MEMORANDUM FOR HONORABLE DOUGLAS CATER

This is in furtherance of our conversation about carrying out the
recommendation of the President's Commission on Heart, Stroke, and
Cancer ard modifies and supplements Dr. Dempsey'’s memorandum

to you of February 4, 1965.

I have concluded that it would be wise for the Administration to
amend the 1966 budget to the extent of approximately $75 million
in order that we might be more responsive to the Commission's
recommendations and accelerate our activities and efforts to con-
quer these dread diseases. I have not yet submitted a budget for
this purpose. I will only do so if this course of action is in
accord with the President's wishes.

There is attached a summary statement of the background, status,
and elements of consideration of the Commission's recommendations
and their relationships to current activities. This is accompanied
by a brief description of the elements which we are considering for
inclusion in a budget amendment.

I would appreciate it if you would determine whether or not the
President would like us to pursue an amendment to the budget. If
this is the preferred course of action, we will arrange with the
Bureau of the Budget for an evaluation of our proposals. It would
be desirable to obtain an early decision as we are now engaged in
testimony before the House Appropriations Committee and they are
pressing for a report on our actions to implement the Commission's
recommendations.

Secretary

Attachments

JFKelly:ec
typed 2/14/65
Implementation of the Recommendations
of the President's Commission on Heart Disease, Cancer, and Stroke

I. Background

Heart disease, cancer, and stroke are the three leading causes of

death in the United States. Taken together they accounted for 71 percent
of all U.S. deaths in 1963, claiming more than 1.2 million lives. The
economic cost of the three diseases amounts to many billions of dollars

each year.

In March 1964 President Johnson appointed a 28 member Commission on

Heart Disease, Cancer, and Stroke. ‘The Commission was asked to identify
the obstacles to progress in controlling the three diseases and to recom-
mend a national program to reduce their toll by applying existing knowledge
more effectively and by accelerating the acquisition of new knowledge.

The Commission Report, presented to the President in December 1964,
outlined 35 major recommendations which, if fully implemented, would
require more than $2.9 billion over the next five years over and above
what was contained in the Department's 1965 Appropriation Act. The
recommendations for the first year total approximately $400 million. Of
this amount there is clear legislative authority for recommendations |
totalling $149 million while additional legislation would be desirable
or necessary for the rest of the recommendations amounting to $251
million (selected demonstrations might be carried out under existing
legislative authority on many of the latter recommendations).

II. Status of Implementation

The Department's 1966 budget contains approximately $70 million to im
pleneit thé first year recommendations of the Commission Report. $50.
million of this amount represents legislation to provide grants for con-
struction and operation of medical complexes to be established in con-
junction with medical schools, research institutions, hospitals and
other health resources for purposes of conducting coordinated research,
training, and demonstrations of patient care in the fields of heart
disease, cancer, stroke and other major diseases.

Under existing authority, the 1966 President's budget presently contains
approximately $20 mitTion in areas covered by recommendations in the
Commission Report. The report was received too late for inclusion of
specific programs and amounts in the budget under existing legislation.

Ill. Current programs in Heart Disease, Cancer, and Stroke
Current activities of the Public Health Service in research, training,

and community health activities specifically related to heart disease,
cancer, and stroke amount to more than $300 million. This is supported
2
by many more general programs of basic research, training, provision of
facilities and support that contributes to the efforts directed at
specific diseases. Substantial efforts are also found in the programs
of the Vocational Rehabilitation Administravion and the Children's Bureau
that are directed to treatment and restoration of the victims of these
three diseases.

Ty. Elements of Consideration

 

The Commission's recommendations were received in December. Time did not
permit an evaluation of the report and inclusion in the budget of amounts
considered necessary to carry out the recommendations. The highest priority
recommendations requiring new legislation were identified and set forth in
the budget. lLIegislation was introduced and hearings are in progress in

the Senate. ‘The budget does contain an additional $20 million under existing
legislation that is fully consistent with the Commission's recommendations.

Failure to amend the budget will defer for an additional year action on much
of the Commission's report or will place in the hands of the Congress the
initiative for action to carry out the recommendations.

Key members of Congress, both House and Senate, have been critical of our
failure to recommend funds to carry out the Commission's report.

Members of the Commission and influential people in the health area have
evidenced disappointment and concern because of the lack of an aggressive
program to carry out the Commission's report.

The report has been well received.
y. Recommendations

Tt is recommended that a 1966 budget amendment be submitted approximating
$75 million which will carry out the highest priority recommendations of

the Commission.

This proposal would increase the regional research, training, and operational
centers of the Vocational Rehabilitation Administration at a cost approx-
imating $3 million as part of the program for carrying out the Commission's
plan for a National Network of Patient Care, Research, and Teaching in

Heart Disease, Cancer and Stroke.

To further the Commission's recommendations that call for expanded Applica-
tion of Medical Knowledge in the Community an increase of $11.6 million
is recommended.

Towards the Commission's program of Development of New Knowledge a budget
amendment of $29.3 million is proposed.

To carry out the Commission's recommendation’ on Education and Training of
Health Manpower proposals totaling $32.1 million are included in the

draft budget amendment.
 

1966 Proposed Budget Amoncments under
miisting Authority to Carry out Recommendations of the
Deasident's Commission on Heart Disease, Cancer, and Stroke
cart disease, cancer, and stroke are the three Leading causes of death
“2 ¢he United States. Taken together they accounted for 7l percent of
ail U.S. deaths in 1963, claiming more than 1.2 million lives. The

5
the three diseases amounts to many billions of collars

1964 Peesidant Johnson appoinced a 28 mombex Commission on
Heart Diseca ancer, and Stroke, The Comaission was asked to iden-
cizy the o es to progress in controiling the three disea

to recomend a national program to reduce their toll by applying
existing knowledge more effectively anc py accelerating the acqui-
sition of new knowledge.

Tae Commission report, presented to the President in December 1964,
ouclined 35 major zsecommendations which, if fully implemented, would
. £

1
@ than $2.9 billion over the nexc five years over and above
t was contained in the Department's Appropriation Act. The
eco a i ne neighborhood of a
400 million. O£ this amount there is clear legislative authority,

or recomendations totalling $149 million while additional legis- |
lection would be desirable or necessary for the vest of the cecommenda-
clons amuvating to $251 million (selected demonstrations might be
caovried out under existing legislative authority on many of-the latter
<ecommendations). a
saccment's 1966 budget coatain

pac ns O million under praposed
ation to provide grants for the con u

L

c

cxuction and operation of
complexes to conduct coordinated vesearch, training, and
dons of patient care in the
e, and other major diseases, T
Son, which were developed before th
i
s

a
o
©

i @
mn increased appropriations of. $2
tent with the Commission's specific recommendations.
nftex a careful analysis of the Commission recommendations that could
be carried out under existing authority, the Department proposes to
amend the 1966 budget by adding $75.4 million to carry out those rec~
ommendations which are of the Highest priority in reducing the national
toll caused by heart disease, cancer, and stroke. There follows a
‘szie£ explanation of each proposal in the Department's request along
with a summary table. The numbers that are’ shown next to each proposal.
_ correspond to. the recommendation numbers contained in the Commission

zeport and the amounts cited are in millions of dollars. |. Cott,

-

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‘27 Community. Health Research , - - as

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om

Commission Pro
Recommendation Budsoet Amendment

-

oke a foe 7 § 2.9

tion to the specific proposals for the creation of categorical oo fs
lL centers, the Commission strongly endorsed the importance of SES
itation centers and suggested doubling the numbers of such to, j :
ow receiving support. increasing the funding of each center 7 re
program may require was also recomaended as a means of fostering |: ;
d expansion of rehabilitation care, vesearch, and training og
ne needs of patients with heart disease, stroke and cancer. To | 4
sa this objective, it is proposed that an additional amount ne
million be provided to the Vocational Rehabilitation Administra-) © 0) 0 fe
increase the potential of the five existing, fully operative Mo
itation centers, and that another $1 million be provided ‘to int
e the level of support of the present five developmental centers. pos ae,

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#4 Centers of Excellence 3.0 (1.0) be:

Tne President's Commission recommended developmental grants to medical~
scnools to enable these institutions to improve their total capability .'.
for both academic and research programs for the ultimate purpose of ue
creating a greatly increased number of true "“centerso£ excellence" in *
madical education and research. The objectives of this proposal are «© |:
similar to those of the new "Health Sciences Advancement Awards" oe
initiated by NIH in 1965 at the direétion of the Congress through. the
mechanism of the general research support grants. “The proposed budget
mendment represents an increase of $1 million for “Health Sciences

vob hobs

Advancement Awards" under the general research support grant authority.

 

  

#5 Community Planning 1.0 © © : 0.5 -
An ~necease of $500,000 over and above the amount contained in the '
President's budget for “other chronicaliy ill and aged" project . ' i,
geants is proposed, to be earmacked specifically for incentive grants Poti
=o communities to stimulate the development of a system for the planning. “' mae
4A
4
‘

ow
and coordination of health activities, as recommended by the Commission.

 

4

 

et ite trent orem tee

and Demonstration 5.0 “ 3.0 Loe ee
mn its report, the Commission concluded that a major investment fn

vésgearch training and support of promising research projects in the  .' 6%
community health field could be expected to pay important dividends.
Accordingly, increases of $2.5 million in research grants for the’. be

pote

  

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Noalth Practice ane Rusearch ute proposce to pegin effactuation of the

Commission vecommendation that greatly increased emphasis and support
@ given to che community health programs within the Public Health

5
Service. -

Commission Proposed
Recommendation Budcet Amendment

26 Beart Disease Control / § 2.5 $ 2.5

Tae Commission recommended that the Public Health Service be given
auchnority and funds to establish and maintain coordinated State-wide |
laboratory facilities necessary for heart disease control programs.
An effort of the type envisioned by the Commission 1s currently
supported by the heart disease control formula grants authorized by
section 314(e) of the Public Health Sezvice Act. it is proposed

that an additional amouat of $2.5 million for 1966 be specifically
earmarked for the support of State-wide laboratory facilitics.

#10 Cervical Cancer Detection 5.0 5.0:

it is proposed that $5 million be added to cancer project grants over
and above the amount contained in the President's budget for 1966, to
develop a national program for the early detection of cervical cancer.

The President's Commission on Heart Disease, Cancer and Stroke rec-
ommended such a progtam directed at the eight million women aged —

25 years and over who are admitted Fores hospitals in the United States
each year. .

~inuing Education of
tae Health Professions .6 mo, 6

‘
*

Continuing education is a categorical imperative of modern medicine.
Consequently, an additional amount of $600,000 is proposed for
Vocational Rehabilitation Administration grants to key medical and
health institutions and agencies for an expansion of short-term
training courses, seminars, conferences, and workshops in rehabilita~
rion services for heart disease, cancer and stroke patients, as rec~

ommended by the Commission report. - ; ao

#14 Specialized Research Centers 1.0 a 1.0

As part of its recommendation, the Commission suggested that three
Rehabilitation Biomedical Engineering Research Centers be established:
over a five-year period in order to take advantage of the potential -

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offered sy bioengineering veseaven in heart disease, cancer and .
stroke. Tae sum of $1 million was recommended as the first year
appropriation necessary to initiate this program.
' Commission roposed
Recommendation Budget Amendment :
#15 Research Project Grants $35.0. $19.0 | :

 

c
¢.
$

intts Commission oa Heart Discasa, Cancer and Stroke endorsed
ug system of review of research project grants utilized by a
ecommended intensified and expanded support of research in oes
ncart disease, cancer and stroke. Toward this end, a total of $105 ;
sillion over and above current appropriations for NIH research project , © ‘S i
grants was suggested in a three-year period. To begin the effectuation pte
cE this recommendation, $14 million is proposed for expanded support Ss
in 1966 of NIH research in heart discase, cancer, stroke and the ae
z sciences. An additional appropriation of $5 million .
ident's budget for Vocational Rehabilitation Administration ‘
nts aimed at rehabilitation of persons with heart disease,
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research gra f
cancer and stroke is also proposed, in accordance with the Commission's
ycocowmendations. "

 

#17 Generali Researen Support Grants Maximum . 9.25 _
, authorized ey

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's Commission recommended that the existing NIK general sor
vt grants program be cre ancsd as rapidly as possible to i .
recent of the total NIH vesearch and training budget. 200. hh,
itutional support of this magnitude represents a very fo

increase over the ongoing general xvesearch support program, a ae

re cautious expansion then that recommended by the Commission a bh
sone. Consequently, it is proposed that the original general .....° +
e support program for health profe nal schools be expanded by ote
roximactely 30 Percent over the present level. This would amount
@ se

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se of $8.25 million in general © arch supporc grants. In.
t *~

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tion, another $1 million over the amount contained in the President's |
for “Health Sciences Advancement Awards" is discussed in connection ~.,..’
vd

omission recommendation #4, Centers of & xcellence. Soy

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#22 Research Training 16.1 16.2. -

 

Failure to expand research training support must, automatically, limit |.

the scope of the entire national health research program in future a
‘ee c . : « sR o oy
years. In recognition of this fact, the President's Commission rec- Dee eS

ommended the expansion of existing programs of xesearch training grancs

and.fellowships in heart disease, cancer and the general medical sciences, .
Tb endorsed the development of a research training grants program ing on te
che field of stroke, A total of $15.6 million over the amount contained | i

in the President's budget for ‘NIH trsising grants and fellowships is ot ony
ete

of aU fh

‘in Atlanta be enlarged in scope and strengthened so that it may become

5

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nroposedé for this expansion. Aa additional $500,000 is also proposed
>
fgr Vocational Rehabilitation Administration training grants in
eehabilitation, as recommended by the Commission.
Commission Proposed
Recommendation Budget Amendment

“

423 Susport of Clinical Training’ $10.0 . $ 9.5

mo meet the need for the training of superior clinical physicians,

a@ $l million pyogram of neurological and sensory disease project grants
new $4 million program of heart discase project grants is pro-

ged fox the establishment of clinical fellowships and full-time "
inical investigatorships in the cardiovascular field. In addition,

$4 million increase over and above the amount in the President's os
udget foyv cancer project grants is proposed to support the recommended -
extension and expansion of the Cancer Control Program. Finally,
$500,0C0 is proposed for support of a program of clinical fellowships
in rehabilitation, as suggested by the Commission. .

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$25 Health Technicians 1.4 1.0

one element of a greatly increased effort and investment in the
sccuitment and-training of health technicians and other paramedical
ersonael, the Commission recommended increased support of the program
for training medical technicians now existing in the Cancer Control

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for Cancer project grants, specifically earmarked for training medical’

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technicians, including technologists and other specialists essential to ete ee,

the detection and treatment of cancer.

#27 Manoower Assessment SO 0.5-, 0.5

The Commission recommended the establishment in the Bureau of State i

Services (Community Health) of a health manpower unit, comparable to
the vesearch manpower unit of NIH, responsible for continuous
assessment of national manpower requirements for health services. An
increase of $500,000 is proposed for the purpose of establishing such
a health manpower unit. pO Cog ,

#31 National Medical Audiovisual Center 7,5

In its report, the President's Commission recommended that the Public
Health Service Audiovisual Facility at che Communicable Disease Center

a National Medical. Audiovisual Center. © Toward this end, an additional =|

bots . , : : can

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Program. It is proposed that an additional $1 million be made available :. ;

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lion is proposed for carvying out the intramural program ‘ '
a t owaission, including production, experimental .use and .
on of educational materials in the various communications media, Dead

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atio
oping, disseminating and evaluating closed circuit television o

develo

 

progvams for the health professions, and production of films for use in
cartridge-type projectors. ne ee aa og tng
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#15

#17,

| $22

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

,
1966 Pro
i. Presid

(Dollars in millions)

dent's Commission on Heart Disease, Cancer,

oposed Budget Amendments to Implement Recommendations
and Stroke

Commission

Recommendation

Regional ‘centers
Vocational Rehabilitation Administration

Centers of excellence

Public Health Services caceccccccsccevces” bd . a

Community planning

Public Health SOLViCCccececececaccvesess

Community health research’.
aad demoustration
Public Health Service. .corevssccccsseces

Heart disease control
Public Health SCXVECE se esasseceesseneres

Cervical cancer detection vee
Public Health SCLVACEsseeeeeeereeeeseree’ on

 

Continuing education - fi
Vocational Rehabilitation ‘Administ¥ation |:

Specialized research centers

‘Vocational Rehabilitation Administration

Research project grants .
Vocational Rehabilitation Administration: _
Public Health Service. cower eeeeteoeoeeos .

General research support grants ar
Public Health Servicessessecseccvseeesee «:

Research training

Vocational Rehabilitation Administration:

Public Health Servicessesesesesesseeeeee

fet:

1

| § Not specified

310

“1.0.

: 5.0

Maximum
_authorized

«Bee specified

16, Le

Proposed
Budget Amendment

$ 2.9

(1.0))/ ©
oe)
3.0°"

 

 

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#23 Clinical training:

 

Commission
Recommendation Budret Amendment

Proposed

 

 

 

 

Vocational Rehabilitation Administration $ 1,0 § .5

Public Health ServicG..cccsscecssevseees 5.0 » 9.0
‘$25 Health technicians ae -

Public Health SCLViCE sccccveresevescee 1.4 1.0
#27 Manpower. assessment

Public Health Service. .cccccsccsceeses re) oo
#31 National Medical Audiovisual Center .

Public Health Service. .ccccvvcesesccee 7.5 5.0

‘ STOCAL  cccccecsevcccevees ww 75.85
would be accomplished through the "Health Sciences Advancement 00 i)

Tais proposal
‘Awards urcar the General,Research Support Grants authority. |
included in the proposal related to re

 

 

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#

commendation #17..-

 

- The amount is’ °.'!

 

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DEPARTMENT OF EZALTIL, csDUCATION, AND WELFARE

 

1966 Budget Amendments to Implement Recommendations wh
of Presidenc's Commission on Heart Disease, Cancer, and Stroke a

¢

(Dollars in thousands) | : ay

Proposed

Budget Amendment

‘ * . . . ‘

 

Vocational Rehabilitation Administration ‘ ge ie
Research and training: ae

#L Regional centers. .cceccecccccccvcccccersscsccvesceees $2,900. 9 , iy

: #LL Continulag education. ....cc cece cece cece cece cneseores : 600 CT 7
#14 Specialized research centerS...ceccccscccvcctescvcvce _ 1,000 oe tg

#15 Rescarch project grants. ..cccececccccecceccveseusecen: 5,000 oS 4

#22 Research training. .cccccccccccccacccecccveccesveceees 500 i

#23 Clinical craining.cccccsccevcsccsveccccccessvceeecee | ‘500 ym

“Y ‘ . Subtotal... .ccuvccccscecsece , 10,500

Public Health Service
Chronic diseases and health of the aged: oe, ;
@ # G Community planning. .cccrcccceccccccsecccvecsseveteen so, 500 toad

# 7 Community health research... ccsccecceccceccsvecsees = 1,500. |. an
#S Heart Gisease controlesccsccccscccccctviosscccseeces 7" 2,500 ES
#LG Cervical cancers. iececccccccccccce career escveccenees 5,000 2
$23 Clinical training...cceccesesecedaecceescseuesvenees - 9,000 Fe
#2Z5 Health techniclans..ccccccccccscvececcevsvcssecveeses | 1,000 cs

Subtotals. ssececeseveveesee 19,500 | | Bs

Comaunicable disease activities: - , a Se Dg
#31 National Medical Audiovisual Center... ...eccecceeeee >? ° ..5,000 oF 2 nos

 

Community health practice and research;

# 7 ° Community nealth LSSCALCH esecersccesvevesvvssveseoee. fo 1,500 co as cc
“#27 Manpower a4Ss@SSMeNnteceececccecsccvecescneeseeeseeese | S00 so 8 i

Subtotals... eee eeedaceees . : ° - 2,000

General research support GLIDY ccc elec cee ceeeneneeenees . - 9,250... - ; 7 oe

National Institute of General Medical Sciences ° . | 7 oF
#1S Research project QrantS...ccessssccececersccsececes 5,000 oa

\ 422 Research training and fellowsShips...csscecsecscoves 6,000 au
Subtotal. ccccccccsevcccese. : . 11,000 .

@ National Cancer Institute ee
WLS Research project SLants.crserecccrecceccvverscvceve 1,500 ee
#22 Research training and fellowshipS....cwcccsscccecce. ,
e

Publ?
Nat

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«a Health Service (continued)
onal Eeart Institute
Research project ELANES ce cesvesessvesevssssosessvevers

15
22 Rascarch training aud Eallowachipiscesvecscsvecsseces

a

2

Subtotal. .cccccccscscevesese

National Institute of Neurological’ Diseases and Blindness
#15 Rasearch project Zrantseccccccrccvevesessesssveveses

’ $22 Research training and Lellowshipseccccscsccccsvesven.

Subtotal ccrcccccssssccvcee

Total, PHS. ..cccccevvevevss

Grand total, DEW... .cereee

La

 

appropriations, but the distribution has not yet. been determined.

Proposed

Budget Amendment

$ 2,500.

“4,300

6,800

7 .
5,000

_2,000

6,000
65,350

75,850

 

 

a

@ The amount proposce for this program will be shown in a number of the

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NIH os hes