CANCER RESEARCH BY DR. SZENT-GYÖRGY

Mr. SHRIVER. On April 29 there was an article in the Washington Evening Star regarding the claims of a Dr. Szent-György, a former Nobel Prize winner, that he has the answer for curing cancer but can't find financing for his project.

Are you familiar with his research?

Dr. MARSTON. I have known of his work in general over the years. He is a man that has contributed to the scientific literature for many, many years.

Mr. SHRIVER. It looks as though there is going to be additional money for cancer research to be administered from NIH. Is it possible his experiments will be funded from NIH?

Dr. MARSTON. It is certainly possible. We seek the best ideas and the best research projects that we can find to achieve the goal of unraveling cancer.

Mr. SHRIVER. I don't know anything about him; I just read the article.

Dr. SHERMAN. He has been a grantee of NIH for many years.

REQUESTED PROGRAM INCREASES

Mr. SHRIVER. You mentioned substantial increases required for genetic research on sickle cell anemia. What other specific areas received increases?

Dr. MARSTON. There is a request for an increase in population and family planning research. I could go down the list of increases.

Mr. SHRIVER. Place it in the record and also the cutbacks.

Dr. MARSTON. Yes, sir. The largest increases that we have, of course, are the cancer program, Sickle cell anemia and population research. There are about two pages that summarize the increases and decreases.

(The requested information follows:)

1 Increase of $205,000 in materials is included under national caries program.

PROPOSED CHANGE IN TRAINING GRANT PROGRAM

Mr. SHRIVER. You will be paying funds for faculty salaries in all research training grants in a lump sum directly to the deans of the institutions if I understand your testimony?

Dr. MARSTON. For those institutions that are eligible for support by that mechanism, yes, sir.

Mr. SHRIVER. You said it would give the deans flexibility in the use of the funds?

Dr. MARSTON. Yes, sir.

Mr. SHRIVER. What do you propose to accomplish by this change? Dr. MARSTON. The goals of this change are modest. We do not expect that there will be major changes in the actual distribution of these funds largely because the requirement is that the same activitythe training of researchers-will be maintained.

The first point is that one should not get the idea there will be major, sweeping changes in the distribution of these dollars. Any given institution will get the same amount of funds it would have gotten if we had not changed the mechanism of giving it to them.

The benefit we would hope-and, quite frankly, I don't think any of us know how well this will-is that by allowing greater flexibility the Federal Government will get somewhat more effective use of the dollars than we would have gotten otherwise.

FUNCTION OF THE NATIONAL LIBRARY OF MEDICINE

Mr. SHRIVER. On page 16 of your statement, you say the National Library of Medicine's role is much broader than is usually meant by the word "library" and it is in fact a national communications center for biomedical information.

Dr. MARSTON. Yes.

Mr. SHRIVER. Why don't you change the name of it then from library to reflect whatever the activity is?

Dr. MARSTON. I hope this is a question you will bring up with Dr. Cummings. One answer is that it is our belief that libraries in general have an appropriate role that goes beyond being a repository of books-and that included in the word "library" is the sense that they are there to facilitate the exchange of information.

Could I ask Dr. Cummings if he wants to comment?

Dr. CUMMINGS. The major reason the change has not taken place is really historical precedent. The institution known as the National Library of Medicine has had this name for 135 years and I think that is an impediment to changing the name.

What I believe would happen, however, in the context of your question, is that someday the Library of Medicine will be a component of the center for biomedical communication, that there will be an inversion of the program so that the communications center will be the parent of the library.

At this point in its history, the center is so small in relationship to the parent library that a change of name wouldn't accomplish much. Mr. SHRIVER. That is a very good answer. Thank you.

Mr. FLOOD. Mr. Patten.

Mr. PATTEN. Doctor, earlier you said you are happy that things are a little bit better as far as money goes particularly for clinical research involving bed patients. I wonder if you would explain this.

Dr. MARSTON. No. I meant research that involves patients. The problem that we have had under a stable dollar budget is that the cost of taking care of patients has gone up much higher than other costs in our economy. Where our research was dependent on paying hospitalization costs, we had an increase averaging 15 or more percent and with a fixed budget we had particular problems in maintaining the level of research.

Mr. PATTEN. It is not you have some new leads as to taking care of people that have to lie in bed a long time?

Dr. MARSTON. No, sir. Although we have new clues and leads in almost all areas of biomedical science.

PRIORITY OF ARTHRITIS RESEARCH

Mr. PATTEN. One more question, Mr. Chairman. All the fellows my age have arthritis. It looks like you made about 10 transfers out of the arthritis fund. Is it you don't have any real leads on arthritis to inspire you to expand the program? Also, you are the first doctor that mentions the word "liver."

Dr. MARSTON. Yes, sir. I hope this can be pursued when Dr. Whedon is here to talk about the specifics of the problem. Certainly the problems of arthritis constitute one of the major health problems of the American people, and it is a major responsibility of that Institute. There are important and difficult problems that are being worked on in the area of arthritis.

I could mention a number of them. During the past few years the possible relationships between infectious agents, in some form, and arthritis has aroused a lot of interest. There are other examples that I hope Dr. Whedon will have a chance to speak to in this area. Mr. PATTEN. That is all, Mr. Chairman.

Mr. FLOOD. Mrs. Reid.

Mrs. REID. Thank you, Mr. Chairman.

PHYSICIAN ASSISTANT TRAINING FUNDS

Doctor, last year you indicated that the 2-year program to train physician assistants was quite successful. Do you still feel this is true? Dr. MARSTON. I would like to get Dr. Endicott to expand on this. While there was that early program, and some other early programs, there are now a number of alternative ways of looking at the general problem of training individuals who can expand the usefulness of physicians.

Dr. Endicott, I think you reviewed that program not long ago. Would you comment on this question?

Dr. ENDICOTT. Up to now the administration has looked upon the physician assistant approach more or less in an experimental framework. This year's budget proposes $15 million specifically for training additional numbers in various facets of physician assistance. So we are clearly moving from an experimental to a production phase.

Dr. MARSTON. Duke is one of the good ones and there are other possibilities we are supporting.

Dr. ENDICOTT. There are probably upwards of 75 different institutions in the country with plans to have physician assistant programs of some sort. The ones at the University of Washington and the Medex program and the program at Duke are pioneer programs, but the idea. is catching on all over the country.

PHYSICIAN-POPULATION RATIO IN SOVIET RUSSIA

Mrs. REID. Last year I asked you Doctor, about the number of physicians we have in the United States in proportion to the population, compared with that of other nations of the world, for instance Russia. And you indicated you would better be able to answer such a question this year because you were going to visit Russia. Dr. MARSTON. Yes.

Mrs. REID. Did you make that visit?

Dr. MARSTON. I made that trip and I learned several things other than just numbers.

The U.S.S.R. has about twice the number of physicians we have in this country.

MALE-FEMALE RATIO AMONG RUSSIAN DOCTORS

Mrs. REID. What about the women physicians in Russia?

Dr. MARSTON. About 70 percent are women, which is a reflection both of the high mortality of men during World War II and also what, I think, was a sense that there are particular opportunities for women in medicine.

The ratio of women to men in the entering classes in medical school has been dropping so it is closer to 50-50 now. When one projects this into the future, one would expect that there will be a lesser predominance of women in the future compared to the immediate past.

While it was not possible to get them to say this was a policy— indeed when I asked about the selection of people for medical school they said women versus men it is the same, it makes no difference, it is a competitive examination.

Yet there has been a change in distribution all over the country, and it undoubtedly reflects some sense of a change in the distribution of women doctors.

Incidentally they feel, although they have something over 600,000 physicians, that they don't have enough physicians and they are planning to expand the number.

THE RUSSIAN FELDSHER

Mrs. REID. You also said that at that time the Russians were reexamining whether they were able to give quality care with relatively independent and unsupervised people.

Dr. ENDICOTT. The point they made is that the Feldsher is not a physician's assistant, the nurse is. The Feldsher is trained specifically to do specific jobs such as in the sanitary area, such as in the first aid stations in industry or such as working in emergency care situations in a remote area, usually with a midwife. They said that our concept that the Feldsher is a physician's assistant or substitute was

an erroneous one.

Individuals are trained for specific purposes. Their goal is to replace all of the midwife Feldshers with physician midwife assistants. If a Feldsher wants to become a physician he has to take additional education and he then stops being a Feldsher and becomes a physician.

FOREIGN M.D.'S IN THE UNITED STATES

Mrs. REID. Is our dependence on foreign medical graduates to provide patient care still on the increase?

Dr. ENDICOTT. Let me say factually that we still have large numbers of graduates of foreign medical schools. They do give patient care and if they didn't, our problems in delivery of patient care would be even greater.

So in that sense, I think, the answer to your question is "Yes"; that we are dependent upon the fact that we have a sizable number of