0 0 NII-1--OD-OPP TO- Special to 'thfi Seci,@,z?t,.iry Novenber 20, 1964 (,flea'2.th i@nti @ @dical F',@?,OM: Director, Niii SUBJECT., re tl-@e o-.@@' the Pre sidenl:'s Cor@oiss-.on- jw2 It I-,, d a r@@ C'@o play the report those vlic'li seeii,@d not really needed or possibly inappropriate for this particuiat I' relieve cutting baci-, on certain of t'lie general recoz,-mndaticti.s, as @iell as on those C@i-@ highly specific @,ul- limited i.iTiport, i@;ould increase the impact of this docuu,.--@it and enhance its sl:,,ature as a report of a Presidential. Cournission. eAc.,co@,-di.rigly, we ii@4,ve -.ake@!,i 34 Recommendations in the report arid dl4atributed. ,-L'Iem categories ,,s fol.loTys: Ca I recoii @Lrtcla-Li.or.-Is that make innovative proposals the siL@)ject matter of the Com- Heart disease, cancer and stroke. Ti-aus tl-4c recopneitdat::LcLis o@'@. this gro-,Ilp the vpry essence of the new, 6,1-ffe-"ept, Riid n@@.@caF@sar, . L 95 .7 @qc-ioy-ts I"lowing from the Cormoission c-y.aminatior,- of Z:'Lke ,.,f t'L,,L r;ise,,,.ses and the problems asro- cialt.'ed, wit@i covering actions of the proposals a@,- 17CY4@-@ Those covering matters which--as I see @.ii)@p,.aar @.s se) riiiiiibered recoiranL-ndations in the C@i,,nissic)n's report proper Pe.@@.sons vary: Some are not felt to be importantly to the., purpose; others I feel -,re liecause nzl c)tlcier action in respect to them; ot@,':ierr, ;,.,@ialiproy,)riate ?-o the circumstances and pur- poses of --L report. proposed of'. t'@,i@ reflects a fairly definite concept of wh@t cliaract@er ird of the Cormission's report should brief @L-.@e proper should! be ,-aiifined to major innovative 2 recommendations and their essential correlaries. Other important matters should be treated with appropriate emphasis but not be made the subject of individual recommendations to a-,mid diminishing the force of the -,more critical matters. The report of the ComnLissi.on proper should indicate its affirtastive view of the many detailed recommendations in the individual panel reports but express a view that these must be the subject of careful assessment within the context of other policy, budgetary and Executive Department considerations. -ibis framework, I believe, would provide adequately for a positive exli,es:31.o@ii o@F the Commission's views on new and essential actions, 'Lnvol@,-t i@@ the Comdssion in a tangle of specifies about Vnic'h the Co@ii L@ @--,oi-ild hardly have had the time to d ',26' judicious I i i exnrTle, one rd.,v.,,tit 1 iAt I (it i,-@ rt i;, b I 'i6 I @, F i, afi b s uu,,? 'Ut ei@ )o-itatit inattf-,,r, i seems to iw-. woul-d Be, i@@ i. i,@ gr-.nO-ral tertrs,, the need out: of t@@v@ich this specific actio:i. co-,jlcl With this as background, hero s our suggested grouping of the recommenda- policy or feasibility aspects: tio-.is, with some toment on , legislative e ca@ I Those numbered recommendations which encompa,ss--'Lnnovative AE oposals cent subject matter of the Commission rt disease cancer and stroke. Reco.=--ndation No. 1---.@al.onal cente s for heqaarrt disee cancer and stroke This recommendation is clearly the basic innovative action- concluded upon by the Comission. A-Ithoug,-, @' air r?. ind operating character is well described, the major policy @,@@@,)ark'ur that they represent, namely Federal involvement in the medical of that portion of the general population afflicted with problems of se, cancer, or stroke, is not treated equisit:e to the rationale for this departure. .1 any way r Grave questions of relatio isl.,4ips to coLiniii@nit-,v medical practice and the financing of medical tare loom bet@reen the lines of this proposal. Insofar as the centers would be confined to r@,,!search and research training and clearly related purposes they would perhaps be encompassable within present legislative authorities of the Ptibl,4,c Health Service. However, it seems clear that the concept of these centers contemplates substantial involve- ment in direct medical care functions. The inclusion of this latter element would mean that new legislative. authorities would have to be sought for the initiation of this program. Indeed, the significance and magnitude of the public policy issues represented by this proposal argue strongly for a clear Co-ogressional consensus in the undertaking of this effort. 3 Another matter In respect to these centers which is not adequately treated is the clear limitation upon the rate of development of such a program that would result from the present manpower resources. While the report does indeed urge many actions in respect to manpower, nevertheless, the schedul- iiig of this center program! in ter= of dollars a-ad magnitudes proposed by year seem completely unrealistic lii, the f act of current manpower capabili- ties plus any reasonable expectations concerning the rate of manpower expansion. Greater recognition of this problem would give a better sense of reasonableness to this il's c@t t Recomnendation No. centers treati@,,@ I"x@ Tissues in the area medical caice, -the la r @.,,s ;ary for initiation of the program, and the iuposed by manpower shortages. I'he schedule of nmiber of enter .i-,cid dollars required by year seems to me to constitute a degree of specificity which has no clear factual base in, the discussion and seems both inappropriate and unwise in a Presidential report because of the almost intrusive, constraints it places upon Presidential jud @-nt. Rec.ommp-ndation No. 5--A national stroke -, o@am unit The creation of a specific organizational entity for the direction and administration of the set of innovat2,@,,e activities proposed by the Com- mission in the area of stroke seeifis indeed appropriate in vieu@ of the fact that there is no present separate location of program concern for the full scope of activities related to stroke within the Public Health Service. The necessary emphasis to b @a this field seems clearly to argue for this organizational rc@ The proposal does present po cy problems in that both rese,,,@, Ice- activities would be encompassed ;,7i thin the unit as re;ro i",,, The present Public Health Service org@,anl.zatio @as zt first principle a distine-@ 19,.ion between research and Some recognition of this fact and the Comission's @,@i F c@f i,6, seem desirable. The three recoiirii--ndatio-.is abc,,@via iqcul(i, i-,,i our view, constitute the essen- tial innovative proposals of -the Coim-n:Lssion. 0 4 -,ate 01 2 These i@r@at recommendation coveriu& qctioxis deemed essential to undetnin the ac-@m)@ishment of the proposals in c 'In this category are encompassed those rtcorcanendations which cap be viewed as essential actions of a broader and general nature to create the set of circumstances necessary to make possible and to underpin the accomp is - -annt of the primary proposals. It ;,7otild appear desirable to treat these Emendations in a ic,h their set of reco ..@i)d. logical whole and in wh important relationships anfi tlLe overall rationale relating to them can ,,@ir@ @te@v,-,'Loped irkithot@it, the l@ii, P..I-te specifics tif dollars an f so ?p 'L@,., p@@ proposals .Y i@ draft two matters which o,iigliit to tie thc-- stiljei@@i@ i@ z @42 t @lla,tion since to us they are almost the side c3tia non o'L ti),e, i @irs l@@ In lt,-@ of the primary purposes: 1. Although several of the reconurendations deal implicitly with the problem of general operating support for medical education, there Is no iiunO.)ered reconmiendation treating this fundamental -matter. It seems to we imperative that the report of the Commission directly, boldly and unequivocally state the need for recogn z..ng Federal responsibility a-,id action in direct. support of medical education as one of the essential icts in the enlargement and inr,)rovemen,L- of the physician raaap(3wer resources of the Nation. Without this direct action none of the other proposals relating to health manpower can really accomplish the task. Furthermore, without such provision ve will again be confronted with pressures to distort existing research and training programs to compensate for the defecli:.s resulting front the lack of direct operating sub- sidy of undergraduate -..me on. 2. It is unrealistic the and in my belief downright @' , 1, -ttitl t- e Congress, to propose misleading to both. Pi, sic! @@ @ , @k, innovative @r4d Trogr ms of the character en- compassed in this rc.@@-l@ort without tl@(-@ frank statement that without significant inc@.rt@,-A.se il'i present Federal salary ceilings it will be impossible to obtain and retain the leadership and scientific and technical capability essential]. i@ the successful mounting of these activities. As you ,ire @7ell aware, vital program of the National Institutes of Health are languishing because of our inability to recruit leadership capabilities-comensurate with the scope, technical demands, and national importance of these programs. To ignore or to equivocate with this problem is, I believe a dis- service to the people of the country who will place great hopes in the vigor and wisdom with which these proposals will be inglemented. 5 Corsients on the specific @,71iich we belic@ve should consti- t:ute category num-ber 2 in 'Louis concept of the organization of the report are as follows: Thia reco.@ndations in this cate&roi-,r cover actions which may be considered essential to make possible or to underpin the accomplishment of the I>rimarl programs included in category 1, TI-iey concern community facili- *ties and programs, Communication activities manpower and training needs, and the furtherance of research., fit concept of the report out of which these general suggesti-c@@@.-@ are developed it would seem beat to g-4--oup the in tl,-.Ls category according aLI)C)@"(@ ad4.i t i@rt, .0 the@ sub@l ct c)"ar:i.fLed, c ear Trade to t@ e prime. conceni t rt: disease, cancer and 4p A. PecomTend@itions &aid d at, strengthening, inTroving integrating the facilities amid Programs; for regional and community activity: P.ecommndat-i.on @No. 3 DL-.@,elopwe-@n-t of ma@lical complex(--s Recom@-n.datio-n No. 6 I)I.az,,ning grants Rect@mmendation No. Support c;f local progrLkw .Zeco@ndation No. 9 Statn-@yide programs for heart disease control P,ec(>v@ndation No. 31- Statist-l-cal Drograms. L@'19L@B. Communications activities Recommrdation, No. 12 P ",nf-@ -7isti.on on eart d sease, cancer RecommL,ndation No. 30 LL'@@ @ii i. audiovisual center gr@)I!p . llanl)m;er, L r ir,,,i ii in et o@@ the educational rocess p o.,E educational centers of excellence ftecommndati.on Itecommendation No. 11 COntil@-.11-1 TI& adi,,f-@@ttion of health professions Recommendatitn No. 18 E:r@zrk ic@ri of res@)urces for preparation of ';L@aal.tb, III,-tnpower Recommendation No. 19 - foi.- the health professions Iteco=neridatiL-n No. 20 - Undek.-g@a(li.,il@-e @-@r@Aning in medical and Recommendation No. 22 - Support c)-!z training Recommendation. No. 24 Training of health technicians l@@(@omendation No. 2r> CoiitJ.iiuous assessment of health m@snpower needs. 6 !,Ir@@D. Research and Dev.@lopznl-lrit This grouping would encopil@@ass much o@@' the material now :(.,siclu@led in Chapter 5 of the draft report. HoTtrever, most of the recommendations encompassed in this chapter seem inriecessary as recommendations since for the most part there is clear definite national policy and support for many of the matters covered, i.e., ri@.!sear,--h project giants, genera research support grants, payment )f 'Ltjll ),,,erhead costs. The reconmenda- tiotis numbers 13 and 14 on non-cal:egor@ic@ll biomedical research institutes and specialized categorical rese trcii @erit@ers do not seem to be distinguish- able from the resources and and. the area of research that will result from the major covered in category I and category 2, On-iup C, c@,E, In ,-iriy 4.@asr-@, the t i y @,zc@@oTpt) i,@ithi,n iq,,.ht)o Is (,Categorical. ce Liters T i s c Li 9 o c@, o u@l the resonances needs relating to medical research which in chapter 7 of the report and provide a basis for the legislative recc)rtira@,-Lidations included in chapter 8, of which recommendation nuriber 16, r,,)rLtracting authority, for research and development, is a major component. Those recormne@ndations coveri!Ti-, matters which should not 0. r recommendations in the Ct The follo,4ing reconnLndations are co@ig-@.der@,,d inappropriate for inclusion as specific recommendations in the report for one or more of the follm,7ing reasons: (-.hey @er.Tiane to the main purposes of %-he report; they -.ire more ,i-i for inclusion in general state-- p -,c concerning factors i'Loiar broad groupings d@scussed under category 2; they are movement b@l recommendations or existing Programs; they are tRore 't.@.ic!,Lided in the detailed statements in Volume II of the report:,. Recommendation No. ilea'ttli research and demonstration This general need could be suitably mentioned as a supporting consider- ati,on under category 2, group A and also discussed under group D. -Redommendation !go. 10--National cervical cancer detector. r@ren This problem has been the subject of major program proposals and appro- priation actions over the past 10 years. It is hardly new and does not enhance the Corraission's report. The specific needs in this area would seem to be covered by recoirwendations nu7ibers 2, 8, 12, and the regular activities of the cancer control progr@ini. Intention of this specific need might be made in Volume II.. 7 Recommendation No. 13--Biomedical. @@f@arch institutes The need for continued and expanding support of fundamental biomedical research could be included i,.i the discussion of research under category 2, group D, where this need could be considered in relationship to the need for research project support and other programs. The rationale for these institutes in the context cf the other major expansion of facilities and programs proposed, is not evident. The need for such a departure from the current pattern o;.' uiedical research is not set forth. Recommendation No. 14--S-peci@@ centers as ill)f t@b@r, Exl>,Fjnsion of research support is a Necessary consequence of the major recommendations of the Commissio-r.. The need for adequate research project grant funds could be mentioned unider category 2. group 1), as a general. underlying factor supportive of the specific recommendations of the Conimission. R@,cor.@-ndation No. for research The General Research Support Progr,-,@-ii @t.,3 .2 I.ogical component of a general d-@LL-cussioii under categorv 2, -rotip D of the @ieed for broad research s@tpi),-@rt and vigorous -1@asti.tutio,.q3 'biomedical research and a separate reconpendatJ.on seems unnecessary. Recommendation Na. 17-A--P of costs The payment of full indire(.1@ been the policy of the Executi.,.re Branch of the Gove@@@ Recommendation No. 21@---Tri These needs could be mentioned in discussion under category 2, group (". Recommendation No. 23--Stabili.zat4..,on of acae,@ I- ositions The purposes of this recorLiierida,tion cotl.d be better accomplished through title provision of general operating support to the medical schools, as previously mentioned, and through the r@ie,4n@, provided in recometidation number 3, and the present general research support grants. Recomendation No. 25--rral-i@l in health communications This purpose would be an appropriate par-, of the detailed discussion in Volume 11 of the reDOrt. The specificity of this recommendation seems inappropriate Recoumendation No. 27- care faciliti@-@ This endorsement could be part of statement on underlying factors supportive of the goals tinder category 2, group A. Recom etidation No. 28--Stren,-,,L,'. l,'P-deral @s k@:L o 'rate could r@i;--r@.tioned -ts y g R(@,.,c@d."),aff@etidation klo. The general need for improvemet,.ts l.r@ the medical library system could be discussed as an important supporting actor under category 2, group B. Recommendation No. 32--Aaii.mal resources for biomedical research The needs in this area are an underlying consideration best discussed uriderk category 2, group D. Recomerdation No. 33--A cleariry c for drtiR information This proposal is not directly ger-ma@ne, noi- does the meeliaxiisut deal witb. the essential problems in the arse ol dru-.s as they relate to cancer, heart disease, and stroke. -P,ecommendation No. 34---Internat r(.@sea-r,ch and training programs_ The role of international pr@', ttie Livportance to the national biomedical research effort ,ire a part of the general discussion under categow,@y 2,, gro(t@,@ A -separate recoumendatioxi seems inappropriate. I hope that these suggestions will be helpf@4A!. I will be happy to discuss them with you ftxri:he.-. Ja@mes A. Sha7.iiion, M. D4