Mr. BATES. I have it here, and it combines quite a few figures. Permits and ambulances, you have 99 employees under that jurisdiction, and contagious disease 11, venereal 26, nursing service 21, nursing hygiene sanitation clinic 45, tuberculosis sanatorium 245, Gallinger 494, maternal and child health 37; that embraces about all your activities, does it not?

Dr. RUHLAND. Yes, but if I may, Mr. Chairman, of course, we will give you the full detail by years; we did not have time enough to get it all tabulated; we have a rather sizable personnel; but this may give you the picture. In 1937 we had in the Health Department proper 262 employees. In 1947 we have 651 employees; at Gallinger Hospital in 1937 there were 494 employees; now, there are in 1947, 1,344. At Glendale we had in 1937, 245, and we now have 549 employees, making a total for 1937 for at least three branches of the services 1,001 as against 2,544, so there is more than a doubling in the number of people employed.

The following may serve in clarifying the increase in the cost for local health service, taking for example the cost of the service of the Health Department exclusive of the added hospitals:

The appropriation of the Health Department proper increased from $507,970 in 1937 to $1,630,657 for 1947, an increase of 271 percent. Although this increase may appear substantial, it should be considered that a large part of it is due to intrinsic factors mentioned previously, namely, salary increases, rise in price levels, and an increase in population. When the appropriations are adjusted statistically for these factors, it is found that the appropriation really only increased from $507,970 in 1937 to $839,488 in 1947 or 65 percent instead of 221 percent. The real increase of $331,518 may be considered as representing the intrinsic factors in health services in the Health Department over that time period.

Mr. BATES. Well, quite obviously your tremendous increase has taken place in the hospitals.

Dr. RUHLAND. Yes, that represents about three-fourths of the entire

Mr. BATES. Sanatorium and Gallinger.

Dr. RUHLAND. That is right.

Mr. BATES. Which altogether in 1937-tuberculosis 240 employees, Gallinger 494; the same for 1948; the estimate is tuberculosis 549 and Gallinger 1,492. In other words, there was an increase from 739 to 2,014; that is nearly three times the number of employees.

Now, I presume a good deal of that can be due to the fact that you have gone on the 40-hour basis.

Dr. RUHLAND. Exactly.

Mr. BATES. What percentage of that, of course, you would not know.

Dr. RUHLAND. I would not know off hand, no.

Mr. BATES. But you are quite certain that the hospitals are not overstaffed.

Dr. RUHLAND. Well, as a matter of fact, we are operating with an inadequate staff. Our ratio of nurses per patient, for example, both at Glendale and Gallinger, is about 1 to 12, when it ought to be 1 to 3, according to accepted standards.

Mr. BATES. That is nurses.

Dr. RUHLAND. That is right.

Mr. BATES. What is your average patient-day? Have you anything to compare the patient-day, say, with 1937?

Dr. RUHLAND. You mean the census of patients?

Mr. BATES. That is right.

Dr. RUHLAND. That has risen from approximately 870 to 1,100 or nearly 1,200 at the present.

Mr. O'HARA. Mr. Chairman, I did not get in here in time when the witness was testifying, but with reference to the cost of the operation of hospitals, that is the maintenance cost, and does not include new construction, is that right?

Dr. RUHLAND. That is correct, sir; these are operating costs, not capital investments.

Mr. O'HARA. In the authorization of, I think, some 20 million which was made last year for new hospitals, that was for construction.

Dr. RUHLAND. That is a Federal bill. You mean the Tydings bill? Mr. O'HARA. Yes.

Dr. RUHLAND. Yes.

Mr. O'HARA. That has entered into the fiscal picture of these figures that you are giving?

Dr. RUHLAND. No, not at all.

Mr. O'HARA. With reference to the matter of considerable increase of employees, is that about equal to the increase in patients during the past years, I mean, as the population went up your number of employees increased, and I suppose the patients, the number of patients increased; is that correct?

Dr. RUHLAND. Well, yes, although we have not been able to get the number of authorized employees at the institutions because of war conditions.

Mr. O'HARA. That is all, Mr. Chairman.

Dr. RUHLAND. It may be of interest to the committee, Mr. Chairman, to know that the per patient-day cost is lowest at Gallinger among all-the local costs-the local hospitals in the vicinity. The per diem figure at Gallinger is $7.44 at the present time as against-I shall be glad to submit the list-Columbia, $10.15; Emergency, $10.07; Episcopal, $13,70; Garfield, $11.48; George Washington University Hospital, $11.11; Georgetown, $8.80; Homeopathic, $10.97; Providence, $10.30; Sibley, $9.28; Casualty, $9.93; Children's, $9.75; Alexandria, $9.28; Suburban, $10.41; Prince George's, $9.55; Leland. $9.53.

Mr. O'HARA. Would you repeat Emergency. What was the cost? Dr. RUHLAND. Emergency is $10.07.

Mr. TALLE. Is it not true that in hospitals as in a good many other institutions, there is such a thing as a most economical unit, considering your physical plant, your staff, the number of people you serve? Dr. RUHLAND. You mean the number of patients that can be handled in the institution?

Mr. TALLE. That is right. Is there not a most economical unit for your kind of institution which may be considered ideal from the standpoint of good management?

Dr. RUHLAND. Ordinarily, it is believed that when you have a total of 450 patients for a hospital you have got about the limit for economic administration.

Mr. TALLE. I see. The cost per unit, the cost per patient, would be lowest at that point?

Dr. RUHLAND. Approximately; that seems to be the opinion of the administrators.

Mr. TALLE. How does the 40-hour week work out in the hospitals? Dr. RUHLAND. Well, it has given us a lot of headaches, you see, because you might have an emergency, and you simply cannot drop a service when you are facing an emergency.

Mr. TALLE. What would be a better number of hours, a better figure per week?

Dr. RUHLAND. Well, I think that we have got to recognize that we should have the 8-hour shift, 3 shifts, through the 24 hours with, of course, reduced the number of employees for the night shift; that is the way they usually operate, you see.

Mr. TALLE. Of course, you have to operate 7 days a week.
Dr. RUHLAND. Yes, indeed.

Mr. TALLE. That is all; thank you, sir.

Mr. BATES. Doctor, I am just making some comparisons. I have had no time to analyze them; but, taking these figures from the Bureau of the Census, in relation to the apportionment and distribution of the tax dollar to the various departments of the city, I notice that the District of Columbia is substantially higher-that is, the Health Department, whatever it embraces, and I presume the classification set up by the Bureau of the Census embraces about all the activities. that the Health Department in the District of Columbia comprisesand according to these figures, out of every tax dollar or expenditure for current operation in the District of Columbia you get 16.3 percent of the total tax dollars, while the average of the other 13 cities is only 11.2, and the nearest to the District of Columbia happen to be the city of Detroit, 14.8, and St. Louis, 14.7.

So, your percentage of the tax dollar from these figures-which, I say, I have not had an opportunity to analyze, and perhaps you have a pretty good answer to it as to your percent of the tax dollar-is more substantial here for health purposes than it is elsewhere.

Dr. RUHLAND. Well, quite obviously, gentlemen, the point to remember in this connection is that in the District we function as State and county as well.

Mr. BATES. And these are set up on the same basis.

Dr. RUHLAND. These are set up on a municipal basis.

Mr. BATES. No; the city area figures represent a total city corporation, and computed portions for what we call overlying local and State governments, so all these figures are supposed to be on that basis. Dr. RUHLAND. Are supposed to include counties?

Mr. BATES. Yes, sir; that is the basis. They would have no meaning otherwise, and there would be a great inconsistency.

Dr. RUHLAND. I would like to know the details of the figures. Mr. BATES. I would be very glad to have Mr. Jackson take a note to have one of the Bureau of the Census men discuss this with you, because it puts the District of Columbia in the light of having the greatest expenditures, at least, of that part of the tax dollar, of at least the 13 other cities of its near size that they could find, both smaller and larger.

Dr. RUHLAND. I certainly would have to see the details of these figures and of their figuring.

Mr. BATES. Of course, the per capita cost here in the District also, according to those same figures, which are based on 1941 figuresthat is 1945 which I just read-and the per capita cost for health and hospitals for the District in 1941 was $9.67, and that was exceeded only by one city, and that was Boston, and the average of the 13 other cities is $7.16. So, you have got about a 30-percent increase in per capita cost in the District over and above the average of those 13 other cities.

I am not saying what those figures embrace, because I have not had a chance to study them, but I think, out of deference to the position that you hold, and your staff, we will have somebody come along and talk to you about it.

Dr. RUHLAND. I should be very much interested.

Mr. BATES. I wish you would see Mr. Jackson, and he will arrange for you to have an analysis made.

Dr. RUHLAND. In the meantime, Mr. Chairman, may I submit this for your consideration and for reflection by the committee. The per capita expenditures for health work in the District of Columbia rose from 1937 when it was 86 cents per capita, to $1.79. That is against an accepted standard by the American Public Health Association of $2.50 to be expended for public-health service. In addition thereto, and this may be of some satisfaction to you and those of us who spend the money and appropriate it, we now in Washington, fortunately, are no longer at the bottom of the list; among 19 cities of a population comparable or larger than our own group, we now are at the head, so far as general mortality is concerned. Our general mortality rate of 9.7 for the past year, 1946, is better even than the national, and in specific mortality rates, we also are doing better than some of our large competitors, and that includes New York, Philadelphia, Detroit, St. Louis, and so forth.

Mr. BATES. I am not complaining about it.

Dr. RUHLAND. So, you have gotten some returns for the expenditure of the money.

Mr. BATES. You understand, Dr. Ruhland, we are not complaining about the expenditures at all; we are just trying to get an analysis as to the reasons for the expenditures, and compare your expenditures here, say, with other communities in the country of like size, some smaller and some larger, and to get your over-all point of view, but the fact that your expenditures here are so substantially higher than these other cities, according to these figures, I was just trying to find out what the basis of these expenditures were.

Dr. RUHLAND. It is quite obvious that we ought to know what the content is that accounts for those figures.

Mr. BATES. I interrupted you for that purpose. You may proceed now, Doctor, if you wish. Do you have anything else to say?

Dr. RUHLAND. I should like to submit, of course, details that will show you precisely for the various bureaus the personnel employed, the expenditure, and how these employees' positions were influenced by reclassification, and so forth, because that finally makes the picture for the increased expenditures.

Mr. BATES. What is your physical property condition here, Gallinger or any other hospital under your supervision, what are the standards that are maintained, are the buildings in good repair? Are they wellstaffed, and what are the over-all conditions?

Dr. RUHLAND. Taking the physical conditions, first; Gallinger, as the oldest institution, includes some buildings that go back before Civil War time; they are still in use. We have, however, some new buildings which Congress permitted us to add in 1940 and '42 for housing internal medicine patients and tuberculosis patients. Also at Glenn Dale we have practically a new plant; that is, it is relatively new, but that is an excellent institution. It needs certain additions. which the Commissioners well recognize, and have presented in their so-called 6-year program of costs.

Washington is deficient in not having housing for chronic patients. You see, the service that we have aside from that for the tuberculosis is essentially a service for the acutely ill. But we inevitably will have a good quota of the chronically ill, and unless we meet that problem we will find ourselves in this position, that chronic patients will have to, of necessity, occupy beds for the acutely ill, and that creates administrative difficulties, and, also needlessly greater expense.

Of course, at the present time, with the shortage of personnel, we cannot fill even the beds we have. I think it is exceedingly unfortunate. Mr. BATES. Then you have ample beds, but not personnel?

Dr. RUHLAND. We have enough beds for certain categories of cases, but not personnel to open those beds, and that is very bad because it throws the problem back upon the community as a possible source for new infections.

Mr. BATES. How closely does the Health Department, say, work with the Welfare Department, having in mind that there are many recipients of welfare in many communities who are able, let us say, and some are willing to work, for the Health Department? Is there any coordination between the needs of the Health Department, say in the hospital services, and the Welfare Department of available help that is being maintained at the expense of the city? You see, if a source of help can be gotten from that

Dr. RUHLAND. Do I understand that you suggest that we could get help from welfare clients and relieve the hospital personnel shortage?

Mr. BATES. That is the ultimate objective I had in mind, only through the fact that there are many well-meaning persons who are anxious to work that by force of circumstances have to go to welfare for relief. If welfare officials are acquainted with your needs, then it seems to me that they ought to show where these welfare recipients can get a job if they are interested in the type of work, and that you do need them for that. Is there any coordination between them?

Dr. RUHLAND. No; we have not tried that, but we have tried to make use of some of the tuberculosis patients, at Glenn Dale. Now, that is not desirable, but we did it from necessity. We also have at Gallinger, because of the close proximity of the jail, some help and workers from that source, but that is also a very questionable and doubtful practice which we do not feel we should welcome, and we do not welcome.

Mr. BATES. It may be that in the welfare category, these people who are on welfare are not all what we would call loafers or indifferent to their responsibilities to maintain themselves or their families whatever they may secure employment. But where the need is so great and the expenses of the Welfare Department, we are given to understand, at least, from the newspaper reports, it seems to be increasing all the time. Where you have such a demand, it is very possible some of these