FELIX: Whether it's because it's politically not so popular or what, I don't know. But, I feel that the Administration and the Congress don't care so much about people's health, as they used to. And I think this is a tragic, a real tragedy!

VANOCUR: The full effects of the medical cutbacks on the nations' medical schools will not be clear for several years. Obviously, the schools will have to try to get additional money from their traditional private sources to offset the loss of Federal money. Whether they can get enough to operate effectively remains to be seen. The St. Louis University School of Medicine, perhaps more than some other schools, in suffering from what might be diagnosed as financial anemia as a result of the cut-backs. But it is not unique. Some other schools, suffering from similar complaints, are Case-Western Reserve, George Washington University, New York Medical College, Marquette, Einstein, Tulane, and Johns Hopkins. That's not a complete list. The financial anemia may not be fatal in most cases; but the symptoms are there: pallor, weakness, internal problems and nervous tension. Some medical schools have been dipping into their endowments, but that provides only temporary relief.

While it is too early to accurately gauge the full impact of Federal cutbacks on the nation's medical schools, the effects of some cuts in the Federal budget have become painfully obvious to doctors and scientists engaged in medical research. Medical research, like everything else nowadays, is becoming more and more expensive. But, when the Nixon Administration cut the Health, Education, and Welfare Budget, it cut four million dollars from the Government's Clinical Research program. This, directly and immediately, offered 19 clinical research centers, which have been trying to develop new methods of treatment for people who desperately need medical care. One of these centers is in New York... Jacobi Hospital in the Bronx. The center has been serving more than a million people, at a cost to the Federal government of 450,000 dollars a year. SPEAKERS: I understand that the Federal Government has a crisis and they're trying to cut back to curb inflation . . . and decrease spending, etc. But, you can't jeopardize the lives of people of people to do this. There's no question who looses most if this Unit closes, it's the patients that are cared for at this hospital... and the patients in the Bronx and in the city of New York. The doctors can always find employment elsewhere. If the Unit closes, I don't have any qualms about the nurses, you know, it's not a question of them being out of employment, but it . . . it's mostly the patients that would suffer.

DEL GUERCIO: We don't know exactly when the money is going to run out and, but it's going to be soon! And when it does, that'll be the end of it. There is no way that the city government or the state government can take over these centers really. They're in just as bad shape. And it's the responsibility of the Federal Government, they started it. You can't just cut back once you've started.

FRIEDMAN: Six West, the clinical research center at Jacobi Hospital in the Bronx, New York, treats only the most critically ill. With full support from the Federal Government, the center used to take ten patients at a time. But the Government decided to stop supporting the center and now with money running out. Six West can use only half its beds. The rest go to waste. This center has pioneered in developing machine doctors and nurses to save lives that otherwise would be lost, especially in cases of severe shock or severe burns. One of the center's innovations is the use of a computer, moved to the patient's side, to get instant detailed information when wasted time and mis-information can mean death. Doctors and nurses are specially trained in using the computer and the techniques developed here are spreading to other hospitals. The cut-off of Federal funds is not taking away any of the center's machines, but it is forcing a reduction in the center's highly-trained nursing staff. There had been 27 nurses, now there is only enough money to pay 19. This loss of nurses is critical.

WEXLER: One of the main features which helps us to get patients like this through very critical periods like this, on our Six West Unit, is the fact that we have a one nurse to two patient . . . and at times one nurse to one patient ratio. When you order things for a patient or you want various barometers monitored on a patient, these things are done instantaneously. They're done accurately. The records from the monitoring of the patient is excellent . . . cause you walk on, you can pick up the . . . sheets and tell exactly what's happened to your patient from the last time you were there. And know and treat your patient with much more authority and accuracy. When you walk on to a ward, on to a General Ward, and they have two nurses for 35 patients, these things are not done as well, not because the girls are any more or any less competent, but because they

just have such a tremendous job to do that they can't possibly give you all the fine details that the one nurse to one patient ratio gives you. And they're trying to feed them, take care of them. . . it's just an impossible task, and the girls do a tremendous job, but they just can't handle it. It's just too much.

RITCHIE: Unlike the General Wards, in Six West, we can closely monitor . . and we can turn patients, we can suction them, we can get them out of bed, we can give them TLC... the baby is crying and because of the extent of his burns, he can't be held. So, this leaves us with talking to him or holding his hand, very important. He's resting, he'd wake up and see me and . . . and just close his eyes again. And it's very important.

FRIEDMAN: A new patient strains the center's ability to provide care. Because of the loss of nurses, forced by the Federal cut-off, the center can handle only five or six patients at one time. When the center is full, a new patient forces the doctors and the head nurse to make an agonizing decision. Sometimes, a decision of who lives and who dies. On this night, the corridor was filled with five patients, including two infants with severe burns and three adults who seemed too near death to be moved.

CONFERENCE: Well, you know we just finished this woman upstairs for a possible operation for cure, she's 65 years old and lost blood like mad. She's been in a hemorrhagic shock, but she's out of it now and the outputs show that it looks like she's going to make it. But not if she's not here. You can't do a patient and her and the others? It would be better if she's moved out. What are the possibilities that we could tie things up for one shift? Then I'll try and move somebody out. If you can take care of four others, Lois is willing to come back in, she's been working all day. I suppose as long as it's like this, we'll have to do something. Bring Delores in and we'll . . . won't have to discharge anybody and we'll hope to carry on unless there's a pump case or something of that sort. . . I think that we're in good shape at least until morning and hopefully some of these people will be able to go home before long.

FRIEDMAN: An auto accident shattered the stop-gap arrangement of calling in a nurse to work an extra shift. One of the injured was brought to the center's burn room, suffering from 3rd Degree burns on 30% of his body, plus the potentially deadly effect of having inhaled hot gasses from the burning car. The patient stopped breathing twice. . . because nurses were there all the time to act instantly, he was brought back to life. He was saved, but the staff was overburdened. Another patient had to be moved out. The decision was made. An order was written to transfer one of the center's patients to a General Ward. NAHMAD: I was forced into moving my patient back to the General Ward because the Unit here did not have enough nurses to take care of the additional load of another patient. We were forced into the situation of having to transfer out of the Unit, one sick patient in order to bring another one in. It's a, you know, it's a decision that I don't like to make. This occurs over and over and over again. Because of the cut backs that were made here, on Six West, people have died who did not have to die. And when the money runs out completely, more people will die.

VANCOUR: About a year ago, the Nixon Administration warned of a breakdown in health care unless concerted action was taken. Nothing was done . . . because the Administration seemed more concerned about holding down government spending as a means of fighting inflation. So what we have wound up with is the worst of all possible worlds. Inflation has increased. The quality of health care has decreased. It has become, really, a question of priorities. In his testimony last month, Louis B. Lundborg, Chairman of the Board of the Bank of America, told the Senate Foreign Relations Committee: our problem now is one of establishing meaningful priorities to meet the quality of life. demands of our citizens. We obviously cannot do everything at once; we need to start strategic planning and action now if we hope to resolve these demands. Lundborg was speaking in the context of the Vietnam War which he called a tragic national mistake. But even if the war ended tomorrow, Administration officials say there will not be a peace dividend. In fact, Defense spending may even go up, because future weapons will be so sophisticated. And so it does come down to priorities, and people are starting to make the connection between what they need and what they can't get because of where government spending is concentrated. And they are beginning to ask, in terms of this country's future, which is the greater need . . . more missile bases or more hospitals. It is, at the very least, a perfectly fair question.

Senator EAGLETON. Our next group of witnesses is from Washington University; Dr. William Danforth, vice chancellor for medical affairs of Washington University, accompanied by Dr. Roy Vagelos, chairman of the department of biochemistry; Dr. Gerald Perkoff, professor of medicine and director, division of health care research; and Dr. David A. Bensinger, assistant dean, Washington University School of Dentistry.

Let me add, while they are being seated, my high personal respect for Father Reinert and his associates is equaled by that I have for Dr. Danforth and his three associates appearing with him. Dr. Danforth is a great doctor, if for no other reason than he was a classmate of my brother at Washington University School of Medicine. Would you please identify yourselves for the record?

Dr. BENSINGER. Dr. David A. Bensinger, assistant dean, Washington University School of Dentistry.

Dr. DANFORTH. Dr. William Danforth, vice chancellor for medical affairs, Washington University.

Dr. VAGELOS. Dr. Roy Vagelos, professor and chairman of the Department of Biochemistry, Washington University School of Medi

cine.

Dr. PERKOFF. Dr. Gerald Perkoff, professor of medicine, and director, division of health care research.

Senator EAGLETON. Let me say to the group, before calling on Dr. Danforth to be the leadoff hitter, you can proceed any way you want. You may put your entire statement in the record-in any event, it will be made a part of the record-and "freewheel" on your statement and respond to other lines of inquiry that have been opened up, because I think all of you have been in the audience during the preceding session, or you may read your statement, whatever your personal incli

nation is.

Dr. Danforth.

STATEMENT OF WILLIAM H. DANFORTH, M.D., VICE CHANCELLOR FOR MEDICAL AFFAIRS, WASHINGTON UNIVERSITY; ACCOMPANIED BY DR. ROY VAGELOS, CHAIRMAN, DEPARTMENT OF BIOCHEMISTRY; DR. GERALD PERKOFF, PROFESSOR OF MEDICINE, AND DIRECTOR, DIVISION OF HEALTH CARE RESEARCH; AND DR. DAVID A. BENSINGER, ASSISTANT DEAN, WASHINGTON UNIVERSITY SCHOOL OF DENTISTRY

Dr. DANFORTH. I appreciate very much the opportunity of being here today and making this presentation.

Washington University School of Medicine has some reputation in the area of research, so I would like, before getting into some of the questions raised in Senator Eagleton's letter, to speak a little bit about how the biochemical research plays a part in the medical school, because I think this is important for the understanding of the whole situation.

Basic and applied medical research has been and is an important national asset. It has contributed much to the health of the American people and much to that of others around the world. Without medical research physicians would have little to offer except human concern

and compassion. These are certainly important virtues, but don't require 4 years of study and a doctor's degree.

The crisis in medical care today and the importance of delivery of services with equality and with justice comes about because modern medicine has something to offer.

One could make just one example. In 1937, before the advent of antimicrobials, a physician had limited resources for pneumoceccal pneumonia. He could follow a patient for 2 weeks until the crisis came, then if the patient recovered, perhaps for 2 to 4 more weeks during the convalescent stage. A doctor-patient relationship developed, everyone felt the doctor was a good fellow. Now a nurse with a syringe of penicillin is more potent than all of the physicians combined 33 years ago. Forty-eight hours after treatment the patient is well and perhaps can't even remember the doctor's name who prescribed the penicillin.

The basic research that has made medical advances possible has flourished in academic medical centers. In the last 69 years approximately three-quarters of the Nobel Prizes in chemistry, physics, biology, and medicine were awarded for work done in universities. I think everyone will agree with that.

I would just like to review very quickly how research money comes to a medical school. A physician, faculty member, or group of faculty members write up a project for specific funds to do a job. They send it through the dean's office to HEW, where it goes to an appropriate study section. A group of individuals selected for their competence in this area study the proposal, review it, recommend either disapproval or approval with a priority level and a certain level of funding. After this it goes to the National Advisory Councils for final review. The proposal via this mechanism gets a hard-needed look to see if it can really do what it is supposed to do, if it will contribute new knowledge at reasonable costs and in a reasonable period of time.

I went through this because I believe this peer review mechanism is an excellent mechanism for passing judgment on the quality and importance of academic and scientific work. I think we have good reason in this country to be proud of the success of a really magnificent national research effort. The fact that this research effort, this kind of funding has failed to solve the problems of medical education the distribution of medical services is, to my mind, no valid criticism of the national biomedical research effort. This effort must be continued and preserved. It should in no way be thought of as an either/or proposition, that is, either research or better delivery of health care, either research or more physicians.

Using Washington University as an example, we have built a strong scientific unit. In making this effort, for better or for worse, we have become dependent on Federal funds. In the fiscal year just ended, approximately 66 percent of our operating income came from gifts and grants, almost entirely earmarked for special purposes. Senator EAGLETON. Is that both public and private?

Dr. DANFORTH. Public and private; yes.

Senator EAGLETON. Can you break it down, Bill, in terms of Federal versus the rest?

Dr. DANFORTH. The Federal was probably between 90 to 95 percent of that amount, of the 66.

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Senator EAGLETON. To put it another way, then, roughly 60 percent of your money came from Federal research grants.

Dr. DANFORTH. From the Federal Government, about 60 to 63 percent, somewhere in there.

Senator EAGLETON. How much of that percentage of your 60 to 63 percent were research grants vis-a-vis other types of Federal payment, medicare, medicaid, and so forth?

Dr. DANFORTH. I am not including medicare and medicaid in the 66 percent, because that's fees for services rendered, although that comes in, too. Seventy percent of the 66 percent was for biomedical research, 25 percent for training grants, much of this for research training, and the remaining 5 percent for miscellaneous.

This has not changed much because 5 years ago 68 percent of our operating budget was what we called soft money compared to 66 last year, so this has held pretty constant between 65 and 70 percent for 5 years.

The other side of the picture is this. Last year endowment income made up only 11.5 percent of the medical school budget and tuition income only 4.3 percent, and much of the endowment is earmarked for special purposes such as research.

I mention these figures because they have to be kept in mind when you consider the role of the academic medical center. We have very little flexibility in our budget. Some of our house officers raised questions a year or so ago about not contributing enough out of our resources in health to the city hospital problem. I did a few quick calculations and figured out that if we put all our free money into the city hospital system we'd close up shop, and we would give only enough money to take care of the increase in budget for 1 year. After that the city hospital system would be back where it started from.

I wanted to bring all these things out because I think the national research effort today is being criticized too harshly in some quarters. Some of this is unavoidable. We have a shortage of medical care, and it is like the problem of eating your seed corn in the days of famine. You don't know how much to eat and how much to set aside for seed the next year and no two people would agree on a proper balance.

To make some specific recommendations and comments on the questions raised in Senator Eagleton's letter, briefly-and I apologize for having no written report, I didn't get into town until yesterday after 2 weeks of being incommunicado-first of all, I do believe we need to preserve Federal support for biomedical research and it should be preserved as it has been in the past on a completely merit basis. This is the best way to get research. For example, we have a major program, heart, stroke, and cancer, but we really don't know what to do for stroke in the way of prevention, and the man who learns how to prevent stroke will have done more for humanity than most of us can ever dream of doing in our life.

We need some research-oriented medical centers, some academic medical centers orinted heavily toward research, such as Washington University. We don't need a hundred medical schools of that type. In my judgment, that would be a bad use of resources. But we need some. These particular medical centers have the ability of training badly needed faculties for other medical schools. There are certain advantages of research to medical education, since students graduating next