Dr. ENGLE. Well, we attended one such meeting, yes, sir. We did not have an opportunity to testify at that session. But as I indicated in my opening statements, the Veterans' Administration does represent the kind of a program that the President was hopeful about elsewhere; namely, we do have a program where the primary emphasis is on clinical research. In other words, the application of specific advances to patient care.

Senator HARRIS. Let me ask you about a series of relationships between Veterans hospitals and, first, universities-you did mention that, but I thought you might go into a little more detail; secondly, NIH and other governmental agencies involved with health; and thirdly, private industry, drugs and instrumentation companies, if any. Start with universities.

Dr. ENGLE. Well, there are about 88 of our hospitals that have formal associations with schools of medicine.

Senator HARRIS. What does that entail?

Dr. ENGLE. This involves a relationship whereby a so-called dean's committee, a group of key faculty members, serve in an advisory capacity to the Veterans' Administration in terms of training and research programs. We in most of these locations assist in the training of medical students. About 45 or 50 percent of all the third- or fourthyear medical students are assigned to Veterans' Administration hospitals for some of their clinical experience. So in these 88 locations, then, the schools would send third- or fourth-year medical students over to the Veterans' Administration.

The relationship also involves the fact that the full-time Veterans' Administration physician working in these localities has been appointed with the approval of the medical school and really serves as a faculty member of the medical school.

In fact, in a way, medicine in the Veterans' Administration is locally oriented. It is not really a career service such as the Army, Navy, or Air Force. In our best associations, the physicians are on our payroll in one location primarily because of the medical school. They really are faculty members of the school and they are not subject to transfer to any other hospital.

Now, in these locations we also train residents and interns. Commonly, the residents are transferred or rotated between the university hospital and the Veterans' Administration hospital. Their training is supervised by the medical school faculty.

Senator HARRIS. Go ahead.

Dr. ENGLE. In research, it is not uncommon to have people from the medical school closely involved, intimately involved in the research project, along with the man who is on the payroll of the Veterans' Administration.

Senator HARRIS. What about the NIH? What sort of contracts do you have with NIH?

Dr. ENGLE. Well, the appropriation language as now constituted does not permit a full-time VA physician to get a grant from NIH directly. The grant has to be processed and administered by the associated medical school, even though the actual research is done in the Veterans' Administration hospital primarily by the VA physician. And at the present time, we are involved with about, $9.5 or $10 million.

Dr. WELLS. Approximately $10 million in direct NIH grants; that is, directly to the university, and about a million dollars in contract. Dr. ENGLE. I would like Dr. Wells to comment on our other association in the form of advisory councils and others.

Dr. WELLS. We have broad liaison with the National Institutes of Health by having representation on practically all of the study sections that involve work that is cognate to our program. Then we also have representatives of the chief medical directors on each of the councils. This includes even such things as the councils of regional programs and the research facilities group and so on. So that actually, we are a party to practically all considerations of research expenditure from NIH and take specific note of those that pertain to our hosiptals. Senator HARRIS. Do you have any research programs not financed by the VA or NIH?

Dr. WELLS. About a million dollars in total. You see, we have about $12 million that is non-VA money: approximately 10 in NIH grants, about a million dollars in contracts. This is mainly for the cancer chemotherapy program. Then we have about a million from industry, practically all from the pharmaceutical industry in small grants for projects.

Senator HARRIS. That is the last thing I was going to ask about, contracts for research with industry.

Dr. WELLS. This is practically entirely limited to the pharmaceutical industry and comes along in relatively small grants as a rule to individuals and sometimes to combinations at the medical schools and our hospitals, largely for straight-forward drug trial, but some of it in very basic work.

Senator HARRIS. What about the regional medical program? How does the VA fit into that?

Dr. WELLS. I think perhaps the most exact answer at the moment is we are not quite certain, but we are very closely related to the people who are trying to work this out. In the many grant proposals, planning grant proposals that have thus far been processed by the council, the Veterans' Administration hospitals have been included as a part of the community resources. Veterans' Administration hospital directors, chiefs of staff and others, have been included (I believe I am correct) in the regional planning groups to help.

Senator HARRIS. That is true in Oklahoma.

Dr. WELLS. It is true elsewhere, too, Mr. Chairman. So this has been universally accepted as something that is important from both our standpoint and the standpoint of the regional medical programs and

NIH.

The exact working relationship is exceedingly difficult to describe, because actually, the whole planning business has not gone along far enough yet for us to be quite certain exactly what people are going to be doing. You see, there have been only four operational grants that have been issued and these are not actually functioning, yet. So it will be a little time before I think we can describe with any accuracy what our relationship would be.

Senator HARRIS. Would you comment, Dr. Engle, about what you think the research budget might be if the VA were to make an appropriate contribution in the field of medical research? I believe you say now it is 4 percent of the medical budget.

Dr. ENGLE. Yes. Well, this is a hard question to answer with any degree of mathematical exactness. Our present research budget represents 4 percent of the total. In contrast, on another end of the spectrum, the teaching hospital beds of the medical schools are about equal in number to our beds. They represent about 110,000 beds and they utilize about $400 million worth of NIH funds in research effort each year. Now, obviously more than money is involved. They have more people employed who are doing the research.

But it does indicate a hope and a potential for the future in terms of our more optimum utilization of the clinical resources that are available to us.

One other fact that might be mentioned is that there are a good number of requests for pursuit of research projects that are not funded in any 1 year. In a way this is healthy, in that it represents a screening process, with the most desirable project being funded. There are at the present time about $10 million worth of research projects that have not been funded.

On the other hand, as I mentioned earlier, we think that we made orderly process with some growth each year in the last decade in the amount of money that we have spent for research and the number of projects that are ongoing and so forth.

Senator HARRIS. What about manpower development? Does the VA play a role now, or does it have an expanded role to play, particularly in regard to semiskilled health personnel or subprofessionals?

Dr. ENGLE. Dr. Wells has been involved in some deliberations within recent months on this issue. I will ask him to comment.

Dr. WELLS. We have a large number of trainees, Mr. Harris, in all categories. As a matter of fact, we have 53 different categories of health service manpower training in the Veterans' Administration. At the present time, we have approximately 23,000 trainees on duty in these various categories. We have estimated that we could increase this number within our present facilities, present teaching resources, by approximately 14,000, with most of these people being in the technical and subprofessional levels. Obviously, the big shortage is really in the nursing occupations, the laboratory, radiologic, technologists and this class of personnel. We would put our emphasis on this if we are able to fund our programs in the future as we would like.

Now, we are cooperating with the other Federal agencies at the present time, particularly under the various antipoverty programs and under the Manpower Training and Development Act, and are receiving into our hospitals at the moment approximately 4,000 trainees under these various programs, the individual trainee being stipended by the other agency and at least as far as the Manpower Training and Development Act is concerned, they have been authorized to fund the cost of instruction in our hospitals. This is being handled on a completely decentralized State level basis. But it has been a rather successful program and I feel it will definitely increase the number of available health service manpower at the key shortage level, the subprofessional nursing aid and technical level. Senator HARRIS. Very good.

Do you have anything to add, Dr. Engle?

Dr. ENGLE. No, sir.

Senator HARRIS. Mr. Mason?

83-470-67-10

Mr. MASON. No, sir.

Senator HARRIS. I want to say we are very pleased you are here and we appreciate both your prepared statement and your response to questions-Mr. Mason, Dr. Engle, Dr. Wells.

Dr. ENGLE. Thank you, sir.

Senator HARRIS. Mr. Wright?

Mr. Christopher Wright is the director of the Institute for Studies of Science in Human Affairs at Columbia University. Without objec tion, we will place in the record at this point a biographical sketch concerning Mr. Wright.

Biographical Sketch: Christopher Wright

Director, Institute for the Study of Science in Human Affairs, Columbia University, New York.

Background Data: Scientist, Manhattan Project Los Alamos, N.M.; Instruetor of Philosophy at Williams College; Research Associate University of Chicago Law School; Associate Director, Executive Director Council for Atomic Age Studies at Columbia University; Lecturer in Public Law and Government, Columbia University.

Senator HARRIS. You have a prepared statement, I believe, Mr. Wright. We are very pleased you are here. You may proceed with that or however you desire.

TESTIMONY OF CHRISTOPHER WRIGHT, DIRECTOR, INSTITUTE FOR THE STUDY OF SCIENCE IN HUMAN AFFAIRS, COLUMBIA UNIVERSITY, NEW YORK, N.Y.

Mr. WRIGHT. Thank you, Mr. Harris. I will proceed with my

statement.

At this time it is especially important to assess the adequacy of Federal institutions for biomedical development in terms of the links between the biomedical sciences and man's social and human needs. It is not sufficient and may even be quite misleading simply to regard biomedical developments as a problem of intellectual development, as if the task were to unfold and refine a pre-existing pattern of biological knowledge and apply it in the most obvious manner. Rather, biomedical development is but a part of a more complex and dynamic system of intellectual and institutional relationships. Federal agencies must not, for instance, be regarded simply as a source of support for an otherwise autonomous development and use of biomedical knowledge. They cannot avoid active and knowledgeable participation in the process of selecting new goals, defining new policies, and implementing priorities in and for the biomedical sciences.

Granted that there is as yet remarkably little comprehensive and specific knowledge of this system, it is clearly possible to identify and cope with many of the major problems in this area. Studies of the issues posed by this subcommittee would provide a very valuable beginning. In this presentation I wish to emphasize the need to charge some central public institutions as well as private ones with specific responsibility for conducting continuous and open policy-oriented studies which will result from and lead to practical experience as well as to scholarly wisdom.

Three considerations should govern the present assessment of our Federal institutions. First, the most important new opportunities for

manipulating the interactions between the natural sciences and human affairs now tend to be associated with organizations and activities on a scale involving the resources and responsibilities of the Federal Government. Second, conscious and wise control of these manipulations depends essentially upon social science understanding of the social and political aspects of science. And third, the biomedical sciences are very likely to provide major intermediate links between the physical sciences and human affairs. To be sure, scientific revolutions in the physical sciences and their technological applications have had many quite direct impacts on man and society, but control of these interactions for the benefit of man really depends upon the development and use of relevant biological, behavioral, and social scientific knowledge. Historically, the pure and applied biological and medical sciences have been more closely coupled to each other and to explicit ethical concerns than have the physical sciences and engineering. Thus, what can be learned about the problems and opportunities of Federal involvement in biomedical development will also shed light on the still more general issue of the Federal Government's relation with the totality of modern science.

I should now like to respond to the specific questions posed for consideration by the subcommittee.

First, as to the need for additional attention by Federal agencies in the field of biomedical development. There is certainly a need. Because this field should be looked at in the context of our social environment there is a special need for more of a sense of direction. Without this it is difficult to justify other biomedical needs. Federal agencies can and must play active roles in studies as well as practice if either basic studies or Federal policies and programs are to develop in viable directions. A number of offices and agencies are beginning to do so, but there have also been setbacks. Progress is still much too slow, given the pressing need to use existing human and financial resources more effectively.

To illustrate topics for study, let us consider the implications of advances in biomedical science and manipulability and control within biomedical affairs. Then I shall mention some techniques which Federal agencies have used or might use to meet these new needs.

RELATING NEW KNOWLEDGE TO PRACTICE

A price we pay for promoting relevant basic research is a general sense of frustration when new knowledge reminds us of the relative imperfections of medical practice and health care as actually provided. It is sometimes observed that present medical training and practice is generally geared to what was known several decades ago and not to what is known today or is likely to be known in the foreseeable future. Alternatively, when and where the most current knowledge and techniques are employed, the accumulated wisdom of the past may very well be disregarded. Somewhat comparable gaps arise when changes in social and human standards and values demand more extensive applications of old biomedical knowledge.

Such changes make it necessary to re-examine intellectual and institutional assumptions about the relationships between basic research, education, training, and medical practice; between treatments to cure