Support Grant (BRSG) program. The BRSG program is a formula-based grant mechanism that provides flexible funds to NIH-grantee-institutions. It is the flexible nature of these funds that makes the program particularly valuable. Institutions can use these funds in a timely, cost-effective manner to recruit new faculty, to assist young scientists in establishing their laboratories, to meet emerging research opportunities, to encourage innovation, to finance pilot studies, to sustain research programs during interruptions in funding and to support additional institutional needs unmet by other NIH support mechanisms. In an increasingly competitive environment for research funding, when both the Administration and the research community have identified the support of young scientists and new ideas as major priorities, it is ironic that the Administration would eliminate such a cost-effective and efficient mechanism to enhance the capacity of institutions to accomplish these goals. The AAMC strongly recommends that BRSG funding be restored to its FY 1989 level of $55 million.

The Administration has targeted a second program, the NIH's Shared Instrumentation Grant program, for a 75 percent reduction, from $32.8 million in FY 1991 to $8.8 million in FY 1992. As this committee is aware, the Shared Instrumentation Grant program supports the purchase of equipment that costs between $100,000 and $400,000. The key is that each instrument must be shared by three or more Public Health Service-supported investigators. This includes such equipment as nuclear magnetic resonance spectrometers, amino acid analyzers, confocal microscopes, and advanced computers. Without such sophisticated, state-of-the-art equipment, scientists will be unable to pursue research at the molecular and genetic levels. The need for such funding is demonstrated by the fact that the NIH received over 400 applications and made 142 awards in FY 1991. Under the Administration's budget request, only 32 awards would be possible in FY 1992. Again, it is ironic that the Administration has proposed such drastic cutbacks in a program that provides necessary equipment in a cost-effective manner.

Health Manpower -- As in previous years, the Administration's FY 1992 budget proposal recommends significant cuts, and in some cases total elimination, for a number of programs in Title VII of the Public Health Service Act that are designed to train primary care health professionals and to improve access to care in under-served areas. Approximately 170,000 (30 percent) of the physicians in the U.S practice primary care, too few to provide Americans with basic health care services. The Bureau of Health Professions has developed a national plan called "Primary Care 2000" that sets out goals to increase the number of primary care practitioners. In direct contradiction to recognized needs, the Administration's budget eliminates all funding for the five programs in Title VII that support primary care training. Without the model programs established by Family Medicine Departments, Family Medicine Residency programs, and General Internal Medicine and General Pediatrics Residency programs, the problems of primary care manpower shortages will intensify. The AAMC requests that Congress reject the Administration's proposed cuts in these programs and appropriate funds that match the authorization level. Congress should also reject the elimination of the Federal training programs in geriatrics and geriatric faculty development which are designed to increase the supply of physicians skilled in caring for the growing number of elderly Americans. The AAMC recommends $26 million for Geriatric Education Centers and Geriatric faculty development.

The Area Health Education Centers (AHECs) programs provide clinical training opportunities to medical students and residents in rural settings. Evidence suggests that the exposure provided by AHECS has influenced physicians to practice in under-served areas and/or to practice primary care. Congress should appropriate $23 million to the AHEC program, and $8 million for Health Education Training Centers (HETCs), which serve as important recruitment and retention tools for rural America. The Administration should not eliminate funding for the AHEC and the HETC programs at a time when the nation faces critical shortages of primary care physicians and growing problems in rural and urban areas with health manpower shortages.

The AAMC welcomes the Administration's budget of $53.8 million, an increase of $5 million over last year's funding level, for the National Health Service Corps (NHSC) scholarship and loan repayment programs. However, to address the problems in the approximately 2,000 communities in this country still designated as health manpower shortage areas (HMSAs) where 4,300 physicians are needed to provide primary care services, Congress should increase the funding level for the NHSC to $60 million for FY 1992. Last year's increase in the NHSC scholarship and loan repayment program has allowed the Department of Health and Human Services to award close to 70 scholarships and 46 loan repayment awards to physicians. These funds will address the problems of geographic maldistribution and assist disadvantaged, minority and highly indebted students who are motivated to work in under-served areas.

The AAMC commends the Administration's support for several programs to increase the number of minority and disadvantaged health professionals. Funding appropriated for scholarships, loan repayment, recruitment and retention programs, and for the Excellence in Minority Health program assists medical schools' efforts to attract and train minority and disadvantaged students. To support these goals, the AAMC recommends $40 million $5 million over the Administration's request for Disadvantaged Assistance, which includes the Health Careers Opportunity Program (HCOP) and $20 million $5 million over the Administration's request for the Centers for Excellence program, which includes centers for Historically Black Colleges and Universities, Hispanic centers and Native American centers.

The AAMC urges Congress to reject the Administration's FY 1992 proposal to phase out the Health Education Assistance Loan (HEAL) program. HEAL is a necessary source of funds for over 30,000 health professions students who rely on the program to supplement borrowing through the Department of Education and other loan programs. Without the HEAL program, medical education would be beyond the financial reach for many low and middle income students. The Administration erroneously suggests that the obligations of HEAL can be replaced by its proposal to increase capital in the Health Professions Student Loan (HPSL). The Administration's FY 1992 budget plan, proposes contributing $90 million over 6 years and combining the $65 million available each year from the revolving fund to enable the program to support and sustain loans to the neediest students. The AAMC agrees that the HPSL program should continue to provide subsidized, low interest loans to needy students. However, because access to HPSL funds is limited to a small sector of students, HEAL must be retained to ensure that all students can borrow the funds necessary to attend health professions school.

The AAMC regrets that time constraints limit the opportunity to discuss other important health and education programs under the Subcommittee's jurisdiction. We appreciate the diligence with which the Subcommittee approaches its responsibility, and look forward to working with the members and staff to achieve our mutual objectives.

RADICAL CHANGE

Senator ADAMS. Thank you, Dr. Coulter.

There is one statement on page 1 of your testimony that concerns me, and I would like to have you indicate the source of your information and what it might involve. I will read you that language:

The Association is concerned about reports that NIH Institutes may be contemplating radical cuts in program project and center grants in order to fetch the greater number of RO-1 grants. If that strategy is followed by all institutes it will seriously and adversely affect the types of cooperative studies essential to converting basic knowledge to clinical applications and will destabilize institutions in which NIH funding research is carried out.

That would be a very radical change, and it is one that if you have information on or if others do, we would certainly want to know about it.

Dr. COULTER. I think as the subcommittee and certainly the excellent staff supporting the committee are aware, if we are to meet the goal set by the committee of whole funding for the number of grants that have been proposed by this committee as a goal to be reached, we are going to have to go into other areas, other support mechanisms in order to reach that goal.

Now the ad hoc group's proposal is predicated on full funding of the investigator-initiated grants at the levels recommended by this and, of course, the corresponding House committee. So what we are saying is that we wish you to look carefully at being able to meet the goals that the committee has itself set in being able to support a full study section, peer-reviewed budgetary levels these investigator-initiated research grants.

We are simply saying that we do not want to see cannibalization occur in other support mechanisms for training or shared instrumentation, for these center grants, for these clinical trials programs in order to meet these RO-1 goals.

Senator ADAMS. Fine. Thank you very much, Doctor. We appreciate your testimony.

STATEMENT OF DR. BRUCE E. SPIVEY, EXECUTIVE VICE PRESIDENT, AMERICAN ACADEMY OF OPHTHALMOLOGY, ON BEHALF OF RESEARCH TO PREVENT BLINDNESS

Senator ADAMS. Our next witness is Dr. Bruce E. Spivey, Research to Prevent Blindness.

Dr. Spivey, welcome to the committee.

Dr. SPIVEY. Good morning, Senator. Thank you very much.

I am Bruce Spivey. I am executive vice president of the American Academy of Ophthalmology, and today I am representing Research to Prevent Blindness, the world's leading voluntary organization supporting eye research. Here to present the fiscal year 1992 citizens' budget proposal for the National Eye Institute [NEI]. You have my written comments, and today I would like to relate briefly to the citizens' budget, to diabetes and to AIDS-related macular degeneration.

We are grateful for the support we have received in the past, but the level of any eye funding is not keeping pace with the rising costs of research and is falling behind in comparison to other NIH components. The fiscal year 1992 citizens' budget in its proposal would provide the NEI with $342.1 million needed to continue research that has been rapidly increasing our capacity to prevent and to treat eye disease.

One of the major success stories of NEI, in fact I would say NIH, research is the prevention of blindness caused by diabetes. Diabetic retinopathy damages blood vessels that nourish the retina. It is the major cause of career-disrupting sight loss and blindness among Americans today. About 12 million individuals have diabetes and are 25 times more likely at risk of blindness than the general population. The NEI clinical trials demonstrated that timely laser surgery can reduce blindness due to diabetes by at least 50 percent, and some studies would indicate as much as 90-percent reduction.

Laser surgery can save the sight of 30,000 working age Americans each year and save the Federal Government more than $400 million annually. Through a program called Diabetes 2000, the American Academy of Ophthalmology is working to translate those clinical trial results to all citizens of this country.

Another serious vision problem requiring much additional research is age-related macular degeneration, the leading cause of new central vision loss in people 65 years of age and older. Nearly 2 million people over 65 will have age-related macular degeneration in 1995. Age-related macular degeneration affects the part of the retina that provides sharp reading vision. People affected cannot read or drive.

PREPARED STATEMENT

The NEI is currently supporting basic and clinical research of the aging eye, and tremendous progress is being made. With your sup

port for research in the aging eye, we will be able to effectively reduce vision loss and the associated decline in independence and the quality of life among our Nation's elderly.

Mr. Chairman, in conclusion, I hope that you will support the citizens' fiscal year 1992 budget request in sight-saving research. Thank you very much.

[The statement follows:]

STATEMENT OF DR. BRUCE E. SPIVEY

Mr. Chairman and Members of the Committee: I am Dr. Bruce E. Spivey, President and Chief Executive Officer of Pacific Presbyterian Medical Center and Executive Vice President of the American Academy of Ophthalmology. I am pleased to represent Research to Prevent Blindness, the world's leading voluntary organization in support of eye research, in presenting the Fiscal Year 1992 Citizens' Budget Proposal for the National Eye Institute (NEI).

As a member of the National Advisory Eye Council, I have participated in the development of the NEI's new five-year plan, entitled Vision Research - A National Plan 1992-1996. This plan,

a comprehensive assessment of the status of vision research, will enable the National Eye Institute to foster a research agenda that will address areas of greatest need and opportunity. Five panels of scientific experts have provided guidance in defining NEI research priorities outlined in the plan.

The Fiscal Year 1992 Citizens' Budget Proposal of $342.1 million would provide the National Eye Institute with funds that are essential to the pursuit of its five-year plan, and the continuation of research that is rapidly increasing our knowledge of the processes underlying eye disease scientific objectives that are crucial in advancing our ability to prevent blindness and visual loss.

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Last year, despite tremendous deficit reduction pressures, Congress provided the National Eye Institute with an increase over the previous year's budget. The vision community appreciates and is encouraged by the commitment to sight-saving research that was demonstrated in the Fiscal Year 1991 appropriations cycle. However, the level of National Eye Institute funding has not kept pace with the rising costs of research, and it is falling behind the level of support provided to the other components of the National Institutes of Health. The NEI share of the NIH budget fell from 3.4% in fiscal 1990 to 3.3% in fiscal 1991, representing a loss of $6,493,000 that is urgently needed to sustain the current level of eye research.

As you know, the National Eye Institute is the only federal organization whose primary mission is to protect and preserve the visual health of the American people. The fruits of NEIsupported research have provided the 18,000 practicing ophthalmologists that I represent in the American Academy of Ophthalmology with an ever-expanding array of therapeutic modalities that today save the sight of hundreds of thousands of people who just five or ten years ago would have been blind.

NEI clinical trials have been crucial in establishing the efficacy of proposed treatments for blinding disorders. Diabetic retinopathy, an ocular complication of diabetes caused by a deterioration of blood vessels that nourish the retina, is the major cause of career-disrupting sight loss and blindness among Americans today. Twelve million people have diabetes, an enormous group of patients who are 25 times more at risk of blindness than the general population. Because diabetic retinopathy so often strikes in the peak years of individual productivity, its victims face a dramatic decline in the quality of life and in their ability to support themselves and their families.

NEI clinical trials have demonstrated that timely laser surgery can reduce the risk of visual loss due to diabetic retinopathy by at least 50%. The American Academy of Ophthalmology, through its Diabetes 2000 program, is working to