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In this country, we find the major origins are from alcohol and insufficient diet.

Senator DOMINICK. So, the recent bill we have reported out in drug abuse and alcohol should be of assistance in this area?

Dr. STEINFELD. You are correct; that is another relationship that should be supported in this broad area.

Senator DOMINICK. It is my understanding at least that Dr. Egeberg on a previous occasion has expressed his support for the establishment of a separate institute. Is that accurate, and would you comment on it?

Dr. STEINFELD. I discussed this with Dr. Egeberg as recently as last Friday afternoon, and it is his feeling, as it is mine, the best thing to do is not to proliferate institutes but to highlight these research and training areas through other mechanisms, through the appointment of a special associate director in NIAMD who would have cognizance of this area, and the appointment of an individual in our own office who would look at nutritional problems. I think we would like to coordinate and facilitate research and highlight it and related training programs by means other than this very expensive proliferation of institutes. We are in agreement on the approach which has been described this morning.

The CHAIRMAN. Dr. Egeberg is in agreement with you on this? Dr. STEINFELD. Yes, sir, we had a long discussion Friday afternoon and Friday evening on this.

The CHAIRMAN. I have not talked to Dr. Egeberg about this, and one reason I was pushing this so far in the closing days was that I had been told by people of very high stature in the medical world that Dr. Egeberg supported it. I felt that this late in the game the only opportunity we had to pass the bill through both Houses was to have his support. I was not going to ask the question on hearsay here, but since Senator Dominick brought it up, I make that comment.

Dr. STEINFELD. Dr. Egeberg and I both feel, as I am sure you do, that gastrointestinal diseases are extremely important, and we must have a way of highlighting them. The two new things we are doing are designed to do that-we are not saying we have done everythingbut we are appointing a new associate director for NIAMD and a special assistant for nutrition in our own office. These are the mechanism we hope will accomplish the same purposes which you want to accomplish without all of the additional bureaucracy and expense required for a new institute.

The CHAIRMAN. Thank you. I have no further questions, Dr. Steinfeld. Thank you very much for your contribution here. We have ranged far afield this morning.

I have one more question concerning age and cancer. Is it true that cancer is the number one killer of children between 1 and 14 years of age?

Dr. STEINFIELD. Yes, I believe I mentioned earlier acute leukemias and some other rapidly growing tumors are the number one killers. I would like to say, in addition, that the cancer chemotherapy programs involve the use of drugs that are most useful in these rapidly growing, rapidly dividing tumors. A number of what we hope are cures have occurred in children with Wilms's tumor, with myocarcinoma, acute leukemia, and some of the others, even when the child

appears to have no evidence of the tumor. So, it is a number one problem; and we do have extremely good leads in the therapy. Prevention is another problem and the viral oncology program is addressing that.

The CHAIRMAN. Again, thank you very much, gentlemen.

Our next witness is Dr. John S. Fordtran, Professor of Internal Medicine, University of Texas, Southwestern Medical School, Dallas, Tex. You may proceed in your own way, Dr. Fordtran.

STATEMENT OF DR. JOHN S. FORDTRAN, PROFESSOR OF INTERNAL MEDICINE, UNIVERSITY OF TEXAS, SOUTHWESTERN MEDICAL SCHOOL, DALLAS, TEX.

Dr. FORDTRAN. Mr. Chairman, I previously wrote an article in opposition to this separate institution for digestive diseases and nutrition which I supplied for the record. I do not plan to outline that today exactly, but I would like to give a summary statement.

The CHAIRMAN. Your statement will be printed in the record, Doctor. Due to the length of time we questioned Dr. Steinfield, we have impinged on the time of the rest of you, so if you can digest your statement, it would be helpful.

(Dr. Fordtran's article follows:)

GASTROENTEROLOGY

Copyright 1970 by The Williams & Wilkins Co.

Vol. 58, No. 6 Printed in USA

ON THE ESTABLISHMENT OF A NATIONAL INSTITUTE OF DIGESTIVE DISEASES AND NUTRITION

We are pleased to present, on the following pages, two points of view regarding the very important question of the establishment of a separate institute in the National Institutes of Health. The outcome of this vital issue will concern us all in the years to come.

MARVIN H. SLEISENGER, M.D.
Editor

The Case Against a Separate Institute

On November 4, 1969, a letter was sent to members of the American Gastroenterological Association stating that "after the introduction of the 'AGA White Paper' in 1967, your organization decided that it was in the best interest of the public if gastroenterology had, together with nutrition, a separate institute in the National Institutes of Health." The letter further stated that Congressman Staggers and Senator Yarborough have introduced in the House of Representatives and in the Senate a bill to establish such an institute. The letter listed the following reasons why such a bill should be supported.

1. A need for research in digestive diseases and nutrition.

2. High level of bed occupancy in civilian, veteran, and military hospitals by digestive disease patients.

3. High work absence rates due to digestive disease and their importance to labor, industry, and public.

4. Other reasons in the White Paper or in Senator Yarborough's introduction to the bill.

This letter to AGA members was pre

Received January 21, 1970.

Address requests for reprints to: Dr. John S. Fordtran, Department of Internal Medicine, Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235.

pared by the Congressional Liaison Committee of the AGA and signed by Hugh R. Butt, Chairman.

In the bill before Congress, reasons for supporting a separate National Institute of Digestive Diseases and Nutrition (NIDDN) were presented. The following is a summary of these reasons.

1. Frequency of digestive diseases; for instance, one-third of all cancer deaths are due to cancer of the digestive tract, and cirrhosis of the liver ranks as the fourth most common cause of death in adults at the present time.

2. Digestive diseases are the leading cause of industrial absenteeism among male employees.

3. The economic loss in this country due to peptic ulcer alone is $1 billion per year.

4. Of all nonobstetrical surgery, 23% is performed for digestive diseases.

5. Education and training of doctors to cope with digestive diseases has lagged seriously. National Institutes of Health (NIH) figures show that 141 trainees in digestive diseases have been helped in their training, compared with 1146 in cardiovascular diseases. The average medical school has only three teachers in digestive diseases, as compared with four in hematology and six in cardiovascular diseases.

6. Digestive diseases receive less than 5% of the extramural research support funds of the NIH.

7. Fewer than 1500 physicians in the country treat digestive diseases as such (presumably fewer than 1500 specialize in digestive diseases).

In spite of the preceding argument, we are opposed to removing digestive diseases from the auspices of the National Institute of Arthritic and Metabolic Dis

eases (NIAMD) and establishing a separate institute. Our reasons are 3-fold. First, we think that the statistics and data presented in the White Paper and in the Congressional bills are irrelevant to the question of how the NIH should support research and training in gastroenterology. Second, there is no evidence that financial support by NIH under current arrangements is rate-limiting to the training of additional academic gastroenterologists. Third, and by far the most important, we feel that the public, the NIH, and gastroenterology would be harmed by the establishment of a separate NIDDN.

Our conclusions are based on the following considerations.

I. The data in the White Paper and in the Congressional bills are irrelevant. A. Of course digestive diseases are important, but even if every figure in the Congressional bills is correct, this has no bearing on whether or not we should have a separate institute or be part of the NIAMD. In our opinion there is only one possible reason to support a digestive diseases institute and that would be if the NIAMD has discriminated against gastroenterology in favor of other subspecialties which it supports. There is absolutely no evidence that this is the case. (The NIAMD even helped to collect the data published in the AGA White Paper.) All of the problems raised by the White Paper and in the Congressional bills can be handled by devoting our energy to getting more support for the NIAMD. B. Some of the figures cited in the Congressional bills may be misleading.

1. Studies on cancer of the digestive tract and hepatitis, infantile diarrhea, cholera, etc., receive support from the National Cancer Institute and the National Institute of Allergy and Infectious Diseases. Are

these and other such examples included in the small amounts alleged to be spent for digestive diseases?

2. Many surgeons in medical schools specialize in treatment of digestive diseases. General surgery is, to a large extent, surgery of the digestive system and thoracic surgeons specialize in diseases of the esophagus. Are these included when ratios of heart, blood and gastrointestinal specialists computed? If gastroenterology is to receive credit for all digestive diseases ($1 billion per year for duodenal ulcer, gallbladder problems, etc.), then we have to count all doctors who take care of these problems.

are

3. The contention that only 141

trainees in digestive diseases are helped in their training by NIH compared with 1146 in cardiovascular disease also may be misleading. These figures apparently are taken from an article by Clifton entitled "Manpower in Gastroenterology" (Gastroenterology 53: 353, 1967), although the numbers are not exactly the same (Clifton's article gives 141 trainees in gastroenterology compared with 1446 in cardiology). Clifton qualifies the data as follows: "The data for support of cardiology by the National Heart Institute are not comparable to those for gastroenterology and hematology, which are funded by the National Institute of Arthritis and Metabolic Diseases. The National Heart Institute supports many training programs whose activities are not limited to cardiology but encompass a variety of related

disciplines." Furthermore, the figure for digestive diseases may be an underestimate, since it does not apparently include surgical trainees, who are usually supported through the National Institute of General Medical Sciences. In another place in his article (p. 356 and figure 7), Clifton states that departments of medicine have approximately 60% as many research trainees in gastroenterology as in cardiology (source of support not specified). C. Although it is impossible to predict from where breakthroughs in digestive diseases will come, some of our major problems such as hepatitis (a viral disease), alcoholic cirrhosis (a sociological disease), and cancer are not likely to be solved by individuals trained in digestive diseases, but rather by research specialists in other disciplines. It is misleading to suggest that any amount of money allocated to an NIDDN would hasten a solution to these important diseases. For such an institute even to attempt to support basic research in virology, cancer, and sociological diseases would create a tremendously wasteful overlap at the NIH.

D. Clifton's article does show that there are twice as many cardiologists as gastroenterologists in the medicine department of the average medical school. However, no evidence has been presented that this is not fully justified, especially since many digestive diseases are treated by surgeons, whereas a relatively small percentage of cardiology problems are handled by surgeons. Furthermore, the amount of teaching and research required on a certain disease is not necessarily related to its over-all frequency in the general population.

II. There is no evidence that the training of academic gastroenterologists is rate limited by lack of financial support. We base this opinion on the following statistics, which we obtained by writing to the NIH. First, as of July 1, 1969, there were 43 active training programs in gastroenterology (not including surgical trainees), with 126 authorized and available positions. However, only 101 of these positions were actually filled. This means that approximately 20% of available traineeships in gastroenterology are not being used. Second, during the past 2 years only five new applications for training grants in gastroenterology have been reviewed by the NIH and all five were disapproved. It is emphasized that these were outright disapprovals, not approvals which could not be supported for lack of funds. The Training Grant Committee is well staffed with gastroenterologists and it must be concluded that no new training grant applications judged to be of high quality have been reviewed by the NIH during the past 2 years (three new applications have recently been received but not reviewed as of December 24, 1969). How can these figures be reconciled with the idea that present NIH support in gastroenterology is grossly inadequate? It should be pointed out that, even if financial support does become rate-limiting, this in itself would not constitute a reason to separate ourselves from the NIAMD and set up a digestive disease institute.

These figures might be used to argue that, since 20% of our available fellowships are unfilled, something is wrong with our ability to appeal to prospective candidates. However, even if this is true, we do not believe that this in any way justifies the establishment of a separate digestive diseases institute. Good men are attracted into gastroenterology mainly through contact with gastroenterologists. We do

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