THE ROCKEFELLER UNIVERSITY
New York, NVY. fooal

February 24, 1971

L. Hollingsworth Smith, Jr., M.D.
Department of Medicine
University of California

San Francisco Medical Center
Third and Parnassus

San Franetseo, Cablfornta 94122

Dear Holly:

I have spent much time pondering what response would be appropriate
to your query for my thoughts on: the recommendations contained in the
Report of the National Panel of Consultants on the Conquest of Cancer,
prepared for the Committee on Labor and Public Welfare of the U.S. Senate;
and the decision of the President, announced in the State of the Union
Message and detailed in the Health Message, to allocate an additional $100
million in the 1972 budget and later, whatever additional funds can be used
effectively, for research on cancer. On an issue as important as this,
there is really no middle ground between an exhaustive analysis and a
relatively brief summary assertion. Assuming the members of PSAC have had
detailed discussions and consultations with knowledgeable government and
non-government experts on the substantive and procedural questions involved,
I feel confident that I can deal with the problems assertively and that by

identifying my position, the logic and data which led me to these assertions
will be obvious.

First, I was delighted to see the emergence of what appears to be a
national consensus to dedicate ourselves anew to the overriding priority
of trying to solve as yet intractable problems of disease. There can be

no qnestton that the nattonts commftment to Findtny, ways to extend Ttfe and
eile healed) ter bee adabofedtitip, afiee the mbde (60h, aa avab Peat ty
relatively stable current dollar budgets, in the face of accelerating tnflatton

and rising costs. Recent actions harbinger the development of new momentum
which will allow the country to make up for recent erosion and more fully
utilize the talents and ideas of the many able young scientists whose pro-
gressive availability paralleled the progressive decrease in the availability
of research support. .
a

Second, I was delighted with the tone of the President's Health Message,
He clearly demonstrated his perception that the science base in the area of
neoplastic disease is far less broad and:solid than those on which the space,
atomic energy, etc., programs were built. During my tenure as Director, NTH,
programs of a highly organized character were put together in the National
Cancer Institute. -There were tendered increasing support and were encouraged
to operate in styles somewhat akin to those employed by the various NASA and
the big weapons systems projects. So far, I would have to say that while
investments have been sizable, and while the intelligence, energy, dedication
and managerial competence supporting them have been of superb quality, the
results have been modest. The reason, as you well recognize, is the inadequacy
of the science base,

My delight in the prospect for new momentum for biomedical research and
at the keen insight of the President into the essential nature of the problem
is balanced by uncertainties about the proper, as well as the proposed, levels
of funding and by deep concern about Congressional views on the authorities
and organizational arrangements for the progran.

The President's decision to make available as much money as can be used
effectively is wise, at least from my point of view. If there is a reasonable
prospect that scientific research can, on the basis of existing leads, soon
produce new knowledge with which the incidence of "cancer" can be reduced or
patients with the "disease", in all of its protean forms, cured, then an all
out effort is warranted and would, in my opinion, meet with the complete
approval of the American people. Unfortunately, at present time I am not in
an optimal position to assess these opportunities with rigor. I should think,
however, that if it has not already been done, PSAC and the Science Advisor
to the President would want to review with the utmost care the mechanisms now
available for evaluating scientific opportunity, the effectiveness with which
they are operating, and the degree to which their impact is felt at the
critical decision points. I would also think that PSAC would want periodic
reviews of this field to make its own independent assessment of the significance
of perceived opportunities, and certainly the Science Advisor to the President
will wish to devote a significant fraction of his attention to the problems
of cancer research.

Depending on the conclusion of these assessments, some decision should be
reached, and reached very soon, on whether the opportunities are worthy of
increased public investments to operating levels in the neighborhood of $1
billion 3-5 years hence, or whether a $100 million quantum jump to a new orbit,
followed by "wait and see" period before further energizing, is the more
reasonable course to follow. If the former route is chosen, it implies some~-
thing close to a 40% increase in the total national biomedical research effort
in a very brief span, considering the long lead time for manpower and facilities.
In such a situation the initial $100 million would almost certainly have to
be invested in manpower development and facilities construction. In 1968, the
NIH projected, from actual 1967 data, a 1970 biomedical research manpower
requirement of 64,000 individuals with 75% holding doctoral degrees, in order
to sustain a total national biomedical research effort of $2.6 billion (1967
dollars). {Resources for Medical Research: Biomedical Research Manpower for
the Eighties]. While this projection was for all fields, the analysis clearly
incicvres that manpower wit™ Nea a ortetont hattleneck in increasing effern te
<3—-

$1 billion, unless an immediate start is made to insure its production. My
point is that a commitment to result in an effective program, must be a
middle range commitment (perhaps for five years), must cover manpower and
facilities as well as support of research, and will require a detailed though
broad planning effort. ,
a4

The several Congressional actions which propose that the new program be
mounted under a separate Authority, perhaps reporting directly to the President,
and, as a corollary, be operated outside the NII, is to my mind without merit
and dangerously destructive. The NIH is many things, but above all, it
symbolizes a set of processes for the governance of the orderly growth and
development of science. While the machinery now available may be less than
perfect, it is infinitely better than any other ever suggested for the set of
problems it must tackle. Through it, biomedical sclence, at least until the
mid-1960's, has grown apace, has been able to offer the overwhelming fraction
of creative scientists attractive career opportunities, and has maintained a
sound balance between: basic and applied research; research and development;
discipline— -and disease-category-oriented research; and among the various

categories of disease. This has heen accomplished by a set of procedures

which: have more or less successfully orchestrated advice from an enormous
number and variety of distinguished non-Federal scientists into a reasonably
balanced and coherent program. Conceding the bias that stems from my past
identification with this effort, I nevertheless insist that the NIH, in the
sense described above, is an invaluable and irreplaceable guarantor to the
nation that order, stability, sound judgment, balance, flexibility, respon-
siveness, and responsibility will characterize the country's assault on the
problems of disease, disability, and death.

The inescapable fact is that biomedical science is a complex, interrelated,
n-dimensional universe. One can wish it were not, but it is. True, there
are within it some large confluences of great density, such as cancer, but
even this is inseparable from other large islands such as aging, human develop-
ment, etc., which in turn relate to atherosclerosis and stroke. To look at
any isolated fragment, no matter how large, apart from its innumerable major
and minor connections in the vast network of relationships, would be at best
naive and at worst self-defeating. This reality animates the processes that
the scientific community has institutionalized in the NIH, to view biomedical
sciences, to the extent possible, holistically and to thereby assess opportunities
not in isolation but in the context of the past state of the art and recent
changes in contiguous domains of science.

The creation of an independent Cancer Authority, removing the NCI from
the ambit of the NIH, would, in my opinion, not accomplish anything that could
not be done within present NIH processes, or trivial and easily realized mod-
ifications thereof. On the other hand, it would unleash forces of a divisive
character which would auickly destroy the integrity of the NIH. I predict that
in a very short time, orderly governance would be replaced by anarchy, and that
instead of a judiciously balanced program of biomedical research, program
emphasis would be entirely determined by uncritical zealots, by experts in
advertisins and public relations and by rapacious "empire builders." These
latter forces are not to be disdained and they have plaved an invaluable role
in the vast cuarter century in making the lay public aware that, through research,
there was a veal possibility of realizing inchoate public hopes and aspirations
ta control dcisense, As forces modulating the selentific judgment process,

their contributions have been positive and important. As determinants, however,
ahem

I would expect them to create chaos.

The vigor behind the "separatist" effort is in no small measure attributable
to the desperation and despair that has mounted in the scientific community as
other high pridrity national concerns have apparently forced choices to the
detriment of science. Now that the nation seems to have turned the corner and
is beginning to repair. the damage to the magnificent scientific research appa-
ratus it has built, it would be tragic to destroy one of the most priceless,
original and unique institutional forms created for the prosecution of science.

Another factor which might have influenced the consultants who prepared
the Report to the Yarborough Committee, had they’ detected it, is the frustration
which occasionally overcomes program people within the NIH. In my years as
Director, scientific judgments frequently got Jost in, or unnecessarily and
improperly diluted by, the bureaucratic machinery at higher levels in the DIUM.
Fortunately, on major issues we were usually able to place our case pefore the
Secretary and thereby restore proper perspective. L£ some way could be devised
to facilitate access to the Secretary, DHEW, by the Director, NIH and the Director,
NCL, something useful would have been accomplished. A staff Scientific Counselor,
or Assistant Secretary position might do this, although the usefulness of the
incumbent would depend entirely on his competence and the confidence the
Seucecary haa in his advice. The Office of the ‘Assistant Secretary for Health
and Scientific Affairs could accommodate such a position, but more than one
layer is probably unnecessary, and the problem of access to the Secretary is,
in my experience, the really critical one.

In closing, I would want to reiterate my long held and oft spoken conviction
that cancer research must have a broad base in fundamental science. In pur-
suing its: conquest, we must not neglect this infrastructure, supported both by
NCI and the other categorical Institutes, and ‘to a lesser extent by the NSF,
other Federal agencies and the private sector. And we must not be so distracted
with the problem of cancer to neglect opportunities for other "conquests" as
they emerge from the whole boiling cauldron of scientific inquiry. Let us hope
that cancer is but one of the truly major discases that beset society which will
now receive systematic and adequate attention. But let us hope that this is
done with the full appreciation that there are others of much the sane
socioeconomic importance that the nation will address when once one establishes
that the science base is inadequate.

I hope this proves helpful to you. If I may be of further assistance,
do not hesitate to call.

Sincerely yours,

AA

James A. Shannon, M.D.