Statement by Joshua Lederberg, Professor of Genetics, Stanford University
School of Medicine San Francisco January 19, 1971

President Nixon, on January 11, signed the Health Appropriation Act for

fiscal 1971. This legislation had been entangled by many side-conflicts,

so that it was delayed more than half of the year to which it -was intended

to apply. Meanwhile, health services and research have been funded by a
continuing-appropriation. This has allowed ongoing projects to continue

at established rates, but has been a serious obstacle to starting new projects.
Even continuing projects have been impaired by budget’ freezes and other
administrative headaches during this interval.

We should now be gratified that the Congress has responded with this new
budget to a perception of national need. Indeed, the funds for the NIH, which
are the mainstay of health research in the U.S., amounted to 1.130 billion
dollars, almost $100 million above the budget requested submitted by the
White House. This request was framed on a policy of "no new money over last
year", despite the fact that price-inflation hits research yield about 10%
per year, and despite of our discovery every day of new challenges and new
opportunities for health research on behalf of human needs.

The Congressional appropriation then amounts to a little over what is needed
to hold the line, and this after several years of equally serious restraint
in the area of health research.

The President's signature of this act may be a sign that we have turned the
corner in the White House's recognition of the mandate, repeatedly expressed
by Comgress, that the American people recognize health research as the most
effective way to minimize the future cost in money, pain and anguish of dis-
ease; that at a time when our commitment to health in the area of services,
of a high standard of care for the whole citizenry, begins to reach what. our
political conscience and social order demand, we cannot afford to destroy
the tools by which a higher standard of life must be reached.

Unfortunately, health research has no particular lobby or political consti-
tuency. The people best equipped to report on the impact of budget cuts are
those who, like my colleagues here and myself, are deeply involved in it. We
command very few votes; and of course we can be accused of self-interest in
pleading for these funds, as can anyone whose work is in public service. We
realize that we will get nowhere in these pleas unless the interested public,
those whose health is at stake in our research, express themselves directly--
in letters to the President, to congressmen, to the editors of their local
newspapers, about their feelings on this matter.

The fact is that there still remains quite a gap between the appropriation
of these funds by Congress, and their actual use for maintaining and invigorating
new projects.

In spite of having signed the act, the President still has the authority to
allocate or to withhold the funds. This is not a partisan issue--many
previous administrations have used this prerogative in order to save tax
moneyS in favor of other programs that had stronger political clout. The
President has not yet expressed himself, one way or the other. Surely his
decisions can be influenced by public expressions of concern at this criti-
cal time.
It is disconcerting that some of the President's advisers have commented

in opposition to the increases in research funds in their testimony before
Congress and in other public statements. It is distressing when their argu-
ments are based on cliches that reflect serious ignorance of the actual mode
of training of physicians, of the relationship of research and clinical
training in the medical schools, and of the desperate financial plight of
many schools when we have unprecdented needs for access to medical education
or for more skilled: professionals to clear up a pernicious scarcity market.

We hear, for example, that research funds should be withheld because we need
practicing doctors rather than laboratory men in white coats. No one who has
studied the careers of the graduates of our medical schools could support such
an argument. We do have problems in providing enough professionals to meet the
needs of community medicine, as well as the high-income and high-prestige spe~-
cialties (surgery, anesthesia, radiology and so on). This discrepancy operates
in spite of the inducements of research, not because of them; fundamentally, it
reflects the very high value we should and do place on the specialists' services
when we need them. It will not solve this problem to drive medical schools into
bankruptcy! This argument is even more factious when we lack a serious commit-
ment to provide for the considerable expansion of fellowships and of facilities
needed to increase the output of practitioners.

Meanwhile, the institutions in which modern medicine can be taught have been
built with support for health research. It would be better if medical education
were supported directly on its own merits, rather than merely as a spillover
benefit of subsidies for research, but choking the source will dry up the entire
stream.

Furthermore, the manpower resources for research, for specialty practice, and

for community medicine are scarcely in competition. They require rather different
intellectual sets, college preparation, and above all basic self-images about

how a given individual can best function in and for his society. More and more

of the basic research in medical schools is, and should be, done by Ph.D.s

who do not require the same’scarce facilities for clinical training as the

M.D. We are beginning to recognize that community medicine may well be approached
better by a different curriculum, and certainly better by a different type of
student, than the clinical specialty. The latter will continue to require ever
more extended training and supervised experience; for the former, we envisage
many productive experiments in accelerated medical education, and emphasis on

the social and interpersonal needs of the patient clientele for primary care.

We must build on all of these fronts; nothing could be more destructive than

to tear down our research competence because we have much unfinished business

in other quarters. Indeed nothing will do more to assure perpetual frustration

at our inability to answer the distress of heart disease, of congenital malfor-
mation, of cancer. Good will and social zeal alone will not solve these problems
that touch us all!

The frustration of ignorance hits us in many ways; not only in our private,
oft-concealed dread of how each of us may be prematurely stricken, and in
our anxieties about our loved ones. It also exacts a serious price in the
confusions and conflicts of our public policy. How much have we saved by

not knowing of the threat of the contamination of seafood by mercury, when
some unknown number of us may have been chronically poisoned? Alternatively,
what needless anxiety has been raised; how do compensate the fishermen; what
do we think of wasting vital protein if the condemnation of deep sea fish
proves not to be justified? The cost of this uncertainty may be less than
the NIH budget. Our confusion, which is founded on pure ignorance that could
be cleared up by research not yet adequately funded, about the health cost of
radiation is probably costing us at least that amount today -- by delaying
the exploitation of nuclear energy on well-founded standards, or by
permitting the continued development of a technology which may be

found untenable with further Knowledge. We have both discovered, and,

with large scale industrial technology, also invented enormous problems

of environmental health -- for mercury and radiation, and also for lead

and pesticides and food additives and many others, we must take enormously
expensive precautions, not out of real certainty as to the scope of the
hazard in every case, but out of wise prudence to protect that priceless
value of health. This is another price of ignorance.

Finally, I must mention one item in the Congressional appropriation

which does not loom very large fiscally (it is for $10 million in total,
one tenth percent of the appropriation) but may be qualitatively as
important at the rest. This is the mandate for the development of a
definite policy on genetic research within the NIH (specifically under

the leadership of the National Institute of General Medical Sciences).

This was carefully examined, and expressly approved by both houses; but

as a new initiative, it is at special risk of being sliced off without

very serious consideration. The significance of genetic factors in disease
has usually been overlooked. This is partly a result of our gratifying
successes in dealing with the infections and other acute threats to life.
Partly, the easiest conditions in which to recognize the role of genetic
factors are rare ones -~ like phenylketonuria or Tay-Sachs disease. Although
about one newborn child in fifty suffers significantly from a genetic defect,
the types of difficulty are distributed over many hundreds of different
conditions, about which some of our knowledge is only very recent. And, for
Lack of knowing what to do about it, we tend to overlook the genetic or
"constitutional" factor in every common disease. The more we learn to

deal with environmental and infectious hazards, the larger the genetic
factors will loom in the residue of unmet challenges.

Our new knowldge of molecular biology gives us the first serious illumination
of how may learn to approach genetic diseases more confidently, to be able
to do better than counsel a troubled couple that they had better not risk
having more babies. The special appropriation was intended in part to
advise the NIH: "take genetics seriously;do not leave worthy projects to
die on the vine, as has been necessary in other scientific areas." It is
also an initiative to look for the ways in which scientific inputs relevant
to useful applications in repairing genetic defect can be kept in better
communication, and especially to close the gaps between the most esoteric,
basic research and potential clinical applications in man. Just because
these also involve the most careful ‘attention to the overriding concern

of conscientious people about the quality of life of their offspring, we
need careful advance planning to be sure that new research findings in
medical genetics are promptly but very critically analyzed for their
scientific validity, and also that every step that is taken has exhibited

a proper regard for the ethical and legal responsibilities of such research.
Much has been said about the need for careful respect for human rights in
the development of new procedures. When all is said and done, one of the
most important considerations is the integrity of the scientific thinking
that has gone into them, and there is no better assurance of preserving
this than careful study and oven ventilation of future plans and programs.

I urge every citizen to communicate to the President his own view of the
priority that should be given to health research at this time.