Dr. STEINFELD. In fiscal year 1968, the expenditures by the NIAMD alone on digestive disease research and training amounted to a level of $13.3 million. In fiscal year 1970, the level was $12.4 million, a reflection of the overall budgetary limitations throughout the Federal Government.

A special indepth study in 1965 established the total expenditures of the NIH related to nutrition research at a level of $23.8 million. A similar expenditure was made for nutrition research in fiscal year 1968, in addition to an expenditure of approximately $1.3 million for nutrition research training. The estimated expenditure level for nutrition for year 1970 is approximately $23 million, which does not reflect diminished concern with nutrition but rather current Federal fiscal constraints. Despite these constraints, such levels of support are evidence that research and training in the fields of digestive diseases and nutrition are being given a high priority by the NIH.

Beyond these research activities related to nutrition and nutritional disorders, HEW also conducts a program of technical consultation and assistance to States and local communities. Responsibility for this activity has recently been transferred to the newly renamed Center for Disease Control-formerly the Communicable Disease Center-in Atlanta. This transfer was made in recognition of the change in major function of the nutrition program from data collection to technical assistance. The Center for Disease Control has had many years of successful experience in working with States and local areas. It also has laboratory and epidemiological expertise and resources which should help to delimit health problems related to nutrition and to relate nutrition to other aspects of health.

The Department is opposed to the further proliferation of categorical grant programs such as the proposed categorical program of formula grants for community programs to control digestive diseases and nutritional disorders. States are now eligible to include digestive and nutritional disorders within their State comprehensive health services plan under the partnership for health program, where funds are presently allotted to the States by formula to assist in the provision of adequate public health services. Project grants for this purpose are also available under section 314(e) of the Public Health Service Act. In addition, we have high hopes for the enhanced effectiveness of the nutrition program under the aegis of the Center for Disease Control, and look forward to its continued efforts to encourage the development of community programs of digestive diseases and nutrition control.

Certain information activities are proposed in S. 3063 which are already in existence. Realizing the importance of a rapid and effective exchange of information on research, prevention, diagnosis, and treatment of digestive diseases, the NIAMD publishes on a regular basis a highly regarded monthly "current-awareness" publication, Gastroenterology Abstracts and Citations. We submit for the record the most recent issue. This publication contains abstracts of, and bibliographic references to the most recent scientific publications in the field of digestive diseases extracted from the current scientific literature throughout the world regardless of the original language or country of publication, and makes it available as promptly as possible to its

readership. The issues of Gastroenterology Abstracts and Citations, which contain about 1,000 individual references each month, are sent free of charge to over 5,000 physicians and investigators in the field of digestive diseases. This specialized information service is aimed at making available to research worker and practitioner alike the latest findings in the field, important for research, diagnosis, treatment, and prevention of diseases of the gastrointestinal tract; this information activity is the only one of its kind in the world and has consistently received high praise from the community of physicians and scientists using it.

(The information referred to may be found on p. 133.)

Dr. STEINFELD. In addition, NIAMD disseminates widely an annual summary of the latest advances of grant-supported research in digestive diseases as well as specialized lay information material in

this area.

The NIAMD and the National Institute of Child Health and Human Development contracted with Vanderbilt University for the preparation of a Guide to Nutrition Terminology-a thesaurus of nutrition terms-the first indispensable step toward establishment of an orderly and useful current-awareness publication effort in the field of nutrition; this useful aid to nutrition research will be published in the next few weeks. Here again the assistance and advise of experts from the United States and abroad have been obtained to make this future information activity as successful as the ongoing one for digestive diseases.

Realizing the importance of good nutrition for the American people, the NIAMD is distributing annually many thousands of its very popular booklet Facts About Nutrition which provides clearly presented nutrition guidelines for everyday situations as well as for special conditions such as pregnancy and lactation, infancy, old age, and obesity.

Mr. Chairman, your committee is as well aware as we are of the constant pressure for the establishment of new national institutes at the National Institutes of Health, with each group identified with a particular disease or group of diseases preferring to have a distinct national institute in Bethesda devoted exclusively to its field of interest. Unquestionably, the establishment of a separate institute for digestive diseases and nutrition science would be satisfying and encouraging to those concerned with these fields. It is easy to foresee, however, that following the successful passage of legislation to establish a National Institute of Digestive Diseases and Nutrition, there will be proposed similar bills, each devoted to other organs of the body or to other specific diseases. In fact, several such bills have been introduced within the last 2 years.

This is neither a desirable nor an effective way to conduct and support research into the health problems of the Nation. Indeed, the proliferation of new institutes for each of many program areas desiring such status could have a devastatingly harmful effect on medical research in the United States. Clearly, this process is inefficient, further fragmenting the resources of the National Institutes of Health in a time of fiscal and personnel constraints throughout the Federal Government.

Under the present organization of the National Institutes of Health, research and training in a related group of diseases, for example, cancer or heart disease, are the responsbility of one Institute. So, too, the National Institute of Arthritis and Metabolic Diseases presently interrelates a reasonably natural grouping of the major chronic and debilitating diseases affecting a major segment of the population. This arrangement at the NIH permits flexibility to allocate funds within an Institute appropriation to capitalize most effectively on emerging and unexpected research opportunities.

Further fragmentation into smaller, more highly specialized national institutes will result in greater administrative overhead for dealing with each disease or organ system, but will not necessarily stimulate better or more productive research devoted to the particular field. Actually, a considerable financial expenditure would result from the unnecessary and costly duplication of existing administrative structures and facilities. We estimate the additional administrative cost associated with the establishment of this new institute to be over $1 million. Equally important would be the need to duplicate experienced scientific and science-management staff, the supply of which is extremely limited.

We doubt seriously whether the establishment of a new and distinct National Institute of Digestive Diseases and Nutrition would enhance the current effectiveness of the attack now being carried out on the problems of digestive diseases and nutrition. This current, coordinated attack allows utilization of a broad base of skilled manpower and technical resources of the NIAMD-and in the case of nutrition, from other National Institutes as well-which could not be assembled under a single new Institute without seriously weakening existing organizations. Furthermore, these efforts are being conducted within the framework of well established and organized management and operational systems which would have to be developed and perfected de novo if a new National Institute of Digestive Diseases and Nutrition were to be established.

Mr. Chairman, we are neither disinterested in, nor unsympathetic to the major problems posed by digestive diseases and nutrition, nor to the case which is made for establishing a National Institute for them. Digestive diseases, as you have indicated, are among the most important health problems: 13 million Americans suffer from digestive diseases, including, e.g., peptic ulcer, colitis, hepatitis, and cirrhosis of the liver, and an estimated $8 billion per year is lost to the nation's economy as a result of these conditions.

Nevertheless, we believe that it is essential that we find some other satisfactory means of giving recognition to these and other important disease problems, other than the creation of new institutes at the National Institute of Health. Elevation of organizational status is not a solution; no mere change in organizational form will cause a research area to flourish. Such a change does not provide an assured solution where the main problems are trained manpower and good research ideas. The broader nature of the problems in digestive diseases is illustrated by the fact that presently available research training opportunities go unfilled. Substantive scientific and technical problems in the diseases and conditions themselves represent addi

tional impediments to more rapid progress. Undoubtedly, current Federal fiscal constraints pose additional impediments. None of these impediments is eliminated by creation of a new institute.

Two recent actions provide some indication of our concern for these important fields. On September 1, Dr. Nathan Smith, professor of pediatrics at the University of Washington School of Medicine will assume full-time duty as special assistant to the Assistant Secretary for Health and Scientific Affairs for Nutrition programs. Dr. Smith will be an important addition to the health staff of HEW, and he will provide a needed focus for analysis and evaluation of nutrition programs and proposals.

In addition, an associate director for digestive diseases and nutrition will be designated in the National Institute of Arthritis and Metabolic Diseases to facilitate increased attention to research and training in this field at NIH.

If I might depart from my prepared statement for a moment, Senator Yarborough and Senator Dominick, we are aware of the problems of not highlighting some of the most important diseases, and not having a coordinated program and focus in the Federal Government. We have., in the last year, been trying several different mechanisms for providing this focus short of establishing new institutes with the attendent administrative and financial charges.

The proposed associate director for digestive diseases and nutrition, who will provide a focal point for these important areas within NIAMD, will review the status of the field and make recommendations for additional activities, where they seem appropriate.

Our goal is to try new administrative procedures and to report back to the Congress where these new techniques are successful and can be successful substitutes for what we feel to be unnecessary bureaucratic duplication.

In conclusion, let me reiterate that the Department is in complete sympathy with the basic objectives of this proposed legislation-to promote research and training and community service in the fields of digestive diseases and nutrition. We feel, however, that adequate authority and an effective mechanism for their achievement are already available and functioning. In these times of fiscal constraints, we recommend against the added burden of establishing a new National Institute for Digestive Diseases and Nutrition at the National Institutes of Health. We, therefore, recommend against enactment of S. 3063.

Thank you. Dr. Sherman and Dr. Whedon and I will be pleased to attempt to answer any questions.

The CHAIRMAN. Dr. Steinfeld, on pages 4 and 5 of your statement, you say that in fiscal year 1968 expenditures on digestive diseases research and training amounted to $13.3 million and in fiscal 1970 the level was $12.4 million. That is a vast decline not merely in round dollars of about 13, some 7 percent, but also due to the inflation; what would you estimate that reduction to be--20 percent ?

Dr. STEINFELD. I do not know what percent inflation would account for, but there is no question that the Federal Government's distribution of funds, not only for research and training has been changed in the last few years as we have moved through Medicare and Medicaid into the payment for health services. I believe that medical

schools and certain people conducting research are now subsidizing certain of their activities utilizing health service funds, rather than research funds as has been the traditional technique in the past.

The CHAIRMAN. In other words, since Medicare and Medicaid, in the area of training of medical personnel and paramedical personnel, the Federal Government's contribution has declined in total purchasing power. Is that what you are saying?

Dr. STEINFELD. I was at the University of Southern California in hematology and oncology, and as the research funds for these fields declined, we found funds from other sources to train people in hematology and oncology. What I am saying is that I think the faculties of medical schools are quite right to do this to make use of funds which are available. However, this is not the ideal way.

I agree with you but I think the figures per se may not accurately reflect what is going on in the country.

The CHAIRMAN. Do you mean the figure is inaccurate?

Dr. STEINFELD. These figures are accurate as they are.

The CHAIRMAN. Do you mean they are getting more out of $12.4 million in 1970 than $13.3 million in 1968?

Dr. STEINFELD. They may be utilizing other funds to carry out the same activities. We do not have a good system for determining the exact level of training.

The CHAIRMAN. I have sent out an appeal to the medical schools of the country to admit 10 percent more students or, if they can't admit 10 percent more, to ask them what additional percentage they could admit. I thought they might come back and say 2, 212 or 5; but thus far there is not a single school that said they would admit one more medical student. Each of these medical schools exist principally on Federal funds.

In the State of the distinguished senator who is sitting here with me, Senator Dominick, the percentage of physicians relative to people is 22 percent higher than the national average. They are in much better circumstances than my State, but even then there are some counties in Colorado without a doctor, as is also true in my State.

I will yield to the distinguished Senator from Colorado. Senator DOMINICK. That is because of our clean Rocky Mountain air and spring water which makes the best beer.

The CHAIRMAN. That is not what they have told me.

Dr. STEINFELD. I agree with you that we have a shortage, and I think we need more than a 10-percent increase in medical students. I think we need considerably larger increases in students and at the same time we need to improve our systems for the delivery of health

care.

The other thing we must do is that we cannot keep on doing business the same old way. We have to figure out new ways to support medical education whether it be having two classes per year, to have classes year-round, or to alter the traditional technique requiring a lot of duplicative laboratory courses in the first 2 years. We have a problem and we have to take a look at the total picture. If we continue to support the schools in the same old way, it is going to be extremely expensive and an extremely long time before we can solve our physician shortage. We agree something has to be done. We have to look at the total picture and attempt to make changes taking advan