Mr. Chairman, I will be glad to answer any questions you have. Mr. ROGERS. Thank you very much, Dr. DeBakey, for giving us your viewpoints on this program and its importance.

Could you give us an example of one region that you may be aware of, or maybe you would want to do this in your statement.

Dr. DE BAKEY. Well, rather than take your time about it, let my statement provide this information. I would like to discuss an area where they have not only accepted the total concept of the program but are utilizing the program in a most efficient way to provide the particular three elements that I think are essential: research, education, and patient care. These three elements must be combined at the level at which the physician meets the patient.

Mr. ROGERS. This has been my concern with the program, and I realize it is still very young. But I am beginning to get feedbacks that the program is not reaching the practicing physician yet. It is not down to the hospital. It has stopped at a little higher level, at the dean's office.

Dr. DE BAKEY. This is understandable at the planning stage. Only at the operating stage will they begin to feel the program.

The most important thing to me is the fact that the program is becoming better understood by the practicing physician, and there is developing an enthusiasm for the program at the grassroots level that really is in striking contrast to some of the earlier experiences. Mr. ROGERS. That is right. I remember very vividly.

I think it might be helpful to point out some of these areas where you feel the program is being effective in getting to the community hospital, and where the people in the community are really beginning to receive the benefits. This would be helpful to the committee, and also to spread upon the record so that other areas can see what is being done in the most successful programs.

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Dr. DE BAKEY. I will be very pleased to do this and include it in the statement I will file with you.

Mr. ROGERS. Thank you.

Mr. Kyros?

Mr. KYROS. We are happy to have you here, sir.

These programs of construction that you are talking about would still have to be initiated at the local level and passed on by the Advisory Council.

Dr. DE BAKEY. Yes; and they would also have to show justification as being within certain guidelines, as being essential to the efficacy of this program.

There are all kinds of construction needs, but we have various types of construction authorities, and I would think the important thing is that we limit the construction to the needs of this program; that is, where it can be demonstrated unequivocally that without the construction space the program couldn't be effective, couldn't be implemented. Mr. KYROS. I don't know how familiar you are, sir, with the money requirements of the program; but the figures yesterday were that it would be about $30 million carryover from the last fiscal year, and the bill this year carries $65 million.

Do you think $95 million will be enough for this kind of planning this coming year?

Dr. DE BAKEY. Well, if I read the situation within the next year correctly, I would say we would come close to that, certainly; and I don't think it is going to jeopardize the program.

What I am concerned about is when we get into the operational phase within the next-well, say by 1971. I would say within this 2- to 3-year period we are going to see a real escalation in activity and, therefore, in funding needs.

Mr. KYROS. I understand, thank you very much.

Mr. ROGERS. Mr. Nelsen?

Mr. NELSEN. I have no questions.

Mr. ROGERS. Dr. Carter?

Mr. CARTER. It is an honor, Dr. De Bakey, to have you here. You are so well known to many of us as being absolutely dedicated to the service of humanity. We are honored to have you here.

I would like to ask about how the funds that you want-are they to be for something similar to intensive care units in different hospitals?

Dr. DE BAKEY. Yes. Well, some of them would be used in that way. For example, let us take the community hospital that is in a program. They need and can use, and in a sense can support, an intensive care unit; but the hospital is built in such a way that they can't even renovate space.

You are familiar from your own experience, I am sure, in your own area of Kentucky, where hospitals, even those built with Hill-Burton funds, are now so jammed that it would be denying the use of the space for some very essential purpose.

So they need additional space. To build this, they have to have money. It may be a relatively small sum. It may amount to a hundred thousand dollars, but it is still money that is hard to find for this purpose.

An intensive care unit would be one wing. Another would be--I hope my colleague will point this out in his testimony to you--in terms of acute stroke units. There will be diagnostic facilities of certain specific character.

We point out in the Surgeon General's report, which the Council had the opportunity to review, the types of space needed. They will need classroom facilities. This is the kind of space that is essential to carrying out the program.

Mr. CARTER. Certainly we have seen that many of our hospitals in the smaller areas, and I am sure it is true in cities, that in the past few years building has taken place, but still it is inadequate.

Dr. DE BAKEY. Completely inadequate, and also it doesn't take into consideration these kinds of needs. They didn't even visualize these needs in the early plans. Their concern was with immediate needs that they had to meet.

Mr. CARTER. I see the need of these things.

Dr. DE BAKEY. May I say to you, Dr. Carter, that it was part of your understanding that helped produce this program, and I want to thank you again for your insight into this whole program.

Mr. CARTER. Thank you, sir.

Dr. DE BAKEY. It was a tremendous help to us.

Mr. ROGERS. Mr. Skubitz?

Mr. SKUBITZ. Thank you, Mr. Chairman.

I have no questions, Dr. De Bakey, but I want to join my colleagues in welcoming you here today. I am looking forward to receiving your recommendations.

Dr. DE BAKEY. I want to express my appreciation to the committee for the wisdom and kindness and generosity they have shown, and it is good to know there are public servants like yourselves. Mr. ROGERS. Thank you.

(Dr. De Bakey's prepared statement follows:)

STATEMENT OF MICHAEL E. DE BAKEY, M.D., PROFESSOR AND CHAIRMAN, DEPARTMENT OF SURGERY, BAYLOR UNIVERSITY COLLEGE OF MEDICINE, HOUSTON, TEX. Mr. Chairman and members of the subcommittee, I am Michael E. De Bakey, Professor and Chairman of the Department of Surgery, Baylor University College of Medicine, in Houston, Texas. I had the honor of being named by President Johnson as the Chairman of the Commission on Heart Disease, Cancer, and Stroke, whose report led to the initial recommendation of the Regional Medical Programs legislation which this committee developed and passed in 1965. Since its creation, I have been a member of the National Advisory Council on Regional Medical Programs and am also a member of the Regional Advisory Group of the Texas Regional Medical Program.

I testify today in strong support of Title I of H.R. 15758 introduced by the distinguished Chairman of your full committee, Mr. Staggers. If enacted, Title I would extend the authorizing legislation for Regional Medical Programs for an additional five years as well as clarify certain technical aspects of P.L. 89-239. I would like briefly to reiterate the basic concept of the Regional Medical Programs, the future of which this subcommittee is presently considering.

The Regional Medical Programs comprise a group of units added—wherever possible to already existing medical centers in regions throughout the country. The units are part of the overall research, teaching, and medical care going on within the medical centers in regard to heart disease, cancer, and stroke.

These units together make up a national network for research, for teaching new developments to doctors and nurses, and for care of patients under investigation. Thus each physician served by this network has, readily accessible to him for his patients, the full range of up-to-date knowledge and skills developed through nation-wide research. At the same time the doctor contributes to research, for his observations add to the total knowledge.

Each of these units we are discussing has its own facilities and staff, though they function as part of the existing medical work force, to pull together and strengthen the medical resources now in existence.

The Regional Medical Programs as initially authorized, placed principal emphasis on regional voluntarism, as the means by which their goal might be achieved. Today I can report that your confidence in this approach has been well placed. Within the last three years 54 Regional Medical Programs have been brought into being. By this summer approximately one-half of these will have entered the operational phase. The remaining regional programs will shortly thereafter begin operation.

With its emphasis on voluntary cooperation the Regional Medical Program mechanism has managed to harness the creative energies of practicing physicians, hospitals, medical schools, voluntary, state and local health agencies. All too frequently in the past these creative energies have been isolated from one another or, even worse, in competition. Regional Medical Programs make it possible for all providers of health services to combine their strengths to improve the care of patients with heart disease, cancer, or stroke. Thus our aspirations of 1965 today are working entities.

One of the most important developments is the large and increasing involvement of the medical profession. In a recent speech the President-elect of the American Medical Association said, "As a whole, the medical profession at the beginning of the year 1968 is probably more deeply involved in the planning process to determine the nature of the Regional Medical Programs than it has been in the planning of any previous Federal program."

Now in considering the future of these Programs, Mr. Chairman, I would like to discuss the legislation before your committee. I was disappointed to

find that Title I of the bill does not propose to broaden the construction authority for Regional Medical Programs. During the initial hearings before the Interstate and Foreign Commerce Committee on Regional Medical Programs in 1965, there was much testimony that construction authority would be necessary if the requirements of the legislation were fully to be met. The committee in modifying the bill deleted the authority for new construction. In its report on the bill the committee reasoned that the program would not be jeopardized by the lack of such authority in its initial planning phases. Furthermore, the committee felt in those instances in which new construction might be required for Regional Medical Programs, other Federal sources of funding should be sought. Finally the committee in its report indicated its intention to review this question at the time of the legislation's extension.

Mr. Chairman, I would like to commend the committee's wisdom on this matter. In fact, the Regional Medical Programs have not been jeopardized during these past three years, during which they have organized themselves, planned their programs and begun to enter the operational phase.

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However, this situation is rapidly changing. Already 12 of the 54 Regional Programs are operational and within the next year or so all of them will have begun operations. Accordingly, their needs for additional facilities will rapidly increase.

The Surgeon General's Report to the President and The Congress on Regional Medical Programs documents the case for limited Regional Medical Program construction authority. It is extremely important to understand that these facilities would principally be located in community hospitals, not our medical schools.

Examples of needed community hospital construction described in the report include class and conference rooms for regional continuing education programs, space for special demonstrations of community patient care, and expanded diagnostic laboratory facilities. These needs are not now being met under existing Federal construction programs. There are two interrelated reasons for this:

(1) The competition for Federal funds for the construction of health facilities has grown enormously as a result of an overwhelming demand for such facilities.

(2) By definition, the nature of Regional Medical Program construction needs goes beyond the needs of a single institution to the needs of the region. Accordingly, it is unreasonable to assume that any single institution would be willing to divert its scarce funds for matching purposes when the benefits of the facility are intended for many institutions.

Since it is essential that there be no substantial distortion of the concept of Regional Medical Programs, I concur that rather strict limitations should be placed on this vitally needed construction authority. The kinds of limitations one finds in the Surgeon General's report, having to do with the amount of funds available for construction purposes, seem entirely reasonable to me.

Having considered the limitations, what kind of Regional Program projects are we working to generate? How does such a project work? An example of the effective implementation of the program involving community hospitals is provided by the Rochester (New York) Regional Medical Program which has inaugurated an initial five-part operational program in the area of cardiovascular disease. Each part is specifically designed to meet observed or expressed needs in the delivery of specialized medical care to the heart patient. One project will provide postgraduate training in cardiology for general practitioners and internists who practice medicine in the ten counties which make up this region. Sereral different training programs will be offered so as to best meet the individual needs of the physicians who will participate. This program is being persented in direct response to the requests of physicians for this type of assistance. One phase of this program includes visitations to peripheral hospitals by the cardiologists who will provide this instruction. Certain audio-visual equipment will be placed in these peripheral hospitals for continued use by the local physician.

A parallel program will present intensive month long courses to prepare professional nurses in the management of coronary care units. The growth in the number of coronary care units which provide essential medical care during the acute phases of cardiac illness, has created an urgent need for an increased number of well trained nurses; the latest advances in nursing techniques and moderu life-saving equipment demands specialized instruction in the nursing skills re

quired. Hospitals in the region have already expressed their intent to have nurses participate in this program as soon as it is activated. The objectives of this program go beyond that of supplying specially trained nurses for coronary care units in general hospitals; every effort will be made to train coronary care unit nurses from the smaller community hospitals as well, even though they may not as yet have such a unit.

Three additional activities will also be pursued under this initial operational program. A regional laboratory will be established for education and training of medical personnel in the care of patients wnth thrombotic and hemorrhagic disorders. This is the first such facility in the region and will be based in one of the general hospitals participating in the Rochester Regional Medical Program. A region-wide registry of patients with myocardial infarction will be implemented which will gather uniform information from the coronary care units of participating hospitals and provide immediate as well as longitudinal data for analysis. A relatively small amount of funds has been made available to the region to develop the first learning center in the region where some of the educational programs in heart disease, cancer, and stroke may be presented to physicians and nurses.

The first year award for this multifaceted program in cardiology is $343,749. Having described an example of what we are building, Mr. Chairman, I should like finally to say a word or two about the level of funding I believe essential if Regional Medical Programs are to have a fair chance to achieve their goal.

We all realize that the maintenance of health is assuming an increasingly important role in our socio-economic area of concern and activities. The health industry today accounts for an expenditure of $50 billion but it is scheduled soon to increase to an expenditure of $75 billion.

If the Regional Medical Program is to fulfill its function as the interface between the moving parts of this health care mechanism, it must continue to be able to influence that increasingly expensive device.

We would be short-sighted engineers, indeed, to derive authorization ceilings for the next five years of this program by looking backward at the cost of these programs at the time they were being planned. The cautious development of those programs has unleased a chain reaction of operational activity which will necessitate substantially increased funding levels. It is already clear that on the average these programs will be operating at a level of between $5 million and $10 million each within the next five years. It is, therefore, necessary that an authorization level of roughly $500 million be used as the yardstick with which one measures the funding levels of the program contemplated by this extension.

Mr. Chairman, I am indeed privileged to again have the opportunity to present my views to the committee which has done so much to shape health legislation in general and the Regional Medical Programs in particular.

Mr. ROGERS. Our next witness is Sidney Farber, director of research, Children's Cancer Research Foundation, Boston, Mass.

Dr. Farber is also an old friend of the committee, and he was helpful in the formulation of the original legislation, having served as chairman of the Cancer Panel of the President's Commission.

Welcome back, Dr. Farber.

STATEMENT OF DR. SIDNEY FARBER, DIRECTOR OF RESEARCH, CHILDREN'S CANCER RESEARCH FOUNDATION, BOSTON, MASS.

Dr. FARBER. Thank you. It is a great honor to be once more before this committee, where my memories are as heartwarming as any memories I have in my entire professional career. I join Dr. DeBakey and all our colleagues in expressing gratitude to this committee and Congress for starting what I regard as the most important program in the field of medicine in the history of our country that is applied directly to the care of the patient.

I speak strongly in favor of H.R. 15758, the purpose of which is, among other things, to amend the Public Health Service Act so as