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I am happy to report that the greatest single reduction in alcohol-involved fatalities on the highway is among that group which is at highest risk. That is among our youth. In the 1980's, at least, the greatest single reduction came among this age group. They are the ones also who need it the most.

We can infer from that, therefore, that the information coming from research showing that even one or two beers is potentially impairing is having some effect. We should continue those efforts.

As Dr. Van Thiel suggested, the agency which has been most active in that and is charged publicly with that research is the National Institute on Alcohol Abuse and Alcoholism, and I think that the distribution which occurs through the scientists on the study. sections to the individual researchers is very good.

Senator ADAMS. Thank you very much for your testimony. It was excellent.

The committee will stand in recess for 5 minutes. [A brief recess was taken.]

Senator HARKIN [presiding]. The committee will resume its sitting.

I apologize. I had two other committee meetings that I had to attend to this morning, and I appreciate Senator Adams filling in for me here.

I know that we are way behind, and it looks as though I will probably have to go through the lunch hour now.

I am aware that some of you have plane schedules and other things, and I will try to accommodate any of you to the extent that I can. If you have a meeting or another thing that you have to do, especially if you have to catch a plane at a certain early time, if you will let our staff know here I will try to move you up in line, and I would appreciate others understanding that.


Senator HARKIN. I know of at least one person, Dr. Pritchard, who is here with the American Association of Neurological Surgeons. He has a plane to catch early, and I want to move him up in line so that he can catch his flight. He is the only neurologist in his area right now. The other neurologist has gone, so he has to get back home.

So we will take some people out of line. If you are confronted with that situation, just let our staff know.

I will call up now Dr. William Pritchard representing the American Association of Neurological Surgeons.

Dr. Pritchard, it is good to see you. I will state for the record that you are a long-time friend of mine and a preeminent neurological surgeon and, I know, one who cares very deeply about the "Decade of the Brain" and the funding and how we are going to reach the goals that we have set out for ourselves by the year 2000.

So Dr. Pritchard, it is an honor for me to have you here. I am delighted to see you here, and I am sorry for the plane schedules but I understand that you have to get back to your practice since you are the sole person there and you have to get home.

Welcome to the subcommittee.

Dr. PRITCHARD. Thank you very much, Senator Harkin. Good morning to other members of the staff and committee. I am Dr. William Pritchard. I have practiced neurosurgery in Fayetteville, NC. If you do not know where Fayetteville is, you may know where Fort Bragg is, the home of the 82d Airborne.

Senator HARKIN. Everyone knows where that is now.

Dr. PRITCHARD. I am here representing the approximately 3,200 neurosurgeons who practice in the United States. We have two major organizations, the Association of Neurological Surgeons and the Congress of Neurological Surgeons. One of these bodies is now in session in New Orleans, and that is why our manpower is spread pretty thinly over the Nation and particularly in Fayetteville.

I want to thank you for the opportunity to be able to speak before this subcommittee and to present the second phase of the neuroscience agenda for the "Decade of the Brain”.

I would first like to report on the status of the programs which this committee initiated last year by appropriate funding to the National Institutes of Health for Research in the Treatment and understanding and research directed toward head injury and research directed toward cerebrovascular disease and stroke.

The response to this committee was very positive to our requests, and, as a result, the National Institute of Neurological Diseases and Strokes is in a position to fund several new programs, in particular research centers directing efforts toward the study and treatment of brain injury. Similarly, funds have been directed toward the study of stroke problems. The neurosurgery community thanks you very much for your support of research in these two important fields during the first year of the "Decade of the Brain".

The "Decade of the Brain" to us means just that. This is a longterm plan of developing research facilities and resources. It is not all going to be accomplished in one year or the next year. As the economy waxes and wanes, these considerations have to take place in your decisions, and we understand that.

Now we are approaching the second year of the "Decade of the Brain", and the neurosurgical community has identified three specific areas for research during the coming year. First, we propose that you provide funding for four new brain tumor centers. The financial need for each center is $1,200,000 each with an additional $250,000 each for training component. This amounts to a total annual budget of $1,450,000 per year per center for a 5-year cycle.

Second, we propose that you fund four tumor research feasibility grants at $250,000 per year per award for 3 years. These funds. help develop research facilities which eventually lead to the development of facilities that may merit designation as a research cen


Our third proposal for funding of 1992 is to extend the ongoing research in the surgical treatment of epilepsy. We propose $500,000 per year to be directed to this effort in addition to the support which already exists.

I would like to elaborate a bit on the subject of brain tumors. The statistics seem to be a very large part of testimony in this session. We have a few that are poignant.

Of tumors that occur within the head affecting the brain 85 percent are malignant; 2 to 3 percent of all deaths are due to brain tumors.

Now there are basically two types of malignant tumors affecting the brain. Most common is the metastatic tumor, the tumor that originates somewhere else in the body and then spreads to the brain. The second type of malignant tumor derives from abnormal cells within the brain itself. 30,000 cancer patients per year develop the metastatic tumors in the brain, and about 20,000 patients per year present with primary brain tumors.

Brain tumors affect all age groups. It is a particularly high and common type of cancer in children. For some reason which we do not understand, the incidence of brain tumors in the population is increasing.

At this time we do not truly have effective means of curing malignant brain tumors. Despite advances in surgery, the use of radiation therapy and chemotherapy, the average life expectancy of a person with a malignant brain tumor is less than 1 year. We need to increase our basic knowledge regarding the growth of these tumors. We need to determine ways to prevent these tumors. We do not have enough scientists trained in this field of research, and we need to increase our facilities for clinical and basic research.

At the present time we have planned four brain tumor research centers in the United States, and our requests presented today target the need for at least four more such centers.

The second recommendation is that you fund tumor feasibility grants of $250,000 each. These are intended to develop additional pilot research capabilities within our overall 10-year plan for the "Decade of the Brain".

I would like to speak a little regarding epilepsy. There is a considerable ongoing activity in the treatment and understanding of epilepsy across the country. Surgical treatment of epilepsy along with drug therapy can definitely affect the course of epilepsy. Epilepsy, as you are aware, is a major cause of physical and social disability.

Now we have been asking this committee to help fund neuroscience, and I would like to point out two examples of how the neurosurgical community is more or less helping themselves and helping others as a result. We have established a research foundation which is funded largely by contributions from the membership of our societies. Young clinical investigators are awarded fellowships to carry out basic neurosurgical research. At this time there are six active fellowships of this nature.

Our other program which we feel the Nation needs to be aware of and which is our primary purpose is our program entitled "Think First". This is a national head and spinal cord prevention program initiated by the neurosurgeons in the country in 1986. It is supported by contributions from neurosurgeons individually and through the various national and State organizations.

The program is directed toward the high risk 15 to 20-year-old population presented through drivers education programs and other school activities. It is intended to influence attitude and behavior regarding the use of helmets, seat belts, the dangers of speeding, dangerous swimming habits, risk of driving recreational

and farm vehicles recklessly, and the role of alcohol and drugs in causing severe injuries in this age group.

Our program has reached as many as 450,000 students this year, and we hope as the program grows we will be able to reach 4 million high risk young people by the year 1999.


Thank you very much for allowing me to speak to you, and I want to thank you again for your continued interest and fine support which this committee has provided for the neuroscience research during the "Decade of the Brain".

Thank you, and I would ask that our full formal statement be entered in the record.

[The statement follows:]


Mr. Chairman and members of the subcommittee, thank you for the opportunity to be here today to present the American Association of Neurological Surgeons' and the Congress of Neurological Surgeons' "Decade of the Brain" fiscal year 1992 neuroscience agenda for the National Institutes of Health. I am William L. Pritchard, M.D., a practicing neurosurgeon from Fayetteville, NC. I speak for the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, which represent more than 3,200 neurosurgeons in the United States.

Before I present our recommendations and justifications for program support in fiscal year 1992, I want to report on the status of the programs you initiated last year. You may recall that last year we suggested you appropriate additional funds for head injury research and an expansion of stroke research support. You responded in a very positive manner, which enabled the National Institute of Neurological Disorders and Stroke (NINDS) to begin new programs in neurotrauma, specifically clinical head injury research centers. With these monies, the NINDS has issued a Request for Application (RFA) that has received an enthusiastic preliminary response. The additional stroke funds have been directed to support approved, but previously unfunded promising research.

One of my happy duties today is to say thank you from the neurosurgical community for your support in year number one of the Decade of the Brain.

A corollary event took place this year that is the product of previous support by this subcommittee. I refer to the positive findings reported concerning the effectiveness of the surgical procedure, carotid endarterectomy. While the study was still ongoing, the officials at the NINDS and the investigators determined that the study's findings were so compelling that they notified the medical and public communities that the procedure is indicated, safe, and life saving. Mr. Chairman, this is an important example of the benefits to patients that can be attributed directly to your support of the NIH system of investigator research.

We have identified three specific areas of research for fiscal year 1992, the second, year of the Decade of the Brain.

First, we propose that you fund four (4) new brain tumor centers. We have made a careful cost analysis of the financial needs of the centers and recommend they be funded at $1,200,000.00 with an additional $250,000.00 for a training component, for a total annual budget of $1,450,000.00 per year, per center, for a five year cycle. Second, to complement this tumor initiative, we propose that you fund four (4) tumor research feasibility grants at $250,000.00 a year, per award, for three years in order to build research competence that would merit a center award.

Third, the NINDS informed us that work has begun to develop a protocol for a trial of surgical intervention for epilepsy. We propose you make a further investment in this effort by providing an additional $500,000.00 so that the planning can proceed in an orderly manner.

Our justification for the four brain tumor centers is straightforward. The incidence of brain tumors is increasing and the current body of knowledge is limited. Human brain tumors are one of the most devastating of diseases. There are two basic types of tumors. The most common type is one that originates as a cancer elsewhere in the body and then spreads to the brain. The second type starts in the brain and does its damage directly to the brain itself. There are as many as 300,000 cancer patients a year who have some form of spread, or metastasis, to the brain and

about 20,000 patients a year with primary brain tumors of various types. Many of the patients are young, and malignant brain tumors are one of the most common cancers of children. A recent study highlighted this in reporting "that brain cancer rates are climbing steeply among people 45 and younger."

We currently have no truly effective strategy for curing malignant tumors of the brain. There have been remarkable surgical advances for treating benign brain tumors, but these have proven to be of only modest value in the treatment of malig nant tumors. For a patient with a metastatic brain tumor, our armamentarium is limited to surgery, radiotherapy, and chemotherapy. Life expectancy is less than one year. For the most malignant primary brain tumors, average survivals are measured in terms of months.

The magnitude and severity of the problem will require a major effort to improve the treatment of this disease. There is a tremendous need for more basic knowledge and research about the growth mechanisms of these tumors. There is an equal need for clinical studies on how to utilize our currently available therapy to treat optimally those patients already afflicted with these dread tumors. In addition, we need studies to determine if there are ways to prevent these tumors. Currently there appears to be a marked rise in the frequency of their occurrence.

This is a new initiative requiring new criteria to perform comprehensive clinical and basic research, as well as preventative treatment, in an integrated manner. It is essential to train additional clinical and basic researchers. Compared to the magnitude of the problem, there presently is only a modest amount of expertise. Thus, it is important for these comprehensive brain tumor research centers to serve as a focus for basic research, multidisciplinary clinical care, and the training of basic and clinical neuro-oncologists. Only four (4) such centers exist in the United States; clearly we need at least four (4) more centers.

A major commitment to the area of brain tumor research is especially apropos at this time. Not only is this a dire disease on the increase but also there is a remarkable opportunity available at this time. The science of molecular biology has given us new insights about the nature of the malignancy process and the approaches needed for treatment. The advances regarding malignant brain tumors have been incredible. We know some of the genes involved, the factors that can cause the tumor cells to grow, and we have begun to learn how to manipulate this new knowl edge in treating malignant brain tumor cells in tissue culture. We are on the threshold of using a whole new set of exciting scientific information, derived from years of extensive NIH-sponsored research, to apply to the treatment of malignant brain tumors. This "Decade of the Brain" initiative serves as a fine focus for directing the resources needed to integrate our basic knowledge into effective clinical care for these patients. If we can develop highly integrated comprehensive centers for research, clinical care, and training, we will see major progress in the treatment of malignant brain tumors.

Our second recommendation asks that you fund four (4) tumor feasibility grants at $250,000.000 each. This is an important investment in the future. It announces, in a meaningful way, that there is funding to develop additional research capabilities. This concept is particularly appealing in the context of a systematic ten year plan. For example, we envision an existing clinical and basic research program being able to improve its capabilities in epidemiology, molecular biology, and neuropathology.

Thirdly, the "Decade of the Brain" plan developed by the NINDS contains a special initiative for epilepsy programs in succeeding years. We strongly recommend that this Committee reaffirm its historical support of research in this area and provide funds to assure the on-going development of a protocol for a trial of surgical intervention for epilepsy. The findings of the NIH Consensus Conference and the scientific literature suggest promising outcomes. For this effort we recommend you provide an additional $500,000.00 to the NINDS.

Our recommendations are consistent with the goals identified by the NIH staff, one of which is "understanding the brain's impact on health."

Mr. Chairman and members of the subcommittee, it has become our custom to tell you what we are doing in our member organizations to enhance science and prevention.

In 1983, the AANS created a Research Foundation to provide funding for basic and clinical research for young investigators. For the 1991-92 funding period, the Research Foundation received 31 applications, our highest number ever. Of the 31, 11 were for Research Fellowships, which are two year awards, and 20 were for Young Clinician Investigator Awards, which are one year awards. The priority scoring of these applications was more competitive than ever. The Scientific Advisory Committee recommended 5 that were fundable on the basis of scientific merit. Along with 1 Research Fellow who will be funded for his second year, the Foundation will

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