The questions which the subcommittee has raised are highly pertinent and the answers will figure importantly in the accomplishment of the goals of our national effort in the biomedical sciences. These goals consist of a complex of many specific objectives but can be stated generally as the achievement and acceleration of continuing improvement in our competence and skill in all areas of health care and the development of efficient systems to assure the availability of this competence and skill to all citizens.

I shall undertake to respond to those of your queries which are relevant to the activities of the Office of Science and Technology. Before doing so, however, I wish to suggest for the consideration of the subcommittee a modest expansion of the area of inquiry. The subcommittee, quite properly, I believe, is centering on what the Federal agencies might do to translate the results of biomedical research more effectively and more promptly into measures for the prevention of disease or the actual treatment and care of patients.

There is no doubt that conscious and continuing effort must be directed to this translation if biomedical research is to serve its ultimate social purpose-that of returning to the public the dividends which they legitimately expect from their investment.

Put in another way, we are concerned with shortening the road from the research laboratory to the bedside or, at least, with shortening the transit time along the road.

My view of the task involved in shortening this transit time can be portrayed by telling a story, a tale of two cities, Bedside and Labtown.

Bedside is a large and busy metropolis, the site of many thriving industries and enterprises. It is a prosperous place, but has its share of congested streets, pockets of poverty, air pollution, lack of recreational facilities, and overcrowded schools. The population is heterogeneous, with a diversity of interests and activities. The citizens of Bedside are bound together in a common cause, however, the result of a tragedy many years ago. During a bitter cold spell, the city auditorium was left open to the public and was crowded with indigent citizens seeking warmth. The building collapsed suddenly, killing hundreds, both old and young. The city resolved to memorialize these victims by erecting a monument to them in the form of a new town hall, a perfect building, uniquely beautiful in design and indestructible in composition. The devotion of the populace of Bedside to this cause increased each year and has come to amount to almost a religious fervor. Every citizen pays a substantial annual surtax for this cause and the money is sent to the City Council of Labtown, a small community, known for the high quality of the bricks manufactured there, located several miles from Bedside.

Labtown is a pleasant, quiet, residential city without industrial plants or factories or other visible means of livelihood. The residents are well dressed, well educated, unusually intelligent, and appear to have many interests in common, the greatest of which seems to be the creation of ceramic articles of original composition and design. They spend much of their time trying to please one another and each seems particularly anxious to achieve the respect of his neighbors. Indeed, they take great pride in exhibiting their new ceramic works to each other and attach uncommon significance to their discussions of each new product of their ceramics studios which seem to be located in

every basement or garage. The citizens of Labtown are a rather clannish lot and, while out-of-town visitors are treated with great courtesy and propriety, they are not given a really warm welcome and never feel completely at ease.

Though the inhabitants of Labtown appear to be happier at home than anywhere else, they actually travel a great deal, particularly to exhibit their latest decorative tiles or other works. Even when traveling, however, they seek each other's company and prefer to converse among themselves. The Labtowners, however, are peculiarly reluctant to visit Bedside; indeed, it appears that anyone who does so acquires a sort of taint which makes him less socially acceptable to his colleagues. The origins of this tradition are not entirely clear, but one encounters impatience and evident irritation when he even brings up the city of Bedside in ordinary conversation.

Other topics that are likely to produce an uncomfortable pause in the conversation are the question of constructing a building with bricks of different shapes and sizes and the whole subject of mortars and cements. The Labtowners seem particularly ill at ease with architects or construction engineers and tend to limit discussions with them to educational standards or foreign policy. It is taboo to speak of the Bedside Memorial Townhall.

On the outskirts, just beyond the corporate limits of Labtown, there is a small, rather wealthy community called Pharmville. Its inhabitants, known as Pharmers, manufacture ordinary bricks and tiles which they sell profitably to the building contractors of Bedside. Generally, Labtowners look upon Pharmers as a race apart and, with occasional exceptions, there is little exchange between the two groups, mostly because the Labtowners regard the Pharmers as rather commercial in their outlook.

The annual donation to Labtown from Bedside is divided each year by the Labtowners according to a complex ritual, devised by the community. The procedure involves certain priorities and a great deal of visiting back and forth in each other's studios. The division process is not entirely satisfactory and, interestingly enough, the grumbling over it is directed primarily at the city of Bedside. The complaints are of two types: the gift from Bedside is never quite large enough and, the Bedside City Council, apparently ungrateful for the many original and unique ceramic works which have been sent to them for exhibitions have an annoying desire to know what happens to every last penny of the gift. Originally, this was not particularly burdensome to the Labtowners, but as the money has increased each year and has come to be the major source of support for the entire community, it has become more and more of a chore to keep track of it.

Labtown was formerly a small community of brickmakers with a few resident ceramic artists who served as consultants but were attracted to the area mainly by its relative isolation and the fine quality of the local clays. The annual subsidy from Bedside, originally intended to finance the creation of the perfect building material for the contemplated monument to the martyrs, clearly has changed the original complexion of Labtown very considerably.

The citizens of Bedside, who are renowned for their patience, indeed, they are often referred to as "patients" rather than "Bedsiders," seemed more or less content with this state of affairs. They were satisfied with the progress evidenced by the ceramics exhibits and the

sturdy bricks and tiles brought in by the Pharmers whom they had come to regard as Labtowners, not being familiar with the niceties of social distinction in Labtown.

Rather suddenly, however, the situation changed. The mayor and City Council of Bedside, thinking to help matters along, decided to acquire a site for the proposed townhall which would memorialize forever the unfortunates who had perished years ago and, to facilitate the eventual construction, they voted to widen and to improve the one existing highway between the two towns. They found that they could do this without diverting funds from their annual donation to Labtown and proceeded with their plans.

News of this decision was received with angry dismay in Labtown and protests were soon heard, apparently based on the mistaken belief that Labtowners would be expected to help to pay for the building site or the roadwork.

Bedside's City Council persisted, however, and the Labtowners realized that something would have to be done to safeguard their way of life. Here, however, there were difficulties and delays. The custom of not visiting Bedside was so entrenched with them, that none would risk lowering himself in the eyes of his colleagues by being the first to flaunt tradition. Secondly, because most of their experience in traveling had been by jet airplane, there were few who knew how to negotiate a short trip overland, especially over a road in poor repair, and they were certainly not going to humble tradition by asking the Pharmers of Pharmville how they had managed to get their bricks to Bedside through the years. Their protests by mail were frustrated, mainly because they were unable to locate anyone to protest to who seemed to have any authority or inclination to ameliorate the situa

tion.

Finally, realizing that regular trips to Bedside were almost inevitable, the Labtowners began to examine the highway between the two cities and were so appalled by what they found that they accepted an invitation from some of the leading citizens and officials of Bedside to meet with them, to discuss the matter, and to consider possible ways of improving the highway from Labtown to Bedside, and here we are today.

As a former resident of Labtown, now on leave of absence, I would like to report to you on the condition of the highway.

There are some difficulties with the present road:

1. The accesses to the road are not clearly marked and are difficult to find.

2. The side roads are not clearly marked and a wrong turn can lead one many miles astray or put one into a deadend alley.

3. There appears to be a slow lane for cautious drivers and a fast lane for others, but neither lane is marked.

4. The authority for patrolling the road is divided among several jurisdictions.

(a) Traffic regulations designed to assure a smooth and efficient flow of vehicles conflict with safety regulations which seem more stringent than necessary, and, so some believe, may not be uniformly enforced.

(b) There is at least one speedtrap along the way in the small township of Patent Gap, the main purpose of which appears to be enrichment of the local constable and justice of the peace.

5. There is a serious question about whether the road is best negotiated by private car or by public transport. Some believe that a combination of the two may be desirable.

6. There is a firm belief among Labtowners that if one decides to travel the road, he cannot return home when he is ready to do so because the road is one-way track from Labtown to Bedside. One must remain in Bedside or must find his way back by a poorly charted, circuitous route.

7. One of the most striking peculiarities of this road is the lack of a regulation prohibiting hitchhikers. This is fortunate, because they turn out to be almost a necessity for the trip and one must learn to pick them up along the way. They should not be fellow Labtowners; most are strangers and it is preferable to include an electronics technician, an engineer, a computer programer, an economist, and a lawyer among the group. It seems that some system of carpooling at the beginning of the trip would alleviate the need to depend upon what turns up on the

way.

In view of the usual road conditions and the inclination of Labtowners to stay home and put off a trip to Bedside, certain questions must be faced:

1. If the road is under utilized, how can one increase the number of travelers upon it?

(a) What induces an individual to travel on this or any other road if he is more comfortable at home?

(b) What are the incentives that will motivate a Labtowner to undertake the journey, with strangers as companions, other than the fear that life will no longer be pleasant in Labtown if he fails to make the pilgrimage?

(c) Is it preferable to find new travelers for the road rather than attempting to mobilize the Labtowners themselves?

I will not push this analogy or allegory any further; it is possible that I have already pushed it so far that I will find myself less than welcome when I attempt to return to Labtown. I wish to emphasize in the strongest terms, however, that no matter how intensive and varied are the pushings, pleadings, and urgings of those who provide support for basic research, they are likely to create among basic scientists neither the inclination nor the capability to pursue programs of development. In the biomedical field particularly, we should discard, once and for all, any notion that sanctions, particularly those which take the form of withholding or restricting funds for basic research, will accelerate significantly the translation of laboratory findings into products or processes that can be utilized in the delivery of personal health care or public health services. The development process encounters many obstacles, but an excess of basic research has not been shown to be one of them. Indeed, a paucity of basic knowledge is often the greatest impediment to a program of development.

It does not necessarily follow that expansion of basic research alone will lead to any appreciable expansion in the development of beneficial applications. Clearly, however, if development and application are expected to occur, there must be adequate support for the individual initiative of qualified, basic scientists. Motivation to do basic research may be complex or it may be nothing more than curiosity about nature; to the scientist, the discovery of something new

is an end in itself, requiring no further justification. As Hendrik W. Bode has pointed out, to ask a basic scientist to justify his research findings in terms of economic, cultural, or military applications is "like asking a young lover to give some sensible reasons why the adored person is really so charming." Certainly, motivation to carry out biomedical research is not a hurdle in the United States.

The results of basic research are the basis of development. A major difficulty in development and technological advance is the incompleteness of most scientific advances, in the sense that a development program is not feasible until additional information becomes available. It is sometimes appropriate, through the additional effort of applied or directed research to attempt to supply the needed knowledge but, often, one needs simply to await additional advances in knowledge; an awareness of the needs and an ability to respond to new findings is also important.

The leadership of the United States in basic biomedical research is beyond question and we must not sacrifice this sturdy foundation in the process of trying to create a superstructure for development and application. Our real problem is to expand our strength by the creation of an establishment for research, development, and application that can function coherently and effectively.

To an increasing extent, studies of the process of transforming research findings into products that are usable and, perhaps more important, products that are used, are demonstrating that the predominant factor in innovation is need. There must be a felt need and a positive demand for innovation, development, and application. This demand must also be an effective demand, meaning that there must be a market (and I use the term, "market," in a broad sense) for new devices, products, processes, services, and systems.

The existence of a real need, even coupled with a sure market, will not bring the solution into existence unless the fund of scientific and technological knowledge prerequisite to a solution exists. There is, for example, an undeniable need for cures for cancers but this need alone will not generate the cures. The present outlook is that there will probably be no single cure, but that through painstaking work, small cumulative advances along many lines will gradually reduce morbidity and mortality from different types of cancer. This is why continuation and expansion of basic research in the field of cancer is important.

A need is often identified simply because scientific and technologic advances have made it feasible to think realistically of such a need when it might have been only a dream of science-fiction a few years ago.

The importance of need and demand in development is borne out by an examination of patents. Do patents come about because an inventor has a spontaneous inspiration or are they the result of work in response to an identified need? Both inspiration and need are significant, but careful study has shown that most patents today are the consequence of an identified need.

If, as I have tried to emphasize, the essence of motivation to development is need, it follows that an investigation of conditions to facilitate development and application in the biomedical field must consider the mechanisms by which needs can be identified, their feasibility (in terms of basic knowledge and existing technology) can be assesed, and some estimate of probable use can be made (in other words, a market survey). This statement may seem more obvious than it is profound,