independent problem like cancer or high infant mortality. Instead, the fact that there is a problem and that it is a major one, is an intellectual judgment based on projections from the bits and pieces of evidence we have available now. I happen to be convinced that the intellectual judgment is a correct one and that it would be socially irresponsible not to mount a massive research and development program in environmental health.

But we are not talking here about the rapidly moving and frequently dramatic events of a diseased patient; we are talking about "water dripping on stone" type of effects exerted on large numbers of people over time periods that might be longer than the professional lifespan of the scientific investigator. This is not a very attractive sort of proposition with which to entice experienced research workers from the study of the fascinating biomedical problems of the here and now. Yet it must be done, but to do it will require not only new institutional forms, but unprecedentedly generous terms of financial support.

For the fourth problem sector, that caused when our technological triumphs outstrip our delivery capacity, I shall choose only one example from a number that are currently available; namely, the recent developments in the treatment of the acute heart attacks of coronary heart disease. It now seems clear that a large proportion of the deaths from these acute attacks are preventable if the patient can be cared for in one of the intensive coronary units that are being set up with the help of the Public Health Service in various medical centers throughout the country. But these units require considerable expensive instrumentation and physicians, nurses, and others with highly specialized expertise. As things stand, therefore, the coronary care unit is not an instrument suitable for widespread application through our clinical physician system nor in its present form is it likely to be. Yet as long as it is not being applied widely, we have a situation in which in certain scattered focuses throughout the country, a man with an acute heart attack has a considerably greater chance of recovery than would have been the case had he been under the care of one of our Nation's most brilliant cardiologists in some other high-standard hospital facility.

It is not clear how this social problem will be resolved. The people engaged in this work are well aware that there is a problem and every effort is being made in electronic engineering and other relevant fields to develop something with greater prospects of widespread applicability. One avenue that is beginning to be explored is the possibility that the focuses of instrumentation and expertise might be functionally linked by electronic data processing over some distance to a number of other hospitals. For, an important element of these successful coronary care units is that the patient's heart is monitored continuously through the early days or weeks by electronic devices. equipped with instantaneous warning systems that provide the few minutes of margin in which useful life can be saved.

With these coronary care units as with other brilliant developments in biomedical science and technology, the physician, notably the clinical physician, has far greater power to influence the events in an individual patient than he had before, but he can wield what powers he has, over a smaller sphere of influence than he could before. When there is a steady increase in the things that can be done only by him or only by him if he is in a particular institution, he is able to do

these things for a smaller number of people. The avenues open to us to try to extend or lengthen this radius would seem to be: to try to simplify and cheapen the technology; to see how much can be taken over by specially trained nonphysicians; and hopefully, from learning how to use electronic data processing and other communications developments in the innumerable decisions that relate to patient care. It should be recognized that the last-named approach, although quite promising, is bound to be extraordinarily expensive, especially in its early developmental phases.

As I have indicated before, these four problem sectors and the many challenges presented by electronic data processing represent in my opinion the principal sectors in which our total biomedical institutional establishment is not yet fulfilling its social purpose. Hence I believe these are the sectors which should form the committee's major

concern.

3

It cannot be too emphatically stated that to say that our biomedical system is not yet meeting these problems is not to say that the Federal part of that total establishment has nothing going on at all. On the contrary, particularly in the last few years, there has been a considerable effort, largely through the Public Health Service and the Agency for International Development, to get appropriate attention from science and technology to an attack on these three sets of problems. A whole new Institute for Child Development with both intramural and extramural programs has been created at the National Institutes of Health; a new Division of Environmental Health is being organized and Secretary Gardner has a task force preparing recommendations presumably for still greater efforts in the environmental field. The National Library of Medicine has been in the forefront of studying ways to apply electronic data processing to medical problems. Some projects in the delivery of medical services in rural and urban slum areas were started through the Office of Economic Opportunity and the Headstart program is also directed to one aspect of the child program, although not to the problems of infancy.

A high caliber research program devoted to finding practical solutions in the high fertility/high childhood mortality sector abroad has been organized through AID, but despite the scientifically high caliber of much of this research program, it has been possible for AID to keep it going at a pitifully inadequate level only by constant struggle.

One might well inquire why so much of this activity is so recent and in little more than the planning stage when the problems must have been identifiable for quite a long time. The answer is to be found in the restricted nature of the instruments at the disposal of the Federal biomedical establishment. Broadly speaking, these are three in number: an apparatus for identifying a problem and bringing it to professional and public attention; an intramural laboratory and field research capacity; and an appropriation for the support of an extramural research and development program. But by no means does the Federal biomedical establishment have all three tools available to it for the attack on every problem. On the contrary, two of them-the in-house and extramural research capacities-usually come into being only after a question has actually ceased to be a problem in terms of getting itself identified, characterized, and supplied with people who

3 National Institute for Child Health and Human Development.

wish to study it. And, at this mature point, the process, including the actual application of the research results, is largely self-propelling.

Research priorities of a comparative sort can be set, in that it is possible to allocate somewhat more funds for heart disease and somewhat less for cancer in a particular year. But this is a kind of research priority that does little more than mirror the budgetary situation of the moment; it is not a research priority in the sense of representing a carefully considered analysis directed to the identification of what appear to be the most important problem sectors to be faced by our society. It is this latter type of research priority that I infer is the one of greatest interest to the committee; it is this latter type that we have not really yet learned how to handle; and I am convinced that in our gropings we may have to set up and discard a variety of institutional forms before we find those that seem reasonably well adapted to the job.

To set up research priorities that reflect pressing social needs is obviously an idle exercise unless there is a reasonable prospect that at least some of the research will be done. Of the three options open to the Federal biomedical establishment, there are two that at first glance seem to represent direct and logical approaches: set up the desired research in the Government laboratories or provide funds for its support in nongovernmental laboratories. In actuality, neither of these approaches represents a very effective instrument with which to get programs started on the important emerging problems. These direct approaches are at their best-to borrow a phrase from Senator Dirksen-dealing with "an idea whose time has arrived.”

And, as things stand today, for all practical purposes, the only approach the Federal biomedical institution has available to it, to get action in what presents itself as a wholly new problem sector, is to try to hasten the process whereby the idea "arrives". It cannot really "order" that research on an emerging problem sector be done; neither is it apt to get very much of what it seeks by using what, in effect, would be bribery.

The biomedical research establishment has immense flexibility and quick reactive capacity to new problems provided they present as logical extensions of what is under study. This great flexibility is attained largely by what might be termed intellectual decentralization in that the system as a whole is broken down into a very large number or related but intellectually quite independent units, a unit frequently being no more than a single person. These many units or research workers are curious, imaginative, and highly self-disciplined individually, but if one were to look at them as a total group-the group would appear as undisciplined or at least unorganized. And this is the way it should be, because it is this intellectual decentralization that energizes the entire system and makes it work. To obtain this rich creativity we have to accept the fact that the assignment of the research worker to a particular research question or problem sector, is by and large a selection made by him. What is more, he seldom makes this self-selection on the basis of the needs of society; he makes it for more personal reasons such as his interest in the federal field of which his question is a part, the facilities he is able to call on, his own strengths and weaknesses with respect to particular techniques and similar considerations. I do not wish to seem to imply that our biomedical scientists, as citizens, lack

social consciousness; on the contrary they are usually among the more socially responsible of a profession with a long tradition of meeting the needs of society. But what I am saying is that the process of selfassignment is in effect a selfish choice in the sense that a great musician or painter makes the selfish choice that he will, indeed he apparently feels he must, create through his particular medium to the exclusion of most other considerations.

The question society faces, and in this case, society is represented by the committee, is how do we harness this immense creative force for the public good without weakening the force in the process? The challenge is a very real one and requires extremely patient and wise scientific statesmanship. I believe President Lincoln once defined the art of statesmanship as "the exploitation of individual meanness for the common good" and in essence, this is our social goal for biomedical research.

With today's instruments and institutions, therefore, the Federal biomedical establishment has found itself largely confined to hastening the time of the "arrival of an idea". It has done these by task forces, PSAC panels, the study sections, councils and ad hoc committees of NIH, and the NSF and Academy-N.R.C. apparatus. It has held sharply focused conferences, prepared presentations to the Congress. Before any of this could be done, various individuals in the Federal Government sometimes assisted by outside advisers have thoughtfully studied the contemporary scene to see what could be identified as emerging problem sectors of importance. In my judgment, this has been a wise use of the available instruments and institutions. The question immediately arises, however, as to whether there are not new institutional forms that could be developed that would provide more direct approaches to the identification, sharp characterization, and actual study of new problems including their practical solution. My instincts tell me that such institution building has now become essential and is possible, but my reason has not revealed to me any clear blueprint of how it should be done.

Nevertheless, I have become convinced of the great importance of certain principles that are my personal set of guidelines so to speak. First, as I have expressed before, I believe the present system is superb for the support of problem-solving biomedical research and the rapid and useful application of its products through what I have termed the clinical physician delivery system to most of our citizens.

Second, I believe that the major problems now being unmet do not lie in a failure of individual physicians to apply what we now know, but in the relative failure of our total biomedical complex not just the Government part of it, to focus sufficient attention on how biomedical science and technology can be applied through less direct delivery systems than the one manned by the clinical physician. I refer to what I call the practitioner delivery system or ideally to what I term the nonphysician system.

Third, the problems that to me seem to be the major emerging problem sectors in biomedicine are largely but not exclusively of such a nature that their practical solution will not come from remedies to be delivered by individual physicians. Therefore, we must find some way to insure that there are some first-class biomedical research workers imbued with the point of view whereby they continually ask "How, by

research, can this disease problem be solved or controlled by some method that does not require a physician for its continued application?" Fourth, I have become deeply convinced that the particular instruments or institutional forms chosen to study a particular problem sector make an immense difference in determining success. The institutional framework selected must be one that fits the nature of the particular problem.

Fifth, except under the conditions of wartime, it is unrealistic to expect that first-class workers will be automatically attracted to emerging problems unless they can perceive them as clearly related to their own skills and interests. This means that if it is desired to organize programs in newly emerging and novel problem sectors, it will be necessary: (a) to set them up with far more flexible and long-term financial support than has been necessary for past programs; and (b) to make Government in-house research a keystone of whatever programs of "the emerging novel" sort are to be set up.

Using these guidelines for the particular problem sectors I have identified as now looming with great social importance, I would: (1) strongly support the National Institutes of Health and especially encourage the new Institute of Child Development to expand its program; (2) set up a number of well-staffed university-based centers for long-range study of the consequences of environmental manipulation and link them to the present Public Health Service Division of Environmental Health; (as one form of support for this and for work of the Child Development Institute, considerable increase support for studies of animal behavior in the medical colleges); (3) set up a new institute at NIH whose charge it was to look at disease both at home and abroad from the viewpoint of how biomedical science can be used to control it quite outside any system that requires application by individual physician; (4) be prepared to invest large sums of money on learning the proper use of electronic data processing both for decisions concerning individual patients and for the use of operations simulation and gaming as a teaching method so that the developing generation of students can identify those disease control methods that are best delivered through the clinical and through the managerial approaches respectively.

The last named is of particular importance, for it really all begins in the medical or nursing school or actually even before that stage. For, if we are to meet the institutionally novel kind of problem we now seem to be facing, we will have to educate and train, in addition to the physicians and nurses we are graduating today, a substantial number who are willing to forego the intense satisfaction of helping to solve the problem of an individual, in order to use biomedical science and technology for the benefit of the group. Our graduate schools of public health have long been concentrating on just that. But they would be the first to concede that they are dealing with a skewed sample and that their efforts would be far more productive if more of the undergraduate students in biology and medicine could have some notion of what can be offered before career choices are made.

In closing I would like to relate what I have presented to the five specific questions that the subcommittee has posed for consideration: (1) Is there a need for additional attention by Federal agencies in the field of biomedical development?

My answer is yes.