in many branches of government, but you can't abolish government because some branch is inefficient. The problem is to step up the efficiency of that branch.

Dr. FORDTRAN. I agree with that.

The CHAIRMAN. Your overall problem-government, industry, education, everything-the problem is built-in inefficiency because vast operations and a lot of people.

To me, the fact that you have some overhead does not mean that you kill the plan, kill the building, kill the research. You just fight for efficiency.

Senator Dominick.

Senator DOMINICK. I don't think I have any questions. It seems to me Dr. Fordtran has made a very forthright presentation of his position, and it seems to fit pretty well what Dr. Steinfeld said.

I have no further question or comments.

The CHAIRMAN. Our next witness is Dr. Nicholas C. Hightower, vice president, American Gastorenterological Association. Scott and White Memorial Hospital, Temple, Tex.

Dr. Hightower, we welcome you to the committee and we appreciate your patience in taking the witness stand after the hearings were supposed to have been over.

I note that there are attachments to your prepared statement. Those documents will be incorporated by reference. You may proceed, Dr. Hightower.

STATEMENT OF N. C. HIGHTOWER, M.D., PH. D., PRESIDENT-ELECT, THE AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Dr. HIGHTOWER. Mr. Chairman and members of the subcommittee, I appear before you today to speak on behalf of establishing a National Institute of Digestive Diseases and Nutrition within the National Institutes of Health. Legislation to create a National Institute of Digestive Diseases and Nutrition has been introduced by the chairman of this committee. My name is Nicholas Carr Hightower, Jr., and I am a doctor of medicine and a doctor of philosophy in physiology having obtained by degrees from the Medical Branch, University of Texas, Galveston, Tex., and the University of Minnesota, Minneapolis. I am the director of the Division of Research and Education of the Scott and White Memorial Hospital Foundation in Temple, Tex. My professional specialty is gastrointestinal physiology in which I have been engaged for over 20 years. My research activities during these years have been almost exclusively concerned with problems of digestive diseases and nutrition.

I am here today representing the American Gastroenterological Association of which I am currently president elect. The American Gastroenterological Association is the oldest professional specialty organization in the world, having been founded in 1897. It currently has a membership of approximately 1,000.

Mr. Chairman, I propose to limit my remarks to problems of digestive diseases and specifically to the role that a National Institute of Digestive Diseases and Nutrition could play in resolving some of the important problems that are facing this Nation today. Others here today will speak to the importance of such an institute to resolving nutritional problems.

DEFINITION OF DIGESTIVE DISEASES

Digestive diseases are disorders of the stomach, intestines, biliary passages, liver and pancreas. The causes of a few digestive disease are known and include cancer, alcoholism, genetic defects and reactions. to life stress. However, we do not know the etiology or cause of most of the major digestive diseases. In less time than is required for me to read my prepared statement today, seven Americans will have died 137 Americans will have gone to the hospital and 23.6 million dollars in economic loss will have occurred; all as a result of digestive diseases.

DIGESTIVE DISEASES AS A NATIONAL PROBLEM

A few years ago the officers of the American Gastroenterological Association became concerned by the lack of public recognition of the impact of digestive diseases on the Nation's health. In February of 1967, the association sponsored jointly with the National Institute of Arthritis and Metabolic Diseases and the Digestive Disease Foundation, a conference on digestive diseases as a national problem. This meeting was held at Bethesda, Md. There, for the first time, representatives of industry, government, health agencies, the Armed Forces and scientific and educational organizations met to bring together, from many sources, accurate facts on digestive diseases. Many data were supplied by the National Center for Health Statistics. As a result of this meeting, the American Gastroenterological Association in 1967 published a monograph entitled, "Digestive Disease An Unrecognized National Problem *** a Report in the Public Interest." This document is attached to my prepared statement as appendix I.

Mr. Chairman, I would now like to provide the committee some data which vividly reveals the national problem that this Nation faces as far as digestive diseases are concerned.

The magnitude of the problem of digestive diseases is great for they account for one out of every six illnesses in the United States. In addition

1. Digestive disease chronically affects 12,800,000 Americans; 2. Digestive disease hospitalizes 5,100,000 Americans each year-more than any other category of disease;

3. Digestive disease accounts for 17 percent of all hospital admissions each year;

4. Digestive disease in the acute form, as infectious diarrhea, is the most common sickness in our army in Vietnam.

The disability caused by digestive diseases is staggering for it ranks second among all diesase categories as to cause of disability due to illness.

1. Digestive disease is responsible for 300 million man-days away from work each year.

2. Digestive disease prevents 190,000 Americans from working each day.

3. Digestive disease is the leading cause of disability due to illness among male employees of major industries accounting for one-fifth of such illnesses.

4. Digestive disease is one of the leading causes of noneffectiveness in the U.S. Armed Forces.

The mortality from digestive disease is also great for it causes more deaths from cancer than any other category of disease.

1. Digestive disease is a primary cause of 163,000 deaths each year in the United States, a contributing cause of 89,000 more.

2. Digestive disease is responsible for 31.4 percent of all cancer deaths.

3. Digestive disease kills four times as many people as do automobile accidents each year.

The cost of digestive disease to the United States is tremendous and currently represents 1 percent of the gross national product each year or currently approximately $8 billion.

1. Digestive disease ranks third among all disease categories as a cause of economic loss.

2. Digestive disease costs a single large corporation $12,222,222 each year in disability benefits.

3. Digestive disease is responsible for the loss of $1 billion each year due to peptic ulcers alone.

4. Digestive disease's greatest impact is on middle-aged men and women, breadwinners, taxpayers, the heads of families.

The CHAIRMAN. I don't want to belabor this point. You say less than one-fourth of 1 percent of the 300,000 physicians in the United States are certified specialists in digestive diseases. How many are specialized in cancer?

Dr. HIGHTOWER. There is no recognized specialty in cancer, Senator Yarborough.

The CHAIRMAN. How many in heart disease?

Dr. HIGHTOWER. I don't have the exact figure, but I would suspect it is three or four times the number in digestive diseases.

The CHAIRMAN. How many of these physicians are certified specialists in different diseases, if you add up all of the specialists? Some are specialists of the eye, and throat and chest. If you add up all of the specialists, how many would there be?

Dr. HIGHTOWER. Probably 15 to 20 percent of the total physician population, because the growth in certification has grown rapidly in the past ten years.

The CHAIRMAN. You now even have a specialist in family practice? Dr. HIGHTOWER. That is the most recent one.

The CHAIRMAN. I agree with you that it is amazing to have so few, because some new diseases have been recognized; but people have recognized diseases of the stomach for a long time.

Dr. HIGHTOWER. A measure of our national effort.

The question was asked, 'How great is this Nation's manpower to deal with the problems of digestive diseases?" The following facts were uncovered:

1. Less than one-quarter of 1 percent of the 300,000 physicians in the United States are certified specialists in digestive diseases.

2. Medical schools have, on the average, less than three full-time teachers of digestive disease compared to six cardiologists. Some medical schools have none.

3. No national programs, governmental cr private, encourage young physicians to specialize in digestive disease.

4. One digestive disease research trainee is supported by the National Institutes of Health for every eight trainees in heart disease.

Mr. Chairman, now let us look at the national and other efforts that have been brought to bear on the problems of digestive diseases. The effort in terms of dollars expended has, indeed, been inadequate.

1. Federal support for digestive disease has been less than $30 million annually compared with $111 million for cardiovascular diseases. 2. Digestive disease is responsible for 16 percent of illnesses in the United States but has received only 5 percent of National Institutes of Health research support.

3. The National Institutes of Health intramural programs supports only one full-time physician scientist in digestive disease as compared to 95 assigned to the Heart Institute.

4. There is no large public philanthropic foundation which has digestive disease as a major interest.

5. There is little support from industry for digestive disease. The pharmaceutical industry is concerned primarily with applied drug research. Industry, suffering great absenteeism, provides none. Disability insurance companies provide none.

Mr. Chairman, the above data are only a brief summary but they indicate the magnitude of the problem of digestive diseases and clearly show the inadequacies of both manpower and dollars expended. The facts that I have just presented were summarized by the Digestive Disease Foundation in a brochure which is attached to this prepared statement, as appendix II.

THE COMMUNIST APPROACH

It is interesting, Mr. Chairman, that in some of the communist countries, the national problem of digestive diseases and nutrition have been recognized and great efforts are being exerted to cope with them. I had a recent opportunity, as a visiting scientist, to personally inspect the major institutions in Czechoslovakia and the Soviet Union that are concerned with digestive disease and nutritional problems. In Prague, Czechoslovakia, there are a group of institutes somewhat similar to our National Institutes of Health. The Institute of Digestive Diseases and Nutrition was the largest, one of the best equipped and there was no shortage of professional and technical staff. In the Soviet Union, the new Institute of Gastroenterology in Moscow which was opened less than 2 years ago is probably the finest institute in that country.

I was impressed by the fact that the Soviet Union had established special polyclinics and spas to deal exclusively with digestive diseases and nutritional problems. In these clinics and spas, patients are instructed in dietetics and preventive measures. Although it was obvious that the technology and facilities available and the methods of therapy used are far inferior to those available in the United States, one could not fail to recognize that these two countries were exerting a major national effort with the capabilities available to deal with the problems of digestive diseases and nutrition.

The CHAIRMAN. I was in Tashkent last fall. At the University of Tashkent they had 15,000 students and 7,500 of them in the medical school. Their ratio of doctors, of course, per 100,000 population is about double ours now. They have not finished educating enough doctors. When they finish in another 5 years they will have at least twice as many doctors for 10,000 population as we have.

Senator DOMINICK. Maybe that is because under communism they have more sick people.

The CHAIRMAN. It could be. We don't have data on that. We have studies here and we received their publications. They are pretty hardy people, though.

Dr. HIGHTOWER. I would now like to address myself to the role that a National Institute of Digestive Diseases and Nutrition could play in overcoming the great losses in lives, health, and dollars this Nation suffers due to digestive diseases.

A separate Categorical Institute within the framework of the National Institutes of Health would provide a physical symbol that the Congress and citizens of this country could identify with. It would stand as a monument to the fact that our Government had identified a national problem and would symbolize to the citizens that something was being done to resolve the problem. It would extend the legal and philosophical reasons that initiated the National Institutes of Health being created.

I cannot state it better than Dr. Robert Marston when he recently appeared before the Subcommittee of the Committee on Appropriations, House of Representatives, 91st Congress, 1st Session, Subcommittee on Department of Labor and Health, Education and Welfare and Related Agencies when he said:

Effective action against disease requires, first of all, a knowledge of what is wrong and availability of some means of doing something about it. In general, the better our understanding of the cause and usual course of disease, the more likely it becomes that we will be able to develop some means of coping with it, that, in essence, is the purpose of biomedical research: the constant expansion of knowledge and its translation into applicable preventive or therapeutic methods.

The record of several of the institutes makes clear that these broad purposes are accomplishable. I believe that the same would be true for a National Institute of Digestive Diseases and Nutrition.

In a recent editorial, published in Gastroenterology (vol. 58, No. 6, June 1970, p. 898 (app. III)), Dr. Thomas P. Almy of Dartmouth Medical School clearly points out the potential accomplishments we might expect from such an institute.

1. The council in each of our national institutes has the authority and responsibility to investigate broadly the means by which needed health manpower can be developed. A categorical institute can and does directly influence the supply of trained manpower in its field and in a number of ways which go far beyond the familiar graduate research training grant. It can develop categorical undergraduate teaching grants for medical schools under which the quality of teaching can be raised to a level comparable with that in other fields.

If deemed sufficiently important by the Council, the shortage of properly trained clinical specialists could also be directly attacked as it has been in the National Institute of Mental Health to supply this Nation with needed psychiatrists. In this country today, there are less than 2,000 doctors who indicate a special interest in, or have had special training in, the field of digestive diseases. In the field of gastrointestinal physiology, which I represent, there are probably less than 50 of us in this country. Many of our medical schools have no one on their faculty who has had training in gastrointestinal physiology.