You said a third.

I would hesitate to place a figure on it. Most of the people in the VA hospital system are undergoing rehabilitation in the paraplegic centers, which usually takes a year or possibly 2 years. These people are in there. They have not reached maximum hospital benefits yet. I think they are probably the largest part of the group that are in the paraplegic centers, people that have not reached maximum hospital benefit.

This other group, some of them have, and because they have no place to go, no homes to go to, or for financial reasons are still retained, so I do not know the exact percentage, but I do know that I have talked to doctors and paraplegics who have felt that these things are real handicaps to them in moving the patients back into active life.

Mr. EVERETT. I do want to congratulate your fine association on the wonderful work that you have done in helping establish the rehabilition centers. The rehabilitation program we have in the Veterans' Administration is one of the finest in the country. It is far ahead of civilian hospitals.

I was in Little Rock a few weeks ago to see the wonderful work that is being done there.

Mr. Ellsworth, do you have any questions?

Mr. ELLSWORTH. Now that I have had a chance to read this statement, I want to compliment the gentleman on his very fine and clear and direct and to-the-point statement. It was really an excellent statement, and no questions occur to me in connection with it. I think I understand his position perfectly.

And I want to tell you how much I appreciate your expressing this position so well and so forcefully before the subcommittee.

Mr. CHRISTIAN. Thank you, sir.

Mr. EVERETT. I think that is exactly right.

We had an old man down home one time who said, "Short understandings prevent misunderstandings."

Mr. SCHADEBERG. Mr. Chairman, may I ask a question?

Mr. EVERETT. Yes, sir.

Mr. SCHADEBERG. What happens to a paraplegic who has an opportunity to go home; he has a family, and then something happens to the family? Does he have to go back to the hospital?

Mr. CHRISTIAN. That depends. I think the family is most important as the paraplegic first moves out of the hospital because there are so many contacts to be made, so many routines to develop, so many situations to overcome at the very first, in the transition period between the hospital and the home. Once this initial period is passed, if the paraplegic has any get-up-and-go at all, he is able to handle it on his own, depending on his situation.

Now, if he is a paraplegic-this is a distinction that I don't think has been made enough. There is a large difference between the paraplegic and the quadraplegic patient. One is a result of breaking your neck; the other is a result of breaking your back, and John and I can give you an example of both. He is a paraplegic; I am a quadraplegic. John is down here by himself today. He came down. He spent the night at a hotel by himself; got over here by himself.

Now, if I travel, I have to carry an aid with me, the big difference being that I can't use my hands, and this creates a whole new world

of difficulties, and in the case of the quadraplegic it might be that, even though he was established for a year or 2 years, and family ties broke down, if he had not been able to develop some sort of aid program that would sustain him, then he would probably have to come back into the hospital.

Mr. SCHADEBERG. Thank you.

Mr. CHRISTIAN. I would like to comment further at this point on that matter of the quadraplegic and the paraplegic, and this is something that is not too popular to talk about in our association because we have a lot of both. But the aid and attendance, I believe, started out as a quadraplegic bill, and was expanded to include the paraplegic, too, which we think is fine. But we hope that in the future the situation will not be jeopardized by feeling that any increased benefits in a certain area, because of particular needs, might be extended to other groups, thereby jeopardizing the whole program perhaps through pricing ourselves out of the market, so to speak, for the quadraplegic. We like to protect him a little bit since he does have those extra problems.

Mr. Chairman, we would appreciate it very much if a statement on research in spinal cord injury by the Veterans' Administration might be inserted. This statement was prepared by Dr. J. M. O'Hare, who is with the VA Hospital in West Roxbury, Mass.

Mr. EVERETT. Thank you, sir. The statement will be inserted at this point.

RESEARCH IN SPINAL CORD INJURY IN THE VETERANS' ADMINISTRATION

It is recommended that the research effort in spinal cord injury be concentrated at first in one or two centers. The present medical image of the paraplegic and quadriplegic care must be changed from a despaired museum piece. The presence of a large number of such patients will not only encourage the solution of clinical problems but will keep the investigator from being discouraged; e.g., the revulsion at needing to make and study paraplegic animals can be overcome by the presence of many paraplegic patients in worse state close by.

VA central office has precedent for setting up such special research programs. This is in VA Manual M-3 "Research and Education," published January 16, 1956, part 1, chapter 3, "Special Research Programs," pages 3-1, 3-2, and 3-3. This was restated under "Program Guide-Research Program," G-1, M-3 published February 29, 1956, part 1, chapter 2, "Special Research Programs," pages 20-21. This procedure has been used for a number of other such programs since. In 1961 there were 16 such special research programs in the VA.

This program should run in conjunction with clinical care at one of these centers. The young men involved will learn much about the multitude of unanswered problems and be introduced to what is known now. The assistance of the dean of the related medical school would be very important in recruitment.

The added benefit of improving the personnel problem at the physician level goes without saying. The difficulty in getting any physicians to replace retired or leaving personnel has been present for at least 10 years. The problem for physician coverage of these fine services can be seen by referring to the age of the physicians now caring for such services-90 percent are 50 years or older. Where have all the young men gone? They are in fields with more attractive medical image. The older physician in this field would act as a ballast instructing in routine care and advising on related patient problems.

As far as the details of such a program I can give only that which would be right for me at West Roxbury VA Hospital. There should be two or more physicians involved. At least part of their time should be spent in direct care of a group of paraplegic and quadriplegic patients as Dr. Talbot has previously recommended. There should be two high grade technicians or a technician and a nurse. There should be a full-time secretary-clerk.

The areas of concentration would be:

I. Studying the changes in the various systems which have adapted to this chronic paraplegic state: (1) My emphasis would be in the cardiovascular field since I feel that the local blood supply contributes much in explaining many symptoms, signs, and physiologic variations in such patients. (2) The urinary tract would occupy the second most important area for study with emphasis on micturition. (3) Naturally there would be a number of other interests which could be touched upon or investigated depending on early sampling; e.g., the quadriplegic hand needs much new work to improve its salvage.

II. At the same time there should be an active program in the animal laboratory. This would be run in conjunction with the patient care problems on an established colony of paraplegic dogs. In addition, at least a small part of such a program's effort should be working toward some ultimate solution to the functional loss due to a spinal cord injury. In our instance we would work toward reconstruction of the cord.

This would be a beginning. As these bear fruit new projects in other areas would present themselves. Even now it is clear that a study of the calcium metabolism in such patients is a large blind spot.

ESTIMATED COST

This would vary from station to station depending on the need for equipment and space. At our installation there would be the basic personnel cost over and above the physicians of $15,000 to $18,000.

Since I had been set up in a prior clinical investigation program at this station, equipment for the long-term studies is partly available. New equipment at first would be relatively minor at $1,000 to $5,000.

Maintenance of equipment, supplies, animals, etc., at $10,000.

The expense of any structural changes would also be involved in such a program and would vary from station to station.

The physician's status and salary could vary between full-time senior investigator, clinical investigator, or ward physician-roughly $10,000 to $20,000 each. Part of their responsibility would be clinical and should therefore be supported accordingly. The distinction of what is patient care and what is clinical investigation is never clear and therefore a fractional financial division would not be clear.

Rough estimate of first year cost at WRVAH would be $50,000 to $60,000. An addendum is in order. The research projects in the spinal cord injury service range through all investigative fields from neurology to urology, from endocrinology to cardiology. Instead of listing these under the different fields it would be more logical to gather them in one title and to add to the recording code spinal cord injury for all such projects.

Mr. EVERETT. We have the president and the national commander of the Paralyzed Veterans of America, Mr. John Farkas.

We would be glad to have a statement from you, Mr. Farkas. We are certainly happy to have you here, and if you want to make any statement or make any comments on the testimony or the questions that have been asked, we would be glad to hear from you.

STATEMENT OF JOHN FARKAS, NATIONAL COMMANDER,
PARALYZED VETERANS OF AMERICA

Mr. FARKAS. Thank you, Mr. Chairman.

I think that Mr. Christian has covered approximately the whole field, definitely and well, and I think he gave a good definition of the paraplegic and of the quadraplegic.

Dixon Christian is practically the maximum recovery as far as the quadraplegic is concerned.

Am I correct?

Mr. CHRISTIAN. Well, practically.

Mr. FARKAS. But we have quite a few who are at a minimum, who don't have the use of their hands as much as Dixon. There are quite a few that are handicapped to that extent, and they have been able to rehabilitate themselves and they have gone home.

The homelife is the most important thing in the life of the quadraplegic or paraplegic, and it is accepted by his family, the responsibility. And, as Dixon stated, once that obstacle is overcome, the first one, why, we sort of shudder at going back to the VA hospital.

I know I haven't made but one trip to the VA in the last 11 years, and I spent 3 weeks just prior to Easter at a private hospital because I know that if I get to the VA, there are other angles they are going to find

Mr. EVERETT. There is what now?

Mr. FARKAS. I get to the Veterans' Administration hospital and they are going to find a lot of other illnesses, other corrective therapies to be done on me, and I don't cherish the idea of staying in a hospital. I spent 3 years in one. That's enough.

Mr. SCHADEBERG. The reason I ask this, Mr. Chairman, the reason really, originally, was whether or not if the family situation deteriorates so that he wasn't able to be with the family, whether there was sufficient support that he could hire someone to take care of him home and enjoy life as he should. Right?

Mr. FARKAS. Mr. Schadeberg, if there were sufficient funds in support, financial aid for the individual to stay out of the hospital, I am positive that he would stay out. He would like to feel independent, accepted in his community as an individual rather than a vegetable or to be looked upon as a freak.

If there is financial aid, he will be on his own. I grant you that, that he will do everything possible to stay out of those hospitals. Mr. SCHADEBERG. Does he have it?

Mr. FARKAS. At the present time we don't.

Mr. EVERETT. In other words, the aid and attendance money that is in the form of compensation is not enough so that he can stay at home and enjoy life as he should. Right?

Mr. FARKAS. Right.

Mr. CHRISTIAN. In the form of compensation, it is sufficient, I would say. In the form of pension it is not sufficient. I mean to make the difference between the service-connected and the non-serviceconnected.

Again, you have to take into consideration whether he is a paraplegic or a quadraplegic, who can do for himself or does require an aid.

Mr. FARKAS. The pension that is received at the present time practically keeps a majority of the boys in because they just can't afford an aid or a family to take care of them, if they're homeless.

Mr. EVERETT. And you have got to have someone that is active. Is that not right?

Mr. CHRISTIAN. I have been through about five or six, and finally I found one that stayed with me over a year, and I feel like he's been with me a hundred years, because it's been that long.

Mr. SCHADEBERG. He's small. He's fortunate.

Mr. EVERETT. That is right. Someone like John or myself, I imagine I would kind of be in a rough shape.

Any further questions?

98-638-63- -57

Well, we just want to thank both of you again, and certainly appreciate your interest in this. We will be glad to have your comments from time to time, and if you do want to come back and make any further testimony we will be glad to have you at any time. Thank you, sir.

(Whereupon, at 10:30 a.m., the subcommittee recessed, to reconvene at 10 a.m., Thursday, May 23, 1963.)

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