The CHAIRMAN. Thank you, Mr. Folsom, for your most interesting and informative statement. We appreciate it very, very much.

Dr. DeBakey?

Dr. DEBAKEY. I also want to express my thanks to Mr. Folsom for his testimony here.

Next, I would like to ask

The CHAIRMAN. Senator Kennedy?

Senator KENNEDY of New York. I understand Mr. Folsom has to leave. Could I ask him just one question? I thought your statement. was very helpful and interesting. I was just wondering based on your experience and the efforts that you made in this field, could you just tell us what you think the relationship between the centers and the stations to NIH and the Public Health Service should be?

RELATIONSHIP WITH NIH

Mr. FOLSOM. Well, I have been thinking lately about how the tieup ought to be here. The NIH now deals with the medical schools all the time on research, and the Bureau of State Services is dealing with medical schools also, I understand, under the Research Facilities Act. It also makes grants to hospitals and communities for planning and demonstration projects under the Community Facilities Act.

There ought to be pretty close tie-in to the agency that now is concerned with making grants for community planning and coordination of health facilities. The local group should be slanted more toward bringing research knowledge to the other hospitals and the physicians rather than be concerned so much with research.

So, I would think it might be better tied in with the State service organizations, in the Public Health Service, rather than NIH, although there should be a close relationship.

Senator KENNEDY of New York. The emphasis really should be then on making sure that the information that is uncovered and which was mentioned earlier brought to the attention of the local doctors and to the local communities so that they can utilize it, is that the thrust of this legislation?

Mr. FOLSOM. Yes; that is the main purpose of it. We have a lot of information and knowledge that is not being generally used. It is pointed out that if we can only use the knowledge we have a lot of lives could be saved. This is a mechanism, a suggestion, of the best way of getting that knowledge out to the communities.

From my experience, I think it could be done. It would be very helpful and could be done fairly rapidly, too, in communities already set up to do it. But there are so many communities that haven't made much effort in planning so a good part of this money the first year will go for planning to getting agencies set up and instructed on how to go about it.

Then they could actually set the stations up and most of the stations would be located, of course, in existing community hospitals. The university medical center would serve as the base and as a regional center. I think that is what we contemplated.

Senator KENNEDY of New York. Thank you very much.
The CHAIRMAN. Senator Yarborough?

Dr. Farber, do you want to make some comment on that?

Dr. FARBER. With your permission, Mr. Chairman, I understand what Mr. Folsom has in mind, and I agree with him certainly as Senator Robert Kennedy has mentioned that the uncovering of knowledge and getting it to the doctors is of tremendous importance here. But I would like to make a point here that I did not make clearly before, and that is that these centers will make possible the kind of medical research in clinical investigation which is not possible today on the scale that is required, not only in the field of cancer but in heart disease and in stroke, and in many other diseases, too. Research on it will be an extremely important part of this, and it is this research as well as the training which I associate with the National Institutes of Health, with the aid of any other governmental agencies or any other parts of the Public Health Service that are required, but the research must be emphasized greatly.

Mr. FOLSOM. I might say I think it is wise to leave the decision in its relationship within the Public Health Service here entirely to the Surgeon General to work out because there must be very close coordination between these two elements.

The CHAIRMAN. Senator Yarborough, do you have some questions? Senator YARBOROUGH. Mr. Folsom, I want to comment on this recommendation for an expansion of the Health Professions Education Act and the Nurse Training Act and also your additional recommendation that career programs be stimulated in community colleges. I might add junior colleges for training medical and dental technicians to help the higher trained medical doctors and the dentists.

In the hearings on this Health Professions Education Act the testimony indicated that it took about $25,000 to educate a young doctor, and that less than 5 percent of the families of the United States were financially able to finance that education. As you pointed out, that is just automatically excluding from medical education the overwhelming majority of the people of the country unless they have outside aid. I have a question or two back when you were explaining the coordinated action in Rochester and how much it saved there, I know two of those actions were that the council got the University of Rochester Medical Center to take over the municipal hospital, the city hospital, and you were successful in getting the State to take over the county hospital.

Apparently you did not lessen the medical treatment but the city and county there were able to shift this off to other governmental agencies.

SAVINGS REALIZED

Mr. FOLSOM. In the case of the medical center we had always had a close tie-in there. But the city was incurring quite a deficit. We were able to get the deficit wiped out before the university would take it over mainly because we got the welfare department to pay what it should have been paying all along for the welfare patients.

Senator YARBOROUGH. Now, if you get the county TB hospital taken over by the State, is this really a true figure that you saved that much? Mr. FOLSOM. No. What we did there was

Senator YARBOROUGH. Somebody pays for it.

Mr. FOLSOM. Thirty miles away there was a State hospital with plenty of beds available for these patients. We had been operating this

county hospital with the patient load going down steadily with no reduction in staff, in fact, an increase in staff. So the patient could be cared for at a much lower cost at the State hospital and the county really saved about a million dollars.

The State has not increased its cost anything like that much.

Senator YARBOROUGH. In other words, you are not giving this as an illustration of how one governmental unit shifts from one to another but a savings by coordinated action.

Mr. FOLSOM. Yes. This had been considered for several years but nobody had been able to do it. With the top leadership in our council we convinced the authorities what an overall savings there would be. We think we are giving better care at a much lower cost.

Senator YARBOROUGH. Thank you, Mr. Folsom; thank you, Mr. Chairman.

Mr. FOLSOM. I might say the reason I have to leave I have to testify before Congressman Celler's committee.

The CHAIRMAN. We certainly appreciate your presence, Mr. Folsom, and I want to thank you very much.

Mr. FOLSOM. I am very glad to be here.

The CHAIRMAN. Thank you, sir.

Dr. DEBAKEY. Senator Hill, before asking Dr. Wright to continue at this point, I would like to amplify just a bit some aspects of the legislation and its purpose at least as we conceive it since I think the question has been raised-Senator Kennedy raised the question a moment ago as to what takes the major thrust of the legislation, I think it is important to recognize, first, that this legislation provides an opportunity to extend an effort and a direction of development that is already in operation, Senator Kennedy.

While it is true in a sense that this constitutes the most innovative aspects of the recommendations of the President's Commission in establishing this concept of a regional network, it is new only in that sense. It is not unrelated to programs, on-going programs. It is, I think, in fact, so closely related that it is an outgrowth of the going programs. It is the natural extension to a great degree of the developments and the fruits that have come out of the National Institutes of Health research and training activities, and the concepts of the centers which are already in operation supported by the National Institutes of Health largely thrust upon the medical community through that means.

So, this type of legislation is new only in respect to providing a further extension of this total concept. I think actually it is derived from this background of activity, and the long experience that has now developed over this period of time beginning with the establishment of the National Institutes of Health and particularly the categorical institutes in combining the research, training, and now patient care, so intimately interwoven in most centers that have been in operation that it is difficult to disassociate one from the other. The reason one can provide the highest degree of skill and knowledge in patient care in such centers is because research and training are an integral part in it.

So, I think it is important to understand this concept, that this is not just an extension of patient care and making available the best knowledge. It is not just an extension of research, clinical research, and it is not just a means of providing training. It is the best mechanism of

43-669-65- -9

combining all three. Anyone who has had experience in a medical center, such as most of us, and, of course, many others whom we consulted, has recognized the importance of this particular objective and that this is the best means of achieving this goal.

It is the best means of providing the best in research and particularly in clinical research, the best means by which it is possible to bring the knowledge gained from basic medical sciences to the bedside and to translate that knowledge into diagnosis and patient care. It is also the best means for providing training for the practitioners who will ultimately provide this care, and it is the best means of expanding the basic sciences in these general areas.

So, I think it is important to recognize that this is not just the thrust of medical care.

Senator KENNEDY of New York. Thank you. That is very helpful. I just gathered from the earlier testimony and looking into this legislation to some extent and the background that there had beem some deficiencies in the being able to get the information which has been developed by all of you to the bedside and to the local doctor and I gather that in the field of cancer from your own testimony and I knew there had to be some emphasis on that. I didn't mean to imply I thought research should be less or we hadn't been doing a great deal in any or all of these fields but I just thought we should really focus some attention on that point so it is quite understood. It is very important.

Dr. DEBAKEY. It is very important and I am glad you did bring it out. But I just wanted to emphasize this concept underlying the centers and its relationship to the experience we have gained in this regard.

Senator KENNEDY of New York. Thank you very much.

Dr. DEBAKEY. May I now ask Dr. Wright to present his testimony, Mr. Chairman ?

The CHAIRMAN. Dr. Wright.

STATEMENT OF DR. IRVING WRIGHT, CHAIRMAN, SUBCOMMITTEE ON HEALTH

Dr. WRIGHT. Senator Hill, and members of the committee, it is a real pleasure to be before you again. I have had the experience in previous years and I hope have made a minor contribution to your efforts in the field of health.

The Subcommittee on Heart Disease was made up of Dr. Samuel Bellet, professor of cardiology at the University of Pennsylvania; Dr. J. Willis Hurst, professor of medicine at Emory University; Dr. Paul Sanger, distinguished surgeon from Charlotte, N.C.; Dr. Taussig, Johns Hopkins, with whom you are all very familiar, I am sure, for her distinguished work on congenital heart disease; and the staff member, Dr. John Turner, who contributed markedly to the work of this Committee.

My own experience has been in practice, in the teaching of medicine, and research mostly on a clinical level at Cornell University. I have also been president of the American Heart Association and a member of the National Advisory Committee for Heart Disease for one term and for part of another term.

I mention this to indicate that I have had a rather broad experience and have been interested in these problems, not just since the inception of this Committee but during my entire professional life of more than a quarter of a century.

The Subcommittee on Heart Disease has presented to you its report. In essence this is my statement, based on the efforts of the entire Committee. I should like to summarize it and perhaps make comments on certain aspects of this report in order to conserve your time. It is all available for your perusal.

The CHAIRMAN. We will have it appear in full in the record, Doctor, in its appendix.

Dr. WRIGHT. This report has already been submitted. It is entitled "The Report of the Subcommittee on Heart Disease." This will appear in the second volume of the report of the Commission.

We are strongly in favor of general principles outlined in the bill as it has been drawn up and submitted to us. There are certain points, however, that appear to be worth while discussing.

The concept of the regional complex and the center working as a nucleus with radiated stations throughout a geographic area is involved. We hope all areas in the country would eventually be covered. This concept is a very valid one, but it is a long-term project. It is important to get it underway now because it won't be very long before we have 50 million more people to take care of in this country. We are not in our present status even in the business of preparing to take care of the total future population unless we enter into a long-term project right now. It will take planning, it will require development of manpower at every level. Physicians, of course, are the key personnel, but we must have more nurses, and more laboratory technicians. Electronics technicians are now being declared essential to medical progress, a field that medicine hasn't really done very much about developing at all. Yet the future of medicine is going to be tied into this new discipline. We need physical therapists, occupational therapists, and rehabilitationists.

We need many more trained workers in the social sciences who are sincerely interested in sick people, not in abstract theories. The plan is a broad one, and it is a long-term one. But in order to get off the ground, this type of bill must be implemented soon.

The Heart Disease Subcommittee has recommended that a total of 25 centers be established during the next 5 years. The total amount of money involved in this will be approximately $166.2 million.

This is a very conservative estimate. It has been felt by some that we were being too conservative in terms of the cost per center, but we tried to be honest in our estimations. Once a center is established, individual investigators within that center may, if they wish, apply for special research and other grants which would supplement the basic grant once the center organization is ready to use extra funds to advantage.

The Heart Disease Subcommittee felt there was a need for 160 new heart stations. The concept of the station as adopted by the entire Commission really came from the development of heart stations in many hospitals during the past 15 or 20 years.

So, this is not an idle dream. Stations are, in fact, in operation in many centers, including Cornell. They have served as a nucleus for