Page images

and Senate Appropriations Committees on several occasions directed the National Institute of Mental Health to come up with 5-year training projections specifically related to the burgeoning demands for psychiatric manpower.

This leads me to a related question which I believe is of considerable interest to this committee. I am somewhat mystified at the number of articles and editorials in professional journals excoriating the concept of “directed research." I am confident that underlying the resistance to this term is the still fairly pervasive view that most, if not all, significant research is accomplished by a single inspired investigator in a garret or a basement. By a strange piece of extrapolation, you then add the individual efforts of all the occupants of the garrets and the basements and you have a significant end result in terms of accomplishment.

The proponents of serendipity point to Sir Alexander Fleming and the mold which killed the bacteria on the petri dish, but they forget that a team effort 20 years later at Oxford University under Florey and Chain first proved penicillin's clinical usefulness, and our agricultural laboratories in Peoria first manufactured it on a scale wide enough to save the lives of thousands and thousands of people. As you all know, the work of Enders, Salk and Sabin in the development of polio vaccine is of like nature; that wonderfully goal-directed

gentleman, Basil O'Connor, president of the National Foundation, was the financial catalyst because he had a distant objective in mind.

The short but exciting history of the National Aeronautics and Space Administration is an illustartion of this point. I have my doubts—and so do many members of the scientific community—that the American people would have supported a broad program of basic research under the amorphous umbrella of space technology. However, the specific goal of landing a man on the moon by 1970 has excited our good citizens, and I presume they are satisfied to pay taxes on the order of $5 to $6 billions a year in support of that and related enterprises.

It is tragically ironic that some leading spokesmen for the National Institutes of Health reflect this blue-nosed aversion to practical goals in the fields of human health and welfare. In a number of opinion polls taken over the past few years, the American people have responded overwhelmingly in favor of additional moneys for expanded national endeavors against heart disease, mental illness, cancer, and the many other killers and cripplers of our time. The Congress, in response to these expressed wishes of the people, has over the past two decades created categorical Institutes devoted to comprehensive attacks upon specific diseases. In answer to the pure scientific breed who have decried this vulgar, categorical approach, the noted surgeon Dr. Michael E. DeBakey asked his fellow panelists at a recent symposium to cite a single example of a patient who had died of a non-categorical disease.

Although our goals in the health field are apparent and manifestthe reduction of disability, the prevention of premature death and the prolongation of the prime of life—we are exceedingly timorous in announcing our aspirations. This leads to our failure to emulate the examples of the Department of Defense and the Space Agency in enlisting industry and other segments of the economy in large-scale research contract and development programs. To a limited degree this contract mechanism is being used at the National Cancer Institute, but in most of the other Institutes we still bow to the dominant thinking of most of the medical schools and universities in canonizing the individual project application from that legendary investigator in a drafty basement.


This reluctance to deal forthrightly with the alleviation of human suffering as the major goal of medical research leads inevitably to the prolonged but not very profound debate now going on between the so-called polarities-basic research and applied research. I am not saying that pursuit of knowledge for its own sake is not a laudable and important objective-as important, say, as the enterprise of the explorer who climbs a high mountain just because it is there. However, I do insist that successive Congresses established the various Institutes which support both basic and applied research with the objective in mind that even the most fundamental research be eventually applied wherever possible to the condition of man.

To illustrate this point that the dichotomy between basic and applied research is largely an artifice, may I refer again to the programs of the National Institute of Mental Health ? Although I have been somewhat critical of the lack of planning during the early years of the Institute, I am proud of the fact that its programs have been continually oriented to the core problem of the mental patient.

At the present time, for example, the NIMH operates the largest program in the country in the evaluation and screening of psychiatric drugs. When a new drug is introduced on the market, we can quickly put it through a 15-hospital screen to determine its effectiveness and its comparative value in relation to previous medications. Now the purists will argue that we are involved in a relatively unsophisticated operation which is outrunning our basic research knowledge in the field of pharmacology. It is true that we don't know the precise mode of action of many of the drugs, any more than we know why insulin acts so effectively in diabetes. However, we work on the premise that we have a bounden duty to apply the best, although admittedly imperfect, results of medical research to our target goal—the mental patient.

Operating upon the same pragmatic premise, we support each year some $20 million in pilot projects designed to test and evaluate new sociological ways of handling the mental patient either in the hospital or in the community. Again, these are programs which do not solicit much enthusiasm from the purists, but they have opened the way to day hospitals, night hospitals, psychiatric units in general hospitals, health insurance coverage of the mentally ill, and so on.

In the administration budget for the coming fiscal year, President Johnson allocates $100 million to the National Institute of Mental Health for training grants. The bulk of these moneys will be granted to universities, medical schools, and hospitals for the training of thousands of desperately needed psychiatrists, psychologists, social workers, nurses, and ancillary personnel. More than $10 million of the aforementioned total will be allocated to short-term refresher courses designed to provide the general practitioner and his nonpsychiatric colleagues with sufficient knowledge so that they can do an effective job in handling the many patients who come to their office with either undisguised or disguised psychiatric complaints. Again, this is a pro


gram which will not win an achievement award from the classicists of the scientific community, but according to a recent issue of the Journal of the American Medical Association, it has made psychiatry the most sought after continuation education program among the physicians of our country:

At previous hearings of this committee, concern has been expressed that clinical application of research findings sometimes runs beyond precise knowledge of the etiology of a specific disease. I don't think I have to remind members of this committee that the modern history of medicine-from the day almost two centuries ago when Jenner first applied a smallpox vaccine to James Phipps—is replete with examples of successful preventive agents against diseases used without a precise delineation of all the causative factors involved.

It may well be that the Salk vaccine was an imperfect agent when it was applied in 1955, but elaborate field tests conducted by Dr. Thomas Francis prior to its use had indicated that it could reduce the incidence of paralytic polio by a considerable percentage. In actual fact, between 1955 and 1962, it saved 154,000 people from being paralyzed. Additional research produced the more effective Sabin vaccine; its widespread application, combined with the earlier advances achieved by the Salk vaccine, has practically eliminated polio in this country.

There are many additional illustrations of successes along the lines of the polio vaccine, but there are many more examples of needless deaths occurring because of a mystifying reluctance to insist upon immediate application of effective preventive procedures. For example, the President's Commission on Heart Disease, Cancer, and Stroke concluded that cancer of the cervix could be almost totally eliminated if the "Pap" diagnostic smear was universally applied to women-at-risk, but in actuality, it is only available to about 20 percent of these women. In another area, a prophylactic antibiotic procedure administered to those who had suffered rheumatic fever was hailed as a major preventive agent against subsequent rheumatic heart disease, but only a small percentage of rheumatic fever victims were actually placed on continued antibiotic medication.

In summary, I believe that the aforementioned data, plus much additional material which cannot be cited for reasons of time, underline the central contention of this paper that overall health planning is achieved only rarely in the present structure of the National Institutes of Health. A major difficulty stems from the fact that the original statutes creating the various National Institutes of Health did not specify longrange planning as a responsibility of either the Advisory Councils or the respective Institute staffs.

I would therefore suggest to this committee that it might consider very carefully the advisability of recommending an amendment to the basic Public Health Service law which would encourage and empower the Institutes to develop long-range plans against the various diseases falling within their purview. The actual language might be similar to that contained in the comprehensive health planning bill of 1966 (Public Law 89–749) which, for the first time, empowers the Surgeon General of the Public Health Service to formulate national health goals.

Secondly, I would require the various Institutes to submit to the executive branch and to the Congress 5-year projections and justifica

[ocr errors]

tions in all research, training, and demonstration areas. Beginning in 1966 the Bureau of the Budget recognized this need when it based its annual review of each program upon a 5-year projection which properly required not only an end goal, but detailed justifications of intermediate steps, including the personnel and funds necessary to achieve that end goal. Such a mechanism, regarded now as quite desirable inside Government channels, should be extended to publicly announced projections available to the Congress and to the American people.

As a direct consequence of these recommendations, the NIH Advisory Councils would devote the major portion of their time to this very necessary planning. I am fully aware that there will be considerable resistance to this from the traditionalists who will cite the past 20 years of searching individual examination of each project, but I repeat that this is not the major function of a council, which must advise the Surgeon General on a broad spectrum of plans.

As those of us who have served on Advisory Councils know-and this is my second term on the NIMH Advisory Council-we do not have limitless amounts of money to pour into research, training, and other areas. We must therefore become highly selectivewe must identify emerging problems which can be tackled, and then place our major bets in these areas. When we do this, we will be serving the American people much better than we are doing now.

In conclusion, Mr. Chairman, may I commend this committee for permitting us to ventilate some of these issues ? Speaking for myself alone, this kind of public forum is a most welcome contrast to private and frequently futile efforts to start a meaningful dialogue with Government officials as to the real responsibilities and functions of the NIH Advisory Councils.

Senator HARRIS. Thank you, Mr. Gorman. I appreciate your testimony and your specific recommendations.

On this National Advisory Council on Mental Health, what sort of time is required on Council business from its members ?

Mr. GORMAN. We meet a minimum of three times a year for 3 days each time; that is about it. It runs 9 days. But I would say that actually we devote an additional five times that amount of time. I figured it out arithmetically because my wife forced me to do it. When she saw me getting through with papers at 2 o'clock in the morning, she asked, “What are you doing?” I had to answer, “Doing applications." So it is a ratio of about 5 days to 1 that we have to spend in advance of each meeting on individual applications. So actually, even though we do this advance review, I feel, Mr. Chairman, too much time in the past has been devoted to individual project review. Too much time is required for that.

Senator HARRIS. Without enough of the overall goals?
Mr. GORMAN. Right.

Senator HARRIS. What sort of remuneration is there for people who serve on this Council ?

Mr. GORMAN. $50 a day for the actual time. We do not get paid for the homework we do; the time we neglect our children, our gardens, and our wives we do not get paid for.

Senator HARRIS. How would your suggestion about the planning aspects and also your statements about 5-year plans fit in with what Dr. Glaser and I were talking about a while ago? We were talking


about a planning approach that was not restricted to health as such, but was Government-wide in its application. Maybe it could be developed around stated 5-year research and development goals. This planning process would be repeated, I am sure, each year and would reflect new needs and possibilities. Do you think there is any merit in that, or would it be too cumbersome for Government-wide application? Do you have any comment on it generally?

Mr. GORMAN. Are you suggesting, Mr. Chairman, a Governmentwide mechanism or just a Government-wide approach?

Senator HARRIS. I am not thinking so much about a mechanism. For example, what we were talking about earlier, and I think you heard the testimony, was that each year the various agencies will be looking for people to accept grants and contracts in research and application. I agree with you that I think we have spent a lot of time in this hearing and in the conference in Oklahoma arguing over a division which is not nearly so clear cut as some of us would think.

Mr. GORMAN. Yes.

Senator HARRIS. But in both fields, generally, what if we had each agency and department say, "Here are our 5-year goals, and this year we are interested in these kinds of things; these are the greatest deterrents we see to the accomplishment of our 5-year plan, or this year's plan”? If that were somewhere generally available, a fellow-suppose he is a physicist—could in some way get access to that kind of information about our needs. He might elect to make a proposal which otherwise he would not do. That same central agency might help him get in touch with the one or more agencies who might be willing to fund his idea for an investigation or for a demonstration.

It seems to me that is tied in with your concept, perhaps even might strengthen it. That is, it would make us plan, it would make us particularize immediate goals, and this would apply to basic knowledge as well as applied knowledge. Also, it would perhaps uncover additional investigators working in a particular field.

Mr. GORMAN. Yes. I think, if I may answer it in this way. In the field of heart disease, where you have the development of the artificial heart, you want your engineers, your physicists, and so forth, to know about it. But we have problems in the mental health field where it seems we could have called in people from the outside to work with us. If we had announced our intentions, had made them clear, and had some central agency from which this could be announced, more of the right people from outside would have been involved.

Now, the most basic example I can talk to is that we are always seeking additional trained manpower, but within our own narrow spectrum. We do not go beyond it, and it is a great failure. All of a sudden, we build mental health centers, or we need somebody to man the alcoholism programs, and all of a sudden, we find that we have not made any plans for training them. We do not go outside of our own spectrum, and it is a great limitation.

I think second, if I may say so, and it also came out in Dr. Glaser's testimony this morning, because over the years we have devoted too much support to individual projects, we cannot draw the deep breath and use the contract mechanism the way it could be used. We do not tap the potential resources of industry. There is no doubt in my mind

« PreviousContinue »