Dr. LANE. We are all for planning. We have been planning for several months. To be right to the point on your discussion of this, if the Surgeon General's Council, which I think is going to be composed of 12 people, if this Council is to receive from all the States recommendations from the local committees in addition to the medical school-oriented type of complex, they are going to have such a monumental job it might be 2 years before they get it off the ground.

So my comment and reaction to what you would state is, I think, the regional committee would probably expedite the results much more rapidly. The policies could be established by the National Council, but a regional council could certainly expedite the planning phase of this so that we would not delay any longer than is absolutely necessary.

Mr. GILLIGAN. My response, Doctor, would be that some sort of at least informal regional advisory boards are going to be necessary to avoid cutthroat competition within regions of the country for these complexes, and to attempt to develop some measure of cooperation in coming up with the best plan for a given region.

But I have felt, sitting in local government as I was for 12 years, watching the operations of such programs as urban renewal, that the programs would have been sounder if more plans had been rejected out of hand as ill-conceived and ill-prepared, rejected at the top level, and the communities had been required to come up with sounder programs, rather than just funding them too quickly in order to justify the continuation of the program.

It would be my hope that that procedure would be adopted under this program. I think the program is basically a good one, and I have been much persuaded by what I have heard from Dr. DeBakey and his distinguished panel. But there is quite a gap between a good idea and its proper implementation, and if we rush it too quickly we are liable to foul the whole thing up.

Thank you, Mr. Chairman.

Mr. ROGERS of Florida. Any other questions?

Mr. SATTERFIELD. Mr. Chairman, I would like to ask one followup question.

Doctor, you mentioned that you thought regional councils might be preferable. Do you have any thoughts as to how these regional councils would be created, and who would appoint members to them?

Dr. LANE. At this time, at least in our area, I am not familiar with other areas, we have a regional hospital planning council which is divided up into areas throughout the State. The purpose of this is, I think, to plan so that there will not be an overexpansion of expensive hospital facilities, leading to the type of competition between adjacent institutions which will detract from their basic purpose, which is to take care of sick folks, and, perhaps, a combination of this sort of group locally already has the expert knowledge, they have already had the experience, of organizing their local planning, their local hospital planning groups, and in conjunction with the medical schools, et cetera, might be the type of group that Mr. Gilligan was discussing.

Mr. SATTERFIELD. These groups you have in your State, were they created voluntarily or were they created by your State legislature? How did they come into being?

Dr. LANE. They were created as a side reaction to area development, an area development

Mr. SATTERFIELD. Who created them?

Dr. LANE. I think it was fairly voluntary, primarily that of-with relation to the hospitals now, it was primarily that of-the Connecticut State Hospital Association in conjunction with a group of organized trustees of hospitals in our State, and the Commissioner of Health as the spark plug.

Mr. SATTERFIELD. Thank you, sir.

Mr. ROGERS of Florida. Any further questions?

Doctor, I see that you are Chief of the Department of Thoracic and Cardiovascular Surgery, and take a very active part in your hospital.

Do you feel that by creating some regional medical complex it will help you at your hospital?

Dr. LANE. Yes, I do, Mr. Rogers.

Mr. ROGERS of Florida. How will it help you as a physician? Do you have time to go up there, to go to the regional complex?

Dr. LANE. Well, I have not had.

Mr. ROGERS of Florida. Do you anticipate that you would?

Dr. LANE. I anticipate that I will have to.

Mr. ROGERS of Florida. Will all the doctors do the same?

Dr. LANE. I would gather that many of the physicians, particularly those who are interested in our specialized programs in the hospital, will take part in this sort of thing.

Mr. ROGERS of Florida. Don't you have any education programs now?

Dr. LANE. Oh, yes. We have a very active education program. Mr. ROGERS of Florida. Isn't this fairly true throughout the country? Dr. LANE. As far as I know, there is a considerable postgraduate medical education program. But the difficulty lies in getting it to the general practitioner, and the reason for this is, I think, very simple. A man in general practice-and I know, because I was a general practitioner for about 10 years, a man in general practice-works anywhere from 15, 16, 18 hours a day if he is solo in his practice, and if he leaves his practice he leaves his livelihood to go away and get some postgraduate training.

Now, no physician is unwilling to make the sacrifice if he feels it is going to do him some good. But locally we have found that we have to produce a colossally excellent program to get our men to take the time away from their practice at our local level in order to get them to come into our postgraduate medical education program.

The telephones are ringing, they are jumping up from the conference room, they are in and out all the time. This is routine.

But if we could just make it a little bit easier for them to do that on our community hospital level without having to travel too far, we think we can extend the input and knowledge by maybe 25 or 30 percent, and that may help in our communications program.

Mr. ROGERS of Florida. Do you think the main thrust of this program to help a physician would be in local community hospitals where you could set up these programs on a local basis?

Dr. LANE. I would hope so.

Mr. ROGERS of Florida. Well, now, I see that you recommend that funds be made available to have a director of clinical services in each of the hospitals, if possible, to try to run these programs. It would be his duty, would it not, to try to have these educational programs going on? Is that what you envision?

Dr. LANE. The director of clinical services would be a full-time man to coordinate the activities, the clinical activities, of the hospital. We think that the director of medical education should be separate from him. Perhaps he could work with the director of clinical services, but it should be a separate organization.

Mr. ROGERS of Florida. Thank you very much. The committee is grateful for your coming and giving this testimony, Doctor.

Dr. LANE. I appreciate your courtesy, gentlemen. Thank you. (The statements of Dr. Lane follow :)

TESTIMONY BY WARREN ZEPH LANE, M.D.

Congressman Harris, distinguished members of the committee, I am Dr. Warren Zeph Lane, Chief, Department of Thoracic and Cardiovascular Surgery, and a member of the Research and Clinical Study Committee of the Norwalk Hospital, Norwalk, Conn. I am also president of the Norwalk branch, Connecticut Division of the American Cancer Society, and chairman of the Protocol Subcommittee on Thermography of the American Cancer Society. I am a charter member of the Connecticut Society for Medical Research.

My purpose in appearing before the committee is to augment the data I filed for the record in support of Senate bill 596 and to encourage the committee to fill out the resolution with further provisions. In support of the original premise that the community hospital needs this aid, I would also offer the suggestion that postgraduate medical education at the community hospital level has become a necessity for the purpose of closing the time lapse between conception and practical clinical use of medications and instrumentation. To this end, our hospital director of medical education has initiated conferences with Dr. Arthur Ebbert, assistant dean, Yale University School of Medicine. The substance of these talks is to enlarge and enrich our teaching program at all levels so that a formal program of participation in clinical and didactic activities may be accomplished. A formal proposal will result from these talks and will, we hope, be acceptable to the council as outlined in section 905 of the bill. Funding for the salary of the director and his staff and the charges due Yale University for the program will be a fundamental factor in the success of the educational experience for the hospital staff.

Under section 901 (c) I would encourage the committee to provide for funds to augment the hospital staff and administration thereof. This provision should be for a director of clinical services who will be employed by the staff and trustees to coordinate the clinical and research activities of the community hospital. The director should be full time and a man of broad experience in the management of patients and have aptitude for administrative functions. I recommend a salary of not less than $25,000 per year and an administration fund of not less than $15,000 per year to pay for secretarial and general expenses.

I have examined the report and hearings of the act passed on June 29, 1965, by the Senate as outlined in S. 596. Special reference is made to the report of the Presidential Commission's Subcommittee on Research. In this area of effort the Norwalk Hospital, we believe, can make an exceptional mark for other community hospitals to emulate. The Norwalk Hospital was the first to

(a) Establish an artificial kidney team in Connecticut. We have made a report on our activities, published in 1963, and our work continues. Funds for research support in this effort are urgently needed.

(b) Establish a cineangiography unit capable of any detailed diagnostic studies on cardiovascular disease. Funds for research with this device and clinical training for clinical cardiologists with this method are urgently required. The fundamental fact that precision in diagnosis can be achieved with this equipment should be emphasized. Prior to the use of this new equipment, much of our diagnostic work was a matter of interpretation of indirect measurements. Now the new objectivity and resolution obtained is very exciting, allowing, for instance, resolution of blood vessels with an internal diameter of one millimeter.

(c) Establish a unit of cryosurgery or the use of freezing devices in the removal of tissue for diagnosis or for the lens of the eye in cataracts. Much further work is needed to establish this method in other specialities.

(d) Establish an infrared thermography unit for research and clinical study of patients with cancer and vascular occlusive disease. Further work in this area will be most desirable to further correlate our findings in the early detection of breast cancer, and for the evaluation of patients with preclinical strokes due to occlusion of the neck vessels.

The above examples are very exciting to us and have seemed to unite the community agencies in their efforts to be of assistance in heart disease, cancer, and stroke.

In support of the program for international medical research and teaching the Subcommittee's report indicates there are plans to phase out some of these activities. I submit to you that it is more in our national interest to enlarge and enrich international biomedical research and education. My reasons are based on my limited experience in Kenya where we are working toward a development program which will include a biomedical research and teaching effort. In brief, our program in Kenya calls for more personal participation. What I am trying to say here is, that it is in our national interest to export our technical expertise and to import the bright people we find in underdeveloped nations. By this reverse-flow program, brought to great perfection by Reverend Robinson's Operation Crossroads Africa, and applied to the biomedical effort, I am convinced we have a counterinsurgency "weapon" of great value. I do not need to remind you gentlemen that Communist efforts to enslave free people include offers to build and staff hospitals and clinics and eradicate endemic disease.

The subject of the patent policy to be established for whatever devices or pharmaceutical products result from research financed by public funds calls for further legislation. A great many concepts or improvements have resulted from our defense and space activities that are not being exploited for the public welfare because of the controversial practices on patents. In order to prevent the delay or suppression of these ideas, concepts and developments, I recommend the following:

(1) Where it can be clearly shown that private funds have been expended as well as public funds, in the research and development of devices or pharmaceuticals, the patent should be allowed for royalties or the like for at least 5 years. The management of our applied science industries would be able to accomplish a great deal of good with such a policy and it would encourage them to make provisions for the budget and personnel to develop new concepts.

(2) Where a device or product is clearly developed with public funds the patent should be issued to permit that the royalties and the like be paid to the research laboratory from which the idea and development emanated. Thereby a source of money for continued activity is possible and will relieve to a degree the burden to provide recurrent budget from Federal sources. This would also give creative motivation to those who require more than fleeting approval to generate the desire to be scientifically productive.

Thank you for any consideration and the privilege of being here.

SYSTEMS ENGINEERING CONCEPTS APPLIED TO INTERNATIONAL HEALTH AND HUMAN FACTORS

(By Warren Zeph Lane, M.D., F.A.C.S.)

PROBLEM

The American physician or scientist when oriented to the problems of world health, human factors, and ecological relationships, is capable of contributions that were undreamed of or only partially implemented a short 10 years ago. This generalization applies to many medical scientists, practitioners, agricultural scientists, and development engineers trained in Western concepts. Many of our foundations and institutions with their interdisciplinary approaches and team research methods are providing leadership in these areas. But all the problems cannot be solved by the "one-disease research" approach, nor can the funds be unlimited for a broad-scale effort. Here lies the thesis for our concept of a management method, which, if applied to developing countries may be the catalyst that produces continuing action programs by providing an escalating source of income.

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PROBLEMS OF LEADERSHIP

The greatest single problem is the development of indigenous leadership in any developing country. To accomplish this educational and sociological efforts are puny in relation to the magnitude of problems. Many of the administrators are grossly overworked and understaffed both in quantity and quality of personnel. Those clerical and technical personnel who are willing to accomplish a workload often are inadequately supervised because of the time factor. Secondly, wage scales are minuscule and frequently delayed. Third, socialistic handouts of food, clothing and other perquisites are frequently used as incentives which contribute to undermined morale and petty jealousy if delayed or varied by bureaucratic whim. And lastly, endemic disease problems, particularly in the bush areas, devitalize the efforts the people are capable of.

Remedial methods are applied often because the previous administrator taught a concept which was his, and frequently these methods are at variance with tribal beliefs. Nationalism cannot be instilled into a population with such beliefs in the timespan of one or two generations without reference to anthropologic data. In some cases the tribal data is not available or is found in remnants and published by amateur observers. The introduction to a paper presented by Spencer is an outstanding example of professional observations which should be made in negotiating with emerging peoples:

"Little has been written on the religions of the Nilo-Hamitic tribes. This aspect of these societies has frequently been treated as if of a minor importance to the extent of being separated from the rest of the system which the writers are at pains to present as a structural and functional unity. In sharp contrast. the Samburu have a set of religious beliefs which, far from being background music to the drama of daily existence, force themselves frequently to the fore. This paper focuses on the belief in and fear of the curse. The curse plays a significant part in the resolution of crises and in socializations, it reflects the structure of the society, and it is interwoven with the norms of behavior. It thus plays a vital part in social control. As well as discussing all these aspects I shall discuss the nature of the curse in relation to other religious beliefs and practices of the society and to its ethos.

The Samburu are a Masai-speaking, cattle-owning, nomadic tribe of northern Kenya. For present purposes it may be assumed that it is sufficiently like the Masai society to need no lengthy introduction. The moran, though no longer strictly "warriors," are in a position ritually separate from the rest of the society and for a period of from 12 to 15 years, young men, of the age set most recently formed, observe a number of ritual prohibitions and do not marry until the end of the period when a new age set is formed. Girls are married at the same age as boys become moran, at about 15, and this results in a high proportion of married women to married men, and a high degree of polygamy among retired moran, or elders. Crosscutting the age-set system is a segmantary clan system, not based on the concept of lineage, but specifically defined nevertheless. This definition of segmentation concerns the ritual and legal norms of behavior between segments at different levels, and below the level of the clan, which is exogamous. Many of these norms are those of the moran. Corporate feeling within the clan is very marked, and an individual tends to be associated with his clan throughout his life. Judging from the literature of other Nilo-Hamitic tribes I would say that the corporateness of the clan among the Samburu is stronger than elsewhere, and that, if this factor serves to weaken the corporateness of the age-set system within the tribe as a whole, it definitely strengthens it inside the clan." a

Social progress, therefore, based on Spencer's studies or the like, when properly interpreted and integrated into a project plan obviously will have a greater chance for success. If coupled with economic, fiduciary, agricultural, and conservation methods for the recognized ecological factors, more insurance for success is possible. From the beginning of such a project attainable goals must be the basis for each discipline recognizing and accepting budgetary management. If each discipline bases planning on the interdisciplinary method and continues with research and development programs as the variables arise, the

1 Forkner, Claude E.. "An International Medical School-Focal Point for an International University." N.E.J. Med., vol. 270, No. 26, pp. 1399-1403, Sept. 17, 1964.

2 Spencer, Paul: "The Dynamics of Samburu Religion," field notes, 1959; East African Institute of Social Research, Kampala, Uganda.