better we do the more is laid upon us. Our cause is as important, perhaps only in a less spectacular way, as the Statesman who once said "give us the tools and we will do the work."

Senator CRANSTON. The testimony of Dr. Fudenberg has indicated great savings in research, and obviously in the long run research can mean savings, can't it?

Dr. DEBAKEY. There is no question about that, I don't think there is any doubt about the effects of research. One can take as a very good illustration the total amount of money that was invested in the research of poliomyelitis compared to the total amount of money that is annually expended on the part of the public and society in general in the care of poliomyelitis patients. With the elimination of poliomyelitis, all that money is obviously saved. That is a very small fraction, the amount of research is a very small fraction of the amount of outlay of moneys for the care of patients of poliomyelitis just in one year alone.

Senator CRANSTON. Last year, Dr. DeBakey, legislation which I authored authorized the designation of VA regional medical education centers to provide continuing education and the opportunity of conducting clinical investigations and demonstrations in VA facilities. I discussed this at the very end of this morning's hearing, while the VA was with us, with Dr. Musser.

The VA hasn't utilized this authority at all. Could I have your comments on the potential benefits to the veteran, and to research in the designation of such centers?

Dr. DEBAKEY. I think there is no question about the potential benefit and value of it. I think it is most unfortunate that they haven't found it possible to proceed to the implementation of that program, but there is no question about its value in terms of its expansion of medical personnel. It is badly needed.

Senator CRANSTON. What do you believe the level of funding for VA research programs should be in fiscal year 1974?

Dr. DeBakey. I would recommend 5 percent of the total budget. Senator CRANSTON. I thank you very, very much, and I am glad we had this opportunity to hear your testimony.

We have to leave, that bell means we have to go to the Senate floor in the Capitol to vote.

Thank you very much for your help and for your testimony.

[Whereupon, at 12:15 p.m., the hearing was recessed, to reconvene at 1:30 p.m. this same day.]

[The prepared statement of Dr. DeBakey follows:]

STATEMENT OF MICHAEL E. DEBAKEY, M.D., PRESIDENT OF BAYLOR COLLEGE OF MEDICINE

Mr. Chairman and Members of the Subcommittee:

I am pleased to have the opportunity to testify before this Committee regarding the importance of medical research in VA Hospitals. I would like to discuss with you the significance of the Veterans Administration's involvement in medical research, its unique qualities which make it best suited to conduct certain types of research, and the desirability of investing funds in research to be performed in this Agency as it relates to the quality of medical care.

Medical research as a part of the Veterans Administration's responsibility began in 1946 and was initiated with the establishment of a Committee on Veterans' Medical Problems in the National Academy of Science, National Research Council, which emanated from a proposal that I had made to the Surgeon General of the Army. This operated through a follow-up agency which

is still functioning today as an important resource in answering critical questions concerning what happens to veterans who contract certain diseases or are injured while in the military service.

The intra-mural research program was started in 1955 and since then has been closely associated with patient care programs of its constituent hospitals. In 1980, the National Research Council reviewed this program and stated, “the affiliated VA hospitals started to attract physicians interested in combining teaching and research with medical practice; many of these doctors entered the employ of the VA only after receiving an assurance of research opportunities."

By 1968, the program had attracted sufficient attention for the National Research Council to make an extensive evaluation of it at the request of the Office of Science and Technology and the President. The first recommendation was "that the Legislative and Executive Branch of the Federal Government explicatively accept the principle that the VA is obliged not only to provide optimum medical care to the veterans, but also, to the extent of its professional and physical resources, to contribute to the advancement of medical knowledge through research and to the dissemination of medical knowledge through education for the benefit of the nation as a whole."

They also commented, "it is the Advisory Committee's conclusion that the research program compares favorably with other broad national programs of vital medical research." And finally, they commended the Agency "for relating the program to its primary mission during a period of rapid growth."

The need for the research budget within the Agency has been examined almost continually since the beginning of its program. In 1960, the Committee of Consultants on Medical Research (of which I was a member) of the Senate Committee of Appropriations stated "other Federal Agencies besides the National Institutes of Health should continue to maintain strong programs in support of medical research. These programs should not only serve the specific health mission of these agencies and make their operations more effective but should also utilize their special opportunities to make contributions of particular value in the total research effort of the country."

What has the record shown? These may be considered as (1) research which has directly helped the veteran patients, (2) research which has affected the nation's health and which could have been performed only in the VA Hospitals and (3) research which has been done in the VA, where it has received immediate and wide application by virtue of close association between the research laboratory and the broad system of clinical care. In any given year, numerous examples could be given of the first circumstance. Moreover, in the VA's annual report for the past year, studies have been identified with immediate and direct improvement. In the care of liver disease, it has been shown that low levels of the plasma protein, albumin, are not necessarily due to the decreased production of this substance. Also, in patients having alcoholic withdrawal symptoms, chemicals have been identified (Aldehydes) which are associated with the symptoms. New forms of suppression of the immune system have been used which have improved the incidence of success of transplantation of organs. (Nearly one quarter of all renal transplants in the country have been performed at VA Hospitals). Taken individually, it is sometimes difficult to demonstrate clearly a major change in medical practice concerning specific illnesses. There is no question however, that research in the drug therapy of tuberculosis, which began in 1946 and was conducted within the VA hospitals, was associated with almost the elimination of the need for hospitalization of patients for this disease. It has also decreased the need for surgical treatment for tuberculosis from commonplace to negligible.

What sort of research is the VA uniquely capable of performing? Obviously, it is the cooperative studies which have been an increasingly important resource for improvement in the nation's health. VA investigators can rapidly amass significant statistics by drawing on the largest volume of clinical records and patients available to any single agency in the western world. The significance of the availability of such voluminous material for study should not be minimized. It makes it possible to determine whether one treatment is better than another in a considerably shorter period of time and more authoritatively than would be possible in a single hospital or group of hospitals, no matter how prestigious. In addition to the successful treatment of tuberculosis, I might cite drug therapy for psychiatric illness, which enabled the VA to decrease its cost considerably for new construction of neuro-psychiatric hospi

tals. Cooperative studies on high blood pressure have been cited by experts of the American Heart Association as "a milestone of inestimably great importance in the therapy of blood pressure", and the researchers received the Lasker Award for this work. These studies are all designed in search of answers to important therapeutic questions, and delay in answering them can only be detrimental to the health of large numbers of individuals, both veterans and non-veterans. Important current studies include evaluation of the effect of coronary arterial surgery, the health implication of the sickle cell trait, and a number of programs designed to identify the best drugs for the treatment of cancer, particularly those malignant lesions most common in veterans. The Special Action Agency on Drug Abuse Prevention, recognizing the unique ability of VA investigators to perform cooperative studies, has urged the VA to increase its research efforts in this direction.

Should the VA restrict its research to studies that cannot be performed elsewhere? To do so would deny the country a great research resource. The intimate association between the research laboratory and patient care promotes rapid clinical application of basic scientific advances and points up the important medical problems that require solution by basic research. To be sure the University Hospitals serve a similar purpose, but the VA has always emphasized its role of patient care and has attracted the scientist most interested in performing research directed toward the preservation of health.

It is difficult to determine the degree to which research support helps to recruit and retain physicians in the VA system. To get the answer would require the withdrawal of such support-a foolhardy approach, since such an act would result in a loss of the Chiefs of all the major bed services as well as most of the staff physicians presently receiving research support in affiliated hospitals.

What is to be gained by decreasing research funding? Presumedly, it would save money, but the available evidence does not support this contention.

Dr. H. H. Fudenberg has assessed the financial benefit of biomedical research (Journal of Laboratory and Clinical Medicine, Volume 79, March 1972). He estimated, on the basis of standard costs benefit analysis, some of the savings which have resulted from the discoveries in several fields. The list is interesting because VA research has played the major role in bringing into practical application the basic research on tuberculosis and viral hepatitis, and has made major contributions in kidney transplantations. The technique of radioimmunoassy, which can measure extremely small amounts of diverse substances, has been developed almost entirely by VA researchers. Dr. Fudenberg's Cost Analysis of this assay alone indicates that: "Application of the radioimmunoassay technique has resulted in a test that will detect at least 85% of Australia Antigen positive blood and should, when applied on a mass basis cost little more than 35¢ per test. It would mean an end to much of America's expensive and damaging transfusion hepatitis problem and will save $100 million yearly." He also states: "It is impossible to estimate the potential savings in the immediate future from recent discoveries such as immunologic measurement of blood digoxin levels and reversals of digitalis toxicity (on the order of $600 million a year)."

I have already commented on the major roles played in the treatment of tuberculosis by the VA. From 1954 to 1959, Dr. Fudenberg estimated savings of hospitalization costs for the country, "conservatively at $3.77 billion, and savings due to elimination of decreased productivity at $1.2 billion for a total estimated economic benefit of $5 billion.

What then is an appropriate research budget for an Agency such as the VA? If this is considered as an investment from which we reasonably expect a good yield, the figure could be unspecified. For comparison, however, it might be pointed out that in 1971 the Department of Defense spent 10.8% of its budget on research. Commercial pharmaceutical companies spent 11.4% while the VA was spending one-half of 1% of its total budget and only 3% of the budget for the Department of Medicine and Surgery. Since 1971, this figure has decreased to 2.5%, the lowest in more than a decade.

In conclusion I should like to urge the funding of VA biomedical research because it will not only provide better quality of health care for the veteran as well as the rest of the people in our country but it will also enable the VA to attract and retain the highly qualified professional staff to guarantee quality medical care.

95-996-73-18

AFTERNOON SESSION

Senator CRANSTON. The hearing will please come to order. I apologize on two counts. First, for the delay; we had one more rollcall than we had anticipated, and that took up some time that I intended to use in a different way.

Second, I apologize to the first witness for the fact that I am going to be eating during his testimony. I will be paying attention, but I had no lunch and I don't know when and if I am going to get dinner. So, please forgive me.

Our next witness is Dr. Stanley S. Bergen, Jr., president, College of Medicine and Dentistry of New Jersey, Newark, N.J.

Before you proceed, I would like to say that Senator Williams, who is chairman of the Labor and Public Welfare Committee, and very interested in our work, wanted to be here and asked me to read a statement in his absence.

STATEMENT OF HON. HARRISON A. WILLIAMS, JR., A U.S. SENATOR FROM THE STATE OF NEW JERSEY

I regret that my schedule does not permit me to be with you this morning at your hearings on the Veterans' Administration hospital program, and its relationship to the VA health budget and the VA medical school bill. I want to make particular mention of the appearance before you, this morning, of Dr. Stanley Bergen, the president of the New Jersey College of Medicine and Dentistry.

I have read Dr. Bergen's testimony and can attest to the facts which he has detailed therein. In my State we have made great strides in recent years to both increasing the number of medical school graduates and to improve the quality of medical education.

A large part of this pertains to the medical school affiliation with the East Orange veterans hospital facility. And, as Dr. Bergen points out, there have been great benefits to the quality of care in the VA hospital itself.

But what is more important to know is the fact that much more needs to be done. The VA hospital budget for the coming year seriously turns the ability of that system to continue to provide good health care to its patients. In addition, there is a great need in New Jersey for a new VA hospital in the southern part of the State, since the demand for medical care is such that the existing facilities elsewhere are inadequate to meet that need.

As you know, Mr. Chairman, I was able to secure an appropriation of $3.7 million to be used for planning and site acquisition of a VA hospital in the southern New Jersey-Philadelphia metropolitan region. Unfortunately, the administration has, to date, refused to release those funds, and this delay will further exacerbate the health care problems for the veterans in that area. And what is worse, is that the administration's refusal to act now, will hamper plans for the establishment of the vitally needed third medical school in southern New Jersey to be affiliated with the new VA facility.

Mr. Chairman, I will not take any more of your time to outline the current problems and prospects in New Jersey. Dr. Bergen's statement will provide this subcommittee with detailed and well de

veloped information in this regard. I am certain that you will give him a warm welcome.

Finally, I just want to commend you for all the fine work you have done over the years on behalf of our Nation's veterans. You have been instrumental in guiding important new programs for these men and women and we can all be proud to have you with us as you continue your fight to assure that America's veterans are not forgotten.

Senator CRANSTON. We are indeed delighted to have you with us. If you can, to some degree, summarize your written statement, which will appear in the record, that will give us time to ask you some questions. Thank you very much.

STATEMENT OF DR. STANLEY S. BERGEN, JR.,

PRESIDENT, COLLEGE OF MEDICINE AND DENTISTRY OF NEW JERSEY, NEWARK, N.J.

Dr. BERGEN. Thank you very much, Senator.

With me here today is Mr. Schatzki of my staff. I appreciate this opportunity to appear before you this afternoon to testify concerning the college's many joint undertakings with Veterans' Administration hospitals in New Jersey, and to relate to you our hope and intention that the college may have the opportunity to substantially expand these beneficial relationships through the creation of a third medical school in South Jersey in conjunction with the construction of a Veterans' Administration hospital in that part of the State.

The college is composed of two medical schools, a dental school and a graduate school, and is responsible for a number of health care facilities including a large public hospital. In addition, the college series as a statewide resource for continuing education, graduate medical education, and the development of models for health care delivery.

For many years we have had a very productive and mutually beneficial affiliation with the East Orange Veterans' Administration hospital. In fact, historically, it should be noted that were it not for the assistance of that hospital at a time when the New Jersey medical school had lost its primary clinical facility, that medical school would probably not be in existence today.

There have been numerous mutual advantages resulting from the medical school-VA relationship over the years. However, listening to this morning's testimony, I must admit to some skepticism about the rosy official picture that was presented, and I thought it might be important to call to your attention two or three adverse elements that may in the future effect our relationship with the East Orange veterans hospital.

While we believe that that hospital is well run and excellently administered, we have noted in the last year an increasing necessity on our part to assume a greater portion of the cost of the physicians working in that institution. Particularly, we note that some of the members of our faculty must take on added responsibilities there in order to assure the continuing functioning of some of the new programs that have been started.