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The study of the National Institutes of Health entitled "Biomedical Science and Its Administration” was carried out by a panel of the Office of Science and Technology, completed in 1965. This so-called Wooldridge report pointed out the desirability of certain moves in the direction of preparing for directed research and development above and beyond the traditional and highly effective project grant program used for basic research. The import and impact of this report may be the subject of additional testimony before the subcommittee.

Finally, at the suggestion of OST and with the cooperation of the Bureau of the Budget, there was created last year a special advisory group, composed of biomedical scientists as well as individuals from other technical and nontechnical fields to examine the broad problem of the treatment of chronic uremia, failure of kidney function. Central to this issue is the use of the artificial kidney. This group has been asked to report on technical feasibility, cost, the needs in the near and short term, and the implications in terms of economic benefits, allocation of health manpower, tradeoffs, and alternatives. The results of this trial exercise may be valuable in helping to guide decisions about the nature of a Federal program in this area and serve as a model for future studies. For the biomedical participants, at least, the experience should be an enlightening one in acquainting them with the many and varied factors that must be considered, weighed, and harmonized before embarking upon a major program of targeted research and development.

The Federal Government and the American people are committed to providing good health care to all and our present health system is strained to the breaking point.

The need for innovation is clear. I hope that these hearings will point the way to the new and imaginative approaches that the future demands and our citizens deserve.

We must take a new look and avoid the shortcomings pointed up by Hasan Ozbekhan when he said, “Today, the future tends always to be viewed, hence, methodologically approached, as if it were the mere extension of the present. Thus we wander in static time."

Senator HARRIS. Thank you, Dr. Bennett. Your allegorical story about Labtown and Pharmville and Bedside was not only enjoyable but constructive. We appreciate your complete statement here.

I would agree with you, as I said earlier, when you say, “The development process encounters many obstacles but an excess of basic research has not been shown to be one of them.” I agree with that.

You also say: "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," the word being "establishment.” I wonder if you might elaborate on that.

Dr. BENNETT. I chose the word “establishment” there purposely because it was not my intent to imply that it should be a Federal establishment as opposed to an industrial establishment, or as opposed to an establishment that might have some of its roots in universities. I made the comment simply to point out that we really have built the foundation, and we don't want to destroy that foundation in attempting to create the additional structure.

I think that there are clearly some areas in which the strength of our industrial laboratories can make a contribution. It is possible that additional incentives might help in this area.

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I certainly think the subcommittee will hear some testimony later in the course of these hearings that will point up some possibilities of adding onto the Federal structure itself.

Senator HARRIS. You said: “The mechanisms by which needs can be identified” and I wanted to ask you about the word “mechanisms.” Are you still speaking in general terms about the diverse ways that might be done or are you thinking of a particular way?

We started in our conference in Oklahoma City, to make an inventory of needs in the biomedical fiield, and we want to do more of that in these hearings. But I was wondering if you might elaborate on the word "mechanisms by which needs can be identified."

Dr. BENNETT. I think one of the ways in which they could be identified would be to hear more individuals like Dr. Lederberg, who has certainly outlined a very pressing need, when he spoke about the need for additional information about populations on a long-term basis, and it seems to me that he has also outlined very well the contraints that one runs up against when one suggests the establishment of such a system.

I think it is illustrative of the fact that this particular need will have to be further evaluated in terms of the existing system that we intend to add it to, and it turns out to be not really a scientific or technological matter, because it is quite clear that given the funds and the direction, this could be established. It becomes a matter of legal definition of privacy, and a number of other things that have already been enumerated. So that I would say that I think it would be relatively easy, and indeed, through the National Institutes of Health, for example, there are certain needs that have been identified and they do carry out a regular review of the possibilities,

What I would like to emphasize is that one has to look at the system to identify the needs rather than at the knowledge pool to try to decide what we can do with this now that we have it. I think that that is the point of view that we have to adopt.

Senator HARRIS. Yes, and a very good one. I compliment you also for your comments about the need for increasing interest in biomedical engineering. You made some particular comments on that point in

your statement.

I suppose the word we heard more than any other in our conference, “Research in the Service of Man", was "interdisciplinary.” It seems to me that may be one of the most important words and concepts of our age. In almost any field of science you begin with an idea and you almost unavoidably get into a whole universe, and I think that is particularly true in the application, development and use of biomedical knowledge.

We have emphasized the social and behavioral sciences, for example. We know very well that political science is basically involved in the "how" of getting these things out in to the thinking of people. And then, too, on biomedical engineering, some of the people who testified, for example, on the artifical heart and the artifical kidney, talked about the difficulties that they encountered in finding medical people who know something about engineering and engineering people who know something about medicine. Sometimes there is a problem of finding people like that who want to know about the other. There is some talk about the engineer in the situation who feels inferior to some degree.

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Perhaps that has been a deterrent to the kind of interdisciplinary work that you talk about.

You mentioned that "It is in the biomedical field that such institutions are largely lacking at present." Are you talking about institutions that are the means for accomplishing innovation and the application of knowledge ?

You then mention some ideas, for example, the establishment of Federal research laboratories. Would you care to particularize on that? Some have said we might well, redeploy the mission of certain existing Federal laboratories into the biomedical field.

Dr. BENNETT. I would say that I would consider this a possibility, but there is a tendency it seems to me these days, whenever one is faced with a large, what I would call social and economic problem, that has the scientific and technological base, one of the routine suggestions that is made is "Perhaps we can turn some of our Federal laboratories to this purpose.”

I have in mind the recent suggestion that was made that we should use some of the laboratories of the Atomic Energy Commission to do applied research on the pollution problem. I would simply say I would not rule out that possibility; but one must look carefully at the details of what would be involved. If you took national laboratories that had been created for quite a different purpose, and attempted to transform these into establishments that were dedicated to the translation of the results of biomedical research into application, you might well decide, after having tried this, that we would be better off if we had started a new establishment dedicated to this problem from the beginning. Because one again runs into the problem of the fact that, in general, people like to do what they have been doing before, and what they feel they can do best.

I would certainly think that it is worth contemplating, that is, the possibility of providing incentives that might stimulate the far more flexible talents of the industrial research laboratories in this country. But here again, I would think that prior to a consideration of providing such incentives, it would be extremely important to obtain the best possible advice from individuals who are directly involved in endeavors of that type.

Senator HARRIS. You have touched on an idea that you mentioned in your paper, as well. As I indicated earlier, the role of the private sector in the broad spectrum of public interest is a concern of this subcommittee, and I think we are going to be hearing a lot about that in this session of the Congress and for many sessions to come. We are realizing more and more that the Federal Government, or the Federal Government in connection with State and local governments, cannot alone attack all the problems of modern life, as, for example, of housing and of urbanization. What do we do about those people who live in depressed areas insofar as enhancing economic opportunities?

In another broad field, how can we stimulate the private sector to take a larger, more active role in the application, development and use of knowledge. I think this will become one of the major focuses of the subcommittee as we proceed.

Senator Hansen?

Senator HANSEN. I don't think I have any questions, Doctor. I am certainly most impressed with your testimony. I think you have focused attention on a number of areas of interest that are deserving of far closer scrutiny and examination than they have had so far.

Senator HARRIS. Thank you very much, Doctor.

Our next witness is Dr. Walsh McDermott. Dr. McDermott is chairman of the Department of Public Health, Cornell University Medical College, New York City. He holds an M.D. degree which he received in 1934.

He was an instructor of medicine, assistant professor and associate professor at Livingston Farrand, professor at Cornell University, and recipient of the Lasker Award and the Trudeau Medal. I will place in the record without objection a brief biographical sketch concerning Dr. McDermott.

Biographical Sketch: Walsh McDermott, M.D. Chairman, Department of Public Health, Cornell University Medical College, New York, N.Y.

M.D. 1934—College of Physicians and Surgeons, Columbia University Background. data : Instructor, Assistant Professor, Associate Professor of Medicine; Livingston Farrand, Professor of Public Health, Cornell University Medical College

Recipient of Lasker Award and Trudeau Medal. Meinber of National Academy of Sciences and many other associations.

Dr. McDermott, we are very pleased that you are here. We will be pleased to hear your statement at this time.

TESTIMONY OF WALSH MCDERMOTT, M.D., CHAIRMAN, DEPART

MENT OF PUBLIC HEALTH, CORNELL UNIVERSITY MEDICAL COLLEGE, NEW YORK CITY, N.Y.

Dr. McDERMOTT. Senator Harris, members of the committee, in your letter of invitation to testify on the adequacy of Federal institutions for biomedical development, you listed five questions the subcommittee has posed for specific consideration. In presenting my ideas on these questions, I find it easier to proceed in a different sequence than they were listed, but plan to give an answer to each one in summary form at the end.

I shall start with the assumption that there are problems of major importance to society whose management is greatly facilitated when it can be based on a body of knowledge and techniques derived from biomedical research. From this arises the question as to the capability of our present biomedical institutions (1) to identify these social problems in terms of the role of biomedicine; (2) to insure proper attention to them in terms of research and development; and (3) to insure that once available, any research results that can be applied are in fact widely applied, for man's benefit.

In approaching these questions it is appropriate at the outset to examine the delivery systems we have developed for the application of biomedical science and technology. If we consider the total sum

1 Most of the material presented in this statement has been presented in greater detail in the following articles : (1) “Modern Medicine and the Demographic-Disease Pattern of Overly Traditional Societies: A Technologic Misfit.” Part 2, The Journal of Medical Education, September 1966, vol. 41, pp. 137-162. (2) “Medical Institutions and Modification of Disease Patterns." The American Journal of Psychiatry, June 1966, vol. 122, pp. 1398–1406. (3) "Summary Remarks, Dedication of the Institute for Biomedical Research,” Journal of the American Medical Association, December 27, 1965, vol. 194, pp. 1374-1375. (4) "The Role of Biomedical Research in International Development." The Journal of Medical Education, July 1964, vol. 39, pp. 655-669..(5) "Science for the Individual—The University Medical Center.” Journal of Chronic Diseases, 1963, vol. 16, pp. 105-110.

of human knowledge of biology and medicine as a pool, there are three main systems by which it gets applied :

(1) the clinical physician system
(2) the managerial physician system

(3) the nonphysician system By the nonphysician system is mean the application of some product from some other sector of science unrelated to biomedicine, that nevertheless results in a beneficial impact on health. I shall illustrate this system by examples later on, but for the moment wish to concentrate on the two systems in which physicians are involved.

The clinical physician system refers to those physicians and surgeons who work with decisive methods in a series of individual personal confrontations, i.e. they care for one patient at a time. These physicians go to the total pool of biomedical science and technology and make discriminating choices of precisely those elements that can be applied directly, or under close supervision, for the benefit of an individual patient. By contrast, the managerial physician works by organizing others, usually not physicians, to play various carefully fitted roles in a total job. He goes to the same pool of science and technology, but he may extract quite different elements for application by some remote system to people in groups. Unlike the clinical physicians, the managerial physician in his professional role never gets to meet those he has benefited. And, therein lies one element of our problem.

In analyzing our situation today it is essential to understand that the past 100-year era of great biomedical achievement represents two quite distinct halves in terms of the respective contributions made through these two delivery systems.

Before 1921, the clinical physician, no matter how much science he knew, had relatively little in the way of practical products from biomedical science that he could apply to the problems of an individual patient. He could control pain, perform surgery of relatively limited scope by today's standards, and possessed a few decisive remedies such as digitalis, quinine for malaria and arsenicals for syphilis decisive in the sense of producing a predictable result in a specific situationdecisive in the sense that penicillin can be decisive today. But until the discovery of insulin in 1921, virtually all of the dramatic changes in the pattern of disease were made by the application of biomedical science and technology through the other system, the managerial physician system. Indeed it is too readily forgotten today that most of our present considerable increase in life expectancy viewed from the time of birth, comes not from our recent achievements, but from the delivery of biomedicine through the managerial physician system, in the early decades of this century. We had then, in simplified terms, two systems operating in parallel. The clinical physician supplied obstetries, some surgery, and human support in the form of hope, confidence, comfort, and, above all, compassion. Biomedical science and technology was applied not by the clinical physician, but by the managerial phvsician, and it was applied impersonally for the benefit of the group.

Thus for the 50 years before 1921, the managerial arm of our dual system had virtually all the science and the other arm, represented by the clinical physician, was getting little nourishment from sciencelittle nourishment in the sense of capacity to take decisive acts.

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