Service has been a leader in research and the development of techniques to grapple with the changing TB picture. The Public Health Service, through its grants to States program, has stimulated case finding and prevention efforts within the States. A reduction of funds for this program will result in a corresponding curtailment of the TB control activities within these States. These funds, which amounted to some $4,500,000 during the fiscal year 1958, support projects and personnel which ordinarily would not have been available. There exists, to be sure, the possibility that the various States would increase their appropraitions for TB control. Unfortunately, many State legislative bodies meet only once in every 2 years and thus will not be afforded the opportunity to appropriate additional funds should the Federal grants to States portion of the TB program be reduced.

Nineteen hundred and fifty-nine is by all means not the year to reduce our efforts. Vital projects such as the isoniazid prophylaxis studies conducted by the TB program are now underway, which may give us real short cuts to our goal of eradication of TB. Increased research activities into the cause and cure of TB must be forthcoming lest we accept the existence of TB as a natural hazard to be faced by many future generations. The National Tuberculosis Association board of directors was greatly disturbed to learn that the PHS had requested $1,614,000 less than the amount appropriated for fiscal 1958. Surely, when one considers the size and scope of the TB problem today, and the fact that almost one-third of our population or an estimated 50 million Americans are already infected with living, virulent tuberculosis germs, and as such are a potential reservoir of new cases and new infection, the cutting of funds for program and research is not justified.

The board of directors of the National Tuberculosis Association strongly recommends the restoration of the $1,614,000 in order that the TB program of the PHS be held at a level which approximates the minimum standards which this country should maintain.

The National Tuberculosis Association has followed with great interest the activities of the Institute of Allergy and Infectious Diseases. This group, through projects supported wholly or in part, is devoting approximately $1 million of its $10,800,000 available for research grants during the present fiscal year for basic TB research. Unfortunately, this amount has not been sufficient to cover the many additional research projects dealing with respiratory diseases, including TB, that have requested support from this Institute. It would seem logical that a concerted effort in the field of research, coupled with the preventive program of the PHS, would in time reduce the human misery, as well as the exorbitant cost to the public.

The National Tuberculosis Association recommends that the Congress increase by $5 million the amount of funds to be made available to this Institute for 1959, and of this increased amount, research relating to TB receive a proportionate share of the funds so available.

The health and welfare of the American Indian has continued to be a major concern of the National Tuberculosis Association. The deplorable health conditions to which these people have been subject have to some degree improved within the last few years. This improvement has, we believe, been a result of the leadership and the improving program of the Division of Indian Health, PHS. It is also gratifying to know that this program has received the understanding and the financial support of this committee. However, like the tuberculosis problem in this country, improvement is a matter of comparison. True, the health standards of many of the Indians has shown an improvement, but by comparison to the remaining population in this country, the American Indian today is in a situation which approximates our Nation's general health of a half century ago. Tuberculosis remains a major problem. Most recent published figures show that the incidence of TB among the American Indian is still nine times the rate of the non-Indian population.

This, coupled with the myriad of other ailments, the growing Indian population, the increased need for health services, especially in the area of outpatient care, has convinced the board of directors of the National Tuberculosis Association that an appropriation of $5 million in addition to the amount appropriated in 1958 is urgently needed to improve the substandard health conditions of the American Indian.

The National Tuberculosis Association is deeply appreciative of this opportunity to present to this committee its information in regard to matters of vital interest to the health of the American people.

Dr. STOCKLEN. I will try to summarize this very briefly, the four points made by the board of directors. The first is the budget of the Public Health Service. Last year that was $7 million for the tuberculosis program and this year it has been cut $1,614,000.

The reason given by the Department of Health, Education, and Welfare was that this reflects the advances made in the control of tuberculosis. In the first place, I do not think there has been 23 percent advance in the control of tuberculosis and this represents 23 per

cent cut.

Second, the control of tuberculosis in the United States last year cost $752 million. This money, the $7 million, particularly the $1,614,000 being cut, represents almost entirely preventive activities, case finding, and research in drugs. Therefore we believe that this cut should be restored.

The second point is the budget of the Institute of Allergy and Infectious Diseases of the National Institutes of Health. This group through its projects supports basic research in tuberculosis to the extent of $1 million. This is one of the most important of all our basic research sources of funds. The total amount of money spent for tuberculosis research is only about $3,961,000. It represents less than one-half of 1 percent of the cost of tuberculosis in the United States. I think Dr. McDermott may speak a little more to that.

The other program I want to talk about is the program of Indian health. In the last 4 years there has been, I believe, particularly in a certain area I am interested in, a tremendous improvement in the health of the Indians although it is still very bad. I went to Alaska 4 years ago with the Parran survey team. When we got there we found conditions really deplorable. The waiting list among that small group of 35,000 Indians, Eskimos, and Aleuts for tuberculosis hospitals was 1,500. This year there is no waiting list. In the meantime large sums of money were expended. The tuberculosis death rate was 329 per 100,000, among this native group. In 1956, the last year for which we have figures available, it was 88.9.

The Federal Government contracted to care for these people, these natives, in the State of Washington, I believe, at a cost of $4.5 million. Those beds now have been entirely closed out so that that expenditure will no longer be needed. We believe the money expended in the past has shown that it has really produced results. We therefore request that the appropriation for operations for the Indian health program be increased $5 million. We are not asking for an increase in the funds for construction. We very frankly feel although Congress has appropriated the money there has been a very distressing slowdown in construction for reasons that we are not sure of and we are therefore not asking increase for construction until this money which has been appropriated has been spent.

The last item I would like to talk about is the Communicable Disease Center in Atlanta. Last year in September a committee of the National Tuberculosis Association visited that center, we were very much impressed with the work being done there. We were very much distressed with the facilities. The building, as you may know, is an old Army barracks type of place, completely unsuited for this type of thing. But they do have a number of devoted people who we believe are doing excellent research and we think they should have more adequate quarters.

I thank you for the time to present this.

Mr. FOGARTY. Thank you, Doctor.

Dr. McDermott, please give us your statement.

STATEMENT OF DR. WALSH M'DERMOTT

Dr. MCDERMOTT. Mr. Chairman and members of the committee, I am Dr. Walsh McDermott, the Livingston Farrand professor and chairman of the department of public health and preventive medicine at Cornell University Medical College, which is at the New York Hospital-Cornell Center, New York City.

Also I am a member of the National Advisory Health Council and editor of the American Review of Tuberculosis.

I have prepared a statement for submission, Mr. Chairman.
Mr. FOGARTY. We will include that in the record.

(The statement referred to follows:)

I wish to make a plea for substantial increases above the budget estimate for two programs of the National Institutes of Health. The first is the National Institute of Allergy and Infectious Diseases-the second is the little known Division of Research Grants which has the official budget listing of "General research and services."

These two programs together form a major part of the underpinning on which all the other Institute programs are based yet they have not been receiving support commensurate with their importance in the medical research program as a whole.

Unlike the other Institutes, the Institute of Allergy and Infectious Diseases has the responsibility for a wide range of diseases, each one of which constitutes in its own right a major public health problem. As the committee knows, the range goes all the way from the troubling, but nonserious colds and respiratory infections, through such potentially serious diseases as Asian influenza, pneumonia, tuberculosis, and hepatitis (jaundice) to the postoperative infections which_frequently compromise the gains attained by modern surgical procedures. Like the other Institutes, the research effort in this wide field of diseases is conducted both in the intramural program at Bethesda and through grants to research scientists in the universities and other nonprofit research laboratories throughout the entire country. In a very real sense, the research conducted in these laboratories represents a program which backs up the programs for many of the other major programs especially those of heart, cancer, and arthritis. For, in order to keep any advance made in these other fields, it is necessary to have an increased fund of information on how to strengthen the bodily defenses against infection and how to develop and use new drugs for the treatment of infection. common experience to see a real therapeutic advance made in, say, cardiac surgery, or in the treatment of a blood disorder, only to see the patient die of an infection, and many of the present day new treatments for heart disease and cancer actually increase a person's chances of developing an infection.

Until 2 years ago this major area in our medical research field was not getting major support. Because of this lag in attaining balance in the medical research picture as a whole, there was a very large backlog of highly recommended research projects which could not be supported. The first substantial increase in this appropriation which was made 2 years ago was an enormous help in getting this major area of research back in balance with the total health program of the Nation. Because of the long previous lag in support, however, even the substantial increase was not enough to support all of the projects with high scientific approval and by the time the year was two-thirds over, virtually no new projects at all could be supported. Despite this fact, as the chairman may recall, I made a plea for this Institute last year only for the amount recommended in the budget estimate. This was based on the idea that it is sometimes unwise for a program to expand too much in any 1 year. It was stated that the amount in the budget estimate would not meet the whole need-but it was hoped that the most pressing needs could perhaps be met. The latter hope proved unfounded; the program just fell further behind.

Accordingly, this year I am making a plea for an increase of $5 million above the budget estimate for the intramural and extramural programs of this Institute.

In addition, I would like to plea for at least an additional $1 million for a traineeship program in this field of allergy and infectious diseases.

In what direction could the program be expanded if such expanded support could be obtained?

A major effort, in my opinion, should be made in the field of attempting to develop vaccines against tuberculosis and a number of other infections-notably staphylococcal infections (the microbes of carbuncles and boils). I am talking not just about vaccines per se but about research on the phenomena which when properly studied lead to successful vaccines. The present extramural program is supporting a number of projects in this field in general, but is not really able to mount a major attack for lack of funds.

For example, there are grossly inadequate facilities for experiments on tuberculous animals in just about every laboratory enaged in tuberculosis research in this country. I am associated with Dr. Rene J. Dubos in a program in tuberculosis vaccine research on a vaccine developed by him. We have been working with mice but have now arrived at a critical phase in the experiments where we need facilities to keep 100 tuberculous guinea pigs for perhaps 4 or 6 months. Dr. Dubos has the extensive research facilities, for infection, of the Rockefeller Institute and I have the comparable facilities at the New York Hospital-Cornell Medical Center directly across the street. Yet between these two great centers we cannot find housing for infected guinea pigs and we are actually having to set up our experiments in Montana and travel back and forth from New York City. We have learned to control the plagues from without, and the waterborne and milk-borne diseases, and to some extent we have learned to control the diseases which sweep from person to person. What we have not yet learned and what is badly needed are vaccines or other methods for the artificial increase of our body's ability to cope with tubercle bacilli and some of the commoner microbes.

An increase of $5 million above the budget estimate for the Institute for Allergy and Infectious Diseases would permit a considerable expanded research effort on this highly important subject of artificially increasing the body's defenses against the commoner microbes including the microbes of tuberculosis. Such an appropriation increase would also allow the Institute to start the support of the very large number of approved projects in the fields of allergy and virology for which no support is presently available.

I would like to turn now to make a plea for a large increase for the item "General research and services."

This is a little-known part of the National Institutes of Health program, and yet it is one of the most important of its many activities.

The item "General research and services" refers to a Division which is not related to any of the categorical Institutes and which is known simply as the Division of Research Grants.

I have rather intimate knowledge of the function and activities of this Division as I am a member of the National Advisory Health Council, the body which reviews all the requests for this Division and makes recommendations to the Surgeon General. The Division was established in 1945 to administer some 50 research grants to which the National Institutes of Health fell heir upon dissolution of the wartime Office of Scientific Research and Development. The domain of the Division, within the limits of its budget, included all extramural research in medicine and the health sciences, both basic and applied, with the sole exception of research having to do with cancer. The latter was financed through funds granted by Congress to the National Cancer Institute. With the subsequent establishment of the National Heart Institute (1948) and other Institutes, research grants of peculiar interest to them were transferred. The Division of Research Grants served as the feeder of research projects to the several Institutes, as research previously basic and supported through Division of Research Grants funds developed, after a longer or shorter time, applied aspects that attracted the support of an Institute. This has become a most important mission of the Division. I do not mean to imply that all research projects supported by the Division are eventually transferred for support to one or another. of the Institutes. The Institutes are now however carrying at least 500 projects that were originally reviewed by the National Advisory Health Council as general research projects. Each Institute has, of course, many other research projects that were initiated directly.

Currently, the funds appropriated under "General research and services" support about 800 projects. Of the 800, roughly 200 projects consist of some area of research not falling within the interest of the Institutes. For one example, the Division is actively supporting research directed toward reducing fetal deaths and deaths of the newborn, toward arriving at an understanding of the causes of

congenital deformities and other congenital impairments, and toward attempting to reduce the appalling mortality and disability resulting from automotive crashes on our highways.

Contrasted however with the magnitude of the basic knowledge that must still be gained for the successful conquest of disease, the program of this Division is unfortunately much too small.

From the limited funds available to it, this Division has been largely responsible for sparking a program in research and in the training of scientists in the field of so-called molecular biology, i. e., the marriage of the technics of the physicist of Massachusetts Institute of Technology with the technics of the medical scientists. This is leading to far more precise studies of how the body works, than was previously possible.

I have given you the figure 800 as the approximate number of projects the Division is now supporting in its current research program. There are, however, nearly 300 other investigators who have applied for research funds and whose projects have been recommended as worthy of support by the Advisory Council on which I serve, but who will be turned away empty handed this fiscal year. Medical and biological scientists are in short supply, yet 300 who are competent and eager to invest their effort in these less than sure-fire research areas are waiting for funds or perhaps must even go without funds with which to carry on.

When these investigators attempt to get funds elsewhere they find that basic research is handicapped in its search for support by lack of the emotional appeal that is so characteristic of applied research. To supply these empty handed 300 next year would alone call for another $4 million, above the present budget for the Division of Research Grants. But next year a new lot of investigators will also be knocking at the doors with new projects stimulated by another year's march of science. A conservative estimate would set the figure for these additional doctors of philosophy and research-minded medical doctors at an additional 400 to 500. Six million additional dollars will be needed to finance their investigations.

In my judgment, therefore, an increase of $10 million over the budget estimate for this item "General research and services" is urgently needed. The research projects thus supported would constitute a sound investment of public funds in the health of the Nation. For the very same reason I would urge the committee also to consider increasing research fellowships and research training grants of "General research and services." An additional $1 million for fellowships and an additional $5 million for general research training grants would pay tremendous dividends in public health and advancement of research totally. These research fellowships and research training grants support the training of future independent investigators in all the sciences basic to medicine and will largely constitute the pool from which fundamental investigators of the future will be developed.

The need for additional funds for training and the need for increase in support of general research projects are inseparable. Each related directly to the other. I would like to illustrate this point through description of a type of research of increasing usefulness today. I refer to research using what is called the epidemiologic approach. It is costly, but can given provisional answers to many questions simultaneously. Does rural life, for example, carry with it any greater life expectancy, physical endurance, fertility, adaptability to climatic extremes, lessened chance of coronary arterial disease, greater resistance to tuberculosis or cancer, freedom from respiratory diseases, peptic ulcer, brain tumor, than does city life? Or does one kind of diet give a person an advantage in any of these (or other) respects as compared with another? Are some occupations more favorable and others less? Do certain previous habits (e. g., smoking) predispose to certain diseases? A single epidemiological study can give simultaneous provisional answers to a whole battery of such questions. No other method of research

can.

There are comparatively few research epidemiologists in the country and they are hotly sought after by research workers in heart, cancer, and the other research fields. The Division of Research Grants now administers a fund for training more epidemiologists and giving them expertness in mathematical and statistical analysis, tools necessary in their researches. The cost of epidemiologic research is so great, however, that this fund has been spread only among some 20 schools. These are mostly schools of public health. There are at least 10 medical schools ready and waiting to join these when funds are available, and 60 more in which epidemiologic research should be stimulated but cannot be undertaken as yet for lack of funds.

To sum up: Two of the most important programs of the National Institutes of Health are also probably the least well known-the Institute for Allergy and