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unpredictable sources. We ask, “How shall we cure cancer or prevent monogolism?” Immediately we realize how much fundamental biology we still do not know, the more elusive because we are beginning to understand the magnitude of the problem.

This is all preface, and the statesman might reply: “I have heard all this before, and I might almost be willing to believe it. Nevertheless, to paraphrase Mr. Johnson, are we making the most effective allocation of our resources for the public good? Are we doing all we can to 'make sure that no lifesaving discovery is locked up in the laboratory? How can we achieve the most constructive ‘payoffs in terms of healthy lives for our citizens??" If we can reach these questions in an atmosphere of sober inquiry, and allay any mistrust that they might be intended to undercut the support of basic science, we will have reached the most important purposes of these hearings, and of the continuing dialogue that should follow.

These are questions of technological development, not of basic science, though these functions are profoundly interconnected. Many discoveries in physical science have resulted in practical utilities rather quickly; it took only 6 years from the first observation of nuclear fission to proving how to make the earth uninhabitable, and hardly longer to go from the principle of the transistor to portable TV. Can we not emulate such rapid progress in the health field? What are some of the difliculties and challenges in the health field? Can we also foresee some of the stressful and unwanted side effects of some branches of health technology?

May I first comment on some of the difficulties and obstacles. Some of them are unfair burdens to place uniquely on biomedical science when they reach some of our most pervasive social problems. Nor can we consider the manipulation of human nature in a vacuum that ignores religious and political controversy about its proper bounds and some of the most poignant ethical and moral concerns for life and death. We are charged to comment on obstacles to the utilization of scientific knowledge for the individual and social good. Some of us have read into this charge the implication that as scientists we might be diverted from the laboratory to implement social change, more bluntly that our science budgets should be divided to help pay for these applications. I hope this is an obvious absurdity; but our concern for an absurd implication should not deter scientists from displaying any insight they can muster to help show what should be done.

The homeliest examples may be the most instructive. It takes very little biological science to know that babies who do not get enough to eat are unlikely to develop into healthy, socially well-adjusted and economically productive adults. Throughout the world—and still even in this country-there are at least a few children who are not getting the benefit of this scientific information, because their parents can't afford it. As important as I believe the furtherance of basic science to be, if I had to choose between it and the applied science of feeding hungry children. I would choose the latter. But I would also ask why that particular choice was obligatory; why is it not made over a wider range of priorities?

Only a question of scale distinguishes this question from many others of economic allocation. Some hundreds of patients with kidney disease are still dying each year essentially because they can't afford an

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artificial kidney machine. It is also true that we might be unwise to sink all of our resources into this year's technology, when it is adVancing rapidly. But meanwhile, there is a simple economic discrimination for the chance to live. Is this a problem chargeable to biological research? If we deal with it on the customary scale for basic research, the cost will inevitably be several hundred more lives than if we gambled a few hundred millions of incentive money to distract some mechanical engineering inventiveness into kidneys away from washing machines.

This does illustrate one of the main problems of health technology: How to provide economic incentive for a new industry, and how to relate Federal support on issues of human life and health to a body of talent which is now embedded in profit-oriented commerce.

It is too obvious to need mentioning that medical care is still not evenly available, that economic factors still dominate access to advanced technical skills in medicine-like psychiatry, nursing care, or batteries of laboratory tests. In the long run, skilled manpower is again the limiting factor in making the best of existing knowledge freely available, though better techniques could be developed to make more effective use of the scarcest kinds of people. The education of the patient population is also of the utmost importance in improving health, by evoking intelligent avoidance of quackery, and encouraging the use of preventive facilities when they are available—like prenatal care and survey screening for cervical cancer.

The discrepancy between existing scientific knowledge and its public availability and acceptance is immediately visible in attitudes on narcotics. The medical case against alcohol and tobacco is overwhelming, yet these agents are tolerated by the establishment. This might seem to reflect a principle that the law hesitates to intervene against determined self-abuse by legally competent adults, despite the enormous health problems raised by the easy availability of these commodities

. But then the savage recriminations against marijuana are incompre. hensible, except insofar as pronouncing any synonym of "hashish" is spitting in the face of organized society. This issue is somewhat remote from the consideration of social benefit of science. However, the failure of the law to follow pharmacological science and discriminate carefully among different drugs in some relationship to their actual hazards is encouraging a defiance of the law in far more damaging ways, like taking on LSD and opiates. In general, the law on narcotics remains the despair of rational medical science, and is a testimony to the power of symbols of conformity. This is a controversial position, but there will be general agreement that social rather than scientific perplexities frustrate our dealing with the narcotics problem.

The situation is even more complicated where conflict of religious belief still enters into public policy. For a long time the importance of birth control for the health of the family has been universally con ceded, but a militant religious minority nevertheless opposed the spread of the appropriate knowledge, and only grudgingly acquiesces in its availability now, even to members of other faiths. Since contraception has been practiced throughout this period by the whole middle class

. the practical consequences of this perverse class discrimination have been to deepen the gulf between rich and poor, by class and by race. The administration has finally gathered the courage to insist on a

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rational policy in furnishing birth control information, and we need not resuscitate settled controversies.

However, a similar conflict is following a similar course in the related field of therapeutic abortion. A scientific understanding of man is of the utmost importance for social policy here in several ways. Most important is the discovery of a number of catastrophes where the continuance of a pregnancy can be predicted to result in a deformed child, or in serious physiological or psychiatric injury to the mother. Then techniques for the safe interruption of pregnancy are now well established. Perhaps most important, biological science offers no support for the theological speculation that the fertilization of the human egg immediately results in a "human being”. On the one hand, the fertilized

differs from that of an ape in a finite number of DNA components;

on the other hand, any tissue of the human body, including cells of the menstrum regularly discarded by every woman, has in it the same hypothetical potential to participate in a developmental process. The egg does eventually develop into a human being, but only gradually does it become differentiated from the forms of other animals. By the time it is a viable infant, we have no doubt about enfolding it into the species, but every scientific observation shows his development to be a gradual elaboration of the potentialities ultimately inherent in every cell.

A Senate committee may be a strange place to defend a heresy, but if we are to ask honestly about the impediments to the utilization of scientific knowledge for human benefit, we must include these strictures despite their relationship to religious controversy. The consequence of a dogmatic position about therapeutic abortion is hardly to prevent the practice. Instead it has been forced underground, and perhaps a sixth of all pregnancies are now terminated illegally under conditions that are a serious medical and psychological hazard to a million women every year! Judging from trends around the world, however, we may hope for a gradual transition of authority in this area from the penal code to private morality where it has a place I would not presume to intrude upon. Our political problem is how to respect the conflicting passions intensely held by different groups of constituents, giving the utmost latitude to individual liberty where it does not intrude on the welfare of the whole group.

The questions I have just discussed are remote from the immediate legislative responsibilities of this committee, but they help to illustrate the complexities of applying merely scientific attitudes to human problems. The allocation of resources is likely to remain subject to the same complexities.

The fruits of biomedical investigation are more importantly medical molecules than even the elegant medical machines like the artificial kidney. It would be highly desirable to subject the whole process of drug research to an optional systems analysis and attempt to rationalize it once and for all. Under the impact of Federal support for research in medical schools, and an aggressively defensive patent policy connected to that support, fundamental biochemical research is becoming less and less effectively coupled to the actual development of useful drugs in the pharmaceutical industry. Indeed, with more effective regulation of drugs, and appropriate demands for more rigorous testing, and with legislative interest in drug pricing, there is serious



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danger that risk capital for drug development will be choked off, that a larger and larger proportion of capital investment in that industry will be devoted to the promotion of existing agents, the few that have passed the scrutiny of an agency pressed to assure the impossible goals of absolute security and perfect efficacy. Promotion versus research is also encouraged by the growing bewilderment of an orer busy medical profession unable to sustain its own education for din criminating criticism of new drugs, and therefore increasingly reliante on the drug industry's slick ads and detailmen for its own expertise

Here, the ultimate problem is the inability of the medical profession to keep faith with the demands of the times. By failing to maintain its own capacity to judge the merits of new agents, it has abdicated AI its responsibility to a Federal agency that inevitably must follow the most cumbersome procedures toward monolithic judgments about their safety and efficacy. In the process, a great deal of flexibility is lost; only those drugs can be allowed even on the ethical market which are safe for the average practitioner who is assumed to be guided by the fine-print disclaimers and precautions in the manufacturer's literature. To the extent that only an enlightened minority of the pretising physicians remain in contact with modern medicine through systematic postgraduate training, the profession as a whole will remain at the mercy of self-interested advertising, which in turn does have 10 be policed by a regulatory bureaucracy. The profession itself must alcept the responsibility of qualifying its membership: the Gorernment could, however, accelerate this process by recognizing a gradation of responsibility that can be assumed by practitioners with more sophisti-solera cated training-a result toward which the roster of qualified drug experimenters is a useful step.

The expertise of the medical profession is, however, so vital to our national well-being that we should also begin to consider more farreaching measures. The most essential is the reinvigoration of our centers of medical education to encourage the training of many more physicians over a wider variety of skills and specialties. Some of these centers must also be dedicated to the continuing education of E mature physicians, being training and information centers for the latest advances. We have modern techniques of dissemination at our fingertips-wideband communications, computerized information retrieval videotape libraries-but we have not yet learned to apply them to this vital use, more out of perplexities of economic policy than because of technical limitations. One of the fundamental difficulties is that the time of the mature physician is so valuable he can hardly afford even his present efforts at continued self-education. The organized profession's tacit attitude in its public representation that every physician is equally and identically perfect offers the most limited encouragement to his self-improvement. It should be possible to devise tax incentives or even more direct subventions to encourage a more positive trend. Consider, for example, the career scholarship proposal

. A meritorious fraction of medical students should be offered full scholarships covering their own living expenses and the cost of their education throughout their initial training period—usually at least 1 years after the college degree. These scholarships would, however, be loans rather than gifts: The regular means of repayment would be not in cash but in credits from (1) later national or community-oriented

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in service, (2) regular intervals of postgraduate education, the credits

partly compensating for the time taken from their practice, or (3) time spent in clinical teaching, as is now generously volunteered by many of our finest specialists. If the prorated cost of education where included in the stipend, the system would already provide a big step to funding the needed expansion of medical education, and the stuidents themselves would constitute a very broad selection committee for allocation of support to beneficiary institutions. Such a program is undoubtedly self-liquidating in terms of the tax yield from improved earnings, but even if it were not, the social interest even exceeds the personal interest of the physician in his own continued education.

Analogous approaches are worth considering to encourage the most creative deployment of the resources of the drug industry. In view of the restraints on profiteering on drugs, secondary incentives for risking capital in research are essential. The operations of FDA ought to be financed by a manufacturer's excise tax on drugs amounting to say, 25 percent of their wholesale value, or about 10 percent of the consumer price. However, the company's research and testing costs (its investment in innovation) should be credits against that tax. Furthermore, companies that contribute matching funds to university research should be franchised to be able to participate fairly in patents in which the Government now would retain a preclusive interest, and even worse, a vaguely defined bureaucratic involvement. The lack of clear definitions of the scope of government interest in patents that bear any relationship whatsoever to Federal health research support is an intolerable bar to industrial-academic cooperation. Perhaps we might bar patents altogether for the more fndamental aspects of drug innovations, and leave them only to the fruits of the later, costlier development work for which industry is better suited. For example, a drug might be patentable only at the stage where it could qualify for FDA approval, the company being allowed some period of time after preliminary registration during which to pursue the development work, the registration itself entailing a substantial commitment of effort.

Every possible measure should be considered to minimize the commerical value of a brand name, which is generated by the huckstering of the medical profession, in favor of the actual merit of the innovation in the drug itself. Another way to approach this is to relax the law that requires a prescription to be filled by the brand-specified product, so as to encourage the use of generic names. Physicians must, however, be left the discretion to specify a particular formulation and manufacturer.

sum, we need to reconstruct the whole system of therapeutic innovation so that the drug companies are encouraged to reinvest in research and development, and so that the medical profession is kept in life-long contact with disinterested centers of medical education.

Fundamental biological research has made the most extraordinary advances within the last decade, especially in the elucidation of the genetic material, DNA, and the chain of events that links this to the synthesis of the proteins from which cells are made. This solid basis for biology is a credit to a cadre of fundamental scientists who funetion as teachers as well as researchers. Their domain of teaching includes the undergraduate who matures into our informed citizen, and also their own graduate students who will continue the traditions of



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