become skilled in scientific method and the design and conduct of experiments, must become proficient in the tools and techniques peculiar to the branch of science to which he has addressed himself and must acquire competenance in research itself, competence which is acquired only by performance of research under the supervision of a mature and sophisticated investigator. The ratio of faculty to students is of necessity small and the apparatus and equipment becomes ever more complex. No university can afford such training without specific financial support.

But it is these programs which will constitute the very lifeline of our national effort in biomedical research. From these programs will emerge the scientists some of whom will address themselves to the crying fundamental problems of human biology while others attack the problems of disease. For research in disease is not conducted by cancer specialists, or pediatrics specialists, or cardiac specialists, etc. The investigator interested in cancer must approach it specifically with the skills and knowledge of one highly trained in one or more of the biomedical sciences. The physician engaged in research on cancer or schizophrenia must bring to bear his disciplinary training in biochemistry, physiology, or genetics, etc. Thus, it is these training programs which will provide the Nation with the investigators who will do both the fundamental and the applied research in the biomedical sciences. If support of these training programs is not continued and indeed expanded, in time it will have become pointless to appropriate money for the support of research for there will be few to perform such research; it will have become pointless to appropriate money for the construction of research facilities for there will be no investigators to labor within them. No program at the National Institutes of Health is any more important than is the program of training grants now operated by the Division of General Medical Science.

My request, therefore, is that this committee recommend approval of the creation of an Institute of General Medical Sciences as proposed in H.R. 8398. The program which would be conducted under the auspices of this Institute is already in being. Indeed, it is presently funded at a level far greater than that of any of the categorical Institutes at the time they were created by the Congress. Considering the paramount importance of its programs, it is fitting that this Division be elevated to the dignity and status of a full-fledged institute, that such institute be a creature of the Congress rather than a device of the administrative officers of the National Institutes of Health.

So vital are the programs of this Division that it is imperative that it continue to be administered by individuals of topflight managerial and scientific talent. To attract and maintain such a staff and permit attractive career development programs for them requires that the organization for which they would be responsible enjoy a status equal to that of the other Institutes at the National Institutes of Health. At the same time this will insure that the wishes of the Congress with respect to the conduct of this vital set of programs in biomedical research and research training shall continue and that, in any one year, the magnitude of this effort shall not be influenced by otherwise competing requests for support of research seemingly more directly addressed to the problems of disease. For the future of our total national biomedical effort lies within this basic program, which "feeds" both investigators and information essential for the conduct of the research programs of the categorical institutes.

There is an added dividend which is not lightly to be discounted. The advisory group which presently serves the Surgeon General with respect to the programs of the Division of General Medical Sciences is the National Advisory Health Council. By law, this is also the Council upon which the Surgeon General should be free to call with regard to the broad responsibilities of the Public Health Service and the latter becomes more vital and significant to the American people daily. From his Advisory Council the Surgeon General should obtain the most competent professional advice with regard to such problems as the operation of the marine hospitals, the health problems of our Indian populations housed on reservations, the management of our pesticide and insecticide programs, techniques for the monitoring of fallout, water pollution, air pollution, accident prevention, the relationships between the U.S. Public Health Service and local and State departments of health and the overall operation of the National Institutes of Health. Clearly, this is already so all-encompassing a mission that it is difficult indeed to find a council of 12 members from whom firsthand competent professional advice can be had in all areas for which the Public Health Service now has responsibility. And it is fanciful to consider that a council capable of providing competent professional advice in all of these areas could also serve the Surgeon General with equal competence with respect to the specific programs of an Institute of General Medical Sciences.

Since creation of the new Institute also entails formation of a new national advisory council, our Nation and the Surgeon General would be assured of more incisive and knowledgeable advice from two independent councils each of which is so constituted as to make available to the Surgeon General those individuals whose competence and professional interests are especially relevant to the tasks at hand. The membership of the National Advisory Health Council has not complained of the dual burdens under which it has labored for the past several years. But as one whose term on this Council expired last year, I believe that I can speak for the entire group in stating that each of us has frequently felt inadequate under the existing circumstances and all would welcome both creation of the proposed Institute and of an appropriate new council.

Had the Division of General Medical Sciences never been created, if its programs were not in being, I should feel compelled to document in fuller detail the national needs for those programs for which the Division now has responsibility. But the Congress has already, by its previous actions, indicated its understanding of the problems involved. The magnitude of the appropriation for the Division of General Medical Sciences (found under the appropriation title, "General research and services") clearly indicates congressional recognition of the national significance of this program. It remains, therefore, for the Congress to invest this program with the dignity and status of an institute so as to assure that, in the future, its programs will be prosecuted with a maximum of vigor, intelligence, and efficiency.

The CHAIRMAN. It gives me a great personal pleasure to have as our next witness, Dr. Frederic G. Burke. He has reared my two youngsters and, if I may be permitted to say so, I think he has done a fine job.

STATEMENT OF FREDERIC G. BURKE, M.D., PROFESSOR AND DIRECTOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY HOSPITAL, WASHINGTON, D.C.

The CHAIRMAN. We are glad to have you, Dr. Burke.

Dr. BURKE. My name is Frederic Gerard Burke. I am professor of pediatrics and director of the department of pediatrics at Georgetown University School of Medicine in Washington, D.C. I am a member of the American Board of Pediatrics and American Academy of Pediatrics. I am cofounder and director of the mentally retarded children's clinic at Georgetown University Hospital and I am medical director of the Children's Convalescent Hospital of the District of Columbia. I am also a member of the Executive Committee of the Children's Hospital of D.C. I would like to present a statement in support of this bill on my own behalf.

Pediatrics is concerned with the concepts of growth and development. This is not a static subject but is concerned basically with the dynamic forces that are continuously changing in the individual with respect to growth (an increase in the cellular mass) and with respect to function as regards development, both physical and mental. Pediatrics is terribly concerned with the prevention of illness and, when sickness occurs, to find out why it appeared, what to do to prevent it, and what effects it will have on health patterns in older life. We are interested in the disease, yes, but more importantly in its prevention. We are interested in cutting down on fetal wastage, in reducing premature birth, in counseling parents of malformed children and in why malformations occur. The economic losses induced by premature births alone in this country are said to exceed $300 million a year (more than all of the costs of medical education in the United States today). An improvement in the reduction of prematurity would more than justify all of the current costs of the

present outlays for pediatric research. We are concerned with the growing individual.

How does an individual grow up? What are the ingredients that go into the making of an healthy individual and how are these influenced? What is the nature of the aberrations in the growth processes that result in defective adolescents and adults and, indeed, what infant and childhood forces operate or fail to operate that affect the life and health pattern of old age, because this probably is a continuous line?

The genesis of many diseases associated with older people have their beginnings in the younger age group.

The philosophy of the longitudinal nature of growing and developing would then be a basic consideration of the Child Health Institute. Consideration of what constitutes normal development from the very beginning of life through the birth process to the changes that characterize aging would be fertile fields for investigation. Genetic disorders, malformations (about 5 percent of all births are associated with malformation of one kind or another), physical retardation and prematurity would be a few of the very important areas for concentrated research that might well be considered by this Institute.

I know a lot has been said about mental retardation, probably, before this committee, but this continues to be a very, very important problem in the pediatrician's mind, and a continuing evaluation and reevaluation by the multidisciplinary approach is necessary, and the effort must be increased since we are dealing in this category of individuals with probably 3 percent of the entire population.

In the Georgetown University Hospital for Retarded Children, a review of our first 500 cases revealed that in fully 50 percent of the cases the cause of the disorder was entirely unknown. It is a difficult task to tell the parents of these children that we do not know why their baby is mentally retarded. This is just one of the problems in dealing with this unfortunate condition. Improved methods for detailed observations and testing of these children, including the application of newer genetic and metabolic techniques, is needed, and this also would appear to be an appropriate area of interest for a child health institute.

The formation of character and personality studied in terms of experiences of infancy and childhood and the importance of growingup processes to adult behavior is well recognized as a causative influence, but the incidence of juvenile delinquency and mental breakdowns in early adult life continues to rise. This Institute could well look into this problem.

There are many other areas that are ripe for investigation that would promise rich and significant rewards in the field of growth and development, including prematures and problems in obstetrics and nutrition.

Currently, the research programs of the present National Institutes of Health are specific-disease oriented; that is, they are concerned with cancer, congenital heart disease, leukemia, and so on. This new Institute might be concerned with developmental problems of the whole individual and his environment, having in mind the preservation of the physiologic reserves, both mental and physical, as they are threatened by disease influences and as they are affected by the processes of growing and developing.

The creation of an institute of child health and human development would provide a council to review and coordinate grant requests for support of teaching and research in these and many of the areas which at the present time are not in the province of any single existing Institute of Health. For these reasons I would like to lend every support for the favorbale consideration of this bill.

The CHAIRMAN. Thank you, Dr. Burke.

I believe that other witnesses yesterday have talked about this problem of prematurity and covered some of the problems in obstetrics. You mentioned one that I think has not been touched on sufficiently here, and that is in the field of nutrition. Would you tell us what, in your opinion, the Institute of Child Health and Human Development could supply in this important field?

Dr. BURKE. Well, the ingredients that make a child grow, basically, are foodstuffs and environmental influences, of which, one is nutritional material, both as they are taken in by the mother who protected the child during the 9-month intrauterine period of life and afterwards. There are any number of puzzling questions that concern pediatricians in terms of what are these right foodstuffs. There is some question as to whether or not we are properly feeding our infants. The question regarding the optimal methods of feeding premature infants, for instance, has been a ripe subject for investigation. Dr. Gordon, who is in the group here today, has been foremost in the field in dealing with this problem.

So that nutrition, dealing with the types of foods and the amounts of foods that constitute the optimal types of nutrition, is, indeed, a very important area of concern to pediatricians. The recent investigations that may associate atherosclerosis and arteriosclerotic heart disease in old age that could possibly relate to infant nutrition is very stimulating.

Although not proven, there is some tantalizing evidence to indicate that food in early life associated possibly with the rich diets that we give our children today, may be taking its toll at the other end of the span, and may be associated with the increasing number of heart attacks and arteriosclerotic heart disease that we are seeing in young men and early adult life.

As I say, these are just questions, but nutrition intimately comes. into the process of continuing change, which characterizes the study of pediatrics.

The CHAIRMAN. In other words, even in areas of planning, you might say that, because of lack of knowledge of proper foods and proper feeding methods, many of the children do not get proper diets, and then later on this is reflected in their lack of growth and development in later years?

Dr. BURKE. I think that is correct, Mr. Chairman.

I think that the "curse" of overabundance is being reflected-I say "curse" in quotation marks, but we need more precise knowledge in terms of what constitutes optimal nutrition, and we have a feeling that, just as excessive nutrition in young adults and the more elderly in terms of obesity is reflected in increased heart disease rates, quite possibly the pediatricians must be dealing with this problem of overnutrition also. At the present time undernutritian, starvation problems, we are fortunately spared in this country to a large degree, at least to the extent that they experience them in the underdeveloped

countries, and in its place we actually have a potential problem of overfeeding.

But just what constitutes optimal feeding and finding the right avenues of estimating proper and optimal nutrition remains a problem. I think that in this area, nutrition will definitely come into our considerations if we are to provide the best environmental situation for growth.

The CHAIRMAN. As you know, we have an Institute which is concerned with allergies and infectious diseases.

What part of that problem in research would this new Child Institute be concerned with, in your opinion?

Dr. BURKE. I think that, here again, without substituting for the very fine efforts made in these particular Institutes, the influence of diseases such as they occur in childhood and their ultimate effects on the growth pattern could be studied. An example, possibly would be asthma. There seems to be an increasing rise in the number of allergic infants that we are called upon to see, and there seems to be a very definite increase in the incidence of asthma.

The causes of this are not quite clear, but I think those in practice recognize that possibly 10 percent, and even higher, of the group of children that they are called upon to take care of have some manifestations of severe allergic disease. Asthma attacks can be controlled and treated by conventional procedures, but at least about 10 percent of asthmatics are not controlled adequately even by the best conventional procedures, and each of these attacks leaves a scar.

The severe effects may not be seen until the adult patient presents the manifestations of emphysema, of lack of resiliency in their lungs in later life.

But I am sure that a good number of these cases had their beginnings in uncontrolled or not completely well managed attacks of asthma. The underlying hypersensitivity nature of the problem, whether it be due to infectious agents or immunological agents, is a subject which could properly be considered.

Each attack of asthma, each attack of severe bronchospasm, may leave a scar which, due to the physiologic reserves that young children have, may permit the child to get along and escape any keen notice until later life, when, as a young adult, they have emphysema.

Mr. ROBERTS. Yesterday, I believe it was Dr. Cooke who testified that we had fallen from 6th place to 10th place in the field of infant mortality in this country; that is, among the advanced nations of the world.

Do you have any opinion as to why that has come about?

Dr. BURKE. I think this is a very shocking and true figure, and I think we need to get more pediatric leadership in terms of attacking the problem. The reasons are probably complex and they deal in no small part with areas, other than basic research, because, actually, I believe our rate has been rising.

We had a drop and then in the last couple of years this figure has risen.

You can check with Dr. Cooke and Dr. Gordon on that, but my impression is that, instead of a continuing rate of decrease which it showed after the first White House Conference, in the last few years this has risen.