Dr. STEWART. No, it is not different. If a mother is somewhere around 3 or 4 months pregnant and she gets German measles, the chances of having a defective child are very high.

Mr. FLOOD. What are we talking about?

Dr. STEWART. We are talking about immunizing people so that when the mother is pregnant she is immune to German measles.

I checked with Dr. Shannon about a month ago on this. The difficulty has been with live virus vaccine that when you immunize children they get a little of the disease and they transmit it to the mothers that are in the area and this is a dangerous situation.

Mr. FLOOD. What is the answer? Do you have the vaccine? You talked to the doctor, what did he tell you?

Dr. STEWART. He told me a month ago that they thought they had isolated an attenuated virus in NIH which looks like it immunizes and does not cause this problem of transmission. He cautioned me that this was tried on a half dozen people at that time but it looked real promising. I have not checked since that month ago.

Mr. FLOOD. The answer is you do not have it.

Dr. STEWART. I think the answer is we do not have it, but it looks like we are well on the track.

Mr. FOGARTY. Do you think you have enough money in the budget to go along at a level that will produce results?

Dr. STEWART. Yes, sir.

TB VACCINE

Mr. FOGARTY. What is the status of the TB vaccine? We don't hear as much about TB as we used to. I thought we were on a plan to eliminate TB.

Dr. STEWART. Yes, and I believe the budget reflects that plan.
Mr. FOGARTY. Does it?

Dr. STEWART. Yes.

LIMITED USE OF BCG

Mr. FOGARTY. You still do not recommend widespread use of BCG? Dr. STEWART. We do not think BCG vaccine is useful except in situations where a person is particularly exposed to high risk TB, a laboratory worker, or a slum area where there is a high incidence of TB.

This is for two reasons. One is that when you immunize somebody with BCG he gets a positive skin test and you lose one of the best tools of case finding that is possible. Secondly, the level of immunity is not like other vaccines. It is a low level of immunity. You do not get a return on a mass vaccination like you do in the measles or smallpox vaccines or the other more conventional vaccinations. Therefore, we think BCG vaccine should be limited to areas where there is a particularly high risk of TB.

PUBLIC HEALTH HOSPITALS

Mr. FOGARTY. On the public health hospitals, Doctor, can you tell us a little more about your plans for these hospitals? What role do you expect them to play in the communities in which they are located? How will they fit in with the communities' other facilities and what

will be their relationships to the Bureau of State Services? Do you plan any change in your admittance policy? Who will be treated in these modernized public health hospitals?

You may supply for the record.

(The information to be supplied follows:)

FUTURE PLANS FOR PHS HOSPITALS

A subcommittee of the Office of Science and Technology made a study of the PHS hospital system just a year ago and developed a number of recommendations.

First, with respect to the role of the hospitals in relation to the Bureau of State Services, these facilities have been used by BSS in a very limited way in the past. What is visualized for the future is a formalized and expanded collaborative relationship in which the hospitals and clinics will serve as the intramural facilities for research by the Public Health Service in ways of providing health services. Between the development of knowledge through basic research and its application throughout the county there is a vital intermediate step in which these hospitals will be extremely useful.

As an example, in the development of the Papanicolaou smear for cancer of the cervix as a product of research the BSS set up a pilot project in one of the PHS hospitals in which the techniques were standardized, procedures and manuals were developed, personnel were trained, and techniques for training and organizing teams of personnel were developed prior to launching a national program. This example illustrates one kind of role that is contemplated for the hospital system. The relationship of these hospitals to BSS will be rather comparable to the relationship the clinical center has to the National Institutes of Health.

As another example, the possibility of involving the hospitals more closely in carrying out missions of other parts of the Public Health Service, such as demonstrations and training in disaster medical care, the new role of the hospital in comprehensive community health services, operations analysis of expanded functions of the allied health worker, and the planning and implementation of Federal employee health programs is being explored. We also hope to develop regional rehabilitation centers in our hospitals where Federal employees who become injured in line of duty could be cared for under the Department of Labor's Bureau of Employees' Compensation. These centers could make substantial savings in both human suffering and money.

With respect to the role of the hospitals in the communities where they are located, a much more extensive involvement than has been the case in the past is anticipated. Toward this end, a panel of experts from both inside and outside the Government will be established to stimulate and review modernization proposals. This group will be broadly representative of the medical community and will be capable of evaluating the views of medical school faculty members, medical practitioners, hospital administrators, and the health department, in the regions served by the general hospitals. It will address itself to such things as the proper relationship of each hospital to health education facilities in the local community. This would entail a delineation of the role, both present and anticipated, which the Public Health Service hospitals should play in the education of students from nearby medical schools. Such an analysis, moreover, might be approached from the standpoint of the hospital functioning as one component of a National Institutes of Health regional medical program. The optimum physical proximity of each hospital to associated institutions of higher learning is yet another question susceptible to fruitful evaluation by the advisory panel. Basically, the caseload will continue to consist mainly of the several groups of statutory beneficiaries now served. Heretofore, existing authority to admit cases from the community for special study purposes has been used very sparingly. It is assumed that as involvement of the hospitals in community health activities increase this authority will be used to a greater extent than in the past.

Mr. FOGARTY. Will Dr. Marsden testify on the plans for the regional medical programs?

Dr. STEWART. Yes: he will.

Mr. FOGARTY. I understand he is a real high-class man. not met him yet.

Dr. STEWART. We think he is great.

IMPLANTABLE ARTIFICIAL HEART

I have

Mr. FOGARTY. You mentioned an implantable artificial heart.
Dr. STEWART. Yes, sir.

Mr. FOGARTY. During last year's hearings we were told these were rather far off in the future but much could be done to improve heartlung machines and other outside heart support devices. How rapidly is this program going forward and does an implantable artificial heart now look possible? Is there adequate provision in this budget for the artificial heart program? You were Director of the Heart Institute.

SYSTEMS APPROACH TO ARTIFICIAL HEART

Dr. STEWART. I was Director of the Heart Institute about the time we began to embark upon the systems approach to development of an artificial heart as well as a long-range goal of the implantable heart. We started this by letting 6 or 7 contracts to really study the feasibility of both approaches. This was really hiring some people to collect data, where are we now, what do we know, what is the state of the art, what is the potential.

Mr. FLOOD. What do you mean by an artificial heart?

Dr. STEWART. There are really two things, Mr. Flood. One is the assist device, a pump that one might use for a part of the time either externally to the body or internally to the body, to assist the heart in its work over a crisis period. The other is complete replacement of the heart with an artificial machine. These feasibility study reports are in, but they just came in and I do not have the results of them. I talked to Dr. Shannon about it last week. He hopes by the time he gets here he will have that.

Mr. FLOOD. I hear you have reached the point where you can point to a cow or a calf contentedly grazing in the pasture in which there had been an implantation of a mechanical artificial heart.

Dr. STEWART. Mr. Flood, I saw the calf. It was in a laboratory and not a pasture.

Mr. FLOOD. I may have overdone it a bit, but it sounds better.

Dr. STEWART. This is an assist device which is implanted. You do not take the heart out. You put a pump in, and in the calf they put it over the lung, which pumps 30 or 40 percent of the blood and therefore the left side of the heart does not have to do that work. Since it does not replace the left side of the heart, you can turn it on or off and the heart can take over in this calf. The blood flows through it and they have a sack around it and a pump outside the body that pushes air in and out. Dr. DeBakey now thinks he has it so that he can use this device on a human being when he gets the proper kind of patient.

Mr. FLOOD. I was intrigued by the report of Dr. Hufnagel in Chicago last week in that he feels he has now perfected a cleansing fluid to prevent stoppages in the artificial valve which was becoming a problem. It was developing stoppage probably because of the nature

of the substance from which the valve was made. Hufnagel had a paper last week in Chicago which indicates that they have this licked. Dr. STEWART. One of the problems in both the artificial pumps and valve is clotting on the surface of the material. They do think that they now have this problem licked. But I think we will have to see whether they do or not.

STUDY ON HEART DRUGS

Mr. FOGARTY. You have not mentioned the heart drug study and the use of drugs for lowering cholesterol. We put in an increase over the budget for that last year. Is that in the 1967 budget at the level that the Congress anticipated when it increased the budget last year?

Dr. STEWART. No, sir. If I recall it is at the same level as last year. Mr. FLOOD. Isn't the cholesterol argument still in the field of conjecture? Isn't there an equally divided opinion at least with respect to its effect on the heart? Isn't that debatable?

Dr. STEWART. There is an association of cholesterol and increased risk from coronary disease. What we do not know is if you lower the cholesterol will this prevent a coronary from occurring? This is the result sought for in this drug study.

OTHER USES FOR ANTICANCER DRUGS

Mr. FOGARTY. I am glad to hear what you said about cancer research because this committee has been dissatisfied in the last few years with the progress made against cancer.

You mentioned a couple of drugs they developed that turned out to be valuable for other purposes. Can you supply a statement for the record on these drugs?

Dr. STEWART. Yes, sir.

(The information to be supplied follows:)

USE OF ANTICANCER DRUGS FOR THE TREATMENT OF OTHER CONDITIONS During the past several years, it has been discovered that a number of drugs originally developed for the treatment of cancer have other uses. In earlier hearings, we have reported the use of anticancer drugs to suppress immunity and encourage the taking of tissue transplants. We have reported the use of methotrexate in the treatment of psoriasis and the use of 5-IUDR in herpes infection of the eye.

The two drugs referred to in the opening statement are Thio-TEPA in arthritis and nitrogen mustard in colitis and enteritis. Both were developed before the National Cancer Institute launched its cancer chemotherapy program. ThioTEPA was developed by the American Cyanamid Co. in 1953. Nitrogen mustard, first prepared by a chemist in Czechoslovakia, was developed as a war gas during World War II, both by the Allies and the Axis Powers, but was never used for this purpose. Its toxicity for the blood-forming tissues suggested its possible use in certain forms of cancer, and studies during and immediately following World War II demonstrated its usefulness as an anticancer agent.

These two new examples, along with others previously reported, exemplify the interrelationship of various areas of biomedical research and the unanticipated benefits to one area as a result of research in another.

PROGRESS IN CANCER RESEARCH

Mr. FOGARTY. It seemed to me you have been leveling off in the Cancer Institute in the last 2 or 3 years and the progress that we had hoped for just is not there. I cannot understand why we do not go

all out in research on cancer.

This is something all the Congress

and the people would certainly go for. We are on a plateau.

Mr. FLOOD. I am certainly for it, belatedly, but I am for it. I could not possibly support the chairman more. Of course, I am concerned about the fact that people do not get examinations to find out and catch the thing in time. This is the thing that concerns me.

Mr. FOGARTY. We have been trying to prod the Cancer Institute into making more progress on diagnosis for years.

Mr. FLOOD. My biggest boast was sitting around the table with fellows like you, saying somebody was sick, Fogarty had a heart attack. Where is he? He is at the hospital with a heart attack. I had hardly been in a doctor's office all my life, and I thought I was a great fellow. I was a damn fool and did not know it until they pushed the building over on me. I was the great masculine ego. "What is the matter with these chickens? I never go inside a doctor's office." I wasn't such a great fellow-I was a halfwit.

AIR POLLUTION AND SOLID WASTE

Mr. FOGARTY. I hope that the work you are doing in the air pollution and solid waste areas keeps going on and on and up and up, because both of them are real problems in this country now.

Dr. STEWART. There is no question about it, they are major problems in metropolitan and even rural areas.

Mr. FLOOD. You mean in addition to sewage.

Dr. STEWART. Yes. Industrial waste, containers, garbage.

Mr. FLOOD. Literally solid waste.

Dr. STEWART. Yes.

Mr. FLOOD. I want to be sure.

Dr. STEWART. It does include the residual solid after you treat the sewage.

Mr. FLOOD. This includes mine acid problems?

Dr. STEWART. No; but it would include the slag heap, the output of an industrial production. Solid waste.

SURGEON GENERAL'S PROPOSED BUREAU FOR DISEASE PREVENTION

Mr. FOGARTY. How are you going to organize your environmental health activities and where do they stand?

Dr. STEWART. What I proposed in my ideas, Mr. Fogarty, is that we would form a Bureau of Disease Prevention and Control. The environmental health activities, particularly air pollution, occupational, and radiological health are aimed at preventing disease.

Mr. FOGARTY. It does not have much appeal with the public.

Dr. STEWART. But it is terribly important. It is built around surveillance, in tools of intervention. This is the same think that CDC does in communicable diseases. It is the same thing some of the chronic disease programs do, although they are much less developed. It is my idea to put these together into a strong disease-prevention control bureau because this is what both are trying to do. The real strength you have in the Public Health Service on surveillance, epidemiology, and laboratory support rests within CDC at the present.