proved and the amount of $185 million didn't seem to be excessive and we hope the full amount authorized by the Congress would in fact be appropriated rather than the reduced amount recommended in the budget.

If we look at health research facilities, only $50 million is called for in the administration's budget.

As you all are very well aware, from 1967 through 1969 the Congress authorized $280 million. Only $35 million of the $50 million appropriated was actually released for expenditure, and if we add that to the $50 million that is proposed, we get only $85 million for the first 2 of 3 authorized years, leaving a phenomenal balance of $195 million for assignment in 1 year.

Now, there is already a backlog of approved requests here totaling $60 million, and with full agreement with Congressman Laird, that the letters of intent are simply that there is, nevertheless, another $82 million that is cited there.

It is our impression that the medical schools could very well and effectively utilize an appropriation of $100 million in fiscal year 1968 as matching funds for health research facilities construction. We request that the committee consider appropriations in this amount.

Animal care facilities represent a very special problem for us. No specific provision is made in the budget to meet the need for improved animal care facilities. Presumably this need is to be met out of the already limited health research facilities appropriation that we have mentioned, and we would strongly urge that the committee add a separate line item of $20 million for the specific purpose of construction of facilities for animal care in the health research facilities budget.

Last year Congress overwhelmingly enacted legislation setting proper standards of care for animals. Our medical schools welcomed the passage of that act and look forward to providing this high quality of animal care, not only for civilized reasons, as citizens of the community, but only healthy and well cared for animals are appropriate to the work that we do in teaching and research. The most conservative estimates that we can find from our institutions-and these, we believe, are reliable indicate that for the next 5 years an appropriation of approximately $20 million a year is necessary to bring the animal resources up to the level that the intent of the Congress clearly projects in the legislation that was passed last year.

As we turn to libraries, a survey was conducted by the association in 1963 that disclosed construction needs and renovation in excess of $100 million. In recognition of this need, the Congress authorized $10 million a year for 3 successive years. Last year $7.5 million was appropriated, but none was released for actual expenditure for construction and it is not at all clear that these funds will in fact be available for obligation this year.

The budget figure for 1968 calls for only $5 million instead of $10

million.

Five projects have already been recommended for support to the Surgeon General in the amount of $7 million and it is probable that by June another $3.5 million to a total of $10.5 million will be recommended to the Surgeon General.

From the number of library construction grant applications known to be forthcoming, and in negotiation with staff, it is estimated that

approximately $24 million will be required to support these new applications. Under these circumstances, we urge the full $10 million authorized under the law be appropriated. This will leave an unmet immediate need, as well as a deficiency of the future and we would anticipate that additional legislative action will have to be considered in the library field.

Mr. Chairman, I would say all this is fundamental to the total program of education, research, and patient service. All of these construction funds will have to be matched out of our own inadequate resources, so that you might rest assured that the medical schools are very careful not to inflate the size of their construction needs; not only Federal fnuds, but private and State funds are more than equally involved in all of these construction proposals. This construction is absolutely essential if we are to have the space and the facilities within which to do our job.

Now, beyond this we would like to call-beyond construction, we would like to call particular attention to just four items out of the many that we might speak to. These are the needs for the general research support grant, the research training grants, the clinical research centers and the educational improvement grants.

There are probably 20 items, as we have looked through the legislation, that could well deserve comment, and many would represent very wise investments for the future. But out of respect to the overall budgetary limitations, and in an effort to identify those points that are, in our opinion, of major importance, we focus on these four.

If these four areas don't receive the support they need, then there will be an interruption in the growth of programs which by their very nature have to have stable support over many years in order to achieve their goals. This will limit the capacity of the university medical centers to meet the expanded health expectations of the people.

We recommend that the general research support grants should be increased to the full 15 percent of research appropriations that is authorized under the law. The budget calls for an increase of $10.7 million, but almost all of this will go to institutions that heretofore have not been eligible.

The net result is that there will not be an increase in the awards to the medical schools and wherever a program has this leveling of budg et in these days of inflation, it amounts to a decrease in the effectiveness of the program.

These general research support grants are of the highest importance to the institutions. They make possible central research support that is otherwise not readily available. Improved animal care management; central facilities available to a number of investigators and teachers who otherwise might have to duplicate them from individual grants; provision of stability of investigators as their programs of research evolve and change. All of these find support from the general research support grant.

Major new programs of research which now, many of them, enjoy independent support, were initiated with the support of this fund. In my own institution at the University of Michigan, just as an example, over 90 percent of the pilot efforts supported by the general research support grant have developed into programs that now have their own independent support.

Through these grants every institution is able to respond very quickly and adequately in the initial phases to the support of research needs, as well as being able to give balance and strength to the research resources of the entire institution.

One of our deans has said-probably accurately-that it is impossible to overestimate the multifaceted value of these grants. I would emphasize that they are awarded as a result of demonstrated research capacity within the institution. They are carefully reviewed to assure that in their expenditure they further improve the basic research capacity of the institution.

In the research training grants only a 3.8 percent increase is recommended. We anticipate there will be a 3.6 percent growth in cost of living. This then, as we see it, is a level of support. The net effect is then that established programs will not experience a normal growth and the needs of the developing and expanding schools will be frustrated.

There are over 800 unfilled fully budgeted faculty positions in medical schools today. To staff the 25 new schools that are needed by 1975 will require hundreds of highly qualified teacher-scientists, whose production depends upon the availability of adequate research training grants.

Once more, using my own university, which I know best, as an example, in the last 3 years over 20 professors have left our medical school to fill chairs or to take over administrative posts in other medical institutions.

Every single one of these important teachers have been supported at one time or another in his career by funds from the National Institutes of Health programs. So we feel it is accurate to say that the training programs from NIH sources are truly essential to the production of the faculty members necessary for the education of the increased number of physicians in other categories of health-related

manpower.

Our most conservative estimate shows a need for a minimum of $153.6 million for research training grants instead of the $139.6 million requested in the budget.

Now we turn to the third item, which is the clinical research centers. A 7-percent increase is proposed for this program and this is inadequate to meet the rising costs inherent in hospital activities. The clinical research centers basically represent a set of hospital beds available for research. It is in this setting that the fruits of laboratory investigation find their prompt application to patient needs.

The problems of renal transplantation, cardiac pacemakers, problems of hemophiliacs undergoing surgery, children receiving transfusions while they are still in the uterus, patients whose intestines don't absorb food normally being restored to good nutrition, all of these efforts are being pursued successfully within these clinical research.

centers.

Inflation has decreased the purchasing power of hospitals by 10 percent and hospital bed costs alone have risen, as you well know, from 20 to 30 percent in the past year.

The administration budget calls for $30.5 million for these clinical research centers and we urgently request this item be raised to a minimum of $40.5 million. Even that will still not meet the needs

for the development of out-patient versions of clinical research activity which the Congress asked to have developed last year.

The last area of grants that we would call attention to is educational improvement grants. Basic improvement grants are for the purpose of improving the quality of medical education for an existing student body and to increase the size of that student body modestly. Special improvement grants are designed to meet special opportunities and

needs that are nonrecurrent.

The recommended appropriation is $2.5 million less than the authorized amount the $57.5 million instead of $60 million.

Medical schools have reflected in their responses a capacity to utilize with great effectiveness very considerably more than the authorized amount. Because the recommended figure will in fact probably meet the most pressing needs, and out of respect for the overall budgetary limitations we are not requesting at this time an appropriation up to the fully authorized amount. We do, however, plead that the figure as it is recommended in the budget is actually appropriated. The medical schools have accepted a contract with the Government to increase their student bodies and to embark upon programs that have to be long range and stable to improve the quality and efficiency of their medical education as well.

Very heavy commitments have been made to expand student bodies, faculties, teaching resources, and it is important to the continuing confidence of the partnership between the medical schools and the Federal Government that the commitments be met on both sides and the funds authorized to support this major program commitment actually be appropriated in full.

We turn now to the question of the hospitals and patient care facilities.

We would express our very deep concern that the present programs that provide Federal grants for the construction of hospitals, ambulatory clinics, and other facilities for the care of patients are not adequate or even appropriate for the urgent and growing needs of a number of our member institutions, especially for the renovation or replacement of teaching hospitals and especially in urban settings.

The amount recommended in the President's budget should by all means be appropriated, but even if it is there will remain a large unmet need which very seriously impairs the ability of the medical schools and teaching hospitals to expand and improve their education and training of health personnel and develop more effective and more efficient ways of delivering personal health services to patients. We would call your attention to the needs for student loans and scholarships. Although some provision and important provision has been made for the support of medical students, we think it is important to emphasize that this program should be markedly expanded in the early future. Although education in the health professional schools is very expensive for the individual, these students receive far less in the way of scholarship and fellowship support than any other students at comparable levels in higher education. Yet it is necessary for over half of our young physicians as they graduate from the professional schools to contribute 2 years of active service in the Armed Forces in recognition of this special need. We think that both as a

matter of equity and recognition of their importance to the Armed Forces, the Federal Government should provide for scholarship support.

THE REGIONAL MEDICAL PROGRAMS

The President has recommended just over $80 million for these programs in 1968 and we very strongly support this recommendation. As this program has gotten underway throughout the country, every medical school is involved in intensive planning and cooperation with many other institutions and groups for programs that are appropriate to a region which really gives great promise for making more readily available to all patients, diagnostic and therapeutic procedures through providing cooperation between medical centers and the community in this area. It is important that these plans be put into operation as soon as they are completed, and the determination to see that these important regional medical programs are not frustrated for lack of funds, we suggest and urge that the recommended support in the budget be reflected in appropriations.

Mr. Chairman, the hard fact that we have to face is that there is simply not enough health manpower to meet the needs of the people. There are not enough doctors and there are not enough supporting people. The shortage of physicians, in our opinion, is without doubt the most critical single shortage in the manpower for health service. Although medical schools have increased their capacities and new schools have been created, the increase is not keeping up with the demand. Growing demands for physicians' services, we feel, can only be met by more physicians.

Despite the hopeful offsetting factors of increasing productivity, these new assistants are as yet undefined in category and untried in practice. It is clear to us that more physicians of high quality must be trained as quickly as possible and the resulting increase in the number of physicians will be healthy not only for people but for the profession itself between now and the middle seventies.

We have these hundred medical schools in the United States that can produce the physicians we need. The adequate support of the faculties responsible for this medical education is a prime need for the future. health of the Nation. These 100 institutions must not have their potential limited by an artificial shortage of funds, artificial because the investment necessary for them to optimize their output is minuscule in comparison to our country's wealth and in comparison to the enormous benefits that such an expediture would bring to the health of the people. The university itself is the typical institutional setting of the interdependent programs of education, patient service, and research that form the academic medical centers. There are 10 established centers that are in effective operation to an analogous setting except that the medical school is independent of the university.

The heart of all of this apparatus, the core of the academic medical center, is the faculty and the facilities that are necessary for the education of the M.D. candidate. Then they serve other essential roles simultaneously. Basic medical scientists are also responsible for the graduate degree programs and the research training that are the source of tomorrow's teachers and investigators in the basic health sciences.

The research efforts of the basic health faculty create a scholarly environment needed for the kind of education that prepares the stu