are directly drug related. For example, the interface between our youth culture and government is a critical one and programs of prevention may be handicapped if they neglect to provide for a coordinating relationship between the proposed Special Action Office and the law enforcement activities.

The centralizing of authority and of functions now distributed through a variety of agencies but principally within the National Institute of Mental Health (Division of Narcotic Addiction and Drug Abuse) optimizes program control. However, it might be asked whether consideration has been given to the feasibility and merit of acting uniformly with the recently passed Staggers-Hughes alcohol legislation which created a National Institute on Alcohol Abuse and Alcoholism.

A National Institute on Narcotic Addiction and Drug Abuse could provide a strong coordinating and planning authority.

Conceivably its coordinating responsibility could extend to the Department of Defense, the Veterans Administration, and community resources-recognizing that will be in this latter sphere that the major responsibility for rehabilitating our returning servicemen will ultimately reside. Such a National Institute might well build on appropriate drug prevention and treatment programs to existing community mental health centers.

It is perhaps understandable that the daring innovations proposed in H.R. 9264 might arouse some concern about continuing effectiveness of existing programs. Would the agency currently charged with the prime responsibility in this field simply house personnel while policy and decisions were made elsewhere? Would its viability be threatened if its highly trained professional personnel saw their status reduced as authority and responsibility were transferred?

It is not clear to me how grants and contracts would be awarded were this bill adopted. The established procedure of review committees composed of one's scientific peers making recommendations to the National Advisory Mental Health Council would surely be retained?

In summary, Mr. Chairman, while one cannot but admire the efficiency such centralization of control confers, H.R. 9264 deals primarily with organizational issues in a general sense-it does not allude in any detail to what existing operational mechanism shall be used in its implementation.

The distinguished Special Consultant to the President for Narcotics and Dangerous Drugs enjoys the respect and admiration of all workers in this field. There are few experts so well qualified to assume the immense responsibility H.R. 9264 would confer upon him and his office.

Mr. Chairman, that completes my testimony.

Mr. ROGERS. Thank you very much, Dr. Knowles. I think some of the points you made here also concern the committee as we consider the specific proposal.

Mr. Satterfield?

Mr. SATTERPIELD. Thank you, Mr. Chairman.

Dr. Knowles, I have just a couple of questions I would like to ask you. I think you raised some very pertinent questions when you spoke. We talk about the possibility of a National Institute on Narcotic

Addiction and Drug Abuse coordinating with the Defense Department and Veterans' Administration.

Do you know of any similar situation now where that kind of coordination is presently being pursued?

Dr. KNOWLES. No, Mr. Congressman, I do not.

Mr. SATTERFIELD. You know, the one thing that has bothered me about this bill is that we are not just talking about treatment, but we are talking about treatment, rehabilitation, research and, as a matter of fact, the question of prescribed treatments.

This committee last year in the Drug Abuse Control Prevention Act wrote into law something new which for the first time would give to somebody other than the Attorney General the authority to determine what is a validly prescribed treatment for addiction. That authority is now vested in the Secretary of HEW, who makes the determination and then would advise Congress that he has done so.

I would like your reaction to the suggestion that this kind of authority be transferred to the Special Office in the White House and whether or not you think that is where it ought to be or should it stay with the Secretary of HEW.

Dr. KNOWLES. Well, we are dealing with an unusual disease, and for unusual diseases you have unusual cures. But I think the issue of cure in this case is still moot.

I have to respectfully point out that the treatment programs that you gentlemen saw last night, which are substantially representative of similar programs in various parts of the country, are regarded by most specialists in the field as experimental.

The problem that we face in dealing with a major and concerted attack on the drug problem in this country might be compared-although analogy is always dangerous-to the situation that existed in this country at the time of the successful launching of the sputnik. We were confronted with what amounted to a major national crisis, in this case in the scientific and technological area, and we did not have at that point the means with which to meet that challenge. We established a national priority No. 1 to bridge the gap which apparently existed.

We were fortunate that we could rather tool up with the needed technologists and engineers and scientists.

The situation is not that dissimilar in the drug field. We are talking about mounting major programs of treatment and prevention, Gentlemen, what are those programs? Those programs will have to be mounted by people who are skilled in their administration.

Gentlemen, where are those specialists? We have the responsibility for training to develop a cadre, an army of specialists, before we could begin to implement even experimental programs on a nationwide basis.

Our experience here in St. Louis, I think, is illuminating, because we were initially very inexpert in the matter of dealing with addicts. Their life style is so different to our own we tend to initially react to them as we react to all of our other patients, and we found out this is inappropriate, and we bought our experience in St. Louis dearly. In our early years of experimentation, the dropout rate of our program approached 50 percent. In the most recent year, I think it was about half that. A dropout rate of 25 percent is still not impressive,

but we are impressed by the fact that we have been able to reduce the dropout rate.

So, although I have not spoken as directly to your question, Mr. Congressman, as you might have wished, I say we are in an interim period of facing a major national problem and not having the wherewithal, as far as personnel are concerned, to meet it. We are in a ship with a leak; half of the crew is suffering from scurvy and have gone overboard, and the captain is asking for full speed ahead.

Mr. SATTERFIELD. What I am getting at is this: I am sure you are aware of the fact that until recently the Attorney General would not accept as a prescribed treatment for addiction, anything other than withdrawal treatment.

We gave to the Secretary of HEW the authority to prescribe other treatments which the Attorney General must accept.

My question is: Do you think this authority ought to rest with the Secretary of Health, Education, and Welfare, or should we consider transferring that decisionmaking authority to somebody in the White House under this Special Office? That is exactly what is involved in this bill.

Dr. KNOWLES. We have witnessed a very interesting change in position in this country with respect to the identification of addiction as an illness. Up until very recently, addiction was viewed in this country as a crime, and the Supreme Court decision in the early 1960's, I believe, pointed out this was inhumane and unconstitutional.

The tendency lingers for us to view addiction as a crime and, because, of course, addiction leads to a criminal life style, it is understandable that there will be major enforcement concerns in the area of addiction.

My feeling is that the merit of having a responsibility in the Department of Health, Education, and Welfare is that we are emphasizing and underlining the decision in this country that was made that addiction is in fact an illness. It is an illness, however, that has social causes, and to deal with those social causes is as important as it is to deal with the illness.

Mr. SATTERFIELD. Thank you, sir.

Mr. ROGERS. I believe, then, actually you are saying that you think the basic decision on treatment should be within the department with the competency of medical and scientific expertise?

Dr. KNOWLES. This is the way through the National Institute of Health that we have handled all health problems throughout the country.

Mr. ROGERS. You feel this is a wise approach, rather than shifting that policy decision over to somebody who has been selected to be czar of it all in the White House.

Dr. KNOWLES. The difficulty there, Mr. Chairman-and I know you are aware of it is that because of the multiple interrelated social problems associated with drug dependency, a variety of other agencies other than Health, Education, and Welfare have appropriately concerned themselves with their aspects of it. We have now seen that with a multiplication of agencies with a multiplication of programs, not all of them meritorious, and obviously the opportunity to coordinate multiple programs is an attractive one.

Mr. ROGERS. I understand.

Mr. Hastings?

Mr. HASTINGS. Thank you, Mr. Chairman.

Doctor, I appreciate the fact that, after reading your biography, especially with the expertise you have in the field in St. Louis, we need some guidance from people such as yourself, about the legislation we write in Washington to correct the problem.

I must admit, I am a pessimist when I look at the whole drug problem, and how to cure it. However, I would like to ask you a couple of questions that might be helpful to us.

We hear from so many people who tell us what to do in the area of rehabilitation, education, and research in 5 years and 10 years. Of course, in some cases it is 20. In law enforcement and foreign negotiations to cut off the source of supply we are talking about 20 years, in many cases.

What we do next month and 2 months from now to try to help solve the problem of drug addiction more than we are doing today? Have you any short, concise suggestions we can take back?

Dr. KNOWLES. Would you like a pill to take maybe?

Mr. HASTINGS. I realize that is not possible. But, I am not satisfied. to wait 5 or 10 years. I don't think the country can afford to wait 5 or 10 years. I am saying I would like to get some suggestions from some experts in the field that might produce some results in the time we are talking about.

Dr. KNOWLES. My expertise is very limited, indeed, and it is confined to one field, namely, the field of medicine. The experts that should testify in this field are numerous. They are the individuals who are concerned with many other aspects of human functioning and human performance and human failure and, also, human being collectively.

I am now talking about sociologists and anthropologists. I am talking about a variety of skills we haven't yet identified. I am sure in connection with the solving of this social problem, we will develop disciplines we don't yet know about.

I think that the St. Louis researchers, whose work I quoted, gives us a very obvious leadoff. Nobody, to my knowledge, has picked up on the very significant data that they have developed which could be used in a preventive fashion. We could go to some St. Louis schools tomorrow, and we could, by applying the criteria they have identified, identify a population at high risk to become addicts within the next 5 to 10 years.

Obviously, the steps that we would take and the steps you are asking for are not to close the stable door when the horse is gone.

Mr. HASTINGS. Doctor, I am not being critical, but what I would like the American public to understand is what I think this committee has found out. No. 1, there are no easy, simple answers to this comprehensive problem. A lot of people suggest there are, perhaps, easy answers, and with all of the experts who have testified before this committee, I must come to the conclusion there are no easy answers, and the American public should be made aware of the fact this is going to take a long time.

On the follow-up to that, if we are able to provide the type of rehabilitation facilities and type of education and research that should go into the problem-and I must say that only as a parallel-what is

your feeling on civil commitment for those addicts who will not respond to any sort of rehabilitation?

I mean by "civil commitment" getting them off the street; not putting them in jail, but some facility that perhaps provides a maintenance dosage, be it a maintenance dosage of heroin or maintenance dosage of methadone. This includes especially those people who fail to respond to more conventional programs, those contributing to the significantly high drug-related crime rate, and those in a position to infect the young members of our society. Do you have a position or statement you can give us on civil commitment?

Dr. KNOWLES. Mr. Congressman, your question is in two parts. I believe you first referred to the lack of rapid or magic cures. I think the American public should know that is the state of the art at the moment. But I regard treatment as coming in three varieties: primary, secondary, and tertiary.

Primary treatment concerns itself with the prevention of the illness in the first place, and we have here in St. Louis, for example, the issue of lead poisoning amongst our city ghettos. The lead base paints are pealing off and being eaten by small children and causing very serious pathology.

We have here a very easy, appropriate and effective method of primary treatment. We stopped using lead-based paints, and we destroy those young people who are currently suffering from it, and there are

The secondary treatment is the treatment of identified case of an illness. So, for example, with respect to lead poisoning, we identify those young people who are currently suffering from it, and there are appropriate medical techniques to deal with it and happily in that case you may have a cure. Is that available to us at this point with respect to the condition with which the committee is concerned? It is doubtful.

We have experimental programs, and we have shown a higher rate of social recovery with those experimental programs than is being shown by the traditional technique of treatment which, in a sense, was not a technique of treatment at all, because it was simply a removal from the addicting agent.

Tertiary treatment might be to take your child, who has been the victim of lead poisoning, and attempt to diminish the residual disability resulting from the illness, an attempt to achieve the maximum possible performance of the young person with the abilities that are remaining despite his lead poisoning.

In the case of our drug dependent person, this becomes an extremely difficult matter. In fact, it is something that we are laboring with at present. You take an addict and you examine him after he has had his secondary treatment to see what the extent of his residual disability is, and it is tremendous. He has impairment in so many areas of functioning. He has, for example, almost certainly harmed himself physically, because hepatitis is endemic among populations of addicts. He would probably have had some other kinds of physical illness that are directly relatable to it. He may be left there for physically less than perfect, and you may have to plan his rehabilitation within the limitations that are imposed upon you by that disability.

You may find that this individual has dropped out of school, dropped out of college. In any case, he has not completed his education. There