LAN 0656* MEMORANDOM NIB-OD-OPP TO: Special Assiatant te the Secretary November 20, 1964 (Health and Medical Affairs) FROM: Directer, Nin SUBJECT: Suggestions re the draft report of the President's Commission 9 the Resort of eit i { ita c for action, and to play « fvom the report those recom mendations which seemed dot ly : ». not really needed or possibly {nappropriate for this particular document. I believe cutting back on certain of the miscellaneous general recommendations, as well as on those of highly specific but limited import, would increase the impact of this document and enhance its stature as a report of a Presidential Commission. Accordingly, we have taken the 24 numbered recommendations in the report aad dietributed them inte three categories as follows: Category 1: Those numbered recommendations that make innovative proposals centered upon the essential subject matter of the Com mission's concern; namely, heart disease, cancer and stroke. Thus the recommendations of this group represent the very essence of the new, different assary actilone flowing from the Commission's examination of ; diseases and the problems asso~ eLated with them. , Gategory 2: Those important onuendations cevering actions deemed essential to ut dy ccomplishment of the proposals da category 1. Category 3: Those recowmendations covering matters which--as i see it--should not appaar as separate numbered recommendations in the GComeission's report proper. Reasons vary: Some are not felt to be importantly germane to the Comiesion's purpose; others IT feel are unnecessary because of other national action in respect fo them; others seem inappropriate to the circumstances and purm poses of a Presidential Commission report. This proposed treatment of the recommendations reflects a fairly definite concept of what the character and scheme of the Commission's report should be. In brief: the report proper should be confined to major Innovative recommendations and their essential correlaries. Other important matters should be treated with appropriate emphasis but not be mede the subject of individual recommendations to avoid diminishing the force of the more critical matters. The report of the Commission proper should indicate its affirmative view of the many detailed recommendations in the individual panel reporte but express 2 view that these must be the subject of careful agsessment within the context of other policy, budgetary and Executive Department considerations. This framework, I believe, would provide adequately for a positive expression of the Commission's views on new and essential actions, withov: involving the Commission in a tangle of specifies about which the Commission could hardly have had the time te draw judiclous conclusions in such ail, For example, one might ask: if@ it appr ae n to single out a particular Saeetionm Gt od AaB St jellar sum? The dmportant matter, :, in general terms, the need out of ) LO? 5 With this ae background, here is our suggested grouping of the recommenda- tions, with some comment on policy, legislative or feasibility aspects: Catepory 1 Those numbered recommendations which encompass innovative and unique proposals centered upon the essential subject matter of the Commission's concern, namely, heart disease cancer and stroke. Recommendation No. i~-Regional centers for heart disease, cancer _and stroke This recommendation is clearly the basic innovative action™ concluded upon by the Commission. Although “Lede nature and operating character is well described, the major policy garture that they represent, namely Federal involvement in the medical c of that portion of the general population affiieted with problems of heart disease, cancer, oF stroke, is not treated in any way requisite to establishing the rationale for this departure. Grave questions cf relationships to commmity medical practice and the financing of medical care loom between the lines of this proposal. Insofar ag the centers would be confined to research and research training and clearly related purposes they would perhaps be encompassable within present legislative authorities of the Public Health Service. However, it seems elear that the concept of these centers contemplates substantial involve~ ment in direct medical care functions. The inelusion of this latter alement 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 lesues represented by this proposal argue strorgly for a clear Congressional consensus in the undertaking of this effort. at 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~ ing of this center program in terms of dollars and magnitudes proposed by year seem completely wmrealistic In the fact ef current manpower capabili- ties plus any reasonable expectations concerning the rate of manpower expansion. Greater recognition of thia problem would give a better sense of reasonableness to this imser?tmt sroposal. Recommendation No, 2-~-Diagr HE Se ge ae ork af ABDOBLEE a eosin § nm the area of medical care, . pesessary for iuitLation of the program, and the seceseary ¢ imposed by manpower shortages. The schedule cf number of units and dcilars 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 Presidantial judgment. Recommendation No. 5-~A national stroke program unit The creation of a specific organizational entity for the direction and administration of the set of innevative activities proposed by the Com- mission in the area of stroke seems indeed appropriate in view 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 be given to this field seems clearly to argue for thig organizational rep Son. The proposal dees present policy problems in that both regen :. vice activities would be encompassed within the unit as recomm Somaission. The present Public Health Service organizatlon ©: ized as a first principle a distinc- tion between research and services programs. Some recognition of this facet and the Commiesion's view of it weuld seem desirable. The three recommendations above would, in our view, constitute the essen- thal innovative proposals of the Commission. Category 2 | These important recommendations covering actions deemed essential to underpin the accomplishment of the proposals in category 1. In this category are encompassed those recommendations which can be viewed a8 essential actions of a broader and general nature to create the set of elreumstances necessary to make possible and to underpin the accomplish- ment of the primary proposals. It would appear desirable to treat these set of recommendations in a cchesive and logical whole and in which their spores re hationshare and the overall rationale relating to them can Bt | he specifics of dollars and i of go many of these proposals. be the draft omit two matters which ‘tion since to us they are almost Tye Recommendations a6 Enuy tow enue gught toe be the sub jeck oe the sine qua non of the 1. Although several of the recommendations deai implicitly with the problem of general operating support for medical education, there is no numbered recommendation treating this fundamental matter. It seems to me imperative that the report of the Commission directly, boldly and unequivocaily state the need for recognizing Federal responsibility and action in direct. support of medical education as one of the essential acts in the enlargement and improvement of the physician manpower 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 prevision we will again be confronted with pressures to distort existiag research and training programs to compensate for the defects resulting from the lack of direct operating sub- sidy of undergraduate medical education. 2, It is wvealistic in the extreme, and in my belief downright misleading to both the Prasident and the Congress, to propose dunovative and sweeping Federal programs of the character en~ compassed in this report without the frank statement that without significant increase in present Federal salary ceilings it will be impossible to obtain and ratain the leadership and scientific and technical capability essential te the successful mounting of these activities. As you are well aware, vital programs of the National Institutes of Health ara languishing because of our inability to recruit leadership capabilities-commensurate with the gcope, technical demands, and national importance of these programs. fo 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 implemented. Comments on the specific recommendations which we believe should consti- tute category number 2 in this concept of the organization of the report are as follows: The recommendations in this category cover actions which may be considered essential to make possible or to underpin the accomplishment of the primary programs included in category 1. They concern community facili~ ties and programs, communication activities, manpower and training needs, and the furtherance of research. Jn the concept of the report out of which these general suggestions for reorganization are developed it would seem beat to group the sscowmenda ore in chia category according to the broad aublect matte: ted abowa, In addition, g ang thened ‘ a clariftled, 8 showld provide clear made to the prime concern sart Glseage, cancer and of a alms i io asie on th me ihe Commission, mars atroke. Group A. Recommendations aimed at enlarging, strengthening, improving integrating the facilities and programs for regional and community activity: } Recommendation Ne. 3 - Development of medical complexes | Recommendation No, 6 ~ Community planning grants Recommendation No. 8 - Support of local programs Recommendation No. 9 ~ Statewide programs for heart disease control Recommendation No. S1- Statistical programs. Group B. Commmicatione activities formation on heart disease, cancer OE Machenel medical audiovisual center Recommendation No, i2 Recommendation He, 30 - Group ©. Manpower, training ” Recommendation Ne. 4 - Recommendation No. 11 - Reconmendatitn No. 18 ~- health ianpower Recommendation No. 19 ~ Recruitment for the health professions Recommendation Nc. 20 - Undergraduate training in medical and dental schools Recommendation No. 22 - Support cf clinical tralning Recommendation No. 24 ~- Training of health technicians Recommendation No. 26 ~ Continucus assessment of health manpower needs. Group D. Research and Development This grouping would encompass much of the material now included in Chapter 5 of the draft report. However, most of the recommendations encompassed in thie chapter scem unnecessary as numbered recommendations since for the most part there is clear definite national policy and support for many of the matters covered, i.e., research project grants, general research support grants, payment of full overhead costs. The racommenda- tions numbers 13 and 14 on non-categorical biomedical research institutes and specialized categorical xresearch centers do not seem to be distinguish- able from the resources and capabiligies and the area of research that will result from the major recommendations covered in category i and category 2, Group C, ae outlined amacandum, in any case, the a4 "ities ren ‘iearly accomplishable within ng of medical schools, LOY categorical centers. st of the resources needs relating to medical research which ara © covmred in chapter 7 of the report and provide a basis for the legislative recommendations included in chapter 8, of which recommendation number 16, contracting authority for research and development, is a major component. aw nitesk of id comp Locmes discussion could a! Categury 3 Those recommendations covering matters which should not appear a8 separate numbered recommendations in the Commission's report. The followlng recommendations are considered inappropriate for inclusion as specific recommendations in the Cownission's report for one or more of the following reasons: they are mot germane to the main purposes ef the report; they are more appropr, for inclusion in general state~- ments concerning factors which udev! four broad groupings discussed under category 2; they are covered by other recommendations or existing programs; they are more apprepriately included in the detailed statements ia Volume II of the report. Recommendation No. 7~-Community health research and demonstration This general need could be suitably mentioned as a supporting consider- ation under category 2, group A and also discussed under group D. Recommendation No. 10--Nacional cervical cancer detection program This problem has been the subject of major program proposals and appro~- priation actions over the past 16 years. It is hardly new and does not enhance the Commission's report. The specific needs in this area would seem te be covered by recommendations numbers 2, 8, 12, and the regular activities of the cancer control program. Mention of this specific need might be made in Volume IT. Recommendation No. 13--Bilomedical research institutes The need for continued and expanding support of fundamental biomedical research could be included in 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 pregrams. The rationale for these institutes in the context of the other major expansion of facilities and programs proposed, is not evident. The need for such a departure from the current pattern of medical research is not set forth. ‘ch centers ae Recommendation No. 24~-Specia') --d fle sarap eg , ait ta ie terh mest : igead es part of the ploank Gentets Ged uti Nea. L 4 Recoumendation No, 15--~ ea ey Pees grants Expansion of research support ie 4 necessary consequence of the major recommendations of the Commission. The need for adequate research project grant funds could be mentioned under category 2, group D, as a general underlying factor supportive of the specific recommendations of the Commission. Recommendation No. 17-~General support for research The General Research Support Program 1s a logical component of a general seussion under category 2, group 0 of the need for broad research apport and vigorous institutions engaged in biomedical research and a separate recommendation seems unnecessary. : o Recommendation No. 17-A-~Paymen” of in he ca mae The payment of full indirect «+s ‘as long been the polley of the Ruecutive Branch of the Govenore ut. Recommendation No. 21-~Trainiay for research These needs could be mentioned in the discussion under category 2, group C. Recommendation No. 23--Stabilization of academic positions The purposes of this recomnendation could be better accomplished through the provision of general operating support to the medical schools, as previously mentioned, and through the means provided in recommendation number 3, and the present general research support grants. 8 @ Recommendation No. 25-~-Training of specialists in health communications This purpose would be an appropriate part of the detailed discussion in Volume If of the report. The specificity of this recommendation seems inappropriate. Recommendation No. 27-~Expanding patient care facilities This endorsement could be part of s general statement on underlying factors supportive of the Commiscice’s goals under category 2, group Ae Recommendation No. 28--Strength: . the Federal hospital program rem could be mentioned as fhe general need for improvements in the medical library system could be discussed as an important supporting factor under category 2, group B. Recommendation Ne, 32--Animal resources for biomedical research The needs in this area are an underlying consideration best discussed under category 2, group D. @ Recommendation No. 33-~-A clearinghouse for carug information This proposal is not directly germane, nor does the mechanism deal with the essential problems in the area of drugs as they relate to cancer, heart disease, and stroke. Recommendation No. 34--Internatico:.. research and training programs The role of international prog cor nd the importance to the national biomedical research effort are « ppropriately a part of the general discussion under category 2, group 5. A separate recommendation seems inappropriate. 1 hope that these suggestions will be helpful. Tf will be happy to discuss them with you further. James A. Shannon, M. D.