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INDEPENDENT OFFICES APPROPRIATIONS FOR 1965

THURSDAY, JUNE 4, 1964

U.S. SENATE,
SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS,

Washington, D.C. The subcommittee met, pursuant to recess, at 8:35 a.m., in room S-128, U.S. Capitol, Hon. Gordon Allott temporarily presiding.

Present: Senators Magnuson and Allott.

VETERANS ADMINISTRATION

STATEMENT OF MIKE GORMAN, EXECUTIVE DIRECTOR, NATIONAL

COMMITTEE AGAINST MENTAL ILLNESS

MEDICAL RESEARCH PROGRAM Senator ALLOTT. The committee will come to order.

The first witness this morning will be Mr. Michael Gorman, National Committee Against Mental Illness.

Mr. Gorman, we welcome you back to the committee.
You have a statement which you provided me with yesterday.
Mr. GORMAN. Yes, sir.

Senator ALLOTT. This statement will be either inserted in the record and you may comment on it, or proceed as you please.

Mr. GORDON. Thank you, Senator Allott. (The statement referred to follows:)

MORE RESEARCH ON AGING MAJOR NEED IN VETERANS' ADMINISTRATION Mr. Chairman and members of the committee, since this is the 10th consecutive year that I have testified on the medical research program of the Veterans' Administration, it is appropriate to take stock of developments during the past decade.

Testifying before this very committee in 1955, I pointed out that a special National Governors' Conference on Mental Health in 1954 had passed a unanimous resolution expressing its conviction that 10 percent of the budget of any public hospital system should be devoted to medical research. The argument behind the resolution was a simple one—unless new knowledge was acquired, the States and the Federal Government would be forced to appropriate constantly increasing sums for hospital construction and for compensatory payments to the sick and the disabled.

I am not a prophet, nor am I the seventh son of a seventh son, but the figures in the President's budget for the Veterans' Administration for fiscal 1965 tell à very revealing and somewhat disheartening story.

OPERATING COST OF VA HOSPITAL SYSTEM In 1955, the operating cost of the VA hospital system was about $800 million ; for the coming fiscal year, it is estimated that it will exceed $1,100 million.

In 1955, the Veterans' Administration spent approximately $3 billion in compensation and pension payments to disabled veterans; for the coming fiscal year, it is estimated that approximately $4 billion will be required for these same payments.

In 1960, the National Research Council of the National Academy of Sciences, an independent organization composed of some of the most distinguished scientists in the country, conducted an exhaustive survey of the entire VA medical care program. I quote one paragraph from its findings to indicate that this distinguished body of scientists felt very strongly that the VA hospital system was in danger of lapsing back into the stagnation which had engulfed it during the 25 years prior to the end of World War II:

"The medical care program of the Veterans' Administration faces a challenge today in no way less than that which was successfully met in the years immediately after World War II. This new challenge is in some ways more difficult to meet because the issue is not as clear. The task in 1946 was to cast out an old, inferior pattern of medical care and to develop a new and better one. The present goal is to defend and improve a well-respected medical care system which is besieged by constantly rising costs of medical care, increasing competition for professional personnel, progressive deterioration in the relative strength of its salary scales, and the general complacency characteristically associated with success."

RECOMMENDATIONS OF NATIONAL RESEARCH COUNCIL

In order to prevent this stagnation, the National Research Council study recommended a minimum annual increase of 20 percent in the medical research budget so that the VA could cut down on hospital costs and realize its true potential as a leading force in medical research in this country.

For the coming fiscal year, the administration recommends $36,987,000 for the medical and prosthetic research programs of the Veterans' Administration, This is theoretically 10 percent over the current year's spending level, but when mandatory salary increases and rising laboratory equipment costs are taken into consideration, it is an increase of less than 5 percent.

Less than a month ago the House of Representatives cut the administration figure by a million dollars, bringing it down below the amount voted by the Senate last year for the medical research activities of the Veterans Administration.

This cut, combined with inadequate administration requests in previous years, compels the VA Central Office to turn down millions of dollars in approved medical research projects which have survived a vigorous double screening-by a hospital and medical school committee at the local level, and by the Medical Research Division in Washington.

During the last 4 fiscal years, the VA has not had sufficient funds to support more than $20 million in approved medical research projects from approximately 160 hospitals scattered throughout this country.

In the coming fiscal year, based upon approved medical research requests already received from its various hospitals, the VA will be forced to turn down an additional $6 million in medical research projects.

EXPRESSIONS FROM MEDICAL SCHOOLS The deans of our medical schools and many of the Nation's most prominent physicians have publicly expressed, in recent months, their deep concern over the lack of forward momentum in VA medical research and medical care. These are the same deans who 17 years ago formed an alliance with the Veterans Administration to lift its hospitals from the level of bitterly criticized rest homes to modern therapeutic hospitals designed to provide a level of medical care second to none in the world.

In February of this year Dr. George Aagaard, dean of the University of Washington School of Medicine and president of the Association of American Medical Colleges, wrote:

"I am sure that we all agree that our veterans should receive the best quality of medical care that scientific medicine can provide. Certainly, this is the only kind of medical care which we wish to use as we teach, by example, residents involved in our university training programs. The program at the Seattle Veterans' Administration Hospital has not been able to keep pace with the demands and the possibilities of good scientific medical care and we earnestly hope that steps can be taken in the immediate future to correct these deficiencies."

The deans committee of the Duke University Medical School a year ago passed à resolution stating that "unless a solution is found to continue high-quality care and high-quality teaching at the Durham-Duke VA Hospital, your deans committee does not believe the Duke University Medical School should long continue service responsibilities at the Durham VA Hospital.”

In a letter dated October 21, 1963, to the VA Department of Medicine and Surgery, Dr. John J. Conger, vice president for medical affairs of the University of Colorado, wrote that "we will be faced with a serious question of our ability to continue one or more joint programs with the Veterans' Administration unless staffing patterns are increased and research and training programs expanded."

Mr. Chairman, I have in my files a large collection of letters from those medical leaders who have been most concerned with carrying out the announced pledge of the Veterans Administration for a level of medical care second to none. They have participated actively since 1947 in an effort to provide a level of superior care for our veterans but, as most of the letters indicate, they will not continue to participate unless the VA medical program moves forward.

As these medical school deans have noted, the years since World War II have seen an enormous expansion of medical school resources and hospital facilities. The Veterans' Administration system has made some progress, but it has not kept pace with the higher standards now prevailing in our medical schools and hospitals.

As I have pointed out in testimony in past years before this distinguished committee, the choices we make now will determine whether the VA in the years to come will operate a chain of truly therapeutic hospitals, or revert to a system of old soldiers homes comparable to those which existed in the 1920's and 1930's.

INCREASE IN NUMBER OF AGING VETERANS The handwriting is on the wall.

The increase in the number of veterans over 65 years of age in VA hospitals has been very sharp over the past few years. For example, in the short interval between 1957 and 1962, the average age of the veteran receiving medical care for long-term diseases rose from 56 years to 61 years. In that same period of time, the number of veterans hospitalized for heart disease rose by 21 percent, for strokes and other brain damage accompanying aging by 50 percent, and for aging lung disease by 60 percent.

These three diseases of aging-heart disease, strokes, and lung disease-cost the taxpayer approximately $50 million in direct VA medical costs in 1962; this figure makes no attempt to include the additional losses in economic productivity and taxes to our country.

In 1950, veterans over the age of 65 comprised only 5 percent of the total VA hospital patient load, but last year there were 38,000 veterans over 65 in these hospitals-about one-third of the total patient load.

Despite the fact the VA is spending $1 million this year for research on aging, and has had lesser sums available in previous years, it has made many contributions which have been hailed by the medical research world.

Five years ago, a team at the VA hospital in Buffalo developed a heart pace maker machine for patients suffering from heartblock. This model has been recently improved to the point where it can be relied upon for 5 years of flawless functioning before the need for a small operation to introduce new batteries in this completely self-contained and internally carried device. At the present time, approximately 1,000 of these heart pacemakers are functioning in patients throughout the world as a result of this VA research contribution to longer life.

VA RESEARCH In the Veterans' Administration Center in Los Angeles, a large-scale study is in the fourth year of evaluating the role of diet in the eausation of heart disease. Four hundred patients have had their diets altered so that normal fat has been almost completely replaced by unsaturated fat. The medical research world is

looking to this study to help settle the problem of the value of unsaturated fats in preventing arteriosclerosis in human arteries. At the VA outpatient clinic in Boston, normal aging is being scrutinized through an intensive study of normal, healthy males between the ages of 35 and 45. Detailed histories, physical examinations, laboratory biochemical evaluations, psychological testing, and socioeconomic data are being repeated at 2-year intervals over the entire lifespan. The group under study is currently being expanded to about 1,100 subjects. A number of VA hospitals are collaborating in an extensive study of 1,600 Spanish-American War veterans. This study is an imaginative attempt to find out, through physical examinations and lengthy interviews, the characteristics which enable these veterans to survive into the eighth and ninth decades of life. When completed, it will be the first body of such research information ever gathered on this elderly group. A major research project, now in its sixth year and involving 15 collaborating VA hospitals, is evaluating the protective effect of anticoagulant drugs in preventing additional heart attacks in a group of more than 700 patients who have already suffered an initial heart attack. The protective effect of lowering blood cholesterol through the use of drugs and its effect in preventing additional heart attacks is also being evaluated in a multihospital collaborative effort.

STROKES AND LUNG DISEASES

One of the most promising new avenues of research—the use of small doses of a nonferminizing female hormone as a preventive measure against strokes– is being evaluated in 15 hospitals among a large sample of veterans who have already suffered an initial cerebral stroke, Aging veterans are particularly susceptible to afflictions of the lungs, resulting in chronic bronchitis, emphysema and other lung diseases. Drugs to stimulate breathing are being used on a number of patients suffering from emphysema in various VA hospitals, and lung capacity is being measured in a massive collaborative study involving patients in 40 hospitals where investigators are interested in alleviating the disability produced by chronic respiratory diseases. Several years ago, recognizing that research on aging would have to be accelerated in the face of the rising flood of elderly patients, WA medical research leaders devised a plan for setting up a group of regional satellite laboratories which would concentrate on the problem of aging. This plan was designed to recruit outstanding university authorities in the field of aging by giving them the opportunity to set up, within a neighboring VA hospital, a satellite laboratory to carry on research among a group of elderly patients whose medical records are the most complete in the world. As I stated a year ago before this committee, it was the original intention of the WA to start with six of these satellite laboratories. However, because of insufficient medical research funds, only one such satellite laboratory is in operation, with the others still on the drawing board.

VA POTENTIAL FOR RESEARCH on Aging

Mr. Chairman, it is the belief of many leaders of the scientific community that the Veterans' Administration has the potential to operate the finest medical research program on aging in the world. Because of central direction and close collaboration, the 163 hospitals which currently conduct research programs really operate as one hospital. Its medical records are the most complete in the world; in its current study of Spanish-American War veterans, it can call upon medical data going back 65 years.

All that is really needed is a clear mandate from the Congress to conduct such a program, and the appropriation of sufficient funds to make it a reality.

This committee does not have to be told of the enormous past contributions of the Veterans' Administration when the mandate was clearly given.

TUBERCULOSIS AND MENTAL ILLNESS RESEARCH

The pioneering VA collaborative attack on tuberculosis is just one case in point. As a result of the mass evaluation and use of new drugs and new procedures, there has been a drop in the past decade of more than 60 percent in the number of veterans hospitalized for tuberculosis, and a score of TB hospitals

in the WA system have either been closed or been converted to general hospitals. In a recent World Health Organization publication, it was pointed out that 8 out of every 10 persons who contracted TB a decade ago eventually died from the disease. Today, 6 in every 10 are cured. There is no doubt in anyone's mind that the pioneer WA attack upon tuberculosis played the major role in this remarkable reduction in deaths. A comparable story can be told in the field of mental illness. Just a decade ago, veterans suffering from mental illness were hospitalized for periods of 10 and 20 years or more. With the advent of the new drugs and the pioneer WA evaluation of them, the picture has been altered dramatically. Since 1954, there has been a 100-percent increase in the number of hospitalized mentally ill veterans discharged to the community each year. The average stay of the nonpsychotic patient has been reduced to 25 days, and patients with a diagnosis of serious psychosis have an average stay of only 96 days. As a result of these dividends of WA medical research—the end result of 12 collaborative, multihospital evaluations of new drugs and other forms of therapy—thousands of psychiatric beds which were on the drawing boards have not been built, and projected operating costs have been sharply cut. But so much more could be done. There are still 57,000 veterans hospitalized for mental illness. Last year, mental illness cost the Veterans' Administration $83.2 million in hospital costs and compensation and pension payments. Yet compared with the astronomical annual costs, the Veterans' Administration in the current year is spending only $3.3 million for all of its research programs in the field of mental illness. Mr. Chairman, we are convinced that if the WA medical research program were sufficiently funded, it would produce research results which would pay back the initial investment 10 times over. Even with the inadequate sums presently available to it, one has only to read the medical and lay press to learn something of the remarkable achievements of medical research workers in the Veterans' Administration. At the present time, WA medical research is leading the country in organ transplantation. In seven WA hospitals—in Denver, West Roxbury, New Orleans, Chicago Research, St. Louis, Nashville, and Richmond—experimental work is going on in the replacement of damaged kidneys, livers, and spleens.

ORGAN TRANSPLANT PROGRAM

The organ transplant program at the Denver VA hospital, under the direction of Dr. Thomas Starzl, is regarded as the leading program of its kind in the country. In addition to 150 experimental animal transplantations, the Starzl group has transplanted kidneys in 76 patients, and has recently embarked on the delicate task of transplanting livers. This whole new frontier of organ transplantation is still beset with numerous difficulties and failures, and additional money is desperately needed to expand and intensify the research knowledge underlying these transplantations. The WA hospital system has also pioneered in the perfection and use of a device which keeps patients with inadequate kidney function alive for many years. The original work, as you may recall from last year's testimony, was done by Dr. Belding Scribner at the University of Washington Medical School, the Swedish Hospital and the Washington WA hospital. Additional lifesaving units, adapted from the Scribner technique, have recently been opened at the Bronx, Coral Gables, and Minneapolis WA hospitals. In the field of diabetes, which afflicts 4 million Americans, WA investigators have won national and international acclaim for their pioneering studies.

ARTHRITIS AND DIABETES LINK

A pair of investigators at VA hospitals in Kansas City and Pittsburgh have discovered a correlation between diabetes and arthritis in hospitalized patients, which suggests that there may be a common mechanism in these diseases. At the VA hospital in Houston, it has been demonstrated that certain microscopic changes in blood vessels can be detected many years before the disease develops in persons who are potential diabetics. These new findings will permit patients to take preventive measures to postpone and, in many cases, prevent the onset of this disease. For the last 2 successive years, a VA research investigator has won the coveted Eli Lilly Award for research in diabetes—one working at the VA hospital in Madison, Wis., and the other at the VA hospital in the Bronx.

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