Senator BURDICK. Thank you, Doctor. The largest percentage increase that you are requesting is for dental research. What is some of the research being done in this area, particularly prevention?

Dr. BELL. Senator, I am unable to give you that information at the present time, but I can get that for you.

Senator BURDICK. Within 5 days?

Dr. BELL. Yes.

Senator BURDICK. Thank you.

STATEMENT OF JAMES R. KLINENBERG, CHAIRMAN, ARTHRITIS FOUNDATION

ACCOMPANIED BY DEBRA R. LAPPIN, CHAIRMAN, GOVERNMENT AFFAIRS COMMITTEE, ARTHRITIS FOUNDATION

Senator BURDICK. The next witness is James R. Klinenberg of the Arthritis Foundation.

Dr. KLINENBERG. Thank you, Mr. Chairman. I am Dr. James Klinenberg, the senior vice president for academic affairs at Cedar Sinai Medical Center in Los Angeles, and I am currently the chairman of the Arthritis Foundation. Accompanying me is Debra Lappin, who is the chairman of our Government Affairs Committee for the Arthritis Foundation, and who herself is an arthritis patient. And she will say a few words in a moment.

The Arthritis Foundation is a national voluntary health organization with 71 chapters throughout the United States that represents an estimated 37 million Americans who have arthritis. The Arthritis Foundation appreciates this committee's support of medical research programs in the past. Had it not been for the support of the Congress over the past decade, we would have considerably less progress in medical research to report to you today. Many of the lifesaving advances for those who suffer from arthritis would not have been possible.

However, despite your strong support of these programs, the NIAMS receives less money than all but two of the NIH institutes. Last year, this committee was most generous in providing funds that enabled NIAMS to raise its percent funded grants to the NIH average. This year, we are looking to substantially increase money for clinical trials and intramural research. In both of these areas NIAMS is again well below the NIH average.

Supporting clinical trials at NIAMS has the added benefit that these trials contain a very high proportion of women, well over 50 percent. Intramural research at NIAMS is entering a very exciting phase with significant advances in finding ways to increase wound healing, fracture healing, cartilage regeneration. And that will have very practical applications and significant cost benefits.

Arthritis refers to more than 100 different diseases which affect the joints. Today, 1-in-7 people, and 1-in-3 families are affected with arthritis. Over 37 million people in the United States have some form of arthritis, and its prevalence increases rapidly with age, and it is a chronic disease.

Arthritis affects more women than men, with at least 23.5 million women of all races having this disease. It also affects children, with 200,000 children having the disease. It is estimated that the cost of arthritis to the U.S. economy in medical care and lost wages is $32 billion, or almost 1 percent of the gross annual product.

Annually, arthritis accounts for 427 million days of restricted activity, 156 million days in bed, and 45 million days that are lost from work. Reduction in these costs may occur with more basic research into the cause of the disease, which can lead to discovery of ways to prevent the disease from occurring.

I am here today to thank you for your generous support of last year's funding request for ÑIAMS, and to again urge the subcommittee to support increased funding for the NIAMS by providing a $47 million increase in funding over the President's fiscal year 1992 budget, for a total of $252 million to support the research and clinical trials needed to reduce the burden to society that disability from arthritis presents.

This funding amount would fill the gap between patient needs and research opportunities, and the Federal investment in arthritis and musculoskeletal and skin diseases.

For most forms of arthritis, there is no cure. I urge you to remember that the current opportunities in medical research are greater, more numerous, and more promising than they have been in any period in the history of modern science. Our scientists can deliver on the promise of medical research only if we provide the support that they need.

The Arthritis Foundation asks your support for funding of NIAMS and a $47 million increase in funding over the President's fiscal year 1992 budget. The Arthritis Foundation urges this subcommittee to continue its record of support for biomedical research in fiscal year 1992, and we appreciate the support you have given us in the past. I now would like to have Debra say a few words. Ms. LAPPIN. Thank you. Senator Burdick, Mr. Hall, members of the staff, the Arthritis Foundation and people such as I and the lovely lady who previously testified who face a challenge. This challenge is to dispel the public notion that arthritis is an inevitable disease of the aging process and that it can be cured by two extrastrength aspirin daily.

I hope to give you a brief glimpse of my own experience with a form of arthritis so that you can better understand that this is not the case.

Arthritis often strikes people, two-thirds of them being women, in their twenties and thirties, the most productive and formative years of their lives. Such was my case. I developed ankylosis spondylitis at the age of 28, 1 year out of law school. Arthritis is a serious, disabling disease.

When the inflammation it brings runs rampant throughout one's system, the pain is immobilizing. So it has been during many periods in my own life. I have had steroid injections in my ankles, my knees, my shoulders, and most frequently in my eyes. I have been hospitalized on two different occasions, unable to move because of rampant inflammation throughout my system.

And yet, I hope you are saying to yourselves, she does not look like she has arthritis. And I believe this is so. You may ask why. I believe I am the product of two realities. First, I have had exquisite care by a rheumatologist. Second, I have received the benefits of tremendous breakthroughs in research in the past decade.

Let me explain briefly. In 1978, when my disease was diagnosed, researchers had literally just discovered the HLA B-27 antigen, the

genetic marker that predisposes one toward ankylosis spondylitis. This made my diagnosis fast, certain, and my entry into proper care available. In 1984, at the conclusion of a long hospital stay, I commenced treatment with methotrexate, an immuno-suppressive drug then in experimental use in arthritis. Today it brings wide relief to many people with forms of arthritis.

Last year for the first time, researchers were able to develop an animal model, a rat, which successfully expresses the HLA B-27 antigen. And to their astonishment, every rat expressing the genetic marker developed serious arthritis. From this model, given money and time, these scientists will soon understand the aberrant interplay between the antigen which I carry and external factors such as bacteria or stress which result in arthritis.

Breakthroughs such as this and several others in the past year alone will mean that young people who are stricken by arthritis in their early years will not be forced to leave a law practice, as I was, will not become dependent upon a broad panoply of drug therapies such as prednisone, anti-inflammatories and immuno-suppressives which carry with them side effects such as bone suppression, bone marrow suppression, ulcers, renal toxicity; will not endure a psychologically difficult roller coaster ride through life, from peaks of seemingly good health to devastating pain.

And finally, I hope you will realize that we are in a turning point in the research in arthritis. On behalf of the 37 million Americans who have arthritis, I do hope that this committee will take a moment to recognize this crucial time in the history of arthritis research at NIH. I hope you will comprehend that this disease costs. $100 billion a year-that is 1 percent of our gross national product. And yet the arthritis institute receives less funding than all but two institutes at NIH.

PREPARED STATEMENT

And finally, I hope you will allocate an additional $47 million to NIAMS so that some of this imbalance can be corrected, and that this very young institute can continue its mission to cure arthritis and the disability it brings. Thank you.

Senator BURDICK. Well, thank you for your fine testimony. We will see what we can do to help you. This is a critical area of research, and we thank you for your testimony.

[The statement follows:]

STATEMENT OF JAMES R. KLINENBERG, M.D., AND DEBRA R. LAPPIN, ON BEHALF OF THE ARTHRITIS FOUNDATION

Mr. Chairman, distinguished Members of the Subcommittee, my name is James R. Klinenberg, M.D., Chairman of the Arthritis Foundation, and with me is Debra R. Lappin, Esquire, Chairman of the Arthritis Foundation Government Affairs Committee. I am here on behalf of the Arthritis Foundation, a national voluntary health organization with 71 chapters through the U.S., that represents an estimated 37 million Americans who have arthritis.

I thank the Chair and the Members of this Subcommittee for the opportunity to testify today. I would also like to express the appreciation of the Arthritis Foundation for this Committee's support of the medical research programs in the past. Had it not been for the support of the Congress over the past decade, we would have considerably less progress in medical research to report to you today. Much of the progress and many of the lifesaving advances for those who suffer from arthritis would not have been possible.

Despite your strong support of these programs, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) receives less money than all but two of the NIH Institutes. Last year this Committee was most generous in providing funds that enabled NIAMS to raise its percent of funded grants to the NIH average. This year we are looking to substantially increase money for clinical trials and intramural research. In both these areas NIAMS is again well below the NIH average.

Supporting clinical trials at NIAMS has the added benefit that these trials contain a very high proportion, well over 50 percent, of women. Intramural research in NIAMS is entering a very exciting phase with significant advances in finding ways to increase wound healing, fracture healing and cartilage regeneration, that will have very practical applications and significant cost benefits.

Demographic facts

BACKGROUND ON ARTHRITIS

Arthritis refers to more than 100 different diseases which affect areas around joints but can also affect other parts of the body. It causes pain and a loss of movement and contributes to 20 percent of all instances of homebound individuals.

Today, one in seven people and one in three families are affected with arthritis. Over 37 million people in the U.S. have some form of arthritis. Its prevalence increases rapidly from age 45, and in most individuals it is a chronic disease-lasting for the remainder of one's life. In addition, arthritis affects more women than men with at least 23.5 million women of all races having this disease. It is also a disease that can affect children—an estimated 200,000 children, under 18 years of age, have the disease.

Osteoarthritis affects an estimated 15.8 million Americans, mostly after age 45. It is the leading cause of bone fractures in women over 65. One-third experience hip fractures; many are unable to walk unassisted or confined to nursing homes. Rheumatoid arthritis affects an estimated 2.1 million people, more often affecting women. An estimated 27 million Americans suffer from osteoporosis and related bone disorders. Finally, arthritis and musculoskeletal and skin diseases increasingly affect the elderly, the fastest growing segment of our society.

Economic facts

It is estimated that the cost of arthritis to the United States economy in medical care and lost wages is about $35 billion, or almost 1 percent of the gross annual product. For approximately 3 million people with arthritis, the disease limits the everyday activities of the individual-such as dressing, bathing and walking. Annually, arthritis accounts for 427 million days of restricted activity, 156 million days in bed, and 45 million days that are lost from work.

Scientific advances

Cost reduction occurs in three ways. Basic research into the cause of a disease can lead to primary prevention, the means of preventing the disease from occurring. NIAMS supported research on Lyme disease led to discovering the cause and immediate treatment to prevent disabling complications.

Examples of recent advances that have reduced disability in arthritis include the use of methotrexate in the treatment of rheumatoid arthritis, the use of ethidronote in the treatment of osteoporosis, the use of arthroscopic surgery in the treatment of sports injuries that might lead to osteoarthritis and total joint replacement in the treatment of severe arthritis. All of these advances were the result of research. All will significantly reduce the burden of arthritis to society.

The need for more advances is great. The opportunity to make such advances through research has never been brighter. The disparity between the need and opportunity, on one hand, and the support requested for NIAMS is glaring.

Arthritis Foundation funding recommendations for the National Institute of Arthritis and Musculoskeletal and Skin Diseases

I am here today to thank you for your generous support of last year's National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) funding request. However, this year, we again need your support this year for increased funding of the National Institutes of Health. Specifically, we urge the Subcommittee to support increased funding for the NIAMS by providing a $47 million increase in funding over the President's fiscal year 1992 budget, for a total of $252 million to support the research and clinical trials needed to reduce the burden to society that disability from arthritis presents. This level of funding will accomplish the following: -Increase funding from 27 percent to 33 percent of approved grants. -Train additional researchers, for a total of 328.

Support urgently needed clinical trials. -Fund 4 additional research centers.

-Increase the intramural research program to $21.2 million.

This funding amount would fill the gap between patient needs and research opportunities and the federal investment in arthritis and musculoskeletal and skin diseases. This level of funding would also permit the Institute to proceed with funding of high priority research programs within their specific areas of expertise. Among the critical Arthritis research areas are the following.

-Discovering mechanisms by which estrogen prevents bone loss.

-Discovery of faulty collagen gene that causes a form of primary osteoarthritis. For most forms of Arthritis, there is no cure. While we recognize there are many worthy causes competing for limited resources, I urge you to remember that the current opportunities in medical research are greater, more numerous, and more promising than they have ever been in the history of modem science. Our scientists can deliver on the promise of medical research only if we provide the support they need. While much has been accomplished in addressing the problems of arthritis and musculoskeletal and skin diseases, clearly there is a great deal yet to be accomplished and much work to be done. For this to be accomplished, it is imperative that Congress appropriate funds sufficient to permit the Institute to keep pace with these opportunities and to undertake new initiatives so vital to research in arthritis. The Arthritis Foundation asks your support for funding of the NIAMS at a $47 million increase in funding over the President's fiscal year 1992 budget.

The Arthritis Foundation urges this Subcommittee to continue its record of support for biomedical research in fiscal year 1992. Thank you for the opportunity to present our views. I would be pleased to answer any questions.

STATEMENT OF LOWELL A. GOLDSMITH, CHAIRMAN OF DERMATOLOGY, UNIVERSITY OF ROCHESTER, AND CHAIRMAN, COUNCIL ON RESEARCH, AMERICAN ACADEMY OF DERMATOLOGY

Senator BURDICK. The next witness will be Dr. Lowell Goldsmith, American Academy of Dermatology.

Dr. GOLDSMITH. Thank you, Mr. Chairman. I am Lowell Goldsmith. I am chairman of dermatology, University of Rochester, Rochester, NY, and I am chairman of the Council on Research of the American Academy of Dermatology, which represents 9,000 dermatologists. We would like to thank this committee for their previous very generous support that they have shown to NIAMS.

In my written testimony I talk about some of the needs and some of the accomplishments and some of the opportunities. I think the needs, the patients who have come before this committee can really more eloquently describe than I can.

This is a very young Institute; the Institute is 5 years old. And in its vigorous and productive youth it already has many accomplishments. The Institute is counting upon this committee for the further growth that it needs to go through, the usual growth phase of an adolescent after the period of youth.

I think the Institute looks upon this committee as the godparents of the Institute. You really have to look out for the Institute and support its growth, and for that reason the coalition is asking for an additional $47 million so that NIAMS can expeditiously obtain many of the goals which the Congress and the people wanted.

In my written testimony this year, I have emphasized skin cancer and the importance of understanding its mechanism and its prevention. It is a consequence of people's work habits and living habits, and is a very common problem for people who have to farm for a living, as still many people do in our country. NIAMS supports much of the basic research related to the cells that form skin cancer, and to the way light causes skin cancer.