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some of the better equipped pharmaceutical houses to break down a large series of steroids into individual components, much as the cancer chemistry group has done with agents which are used to combat cancer.
I am sure that some of these companies—I hesitate to mention names are prepared or could be prepared to do this in a much more organized and systematic and large-scale way than medical schools,
medical schools we have today. Mr. FOGARTY. Would they be willing to do it on the same basis that the pharmaceutical companies are cooperating with the cancer chemotherapy activity?
Dr. WRIGHT. It is my hope we will get into this not only in this field but in perhaps some other areas and try to develop a program of this nature in certain areas such as the hormonal one-we will use that as an example—or such as further development of anticholesterol agents. Perhaps we will find there are certain chemical components within safflower oil or corn oil that could be brought down to something that could be taken in very small doses and would be much more potent than anything we imagine today. These are possibilities; but the average medical school laboratory is not equipped to do this on a big scale, whereas the large pharmaceutical houses are. It is something that I personally hope to see developed as a part of the program of the National Heart Institute within the next year or two.
I think it is important to have long-term clinical followup studies of cases. It is surprising how little we know about some phases of disease where patients should be studied for a period of 10 or 15 or 20 years or 2 generations. Therefore, clinics or groups where they are studying these patients over many years get to know a good deal about the life history of those diseases which were not known before.
For example, we have set up our own long-term anticoagulant clinic some 12 years ago. Now as you note from the reprint I gave you we have patients who have been studied for 10 years and actually some of them not included there have been studied for 12 years during which time they have been observed on the average of a period of once a week or once in 2 weeks so we really know what happens to these patients.
Frequently in the past if the man had a stroke the neurologist saw him. He was not seen by the neurologist when he had his heart attack, he went to the cardiologist. With something else he went to another doctor. Nobody really knew what happened to this patient and did not know his life expectancy and how likely he was to have additional strokes compared with other things.
Mr. FOGARTY. When a person has a stroke should he go to a heart specialist or a neurologist ?
Dr. WRIGHT. In our own team we have a cooperative group. We are interested in the thrombosing aspect of the stroke and the anticoagulant aspect. We have a neurologist who reviews all cases before a decision is made whether they should or should not be suitable for anticoagulation. As soon as he is past the immediate or acute stroke phase we call in the rehabilitation people because it is extremely important to start rehabilitation within the next couple of days.
Mr. FOGARTY. What about the average person? He could not take advantage of all these different doctors. What would he do? Who would he call ?
Dr. WRIGHT. I should think he should call probably a good internist or a good neurologist, whichever happened to be available.
Mr. FOGARTY. Are there many good neurologists? There are many more internists than neurologists.
Dr. WRIGHT. That is right, and more internists are now taking an interest in this because of the natural interest that has developed whereas before they did not pay any attention to it at all because nothing could be done anyway. Now they are taking an interest and I think a good internist can handle this type of case and make the decisions very well.
Dr. ANDRUS. It is in part a matter of communication. As information in regard to these possibilities reaches the general practitioner, he will be alert to the advisability of handling strokes in this way.
Dr. WRIGHT. This article was published jointly with one from the Mayo Clinic in the Journal of the American Medical Association to familiarize the general practitioner with this situation and to urge him to give it careful consideration.
Mr. FOGARTY. On this 10-year study you have two women doctors ?
Dr. WRIGHT. One is a doctor, Ellen McDevitt, who is our senior person in charge of our research fellows, worked with me more than 20 years except for some time out. She started as a technician, got so interested that she took time out to go to medical school, finished her residency and she has worked with me really a total of 20 years
The other is not a doctor but is in charge of the reference work and literary work and also runs the double blind tests where they are used as in the cholesterol study. She controls that. She has nothing to do with the direct care of the patients.
USE OF ANTICOAGULANTS
Mr. FOGARTY. Without my reading this whole thing, just what are your conclusions from this 10-year study of these hundred patients in the use of anticoagulants?
Dr. WRIGHT. We point out that, first and foremost is the need for very careful differential diagnosis, and we indicate the difficulties of making this diagnosis between thrombosis and embolism and hemorrhage. However, we suggest the methods by which such a diagnosis can be arrived at within a reasonable degree of certainty, but reemphasize its difficulties. We have followed groups of patients, the same patients, while they have been on anticoagulants for many months and off anticoagulants for many months, and have recorded the trouble they get into
under each regimen. We summarize our results in this block area. Shall I read that for the record ?
Mr. FOGARTY. No, I have read that.
Where should we go from here? This field certainly has had attention called to it by the President having suffered a coronary thrombosis, and then having a stroke recently, and taking anticoagulants,
as I understand he still is. I understand this is one area that we certainly ought to be doing more than we are doing now. I am wondering why we are not spending more money in this area and doing more research and going a little faster than we are going.
Dr. WRIGHT. I would only say that the rate of acceleration has picked up enormously in the last 3 years in many areas. We should intensify the activity still further. I would like to see other universities and other groups working intensively in this field.
Mr. FOGARTY. What about the pharmaceutical industry?
Dr. WRIGHT. The pharmaceutical houses are taking a very active interest, in fact they are producing a new anticoagulant about once a month. Unfortunately, except for one or two, there haven't been any very striking improvements but they are moving in that direction. Somebody could encourage them to do a larger service. Dr. Carl Paul Link isolated and synthesized about 200 coumarin compounds by 1945. They haven't all been tested in detail in man. Many of them have been tested in animals and the most likely ones were tested in man.
Mr. FOGARTY. Do you have any specific recommendation that you would like to make to this committee in this regard ?
Dr. WRIGHT. I would like to recommend that additional well-controlled series of patients be investigated with anticoagulant therapy.
Mr. FOGARTY. Similar to this project?
Dr. WRIGHT. He has promised us that as soon as he has enough material to release that seems safe, he will supply some for investigation immediately.
Mr. FOGARTY. Is it true that the Heart Association could help a person like that if he thinks he has a good lead, to help them in manufacturing this material, however it is made ?
Dr. WRIGHT. Dr. Stefanini has had considerable support from the Heart Institute and the Heart Association. It is possible he could be encouraged or supported to a greater degree.
Mr. FOGARTY. Who would know that? Dr. WRIGHT. It would be very easy to find out. I actually talked with him Saturday, as I said. He was so disturbed at that time that he probably couldn't have given me a very well considered answer, but would be very easy for us to have the proper group approach him and make sort of a survey, sit down with him and see where he is and where other people could help him.
I'think this is a very feasible way to do this and that it should be done.
He may not be ready to release his material to others yet, but I think that he would probably be glad to accept additional support.
There are several other areas, if I might mention them, that I think we should get into. One is the further development of the idea of the United States having its own primate, or monkey colony. This was covered to some degree by the testimony last year, and a committee has been studying this problem and has come up with fairly definite recommendations, indicating the type of facilities we need.
The importance of such a colony is that it will enable us to study in animals more nearly related to man than, shall we say, the guinea pig or the rat, various factors on a long-range basis.
For instance, the cause and development of old age. For a specific example, we could study the more rapid development of aging as a result of radiation. We could develop a good deal of information about the way in which reproduction takes place in the primate and the effects of various prenatal activities on these primates. We can study the question of stress in the development of high blood pressure, by subjecting them to stress, and other things of this importance.
I might point out that Russia has had such a colony for many years, and conducted it throughout the last war without interruption. This colony has made some interesting contributions although we
familiar with all of them, some of them we know about. They are
potentially very important.
This is a long-range project but I am convinced that this is something our country needs and needs to get underway. The cost of such a project, the building of it, to house 5,000 animals, including 800 breeding females, et cetera, is expensive-perhaps not in terms of the overall budget of the United States but it is expensive in terms of immediate requests.
It would require, for building facilities, approximately $9,250,000, 1957 dollars, and about two and a half million a year to operate.
A survey is being made to select the most suitable location for this colony, and this is one thing we should get into in an important way.
Mr. FOGARTY. It would have to be in this country?
Dr. WRIGHT. We think it would have to be in the United States. There is a colony off the island of Puerto Rico, but it is quite a few miles from San Juan. It is not in a place where you can get professors to go and spend a lifetime.
We should not depend upon Russia for information, and yet they have a well developed colony from which they are getting information.
Mr. FOGARTY. Who was running the colony on this island off Puerto Rico prior to this Government getting into the business? Dr. Andrus. It was run under Columbia University for a number
Dr. WRIGHT. That location is impractical from the viewpoint of the type of project we are interested in.
Mr. Forårty. That will be for neurology, apparently.
Dr. WRIGHT. What we need is something within easy striking distance of a university environment yet isolated enough so the monkeys don't pick up all kinds of human diseases. Boiled down, that is what it amounts to—adequate facilities and a long-range, 50-year viewpoint, not a 2-, 5-, or 10-year viewpoint, because we won't learn enough to do it on that basis. This is a long-term project for the benefit of the people of this country.
Finally, I should like to review briefly what I consider, at any rate, to be the reasonable budgetary need or request for this coming year for the National Heart Institute, including the grants to research institutions throughout the country, as well as support of the Institute in Bethesda.
I think-and Dr. Andrus will comment on this we should use a figure for new research projects of $26 million; for research fellows, $2,375,000.
Mr. FOGARTY. When you give us those figures like that, Doctor, compare them with what we are spending now, please.
Dr. WRIGHT. All right.
In 1958 for research projects, we used $19,364,000. For 1959 I suggest $26 million.
Mr. FOGARTY. Does that include 25 percent for overhead?
Dr. WRIGHT. The indirect costs in my opinion should be on the basis of 25 percent, but this is not included in the $26 million figure just mentioned. This $26 million figure is calculated at the present 15 percent overhead cost.
For example, if we used the figure of $19 million this year, and upped our indirect cost to 25 percent, we would in fact be depriving those who are actually working of something like $2 million, or whatever it would add up to, of research funds.
We would be going backwards in terms of research whereas at the same time we would be doing something which is absolutely essential for the medical schools. In other words, we should support our research completely. We shouldn't give money and then make it necessary for the medical school to go out and raise the money to support the laboratory that we are giving money to help.
Mr. FOGARTY. But this $26 million figure includes overhead costs up to 25 percent? Dr. WRIGHT. No. pardon me. It should be in addition. Mr. FOGARTY. To the $26 million? That includes 25 percent?
Dr. WRIGHT. No; that includes 15 percent. I understood that the 25 percent has not gone through. Is it true?
Mr. FOGARTY. That is the budget request. Congress hasn't acted yet, but the administration has put in 25 percent.
Mr. LAIRD. Mr. Chairman, I understood his figure of $19 million does include the 25 percent.
Dr. Andrus. He is using that as a hypothetical figure.
Mr. FOGARTY. The 1959 request includes 25 percent, 1958 was 15 percent.
Dr. WRIGHT. To restate this, we could use wisely $26 million for research, plus the sum needed to bring the overhead from 15 percent to 25 percent. Dr. ANDRUS. I think the figures speak for themselves. If you
take a 10 percent of $26 million, it means that you cut down the available funds for research by $2,600,000. At the rate of momentum which I think the widely distributed funds are now needed, I should say unequivocally that the overhead should be added to that. Ten percent overhead should be added to that rather than subtracted.
Dr. WRIGHT. We have incorporated the 15 percent within it, and would add 10 percent if that is approved. That would be my reaction.
Dr. ANDRUS. Let me emphasize, if I may, while you are on this point, that to take $1.9 million out of the $19 million available for research grants would mean literally that some grants now and in progress would have to be stopped.
Dr. WRIGHT. That is right.
Mr. LAIRD. Are you sure your $26 million figure does not include the 25 percent? In this comparison you use the budget figure which does include it.