 per cent of those living five miles or more from a doctor were charged $5.00 for a day visit, while those living within a five-mile zone were charged $3.00 a visit. Families living longer distances from doctors were reported having to pay from $5.00 to $15.00 or even more, for a day visit. The results of national medical care studies in 1941 are shown graphically in the accompanying charts. The medium income for farm families is $760 and for urban families $1,857. The average annual ex- penditures for medical care for farm families of all income groups in 1941 was $60 per family. Those with incomes under $500 spend only about one-eighth as much for medical care as those with incomes of from $3,000 to $5,000. (See Appendix Charts I and II.) Aside from humanitarian considerations, adequate medical care within the financial reach of rural people is a matter of concern to urban centers as well as to country folk themselves. The country is a population seed bed from which cities must be constantly replenished. The good health of workers from rural areas should be a matter of great interest to industrial concerns. According to an inquiry made in 1941 by the Experiment Station the cost of medical care is greatly out of proportion to the income of farm people. The same study shows that many doctors in rural areas do not have large professional incomes. Net professional income of 231 rural doctors by income groups and years practicing, as reported for 1941 income taxes. Reporting Years Practicing Income Groups Number Percent Under 10 11-29 Over 30 Under $1500 48 20.8 4 10 34 $1500 - 2999 70 30.3 14 21 14 3000 - 4999 50 31.6 12 16 37 5000 - 6999 34 14.7 4 18 11 7000 and over 29 12.5 7 11 7 231 41 76 105 16 Senate Document No. 6 Health Centers IV In this report, it has been shown that even before so many physi- cians joined the armed forces, a long-standing dearth of doctors existed in the rural areas. Those remaining were in the older age group and the younger recent graduates almost invariably settled in urban practice. This appalling lack of adequate medical care in country districts is recognized by both medical authorities and the laity, as evidenced by the discussion about the subject carried on in political and medical circles during recent years. The lack of adequate medical care and facilities in the rural areas is of immediate and fundamental importance. What are the existing reasons for the flow of doctors into the cities, leaving the rural areas without sufficient medical care? Many factors play a part in this situation. Of primary importance is the fact that medical education has undergone radical changes in the past twenty- five years or more and, that young doctors are now trained to utilize to the fullest laboratory and other facilities which are not now available in the country districts because of the expense of purchase and main- tenance, the lack of time to perform tests, and the absence of technical help to aid in making the various tests. The stimulus to the use of such facilities, even if they were on the spot, must come from intellectual contact with one’s medical colleagues, which is impossible with the pressure and isolation experienced in practicing medicine in the coun- try today. Financial return must too play a part, for the education of a doctor is a long and costly affair, and the city practice is more re- munerative under present conditions. The social welfare of the popula- tion as a whole is inseparable from this problem and where the basic income is greater, better medical care is invariably present. In a hear- ing before Congress on the Hill-Burton Bill, S-191, Senator Pepper gave the following figures: No. of Per cent of Average amt. of Total amt. spent Per cent Families U. S. Population income per on medical care of income year per year 6,900,000 21% Less than $1000 $ 42 6.8% 9 800,000 29% $1000 to $2000 $ 68 4.5% e'800,000 20% $2000 to $3000 $ 96 3.9% 6,700,000 20% $3000 to $5000 $143 3.7% 3,300,000 10% $5000 or more $241 2.4% Ninety-four per cent of the total United States population earns less than $5,000 per year. Some doctors move to the city when their children come of school age because of poor educational opportunities in the rural areas. Analysis of the plans of 60,000 doctors in the armed forces show that only 12% indicate a desire to return to rural practice and most of these will only go to the country if hospital facilities and opportunities for group practice are available. This number, 12%, will only scratch Medical Facilities Available in Rural Areas of the State 17 the surface of solving the problem, so we must look elsewhere for the solution. Before our present era of war prosperity, 33% of the population received free medical care of one sort or another, according to Dr. Thomas Parran, Surgeon General of the Public Health Service. Elsewhere in this report it is shown that (a) facilities must be pro- vided for adequate care and (b) that coincidentally plans must be made to assist the medically needy. Solutions: Adequate medical facilities and personnel are fudamental. All are agreed upon this fact. Provision of these must go hand in hand with preventive medicine and the development of health departments for all of the State. Establishment of so-called “health centers” which will pro- vide public health facilities combined with curative medicine is in our opinion of primary importance and should be the first move in any over- all plan. In such centers, there should be provision for doctors’ and dentists’ offices, technical personnel, clinic rooms and a small x-ray unit. A few beds must be provided in these units, ten to fifteen in the smaller, so that certain patients and obstetrical cases can be handled efficiently. It is estimated that approximately fifty health centers should ulti- mately be provided for the State of Virginia, the location of which to be decided upon after a comprehensive survey. Studies have been made by the United States Public Health Service and three general types of centers were developed as a result: Type A, to serve a population under 30,000, type B, to serve a population of 30,000 to 60,000 and type C, to serve a population of 100,000 or more. In the original plans developed by the United States Public Health Service no provision was made for doctors’ and dentists’ offices and patients’ beds. We think these are essential in most in- stances and should be an integral part of the plan. While many of these structures may be isolated, it is recognized that some may be built in connection with adjacent existing hospital facilities. The Council recommends the immediate establishment of six units costing about $60,000 each, estimated on the basis of current costs either type A or B, in areas to be selected. We feel that these should be planned and begun even before a state-wide survey for overall need of health centers and hospitals can be completed. The Council recommends that such a survey, which will also include the need for hospital beds, be immediately instituted and an appropria- tion of $15,000 in this biennium be made for this purpose. The Coun- cil believes that Federal aid will be forthcoming in the future for these projects but they feel that a start must be made now to enable the State to efficiently take full advantage of this aid. The administrative control of such units must perforce be under some agency and that should be, in the opinion of the Council, the State Department of Health. However, because of the scope of the serv- 18 Senate Document No. 6 ice rendered, an advisory council should be set up for each center com- posed of the local health board, (chairman of the board of supervisors, secretary of this board, a dentist and a physician and, in addition, mem- bership from the local medical society, local welfare representative and prominent citizens). The local responsibility must be developed to the utmost. The decisions regarding the practice of medicine in these centers and matters regarding medical ethics, etc., should be'discussed and de- cided by a State Advisory Committee on Medical Practice, composed of ten members, of whom nine would be appointed by the Governor. The State Medical Society should submit at least three nominations for each position on the Committee but the Governor would not be limited in his appoinments to such nominations; the Governor would, however, be required to appoint a member from each Congressional District, and the State Health Commissioner would be an ex-officio member of the Committee with full right of voting and participation in the decisions of the Committee. Initial appointments would be made as follows: three members would be appointed for terms of one year, three for terms of two years and three for terms of three years. At the expiration of such appointments their successors would be appointed for terms of three years. No member would be eligible to succeed himself for more than one term ’ (initial appointments would not be counted as terms when the Committee is first established) without a lapse of at least three years between terms. The cost of construction of these health centers should be on the basis of not more than seventy-five per cent appropriated by the State and not less than twenty-five per cent by the local area served. The cost of maintenance of these centers should be divided between the State Health Department and the area served, which would support certain facilities, laboratory, technical help, health officers, public health nurse, etc. V Two-Fold Purpose of Medical Facilities.—Hospitals, medical centers, and diagnostic laboratories serve two fundamental purposes: (1) the admini- stration of preventive and curative medicine in all of its branches for the welfare of the general public, and (2) attraction and continuance of able practitioners of medicine and health authorities required to assure high class services. The average layman hardly realizes that medical facilities have become the sine qua non of medical practice both preventive and curative. He is likely to think of a hospital, for example, as a place to secure treatment when he is ill, forgetting that this type of “work shop” is just as essential to the physician as a university laboratory is to the scientist or a school building to the teacher. As the physician of the older day, practicing in rural communities, passes away, which un- fortunately we note on every side, there are few doctors to take their Facilities for Medical Service and Practice Medical Facilities Available in Rural Areas of the State 19 places because current medical education and practice presuppose cer- tain facilities which must be made available. This means that no rural state like Virginia can solve its rural medical care problem merely by multiplying the graduates of its medical schools. To assure physicians and allied health personnel these essentials must be provided: (1) Facilities for practice such as diagnostic labora- tories and hospitals of varying size and scope as local conditions re- quire, as mentioned above; (2) opportunities for association with other practitioners and auxiliary personnel to supplement their own interests and abilities; (3) reasonable economic returns; (4) desirable living con- ditions as will make for rearing a family in proximity to good schools, churches, and other cultural influences. Virginia Lacks Medical Facilities.—Inasmuch as the requirements of the State in health centers will be discussed elsewhere in this report this section will be limited to a discussion of Virginia’s requirements in hos- pital beds. In 1940 the United States was reported as having almost 3.9 hos- pital beds per 1000 population, not including beds for mental disorders, tuberculosis, communicable diseases, or convalescents. This falls short of the current standard set, 4.5 per 1000 population. At the same time Virginia was said to have 3.1 hospital beds, ranking thirty-third in the nation, but it must be borne in mind that the distribution of hospital beds is also an important consideration. Many cities of our country and nine states have reached the standard of 4.5 beds per 1000 population but in no rural state like Virginia are hospital beds made available within reasonable distance, 25 to 40 miles, of most citizens. With better roads and better transportation this distance may have to be extended in considering making hospital beds reasonably available. Sixty-three of our rural counties recently studied by the Farm Security Administra- tion showed an average of 1.1 beds per 1000 rural population. From this it can be seen that much remains to be done in supplying hospital beds for our total population; on the other hand it must be remembered that if the standard of 4.5 beds per 1000 population is a reasonable one it can hardly be expected, or even wise, to make this number available within all rural districts, because inevitably many rural people patronize city hospitals, and to that extent as far as hospitals go they cease to be rural. The very complexity of this situation suggests that the location of hospitals is a complicated matter, requiring the most careful study. Providing for Organized Hospital Systems by Regions.—The complexities of modern medicine as stated are such that the young graduate can no longer establish himself at the crossroads and work in isolation; nor can diagnostic centers and community hospitals be expected for long to perform their functions as they should in isolation. The time is fast ap- proaching when the smaller hospitals will also seek association with other larger hospitals for the assistance which they can give. Leaders in this field today emphasize that medical facilities from the smallest to the 20 Senate Document No. 6 largest units must for maximal results be organized into systems with a medical center or “base hospital” at the center of each, with strategically located community hospitals and health centers, organized like a solar system. See plan on following page. The purpose of this organization is not merely to provide for easy referral of difficult or complicated cases from the smaller to the larger institution but equally important to pro- vide consulting service, both laboratory and clinical, working out from the center to the circumference of the organization, to afford on an itinerant basis what the small communities lack and at the same time make possible a continuation education program both in the field and at the central institution of the system. This educational program is as much the heart of the regional hospital organization as any of its many other features, including large economies through joint purchasing. Developing a hospital system for a Commonwealth like Virginia will take time but unless Virginia can take initial steps now in providing local hospital facilities and can properly organize them, inevitably our rural population will be left without medical care. Ultimately Virginia should probably have three hospital regions: One, roughly defined as covering Southwest Virginia, one organized with the University of Vir- ginia medical school and hospital as its center, and one organized around the Medical College of Virginia. In working out any such plan all local hospitals, whether non-profit community organizations or private institu- tions, must be taken into consideration. Health like education is close to the hearts of our people and hospi- tals like schools will in time come largely under the control of local lay boards, supplemented by medical advisory committees. The physician should no longer be expected to provide his hospital any more than the teacher is expected to provide his school building; these are local responsibilities with such help as may come from State and Federal governments. In many respects hospital development, though considerably later, parallels our school development. We should be able to avoid the mis- takes of the latter in establishing community hospitals. Their size and distribution must be accurately related to the population groups which will use them; a fifty-bed hospital, for example, designed to add fifty more beds, should be located in a trading center with a population of 50,000 within a radius of thirty-five miles. Patients can be transported by ambulance, or otherwise, if necessary, not unlike school children are transported, but of course in less numbers. Some states have developed a regular ambulance system controlled by its chief medical center. Hospital development most naturally occurs near the larger consolidated schools and other public undertakings of widespread interest to our people. Im- portant State and local activities should be planned on the basis of functional association. Hospitals have long appealed to the generous as suitable memorial structures and activities. Following the greatest war in history com- munities will be considering proper war memorials. Already a trend towards planning living memorials is evident. The question naturally Coordinated Hospital Service Plan Plan provides for constant exchange between hospitals of information, training, and consultation service, and personnel, and for'referral of patients when indicated. The health centers may vary in size and scope of service offered. .BASE DISTRICT RURAL HEALTH CENTER Teaching Research Consultation CANCER CLINIC PSYCHIATRIC SERVICE HEART CLINIC MAJOR SURGERY INTERNAL MEDICINE OBSTETRICS PEDIATRICS ORTHOPEDIC SURGERY COMMUNICABLE DISEASES TUBERCULOSIS VENEREAL DISEASE TEACHING NURSES INTERNS RESIDENTS POST-GRADUATES LABORATORY X-RAY PATHOLOGY BACTERIOLOGY CHEMICAL PHYSIOTHERAPY DENTISTRY EYE, EAR.NOSE, THROAT .DIETETICS Aajor SURGERY OBSTETRICS INTERNAL MEDICINE COMMUNICABLE DISEASES TUBERCULOSIS VENEREAL DISEASE OTHER PEDIATRICS EYE, EAR. NOSE. THROAT DENTISTRY PHYSIOTHERAPY LABORATORY X-RAY PATHOLOGY BACTERIOLOGY CHEMICAL TEACHING NURSES INTERNS DIETETICS INTERNAL MEDICINE OBSTETRICS EYE,EAR, NOSE, THROAT DENTISTRY MINOR SURGERY LABORATORY X-RAY BACTERIOLOGY OBSTETRICS EMERGENCY MEDICAL AND SURGERY LABORATORY X-RAY BACTERIOLOGY DENTISTRY PRIVATE OFFICE OR OFFICES FOR PRIVATE PHYSICIANS ADMINISTRATIVE PUBLIC HEALTH OFFICES HEALTH OFFICER SANITARIAN PUBLIC HEALTH NURSES PUBLIC HEALTH CLINICS MATERNAL AND CHILD HEALTH TUBERCULOSIS VENEREAL DISEASE PUBLIC HEALTH EDUCATION PLAN DRAFTED BY THE U. S. PUBLIC HEALTH SERVICE. HOSPITAL HEALTH CENTER INSTITUTION (CHRONIC DISEASE) NURSING HOME (CHRONIC DISEASE) A Coordinated Hospital Health Plan A Necessity in the Practice of Modern Medicine Medical Facilities Available in Rural Areas of the State 21 arises as to whether a more really useful living memorial could be found than a hospital or a health center. Their construction should be widely encouraged but in doing so care must be exercised to prevent the great hazard of wrongly placed and oversized service units. Misdirected local pride and patriotism can often easily enough make buildings available without adequate resources for operation. Planning and locating a hos- pital is work for .experts, requiring exacting surveys. The hospital site as well as the building itself call for the work of specialists; unfortunately, their number is limited at this time. On that account and to secure the best return for funds spent the State should provide this service through the State Health Department. Future Pattern of Medical Practice.—The trends of medical practice today definitely indicate that tomorrow a much smaller percentage of medical care will be delivered to the homes of the sick, a consideration to be properly weighed in planning better health service for our people. When those who live in the country require medical service except when desperately ill, they increasingly will seek this in a doctor’s office, often located in or near a medical center or community hospital. If bed care is required that will be taken care of locally as far as possible. If no hospitalization is recommended the patient will be seen subsequently in the doctor’s office. There are communities now in this country where the public has been trained to go to a community hospital for service either as an outpatient or as an inpatient with only occasional home calls to meet emergencies. This involves proximity, good transportation, good physical facilities and good personnel. When the patient travels more, not infrequently when he goes to town on business, and the physi- cian travels less the community can get along with fewer physicians. Another trend of our time which is likely to assume even more rapid tempo after the war is the practice of doctors, dentists, and techni- cal personnel to associate themselves in groups, frequently in or near hospitals, with advantage both to the patient and to the practitioner. Many practitioners in the armed services have had the very kind of ex- perience which has deepened their convictions about the wisdom of group practice and not a few have indicated that they will never return to individual practice again. There are many who believe that the ac- celeration of this type of practice will be hastened as a result of the war far beyond what could have otherwise been expected. It should be pointed out that Virginia in common with other states has sparsely settled or isolated communities to which the delivery of medical services needed can never be expected unless the physicians serving them are given a subsidy by the State or by a corporation for whom the potential patients of the area may work. This has to be borne in mind in any over-all plan of medical care. Such communities cannot support local hospitals and some of them may be even inaccessible to health centers for they, too, must be located strategically. 22 Senate Document No. 6 VI The Supply of Rural Doctors One of the most alarming trends in recent years as regards the medical care situation is the steady decrease in the number of doctors in rural areas and, as pointed out elsewhere in this report while the num- ber has decreased the average age of those in rural practice has increased greatly. One of the causes for this has been the lack of proper local facilities needed by these doctors to engage in the practice of medicine. The recommendation as to establishing rural health centers will supply the facilities but some method is needed to foster the location of doctors in rural areas. In 1942 the General Assembly of Virginia passed an act (Acts 1942, p. 531) authorizing the two medical schools to establish four annual medical scholarships in each school. These scholarships were to be granted to residents of Virginia who would contract to engage in the practice of medicine in a rural community in the State, selected by the State Health Commissioner with the approval of the State Board of Health, for a period of years equal in number to the years that such person was the beneficiary of such a scholarship; a year’s internship in a rural hospital under certain conditions was considered the equivalent of a year’s practice of medicine in a rural community. $2200 a year was appropriated to each of the two medical schools for such scholarships; the value of the scholarships was $550 each. Due to the war and the program of the armed forces, which placed all able-bodied medical stu- dents in a training program at federal expense and required them to enter the armed forces upon their graduation, carrying out the progrem envisaged by the 1942 act has not been possible. After the close of the present war it is the opinion of the Council that the program set forth in the 1942 act should be enlarged materially. There are many young men and women in rural areas who wish to become physicians but, due to the high cost of medical education, are not able to afford it. By granting a service scholarship under the con- ditions outlined the State and the public will profit materially. Some of the recipients of these scholarships, as soon as they complete their term of practice in rural areas, will move to the cities but many of them will remain in the country if the health centers recommended and ad- ditional centers are established. The program is necessarily slow but it has the merit at least of being sure. The alternatives to this method of inducing doctors to establish in rural communities are to grant a subsidy to doctors who are willing to locate in such areas or to permit the supply of rural doctors to take care of itself. The first of these alternatives will require large outlays of public funds, close supervision on the part of the State Health Department, constant criticism that such doctors are not giving efficient service, and hostility on the part of the other doctors in the area who are not receiving a subsidy. The second alternative will mean that those persons living Medical Facilities Available in Rural Areas of the State 23 outside of urban areas will receive less and less adequate medical care. In this event it is quite likely that the Federal government will step in. The recommendation of the Council is therefore that the sum of $50,000 a year be- appropriated by the General Assembly for establish- ment of such service scholarships. This sum will be divided equally be- tween the two medical schools to establish these service scholarships annually under the terms of the 1942 act. VII Financing Medical Services The Council is convinced that some better method of financing medical services is essential to the improvement of the medical care situation. It believes that plans to this end should be based on the fol- lowing governing principles; (1) everyone, as far as able, should pay the cost of their medical care, (2) where a family is financially unable to pay for essential medical services, the cost should be borne wholly or in part by the public, thus making real the principle that everyone should receive medical and surgical care as an inherent right—not as a matter of charity, (3) public aid for medical care is a local, state and national responsibility, (4)' the administration of public aid for medical care should, as far as possible, be local, (5) any program for financing medi- cal services should be such as to encourage the medical care essential to positive health, (6) greatly extended use should be made of the insurance principle in connection with payment for medical care, (7) any plan adopted should be sufficiently flexible to be adjustable to an expanding medical care program. The Council recognizes that proposals for improvements in the present system of financing medical services must take account of vary- ing conditions and needs of different elements of the State’s population, such as: (1) The fairly prosperous commercial farm families and the non- farm rural families of similar status who can pay medical bills without great difficulty—approximately /% of the rural population. (2) The indigent rural group which is estimated by the State De- partment of Public Welfare to number at least 30,000 families in normal times. (3) The low income and marginal standard of living rural group just above the indigent line, or the medically needy who pay medical and hospital bills with great difficulty and frequently go without ade- quate medical attention because of the cost, in normal times over 1/3 of the rural population, or approximately 150,000 families. A recent estimate made by a representative of the United States Department of Agriculture, Bureau of Agricultural Economics, places the present num- ber of Virginia medically needy rural families at 85,000. (4) The chronically ill or incurable cases for whom their families are not in position to properly care. Such cases are found in all groups, 24 Senate Document No. 6 but they are most numerous among the indigent and other medically needy where proper medical care has been long neglected. (5) The urban indigent and medically needy. Urban people gen- erally have easier access to hospitals and other medical care facilities than rural. In cities, there is better provision for aid to the medically needy. Income levels are generally higher and hospital and surgical insurance under existing plans are more common and easier to admin- ister. Although the present report is primarily concerned with rural needs, it is not possible or desirable to entirely separate the rural and urban aspects of medical care or its financing. The medically needy urban groups are in need of further public aid as well as rural—a situa- tion of which a comprehensive plan must take into account. The Council also recognizes that every family not only needs to make provisions for catastrophic illness which requires expensive hospital and nursing care, but that most families also have doctors’ home or office bills, the expense of drugs and dental work and frequently charges for eye examinations and glasses. The Council believes that with a better system of financing medi- cal care, a system which will make possible fuller use of available aids to positive health, all types of medical care expense will tend to decline. To this end it advocates the development and support of prepaid medi- cal care plans. Hospital insurance is available to Virginia people through Blue Cross plans, the Farmers’ Health Association (F.S.A. clients only) and commercial companies. See Appendix Chart III for urban and rural participation in prepayment plans. The last two furnish surgical in- surance as does the Virginia Medical Service Association which together with commercial companies also have contracts to cover physicians’ hos- pital care. A Blue Cross Association, a non-profit organization sponsored by the American Hospital Association, was first organized in Virginia in 1936. On January 1, 1945, the five Blue Cross Associations now operating in the State had 167,939 members, or 6.1 percent of the State’s popula- tion. Blue Cross Associations in the nation as a whole, have grown in seven years from a little over one-half million members to the present enrollment of over 16 million. Such phenomenal growth indicates that hospital insurance meets a very definite public need and hence should have every possible encouragement as a desirable means of financing catastrophic medical care expenses. In Virginia most of the hospital insurance through Blue Cross plans is among urban families. In the Experiment Station survey of 2400 rural families in 1941, less than four percent of the white and one and one half percent of the Negro families, reported having hospital insurance. The Virginia (formerly the Richmond) Hospital Service Association and the Roanoke Blue Cross Association have recently begun efforts to reach rural members. It is the opinion of many students of the subject that in view of the normally low income of a high percentage of rural families, and the need of providing for the cost of other medical care needs, neither the Blue Cross plans nor commercial insurance com- Medical Facilities Available in Rural Areas of the State 25 panics will reach a large proportion of rural families, probably less than half, unless they are able to furnish more complete service at a smaller cost. For instance, the Virginia Hospital Service Association contract which provides for a semi-private room and certain hospital services, costs $2.00 per month per family. The Medical-Surgical-Obstetrical Service of the Virginia Service Association also costs $2.00 per month per family. The Roanoke Blue Cross Association has a ward contract for $1.40 per month per family, with the same hospital service as the more expensive one. Several states, especially those where Blue Cross plans operate on a statewide basis, have succeeded in getting cheaper hospital insurance than the rates now prevailing in Virginia. After reviewing the situation, the Council concludes: a. That actuarial data is inadequate on which to base rates for some types of insurance, especially for rural families. b. That a high percentage of families, particularly rural families, in normal times are unable to pay the full cost of complete medical care insurance; which, in the few places where it has been tried, amounts to from $40 to $60 per year per family. c. That the collection of medical care insurance from rural families is more costly and more complicated than where premiums can be taken from payroll deductions. In view of these complications, the Council concludes that before final recommendations, further study of the subject should be made, and possibly some experimentation with complete medical care insurance for rural people should be conducted in a limited area. With the several considerations outlined above in mind as steps toward better means of financing medical services, the Council rec- ommends: 1. For those able to pay their own medical care bills without public aid: That there should be greatly extended use of prepayment or in- surance plans. II. For the medically needy requiring some public aid: 1. That an appropriation be made of $803,332 per year, or 30 cents per capita of the 1940 population, in addition to the present ex- penditures of the Departments of Public Welfare, (Appendix Table 5), and the expenditures of the two medical school hospitals, for medical treatment and hospital care of the indigent. 2. That the State’s appropriation be alloted to the several counties and cities on the basis of a fair formula. 3. That the appropriation be used to aid in securing needed medical treatment and hospital care for both the indigent and the medically needy above the indigent line. 4. That the appropriation be administered by an appropriate agency. (While a certain part of the appropriation will for a time need to be used in extending aid to chronic or incurable cases, it is expected that more adequate permanent provision will be made for such cases through the work of some other Committee.) 26 Senate Document No. 6 Licensing Hospitals VIII The hospital and nursing home picture in Virginia today is as fol- lows: there is absolutely no limitation on who may establish or operate a hospital or nursing home. There are many safeguards thrown around the practice of medicine, dentistry, nursing and other aspects of the heal- ing art. Yet a most important step in the curative process—the nursing home or hospital—has no safeguards whatever thrown around it to in- sure that patients will be cared for under sanitary conditions and with the proper facilities as regards housing and equipment. No one knows how many nursing homes there are in Virginia because there is no re- quirement as to reporting the establishment of such businesses. The number of hospitals is fairly well known, though establishment thereof need not be reported. By statute a person operating a hotel of a certain size must have fire escapes; a person desiring to enter the small loan business must obtain a license from the State Corporation Commission; anyone desiring to practice any one of many professions must take an examination in order that his qualifications can be determined. It appears that the care of the ill and convalescent should be safeguarded to the extent of at least assuring them of safe housing and sanitary surroundings. The lay- man cannot judge whether a particular hospital is or is not properly run and maintained. Nursing homes which ordinarily care for the con- valescent or chronically ill should be subject to regulation in the interest of the patient to avoid abuse since persons entering such institutions are usually not capable of passing upon the sanitary and medical facilities in the home. Hospitals and nursing homes which are properly housed and staffed have an important place in the care, cure and treatment of the sick, convalescent or chronically ill and their establishment and operation should be encouraged and protected. On the other hand, any such insti- tution which is improperly housed or operated can be a very serious menace to those entering them for treatment. The Council is aware of the criticism which has been directed at unlimited grants of the rule-making power to administrative agencies under the police power of the State and it is of opinion that such criti- cism is frequently justified. It has sought in the bill attached to limit the exercise of the power as far as possible by writing into the law the standards which should be maintained. It is not the wish of the Council to put anyone out of business nor to hinder the establishment and opera- tion of facilities for the ill. It does believe that any person who enters a hospital or nursing home should be able to do so, knowing that the housing is adequate, that in case of fire or other disaster he can readily escape, and that in the operation of the establishment such sanitary measures are enforced as will insure that his stay in the institution will not endanger his health or life. The Council submits that under present conditions, except as to institutions which are accredited by national Medical Facilities Available in Rural Areas of the State 27 organizations, there is no assurance whatsoever as to these matters. In closing, the Council wishes to point out the salient features of the bill. All hospitals and nursing homes are required to be licensed by the State Department of Health. They are required to be housed in buildings which are reasonably fireproof if the patients are housed above the ground floor. In any case where patients are housed above the ground floor proper fire escapes must be provided. A hospital must be staffed by licensed doctors. Nursing homes must have at least one registered nurse in charge. The water supply must be from an approved source and sanitary and waste disposal facilities must be provided in such a way as to avoid the transmission of communicable diseases. All such institu- tions are subject to inspection by the Department of Health at reason- able times and intervals. Food must be prepared by persons having certificates that they are free from certain diseases, and shall be prepared and served in a sanitary manner. The licenses of such institutions may be revoked for failure to observe such measures. The Department of Health may provide by regulation for such other matters as will pro- mote the safety, and insure proper treatment, of the inmates. Provision is made for different treatment, in certain respects, of existing and future hospitals. The Council acknowledges its appreciation for the services rendered by the members of the Committee who gave bountifully of their time, knowledge and best endeavor to the work of the Committee. The Assist- ance rendered by the officials of Virginia Polytechnic Institute and the Experiment Station in making available the services of Dr. W. E. Gar- nett is gratefully acknowledged. Respectfully submitted, Edward L. Breeden, Jr., Chairman Edward O. McGue, Jr., Vice-Chairman Willis E. Cohoon Charles R. Fenwick Garland Gray E. Glenn Jordan E. Blackburn Moore John B. Spiers Robert C. Vaden 28 Senate Document No. 6 A BILL To amend the Code of Virginia by adding in Title 15 entitled “Public Health”, a new chapter numbered 63A, entitled “Licensing and Inspection of Certain Kinds of Hospitals” and 16 new sections therein numbered 1514-a 1 through 1514-a 16, in order to provide for the regulation of. the establishment and operation of certain kinds of hospitals in the exercise of the police power in the safe- guarding of the health, safety and welfare of members of the public when patients or inmates in such hospitals and to such end, to re- quire all such hospitals to be licensed, inspected and supervised; to provide for the issuance by or under authority of the State Board of Health of licenses for the establishment and operation of such hospitals; to provide likewise for their inspection, supervision and regulation in accordance with the provisions hereof and the pro- visions of rules and regulations made under authority of law; to provide for the payment of certain fees; to authorize the Board to make, promulgate and enforce reasonable rules and regulations in accordance with the guiding principles hereof governing the exercise of its functions hereunder of issuing licenses to, inspection, super- vision and regulation of, such hospitals; to provide for revocation of such licenses under certain circumstances; to provide for review by the courts of actions hereunder in certain circumstances; to provide for injunctions to prevent continuance of operation in certain cases; to prescribe penalties for violation of provisions hereof or of valid rules and regulations made under authority of law; to prescribe effective date or dates for the operation hereof or of certain provi- sions hereof. Be it enacted by the General Assembly of Virginia: 1. That the Code of Virginia be amended by adding in Title fifteen entitled “Public Health”, a new chapter numbered sixty-three A entitled “Licensing and Inspection of Certain Kinds of Hospitals” and sixteen new sections therein numbered fifteen hundred fourteen-a one through fifteen hundred fourteen-a sixteen, as follows: CHAPTER 63A Licensing and Inspection of Certain Kinds of Hospitals Section 1514-a 1. Short title.—The short title of the law embraced in this chapter of the Code is Virginia Hospital Licensing and Inspection Law. Section 1514-a 2. Definitions.—As used in this chapter unless a different meaning or construction is clearly required by the context or otherwise (1) the expression “the law”, “this law”, means the Virginia Hospital Licensing and Inspection Law as embraced now or hereafter in this chapter of the Code; (2) “person” means and includes individual, partnership, association, trust, corporation, municipality, county, State and local governmental agencies, and any other legal or commercial Medical Facilities Available in Rural Areas of the State 29 entity and every manager or operator of a hospital embraced in this law, as requisite, excepting the United States, its departments and employees, and agencies thereof solely owned or directly controlled by it; (3) “hospital” means any institution, place, building or agency by or in which facilities for any accommodation are maintained, furnished, conducted, operated or offered for the hospitalization of two (2) or more non-related mentally or physically sick or injured persons, or for the care of two (2) or more non-related persons requiring or receiving medical or nursing attention or service as chronics, convalescents, aged, disabled or crippled, including, but not to exclusion of other particular kinds with varying nomenclature or designation, ordinary hospitals, sanatoria, sanitaria, rest homes, nursing homes, infirmaries and other related institutions and undertakings, exclusive of maternity hospitals to the extent same are included within the scope of the provisions of chapter three hundred twenty-two, Acts nineteen hundred forty, as from time to time amended, so long as the licensing, inspection and super- visory provisions thereof remain in full force and effect but no longer, and exclusive of dispensary or first aid facilities maintained by any commercial or industrial plant, educational institution or convent, and exclusive of those State institutions now or hereafter subject to control of the State Hospital Board; (4) “Board” means the State Board of Health; (5) “Commissioner” means the State Health Commissioner;; (6) “non-related” means not related by blood or marriage, ascending or descending or first degree full or half collateral. Section 1514-a 3. Establishment or operation of hospitals prohibited without license.— (a) After December thirty-one, nineteen hundred forty- six no person shall establish, conduct, maintain or operate in this State any hospital as defined in and included within the provisions of this law without having a license so to do as provided in this law. (b) No license issued hereunder shall be assignable or transferable. (c) No person shall establish, conduct, maintain or operate in Vir- ginia any new hospital without first having obtained a license as pro- vided in this law. (d) No person may continue to operate an existing hospital unless such operation is approved and licensed as provided herein, provided that all hospitals in actual bona fide operation on the date of passage of this law shall be given a reasonable time not exceeding six months from December thirty-one nineteen hundred forty-six to comply with the minimum standards and requirements prescribed by this law and by all applicable rules and regulations adopted in accordance with law. Section 1514-a 4. State Board of Health to issue licenses to and inspect hospitals; additional personnel, etc.— (a) The State Board of Health shall issue licenses to establish, conduct, maintain and operate hospitals which after inspection by it or under its authority are found to have complied with the applicable provisions of this law and with all ap- plicable valid rules and regulations adopted by it under authority of law. (b) The Board shall cause each and every hospital subject to pro- 30 Senate Document No. 6 visions of this law to be periodically inspected in accordance with the pro- visions of this law and of the rules and regulations adopted by it as provided by law. (c) The Commissioner is authorized to employ such additional technical and secretarial assistants as found necessary to administer and enforce the provisions of this law and fix their compensation, subject to such limitations as imposed by the current appropriation and by the applicable laws and regulations governing personnel; except that no such existing hospital shall be required under the provisions of this law or by any rule or regulation made by the Board to comply with the re- quirement of section fifteen hundred fourteen-a five (a) (1514-a 5 (a)) as to rendering its then existing building “reasonably fireproof” but in lieu thereof it must provide reasonable protection against fire hazard to patients or inmates in all cases in which a new hospital or newly con- structed portion of a hospital would under the provisions of section fifteen hundred fourteen-a five (a) (1514-a 5 (a)) have to be or be made “reasonably fireproof”. Section 1514-a 5. Minimum standards and requirements.— (a) Every hospital shall be located in a building which is fireproof if patients or inmates are or are proposed to be placed above the ground floor and in every case in which patients or inmates are placed or are pro- posed to be placed above the ground floor proper fire escapes, reason- ably accessible to the rooms in which patients or inmates are located or are to be located, with proper provisions and facilities for guiding lights, must be provided. (b) Every hospital undertaking to furnish facilities for the treat- ment of disease or for the performance of operations therein must be staffed by licensed doctors. Every hospital undertaking the care of in- mates to the exclusion of furnishing facilities for treatment of disease or performance of operations must have at least one registered nurse in charge. (c) Water supply must in all cases be from an approved source. Sanitary and waste disposal facilities must be provided in such a way as to avoid transmission of communicable diseases. Food must be prepared by persons having certificates of freedom from diseases known to be or probably communicable by contact or through the alimentary canal, particularly venereal diseases, active pulmonary tuberculosis, and diseases as to which the science of the particular time indicates that there are or may be carriers of the germ of the disease even though there be no active illness from the disease. (d) Preparation and service of food in all cases must be under sanitary conditions and in a sanitary manner. (e) The foregoing and all other requirements imposed by or under authority of this law having in view the health, safety or welfare of patients or inmates of hospitals shall be construed as being cumulative and supplementary to all other applicable requirements, State or local, having in view the same or similar objectives or any of them. Medical Facilities Available in Rural Areas of the State 31 Section 1514-a 6. Board authorized to adopt rules and regulations prescribing additional minimum standards, etc.—(a) In addition to the general authority heretofore or hereafter conferred upon the Board to prescribe rules and regulations it may provide by reasonable rules and regulations as to such other relevant matters as will promote the safety and insure proper attention and service to and care of patients and in- mates of hospitals and it may classify hospitals in accordance with the character of treatment, care, or service rendered or offered, and prescribe the minimum standards and requirements for each class in conformity with provisions of this law, with the guiding principles expressed or im- plied herein, and with due regard to and in reasonable conformity to the standards of health, hygiene, sanitation, and safety as established and recognized by the medical profession and by specialists in matters of public health and safety. (b) The Board may modify, amend, add to or rescind any such rules and regulations from time to time as the public interest appears to require provided that no such change in existing rules and regulations detrimental to the interest of any existing licensee shall be made effective in less than thirty (30) days from date of adoption except in case of extreme emergency. Section 1514-a 7. Rules a:nd regulations, when effective, etc.—All such rules and regulations shall be made effective only after a reasonable time, not less than thirty (30) days after date of adoption, except in case of extreme emergency, shall at all times be available for inspection during business hours at the office of the State Department of Health, and printed copies shall be made available to licensees and to others having apparent interest to such extent as is reasonably possible under then exist- ing circumstances. Section 1514-a 8. Application for license.—Any person desiring a license to establish a hospital or to continue the operation of any exist- ing hospital shall file with the Board a verified application setting forth the name, age, which must be at least twenty-one, and address, of the applicant; that he is of reputable and responsible character; the class or kind of hispital being or proposed to be operated; the location thereof; the name of the person in charge; and such additional relevant informa- tion as the Board requires. Applications on behalf of a corporation or association or a governmental unit or agency may be made and verified by any two officers thereof. Section 1514-a 9. Fees.—(a) Each application for a license to operate a hospital shall be accompanied by a fee to be determined by the number of beds available for patients or inmates; as follows: less than fifty (50) beds—ten dollars ($10.00) ; fifty (50) or more and less than one hundred (100) beds—fifteen dollars ($15.00) ; one hundred (100) or more and less than two hundred (200) beds—twenty dollars ($20.00) ; two hundred (200) or more beds—twenty-five dollars ($25.00). No fee shall be refunded. (b) All licenses shall expire at midnight December thirty-one fol- 32 Senate Document No. 6 lowing and be renewed annually upon payment of a like fee unless cause appear to the contrary. (c) All fees received under the provisions of this law shall be paid into the State Treasury and be credited to the general fund. Section 1514-a 10. Alterations or additions to hospitals; additional fees, when necessary; new constructions or operations.— (a) Any person operating a hospital who desires to make any alteration or addition to the building or plant or any material change in any of its facilities may, be- fore making such change, alteration or addition, request the Board to ap- prove same, provided that nothing contained in this law shall be con- strued as in any way superseding the provisions of any local building code now in existence or hereafter enacted. Thereupon, the Board shall investigate the change, alteration or addition so contemplated to be made and as soon thereafter as reasonably practicable notify the licensee that the change, alteration or addition is or is not approved with such recom- mendations as the Board may care to make. (b) In case any alterations or additions have the effect if approved before or after being made of placing the licensee in a different category a supplementary license for the remainder of the license year, after pay- ment of pro rata aditional fee if any necessary under the scale of fees prescribed, must be obtained before beginning operation of the additional facilities or in the new category. (c) The Board may by its rules and regulations provide for simi- lar consultative advice and assistance, with such limitations and restric- tions as deemed proper, as to,the construction or reconstruction, equip- ment and so forth of any proposed hospital the owner or operator of which is desirous ultimately of making application for a license and the Board may fix reasonable fees for such service, subject to credit on the ultimate license application fee if or to the extent it deems proper so to do. Section 1514-a 11. Display of license.—The current license shall at all times be posted in a conspicuous place in or plainly visible from the main entrance to the hospital. Section 1514-a 12. Revocation or suspension of license.— (a) The Board is authorized to revoke or suspend any license issued hereunder, on any of the following grounds: (1) Violation of any provision of this law or of any applicable and valid rule or regulation made pursuant to law; (2) Permitting, aiding, or abetting the commission of any illegal act in the hospital; (3) Conduct or practices detrimental to the welfare of any patient or inmate in the hospital. (b) Before any license issued hereunder is so revoked or suspended, thirty (30) days written notice must be given the licensee of the date set for hearing of the complaint and he must be furnished with a copy of the complaint and shall be entitled to be represented by legal counsel at the hearing. The notice may be given by the Board by registered mail. (c) If a license is revoked as herein provided, a new application for license may be considered by the Board if, when, and after the con- Medical Facilities Available in Rural Areas of the State 33 ditions upon which revocation was based have been corrected and satis- factory evidence of this fact has been furnished. A new license may then be granted after proper inspection has been made and all provisions of this law and applicable rules and regulations hereunder have been com- plied with and recommendation to such effect has been made by the Commissioner upon basis of an inspection by any authorized and quali- fied agent of the State Department of Health. (d) Suspension of a license shall in all cases be for an indefinite time and the suspension may be lifted and rights under the license fully or partially restored at such time as the Commisisoner determines, upon basis of such an inspection, that the rights of the licensee appear to so require and the interests of the public will not be jeopardized by resump- tion of operation. No additional fees will have to be paid but any extra- ordinary expense incident to any such inspection must be paid by the licensee whether the suspension be lifted or not. Section 1514-a 13. Review by court; appeal.—Any person aggrieved by the refusal of the Board to issue a license or by its revocation or sus- pension of a license may, within thirty (30) days after receipt of notice of such action or within a reasonable time after its failure to take action upon a completed application for a license, obtain a review by any court having equity jurisdiction in the county or city in which the hospital is or is proposed to be located and a copy of the petition for review shall be filed with the Board. Within five (5) days after the receipt of the copy, the Board shall transmit to the court all of the original papers pertaining to the matter to be and the matter shall be there- upon heard by the court or judge in vacation as promptly as circum- stances will reasonably permit. The court may enter such orders pending the preceding as arc deemed necessary or proper in accordance with the principles of equity jurisprudence and procedure. The hearing may be upon the record so transmitted, but the court may hear such additional evidence as it deems proper, and upon the conclusion of the hearing, the court may affirm, vacate or modify the order appealed from. Costs may be ordered to be paid as the court or judge deems proper in accordance with principles of equity. Any party to the proceeding may appeal from the decision of the court to the Supreme Court of Appeals, in the same manner as appeals are taken from courts of equity generally. Section 1514-a 14. Injunction to prohibit operation without license; effect of review.— (a) Any court of record having chancery jurisdiction in the county or city where any such hospital is located shall have jurisidic- tion to enjoin its operation without the requisite license, at the suit of the Board. • (b) A review had as herein provided of the decision of the Board revoking, suspending or refusing to issue a license, or upon its failure to act, shall operate to stay any prosecution hereunder and to suspend the operation of any injunction pending a final disposition of the proceeding for review, and if the court in such proceeding order the license to be rein- stated or issued by the Board, a prosecution on account of the particular matter involved shall be barred. 34 Senate Document No. 6 Section 1514-a 15. Violation; penalties.—Any person establishing, conducting, maintaining or operating a hospital without a license shall be guilty of a misdemeanor and upon conviction shall be punished by a fine of not more than one hundred dollars ($100.00) for the first of- fense and not more than five hundred dollars ($500.00) for each subse- quent offense, and each day of any such violation before any conviction shall constitute a separate first offense. Section 1514-a 16. Severability.—If any provision of this law, or the application thereof to any person or circumstances, is held invalid, the remainder of the law and the application of such provision to other persons or circumstances shall not be affected thereby. If any provision, clause, sentence or section of this law is declared to be invalid or in viola- tion of any provision of the State or Federal Constitution, the remaining provisions of this law shall stand and be effective notwithstanding. 2. The sections added to the Code by this new chapter shall become effective July one, nineteen hundred forty-six, except that provisions requiring the holding of a license to establish or operate a hospital and the provisions inhering in and dependent upon the holding of such a license shall become effective on and after January one, nineteen hundred forty-seven. Medical Facilities Available in Rural Areas of the State 35 APPENDIX I STATEMENT of THE VIRGINIA FEDERATION OF HOME DEMONSTRATION CLUBS The Virginia Federation of Home Demonstration Clubs, represent- ing more than 25,000 rural women, considers the health and medical care situation in rural Virginia a matter of serious concern, and we wish to urge that corrective measures be undertaken as soon as possible. We believe that good health is next to life itself, and that for the safeguarding of family and national life adequate medical care should be available to all people regardless of income or of place of residence. We recognize that the work of State and of local health departments —where the latter exist, their clinical services, their educational and pre- ventive programs have accomplished much in improving the general health of our population. We know well, also, the foundation for better health laid by our Agricultural Extension program in promoting better nutrition, housing, and sanitation among rural people. However, even under ideal conditions which no one claims for our State, the services of doctors and hospitals are necessary, but these are often lacking in our rural areas, and the situation has become acute. Among our most serious health and medical care problems we list these: Many counties still do not have the services of public health units. There is an acute shortage of doctors in rural sections as old doctors who retire are not being replaced by younger ones. The residents of many counties find access to hospitals most difficult because of great distance and expense. The cost of medical care in relation to farm income is becoming prohibitive to many. In many rural sections little free medical service is available, and therefore many people go without needed care. Funds available to welfare departments are limited so that hospital care for clients can be provided only in emergency cases. These emer- gency cases might often be prevented by more timely medical attention with much saving of human suffering to the people concerned, and of money to the taxpayer. Many people who are anxious to pay their way go without medical attention because they cannot afford it, or cannot get it. This was found to be true in 1 out of 14 cases according to a study of about 1880 rural families made in 1941. We believe this to be a conservative figure. Many people who are above the relief level cannot get the services of a doctor in rural areas unless some one stands for the bill. Physical examinations of school children are not always made by doctors. There is too little follow up work of defects found among school children. Needed corrections are often neglected because of difficulty of 36 Senate Document No. 6 securing medical services, because of poverty, and sometimes ignorance or indifference of parents. The Virginia Federation of Home Demonstration Clubs is stressing health as one of its major goals. It is educating its members to take ad- vantage of medical facilities that are provided, and has asked them to assume responsibility of getting this information to neighbors. As a means of helping themselves the Federation is also urging rural people to partici- pate in hospital insurance and in prepayment surgical and medical care plans which are being worked out. However, these programs do not meet the needs of the very low income groups because premiums are often too high in relation to their income. Then, too, to make these plans wholly successful or effective, more doctors are needed in rural sections and more easily accessible hospitals or health centers. The Federation wishes to give recognition to the doctors of our country districts who have done a great deal of free practice, but in spite of this a great many people have to go without needed medical care. We believe that the following measures would go far toward correct- ing some of the most outstanding medical care problems in rural Vir- ginia, and submit them to you for consideration: 1. The establishment of health units to cover every county in the State, with emphasis on treatment as well as on preventive work. 2. The extension of present hospital facilities into a state-wide hos- pital center system, with a health center for treatment and preventive work easily accessible to every rural resident. Well qualified physicians should be connected with these centers which would provide the labora- tory facilities necessary to attract young doctors into country practice. .3. Provisions for examinations of all school children and teachers by doctors at regular intervals with follow-up work when defects are found. If parents cannot afford to pay for the necessary corrections these should be provided by public health service. 4. Expansion of services of the State Health Department such as its traveling dental and other clinics. 5. An increase in public funds to make possible more medical help to the needy— a. through public school health services to children b. through health and welfare departments to needy families 6. State aid to establish local health centers. 7. Increased support to State institutions rendering health services. We are deeply grateful for this opportunity to express our views, and pledge our full cooperation and support to programs undertaken for the correction of the rural health and medical care situation in Virginia. Respectfully submitted, Health Committee, Virginia Federation of Home Demonstration Clubs Bertha Wailes (Mrs. Ben), Co-Chairman Medical Facilities Available in Rural Areas of the State 37 APPENDIX TABLE 1 Average Percentage or Ratio Virginia’s Rank FACTOR United States Virginia Virginia + or — U. S. Hospital beds per 10,000 population. . 35 31 - 4 33 Hospital admissions per 1,000 popula- tion 70 61 - 9 35 Percent hospital beds occupied 70.3 68.7 - 1.6 19 Days hospitalization per 1,000 popu- lation 90 77 -13 31 * Dentists per 100,000 population 58 32 -26 35 Physicians and Surgeons per 100,000 population 125 98 -27 31 Trained nurses and student nurses per 100,000 population 270 210 -60 32 Total percentage of live births oc- curring in hospitals, 1942 67,9 44.8 -23.1 38 Percentage of white live births occurring in hospitals, 1942. . . . 72.7 54.5 -18.2 39 Percentage of Negro live births occurring in hospitals, 1942.... 28.9 16.3 -12.6 39 Percentage urban births in hos- pitals 80.5 67.0 -13.5 38 Percentage rural births in hos- pitals 36.5 22.9 -13.6 38 Total percentage of live births not attended by physicians, 1942 7.4 18.8 11.4 39 Percentage of white live births not attended by physicians, 1942 2.5 6,8 4.3 42 Percentage of Negro live births not attended by physicians, 1942 46.8 54.5 7.7 41 Percentage of urban live births not attended by physicians, 1942* 2.6 8.6 6,0 38 Percentage of rural live births not attended by physicians, 1942f 14.2 24.8 10.6 40 Total maternal cjeaths per 1,000 live births 3.8 4.5 0.7 34 Rural maternal deaths per 1,000 live births 4.0 4.4 0.4 33 Non-white maternal deaths per 1,000 live births 7.7 7.5 - 0.2 29 Total infant deaths plus stillbirths per 1,000 live births plus stillbirths. 76 91 15 39 White infant deaths plus still- births per 1,000 live births 69 76 7 39 Non-white infant deaths plus stillbirths per 1,000 live births. 123 129 6 39 Virginia’s Rank in Health and Medical Care, 1940 38 Senate Document No. 6 Average Percentage or Ratio Virginia’s Rank FACTOR United States Virginia Virginia + or — U. S. Total adjusted death rate per 1,000 population 10.8 11*1 0.3 29 White adjusted death rate per 1,000 population 10.4 9.6 - 0.8 29 Non-white adjusted death rate per 1,000 population 13.8 15.6 1.8 29 Rural adjusted death rate per . 1,000 population 9.8 10.6 0.8 29 Tuberculosis death rate per 100,000. . 45.9 58.1 12.2 40 Rejections per 100 men called in Selective Service July 1, 1942 to January 1, 1944j; 39.2 45.6 6.4 43 Public Health expenditure per capita. $ .37 $ .47 $ .10 17 Per capita State Government expen- ditures for all purposes $ 36.80 $ 28.23 S- 8,57 36 *Urban above 10,000 population. fRural under 10,000 population. JVirginia Director of Selective Service. Sources: Medical care services in North Carolina, Progress Report No. R.S.-4, N. C. Agr. Exp. Sta., 1944: also U. S. Census and U. S. Vital Statistics, and Reports of Senate Committee hearings on Wartime Health and Education. APPENDIX TABLE 1—Continued Medical Facilities Available in Rural Areas of the State 39 APPENDIX TABLE 2 Percent of Virginia School Children Reported in Teachers Inspections as Having One or More Physical Defects, and Percent Having Defects Corrected, White and Negro 1941-42 Session, and County Comparison’s with State Percentages1 COUNTIES White Negro Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage The State 61 32 44 34 Urban 49 -12 44 12 39 - 5 38 4 Rural 64 ' 3 29 - 3 ' 46 2 33 - 1 Accomack 54 - 7 26 - 8 37 - 7 8 -26 Alleghany 66 5 18 -14 41 - 3 10 -24 Albemarle 72 11 35 3 61 17 51 17 Amelia 54 - 7 25 - 7 57 13 35 1 Amherst 64 3 23 - 9 46 2 76 42 Appomattox 66 5 46 14 53 9 52 18 Arlington 40 -21 45 13 53 9 65 31 Augusta 52 - 9 24 - 8 20 24 29 - 5 Bath 95 34 45 13 53 19 Bedford 72 11 12 -20 41 - 3 20 -14 Bland 24 -40 16 -16 Botetourt 65 4 17 -15 38 6 15 -19 Brunswick 72 11 34 2 44 0 20 -14 Buchanan 38 -23 26 - 6 Buckingham 79 18 38 6 44 0 20 -14 Campbell 59 - 3 20 -12 41 - 3 71 37 Caroline 62 1 42 10 49 5 24 -10 Carroll 69 8 33 1 50 6 Charles City 56 - 5 33 1 42 - 2 16 -18 Charlotte 65 4 26 6 53 9 9 -25 Chesterfield 43 18 42 10 51 7 61 27 40 Senate Document No. 6 COUNTIES White Negro Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage Clarke 62 1 28 - 4 53 9 36 2 Craig 69 8 75 43 Culpeper 71 10 32 0 55 11 27 - 7 Cumberland 80 29 35 3 55 11 11 -23 Dickenson 84 3 10 -22 44 0 4 -30 Dinwiddie. .. 62 1 25 - 7 57 13 37 3 Elizabeth City 60 - 1 26 - 6 62 18 50 16 Essex 46 -15 13 -19 24 -20 26 - 6 Fairfax 85 24 36 4 42 - 2 66 32 Fauquier 69 8 31 - 1 31 -13 90 56 Floyd 62 1 27 - 5 79 35 10 -24 Fluvanna 89 28 27 - 5 66 32 Franklin 58 - 3 23 - 9 39 - 5 29 -11 Frederick 79 18 28 - 4 52 8 17 -17 Giles 80 29 14 -18 Gloucester 41 -20 21 -11 17 -27 14 -20 Goochland 44 -17 41 9 56 12 63 29 Grayson 70 19 20 -12 29 -15 42 8 Greene 48 -13 49 17 33 -11 3 -31 Greensville 69 8 28 - 4 54 10 11 -23 Halifax r 62 1 22 -10 62 18 14 -20 Hanover 23 -38 20 -12 33 -11 18 -16 Henrico 48 -13 62 30 44 0 54 20 Henry 83 22 17 -15 56 12 23 -11 Highland 74 13 11 -21 35 - 9 0 -34 Isle of Wight 22 -39 77 45 22 -22 23 -11 James City 34 -27 30 - 2 19 -25 52 18 King and Queen 73 12 55 23 68 24 44 10 APPENDIX TABLE 2—Continued Medical Facilities Available in Rural Areas of the State 41 King George 35 -26 41 9 25 -19 14 -20 King William 45 -16 36 4 25 -19 35 1 Lancaster 64 3 20 -12 36 - 8 12 -22 Lee 68 7 13 -19 39 - 5 50 16 Loudoun 75 14 35 3 44 0 69 35 Louisa 64 3 19 -13 32 14 10 -24 Lunenburg 71 10 20 -12 49 5 25 - 9 Madison 64 3 38 6 46 2 12 22 Mathews 74 13 24 8 65 21 28 - 6 Mecklenburg 54 - 7 45 13 28 -16 29 - 5 Middlesex 33 -28 63 31 33 -11 88 54 Montgomery. t 75 14 17 -15 61 17 33 - 1 N ansemond 69 8 21 -11 67 23 68 34 Nelson 75 14 25 - 7 • 57 13 14 -20 New Kent 62 1 45 13 57 13 22 -12 Norfolk 96 35 33 1 39 - 5 37 3 Northampton 48 -13 32 0 35 - 9 17 -17 N orthumberland 54 - 7 34 2 48 4 26 - 8 Nottoway 91 30 34 2 33 -11 3 -31 Orange 49 -12 48 16 55 11 35 1 Page 73 12 25 - 7 7 27 Patrick 61 0 37 5 15 29 77 ' 43 Pittsylvania 65 4 31 - 1 46 2 30 - 4 Powhatan 57 - 4 11 -21 73 29 12 -22 Prince Edward 70 9 44 12 63 19 10 -24 Prince George 55 - 6 34 2 57 13 98 64 Princess Anne 44 -17 24 -12 19 -25 49 15 Prince William 67 6 49 15 52 8 69 35 Pulaski 95 34 29 - 3 42 - 2 6 -28 Rappahannock 63 2 51 19 40 - 4 73 39 Richmond 62 1 82 50 60 16 66 32 Roanoke 68 7 37 5 43 - 1 92 58 Rockbridge 63 2 42 10 50 6 63 29 Rockingham 69 8 30 - 2 41 - 3 5 -29 Russell 69 8 21 -11 28 -16 28 - 6 Scott 61 0 13 -19 58 14 63 29 Shenandoah 77 16 37 5 55 11 18 -16 Smyth 79 18 33 1 41 7 Southampton 66 5 42 10 35 - 9 21 -13 42 Senate Document No. 6 COUNTIES White Negro Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage Percent with Defects + or — State Percentage Percent with Corrections + or — State Percentage Spotsylvania 62 1 45 13 72 28 7 -27 Stafford 90 29 40 8 58 24 Surry 64 • 3 31 - 1 74 30 15 -19 Sussex 61 0 27 - 3 35 - 9 29 - 5 Tazewell 74 15 26 - 6 33 - 1 Warren 76 15 23 - 9 49 5 12 -22 Warwick 77 16 32 0 62 18 14 -20 Washington 59 - 2 32 0 61 17 16 -18 Westmoreland Wise 62 1 26 - 6 62 18 23 -11 Wythe 71 10 33 1 65 21 4 -30 York 29 - 2 30 -14 7 -27 ■Data based on teachers’ inspections and corrections reports, 1941-42. Report of State Department of Education. Percentages of Col. 1 are based on 90 percent school enrollment. Percent corrections (Col. 3) percent of those with defects. APPENDIX TABLE 2—Continued COUNTIES Deaths Per 1,000 Live Births Percentage of Births in Hospitals White Negro White Negro Percent -|- or — State Rate Percent + or - State Rate Percent or — State Rate Percent + or — State Rate State (Rural) 54 95 31 6 Accomack 51 - 3 124 29 28 - 3 5 - 1 Albemarle 71 17 123 28 63 32 52 45 Alleghany 32 -22 52 -43 29 - 2 12 6 Amelia 53 - 1 164 69 12 -19 2 - 4 Amherst 49 - 5 117 22 39 8 7 1 Appomattox 40 -14 159 64 31 0 5 - 1 Augusta 71 17 113 18 34 3 20 14 Bath 106 52 67 -28 17 -14 7 1 Bedford 80 26 88 - 7 32 1 5 - 1 Bland 95 41 6 -25 Botetourt 31 -23 119 24 17 -14 5 - 1 Brunswick 58 4 64 -31 16 -15 3 - 3 Buchanan 92 38 9 -22 Buckingham 58 4 99 4 23 - 8 3 - 3 Campbell 46 - 8 72 -23 36 4 8 2 Caroline 46 - 8 71 -24 18 -13 3 - 3 Carroll 83 29 3 -29 Charles City 71 -24 50 19 5 - 1 Charlotte 49 - 5 89 - 6 20 -11 3 - 3 Chesterfield 25 -29 133 38 67 36 4 - 2 Clarke 37 -17 111 16 28 - 3 22 16 Craig 95 41 14 -17 Medical Facilities Available in Rural Areas of the State APPENDIX TABLE 3 Deaths Under One Year of Age Per 1,000 Live Births, and Percentage of Maternity Cases in Hospitals, White and Negro, 1941-421 44 Senate Document No. 6 COUNTIES Deaths Per 1,000 Live Births Percentage of Births in Hospitals White Negro White Negro Percent + or — State Rate Percent + or — State Rate Percent + or — State Rate Percent + or — State Rate Culpeper 55 1 54 -41 34 3 8 2 Cumberland 54 0 ' 75 -20 38 7 3 - 3 Dickenson 66 12 19 -12 10 4 Dinwiddie 16 -38 108 13 22 - 9 2 - 4 Elizabeth City 37 -17 97 2 95 64 24 18 Essex 105 51 82 -13 28 - 3 5 - 1 Fairfax 36 -18 71 -24 75 44 49 43 Fauquier 45 - 9 122 27 36 5 11 5 Floyd 49 - 5 214 119 5 -26 7 1 Fluvanna 77 23 182 87 33 2 14 8 Franklin 56 2 122 27 9 22 2 - 4 Frederick 40 -14 273 183 46 15 9 3 Giles 78 24 111 16 13 -18 Gloucester 61 7 86 - 9 26 - 5 2 - 4 Goochland 28 -26 63 -32 24 - 7 5 - 1 Grayson 60 6 125 30 6 -25 Greene 103 49 56 -39 48 17 28 22 Greensville 39 -15 80 -15 41 10 2 - 4 Halifax 56 2 80 -15 21 -10 2 - 4 Hanover 76 22 63 -32 27 - 4 4 - 2 Henrico 30 -24 101 6 82 51 28 22 Henry 79 25 64 -31 15 -16 8 2 Highland 56 2 5 -26 Isle of Wight 81 27 102 7 24 - 7 1 - 5 James City 12 -42 68 -27 73 42 6 0 APPENDIX TABLE 3—Continued Medical Facilities Available in Rural Areas of the State 45 King and Queen 33 -21 82 -13 50 19 10 4 King George 65 11 141 46 21 -10 4 - 2 King William 56 2 145 50 33 2 4 - 2 Lancaster 24 -30 79 -16 13 -18 3 - 3 Lee 89 35 5 -26 Loudoun 48 — 6 78 -17 41 10 12 6 Louisa 44 -10 49 • -46 23 - 8 7 1 Lunenburg 54 0 62 -33 22 - 9 6 0 Madison 55 1 41 -54 59 28 18 12 Mathews 29 -25 97 2 ' 38 7 7 1 Mecklenburg 45 - 9 82 -13 22 - 9 2 - 4 Middlesex 44 -10 76 -19 24 - 7 Montgomery 60 6 122 27 31 0 5 - 1 N ansemond 47 - 7 123 28 33 2 2 - 4 Nelson 74 20 148 53 41 10 16 10 New Kent 50 - 4 39 -56 65 34 8 2 Norfolk 43 -11 63 -32 74 43 5 - 1 Northampton 51 - 3 161 66 59 28 2 - 4 Northumberland 98 44 194 99 16 -15 2 - 4 Nottoway 15 -39 70 -25 31 0 5 - 1 Orange 72 18 102 7 56 25 22 16 Page 56 2 429 334 22 - 9 14 8 Patrick 50 - 4 91 - 4 6 -25 Pittsylvania 65 11 57 -38 46 15 3 - 3 Powhatan 87 33 122 27 37 6 6 0 Prince Edward 45 - 9 108 13 52 21 5 - 1 Prince George 83 29 129 34 53 22 1 - 5 Princess Anne 50 - 4 32 -63 42 11 16 10 Prince William 71 17 114 19 60 29 4 - 2 Pulaski 50 - 4 57 -38 34 3 Rappahannock 29 -25 107 12 18 -13 11 5 Richmond 54 0 137 42 11 -20 Roanoke 52 - 2 87 - 8 64 33 6 0 Rockbridge 49 - 5 63 -32 22 - 9 3 - 3 Rockingham 52 - 2 217 122 40 9 61 55 Russell 57 3 77 -18 10 -21 8 2 Scott 72 18 8 —23 Shenandoah 48 - 6 125 30 41 10 38 32 Smyth 78 24 12 -19 46 Senate Document No. 6 COUNTIES Deaths Per 1,000 Live Births Percentage of Births in Hospitals White Negro White Negro Percent + or — State Rate Percent + or — State Rate Percent + or — State Rate Percent + or — State Rate Southampton 81 27 121 26 56 25 3 - 3 Spotsylvania 66 12 29 -66 48 17 14 8 Stafford 58 4 98 3 53 22 7 1 Surry 133 38 25 - 6 Sussex 18 -36 98 3 51 20 1 - 5 Tazewell 65 11 68 -27 14 -17 3 - 3 W arren 44 -10 49 18 16 10 Warwick 47 - 7 58 -37 90 59 9 3 Washington 59 5 63 -32 17 -14 13 7 Westmoreland 35 -19 131 36 32 1 1 - 5 Wise 81 27 167 72 10 -21 Wythe 40 -14 91 - 4 11 -20 6 0 York 40 -14 128 33 72 41 11 5 'Based on 1942 Report of State Department of Health. Later reports show slight improvement in State and some county rates. APPENDIX TABLE 3—Continued Medical Facilities Available in Rural Areas of the State 47 APPENDIX TABLE, 4 Approximate Average Net Farm Income Per Capita of Farm Population, and Other Indices of Economic Status, 1940 COUNTIES Approximate Net Farm Income Per Capita of Percent Farm Operators With Gross Farm Income Average Value Home Produced Marginal Standard Homes, 19394 1940 Farm Population1 of Under $600 in 19392 Supplies, 19393 Total White Negro State $ 100 61 $ 252 156,543 90,940 65,603 Accomack 207 17 207 6,454 4,146 2,308 Albemarle 68 70 273 3,074 2,340 734 Alleghany 122 45 357 1,399 1,354 45 88 66 205 1,240 483 757 Amherst 72 74 266 2,206 1,417 789 Appomattox 98 56 253 1,277 909 368 130 Augusta 135 53 273 3,298 3,140 158 Bath 76 57 270 599 567 32 Bedford 83 70 232 3,560 2,693 867 Bland 113 56 341 897 892 5 Botetourt 93 68 261 2,049 1,778 271 Brunswick 87 55 209 2,605 1,086 1,519 63 74 419 3,731 3,731 Buckingham 67 75 232 2,047 1,113 934 Campbell 83 61 255 3,087 2,176 911 Caroline 56 71 150 1,877 852 1,025 Carroll 62 76 259 3,635 3,617 18 59 85 77 180 Charlotte 59 215 2,187 1,164 1,023 Chesterfield 55 79 193 2,130 1,638 492 Clarke 153 40 250 774 640 134 Craig 79 59 269 390 378 12 48 Senate Document No. 6 COUNTIES Approximate Net Farm Income Per Capita of 1940 Farm Population1 Percent Farm Operators With Gross Farm Income of Under $600 in 19392 Average Value Home Produced Supplies, 19393 Marginal Standard Homes, 19394 Total White Negro Culpeper $ 122 54 •I 270 1,361 913 448 Cumberland 68 77 180 1,030 352 678 Dickenson 52 87 336 2,682 2,682 Dinwiddie 83 47 276 1,744 '644 1,100 Elizabeth City 113 71 152 943 629 314 Essex 68 74 221 985 475 510 Fairfax 115 60 268 1,447 1,275 172 Fauquier 119 60 267 2,189 1,487 702 Floyd 79 69 227 1,734 1,667 67 Fluvanna 53 74 231 950 496 454 Franklin 79 67 242 3,097 2,610 487 Frederick 132 56 244 1,390 1,377 13 Giles 90 59 343 1,308 1,291 17 Gloucester 31 85 175 1,441 863 578 Goochland 61 79 217 1,286 501 785 Grayson 85 71 258 2,921 2,829 92 Greene 47 79 189 710 582 128 Greensville 96 39 245 1,573 478 1,095 Halifax 113 46 224 4,894 2,497 2,397 Hanover 73 62 219 2,027 1,258 769 Henrico 136 64 243 1,635 1,364 271 Henry 56 76 240 3,032 2,214 818 Highland . 128 49 301 551 534 17 Isle of Wight 153 23 221 1,918 885 1,063 James City 112 63 250 687 370 317 King and Queen 71 75 234 1,062 428 634 APPENDIX TABLE 4—Continued Medical Facilities Available in Rural Areas of the State 49 King George 80 70 264 882 544 338 King William 76 73 198 888 407 481 Lancaster 56 73 152 1,588 881 707 Lee 81 74 280 5,739 5,707 32 Loudoun 211 40 337 2,069 1,646 423 Louisa 55 77 213 1,799 974 825 Lunenburg 123 45 276 1,759 864 895 Madison 89 67 283 968 655 313 Mathews 36 81 243 1,020 727 293 Mecklenburg 123 39 243 4,177 1,892 2,285 Middlesex 50 83 145 1,074 577 497 Montgomery 111 58 302 2,841 2,718 123 N ansemond 128 30 217 3,283 913 2,370 Nelson 60 73 269 2,303 1,675 628 New Kent 61 64 222 808 312 496 Norfolk 162 53 189 3,484 2,133 1,351 Northampton 265 13 280 2,504 1,127 1,377 Northumberland 50 68 178 1,411 820 591 Nottoway 90 64 215 1,404 644 760 Orange 79 ' 64 294 1,544 1,019 525 Page 72 72 226 1,700 1,685 15 Patrick 71 73 239 2,151 1,967 184 Pittsylvania 130 36 284 7,651 5,223 2,428 Powhatan 48 80 205 625 280 345 Prince Edward 75 68 193 1,616 730 886 Prince George 61 62 213 1,256 696 560 Princess Anne 187 42 252 ' 1,984 1,131 853 Prince William 126 59 176 1,033 826 207 Pulaski 78 71 219 1,923 1,735 188 Rappahannock 116 68 278 905 705 200 Richmond 84 62 216 913 550 363 Roanoke 81 67 265 • 1,886 1,798 88 Rockbridge 75 67 220 2,419 2,298 121 Rockingham 151 42 270 3,144 3,112 34 Russell 111 62 303 . 3,493 3,476 17 Scott 102 60 306 4,026 4,020 6 Shenandoah 142 51 225 2,448 2,444 4 50 Senate Document No. 6 COUNTIES Approximate Net Farm Income Per Capita of Percent Farm Operators With Gross Farm Income Average Value Home Produced Marginal Standard Homes, 19394 1940 Farm Population1 of Under $600 in 19392 Supplies, 19393 Total White Negro Smyth $ 132 61 $ 275 ‘ 3,179 3,165 14 Southampton 133 26 165 3,022 1,015 2,007 Spotsylvania fc?4 74 277 1,098 751 347 Stafford P 59 71 231 896 660 236 Surry 156 38 226 998 392 606 Sussex 121 36 259 1,738 503 1,235 Tazewell 141 63 374 3,499 3,418 81 Warren 114 84 270 627 587 40 Warwick 62 158 633 452 181 Washington 118 55 283 4,287 4,185 102 Westmoreland 65 59 221 1,468 735 733 Wise 51 90 280 5,437 5,066 371 Wythe 112 59 287 2,281 2,206 75 York 72 75 185 1,303 751 552 iTo get family income, multiply by 4.5 or the approximate median size of farm families. sGross farm income includes value of home produced supplies and the expenses of farm operation. 3Home produced supplies do not include house rent. of rural marginal standard homes based on: (1) Two thirds of farm tenants and wage laborers in 1940 plus (2) farm and rural non-farm owners living in houses valued at less than $700 in 1940 Census, plus (3) rural non-farm families paying under $7 per month rent in 1940. Source: Based on 1940 Agricultural Population and Housing Census for Virginia. APPENDIX TABLE 4—Continued Medical Facilities Available in Rural Areas of the State Total Medical Care Hospitalization From Local Funds From State Funds AREA UNIT • Amount Per Capita Amount Percent Amount Percent Amount Percent Amount Percent State $ 535,521 382,379 .19 $ 106,126 20 $ 429,245 80 $ 489,551 91 $ 45,970 .9 Cities .35 76,610 20 305,770 80 380,280 99 2,099 1 Percent 71 72 71 78 5 Counties 153,142 .09 29,516 19 123,476 81 109,271 71 43,871 29 Percent 29 28 29 22 95 COUNTIES Accomack 939 .03 186 20 753 80 650 69 289 31 Albemarle 3,938 1,465 .20 738 19 3,200 81 3,846 98 92 2 Alleghany .07 647 44 818 56 907 62 558 38 885 .12 360 41 525 59 885 100 402 .06 402 100 151 38 251 62 Appomattox 578 .07 287 50 291 50 232 40 *345 60 Arlington 4,202 2,377 643 .05 482 12 3,620 88 3,971 95 230 5 Augusta .11 920 39 1,458 61 1,411 59 966 41 Bath .03 315 49 328 51 588 91 55 9 Bedford 728 .03 185 25 544 75 298 41 430 59 Bland 213 .04 50 23 163 77 80 38 133 62 Botetourt 2,115 324 .16 1,249 59 866 41 1,504 71 611 29 Brunswick .02 112 35 212 65 121 37 202 63 Buchanan 1,460 901 .06 262 18 1,198 82 556 38 904 62 Buckingham .08 18 2 883 98 650 72 251 28 Campbell 1,316 .06 284 22 1,032 78 843 64 473 36 APPENDIX TABLE 5 Expenditures from Public (Tax) Funds for Medical Care and Hospitalization, July 1, 1943 to June 30, 19441 52 Senate Document No. 6 AREA UNIT Total Medical Care Hospitalization From Local Funds From State Funds Amount Per Capita Amount Percent Amount Percent Amount Percent Amount Percent Counties—Continued . • Caroline 1 317 .03 $ 68 22 $ 249 78 $ 119 37 •1 198 63 Carroll 2,637 .12 867 33 1,770 67 1,083 41 1,554 59 Charles City 35 .01 35 100 13 37 22 63 Charlotte 1,150 .08 60 5 1,091 95 716 62 434 38 Chesterfield 3,764 .13 656 17 3,108 83 2,720 72 1,044 28 Clarke 1,299 .20 800 62 499 38* 1,175 90 124 10 Craig 162 .05 162 100 102 63 60 37 Culpeper 455 .04 61 13 394 87 172 38 283 62 Cumberland 56 .01 20 36 36 64 21 38 35 62 Dickenson 1,092 .06 502 46 590 54 678 62 414 38 Dinwiddie 625 .04 491 79 134 21 464 74 161 26 Elizabeth City 2,105 .07 * 2,105 100 1,192 57 912 43 Essex 888 .14 467 53 421 47 666 75 222 25 Fairfax 2,525 .05 70 3 2,455 97 2,480 98 45 2 Fauquier 3,205 .16 138 4 3,067 96 2,982 93 223 7 Floyd 312 .03 91 29 221 71 117 38 195 62 Fluvanna 911 .13 518 57 392 43 718 79 193 21 Franklin 444 .02 444 100 198 45 . 246 55 Frederick 2,098 .15 87 4 2,010 96 2,098 100 Giles 3,050 .20 1,550 51 1,500 49 3,050 100 Gloucester 438 .05 150 34 '288 66 219 50 219 50 Goochland 206 .03 36 17 170 83 162 79 44 21 Grayson 781 .05 304 39 478 61 293 38 488 62 Greene 39 .01 39 100 15 38 24 62 Greensville 1,681 .12 703 42 978 58 780 46 901 54 Halifax 3,134 .09 1,370 44 1,764 56 2,677 86 457 14 APPENDIX TABLE 5—Continued Medical Facilities Available in Rural Areas of the State 53 Hanover Henrico Henry Highland Isle of Wight James City 1,960 4,646 850 577 2,108 131 .11 .16 .03 .14 .16 .03 104 214 122 96 * 85 5 5 14 17 4 1,856 4,432 727 481 2,023 131 95 95 86 83 96 100 735 4,494 319 216 1,643 131 38 97 37 37 78 100 1,225 152 531 360 465 62 3 63 63 22 King and Queen King George King William Lancaster 280 27 54 .05 .01 .01 22 15 36 8 56 67 258 12 18 92 44 33 158 24 20 56 89 37 122 3 34 44 11 63 Lee 412 .01 146 35 267 65 154 37 258 63 Loudoun Louisa 2,929 .16 901 31 2,028 69 2,316 79 613 21 Lunenburg 1,010 .08 275 27 735 73 839 83 171 17 Madison 181 .02 17 9 164 91 68 38 113 62 Mathews 22 .00 6 27 16 73 8 36 14 64 Mecklenburg 2,037 .07 346 17 1,691 83 888 44 1,149 56 Middlesex 468 .08 70 15 398 85 231 49 237 51 Montgomery 752 .03 95 13 657 87 282 38 470 62 N ansemond 1,291 .06 609 47 682 53 931 72 360 28 Nelson New Kent 516 266 .04 .07 132 39 26 15 384 227 74 85 333 266 65 100 183 35 Norfolk 13,592 .15 409 3 13,183 97 11,832 87 1,760 13 Northampton 3,890 .23 58 1 3,832 99 3,841 99 49 1 N or thumberland 215 .03 13 6 202 94 207 96 8 4 Nottoway 531 .03 110 21 421 79 229 43 301 57 Orange 268 ,02 74 28 194 72 266 99 2 1 Page 2,323 .17 1,581 68 742 32 1,718 74 604 26 Patrick 1,015 .08 504 50 511 50 380 37 634 63 Pittsylvania 2,778 .05 672 24 2,106 76 1,718 62 1,061 38 Powhatan 128 .02 78 61 50 39 48 38 80 62 Prince Edward 5,424 .42 76 1 5,348 99 5,264 97 161 3 Prince George 960 .09 118 12 843 88 959 100 1 Princess Anne 3,551 .14 430 12 3,121 88 2,252 63 1,299 37 Prince William 2,966 .20 319 11 2,647 89 1,293 44 1,673 56 Pulaski 4,673 .20 1,185 25 3,489 - 75 1,753 38 2,921 62 Rappahannock 401 .07 72 18 329 82 180 45 221 55 Richmond 69 .01 9 13 60 87 28 41 41 59 Roanoke 2,366 .06 435 18 1,931 82 1,137 48 1,229 52 54 Senate Document No. 6 AREA UNIT Total Medical Care Hospitalization From Local Funds From State Funds Amount Per Capita Amount Percent Amount Percent Amount Percent Amount Percent Counties—Continued Rockbridge $ 1,147 .06 $ 127 11 I 1,020 89 $ 930 81 I 217 19 Rockingham 2,643 .07 766 29 1,877 71 2,154 82 489 18 Russell 901 .04 224 25 677 75 369 41 532 59 Scott 656 .03 312 48 344 52 246 38 410 62 Shenandoah 869 .05 166 19 703 81 449 52 420 48 Smyth 1,040 .04 268 26 772 74 390 38 650 62 Southampton 2,360 .10 389 17 1,970 83 1,389 59 971 41 Spotsylvania 105 .01 72 69 32 31 39 37 65 63 Stafford 162 .02 82 51 80 49 120 74 42 26 Surry 870 .16 116 13 754 87 422 49 447 51 Sussex 1,032 .09 37 4 995 96 648 63 384 37 Tazewell 1,325 .03 98 7 1,227 93 584 44 741 56 Warren 9,848 .86 208 2 9,640 98 9,333 95 515 5 1,011 .04 1,011 100 402 40 609 60 Washington 3'477 .11 694 20 2,784 80 1,460 42 2,017 68 187 .02 187 100 70 37 117 63 Wise 1,460 .03 621 42 840 58 566 39 894 61 Wythe 2,485 .12 524 22 1,912 78 932 38 1,553 62 York CITIES • I 13 427 26 $ 1,983 15 $ 11,444 85 S 13,427 100 Bristol 3^861 ,27 106 3 3,755 97 3,770 98 $ 91 2 Buena Vista 29 .01 29 100 10 35 19 65 APPENDIX TABLE 5—Continued Medical Facilities Available in Rural Areas of the State 55 Charlottesville 3,741 2,576 8,077 3,203 76 .19 741 20 3.000 1,595 6,814 3.000 76 80 3,741 2,247 8,077 3,182 60 100 Clifton Forge Danville .46 .26 981 1,263 203 38 16 62 84 87 100 329 13 Fredericksburg Hampton .26 .01 6 94 100 99 79 21 16 1 21 Harrisonburg 5,403 272 17,910 215 17,444 99,078 7,820 25,867 .62 272 5 5,131 95 5,403 102 17,910 80 17,437 98,869 7,820 25,867 162 126,387 29,395 2,942 2,233 2,665 100 Hopewell Lynchburg .03 .43 15 2,750 37 2,218 28,743 6 15 257 15,160 94 85 38 100 170 62 Martinsville Newport News .02 .33 17 13 178 15,225 70,335 4,000 83 87 37 100 134 6 63 Norfolk .52 29 71 100 209 Petersburg .24 3,820 9,659 90 4,026 13,477 530 49 51 100 Portsmouth .42 37 16,208 342 122,361 15,917 63 100 Radford Richmond 432 126,387 29,395 3,191 2,354 3,128 .05 .56 21 3 79 97 38 100 270 62 Roanoke .46 46 54 100 South Norfolk Staunton .32 .18 17 2,661 2,354 1,624 83 100 92 95 85 249 121 8 5 Suffolk Williamsburg .24 1,505 48 52 463 15 Winchester 8,492 .70 4,159 .49 4,334 51 8,490 100 2 Source: Based on data furnished by State Department of Public Welfare from special reports of local Welfare Dep artment. Chart I Amount spent Income group Income group Income group All medical care I Physicians' care Dental care I -Hospital care i Eye care I All medical care I Physicians' care Dental care I Hospital care Eye care I i All medical care I Physicians' care Dental care I Hospital care I Eye care Flgury 2. More itoner Is Spent For Medical Care As Farmer's Income Increases (U.S.D.A.^ Chart II WHAT FAMILIES SPEND FOR MEDICAL CARE Income group Percentage of all families Amount spent per person ON THE FARMS IN THE VILLAGES IN THE CITIES Coen eymM reprewnts 4 portent of fftt fomiiiw Caen ijmbol roprtiK.'i *4 Figure 1, April 19UI*. Chart III PERCENTAGE OF URBAN AND FARM FAMILIES SUBSCRIBING TO PREPAYMENT PLANS FAMILIES ( PERCENT ) INCOME ( DOLLARS ) Figure 3* Urban families Farm families FSA MEDICAL PROGRAM ACCOUNTS FOR HIGH RURAL PERCENTAGE IN LOW INCOME GROUP. ( D.S.D.A. APRIL, 19U.)