J. H. WHITNEY & CoO.
630 FIFTH AVENUE
NEW YORK, N.Y. 10020

March 22, 1971

Senator Edward M. Kennedy

Chairman, Health Subcommittee
Committee on Labor and Public Welfare
Washington, D. C. 20510

Dear Senator Kennedy:

I have reviewed with great interest the testimony
presented before your Subcommittee on March 9, 1971, in connection
with your consideration of S. 34, the "Conquest of Cancer Act,"
introduced by you and Senator Javits and cosponsored by a number
of your colleagues. I am pleased to provide you in this letter
my comments on that testimony. I am also enclosing a copy of the
statements made by members of our Panel on March 10, much of
which is responsive to the testimony presented on March 9.

First, with respect to the statement of Dr. Egeberg,
Assistant Secretary, H.E.W., as read by Dr. Jesse Steinfeld, Surgeon
General, I am pleased to note the very substantial areas of agreement
between that statement and the findings and recommendations of our
Report. The bulk of Dr. Egeberg's statement follows precisely the
lines of our Report, and I have no differences with those portions
of his statement. However, on the question of how the job can
best be done, there are very important differences between our
recommendations and the views expressed in Dr. Egeberg's statement.
We recommend the creation of a National Cancer Authority, while
Dr. Egeberg urges that the effort remain within N.I.H. and H.E.W.
In arguing against the independent agency, it seems to me that Dr.
Egeberg lost sight of the real thrust of our recommendations. We
were talking about management, and management only. We were not
talking about isolating the cancer effort from other aspects of
biomedical activities. On the contrary, we would expect the
closest cooperation and coordination in this respect. Dr. Egeberg's
statement speaks of the new authority “replicating management
resources for its own programs at some location distant from the
National Institutes of Health," and suggests "that very high costs
would be involved, as well as time delays." We have absolutely
no thought of moving the National Cancer Institute physically
or of terminating or curtailing its efforts while another organi-
zation gets started. The N.C.I. would go right along as it is
Senator Edward M. Kennedy —-2.

today, becoming the nucleus of the National Cancer Authority.
We are talking only of the simplification and clarification of
the management of the cancer effort.

We believe that the effective conduct of the cancer
effort requires clearly defined authority and responsibility, and
that there should be an independence in management, planning, budget
presentation and assessment of progress that does not exist under
the present setup. Dr. Egeberg speaks favorably of the management
capability and efficiency of the National Cancer Institute, but
that is not primarily where the management problems exist today.
The primary source of the delays, inefficiencies, competition for
funds, and dilution of the cancer priority are not within the
N.C.1I., but are within the layers of decision-making authority
over N.C.1I. within. the N.I.H. and H.E.W. It is here that we find
the six tiers of bureaucracy with multiple decision makers and
influences at every level that blur the definition of authority
and responsibility, and that preclude the independence in manage-
ment, planning, budget presentation and assessment of progress
that is required. If you assume that the director of the National
Cancer Institute was given full authority and responsibility for
the cancer effort and was told that he was responsible for manage-
ment, planning, budget presentation and assessment of progress,
and if you assume further that there was created a National Cancer
Advisory Board with the powers and functions outlined in our
recommendations, and if the director of the N.C.I. then proceeded
to implement the recommendations of our Report, this gives you the
picture of how the National Cancer Authority would actually work
in practice.

This would not move the National Cancer Institute physically;
it would not fragment or isolate the cancer effort from other bio-
medical sciences; it would not minimize basic research or diminish
the emphasis on grants; it would not in any way threaten the basic
scientists or the support of medical schools, but it would provide
clearly defined authority and responsibility; it would provide
independence in management, planning, budget presentation and assess-
ment of progress; it would provide participation in the planning
effort by the scientists who will be primarily involved in the
execution of the effort; it would provide the mechanics for peer
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review without the inefficiencies and delays that exist today;
and it would assure that the cancer effort retained whatever
priority the Congress assigned to it and that the funds provided
for the cancer effort were not used for the support of other
purposes, however meritorious, such as unrelated biomedical
research in other fields and medical education.

I would like to emphasize that our Panel is strongly
of the view that the cancer effort should not be funded at the
expense of other biomedical research or medical education. But
the way to avoid this is not to divert funds appropriated to cancer
to these purposes, but to use the cancer funds for cancer and look
squarely at the funding needs of these other areas.

When I speak of using cancer funds for the cancer effort,
I would like to make it clear that I am not talking about a limited
programmatic or systems approach. Using cancer funds for the cancer
effort would include large segments of basic biomedical research
which are relevant or possibly relevant to cancer, but a qualified
advisory board which includes eminent basic scientists can draw
that line wisely and not narrowly, and it is not essential to the
protection of basic science or medical education that the boundaries
of the cancer effort be drawn by those whose primary interest
is in areas other than cancer.

Dr. Egeberg expresses the fear that a cancer priority
"outside the context of requirements for other biomedical research
activities and for health as a whole ... ignores not only the question
of what constitutes a balanced and reasonable coordinated approach
to problems of health, but also the question of competing needs for
resources." I believe this is really the crux of the argument for
keeping the program in N.I.H. As long as the program is in N.I.H.,
if cancer receives a disproportionate part of the funds, ways can
be found to "balance the program." This seems to me to be the wrong
approach. Appropriations for cancer should be used for cancer, and
if this slights other basic research or medical education or other
health fields, H.E.W., N.1I.H., and the Congress should face up to
that fact and do what is necessary for these other fields. I certainly
would not want to see these other areas slighted, but I think they can
get better support on their own merits than through the supposed benefits
of having a common budget with the cancer effort.
Senator Edward M. Kennedy -4.

Finally, Dr. Egeberg makes the argument commonly made
that the cancer effort is not scientifically comparable to the
space effort or the splitting of the atom. This is, of course,
correct. Our Panel was well aware of this distinction and took it
into full account. The analogy we were drawing was not the scientific
analogy, but the organizational analogy. The cancer program, in
order to succeed, needs the same independence in management, planning,
budget presentation and the assessment of progress that those programs
needed, and in those respects the independent authority analogy is
a valid one.

Following the presentation of the prepared statement,
the Chairman asked Dr. Baker whether there is a comprehensive, overall
cancer program today. Dr. Baker referred to several managed programs
within the N.C.I. Our Panel is, of course, familiar with those
programs, and we concur with the view that those are sound programs
that have been well managed. However, there is no comprehensive
overall program plan today, and such a plan is a sine qua non of an
effective assault on cancer. Dr. Baker was emphatic about this in
his own presentations to our Committee. However, for an overall
program plan to be formulated or executed, there is need for the type
of independence advocated in the Report, supported by the scientific
participation that would be afforded through the National Cancer
Advisory Board or some similar mechanism. In the light of the
testimony given by the departmental witnesses in answer to questions,
I would like to emphasize again that our Panel has not the slightest
notion of eliminating the cooperation, coordination, cross-fertilization
and interchange between the cancer effort and other Institutes of
Health. This cooperation is essential, just as is the cooperation
between the federally sponsored effort and the private efforts which
are going on throughout the nation. However, under a clearer definition
of authority and responsibility and with greater independence of manage-
ment, this cooperation should be improved rather than retarded.

In the questioning of the witnesses, it was pointed out by
Senator Dominick and others that many leads and possibly important
answers in the cancer field may come from medical research in areas
other than cancer. This is entirely true, was fully recognized by
our Panel, and there is no question of the importance which research
aimed at cancer has in other fields and research aimed in other
Senator Edward M. Kennedy ~5.

directions has in the cancer field. However, there is absolutely
no reason why more efficient or more independent management of

the cancer effort would cut off this intercourse between the
different research areas. This would, of course, continue and with
the improved communications that we recommended and envisaged, and
which we believe independence in management will facilitate, this
intercourse should be vastly improved.

Repeatedly in the testimony on March 9th there was talk
about "keeping the program within the entire scope of biomedical
research and taking advantage of all new ideas and new concepts
rather than pursuing a single program on a single tract." May I
repeat again that there is not the slightest support in any aspect
of our recommendations for pursuing a single program along a single
tract. We are taking an even wider approach, recommending greater
use of broadly based biomedical research and a greater use of new
ideas and new concepts. We are only advocating the more efficient
Management of a better and more broadiy defined overall plan.

There was a good bit of dialogue initiated by Senator Pell
on the question of whether there exists today adequate data processing
facilities for current communication between the various researchers
interested in a particular aspect of the cancer field. The answer
to that question is "no." We believe that there should be such
facilities and we strongly recommend that such facilities be developed,
and here again we believe that the effective development of such
facilities is much more likely under independent management. The
discussion before the Committee was somewhat confused by reference
to Medlars, a computerized system maintained by the National Library
of Medicine, wherein an attempt is made to put all published medical
information on tape and make it available from a data bank. However,
this system is not programmed specifically to cancer and it stores
only published information. Although this is useful, we believe
that there is an urgent need for a central data bank where current
research information and other information can be stored and exchanged.

I was pleased to hear Dr. Egeberg say "that the Secretary
feels that within the N.I.H. he can, with the proper people and with
the proper group surrounding those people, create in effect an authority
that would focus on this in a quicker way than one can do at the
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present time." This is precisely what our recommendations are
designed to achieve. For example, if one could visualize the
National Cancer Institute being set up with the same clearly
defined authority and responsibility, with the same independence

of management, with the same type of cancer advisory board, and
with the same powers and missions as are set forth in our recommen-
dations, this would in effect provide the results we are seeking.
However, this will not be true as long as N.I.H. is over the
National Cancer Institute, H.E.W. is over N.I.H., they operate
under a common budget, and decisions are made as they are today.

Dr. Cooper spoke on behalf of the Association of the
American Medical Colleges and expressed apprehension lest the
creation of a separate cancer authority might begin the destruction
of the National Institutes of Health and thus eliminate this source
of support for medical education. We see no reason for believing
that the creation of a National Cancer Authority would destroy
or even weaken the National Institutes of Health. This would be
true only if the Congress acted in such a way as to produce that
result, and I have seen no evidence that the Congress is likely to
take such action. We are not only in favor of a continued strong
N.I.H., but we also favor a strengthening of the support of medical
education. An independent cancer authority would undoubtedly
support basic and other research relevant to cancer conducted by
medical schools and hospitals associated with medical schools at a
higher rate of support than is the case today. Moreover, no part
of the cancer program is intended or should have the result of
reducing other support for medical schools. However, support of
medical schools from funds appropriated for cancer research should
be based upon the merits of the proposed research. Under this
criteria, I would see no threat to the medical schools from the
recommendations of our Panel.

Several of the scientific and professional members of
our Panel are from leading medical colleges and I think that they
understand clearly the thrust and implications of our Report and
see therein no threat to the medical colleges. My personal view is
that the threat that is seen in our Report to the medical colleges
comes from a misunderstanding of our recommendations. I think here
again the worry is that cancer will get a higher priority in funding
than other equally meritorious causes such as the support of medical
education.
Senator Edward M. Kennedy -7.

Dr. Schneider spoke on behalf of the American Societies
for Experimental Biology. His remarks indicated a worry that the
recommendations of the Panel would lead to a reduction in the
support of basic biomedical research or a reduction in the inde-
pendence of the researchers. I believe a thorough reading of our
recommendations makes it clear that precisely the opposite wiil flow
from the implementation of our recommendations. The support of basic
research will be increased. The use of the grants mechanism will be
increased, scientists will participate in the formulation of the
overall plan as well as the specific plans, and there will be much
larger segments of non-programmed basic research than is the case
today. I believe the worry here stems from the fact that today
this type research derives much of its support from the N.I.H., so
that naturally the recipients of that support are uncomfortable
with the prospect of a change when they are not certain how that
change will affect them. I have no question that they will find that
the implementation of our recommendations will affect them favorably.
This was the view of the very distinguished basic scientists on our
Panel. This view was elaborated in more detail in the testimony
of Dr. Kaplan before your Committee.

Dr. Lee pointed out once again that the problem of cancer
"represents a complex, multifaceted challenge at least as perplexing
as the problem of the various infectious diseases," and therefore
“is in no way comparable to a moon shot." As pointed out above,
this was clearly understood by the Panel, but it was not thought to
militate against striving for a more efficient management of the
cancer effort. I have no doubt that those managing the cancer
effort under an independent authority would be as fully aware of
the complexity of the cancer problem and what is required to solve
it as are those who point out this distinction between cancer and
other programs. Once again, the analogy we are drawing is not the
scientific analogy, but the organizational analogy. Dr. Lee also
suggests that independence of management means separation and a
loss of intimate interchange of ideas and interaction among
investigators. This clearly need not follow. For example, there
is as much interchange between investigators at Rockefeller University
and others working on similar problems as there would be if Rockefeller
University were a formal part of and governed by a larger medical
school. There can be efficiency without isolation on program control.
Dr. Lee then expresses his concern about competition for scarce
resources. Here again, the crux of the criticism is the fear that
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an independent cancer authority will enable the cancer effort

to drain resources from other medical areas. This would be so
only if the Congress makes it so. But, in my view, it is a
principal basis of the opposition from those who currently receive
support from N.I.H.

Dr. Carl Baker, Director of the National Cancer Institute,
and two of his colleagues testified before our Panel, and several
hours were spent with Dr. Baker discussing the recommendations
of our Report. Following Dr. Baker's appearance before our Panel,

I asked him to outline in a memorandum the points covered in his
testimony. I would like to quote from that portion of his memo-
randum dealing with organization. In so doing, I would like to
make it clear, as Dr. Baker did, that he was speaking personally
from his own experience and was not professing to voice the views

of the Department or the Administration. I would also like to make
it clear that Dr. Baker's remarks were not the basis of our recom-
mendations. However, they touch in a very important way on many

of the factual points which led to our recommendations. Dr. Baker's
memorandum reads as follows:

"The managerial needs were briefly out-
lined which would be necessary if a much larger
attack was instituted. Primarily, much more rapid
decision making and much more rapid response time
after decisions are made would be absolutely necessary.
A drastic reduction in the number of people involved
in decision making (whether advisory or otherwise)
would be required, and great simplification of
organizational arrangements would be necessary in-
cluding particularly a return to a hard pyramidal
line command structure. The Director cited the
importance of such features as seen from his review
of a number of major technical successes of mankind
of large scale such as the air defense in the Battle
of Britain, the Manhattan Project, and the moon
shot.... Moreover, the cost of review time and delay
spent on reviewing small packages of research
efforts would preclude much greater expansion if
program size were considerably enlarged, to say
nothing of questionable efficiency of such use of
senior talent on relatively small matters. Lastly,
the difficulties of sound program management when
budgets are not known until the fiscal year is
Senator Edward M. Kennedy -9.

nearly gone do not require much elaboration.

The need for no year money or five year money

or even three year money might be helpful in

this regard, as would budget review cycles

based on something other than our present fiscal
year constraints. The time required currently for
approvals of certain appointments and promotions,
for construction and renovation clearances, and

for other so called "staff" functions would require
changing if a major, larger attack is to be success-
fully launched."

I believe that the views expressed by Dr. Baker to our
Panel give a better picture of the nature of the problems than does
the testimony of the Department's witnesses before the Subcommittee.

Finally, I would like to make it clear that neither I nor
any of the members of our Panel want any political conflict or any
conflict with the Administration on a matter that ought so clearly
be a nonpartisan or bipartisan question. We all realize that the
American people do not want to see the cancer problem become a
political or partisan issue. It has been our aim to work as closely
with the Administration as with the Congress. Soon after the appoint-
ment of our Panel, I sought and received an appointment with Secretary
George Shultz at the White House to acquaint him with our Panel and
its mission and to assure him of our desire to work closely with the
Administration. Dr. Farber, Dr. Clark and I met with Secretary
Richardson and members of his staff to discuss our recommendations
soon after they were presented to the Senate. Dr. Kaplan and I met
with Dr. David and the President's Scientific Advisors and discussed
the Report for two hours. The staff of our Committee was housed
at the National Cancer Institute and we worked most closely with the
N.C.I. on the development of the facts on which our recommendations
were based. There is no desire to dismember or weaken in any way
the N.I.H. Our only interest is in seeing the cancer effort succeed.
I agree with everything in Dr. David's recent address on this subject
except his conclusion that the cancer program can best be carried
out within the N.I.H.

Whatever the outcome of the organizational discussions,
I hope you will insist upon a clear definition of authority and
Senator Edward M. Kennedy -10.

responsibility and the independence in management, planning,
budget presentation and assessment of progress which a complex
scientific program of this sort requires. Without these attri-
butes, the chances for the Conquest of Cancer hold considerably
less hope.

With deep appreciation for the courtesies shown to me
and the members of our Committee, and for your cooperation in
this subject which so vitally affects so many of our citizens, I
an,

Sincerely yours,

j bare pie biff

Benno C. Schmidt

Attachment