Dr. WELLS. Approximately $10 million in direct NIH grants; that is, directly to the university, and about a million dollars in contract. Dr. ENGLE. I would like Dr. Wells to comment on our other association in the form of advisory councils and others.

Dr. WELLS. We have broad liaison with the National Institutes of Health by having representation on practically all of the study sections that involve work that is cognate to our program. Then we also have representatives of the chief medical directors on each of the councils. This includes even such things as the councils of regional programs and the research facilities group and so on. So that actually, we are a party to practically all considerations of research expenditure from NIH and take specific note of those that pertain to our hosiptals. Senator HARRIS. Do you have any research programs not financed by the VA or NIH?

Dr. WELLS. About a million dollars in total. You see, we have about $12 million that is non-VA money: approximately 10 in NIH grants, about a million dollars in contracts. This is mainly for the cancer chemotherapy program. Then we have about a million from industry, practically all from the pharmaceutical industry in small grants for projects.

Senator HARRIS. That is the last thing I was going to ask about, contracts for research with industry.

Dr. WELLS. This is practically entirely limited to the pharmaceutical industry and comes along in relatively small grants as a rule to individuals and sometimes to combinations at the medical schools and our hospitals, largely for straight-forward drug trial, but some of it in very basic work.

Senator HARRIS. What about the regional medical program? How does the VA fit into that?

Dr. WELLS. I think perhaps the most exact answer at the moment is we are not quite certain, but we are very closely related to the people who are trying to work this out. In the many grant proposals, planning grant proposals that have thus far been processed by the council, the Veterans' Administration hospitals have been included as a part of the community resources. Veterans' Administration hospital directors, chiefs of staff and others, have been included (I believe I am correct) in the regional planning groups to help.

Senator HARRIS. That is true in Oklahoma.

Dr. WELLS. It is true elsewhere, too, Mr. Chairman. So this has been universally accepted as something that is important from both our standpoint and the standpoint of the regional medical programs and NIH.

The exact working relationship is exceedingly difficult to describe, because actually, the whole planning business has not gone along far enough yet for us to be quite certain exactly what people are going to be doing. You see, there have been only four operational grants that have been issued and these are not actually functioning, yet. So it will be a little time before I think we can describe with any accuracy what our relationship would be.

Senator HARRIS. Would you comment, Dr. Engle, about what you think the research budget might be if the VA were to make an appropriate contribution in the field of medical research? I believe you say now it is 4 percent of the medical budget.

Dr. ENGLE. Yes. Well, this is a hard question to answer with any degree of mathematical exactness. Our present research budget represents 4 percent of the total. In contrast, on another end of the spectrum, the teaching hospital beds of the medical schools are about equal in number to our beds. They represent about 110,000 beds and they utilize about $400 million worth of NIH funds in research effort each year. Now, obviously more than money is involved. They have more people employed who are doing the research.

But it does indicate a hope and a potential for the future in terms of our more optimum utilization of the clinical resources that are available to us.

One other fact that might be mentioned is that there are a good number of requests for pursuit of research projects that are not funded in any 1 year. In a way this is healthy, in that it represents a screening process, with the most desirable project being funded. There are at the present time about $10 million worth of research projects that have not been funded.

On the other hand, as I mentioned earlier, we think that we made orderly process with some growth each year in the last decade in the amount of money that we have spent for research and the number of projects that are ongoing and so forth.

Senator HARRIS. What about manpower development? Does the VA play a role now, or does it have an expanded role to play, particularly in regard to semiskilled health personnel or subprofessionals?

Dr. ENGLE. Dr. Wells has been involved in some deliberations within recent months on this issue. I will ask him to comment.

Dr. WELLS. We have a large number of trainees, Mr. Harris, in all categories. As a matter of fact, we have 53 different categories of health service manpower training in the Veterans' Administration. At the present time, we have approximately 23,000 trainees on duty in these various categories. We have estimated that we could increase this number within our present facilities, present teaching resources, by approximately 14,000, with most of these people being in the technical and subprofessional levels. Obviously, the big shortage is really in the nursing occupations, the laboratory, radiologic, technologists and this class of personnel. We would put our emphasis on this if we are able to fund our programs in the future as we would like.

Now, we are cooperating with the other Federal agencies at the present time, particularly under the various antipoverty programs and under the Manpower Training and Development Act, and are receiving into our hospitals at the moment approximately 4,000 trainees under these various programs, the individual trainee being stipended by the other agency and at least as far as the Manpower Training and Development Act is concerned, they have been authorized to fund the cost of instruction in our hospitals. This is being handled on a completely decentralized State level basis. But it has been a rather successful program and I feel it will definitely increase the number of available health service manpower at the key shortage level, the subprofessional nursing aid and technical level.

Senator HARRIS. Very good.

Do you have anything to add, Dr. Engle?

Dr. ENGLE. No, sir.

Senator HARRIS. Mr. Mason?

83-470-67-10

Mr. MASON. No, sir.

Senator HARRIS. I want to say we are very pleased you are here and we appreciate both your prepared statement and your response to questions-Mr. Mason, Dr. Engle, Dr. Wells.

Dr. ENGLE. Thank you, sir.

Senator HARRIS. Mr. Wright?

Mr. Christopher Wright is the director of the Institute for Studies of Science in Human Affairs at Columbia University. Without objection, we will place in the record at this point a biographical sketch concerning Mr. Wright.

Biographical Sketch: Christopher Wright

Director, Institute for the Study of Science in Human Affairs, Columbia University, New York.

Background Data: Scientist, Manhattan Project Los Alamos, N.M.; Instructor of Philosophy at Williams College; Research Associate University of Chicago Law School; Associate Director, Executive Director Council for Atomic Age Studies at Columbia University; Lecturer in Public Law and Government, Columbia University.

Senator HARRIS. You have a prepared statement, I believe, Mr. Wright. We are very pleased you are here. You may proceed with that or however you desire.

TESTIMONY OF CHRISTOPHER WRIGHT, DIRECTOR, INSTITUTE FOR THE STUDY OF SCIENCE IN HUMAN AFFAIRS, COLUMBIA UNIVERSITY, NEW YORK, N.Y.

Mr. WRIGHT. Thank you, Mr. Harris. I will proceed with my

statement.

At this time it is especially important to assess the adequacy of Federal institutions for biomedical development in terms of the links between the biomedical sciences and man's social and human needs. It is not sufficient and may even be quite misleading simply to regard biomedical developments as a problem of intellectual development, as if the task were to unfold and refine a pre-existing pattern of biological knowledge and apply it in the most obvious manner. Rather, biomedical development is but a part of a more complex and dynamic system of intellectual and institutional relationships. Federal agencies must not, for instance, be regarded simply as a source of support for an otherwise autonomous development and use of biomedical knowledge. They cannot avoid active and knowledgeable participation in the process of selecting new goals, defining new policies, and implementing priorities in and for the biomedical sciences.

Granted that there is as yet remarkably little comprehensive and specific knowledge of this system, it is clearly possible to identify and cope with many of the major problems in this area. Studies of the issues posed by this subcommittee would provide a very valuable beginning. In this presentation I wish to emphasize the need to charge some central public institutions as well as private ones with specific responsibility for conducting continuous and open policy-oriented studies which will result from and lead to practical experience as well as to scholarly wisdom.

Three considerations should govern the present assessment of our Federal institutions. First, the most important new opportunities for

manipulating the interactions between the natural sciences and human affairs now tend to be associated with organizations and activities on a scale involving the resources and responsibilities of the Federal Government. Second, conscious and wise control of these manipulations depends essentially upon social science understanding of the social and political aspects of science. And third, the biomedical sciences are very likely to provide major intermediate links between the physical sciences and human affairs. To be sure, scientific revolutions in the physical sciences and their technological applications have had many quite direct impacts on man and society, but control of these interactions for the benefit of man really depends upon the development and use of relevant biological, behavioral, and social scientific knowledge. Historically, the pure and applied biological and medical sciences have been more closely coupled to each other and to explicit ethical concerns than have the physical sciences and engineering. Thus, what can be learned about the problems and opportunities of Federal involvement in biomedical development will also shed light on the still more general issue of the Federal Government's relation with the totality of modern science.

I should now like to respond to the specific questions posed for consideration by the subcommittee.

First, as to the need for additional attention by Federal agencies in the field of biomedical development. There is certainly a need. Because this field should be looked at in the context of our social environment there is a special need for more of a sense of direction. Without this it is difficult to justify other biomedical needs. Federal agencies can and must play active roles in studies as well as practice if either basic studies or Federal policies and programs are to develop in viable directions. A number of offices and agencies are beginning to do so, but there have also been setbacks. Progress is still much too slow, given the pressing need to use existing human and financial resources more effectively.

To illustrate topics for study, let us consider the implications of advances in biomedical science and manipulability and control within biomedical affairs. Then I shall mention some techniques which Federal agencies have used or might use to meet these new needs.

RELATING NEW KNOWLEDGE TO PRACTICE

A price we pay for promoting relevant basic research is a general sense of frustration when new knowledge reminds us of the relative imperfections of medical practice and health care as actually provided. It is sometimes observed that present medical training and practice is generally geared to what was known several decades ago and not to what is known today or is likely to be known in the foreseeable future. Alternatively, when and where the most current knowledge and techniques are employed, the accumulated wisdom of the past may very well be disregarded. Somewhat comparable gaps arise when changes in social and human standards and values demand more extensive applications of old biomedical knowledge.

Such changes make it necessary to re-examine intellectual and institutional assumptions about the relationships between basic research, education, training, and medical practice; between treatments to cure

and to prevent illness; and between concerns for people as individuals. and as statistics.

Much too little is known about the ways in which gaps resulting from biomedical advances affect these kinds of relationships. Nevertheless, it is evident, for instance, that the reasons for associating medical practice and training with university research and education must be quite different today than they were 50 years ago. The desire to assure use of new knowledge has led to increased university involvement in the machinery of medical practice and continuing education. Federal agencies and private institutions have acquiesced without sufficient study and monitoring of what seems to be a dubious and unnecessary trend. The high prestige now attached to research activity may even be counterproductive. Medicine is a social discipline as well as an intellectual one. I question whether the relevance of one to the other and their optimal relation to the other biological and social sciences are well enough understood to sustain the present biomedical enterprise, let alone its further development. Appropriate Federal agencies along with the universities and medical centers must become more openly and institutionally aware of these questions.

While the problem of relating discovery to practice may be leading to too tight an affiliation between biomedical research and medical care, our institutions tend to preserve increasingly untenable distinctions between the concerns for the cure and the prevention of illness and between specific and statistical health hazards. Since Federal agencies have pioneered in breaking down some outmoded distinctions, the question is one of adequacy relative to the present needs and possibilities. In my judgment the greatest limitation is the lack of persons with the positions and temperament to engage in and make use of policy-oriented studies and long-range planning concerning these kinds of issues.

Heretofore constructive thought about these matters has been an undifferentiated part of the activities of many researchers, doctors, and statesmen of medical affairs. Now, quite apart from the gaps between knowledge and practice produced by new discoveries, the rapidity of discovery and the vast scale of biomedical development require that these high-level activities be differentiated from, yet integrated with, other parts of biomedical development. Not enough is known about biomedical affairs and what is known to the expert specialist is not readily accessible to the expert generalist who can use this knowledge.

RELATING ENDS AND MEANS

Biomedical development is unquestionably affected in very basic ways by Federal agencies and the budgets available to them. But it does not follow that all manipulative effects are precisely controlled. Control depends upon the deliberate and viable coupling of specific ends and specific means. As a matter of public policy, biomedical development is supported because of anticipated social benefits meeting such social needs as, for example, the reduction of cancer, heart ailments, and mental disorders.

The goals have been made clear. Government policies also reflect the fact that the conditions for new discoveries are rather unpredictable, as are their specific consequences. It is less evident that the present