Senator HARRIS. Dr. Engle, do you have associates with you?
Dr. ENGLE. Yes, sir.

Senator HARRIS. Fine. Have them come up and present them. Dr. ENGLE. Dr. Benjamin Wells, Assistant Chief Medical Director, Research and Education.

Senator HARRIS. Dr. Wells took part in our conference in Oklahoma last fall.

Dr. ENGLE. Mr. Joseph Mason, his special assistant in Research and Education.

Senator HARRIS. Good morning, gentlemen. Proceed with your statement as you wish.

TESTIMONY OF H. MARTIN ENGLE, M.D., CHIEF MEDICAL DIRECTOR, VETERANS' ADMINISTRATION, WASHINGTON, D.C.; ACCOMPANIED BY DR. BENJAMIN WELLS, ASSISTANT CHIEF MEDICAL DIRECTOR, RESEARCH AND EDUCATION; AND JOSEPH MASON, SPECIAL ASSISTANT, RESEARCH AND EDUCATION

Dr. ENGLE. Thank you, Mr. Chairman.

The Veterans' Administration operates 165 hospitals, providing just over 120,000 operating beds; 211 outpatient clinics that handle more than 6 million patient-visits a year; 16 domiciliaries that accommodate about 14,000 members, and more than 30 nursing-home facilities. The VA patient-care facilities are in the aggregate slightly more than the total major hospital affiliates (non-Federal) of all the medical schools in the United States.

When measured by the usual governmental criteria-number of dollars and number of personnel-the VA medical research program is a small one. Our research budget is only about 4 percent of the VA medical-care expenditure, and a minor fraction of the total VA budget of approximately $6.5 billion. Our research budget is less than 0.3 percent of the total Federal outlay for research and development.

If, on the other hand, we view VA's research program in relation to the category of clinical applications and essentially disease-oriented research, the effort looms as a rather large one by any set of standards. At the present time, we are supporting about 7,000 projects that are being conducted in 146 hospitals and 12 outpatient clinics. About 3,000 physicians and 1,000 Ph. D. scientists are involved. During the past year, our programs have yielded more than 3,000 publications in professional and scientific journals, not to mention thousands of verbal presentations, exhibits, and other forms of communication. More than 85 percent of our total effort is clearly identifiable as applied or clinically oriented research.

It is relevant, also, to note that VA employs about 6 percent of the Nation's medical manpower, including more than 2,000 physicians who hold active academic appointments in medical schools and universities. At present, 88 of our hospitals are affiliated with 74 of the Nation's 88 medical schools. In addition, VA hospitals are affiliated with 32 of the Nation's 47 dental schools, all of the 56 accredited schools of social work, the 58 universities approved for graduate training in clinical and counseling psychology, 145 basic nursing programs, and 127 schools that provide clinical training in physical medicine and rehabilitation therapy.

In summary, the Veterans' Administration system is an enormous and on-going national resource for biomedical research and health personnel training with an enormous potential. VA has achieved an impressive record of positive contributions to medical practice, both by individual researchers and by large cooperative studies that are now engaged in the investigation of no less than 44 different clinical fields. 1. Is there a need for additional attention by Federal agencies in the field of biomedical development and application?

Yes, in my opinion an urgent need exists for additional attention by Federal agencies in the field of biomedical development and application. Even now, for example in the dental field, the frequency of disease far exceeds current or future potential for training enough professional people to meet the Nation's requirements for oral health. This kind of unfavorable situation exists in other areas of medicine and will worsen, particularly in the light of current trends:

(a) The population explosion will furnish an ever-growing number of people needing medical care.

(b) The increasing percentage of older people in our population will result in greater numbers requiring treatment for the degenerative and long-term diseases associated with aging-cancer, heart disease, stroke, emphysema, rheumatism, mental illness, and others.

(c) With the recognition of alcoholism as a disease, vast resources will be needed to treat the alcoholic, of which there are an estimated 4 to 5 million, with the incidence steadily increasing.

(d) The greater Federal commitment in assuming responsibility for the health care of its citizens.

Within the VA system, the need is for ample resources to take advantage of a unique opportunity to look for solutions to the health problems created by an older population, problems that will face the Nation since the proportion of older persons in the general population is increasing but at a slower rate.

Unusual opportunities also exist for investigating mental diseases; half the hospital beds are occupied by psychiatric patients, again reflecting the situation in the general population.

Bioelectronics and bioengineering need support to improve and standardize detection and treatment of disease and help in rehabilitation. This field also offers the potential of being able to cope with the vast numbers of people that will require medical attention.

2. What means are employed by your agency to establish research priorities and long-range research plans?

Realizing the need, the Veterans' Administration has been developing techniques to establish research priorities and long-range research plans. The Assistant Chief Medical Director for Research, Director of the Research Service, and central office research coordinators are chosen for competence in and broad knowledge of their special areas, consultants are used to implement skills and information otherwise lacking, and the close working relationship between the Nation's medical schools and affiliated VA hospitals keeps the VA in the forefront of medical progress. The VA has now twice asked the National Academy of Sciences-National Research Council to evaluate its programs and

make recommendations. The first such survey by this august body was completed in June 1960 and another survey is now in progress. We are now at a stage where we are working on a formal structure to provide guidance.

The needs of our patient population establish priorities. Among these are the problems of the aging veteran but also including young patients requiring long-term care. Mental illness ranks high because of the heavy patient load. Physical medicine and rehabilitation is important because so many veteran patients have severe and massive injuries. Heart disease and cancer pose substantial problems. And new programs of specialized care-such as renal dialysis, cardiac catheterization, intensive care units-are being implemented as rapidly as resources permit.

3. How do you evaluate and maintain a continuing examination of ongoing projects and programs?

Station research and education committees first pass on the merits of a research proposal. If a station approves a project, the research coordinators carefully scrutinize the proposal before determining a level of funding, and research program evaluation committees (comprised of VA and non-VA experts) now continually examine programs and make appropriate recommendations, such as increased support because of the excellence of the research, continued support at the same level, reduced support, and withdrawal of support.

4. What means does your agency use to maintain adequate communication with scientists and engineers in the field of biomedical development and applications as well as with medical practitioners and hospitals? Are they adequate?

The means used by the VA to maintain communications with scientists and engineers, internally and externally, are primarily those of publishing in scientific and professional journals-3,417 articles during fiscal year 1966- and presenting papers before lay groups and scientific meetings. Informal exchanges between investigators at scientific meetings is a standard practice, but necessarily limited in scope. Annually, the VA holds a medical research conference which is valuable for intramural exchange of information with some exposure to other information through the device of inviting prominent non-VA scientists. Some 2,000 of the 6,000 VA physicians hold academic appointments and contribute biomedical information as teachers.

Recently an Office of Scientific Communications was established and is quite active in developing more extensive exposure of biomedical information. VA investigators now have a more facile channel for obtaining information about government research through the Science Information Exchange and the Department of Defense. This department also writes and disseminates brochures and pamphlets about aspects of research, publishes a bimonthly Research and Education Newsletter, furnishes weekly highlights about research, and cooperates with the Office of Information Service in publicizing newsworthy projects. Circulars and medical bulletins also serve to distribute needed information to field stations. A Termatrex information storage and retrieval system is being developed for technical information and an Automated Research Information System (ARIS) is

about to be launched and will quickly furnish needed administrative information about the program.

As for adequacy, the programs are not currently adequate and it is doubtful if they will be even when the Termatrex and ARIS systems are functioning, though this will represent a substantial improvement over the present situation. A more adequate staff in the Science Communications Office further would improve the situation. But to derive a truly adequate system would be to solve a problem that plagues the entire scientific and medical community. We do not know the answer.

5. What procedures do you employ to translate results of biomedical research into actual treatment and care of patients?

The transition from biomedical research into actual treatment and care of patients poses no real problem within the VA. Because the VA is hospital based and mission bound to provide the best available patient care, research frequently serves as the forerunner to improved patient care. A very considerable part of our biomedical research is directed or conducted by physicians who have a large and often a dominant commitment to patient care. The close cooperation of the clinician with the basic scientist eases the path from research finding to clinical application.

The potential for socially meaningful research, particularly in matters having to do with the delivery of medical services, is enormously greater than anything thus far attained by any other organization. VA research and education programs, however, cannot stand alone. They require the medical community; they, in turn, can make valuable contributions to the community. The VA can best benefit the Nation by uniting and conducting its programs with the total health effort of the Nation.

6. What further steps might be taken by Government agencies to bring about more biomedical development without diminishing basic research and without disorienting institutions involved in basic research?

Since basic research and applied research are complementary activities, the problem of one disorienting the other appears to be an unnecessary concern in the Veterans' Administration. The attitude of the VA and steps which might profitably be taken, are aptly summed up in a report of the Committee on Government Operations Subcommittee on Reorganization and International Organizations. The report, "Interagency Drug Coordination," printed as Senate Report No. 1153 of the 89th Congress, second session, in part recommends establishing separate, identifiable allocations for medical research and development.

A considerable portion of the VA research budget is diverted to activities which might more appropriately be classed as development. A few examples of these are the refinements on the cardiac pacemaker, the conversion in the use of radioisotopes for diagnostic purposes, the changeover from pulmonary physiology research to routine testing procedures for diseases of the respiratory system, renal function studies leading to the lifesaving methods of hemodialysis, and

others.

Senator HARRIS. Well, we appreciate your presence here and the presence of your associates, Dr. Engle.

You have 165 hospitals now?

Dr. ENGLE. Yes, sir.

Senator HARRIS. That number has been reduced in the last year or so?

Dr. ENGLE. Yes, I believe six hospitals were closed.

Senator HARRIS. Was that all it was nationwide?

Dr. ENGLE. There was consideration about closing 11. I think they ended up with closing of six. But of course, we have a construction and modernization program and some new hospitals have been opened since that time.

Senator HARRIS. What will be the effect of the Vietnam situation? Will your patient load increase now?

Dr. ENGLE. We think so. We have an arrangement with the armed services, actually an arrangement that goes way back to the late 1940's, wherein they can transfer seriously disabled people, people that are scheduled to be discharged from the services. They can transfer them in advance of their discharge to Veterans' Administration hospitals. Currently, we are getting about 150 patients a month directly related to the Vietnam conflict.

In addition, the so-called new GI bill passed during the last session of Congress, as you know, added all of the post-Korean veterans to the list of potential eligibles for VA care. This has represented an increase of about 1,500 patients in the hospital at any one time, related to this group of people.

Senator HARRIS. It would be fair to say, probably, that at least your patient load is not going to go down within the immediate future.

Dr. ENGLE. Well, it is hard to say. This is a very interesting question because there are a variety of influences that are operative. We have mentioned two that are tending to increase the load. But on the other side of the coin, medicare legislation will undoubtedly influence our demands in the reverse direction.

Senator HARRIS. That is a good point.

Dr. ENGLE. So far on the basis of statistics compiled in the last year, it seems like there is about a 5-percent decrease in applications from people over 65, which is in large part, we think, attributable to title 18 and title 19.

Senator HARRIS. And those people now represent about 30,000 out of the 100,000-plus, of your patient load?

Dr. ENGLE. Yes, sir.

Senator HARRIS. Now, if you were to expand your opportunities for research and for clinical trials and so forth, would that require just money? Is that the only factor involved here?

Dr. ENGLE. No, sir, we think that money is only one part of the problem, that you have to have people appropriately motivated, with the right kind of skills to do research, and we think an orderly growth of the program is commendable.

Senator HARRIS. Have you been called in on any of the meetings that have resulted from the President's statements at the inauguration of medicare in June of 1966 and the actions since, as he said, to get more results from medical knowledge?