been acquired in recent years to the needs of our patients; and that is what our research is all about.

CONCEPTS OF THE ORGANIZATION OF HEALTH SERVICES

The public and governments are proud of the accomplishments of the biomedical research community. They are distressed, however, by failures in the health care system that center on access to the system, geographic and specialty maldistribution, and the increasing number of foreign medical graduates training and practicing in the United States. The emphasis is on primary care. It is ironic, I believe, that one of the major purposes of the Regional Medical Programs instituted by President Johnson in 1966 was to reorganize tertiary care. That effort failed; rather than examining why it failed, then develop alternative approaches, the emphasis has shifted to newly perceived needs in primary care, and the reorganization of tertiary care largely has been forgotten.

In Europe, neurosurgery services, which I know best, are organized into university units responsible for patient care, teaching, and research. Probably no more than 5 percent of all operative neurosurgery is performed outside of the university setting. In cooperation with regional and national governments, each country has been divided into referral areas for the neurosurgery centers such that no center serves less than 1 million nor more than 2.5 million inhabitants. Lines of communication and ambulance service have been established between peripheral hospitals and the centers. The volume of neurosurgery performed by most of these centers exceeds the volume of neurosurgery performed in any university in the United States with only a few exceptions. The number of head and spinal cord injuries on European neurosurgical services is 50 to 80 percent of all neurosurgical patients hospitalized on the unit at any given time. A few years ago, when I visited the largest social service hospital in Madrid, there were 75 patients with severe or moderately severe head injuries on the service. The patients were managed well, but investigation of head injury was impossible because the service was understaffed. The physicians and nurses had difficulties enough keeping up with the patient load. In contrast, it is unusual for a single hospital in the United States to admit more than 100 severe head injuries in 1 year despite the fact that there are a total of 3 million head injuries and upwards of 50 thousand deaths per year from head injuries in the United States. The reason is that most head injured patients are taken to the nearest hospital and remain there irrespective of the quality of the facilities available to treat them. Some cities have made progress in recent years in identifying hospital centers for trauma, but much work remains to be done. In Philadelphia and the Delaware Valley, for example, a severely head injured patient is transported to the nearest hospital.

The results of these practices is that European neurosurgical units have the patients but neither the time nor the resources to investigate them, whereas many American neurosurgical units have the research team, the physical resources, and are brimming over with ideas but do not have enough patients. At the heart of the problem in the United States is the plethora of neurosurgeons practicing in nearly every hospital in the city and in the countryside. They refuse to give up their patients because of personal pride, sometimes well justified, and because of the pride of the local hospital and the necessity to fill its beds. These are also the major reasons why reorganization of tertiary care under the Regional Medical programs fail. We need to, and will, reduce the number of neurosurgeons trained in the United States, but the effects of the program will not be felt for a long time. Meanwhile the enormous potential of the NINCDS Clinical Research Centers cannot be realized, and probably never will be realized irrespective of improvements in manpower numbers and distribution, until our system for health care delivery is reorganized in directions that have served so many European countries so well.

Dr. SCHMIDT. Furthermore, I have my own written statement.
Mr. FLOOD. Very well.

STATEMENT OF DR. RICHARD P. SCHMIDT

Dr. SCHMIDT. Mr. Chairman and members of the committee, I am honored by the opportunity to appear before this distinguished committee of the Congress to testify on behalf of an adequate budget for the National Institute of Neurological and Communicative Disorders

and Strokes. In so doing, I speak as the chairman of the National Committee for Research in Neurological Disorders, which represents more than 50 voluntary and professional organizations interested in the neurological, neuromuscular, and communicative disorders. To go one step further, I represent the millions of Americans who suffer from the yet unsolved or incompletely solved diseases of the brain, spinal cord, neuromuscular system and the communicative functions of speech and hearing.

By way of personal introduction, I am a physician who has specialized in neurology. I am a native of Ohio, a graduate of the University of Louisville School of Medicine in Kentucky. I have served on the faculties of several universities, including my alma mater; the University of Washington in Seattle, the University of Florida, and the State University of New York, Upstate Medical Center in Syracuse of which I am currently president. I have served on a variety of advisory committees of voluntary organizations and government, including a recently completed term as a member of the Council of the NINCDS and the National Multiple Sclerosis Commission. I am past president of the American Academy of Neurology and of the American Epilepsy Society.

Mr. Chairman, you and the other Members of the Congress are faced with the awesome responsibility of deciding the budget priorities of our country and I fully realize that you are unable to give all that may wisely be used for each project or function which may come before you. The budget proposed for the NINCDS is, however, a drastic reduction from fiscal 1975, and is only slightly above the rescission level which you have rejected. The sum of $114,955,000 will be a serious setback in the vital research areas which are the responsibility of this Institute. This is an absolute reduction of $27,545,000 from the 1975 budget of $142,500,000. This will mean that many high-quality and important research projects will not be funded or will be seriously limited in their capabilities of performance.

In December, the committee on budget of our national committee recommended a total of $193 million for the 1976 budget of the Institute. It recognized that there were significant staff shortages which curtailed administrative functions and intramural research. There should be a minimum of 68 new positions for the Institute to meet its responsibilities. The committee emphasized that there should be at least an amount equivalent to 20 percent of the NINCDS budget for training of scientists for fundamental and clinical research. The total recommendations are as follows:

The group of diseases represented by this Institute are among the major killers and causes of chronic disability. The Director of the Institute, Dr. Donald Tower, in his testimony has presented an excellent outline of these and of the progress being made. I will not repeat his testimony in this regard since it has already been before you and you have asked very good questions of him. I do, however, most respectfully ask that you give very serious consideration to a more adequate support for these vital programs than has been put before you in the President's budget for 1976.

We feel that the budget as presented in the executive budget of $114.955 million is a gross shortage of that which needs to be done in the research and other programs of this Institute.

It represents an absolute reduction of over $27 million over the fiscal 1975 and is only slightly above the rescission level which the Congress has already turned down.

Our Budget Committee, which I support, would submit that the wise spending in the variety of research programs in multiple sclerosis, in stroke, injuries of the head and spinal cord, cerebral palsy, epilepsy, all of these things, including deafness, all would be best supported by a budget of $193 million. We, the NCRND membership, feel this is a wise budget, researched and substantiated by the accompanying statements, and this is what I testify on behalf of, Mr. Chairman. If the appropriation is for 15 months it should be $241,250,000.

It would permit the trust to go forward in such things as the Commission recommendations for the Multiple Sclerosis Commission, the funders of the plan for comprehensive epilepsy centers in several areas of the country, and eventually abolishment of crippling, disabling neurological and communicative disorders. It would also prevent good research from being neglected.

At the $114 million-I believe Dr. Tower, the Director of the Institute, himself testified, only 20 percent of the research that would be applied for of the applicants could be supported at that level of funding, which we feel is grossly inadequate, Mr. Chairman. Mr. FLOOD. Thank you very much.

ARTHRITIS RESEARCH

WITNESSES

JUDGE THOMAS A. MASTERSON, PHILADELPHIA

DR. JOHN L. SBARBARO, JR.

Mr. FLOOD. Next is Judge Thomas A. Masterson on arthritis research.

Mr. MASTERSON. Good afternoon, Mr. Chairman.

I, too, have prepared a written statement with an attachment, which is a statement of Dr. John Sbarbaro, who is accompanying me here today.

I also would like permission to have them made part of the written record of these proceedings.

Mr. FLOOD. Without objection, that may be done.

[The statements follows:]

Mr. Chairman and committee members, my name is Thomas A. Masterson. I am an attorney and a partner in the law firm of Morgan, Lewis & Bockius in Philadelphia.

I have been ased by the eastern Pennsylvania chapter of The Arthritis Foundation, as a member of its governing board, to represent the views of some of the scores of arthritis volunteers who assist the foundation's 73 chapters across the Nation in trying to explain arthritis to the American public, especially what is being done to improve treatment for the 20 million Americans who suffer from our No. 1 crippling disease. My acquaintance with this terrible disabler of young and old is personal, not professional, and the views which I express here today are my own, and do not necessarily represent the official position of The Arthritis Foundation. However, since I have seen first hand what this disease can do in every generation of my own family, I think that I can speak from some direct knowledge of the immediate need for a massive attack upon this disease.

Dr. Evans Calkins will appear before the committee later with an eloquent plea concerning the importance of funding further basic research and the establishment of arthritis centers throughout the country with which I am in entire agreement.

I would like to spend just a few minutes, however, to emphasize to the committee the importance of insuring that a significant amount of the money is made available for the purpose of a broad based professional educational program designed to give the practitioners in the field the benefit of the latest technique of diagnosis and treatment of this dread disease.

I brought with me a simplified map of the area included in the Eastern Pennsylvania Chapter of the Arthritis Foundation, and I think it tells a story which is typical throughout the country with respect to the epidemiology of the disease and the medical resources available to treat it. Look at the exhibit; you'll see that the disease is, of course, significant in every single county covered by the Eastern Pennsylvania Chapter. The numbers in black show the estimated numbers in bracets show the number of physicians who are members of the Amershow the number of qualified rheumatologists in that county, and the red numbers in brackets show the number of physicians who are members of the American Rheumatism Association and who have had some exposure to the updated methods of diagnosis and treatment of this disease. The numbers in blue which are bracketed represent the total number of physicians in each county.

The first thing that strikes one in looking at this exhibit is that in this 22county area of Pennsylvania, there are approximately 572,000 sufferers of arthritis with 44 fully qualified rheumatologists, 91 physeicians who are members of the American Rheumatism Association, and some 11,000 general practitioners. These figures and the way they are scattered on the map make it obvious that the average suffer from arthritis, if he is going to get any relief at all, must look to the family physician for help. The simple mathematics of the situation in this area alone demonstrate that there is 1 qualified rheumatologist for every 13,000 sufferers, and 1 member of the ARA for approximately every 6,000 sufferers, but there is approximately one family physician for every 52 sufferers. It is obvious then that if any meaningful relief is going to be given to the overwhelming bulk of people suffering from arthritis, a massive effort has to be made to bring to the general practitioner the tools that have already been developed to diagnose and treat this disease.

Another significant and probably typical phenomenon about the disease and the resources to meet it which is demonstrated by the exhibit is the clustering of both the qualified rheumatologists and the members of the ARA in the areas immediately adjacent to the six medical schools which operate in Philadelphia. Of the 44 qualified rheumatologists in a 22-county area, 41 of them are located in Philadelphia, Montgomery, and Delaware Counties. Of the 22 counties covered by this exhibit, there are 13 in which there are not only no rheumatologists, but there isn't even a single physician who is a member of the American Rheumatism Association to whom the Arthritis Foundation would normally refer patients as a qualified specialist in arthritic diseases.

The seriousness of this situation can be grasped when it is realized that recent revolutionary advances in the early diagnosis and treatment of many of the most

crippling forms of arithritis are comparable with the revolutionary success which has accompanied the early detection and treatment of breast cancer in women. The busy general practitioner whose every 10th patient complains of a vague back pain or a vague pain in the joint, tends naturally to treat these complaints symptomatically. As a result, there is an inevitable tendency for the arthritic process to advance in an insidious manner until the pain becomes excruciating or disabling. At this point, too often, the process has advanced too far for complete rehabilitative measures to be taken. The same patient treated by a physician who had been adequately trained to recognize and treat the disease with the armamentarium of knowledge presently available would be able to arrest the disease before it became crippling in an estimated 80 to 85 percent of the cases. The Eastern Pennsylvania Chapter of the Arthritis Foundation has been fortunate in the past 15 years of having an extremely dedicated group of physicians and laymen who have been willing to give of themselves in an attempt to broaden the base of medical knowledge of the disease throughout the chapter area. They have recognized that as important as basic research and the establishment of centers is the disemmination to the frontline general practitioners of the knowledge of the most recent techniques of diagnosis and treatment. This effort has been carried on by the physicians on a limited basis for the past 15 years. Currently, through the regional medical program, some $200,000 is being spent in a pilot program designed to reach the general practitioner. In order to take the current knowledge of the disease to the practitioners in the field, qualified rheumatologists are conducting training seminars, demonstration clinics, and public awareness programs at the local level.

Dr. John L. Sbarbaro, a distinguished orthopaedic physician, who is also president of the Eastern Pennsylvania Chapter of the Arthritis Foundation, has prepared a brief statement describing in detail what has been done in this chapter by way of educating primary care physicians who must deal with these patients on a day-to-day basis. A copy of his statement is included with my written statement, and I would appreciate it being added to the record of these hearings. He has estimated that in order to mount a program which would begin to make the knowledge which exists in the laboratories and medical schools available to the physicians for use in their practice every day would require a program involving two symposia of 2 to 3 days duration per year at a convenient location, and 12 half-day demonstration clinics followed by half-day seminars at key areas throughout the region. To staff these seminars and demonstration clinics would require a group of physicians and associated personnel experienced in the whole range in diagnosis and management of these arthritic patients. These teams and the need for them in the management of the disease will be described in greater detail in Dr. Calkin's testimony. Such a program in this 22-county are would require an annual budget of something in the order of $250,000. Project this need nationwide, and it would suggest a national annual budget for this educational purpose alone of approximately $10 million.

This represents an approximate doubling of the amount currently being expended by 29 regional medical programs on the first year of a similarly designed program.

These programs should be regarded as an essential part of the implementation of the National Arthritis Act.

I thank you, Mr. Chairman, for allowing me the time to appear before you today on behalf of one of our most serious national health problems, arthritis.