disease affects the eyes and brain of children at about the age of 6, resulting in blindness, mental retardation, and usually death. Biochemical studies have disclosed that the patient and close relatives have an abnormal kidney function indicating inability to handle certain amino acids. It is basic research of this type that gives the best hope today of progress against the vast problem of mental retardation-a problem of multiple and complex causes, calling for a methodical, diversified, and very fundamental attack. In discussing metabolic disorders, the field of diabetes comes to mind as one in which several significant findings were made last year. In a long-term study by an NIH grantee of Boston City Hospital, over 20,000 women have been tested for glucose tolerance while under prenatal care. A high incidence of abnormal glucose tolerance was found (confirming earlier studies by other workers). Continued observation of patients with this condition revealed that 28 percent developed diabetes mellitus within 5 years of delivery. This suggests that pregnancy provides a unique opportunity for the study and possible detection of latent diabetes. Grantees at the Joslin Clinic in Boston have devised a test for detecting prediabetic individuals before they develop an abnormal glucose tolerance. The test involves photography of conjunctival blood vessels and electron microscopy of tissue from the ear lobe. One objective in these studies is to learn whether diabetes and subsequent complications can be averted through early treatment. One other result, which seems particularly promising, will illustrate the continued progress being made in the field of infectious disease. Since November 1961 NIH investigators have been testing an experimental Parke-Davis drug, DI-501, against malaria in prison volunteers. A single injection has protected the volunteers for a year against infection from repeated bites by malarial mosquitoes. This is nearly 10 times as long as the protection conferred by conventional agents. If these results are borne out in field trials, we will have a potent new weapon against malaria-at a time when resistance to the known synthetic drugs is becoming a critical problem. These accomplishments of 1962 are typical of the more dramatic results that NIH and its sponsored laboratories and clinics are producing. It is gratifying that further advances may be expected along the same lines. The 15,000 research projects supported by NIH in more than 1,000 institutions, as well as the studies of 3,000 professional and scientific workers at NIH itself, are prolific sources of new knowledge, and will surely yield a constant flow of findings applicable in medical and public health practice. Moreover, many new research approaches and techniques-biomathematics, physical biology, and bioengineering, to name a few-are extending the capabilities of science at a rapid pace. There can be no doubt that the potential for scientific productivity is higher today than ever before. This potential rests to a large extent on a framework of sound relationships within the scientific and academic communities. NIH programs and policies, grounded in national law, have progressively forged and reinforced those relationships. The grantmaking system of the Public Health Service, for example, with its utilization of expert advice by non-Federal consultants serving at both the scientific and policy-forming levels, has gained the respect and admiration of the entire scientific world. Efforts are now being made to gird this framework for an extended period of productivity at adequate levels of support. Factors influencing past development It may be seen from the foregoing review that the development of Public Health Service research programs has been shaped by the interaction of many trends and influences. The paramount factor has been the health problem itself, with its own modulation from diseases predominantly communicable to those heavily weighted by chronic and degenerative disorders. Although health problems have always plagued and burdened mankind, a systematic attack upon them awaited the advance of civilization, institutions, and science to the necessary level of organization and competence. Thus a second influence to focus upon the state of the art-is often called research opportunity. We have seen how the exigency of communicable disease and the state of bacteriological science converged in the latter 19th century to make possible a successful public health movement in this country. Tradition and economic structure dictated that private philanthrophy should be the main source of funds for the essential research behind this effort. The Public Health Service, however, established its own tradition of a parallel, often complementary effort meeting the highest standards of academic and private operations. Its laboratory and field programs pioneered in the fundamental research through which nutritionaldeficiency and epidemic diseases have been virtually eradicated. The 1930's and 1940's brought revolutionary advances in basic science. Among the most important innovations were the techniques for tracing chemical reactions within tissues. These permitted the precise study of enzymes, which are necessary catalysts for these reactions in all living things, and the tracing of metabolites, or chemical currency of the life processes. The latter work has been greatly furthered by radioactive isotopes, a byproduct of atomic research. These techniques alone, in the hands of competent workers, would have sufficed to advance the life sciences far beyond the most optimistic hopes at the turn of the century. In addition to these techniques, however, many precise instruments and processes, such as the electron microscope and chromatography, have equipped the fundamental investigator with formidable tools for probing the unknown. These techniques and tools have enabled the various branches of the life sciences to advance their frontiers-anatomy into histology, or the architecture of tissues; physiology into the physicochemical basis of body functions; genetics into the fundamental molecular dynamics of heredity. In addition, it is now possible to relate brain, mind, and behavior; to learn the mechanics of drug action; and to understand the fundamental processes of disease as departures from norms explainable in basic terms. There has been, in general, a broadening in scope and a deepening in penetration of the medical-science attack. One aspect of this development has been the application of disciplines from other fields of science. Mathematics, electronic data processing physics, engineering, economics, and the behavioral sciences are all being applied fruitfully to problems in the health field. The progressive broadening of the Federal role in medical research has resulted from several factors. One is a general change in the economic picture which makes it no longer feasible for private philanthropy to bear the major share of the cost. Another is the enlightened aspiration of the Congress to utilize every opportunity to bring the benefits of modern science to the people. Another is the availability of a framework-namely, the advisory structure and administrative capability of NIH-which permits the expansion and application of the Nation's research potential, strong today in academic and other institutions. And still another is the endorsement of public-spirited leaders, Federal and non-Federal alike, who view public support as a necessary complement to private effort in the tremendous task ahead. These are some of the reasons for the growth in Federal support of medical research from $28 to $973 million annually since World War II. And the expansion of non-Federal support, from $60 to $577 million over the same period, is testimony to the viability and cooperative nature of the total enterprise in which NIH so prominently shares. The change in the Federal role has been more than one of expansion. Through successive acts of Congress, the research programs of the Public Health Service have progressed from limited support of ongoing medical research to purposeful expansion of national research capacity in the health sciences. This has been effected through the training of research workers at all levels of higher education, the construction and improvement of research facilities, general institutional support, the development of certain limited and regional resources, the opening of new fields of investigation, the seizing of research opportunities in foreign countries, and the encouragement of ancillary activities such as conferences and translations of the scientific literature. Throughout this endeavor to expand research potential, there has been a studied effort to adapt the support to broad needs of investigators, research programs, and institutions. A natural consequence has been an involvement with institutions as such, particularly universities, in a way that places additional responsibilities upon the Service in the administration of its support programs. Provision for future research The further advancement of medical research and the biomedical sciences presents several major needs, some of which will require intensive study, program development, and perhaps new legislation. A paramount consideration, already mentioned above, is the need for extension of resources. The Nation's plant for research, teaching, and communication of results in the search for new knowledge of health and disease should be expanded if medical research is to attain a level commensurate with the health problem and research potential. This is not a need that may be viewed apart from the Nation's broader demand for physicians, ORGANIZATION OF PUBLIC HEALTH SERVICE It must be approached scientists, and other professional and technical workers. Looking ahead to 1970, an estimate of $3 billion for total national expenditures for medical research has been widely accepted. Such an estimate is not a proposed goal or target for medical research, but rather a consensus of projections, by expert groups, taking into account broad scientific, economic, and social factors. The estimate represents apprxoimately a threefold growth in medical research expenditures over the decade of the 1960's. To mount such a program, professional manpower for health and health-related research will have to be doubled. This means an average annual addition of approximately 5,000 scientists to the manpower pool. Continuing analysis of the Nation's scientific resources by the planning group at NIH has given broad guidelines by which components of this manpower need can be determined. An addition of 45,000 scientific workers to the manpower pool during the present decade (allowing for loss by attrition) is indicated. Of these, approximately 56 percent should be Ph. D.'s and 25 percent M.D.'s. With respect to physicians for clinical investigation, the estimate calls for maintenance of the productivity of existing schools, full activation of schools already established, and completion of schools now firmly planned. The total forecast of M.D.'s and Ph. D.'s assumes deliberate efforts to expand output. Careful consideration of the requirements for biomedical investigation have indicated that special efforts should be made to develop talent through adaptaIt is believed that this would not detract tions of the educational process. from the capacity of schools and teaching hospitals to turn out physicians for medical practice. Emphasis would be toward shortening the process whereby the student preparing for clinical investigation acquires his medical education, clinical training, and finally his preparation for independent research. The schools that are engaged in experimental programs along these lines, using students with special aptitude and interest in research careers, have begun to report encouraging results. A need parallel to that of expanding research in the Nation's institutions is to recruit and retain workers of exceptional ability in the direct research programs of the Public Health Service. This need has become critical. As career opportunities in the Nation's institutions are expanded both through NIH support programs and those of other agencies public and private, the difficulty of maintaining excellence in intramural programs increases. The root of the problem is broader than medical science. Demand for talent within the Nation's total manpower market in research, development, and medical practice has resulted in levels of opportunity which the Federal Government cannot match. There is urgent need to redress this differential. Conclusion The fundamental research programs of the Public Health Service, centered in the National Institutes of Health at Bethesda, have grown and evolved since 1887 to attack the Nation's most urgent health problems. Principal guidelines have been amendments to the Public Health Service Act, research opportunity, and the needs of physicians, medical schools, and other research institutions. With respect to the broad programs undertaken, the will of the people as known by their representatives in Congress has been the major determinant. The result is a state of activity in the medical and biological sciences which augurs well for the solution of major health problems. The role of the National Institutes of Health is to sustain the vigor and productivity of this effort, to resolve wisely the problems and issues that have arisen in the conduct of supportive programs, and to secure the benefits of scientific progress for the well-being of people everywhere. Dr. SHANNON. The statement I have with me, Mr. Roberts, covers the present program, how these functions are served by what programs, how the programs came into being, what is their general legislative background, and what are the unmet problems of the future. I would be glad to discuss these problems individually or, if you prefer, take a more orderly approach and read a statement, the statement being some 27 pages in length, as you wish, sir. Mr. ROBERTS. I think, Doctor, I will leave the matter of presentation up to you, however you desire to proceed. Dr. SHANNON. Mr. Roberts, since it is such an important area, then I would prefer the more orderly presentation that is in the prepared statement. I welcome this occasion, Mr. Chairman, to review the development of the research role and functions of the Public Health Service as exemplified in the programs of the National Institutes of Health. The Surgeon General, in his statement yesterday, outlined for the committee the historical origins of the Public Health Service and its major functions, including the Service's research activities. I have prepared and should like to submit for the record a somewhat fuller statement of this process of growth as it relates to research. This will enable me in the time available today to select out of this complex background the significant factors that have been influential in the evolution of our present-day programs. I should like then to explore briefly the problems of the present scene and what appears to be the prospects for the future. THE BROAD CHANGES As a setting for this discussion, it may be well to note for the committee the broad nature of the changes that have taken place in the organization and operational character of the National Institutes of Health and to provide a current view of the diverse activities now comprised within this complex entity. For the purpose, Mr. Chairman, I think it would be helpful to the committee if I could make use of some charts. I believe they will convey quickly and clearly the points I wish to make. Mr. Chairman, these charts are included in the prepared statement and perhaps it would be easier, though, if we used the larger charts over there to my right which are simply reproductions of those that are contained within the text. (The chart referred to follows:) |