ne » oO ore, ue PRESIDENT’S COMMISSION ON HEART DISEASE, CANCER AND STROKE e bs A NATIONAL PROGRAM TO CONQUER HEART DISEASE, CANCER AND STROKE ( Volume tI Dd February, 1965 THE PRESIDENTS COMMISSION ON HEART DISEASE, CANCER AND STROKE MEMBERSHIP OF THE COMMISSION Dr. Michael E, DeBakey, Chairman Dr. Samuel Bellet Mr. Barry Bingham Mr. John Mack Carter Dr. R. Lee Clark Dr. Edward W. Dempsey Dr. Sidney Farber Dr. Marion Fay Mr. Marion B, Folsom Mr. Emerson Foote Gen. Alfred M. Gruenther Dr. Philip Handler Mr. Arthur Hanisch Dr. Frank L. Horsfall, Jr. Dr. J. Willis Hurst Dr. Hugh H. Hussey Mrs. Florence Mahoney Dr. Charles W. Mayo Dr. John Stirling Meyer Mr. James F. Oates Dr. E. M. Papper Dr. Howard A. Rusk Dr. Paul W. Sanger Gen. David Sarnoff Dr. Helen B. Taussig Mrs. Harry S. Truman Dr. Irving S. Wright Dr. Jane C. Wright STAFF OF THE COMMISSION Dr. Abraham M. Lilienfeld, Staff Director Mr. Stephen J. Ackerman Dr. Nemat O. Borhani Mr. Louis Carrese Dr. Maureen Henderson Dr, William L. Kissick Mr. Lealon E. Martin Dr. Bayard Morrison Mr. Horace G. Ogden Mr. Marcus Rosenblum Dr. David Schottenfeld Dr. John D. Turner Mr. Daniel Zwick Faerie nena nran eSenepee ner gre FOREWORD Volume 1 of the Report of the President’s Commission on Heart Disease, Cancer and Stroke contains a summary of the dimensions of the problem, the national resources and needs, and the specific recommendations for developing a national program to combat these diseases. The contents of volume 1 were derived from the reports of the Subcom- mittees of the Commission and from special reports on selected subject areas. The Subcommittee reports were prepared after each Subcommittee held a series of hearings at which testimony was obtained from experts and after the mem- bers of the Subcommittee had reviewed the special reports and other material. These Subcommittee reports and staff papers provide in greater detail the views and judgments of the Commission and some of the bases for such judg- ments. It was considered desirable to publish them as volume 2 of the Com- mission’s Report, since the material has value for guiding programs and policies and for stimulating additional research. Much of the material represents fresh data, unavailable elsewhere. The special reports that were prepared for many of the Subcommittees are designated as source papers and follow the relevant Subcommittee report. State health departments, schools of all the health professions, municipal governments, research institutions, hospitals, foundations, and voluntary or- ganizations will find in these pages support for their earnest aims, We believe that these reports and documents will strengthen the case for their present pro- grams and light the way to their fulfillment. We hope that the reports will stimulate health organizations to open new pathways of research and health practice. Despite the emphasis on Federal action and Federal financing, as might be expected in a report to the President, it will be obvious to the discern- ing reader that there are opportunities to move ahead on the recommended pro- grams at State and community levels. Indeed, many recommendations of the Commission are based upon exemplary action which has already occurred in many communities. In volume 1, we have already listed the many who have contributed their time and talent to the work of the Commission. There is little to add to these grateful acknowledgements except to note that the editorial services for volume 2 were performed by the Commission’s Staff Director, Dr. Abraham Lilienfeld, and Marcus Rosenblum. Daniel M. Bailey reviewed the special report on li- braries by the Subcommittee on Facilities. The staff of the National Library of Medicine assisted in the preparation of the bibliographies; the citations in this volume conform to the system used by the National Library of Medicine. The design of volume 2 was contributed by the capable staff of the Government Printing Office. Micnaet E. DeBakey, M.D., Chairman. CONTENTS Forword....------------ ne ee en nn nn en ee nee en en eres Vv Heart Disease: Report of the Subcommittee.--.---------------------------------- 1 Source Papers: The Magnitude of the Cardiovascular-Renal Disease Problem... 14 Congenital Heart Disease. ...----------~-------------------7-- 48 Rheumatic Fever__....-...---------------------------------- 61 Arteriosclerosis_....-----.---------------------------------- 74 Hypertensive Heart Disease--...----------------------------- 92 Cancer: Report of the Subcommittee. ------------------------------------- 105 Source Papers: The Magnitude of Cancer..---------------------------+---77- 118 Stroke: Report of the Subcommittee-------------------------------0----"~ 129 Research : Report of the Subcommittee..-------------------------27--------- 138 Source Papers: Atherosclerosis: Current Concepts and Research Trends--------- 162 Essential Hypertension : Current Concepts and Research Trends._ 177 Cancer: Current Concepts and Research Trends_.----~--------- 185 Rehabilitation : Report of the Subcommittee---.------------------------27-------~ 227 soos - a enass quest pw ppseyia jo wa Odag SF opsayy AIS YOM syn B40, AK PUR wounapy “Yay pw yo waus pdeg $f z= = — a ant NAS NA viil Manpower: Page Report of the Subcommittee_---------------- notre 262 Appendix A----------------2- 2 nnn 288 Appendix B--------------2-20-9 700 r 306 Appendix C..--------2---22n nnn 308 Appendix D_----------------2- 90 315 Bibliography---------------- 22 316 Facilities: Report of the Subcommittee.---------------- 220 321 Source Paper: Biomedical Institutions, A Survey of Facilities------- 341 Special Report: A Program for Developing Medical Libraries- ------- ao Communications: Report of the Subcommittee.----------------2 200 401 Source Paper: Information Handling for the Biomedical Sciences---- 410 Economics: ; Economic Costs of Cardiovascular Diseases and Cancer__------------ 440 Conference on the Economics of Medical Research....-------------- 631 cay Jt REPORT OF HE SUBCOMMITTEE ON COMMUNICATIONS SUBCOMMITTEE ON COMMUNICATIONS Mr. Exerson Foore, Chairman Mr. Barry Bineuam Mr. Jonn Carrer Dr. R. Lee Cuark STAFF Dr. Bayarp H. Morrison Mr. Marccs Rosenslum Dr. Aprananu M. LitrenFeLp CONSULTANT Mr. Mixes Gorman 1 1; js i; ye { i i i REPORT OF THE SUBCOMMITTEE ON COMMUNICATIONS . The prevention and control cf heart disease, cancer, and stroke—the saving of a human life—begins not with the doctor, the hospital, or the medical center. It begins with the indi- vidual himself. He decides to go for a checkup—either before symptoms appear or at the earliest sign of trouble. Or he decides not to. The decision, often made casually or even subconsciously, may add or subtract a decade from his life. Many factors influence his decision. One is his financial condition. Another is the con- venience and accessibility of medical attention. The most important factor is the state of his knowledge about health matters. Once he enters the medical orbit, his fate is again subject to many whims of chance. If he is wise enough to make his appointment soon enough, and if the physician he chooses is trained and equipped to detect. an incipiently dangerous condition and make the proper re- ferral, and if his community is blessed with the special skills and facilities his condition re- quires and if he is able and willing to follow through the prescribed course of treatment—in this happy conjunction of circumstances—his life will be prolonged, his function unimpaired or restored. Breakage of any link in this chain can nullify the strength of the others. Nearly every link depends upon the right knowledge in the right place at the right time. Conversely, many thousands of heart disease, cancer, and stroke deaths occur because of failures in the com- munication of lifesaving knowledge to the po- tential victim or to the physician who treats him. It is to these costly failures that the Subcom. mittee on Communications has directed its prin- cipal attention. We recognize the vital impor. tance of research communication—between sci- entist and scientist. We wholeheartedly endorse the recommendations of other subcommittees concerning the need for strengthening the med- ical library system and adding to the electronic capability for handling research information. But we feel that the greatest impact on death and disability from heart disease, cancer, and stroke, now and in the years immediately ahead, can be made through intensive nationwide effor to bring to the physician and the public the» information they need about these diseases. It has been said that knowledge is power. In health, it is the power of life and death. A Federal Mandate The Federal Government, as described else- where in this report, has been given a clear mandate and substantial resources to support the generation of health knowledge through biomedical research. The results of this policy have been the great scientific advances that characterize our time. But knowledge unused is knowledge wasted. And strangely, the Federal Government has not been given a similar mandate and similar re- 402 sources to support the transmission of medical * knowledge to its point. of application. : One point of application is the meeting place = of physician and patient. Knowledge oF the lack of it on the part of the patient brings them together in time or keeps them apart too long: Knowledge or the lack of it on the part of the doctor determines the success of their encounter Clearly, this is the ultimate target of biomedica research. These are the prime audience edi COMMUNICATIONS 403 Equipping both patient and physician for their encounter is 2 communications task: A process of education and information. There are long-standing and largely un- spoken obstacles to vigorous Federal participa- tion in this process. Federal support of educa- tion in any form has been viewed darkly because of fears of Federal control in a political sense. Strong Federal programs of public information have been treated with suspicion through fear of self-aggrandizement via press agentry. Without seeking to judge broader policy mat- ters, we submit that in the communication of health knowledge these fears are illusory and jrrelevant. They are worse: They contribute to unnecessary death and disability. In the generation of health knowledge, the Federal Government has abundantly demon- strated its ability to stimulate and support pro- ductive effort without stifling control. It has done so by developing a partnership of Federal and non-Federal scientific resources in a system which promotes individual freedom and initia- tive. Similarly in the communication of health knowledge, it can and must develop a partner- ship whereby scientific and communications skills and resources, both Federal and non-Fed- eral, work together to transmit the urgent mes- sages upon which health depends. The Subcommittee on Communications there- fore recommends, as a fundamental policy underlying its subsequent specific recommenda- tions, that the communications functions of the Public Health Service, and especially those re- lated to public information and the continuing education of the health professions, be recog- nized and supported on a scale commensurate with their importance as a major weapon in the prevention and control of disease. Public Information The public has an almost insatiable thirst for health information. Newspaper readership studies have shown that health articles rank high both in number of readers and in retention of information. Every major daily newspaper has at least one column devoted to health. News which suggests a scientific breakthrough is given front page prominence. The general interest magazines rarely go to press without a substantial quota of health information. Yet the public remains remarkably unin- formed, or remarkably slow to act, on many matters which are quite literally “of life and death.” Part of the problem may stem from the sheer profusion of available information, Sometimes contradictory and frequently half true or halfhearted. In all three disease fields falling within our purview, we were told by medical experts that the average American family today is not aware of the simple, fundamental measures necessary Protect its members from these diseases. 1s is a failure of communications. The ‘oronary-prone middle-aged male, the young mother with one of the seven danger signals of *ancer, the corporation executive who is suffer- ing from one or more precursors of stroke— why don't they act while there is still time? Because they either lack the information, or the information has been presented in such a fash- ion that they lack the motivation to act upon it. We must therefore make much greater and more imaginative use of existing communica- tions media, and we must create bold new chan- nels of information to close the alarming gap between the acquisition of research knowledge in our medical centers and laboratories and its dissemination to the family physician and to the general public. We have a magnificent and exciting story to tell. Every American is deeply concerned with the preservation of his own health and that of his loved ones, yet we have not capitalized upon that concern. We must take the plunge into the mainstream of modern communications. We must use the advertising and promotional tech- niques which have been so successful in creating a demand for consumer goods to create a similar demand for the knowledge which will save thou- sands of precious lives. We therefore recommend the following steps be taken: STRENGTHENING PHS INFORMATION SERVICES We believe the Public Health Service has a duty and a responsibility to use every possible resource to bring the latest health information to the American people. In a matter so urgent as the prolongation of life and the prevention of needless disability and death, we must insist upon the highest priority for these communica- tions activities. For this reason we recommend that the funds appropriated for the Office of Information and Publications in the Office of the Surgeon Gen- eral should appear as a budgetary line item. They should be increased by $750,000 per year to finance such additional activities as: a. Recruitment and inservice training of in- formation specialists, selected from among young college graduates, to improve dis- semination of health information to the public. 6. Creation of materials for free public serv- ice announcements on health for use by radio, TV, and magazines. c. Development of fact books on specific health topics, summarizing present scien- tific knowledge for the use of reporters and community leaders. d, Development and production of a health yearbook, similar in scope and quality to the Agriculture Yearbook, to create a series of authoritative and understandable ref- erence volumes in specific health topics. e. Assignment of writer-editors to accompany foreign PHS missions and to report promptly on the findings and experiences of such missions, f, Assignment of writers to produce prompt summary reports of scientific conferences ° in forms suitable for the health pro- fessions. TRAINING IN HEALTH COMMUNICATIONS Because the transmission of medical informa- tion has been given such a low priority in our total national health effort, we have given little attention to the recruitment and training of communications specialists in the health field. REPORT TO THE PRESIDENT There is a desperate shortage of these skilled specialists, both in the Public Health Service : and in medical centers and universities through. out the country. We therefore recommend that the Office of Information and Publications in the Office of the Surgeon General be allocated a specific an nual sum of $1 million solely for these training purposes: a. A grant program to educational instity. tions for the development of pilot training programs in the field of medical communi. - eations. Such grants should support the development of a core curriculum, the pay- ment of faculty, and provision of stipends for trainees. A university which has both a medical center and a school of journal. ism would probably serve as an excellent - setting for these pilot training programs in communications. b. Provision of fellowships for the on-the- job training of a variety of personnel in the gathering and writing of science infor- mation materials. Many of these fellows would be trained in the various agencies of the Public Health Service: many would be trained in our medical centers and large research institutions throughout the country. In addition, we recommend that the Publie ‘ Health Service conduct and support seminars and other methods designed to give professional - science writers the background they need t write accurately, responsibly, and clearly on: health subjects. Science writing is a highly developed skill. The popularization of such scientific fields as- nuclear physics and space has been brilliantly successful. In the medical field, both within and outside government, there has been a pel sistent reluctance on the part of scientists and physicians to take professional writers behind the scenes on a basis of mutual confidence and open doors to genuine understanding on matters of profound interest to the public. Asa result, medical writing in the popular media—aga™ with some outstanding exceptions has tended, to be fragmentary and often misleading. Public Health Service should take the lead ™ SB se ski} pamed ying this condition, and its public infor- h Sery Dn ation offices should be authorized and encour- 3 throy aged to do so. Office “RESEARCH CENTER ON HEALTH Of MOTIVATION . pecihe In mounting preventive attacks upon heart “disease, cancer, and stroke, we face the difficult ‘challenge of changing the life patterns and abits of millions of people. For example, it , fairly easy to put out a pamphlet listing the = port t _yarious factors which predispose an individual 1, the to a heart attack, but it is extraordinarily dif- f stipen e ficult to get that individual to reduce his ealorie rhas hol : intake, to give up cigarette smoking, or to limit f sournal _ the stress factors in his daily life. . excellent’ a Little research has been done on the effec- progra ni ; ‘tiveness of the various approaches which have attempted to change the ingrained habits of people. Unless this important research is con- somcle ducted by behavioral scientists, sociologists, and nee infor se fellows’ iny woul _ The forward sweep of medical science has ae brought a kind of “instant obsolescence” in med- iters and, ical knowledge. Most physicians practicing to- ghout the; day received their medical education in the 1930's and 1940’s. The fact that they are prac- ticing two or three decades later poses a critical obstacle to the delivery of up-to-date health care. For many years, lipservice has been paid in the medical profession, as in most other profes- sions, to the concept of continuing education. But the facts of daily life are hard to overcome. ped skil felds Most doctors work a 60-hour week. Even prilliantly their free time is never truly free. They are th withi eluged with paper, ranging from professional journals to flyers advertising the latest medical gimmick, Among the papers are invitations to Attend lectures, seminars, clinical conferences. But only the supermotivated or the semileisured are able to respond often enough to keep pace With their changing profession. Thus the greatest single obstacle to a cohesive in Program of continuing education for the medi- as tended, cal profession is time. The second is diversity ing. Th of interests and needs. The third is the fact that re lead Continuing education, although it is recognized 783-310 O§5 27 COMMUNICATIONS 405 other specialists, we will lack a solid scientific base from which we can tailor our educational efforts toward motivating change in people. We therefore recommend that the Public Health Service be provided with funds to initi- ate the development of a Center for Research in Health Motivation. In addition to specific behavioral studies directed at the individual decisionmaking process in changing patterns of living, the center would analyze the contents of public campaign materials with reference to their effectiveness and influence upon behavior, and it would hopefully concentrate particular attention upon hard-to-reach population groups which reject existing educational campaigns emphasing individual initiative and changes in living patterns. It is estimated that $500,000 a year for 5 years would be necessary to initiate the devel- opment of such a Motivational Research Center. Continuing Education of the Health Professions as a critical problem in medicine today, is not the primary responsibility of any significant segment of our national health resource. Medical schools, the logical locus for the major effort, are correctly preoccupied with undergraduate education first and research sec- ond. Continuing education, if it receives any attention at all, must settle for what is left of already inadequate resources. Similarly, com- munity hospitals could contribute greatly to the continuing education of community physicians, but their first job is to care for the patients. Professional societies have many other respon- sibilities. Yet continuing education is a categorical im: perative f contemporary medicine. Without @ large-scale, effective organized effort, the worlds of science and practice will spiral still farther The gap between what is known and apart. oe ee ie will be harder @ what is received by atients will be harder and “harder to bridge: The Public Health Service clearly has a lead- ership role to play in helping to forge a national continuing education effort, by assisting all the available resources in giving due attention to this problem. nerd ee eee eee PRRs Spee eer eR ai ne ror eee Pet SNA TE TE Lp atten eSS EY TO 1a emnemmeeegnemerinmnitictinn go BARRED MERE AY Serre STRENGTHENING CONTINUING EDUCATION PROGRAMS The Subcommittee recommends that appro- priate units of the Public Health Service be pro- vided with funds and authority to: a. Stimulate and support through grants, contracts or in other appropriate ways, demonstration projects and experiments directed by medical schools, community hospitals, professional organizations or any appropriate agency, designed to make im- portant scientific knowledge systematically and conveniently available to practicing physicians. 6. Stimulate and support research projects designed to develop new and improved methods of conducting continuing educa- tion programs, including experimentation with various media (i.e. closed- or open- circuit television, etc.), various instruction methods (i.e., programed instruction, semi- nars, etc.), and various means of evaluat- ing such programs in terms of their actual impact in upgrading medical practice; e. Disseminate as widely as possible the re- sults of experiments, demonstrations and other projects in the continuing education field, whether sponsored by the Public Health Service or by others, so that all ‘interested organizations may benefit from the experience of others. d. Conduct studies and demonstrations in communications technology and educa- tional methodology. For these purposes the Subcommittee recom- mends appropriations of $2 million for the first year, $4 million for the second, and $6 million for the third. A NATIONAL MEDICAL AUDIOVISUAL FACILITY The imaginative use of new communications media offers the best hope for necessary break- throughs in continuing education, The Sub- committee believes that in addition to its broad program of support for continuing education outlined above, the Public Health Service should also take leadership in producing, dis- seminating, and promoting the use of audio- REPORT TO THE PRESIDENT visual materials for continuing education of th health profession. The Public Health Service Audiovisug] Fa cility, located at the Communicable Diseagy Center in Atlanta, Ga., on a small Scale, has 3s already demonstrated high competence in the d production of training and educational] Mate: rials, and in the collection and dissemination of such materials produced elsewhere. We therefore recommend that the Publig Health Service Audiovisual Facility be ep: larged in scope and strengthened so that it may become a National Medical Audiovisual Center 22 To this end we recommend the following spe cific steps: (a) The appropriation of $1.5 million for: necessary renovation and expansion of facilities, (6) Appropriation of $1.5 million for the first year, scaled upward to $4.0 million for the fifth year, to develop an intra. mural program which would include pro- duction, experimental use and evaluation of educational materials in such areas as radio, television, motion pictures, pro- gramed instruction, etc.; research and training programs in audiovisual fields; international exchange of medical motion pictures; and other purposes. : (e) Authorization of an extramural program of grants and fellowships and appropri- ations to support such a program, begin- ning at the level of $1.5 million per year and rising to $8 million at the end of a 5- year period; such a program would en- able the center to support selectively promising projects in audiovisual com- munication at medical schools, commu- nity hospitals, and other institutions am to assist, through training grants and fel- lowships, in the development of a national cadre of medical communications: specialists. In addition to the program outlined above . the Subcommittee feels that the National Medi- ca] Audiovisual Facility should exert immedi ate and strong leadership in two communicé tions media of particularly high promise for’ continuing education of the health professions _ These are, first, the field of closed-circuit tele : sion which is already being used sporadically, , limited extent, by medical schools, hospi- C* sals, and other health agencies; and, second, the ~ yse of portable projectors for cartridge-type glms which are especially adaptable to private use bY physicians in their own offices, at times of their own choosing. , - We therefore recommend : (a) That an appropriation of $2 million per year, initially, be made to the National Medical Audiovisual Center for the spe- cific purpose of developing. disseminat- ing, and evaluating closed-circuit tele- vision programs on subjects of vital interest. to the health professions. (b) That an initial appropriation of $1 mil- lion per year be made to the National Medical Audiovisual Center to produce short films for use in cartridge-type pro- jectors, and to promote the widespread use of this promising new educational device by the medical profession. TELEVISION The health world has been slow to focus the awesome power of television on specific health problems requiring specific public understand- ing and response. The medium is ideally suited for delivering clear visual information in dramatic and force- ful terms. The art of the documentary film, true to science and at the same time challenging to the interest, is highly developed. Commer- cial television is capable of reaching an over- whelming majority of the American people, and educational television is growing rapidly. Yet health documentaries have been few in number, uneven in quality, and generally drab in presentation. It has been their quality, rather than their subject matter that has rele- gated them to unattractive scheduling and doomed them to small audiences. Television producers are as aware as newspaper and maga- zine editors of the tremendous public interest in health. The products, with a few shining exceptions, have simply been inferior in the highly competitive world of commercial tele- ¥ision, f The Subcommittee recognizes the problems aced by a Government agency like the Public 10 COMMUNICATIONS 407 Health Service in recruiting and employing scarce topflight creative talent in motion pic- tures and television. It recognizes the scien- tific knowledge necessary to give complete ac- curacy and authenticity to health documentary programing and the impressive beginnings al- ready made at the Service’s Communicable Disease Center in creating a truly national medical audiovisual center. We therefore recommend that the Public Health Service be authorized, and that funds be appropriated, to contract with professional tele- vision producers for the production of twelve 30-minute documentary films each year of the highest quality, on subjects related to heart dis- ease, cancer, and stroke, and any other subjects as may later be deemed desirable. Each film should be budgeted at or about the level of $150,000 to assure writing and production that will make the films competitive with the best of commercial television. This price should in- clude a sufficient number of prints to assure widespread use on local commercial television outlets across the nation. The contract should also provide for the full participation of the producer and his organization in the marketing of the films. The Public Health Service, in con- junction with non-Federal scientists and physi- cians designated by the Service, should have full control of the content of each film. The films should be available for commercial sponsorship within a predetermined range of appropriate product classifications, excl uding such obviously inappropriate sponsors as tobacco companies, pharmaceutical firms, and the like. In the Subcommittee’s view, the potential of television as a disseminator of health informa- tion to the public can be realized only through quality production of authoritative material, made available in such a way that it can be viewed in prime television time by the widest possible audience. The method proposed, which consists essentially of a Federal investment in communication talent, would cost about $1.8 mil- lion per year. Alternative methods, such as the governmental purchase of prime time, would cost as much and result in the showing of in- ferior products, with inevitably inferior results. The impact of 12 first-class documentary films, each carrying a message of urgent importance i ! | yi | Ie 1 f . Le Pinedice FERRET i sneacteata atten eee rere Ee eed ae gov ne PWS re oy 408 for the protection of American families, would be immediate and overwhelming. The Subcommittee further recommends that the Public Health Service be authorized, and that funds be appropriated to the National Medical Audiovisual Center to support through appropriate mechanisms, such as grants or con- tracts, the development of effective television programing in the health field on the nation’s educational television stations. The sum of $1 million per year is recommended as a beginning figure. ETV programs reach school audiences at all levels from primary school through college. In many communities, the ETV program is viewed widely by the adult intellectual and civic leader- ship as well. It represents an excellent medium for attracting young people to health careers, for establishing and maintaining desirable health habits, and for stimulating desirable com- munity-wide health activities. In many areas, ETV facilities can also be used for continuing education of health professionals. The health potential of this growing educational force has scarcely been touched. A CLEARINGHOUSE FOR DRUG INFORMATION The Subcommittee recognizes the fact that improper use of drugs is today an important cause of avoidable disease. Because the gaps and wasteful duplication associated with pres- The Promotion of Health The Subcommitee on Communications is well aware of the fact that its recommendations range beyond the problems of heart disease, can- cer, and stroke, if these problems are considered narrowly. We feel strongly that more effective transmission of health information to the pub- lic and the professions—whatever the specific subject may be—is essential to the saving of human lives. We believe further that strengthening our health communications resources must. inevi- tably advance the crusade against heart disease, REPORT TO THE PRESIDENT ent independent efforts to handle drug informa, tion are responsible for much important in formation failing to reach those who need jt most, and in view of the progressive increase in. the consumption of medications and other chemical products, the Communications Syb. =: committee endorses current proposals for the establishment in association with the Nationa] Library of Medicine, a national drug informa. tion clearinghouse, serving and supporting gov. - ernmental and nongovernmental drug informa. “#e tion units. ‘4 We believe that the clearinghouse should be given authority and eventually additional funds “4 for providing grants to promote compatibility and cooperation among drug information units, : The clearinghouse should include full in- || formation on the chemical structures and bio. -} logical properties of all known compounds and the derivatives of such chemicals, with regard for their cellular, environmental, and social ef- fects. It should gather information from all %. reliable sources, including the published litera- ture, conference proceedings, government re- 7 ports and other records. Further, that the " clearinghouse should produce, both for general and specific users, annotated bibliographies, . systematic files of information on drugs in 7 forms suitable for replication, critical reviews, compilations of evaluated data, judgmental re- sponses to individual inquiries, and other ap- propriate information. cancer, and stroke. As a member of the Com- mission stated early in its deliberations: We have a majority interest in personal disaster !2 the United States—and conversely a majority oppor tunity to help improve the health and prolong the life: of the U.S. population. That is because 71 percent of all U.S. deat caused by heart disease, cancer or stroke. Seventy-one percent is a majority interest thing. 3 People want information about heart disea%, cancer, and stroke. If reliable informatioD 1 presented to them, they will act upon it. hs are. in any- eir action will set in motion a chain of events t will sharply reduce the toll of these dis- n this sense, communication is as funda- ‘ental to health as research itself. We of the mmunications Subcommittee urge that the orlds of medical science and medical practice COMMUNICATIONS 409 accept this added challenge. And we strongly recommend that the Federal Government ful- fill its responsibility to promote the health of the nation through strong and effective com- munications pregrams. Mr. Everson Foore, Chairman. eee Source Paper INFORMATION HANDLING FOR THE BIOMEDICAL SCIENCES: BACKGROUND AND POSSIBILITIES Evolution In the history of the race, as in the history of the individual, medical communication be- ginsat home. Transfer of knowledge by nucleic acids in the genes, imprinting of habits, and direct sensory observation, the pristine means of learning the medical arts and sciences, remain the most elementary and probably most effective methods of communication even today. PARENT TO CHILD Asa child learns from its parent, the student. of medicine learns from his preceptor. It is this tradition rather than sentimentality which leads physicians to regard their teachers as “parents” or the teacher to think of graying practitioners as his “children.” Personal ex- perience and personal conversations and associ- ations continue to have a power that underlies the influence of formal systems of information exchange : textbooks, manuals, libraries, and the mass media. Nevertheless, personal experience has its limi- tations. Such limitations may have motivated those who tried to encompass the living treasury of medical knowledge in the writings attributed to Imhotep, Hippocrates, and Avicenna, at. dif- ferent stages of human progress. Even in an- cient Egypt, Greece, and Iran, the body of medi- cal knowledge challenged the ability of the individual physician to contain in his own small head all the medical knowledge that his precep- tors could bequeath. physician and patient to cope with a dazzling and confusing array of knowledge, fact, and opinion. And then as now, the task of putting this in- formation into some rational order developed along with the process of recording the informa- tion on stone, metal, papyrus, clay, glass, and wood, with chisel, pen, brush, stick, paint and ink. Concepts and technics have changed, but the process of organizing and exchanging in- formation has remained constant and contin- uous. These changes in concepts and technics area product of necessity, perception, invention, and acceptance. “The genius so-called is only that one who discerns the pattern of things with- in the confusion of details a little sooner than . the average man.” (Z). INTERCHANGEABLE PARTS It is conventional to associate a startling tum - in the technology of communication with a com mercial failure, a Bible assumed to have been printed by Johann Gutenberg at Mainz late 2 the 15th century. Gutenberg was not the first to use movable blocks of type. They had been” used earlier in Korea. But Gutenberg was to exploit the phonetic alphabet of the Occiden! with morable letters, That fact, and the prec sion of the type in the Mainz Bible, necentuat the importance of Gutenberg’s adoption to printing of the principle of interchan standard parts, applied to the manufacture ® rifles by Eli Whitney and used so successful y Then, as now, the search for methods of man- aging medical information sought to aid both 410 : : 106 in the manufacture of automobiles and rad om “ay Arg ot nl The principle of employing interchangeable ard parts is critical to the construction of _modern medical information systems, as sug- gested by efforts to establish standard nomen- oejature and a universal system of chemical cod- ‘ing (2) The fundamental relation. of this principle to both the intellectual and technical elements of information management is a ma- sor theme of this account. The technique of Gutenberg in producing standard interchangeable pieces of type did not immediately release a volume of literature. Other technical innovations were required, such as the rotary press, papermaking machinery, casting of metallic type, quick-drying inks, and especially the contributions of Faraday, Henry, and Maxwell to the electromagnetic movement of precisely machined tools. A major retardant on the cultural side was the distrust of scientific thought, as opposed to authoritarian dogma or mystic revelations. So surreptitious were many scientific studies that their authors recorded results in cryptic forms intelligible only to themselves. (The appre- -stand a dazzling fact, and ng this in- developed ie informa- glass, and , paint and hensions of that time seem to linger in the ianged, but g cryptography of some scientific writers today.) anging Ww - Under these circumstances, the writing and col- ind contin lection of medical literature tended to be se- questered in discrete enclaves which served as centers of medical learning, and the exchange of information among these centers was hap- “hazard rather than free and systematic. THE OPEN SOCIETY lled is onl \RTS America was the logical focus of a move- artling turl ment counter to the Old World pattern. Being with a comg dependent at first on important medical litera- o have been: ; ture, American physicians could easily see the fainz late 2 : § ¢ of an open system of medical knowledge. not the firs uch a system, with a complete central deposi- rey had be a Was envisioned, in 1878, by John Shaw erg was fi eS ings, who chose to call the Library of the the Occid ea rated General's Office (in the Department of nd the preg ‘in Army dy “The National Library of Medi- e, accent Parad (This term first became legal in 1956.) adoption ' oxically, the frontier tradition of Amer- erchan : ae disdaining precedent, also tends to dis- nufactur® bef &¢ the scientist who examines the literature euccess be. he does his experiments. He is not felt - ad Working as hard as the man who plunges 3 a COMMUNICATIONS 411 right into manipulations. Such a circumstance led Calvin N. Mooers to formulate the law that “Where there is a penalty imposed upon the people who use information, the better the in- formation system, the less it will be used.” Billings not only elected to acquire the most comprehensive collection of medical literature on earth; as his career coincided with the first flowering of periodical publications, he was quick to see the need for a monthly report on new medical titles. In 1879, he established the “Index Medicus” and the following vear he pro- duced the first volume of the first series of the “Index-Catalogue” of the Library of the Army Surgeon General’s Office (3). Since then, the history of these publications and companion works issued by the American Medical Association has been a struggle to pro- vide an up-to-date and effective guide to the volume of literature (J.5). When in 1955 the “Tndex-Catalogue” ceased publication in mid- alphabet with the 11th volume of its fourth series, the number of entries in the unpublished backlog of completed indexing exceeded the total number of entries published in four series in 78 years (6). MEDLARS The need to cover more literature better and quicker prompted: a report to the National Li- brary of Medicine Board of Regents, November 1957, which led to a proposal to the Council of Library Resources, April 1958, that funds be provided to investigate the feasibility of mech- anizing the bibliographic process. Mechaniza- tion of the index to current medical literature (“Index Medicus”), with support of_a_grant _to. the Department of Health, Education, and Welfare from the Council of Library Resources was a step toward an electronic system for fa- cilitating search and retrieval of medical titles. Funds alloted _ by the NX rt Institute... which was interested in special bibliographie of the cardiovascular literature, enabled the li- brary to develop the computerized Medical Lit- erature Analysis and Retrieval System, MED- LARS. Today MEDLARS appears to have the technical potential for recording and dis- tributing all scientific literature (7). There- fore, the present challenge to handling medical Saga aie NEOs Seer oo 20 ae SEE 412 information seems less technical than intellec- tual and social. Can information scientists devise effective plans for organizing knowledge? Will society support the information system and encourage and reward its users? Such questions haunt the librarian who tries to match individual, impor- tunate demands for information with the dis- orderly contents of the scientific literature. THE MATHEMATICS OF BABEL The following data offer some concept of the volume and variety of literature which the mod- ern information system may be expected to manage. The rate of output of biomedical publications for the past 10 years has been fairly constant, at 1.4 papers per man-years employed in bio- medical research and development, and 1.4 per project 1 to 2 years old (8), but the volume has grown in proportion to the expansion of re- search and development. In 1960, there were 5,800 biomedical serial publications. The total number of papers covered in 1 year by “Index Medicus” was 120,000 in 1960 and is expected to be 250,000 in 1970 (7). Although the chem- ical literature is estimated to double every 8.5 years, the National Library of Medicine calcu- lates that the volume of biomedical literature doubles only every 25 years (9, 10). The Library estimates that it received 4 mil- lion titles between 1933 and 1968, in contrast TOTAL NUMBER OF THLES RECEIVED BY THE NATIONAL LIBRARY OF MEDICINE 1800-1933 1933-1963 Number of Titles (Millions) REPORT TO THE PRESIDENT “is not only indexed; it is also abstracted an a DISTRIBUTION OF CHEMICAL LITERATURE BY LANGUAGE OF ORIGINAL TEXT, 1963 ENGLISH NON-ENGLISH SS SS Sow Based on unpublished data developed by Chemical Abstracts to 3 million received between 1800 and 1933 (9). : A productive minority among scientists - writes the majority of the papers published, 3 How small is this minority no one knows ex- 3% actly, but it is probably between 10 and 20 per. a cent of the total (8). For that matter, a small E minority of journals carry the bulk of the cited “3 literature (8 19), : Of the serial publications founded after 1950, one-third died before 1960. The great majority « of those founded in that period (80 percent) 2 were foreign: As biomedical research increases 3 among scientists who do not ordinarily speak .*3 English, publication of scientific reports in for- “44 eign languages will expand, unless there are special incentives for favoring English as &- common scientific language. An unpublished - study by “Chemical Abstracts” indicates tha in the years 1961-63, there was a slight increas¢ in the proportion of papers written originally. in English, composing not quite half of the, total. The proportion written originally 1 Russian increased substantially, while mom. other non-English languages declined, Telé-: tively. Secondary Publication ‘The current volume of biomedical Jiteratu some degree translated. Approximately re such secondary publication services, 4 third o them American, are concerned with piomedic literatura alone. The number of seco? a COMMUNICATIONS 413 services for all scientific and technical litera- ture is about four times as large (11) . - The annual total of biomedical abstracts is i 200,000. An additional 700,000 titles are sted oF indexed. (Many documents are covered more than once, and some listed er ab- stracted are strangers in the biomedical field.) There are 31 secondary sources in the United States for drug information alone (72). (In- tramural services of pharmaceutical companies are not. included in these estimates. ) Of 882 journals carrying 14,334 papers cited by NIH grantees as products of their work, almost all were processed by at least 1 of 18 major secondary services, and the average proc- essing was by more than 3 of the secondary ublications. Two services, “Index Medicus” (IM) and the “Bibliography of Agriculture” (BAg), covered 94 percent of the articles (71). A 1961 study of the coverage of cardiovascu- _ Jar, endocrine, and psychopharmacological lit- erature found that the combined efforts of “Ex- cerpta Medica” (EM), “Psychological Ab- stracts” (PA), “Chemical Abstracts” (CA), and “Biological Abstracts” (BA) covered 70 percent of the articles, all 1 to 14 years old. “Excerpta Medica” alone covered 42 percent, the best of the four (73). Forty percent of all the sample articles were covered by more than one of the four services cited. A study of coverage by six services (EM, BAg,CA, BA, PA, and IM) found a symmetri- cal distribution. None covered 4 percent and all six covered another 4 percent. About 13 per- cent of the sample journals were covered by no more than one service; 14 percent were covered by five and 17 percent were covered by two; 24 Penvent were covered by three and 24 percent _*yfour. (11). On the average, the world’s scientific journals are being covered four times over by U.S. ab- ecting indexing services, but not always for © same content. TM indexes 145,000 documents a year (1963), creme number abstracted by the US.S.R. nyi Zhurnal: Biologiya.” The vari- us sections of “Excerpta Medica” total about 90,000 abstracts a year. CA produces 165,000 tracts 9 year, in contrast to 30,000 for “Re- PERCENTAGE OF 14,275 U.S, BIOMEDICAL DOCUMENTS IN 891 JOURNALS ABSTRACTED OR INDEXED BY SEVERAL SERVICES Number of Services Covering COVERAGE BY INDEX NEDICUS OF 14,275 DOCUMENTS YY YL MY. ferativnyi Zhurnal: Biologicheskaya Khimiva” (14). BA produces 100,000 abstracts a year. Its French counterpart, “Bulletin Signale- tique,” claims to annotate 200,000 titles. Most services in specialized categories produce fewer than 10,000 or even fewer than 1,000 abstracts a year. Not Covered Coverage Technical Reports In addition to items in books and serial pub- lications, the biomedical literature in recent years has been peopled with a new breed called the “technical report.” Some such reports are deemed ineligible for formal publication be- cause of “length, degree of detail, specialized language, or restricted interest,” according to criteria used by the Division of Biological Standards of the Public Health Service. An- other factor is that the criteria for review before printing of technical reports differ sometimes from those for journal publication. Some are presented in preliminary form at scientific con- ferences before a refined version is offered for formal publication. Some consist of author ab- stracts, submitted for distribution at meetings, for publication with the proceedings, and these are regarded as seriously as a formal publica- tion. In 1962, 1,615 biomedical technical reports were identified, half from the Department of Defense. The indexing services cover such re- ports only on a selective basis. A clearinghouse in the Department of Commerce has been desig- nated to announce and distribute all nonclassi- i 4 414 fied technical reports issued under Federal auspices, Sources of announcements of technical pub- lications include, “Technical Abstract Bulletin” (TAB), issued by the Defense Documentation Center (DDC); “Nuclear Science Abstracts” (NSA) of Atomic Energy Commission (AEC) ; “Technical Publications Announcements” (TPA) of National Aeronautics and Space Ad- ministration; and “Government Research Re- ports” (GRR), Office of Technical Services (OTS) of the Department of Commerce. Each lists a separate category of documents for the biomedical sciences. Technical reports usually are published with- in a month, in contrast to journal articles, which usually take 6 to 8 months. In TAB, the lag from publication to announcement is 6 months. The American Documentation Institute, Li- brary of Congress, provides a depository for papers, or portions thereof, which are denied formal publication because of length or degree of detail, provided they are recommended by the editor of a scientific journal and announced in the journal. LIBRARY SERVICE Few medical libraries today are much better off than the scientists in managing the volume of information available. The librarian is ex- pected to stock or procure all documents re- quested, to prepare announcements and bibliog- raphies, and to keep all this information in neat order. As if this were not enough of a burden, librarians have been attacked for not providing answers instead of documents and for failing to alert scientists and practitioners to new infor- mation. Far from being able to provide the re- search services in which they are trained, most librarians are compelled to give most of their time to housekeeping and administrative duties. In 1962, only two of every five hospitals with fewer than 99 beds reported having a profes- sional library, and these had an average collec- tion of only 158 books. Of the total of 5,444 short-term non-Federal general hospitals regis- tered with the American Hospital Association, ‘only 3 out of 5 had professional libraries (15). The average collection in professional li- REPORT TO THE PRESIDENT | \ \ braries in hospitals with more than 400 beds was 2,657 books, in contrast to one recommenda. tion for more than 6,000 books and more than 126 journals for the larger hospitals (16), For = hospitals with more than 100 beds, one profes. » sional body recommends at least 1,000 books published within the past 10 years (77), The 3,192 hospitals with professional libraries employed only 863 full-time personnel ang barely 3,000 part-time personnel (15). Despite this shortage of trained personnel, only 994 have attended the four institutes on hospital librarianship held since 1959 by the American’ Hospital Asssociation. : A particular difficulty in this setting is the | hospital’s tendency to confuse the separate call. ings of the medical librarian, the medical rec. ords librarian, and the librarian who serves the patients (18). Doing their utmost with limited resources, small libraries lean heavily on the resources of -. the National Library of Medicine and other- major depositories. They have participated in. an interlibrary Joan system to exchange rela-. tively rare documents, but the demands upon. * this system, too, are on the verge of a break-. down, ° Interlibrary loans by the National Libra of Medicine, which stocks 1 million volumes, in. creased 82 percent from 1958 to 1961. The de-: mand for such Joans is expected to accelerate as. MEDLARS expands its coverage from 2,200 journals to 3,500 journals plus 5,000 books. annually, There is some expectation that MED-; LARS, instead of supplying bibliographies,: whether recurrent or on demand, will simply " supply tapes to regional centers which will con-; duct the searches and provide the bibliographies, to answer the prospective volume of requests: — The value of such bibliographies is suggested by a test run of a prototype prepared for card ovascular studies. Investigators in this field, who are well read even by the standards of th profession, found that 85 percent of the refer ences pertinent to their work in the MEDLAR “prototype bibliography were new to them al thoigh' the average age of the titles listed more than 6 months, according to an unpub- lished study by Herner and the Institute fo | Advancement of Medical Communications. = COMMUNICATIONS 415 INTERDISCIPLINARY AND INTERNATIONAL COMMUNICATION ‘The above figures are a rough indication of the dimensions of biomedical literature. To add all scientific and technical literature to biomedi- eal writings would multiply the number and _ yariety of publications by a factor on the order - of 10, and the complexity of the information pattern by a factor of 100 or more. Improve- ments in the arts of medicine nevertheless de- pend more and more on the sciences of chem- istry, physics, engineering, and mathematics: Most. medical missions today are interdiscipli- nary: ; arr a One result of the interdisciplinary mission has been a realization that communications in any one subject are limited by the quality of scientific communications in general. This con- clusion was voiced by the President's Commis- sion on Mental Retardation which observed, It is * * * essential to support the foundations of scientific research in all fields. and to stimulate the communication of both needs and solutions among in- yestigators and cliniclans working at every level * * * (19). Requirements of improved and accelerated communi- cations across the boundaries not only of disciplinary lines but of Nations can be met in part by vigorous exploitation of conventional methods as well as new methods * * * prompt exchange of unpublished sci- entific data and development of efficient, systematic retrieval of results of research is urgently need- ed * * * increased support for research in communi- tation theory and technology must be provided if we are to make effective use of our scientific potential and translate new scientific knowledge into practice (19). On a limited scale, the foregoing data offer a fair view of the pattern and volume of biomed- tal information. But the dynamics of com- munications are not as easily described as the dimensions. There is some evidence that the €xponential growth of scientific literature will level out (8, 20). There is also considerable pinion that the formal literature may be a rel- atively minor force in biomedical communica- tions, outpaced by the grapevine, the invisible volleges, conferences, and specialized informa- ‘on centers, The influence of cybernetics, *mploying computers, TV, microforms, photo- Printers, magnetic tapes, and long-line circuits, may strengthen methods of handling medical information in years to come, but Mooer’s law, cited above, will also operate. INVISIBLE COLLEGES AND INFORMATION CENTERS Two typical and somewhat contradictory re- sponses are heard from most scientists or prac- titioners when they are asked how they obtain scientific information. (A) Smug: “T have no trouble. When I wish to know something, I know where to look or whom to call.” (B) Desperate: “How can I cope with the quantity of information published ?” It may be argued that neither is sophisticated. But both indicate a disposition to turn to per- sonal acquaintances for information rather than to the bewildering jungle of the formal litera- ture. Neither is much help to the middleman whose job is to help all users get the medical in- formation they need. In the exchange of scientific and technical in- formation, available data indicate that scien- tists spend several times as many hours at meet- ings or on the telephone as they spend reading the literature. Even though delays or frustra- tions in efforts to use the literature may be re- sponsible for this relative dependence on con- versation, such conferences are not. in themselves necessarily an economical method of exchanging knowledge. The number of meetings alone seems extravagantly high. The biomedical meetings in the United States and Canada listed by calendars published by the American Medi- cal Association and others total more than 1,500 a year, and these are said to be only a fourth of the number actually held. (27). At the cutting edge of science, among families of specialists, such as those concentrating on viral etiology of cancer, resort to personal con- versations, telephone calls, and occasional visits or conferences is understandable and justifiable. Such scientists need not and should not wait for publication of final results by their colleagues. It is a tribute to the camaraderie of science that they form and maintain associations for free exchange of information. At the same time, such sources of specialized information grad- 416 REPORT TO THE PRESIDENT ually expand to include others outside the inti- mate circle. Once a body of special information is solidly established and of wide enough concern, it is common for the not-so-invisible college to set up a specialized information center, a focus for the storage of specialized knowledge to answer or anticipate germane inquiries. The National Referral Center for Science and Technology, Library of Congress, has produced its first directory to shed further light on the number and distribution of such specialized in- formation centers. An early study of informa- tion centers (22) necessarily dodges the duty of idealizing their function (23). But it seems widely agreed that such centers area logical de- vice for matching specialized questions to the quantities of data in specialized fields. This all too hasty summation of the evolu- tionary changes in the technology of medical information transfer—from preceptor to man- ual, journal, library, and information center— has given sparse attention to the concepts of medical knowledge. The concept of medical communication has shifted from a private con- versation among a hierarchy of physicians to an international, permanent, floating caucus of scientists, practitioners, and laymen. The pathways of information have opened up. Straight lines, from preceptor to apprentice, Definitions and It is widely assumed that interchangeable standard terms, meaning the same in all Jan- guages and disciplines, will facilitate the flow of information, even though achievement of a standard language is slow and difficult. It may be assumed also that a technology which links all the cities of the world with in- stant information will accentuate the use of standard terms. Although undisciplined natural language will undoubtedly continue to prevail in common dis- course and in much professional writing, its automatic translation into standard disciplined forms will be necessary if a network of scientific information is to operate satisfactorily. have been supplemented by a network that radj. ates and ricochets in all directions (24). But little has been said here of the shift of medica} emphasis from treatment to cure or, still better, to prevention; from specific single predispos. ing, provocative, precipitating, and perpetuat. ing events to multifactorial processes; from discrete, isolated specialists to a multidisciplin. | ary team; from sporadic clinical observations to systematic genetic, clinical, epidemiologic, and laboratory studies of individuals and of large populations. And yet these conceptual changes radically revise the “pattern of things within the confusion of details” (7) as envisaged in the past. Equally significant to the process of informa- tion transfer has been the increasing ability to identify specific pathogenic agents and condi- | tions with names which are almost universally understood and accepted, whether parasites, chemicals, or forces of temperature, velocity, mass, or electromagnetism. The terminology of anatomy also is well established. Even the language of biochemistry and virology has be- come less occult among the specialists. Defini- tion and precision of concepts are the intellec- - tual counterpart of the system of standard interchangeable parts used in the technology of information handling. Assumptions Perhaps the most egregious assumption is that it is possible to frame and employ such & disciplined language, but that is the faith of many “information scientists,” a category which in this context includes documentalists, librar- ians, indexers, bibliographers, writers, @ editors. . “Information” itself is defined, succinctly, 3 “meaning assigned to data” (25). The impli- cation of this definition is to exclude transmis: sion-of- random signals: Casual conversation unsystematic records, and accidental collections or accumulations, not to mention noise ane dysplastic art. “Communication” may be conceived as & step ormation: It implies perception of ee meaning on the part of both sender and a ver and exchange of information, but it e not necessarily imply active response. An het words, the function of the information Pe jentist is to facilitate delivery of the-message and to be sure that it is understood. Z dback ordinarily tells how the user inter- sa message. But it ought not be the duty ond inf acts upon the information given. The be- havior of the user is something to be determined his individual judgment in the context of public affairs: e.g., it is the information sci- entist who informs the practitioner of the char- scter of a vaccination ; administration of the yaccination may depend on the judgment of the physician, the decision of the patient, or the requirements of law. This distinction may serve to disabuse information scientists of ap- rehensions of messianic responsibility and to anticipate extraordinary expectations on the # part of administrators. Such a concept of communication also an- swers the natural question: Why bother with fresh messages for people who do not apply * what they already know? The task of motivat- ing people to act is a responsibility for the com- munity at large. Motives for action involve common goals and aspirations. The basis for feeding information is the assumption that peo- _ ple may act more suitably with the right in- ay _The impedance factors in message transmis- , Son usually cited are: A weak or confused sig- nal; circuits insufficient to carry or distribute the load; receptors of insufficient sensitivity; or the absence of a feedback to regulate the nature or flow of the signal. ' Asignal may be confused by competition with other louder or contradictory signals, or by the Presence of a mere multitude of signals. The ‘ireuits may suffer from a shortage of filtering _ & switching mechanisms. Human as well as Physical failings may impede reception and feedback, COMMUNICATIONS 417 formation than with wrong information or with no relevant information at all. A further assumption is that the flow of in- formation is screened and regulated at key points. These include the scientific colloquies, the medical societies, the medical schools, the professional journals, science writers, librarians and other science information specialists, and the directors of various mass media. Publishers and TV producers in particular are assumed to have a responsibility, as well as 2 rare opportunity, to satisfy the manifest in- terest of their clientele in health information (26). While it is incumbent upon professional journals and libraries to speed exchange of in- formation among scientists, and while it is the presumptive duty of medical schools, medical societies, and hospitals, in cooperation with various voluntary and official health agencies, to maintain and improve the competence of the health practitioner, such enterprises require public sympathy and support. It is assumed that. the health sciences are best fostered in a society where knowledge is widely diffused. The mass media, including the carriers of ad- vertising, are among the most potent forces for conveying information or misinformation, as the case may be, for the improvement or im- pairment of the species. The success or failures of such efforts are in- fluenced materially by forces described in the following paragraphs. Impediments of Message Transmission This model does not serve our present pur- pose, however, except for its bearing on the volume of information as it affects the entire cir- cuit. Other factors discussed below are obsoles- cence, which concerns the speed and timing of transmission; accuracy and evaluation, which are judgmental rather than physical factors in communications; language, related not only to the nature of the signal but to the nature of the mind; and a radical revision of “the pattern of things within the confusion,” affecting the de- sign of the information system. Sty bcp ot ee Sore Samepor: fier BES imge ss a 3 418 REPORT TO THE PRESIDENT FLOOD OR SCATTERED SHOWERS Most of the studies of biomedical information promptly conclude that the mere volume of literature in itself is a major impeding factor. To quote but one such study, Science and technology can flourish only if each scientist interacts with his colleagues and his predeces- sors, and only if every branch of science interacts with other branches of science; in this sense science must remain unified if it is to remain effective * * *. Yet, because of the tremendous growth of the literature, there is danger of science fragmenting into a mass of repetitious findings, or worse, into conflicting special- ties that are not recognized as being mutually incon- sistent. This is the essence of the “crisis in scientific and technical information.” (27). Faced with an overload of information, the receiver resorts to one or more of the following actions. He may skip, ignore his mistakes, let a backlog build up, select only important items, abbreviate the response, call for help, handle messages wholesale, or quit. These actions are also known as omission, error, queuing, filter- ing, approximation, multiple channels, chunk- ing, and escape (28). Filtering or selection is an elementary action on the part of all receivers. As Freud has pointed out, the art of forgetting is more im- portant than remembering: Otherwise the mind would be completely cluttered, The develop- ment of specialties in science is a filtering proc- ess, an effort to select. only items of information that are pertinent to a given discipline or mis- sion. In most discrete specialties, there does not appear to be an overload of information, despite the experience noted above with the bibliog- raphy of cardiovascular literature. Within a narrow specialty, the available work of the leading contributors is quickly located and studied, and if an unknown comes up with a significant report, the grapevine soon has the word, often before formal publication. Nevertheless, the task of dealing with the current volume of medical literature remains critical for producers and users of informa- tion and above all for the middleman, the in- formation scientist. The user who ranges over the great mass of literature sees only a limited, biased sample, even though such stimulating browsing may be the road to serendipity. For systematic interaction among specialties, vari. ous forms of linkage and switching of informa. tion sources need to be developed (27). The task of the information scientist may be ong of building irrigation ditches to handle the runoff from scattered showers, rather than ong of damming or channeling a flood (27). OBSOLESCENCE BY THE HOUR The rapid obsolescence of medical informa. tion is suggested by survey data as well as by reports of medical research. A study of inter. library loans by the National Library of Medi. cine found that 59.6 percent of the serial publications requested were less than 10 years old, 78.3 percent were less than 20 years old, and only 5.6 percent were more than 40 years old (29). Without implying that the more recent information is necessarily new, the figures in- dicate that the reference works in the physi- cian’s bookcase may not tell him all he needs to know. A more dramatic figure, widely cited, is that 90 percent of the pharmaceuticals on the market today were unknown 20 years ago. Again, it is not implied that the 90 percent are necessarily better than the durable 10 percent. Neverthe- less, rapid and notable changes in the practice of medicine such as prophylaxis of rheumatic heart disease, exercise of stroke victims, and cytological diagnosis of cervical cancer have . tended to replace older methods. These changes in clinical practice sound a clear challenge to pracitioners to keep up with the times, in part by consulting current. literature. The rise in U.S. funding of biomedical re- search and development, an increase from $148 million in 1950 to $890 million in 1961, has unquestionably multiplied such changes in clin- ical practice. And realization of these medical advances has been disturbing to many practi- tioners and some of their patients, While ordinarily they recognize it is wise to eschew novelty, to stay with tried and tested proce — dures, they cannot help but be tempted by the fact that. many medical novelties of the past - 20 years, such as valvular surgery, antibiotics and steroids, have become established and. re spected. Between caution and hope, they 97° as badly torn as Hamlet. And nothing can re- ther so much as scientific information ghich will distinguish between genuine dis- cover ies and mere changes of fashion. The hazard they fear is that they may be yictims of fashion. Medical fashions in diag- nosis have prompted the flippant comment that we sometimes have epidemics of statistics rather than epidemics of disease. Treatment also may be a fashion as much as diagnosis, event to the extent of surgery. The assertion that 75 percent of the cancer victims might have their lives “saved,” meaning “prolonged,” py early diagnosis and preventive surgery, for example, has been shaken by data offered with respect to mammary sites (30). Information is available to support the claim in behalf of surgery, but the question is, is the claim truly scientific? In such a situation the conscientious physician needs evaluative infor- - mation rather than mere documents. The uncertain scientific basis for other forms of medical practice is reflected in serious litera- “ ture on acupuncture, the Chinese technique of treating ailments by putting needles in the joints, and moxibustion, known in the West as cupping, a technique of drawing blood to the skin with a vacuum. The persistence of these ' practices in the Orient may encourage curiosity as to their value, but a conclusive scientific ex- periment has not validated these technics. Arguments over dietary factors or the use of anticoagulants in heart disease offer another ex- ample of the need for scientific evaluation of transient reports. Such arguments also illus- trate the volatility of scientific theories and the tendency for fashion and discovery to be con- fused with one another. . While such disputes are best settled by experi- Ment and careful accumulation of evidence, a desperate patient is seldom willing to wait for , the final verdict. Having seen first hand the Ubiquitous achievements of modern science and - technology, he insists that something new be tried, especially when established methods are ret and unsatisfying. Moreover, the possi- “2uity that something new may actually be use- tod 18 One that no practitioner cares to discount ay, ; But the physician will be handicapped in ap- . P'ying new methods unless information methods 5. Jieve * “%, wractice | amatic ’ is, and COMMUNICATIONS 419 become capable of supplying fresh information promptly, mm perspective, and well evaluated. The present rate of research and development is so far ahead of the reporting and evaluation that much scientific information is out-of-date before it is in print. The time lag between the delivery of a report and its publication ranges from a few months even to a few years. Secondary publication in- variably takes a few months more. But the de- lay between the completion of the report and delivery of an acceptable report usually is even longer than the delay in publication. In the process of announcing new information, there- fore, both the writing and publication phases are too slow for the modern pace of obsolescence or for the scientific appraisal of the newest in- formation. FREE MARKET vs CARTEL: THE PROCESS OF EVALUATION It is considered by many that a critical step in managing scientific information is to weed out false, frivolous, or foolish contributions, or con- versely to select for publication only the sig- nificant and the sound. In other words, evalua- tion and screening are trumpeted as critical to information handling (22), except among those who feel frustrated by obdurate critics and edi- tors (27). The evaluation system is both formal and in- formal. Evaluation begins in the author’s struggle to select precise words, proceeds with comments by his preceptors and reviewers, and concludes in the response of readers to his work, if not in this generation then ina later one. The theme of critics of this process is that evaluation needs to be refined, to be more self-conscious and critical, and to exert more influence. At the same time it appears that, despite all hurdles and hazards presented by editors and referees, the author who really tries can succeed in having almost anything published and dis- tributed. By this means the free market in sci- entific information tests a scientific work by the ancient rules of supply and demand. If the open market is indifferent, few copies will be read; if readers are respectful, the paper will be reproduced and broadcast. Apologists for this procedure assert that such freedom is necessary to escape from hardening of the hierarchies, sensi Experience with an epidemiological study of encephalitis (32) serves both as a warning against restricting publication and as evidence of the futility of such restriction. L. L. Lums- den was alone among 100 eminent colleagues in ascribing a St. Louis epidemic of encephalitis to a mosquito vector. Although his paper was not published formally for 25 years, the rejected text was mimeographed and circulated among a select scientific underground until the frayed copy was recognized for the classic analysis that it proved to be. A similar history attended a theoretical and creative study which was rejected by 32 journals before one bold editor eave it space. The author predicted, on the basis of his theories, that biologists would find a free-living trepo- neme and a simian reservoir of malaria. These predictions were vindicated within a year (33). Such incidents also indicate some hazards in evaluating factors of impedance or intensifica- tion of biomedica] communications. Dr. Richard Orr, director of the Institute for the Advancement of Medical Communications, has asserted that many prized assumptions about the process of information transfer do not stand up under the test of experience. His ad- vice is well warranted. Studies undertaken to assess such assumptions are pathetically few. Meanwhile, demands for a free flow of in- formation cannot be stilled by a plea for addi- tional evaluative studies. Decisions to improve scientific communications must be taken on the basis of temporary assumptions, however uncer- tain they may be. In this sense, each commu- nications program is an experiment, and the quality of its assumptions is to be judged less by the superficial success of the communications program than by the discernible relation be- tween those assumptions and the results. A free market for science information should be the logical response to the uncertainty of our as- sumptions as well as an expression of confidence in the experimental method. Nevertheless, free circulation of important in- formation is restricted by considerations of na- tional security; by zealous protection of pro- prietary interests; by rivalry in the contest for REPORT TO THE PRESIDENT professional eminence; by reluctance to report - negative results, so called ; and by simple indig. ference to publication. Under these circum. stances, the common market for science informa. 3 tion suffers from a variety of political ang’ | psychological trade barriers. THE PATHOLOGY OF LANGUAGE Although it is a truism that verbal skills apy - fundamental to the communications pro current awareness of the health and pathology of language is largely pragmatic or intuitive, © Achievement. of verbal skills is an art rather“ than a science. Knowledge of the source of ver. : bal skills or their real nature is on the level of © medical knowledge of malaria or typhoid fever . 3 200 years ago: The symptoms are obvious, but - 3 the agents and the biological process are mys-- terious. It is possible that. psychological factors, such as fear, exhibitionism, greed, brutality, sloven. liness, egotism, or libido may handicap commu- nications more than ignorance of the rules of grammar or vocabulary. Otherwise, stylebooks, dictionaries, and teachers presumably would have far wider effects than we see. There are reasons to believe that many good writers ap- parently learn their craft unconsciously by echoing the style of books they read (34). But most authors who contribute to the scientific and technical literature seem untouched by any .*33 literary aids. The question, “Can we teach scientists to write well?” is answered by the question, “Do we teach scientists to write well?” Despite the fact that English occupies a disproportionate amount of time in classrooms, much scientific prose consistently fails to achieve lucidity oF accuracy, not to mention elegance. High schools, colleges, and publishing companies @P- parently are social forces which either have failed to cope with resistant psychological forces or have been undermined by more power ful social forces, such as the lame verbal habits of peer groups or the pressure to publish haste and repent at leisure in the competitive struggle for recognition. The increase of research and developme! countries which do not favor English, 28 ne earlier, is claiming an increasing portion © the: it in spor ae body of scientific literature, Consequently, hose who read only English may expect to be restricted toa progressively smaller share of the * ‘sepature ne principle of interchangeable standard rts implies a single language, preferably Se English. which is still dominant in biomedical \GE yiterature; precise, consistent terminology! and orderly arrangements of words. How this prin- ciple is to be applied will depend on the ability ‘to design successful studies of the process of ‘mastering yerbal skills and on such acminist ra- tive measures aS May convert most of the scien- tific world to the use of a standard vocabulary, neatly organized. It remains to be seen what may be the effect of contracts with foreign journals to publish English text or of world- wide use of MEDLARS tapes. One disadvantage of the variety of languages is the need to translate a single document into four or more other important languages. While there may be some justification for such duph- cation, there is far less excuse for creating sev- eral English translations of one document. Under aegis of the Organization for Economic Cooperation and Development, a European - Translations Center has been established to give #. western Nations knowledge of eastern European research and to make available translations not otherwise obtainable. Various national agen- cies cooperate in this activity. MULTIDISCIPLINARY MISSIONS m, “Do Perhaps the most important storm center in rite theg the informal biomedical communications system ‘tionat As Dr, James Miller observed (28), there are only a limited number of things to be done with _Moverload of information, but within the proc- esses he described, there are many refinements. For example, in the processes of queuing and filtering, or in storage and selection, there are Many techniques of organizing or indexing (35) } habits} blish tug. petitive ds ment 10; the information so ‘as to simplify the process as noted, 2 of finding it (search and retrieval) (36). nm of the 783-310 065-28 COMMUNICATIONS 421 today is none of the physical, institutional, or psychological forces cited above, but a historical process. Scott Adams, Deputy Director of the National Library of Medicine, recently stated in an address to the American Library Associa- tion (July 1964) that much of the unrest ex- pressed about information among scientists re- sults from the fact that their traditional tight, tidy disciplines are moving into missions which draw upon a wide variety of scientific resources. This process was accelerated by the Manhattan District. project and others with military asso- ciations, but it now extends also, if less desper- ately, to a wide variety of public health missions. To illustrate, a scientist trained to recognize physical characteristics of cardiac tissues may have a cozy grasp of his subject. But if he en- lists in a mission to study dietary, biomedical, and viral factors as well as social, environmen- tal, und genetic influences on cardiac tissues, he is subject to new demands. If different. effects are ussociated with different viruses or environ- mens, he aims to learn to distinguish all such differences. In correlating various factors as he analyzes the tissues, he tries to acquire new knowledge in a host of unfamiliar subjects. Sinwlarly the traditional hierarchies of subject mater of each conventional discipline tend to be fattened by word lists with a new range of ass¢lation. Mission and experiments designed to deal wit:. this ferment of biomedical information are dis: :ssed in the following section. Experiments and Missions INDEXING POLICY I. the small card file on the desk of a scientist and :n catalogs, bibliographies, and directories in tae National Library of Medicine, there is a e.camon need to conceive of a pattern or sys- ten. »f organization and to arrange the informa- tion accordingly. Even when information is pile? up in the order of arrival, some scheme is use to find a specific item. In a small collec- rae nearest tees nt ah Leno 422 tion, the search may be Lised upon free associa- tion, such as a “small lek with a green cover that came in about 2 wets ago,” or “the letter James asked about.” In 1 larger collection, the search will be related u: dates, names, serial numbers, sizes, forms, sozrces, titles, or topics, separately or collectively. Numbers, dates, and aizhabetical lists of au- thors are among the met familiar bases for organizing information. but not always the easiest for the prospective user with only one subject on his mind. Fev ask a librarian for “Number 59-60045 in th+ Library of Congress catalog.” Although ther: is a strong interest among scientists in all p:blications of certain authors, their searches ually concentrate on specific topics, such as the-mal therapy. Because of the prime nd to organize topical information in accessible patterns, the tactical management, of informati-n, whether stored on cards, tapes, microfiche, or notes scribbled on the back of an envelope. :s less crucial in the biomedical field than the strategy. (It is un- likely, however, that a si.gle strategic topical pattern will rule the bior-edical sciences com- pletely. The current mu‘-iple sympathetic if not precisely compatible s:hemes of biomedical knowledge have demonstrated persistent sur- vival values.) PLATO VERSUS TOPSY A fundamental differer.-e of policy in the strategy of planning an indexing system is what might be called the deductive versus the indue- tive method. The first seel:s to assign topics to a prearranged set of categories; the other de- rives categories from the topies encountered. One is the hierarchic system contrasted with the so-called UNITERM systern. In practice, such systems tend to approach one another. Herner has said that “the phenomenon that best characterizes modern documentation is the recurring denunciation and discovery of the need for context and resolution in index entries” form clusters, Simultaneously, those who em- bark on a program of rigid categorization are certain to encounter items that let the category out of the bag. REPORT TO THE PRESIDENT . body (A1), musculoskeletal system (AQ), and ~ - Sewell, subject. heading specialist, states, “Our (36). On one hand, discrete terms inevitably~ ~ basic principles of assigning subject heading* A general theory as a logical framework of events has been a driving force and a Powerfy | ; instrument in the physical sciences, exemplifigg -€ in the works of Gibbs, Newton, Einstein, and Bohr, as James Conant has demonstrated in hig .£ essays collated under the title, “On Understang. ! ing Science.” General theories in medicine, thy $ pythogenic theory, the germ theory, and Mog $ recently the stress theory, have been productiyg also, if not always valid. The hope of construct. ing a genera] theory of behavior, based on the information concept, animates the studies of 2 Miller and associates (37). In one sense, al] -2 reasoning is deductive insofar as generalizations are based on incomplete data (38), On the other hand, the pragmatic approach, or the inductive method, is relatively open, more | inclined to allow events to define concepts, pat. terns, or structures, Such a contrast in strategy is exemplified in. two publications issued by the Public Health { Service to facilitate the search for scientific information. z One, “Medical Subject Headings,” called 4 MeSH, frequently is assumed to be typical of the hierarchical structure of information (39), § although it is actually based on the literature. ¥ rather than on classical concepts. Under 13 f main headings, such as anatomical terms, or- | ganisms, humanities, or communication, MeSH | arranges various subcategories and terms or de ~“# scriptors, which in turn contain cross-references... To illustrate, under anatomical terms (A), nose : appears under three categories; parts of the ° respiratory system (A4). Nose is also indexed : under face (Al); and, in the other categories % (A2), (A4), it is subdivided into nasal septum, ; turbinates, nasal mucosa, and nasopharyn® These classifications provide a road map for storing and recovering information about the nose. MeSH is used primarily as a skeleton for “Index Medicus.” oy In the introduction to MeSH, Winifred in medicine have not changed from those ir forth in the * * * first edition. We are col vineed of the value of using an identical auth ity list for the indexing of periodicals and th taloging of books. | Experience has led us to ke some changes in specific practices and a or change in discontinuation of the use of ‘cal subheadings * * * But we continue to rd subject headings * * * as directional or vectors which * * * serve to locate.. e of a particular paper * # EY (39), In contrast, the Division of Research Grants -gevised an index with 6,700 main headings in Iphabetical order, based upon the terms used Eby investigators in describing their work (49). # The system of deriving index terms from titles B: ortest is known also as permutation or keyword pa indexing. When these terms are grouped with E others, by links, roles, or codes, the system 1s * called coordinated (36). But like the editors of MeSH, the editors of the “Grants Index” find gneed for categorical treatment. With the 1963 edition, the staff of the Divi- gion of Research Grants concluded that their system had proved “too rigid and cumbersome” é gnd they therefore introduced modifications. : The more significant changes were to group Te- lated items “as convenient categories ++ # rather than as hierarchical classifications.” The iteratue®: editors aim at compatibility with MeSH but *n der i : have formed no hierarchical system to cover the many descriptors which are needed to identify the work of grantees. In such a wordlist, cross-references in them- selves tend to form categorical groupings: for example, under “heavy metals,” there is a com- Pite list of the heavy metals preceded by “see & so? Use of the keyword system has been encour- aged by two developments. One is the shift, noted above, from disciplines into missions, a shift which creates new categories of associa- ton. The other is electronic machinery which makes it possible to set up an index automati- : cally, the so-called permuted index. For exam- ve given certain instructions and a title, such dundones > mechanisms, the reduction of re- the tex cy and intelligence,” a machine may list _. etms alphabetically as follows: intelligence/ sensory mechanisms, the reduc- men of redundancy and System than are contracts and budgeted To ot de amiss For example, contracts were issued .. “€velopment of MEDLARS, for developing biological activity cards based on literature of eancer chemotherapy, for preparing cancer chemotherapy abstracts, and for the secondary heart literature described above. These few contracts alone exceeded an outlay of $3 million in 1 year. INTRAMURAL PROGRAMS A superficial study of the science information programs conducted internally by various health agencies and organizations finds a va- riety of commendable, discrete enterprises in a relatively loose relationship to one another. Such relations as are found tend to be in- formal, spontaneous, and voluntary, as befits a freely functioning institution. The price of such freedom, unfortunately, is the sacrifice of much economy of money and effort. submersion of primary needs and ob- jectives, and limp exploitation of the technical potentialities of a well-organized information system. To illustrate, the preparation of au- thority lists or word lists for use in various in- dexing schemes frequently proceeds without interchange among the various programs, grantees, or contractors, although their judg- ments will determine the compatibility of their systems. Sporadic contracts for translations and abstracts incur needless duplication and expense. Support of publications proceeds on an ad hoc basis with little regard to the design of a total information system. Little heed is given to the fact that progressive automation of library services requires editorial coopera- tion in the form of titles, abstracts, and key words. There is little insistence that evaluative procedures be built into information experi- ments and even less regard for the contribu- tion of these experiments to continuing educa- tion of the practitioners and to public enlight- enment and encouragement. It is far easier to criticize this condition than to correct it. The administrative, legal, and psychological barriers to coordinating infor- mation activities even in a totalitarian state are formidable (59): How much more difficult is the task in an institution which stakes its scien- tific life upon freedom to experiment, which de- pends wholly on cooperation and persuasion to obtain acceptance of authoritative channels and 430 REPORT TO THE PRESIDENT procedures in the interest of economy, priori- ties, and effective exchange of information? No individual reproof is warranted for the flaws in the biomedical information programs of the Nation. As Dean Rusk said of the Bay of Pigs fiasco, “There is something in it for everyone.” For those burdened with this difficult task of coordinating information, there should be less criticism and more sympathy, cooperation, and support. ‘Asa move in this direction, the Public Health Service has established a focal point of respon- sibility in the office of the Special Assistant to the Surgeon General for Science Information. Many PHS divisions also have appointed sci- ence information officers. Several of the recom- mendations of the Surgeon General’s Confer- ence on Health Communications (60) have met with a conscientious response. New functions have been defined, new programs have been developed in communications, and ambitious plans for the future have been drawn. Similar steps by the American Medical Association have been noted above. Nevertheless, the Nation is only on the threshold of an expanded program of health communications and continuing edu- cation. It is to be expected, moreover, that these steps will go in the direction of national and world- wide developments. (An exceptionally cogent review of the in- formation facilities available to pharmaceutical firms has been prepared by Mr. S. T. Zelter for the Organization for Economic Cooperation and Development, Paris, October 23, 1964.) FEDERAL PLANS Conception of a Federal information system had its origin in Thomas Jefferson’s vision of a university and in the Constitutional authority of Congress to fix standards of weights and measures. For the most part, the system has developed informally; much of it is regulated officially by the Government Printing Office and the Joint Committee on Printing but otherwise it is disciplined on a voluntary and cooperative basis. The need to improve interchange of scientific information intensified 25 years ago. Scientific and technical development of nuclear weapons, for example, demanded information in the fields of physics, chemistry, and engineering at a speed and on a scale without limit. This demand for ‘nformation continued, under postwar condi- tions, in development of unconventional weap- ons, nuclear energy, space vehicles, and medical techniques. In 1950, the National Science Foundation was established. Among other duties, it was asked to “bring about the effective coordination of tha various scientific information activities within the Federal Government, develop new or 1m- ~ mittee proved methods for making scientific informa- compe tion available, foster the interchange of scien- the Fe tific information among scientists in the United =f © of vol States and foreign countries, and provide fi- * patib] nancial support for translation of foreign sci- The ence,” as well as to “maintain a register of scien- - tions « tific and technical personnel in the United fF caret: States” (67). and f Early efforts at coordination by the Office of fF ” the in Science Information Services (OSIS) of the ® respo! National Science Foundation, including forma- Ma: tion of a Federal Advisory Council on Sciens f— — - ments tific Information, were strengthened by estab- “ Xatio lishment in 1959 of the Federal Council for “tional Science and Technology, composed of officers of - policy rank from the major Government agen- cies. A Presidential task force, headed by. James H. Crawford, Jr., in a report to Jerome Wiesner, chairman of the Council, stated that: As one of the many agencies supporting R&D (re search and development) the Foundation cannot rea- sonably be expected to exercise any forceful direction of other agency STINFO ( scientific and technical in- formation) policies and practices” (62). The Crawford recommendations included creation of Governmentwide clearinghouses to deal with reports on current research, research results, specialized information centers, 22 scientific meetings. The report also proposed 7 referral center to provide “coordinated access to specialized information centers and service Issuance of this report had been preceded by a series of hearings conducted by congression committees, notably the Senate Committee Government Operations, and by a great deal +n scholarly activity, much of it supported byt National Science Foundation. (A bibliog?@P on handling scientific information (63) int nent agen" readed bys to Jerome ®: R&D (ree cannot rea: ‘ul airection ‘echnical in-3 ; included ; houses to. h, researc. nters, ands proposed §3- ted access'ys §: id services receded b; - “eat 1957-61 listed 1,121 items without includ- 7 reference to commercia] applications, lin- Ime ties medical records, or technical writing.) Upon reviewing the Crawford report, the Council proposed that the Office of Science and Technology, serving as Secretariat for the Coun- ci] and for the President’s Advisory Committee on Science and Technology, provide “general olicy guidance but not control or direction” for the Federal information system (64). Also, in June, the Council established a Com- mittee on Scientific and Technical Information, composed of science information specialists in the Federal agencies, to carry forward the task of voluntary coordination of effective and com- patible information systems. The components of this system include collec- tions of documents, facilities for analyzing and searching the collections or recalling documents, and facilities for organizing and distributing the information contained in the documents in response to user needs, Major Federal collections of scientific docu- ments are in the Library of Congress (LC), the National Agricultural Library (NATL), the Na- tional Library of Medicine (NLM), the Science Information Exchange (SEI), and the Clear- inghouse for Federal Scientific and Technical Information. The first three collections are composed mainly of reports of research results and asso- ciated information. The National Library of Medicine is the most comprehensive single col- lection of formal biomedical literature any- where. The SIE collection cons’sts wholly of Teports of research in progress: Its main task is to enable administrators to review the allocation of research funds and activities, but it is useful also in some situations for advising scientists What others are undertaking in a given field. The Clearinghouse deals entirely in unclassified technical reports issued by Government agen- tes: It announces them, distributes notices to _ Specialized users according to their interests, and provides copies on request. © Federal system has no facility with re- - *Ponsibility for collecting and organizing bio- Medica) j nformation which does not appear in the form al literature. This neglected category AUeb de eta! to1 of “unpublished” literature includes informa- tion presented more or less informally at meet- ings, reports to Government agencies such as the Food and Drug Administration, medical or clinical records, letters, advertisements, films, and unpublished reports of research which in- clude much valuable information about so-called negative results. Lack of such a facility tends to delay the prompt application of research findings. For example, the fatal effect of dieth-_ ylene glycol to the kidneys was known to_an se gates nk a NOE gent es tion. In ignorance of this finding, a pharmaceu- senate? did not bother to. __publish its findings. because it had no intention. _of offering the. chemical for human consump-_ tical company used the chemical as a solvent._ re chemical as_ for sulfanilamide, causing 100 deaths before the _drug was withdrawn. This proprietary infor- mation was not intentionally concealed: There was simply no established channel for circulat- ing this information. A clearinghouse function, to evaluate, pack- age, and distribute biomedical information widely but selectively, is an essential component of an effective biomedical information system. The National Referral Center for Science and. _Technology, established recently in the Library of Congress, promises to be useful in facilitating access to present sources of information. But referrals in response to inquiries do not serve the purpose of announcements, explanations, warn- ings, cautions, alerts, alarms, and glad tidings. To a considerable extent, the mass media have served to distribute biomedical information in popular forms, with varying degrees of accu- racy. Their participation, along with the Ad- vertising Council, has been creditable. But reporters for the mass media can not perform the task of collecting, associating, and evaluat- ing information about diet, exercise, surgery, drugs, or medication for selective users, espe- cially scientists and health practitioners. Groups of scholars are needed to form judg- ments upon the available literature and to direct their findings through strategic channels. For the most part, such a service is available in some degree only through universities and research institutions. ah 432 Even without an effective clearinghouse op- eration for biomedical information, various societies and institutions have formed indi- vidual specialized information centers to collect germane documents and provide a focus of bio- medical scholarship. Many are one-man opera- tions: Others are supported with elaborate ref- erence facilities. Eventually, it is to be hoped that all special information centers will be linked in a system which will enable them to share resources and knowledge. A set of clear- inghouses would be a logical binding force in such a system. It is a tribute to democratic institutions and to the professional dedication of those con- cerned that a remarkably effective information system for science as a whole already has de- veloped in an informal manner, in part thanks to the Special Libraries Association and similar bodies. In a free society, moreover, it is to be expected that many specialized information REPORT TO THE PRESIDENT centers will be self-generating and autonomous, As Jerome Wiesner said, We must take care that the Government information systems not overwhelm the non-Government Activities, particularly those of the technical societies which are particularly sensitive to the needs of the users. The process of scientific communication with its long tra. dition of self-criticism plays an indispensable role, The existence of a healthy, impartial system of scien. tific communication helps assure the country that the science it supports is valid. The first scientific in. formation panel of the President’s Science Advisory Committee insisted on an articulated, rather than q centralized, scientific communication system to main. tain independent avenues of scientific criticism. It is my strong belief that these considerations are stil] valid * * * (64). An articulated system rather than a controlled system satisfies the need for freedom and flexi- bility and still provides the cooperation and agreement on standards, on interchangeable parts, which facilitates exchange of informa- tion. The present informal system, however, stands in need of more articulation. Information Costs Considering the economic significance of com- munication techniques, it is unfortunate that there is not. more direct. budgeting and account- ability of these activities in Government. Al- though the Bureau of the Budget has attempted to encourage accountability, specific charges for science information remain imprecise. ACCOUNTABILITY Among the reasons is that it is difficult to agree on what constitutes a proper charge against science communication. For example, to what extent are printing costs chargeable to science information? Travel to meetings? Ad- ministrative operations? At what point are ex- periment and data collection overtaken by the process of communication? Are the creative and intellectual aspects of communication sep- arable from mechanical and clerical services! Do the costs of searching for information count as charges for communication? Does one count as communication the costs of distributing in- formation? Such questions are likely to occur to the budget officer. Meanwhile, it is possible only to speculate on the total amounts paid to finance publication of scientific reports in professional journals, or the total amount of conference expenses which are allocated to travel, to operations, and to publication of proceedings. About 214 percent of the PHS grant funds are spent on travel, but it is not known what part of this sum Te lates to travel to scientific meetings. Publica tion costs are on the order of $20-$50 a printed 4 page. Herner found a cost range of from 6. to 10.4 cents a word. Some journals chargé authors $50 a page. : On the basis of 15,000 papers a year resulting from NIH-supported research, it may be %* sumed that about $3 million was paid to put these into print. Out-of-pocket costs for ab tracts and fratislations may be nothing, if pe formed by the author, but when such services are paid they are on the order of $25 a Outlays by the Department of Health, Educ tion, and Welfare for 1964 (fiscal year) were estimated at $5,802,000 for publications; $125 199,000 for bibliographic and reference se ices; $4,842,000 for scientific meetings} an n item ~ In evaluatin; fig easy to reco I: tures, such as | “* which will prin 2 instead of 10 cc quality. In o } = judgments hing _ saving of 1 or £ ‘regular postag: ; pedite exchange and Palo Alto “2 worth $200,000 } = neously from cx | |, picture service? “up an automat “on tape and mici cation be serve viewer which w | “particular film ",,88 putting a nic] r viewer and worth $20 millic but authoritativ ciple that “t! § dimension a Medical services. 967,000 for research and development in ‘munications. EVALUATION In evaluating outlays for communications, it is easy to recommend money-saving expendi- ndispensable racks tures, such as purchase of a copying machine which will print reproductions for-1-cent a page 2 country that th instead of 10 cents a page, with no sacrifice of quality. In other circumstances, however, ed, rather than judgments hinge on uncertain values. Will the n system to maix@$- saving of 1 or 2 days justify airmail instead of tific criticism. If: regular postage? Is it worth $20,000 to ex- iderations are stilt ite exchange of messages between Bethesda and Palo Alto with a teletypewriter? Is it gorth $200,000 to send documents instanta- neously from coast to coast by a long-distance picture service? Is it worth $315 million to set up an automated system of science abstracts ontapeand microforms? Will continuing edu- cation be served by a desk-size sound movie viewer which will enable a physician to see a particular film (in cartridge form) as easily as putting a nickel in a slot, at a charge of $400 per viewer and $20 per film cartridge? Is it worth $20 million a year to broadcast popular but authoritative and accurate information on reducing heart disease? Cost studies of libraries indicate that it takes $l a year to pay simply for the storage of a book: The total outlay of university libraries in dollars is about equal to the number of volumes in their collection (65). It costs the library $2 to borrow a book and $2 to lend it out (29). The holding charge of a book, if compared to & 5-percent interest charge on capital, is equiv- alent to valuing the average book at $20. Is it Worth a dollar a year to maintain a $5 book in the stacks on the odd chance that it will be re- a once in 5 or 10 years? ab Such considerations force reliance on the os pee the ae that “the fundamental determinant of chen such servic ae mension and character of our effort in for of $25 an ites. one services and medical research is not and of Health, Edu®: Bon ‘ot be the arcane formula of cost-benefit eco- (fiscal year) weit me ba but the set of values around which publications; $12; tigo uild our great national purposes and the CE r and degree to which we pursue these na- nal intentions in the context of the needs and m com iment information’ rnment activities than a controlled eedom and flexi.3 cooperation and: § interchangeable”: nge of informa.” system, however, . ition. ‘S ly to speculate on’: ace publication of. onal journals, or xe expenses which . perations, and to About 214 percent. 2 spent on travel, rt of this sum Te. eetings. Publice’. $20-$50 a printed. § range of from 64 e journals charge rsa year resulting ‘ch, it may be a. 2 was paid to put. ind reference S&L. ¢ ific meetings; 9.8 COMMUNICATIONS 433 opportunities to improve the quality of life * * *” (66). In the words of the Right Hon. J. Enoch Powell, then Minister of Health for Great Britain, “the progress of medical science and the increase in outlay upon medical services must render this outlay more and more uneco- nomic. On many fronts the progress of medical science consists not in doing things more cheaply and simply than before but in discovering com- plex and difficult things to do which previously could not be done at all. On these fronts medi- cine is buying life at an ever-increasing margi- nal cost.” At the same time, the cost-benefit school can argue that there is a chance the one neglected volume may contain the one bit of information which will more than repay the years of cost ofits maintenance. Moreover, this cost is shared for the purposes of an entire information sys- tem: It is not a “loss leader” in a department store. CONSTRUCTION COSTS A core library of 100,000 volumes (67) at $45 a square foot would cost more than a million dol- lars to build (68). Althongh technological in- genuity may reduce this cost, the development of the technology will require considerable in- vestment. In the feasibility report on automation of the Library of Congress, the survey committee rec- ommended an appropriation of $750,000 to de- velop specifications for partial automation of the Library, with an investment estimated even- tually to reach from $50 to $70 million (52). An information center in a hospital would re- quire space for lectures, publishing activities, and broadcasting, as well as for search and reading. Broadcasting facilities alone would cost on the order of a million dollars for closed circuit television, including auditorium, stor- age, and studios at $30 a square foot, and equip- ment at $250,000. These facilities, the library and the broadcast- ing studio, are only two components of a center that could be operated to support continuing medical education. Other facilities would in- clude a film exchange and viewing room; a de- pot for reference slides, tapes, and radiographs; 434 REPORT TO THE PRESIDENT an audiovisual workshop; and demonstration laboratories. Considering that a medical school, with 64 students entering, needs a short-term general-special hospital of from 350 to 500 beds for teaching, there are enough hospitals of that size to accommodate twice the present number of medical schools. The total cost. of construction for a national biomedical communications system may be cal- culated by assuming a total of information fa- cilities based on 150 major medical centers, beginning with medical schools with teaching hospitals. Assuming that such a system would not have to be built entirely from the ground up, a 10-year capital outlay of $300 million, or $30 million a year, would at least approach ful- Aliment of the need. This sum stands in the perspective of annual outlays of more than $30 billion in the United States for health services, including more than $4 billion spent. by the Federal Government. OPERATING COSTS Library operations in a medical center with at least a core library would cost not less than $100,000 a year. Another $100,000 might. be spent on collecting documents. The costs of broadcasting are elastic, but they may be expected to run not less than $50,000 a year for closed-circuit television on an inter- mittent schedule. A unit composed of 144 half- hour programs in 36 weeks, $a week, costs about - $20,000 to produce, on an extremely modest scale. With an investment of $16,000 in tape, good for about 100 passes, or about $1.40 per half hour, the entire unit may be broadcast at a cost of $15 a half hour, including technician salaries, recording, and amortization, if the cost of the studio and equipment is allocated on the basis of 50 weeks a year, 40 hours a week (69). With a production budget of $140 for each half-hour program, it is obvious that Holly- wood standards would not prevail. If the ad- - vice of experienced producers is to be heedeck the investment. of time and talent in the orig- inal production could materially exceed the figure given, which is based on the full-time services of one teacher, half-time services of a producer/director, two camera men at $1.50 an hour, and only $2,500 for art and props. Reten- tion of master tapes would also increase Coste’ slightly. The figures given, therefore, woutg appear to be rock bottom. On the other hang, the present resources of medical films, once eva}. uated and carefully selected, can possibly pro. vide programs at. figures as low as those given Much interest is evinced in 8-millimeter films with sound to be exhibited simply by insert. ing a cartridge or cassette in a viewer ang ‘4 pressing a button. The viewer costs $485 at 2 present, with negligible maintenance and oper. ation charges. In volume production it may be# less, The cassette costs less than $3 and the : film may be printed at 6 cents a foot. There a fore, educational films at $15 each in the 8-milli- meter size are a practical possibility in such + cartridges. They may be used more than 10 times each for as many as 30 viewers at atime One may contemplate a catalogue of 10,000 basic | medical films, at a cost averaging $10,000 each, * b or $100 million for production, built up over. & a period of 10 years, for viewing at 1,000 sta- ; tions, costing in total $500,000 for equipment, | booking prints out of 100 distribution centers, -3: with a stock of film cassettes costing $150,000 at $15 a cassette. * The total costs of the information program in each center are likely to overshadow such - audiovisual services. Bloomquist (67) reported the busiest medical school library provid more than 10,000 hours of student assistance in : ayear. If to this workload one adds a program of continuing education for practitioners, alert -& for the public, even the medical school library ‘| d with the present maximum of 11 profession) employees would need more help. Considering that the medical school libraries at the median have only three professional employees and pay“ them a median salary of $6,000, the number of such professionals in the information scienc and their average salaries may be expected f double. - . The human charges for science information for the training and employment of teacher librarians, writers, editors, searchers, transl tors, indexers, and audiovisual teams may the most costly, as well as the most importals component of the biomedical information system. ing services for scientists, and health education -@ The review of biomedical communications of- . here is no more a true picture than a strob- epic photograph which arrests Niagara Falls It is impossible to capture the fluid and ‘yoman components of the informal biomedical - dem in motion. These pages are aimed at qutlining the information processes: The pro- - duction of information based on research and -gevelopment, on data and experiment, and the ‘methods of evaluating, categorizing, collecting, soring, searching, recalling, reviewing, packag- ing, distributing, and assimilating this informa- jon. : ° If there has been undue emphasis on libraries, on mass media, on automation, on language, on . research, or on user needs, the asymmetry was not intended. The process as a whole was the object in view. It is impossible to avoid, if only by implica- ¥ tion, a bias in favor of one kind of remedy or = snother. There are many proposals for improv- ing the system, from the grand design of the ; Crawford report to the basic plea of the Presi- (1) SHaun, Bex. The shape of content. Cambridge, wo fe Mass., Harvard University Press, 1960. p. 28. .@ # * (2) National Research Council. Committee on Mod- ern Methods of Handling Chemical Informa- tion. Survey of chemical notation systems, by ¥. Hunsberger and others. Washington, 1964. (NRC Publication No. 1150.) (3) Rocers, F. B. John Shaw Billings: 1838-1913. Library J. 88 : 2622-2624, 1963. (4) Bropsrax, ESTELLE. The development of medical bibliography. Baltimore, Medical Library As- sociation, 1954. {5) Sewer, Winirrep. Atherton Seidel: an appre- : clation (1878-1961). Amer. Doc. 13: 123-124. a 1962. , —l6)_The National Library of Medicine index meenat— 7 ization project. Bull. Med. Libr. Ass. 49 (1,_- = .2)::1-96, 19 (1) U.S, National Library of Medicine. The MED- LARS story at the National Library of Medi- ‘ Cine. Washington, 1963. aoe (8) Price, D. J. pe S. Little science, big science. New York, Columbia University Press, 1963. (9) U.S. National Library of Medicine. Annual re- port, 1963. Washington, 1964. COMMUNICATIONS 435 Conclusion dent's Science Advisory Committee to take in- formation seriously and to compose informative titles (27). Such small improvements are not separable from a grand design. The writing of a title has its impact on the structure of an index and the performance of a clearinghouse. Each con- sultation at an information center is dependent on such resources as MEDLARS and a film library. Opportunities for improving the handling of science information unfold from hour to hour (70). Given the backing of the medical com- munity and the taxpayer, science information services can provide scientists, practitioners, and the public with instruments of intelligence as productive in their way as the electron micro- graph, electrocardiograms, or radiotracers. In an age when a message travels around the world in a second, it is unthinkable that it should take months or even years for physicians and their patients to learn essential medical truths. Marcus RosENBLUM. References (10) GottscHacx, C. M. and Desmonp, W.F. World- wide census of scientific and technical serials. Amer. Doc. 14: 188-194, 1963. (11) Org. R. H. and others. Reference retrieval tools: biomedical abstracting and indexing services. Fed. Proc 23 (5, pt. 1) : 1165, 1964. (12) Sprine, W. C., Jr. and HonickeEr, F,, Jr. Drug information for the biomedical community. Bethesda, Md., Institute for Advancement of Medical Communication, 1963. (13) Orr, R. H. and Crouse, E. M. Secondary publi- cation in cardiovascular, endocrine, and psycho- pharmacologic research. Amer. Doc. 18: 97- 203, 1962. (14) US. Library of Congress. Science and Tech- nology Division. Guide to world’s abstracting and indexing service in science and technology. Washington, 1963. (National Federation of Science Abstracting and Indexing Services Re- port No. 102.) (15) Giester, R. H. and Yast, H.T. A survey of cur- rent hospital library resources. Hospitals 38: 53-54, June 16, 1964. (16) Committee on Hospital Library Architecture. Planning the hospital library. New York, United Hospital Fund of New York, 1957. ti i ’ a u fe ve eet SS ST (17) Joint Committee on Standards for Hospital Li- barles. Hospital libraries: objectives and standards. Chicago, American Library Asso- ciation, 1953. (18) Apams, Scorr. Hospital libraries: undeveloped base for continuing education. Hospitals 38: 52-53, June 16, 1964. (19) U.S. President’s Panel on Mental Retardation. A proposed program for national action to com- bat mental retardation. Washington, 1962. p. 19-20, 34-36. (20) Baz-Hritet, Yexosuva. Is information retriev- al approaching a crisis? Amer. Doe. 14: 95-98, 1963. (Also see: Letters to the Editor. Ibid., October 1963). (21) Orr, R. H. Trends in oral communication among biomedical scientists: meetings and travel. Fed. Proc, 28 (5, pt. 1), 1964. (22) Srepsox, G. 8, Scientific information centers in the United States. Amer. Doc, 18: 43-57, 1962. (28) Suittinc, C. W. Requirements for a scientific mission-oriented information center. Amer. Doc. 14: 49-53, 1963. (24) NeaL, Heten, ed. Better communications for better health, New York, National Health Council, 1962. (25) Weir, M. H. and others. Glossary of informa- tion handling. Washington, U.S. Department of Defense, 1964. (26) National Association of Science Writers. Pub- lic impact of science in the mass media by R. C. Davis and others. Ann Arbor, University of Michigan, Survey Research Center, 1958. (27) U.S. President’s Science Advisory Committee. Science, government, and information, by Al- vin Weinberg and others. Washington, 1963. (28) Mutter, J. G, Information input overload and psychopathology. Amer. J. Psychiat. 116: 695- 704, 1960. (29) U.S. National Libary of Medicine. Survey of the inter-library loan operation of the National Library of Medicine, by W. H. Kurth. Wash- ington, U.S. Public Health Service, 1962. (30) SHiuKin, M.S. The numerical method in thera- peutic medicine. Public Health Reports 79: 1-11, 1964. (31) RosexstuM, Marcus. The publication process seen as a biological phenomenon. AIBS Bull. 12: 21-23, December 1962. (32) Lusespen, L. L, St. Louis encephalitis in 1933—. observations on epidemiological features. Pub- lic Health Reports 78: 340-353, 1938. (33) Cocksury, T. A. Evolution and eradication of infectious diseases. Baltimore, Johns Hopkins Press, 1963. “os (34) Sicrnist, H. EB, Thoughts on the physicians’ writing and reading. Int. Rec. Med. 168: 609- 615, 1955. (35) Markus, Jony. State of the art of published indexes. Amer. Doc. 18: 15-30, 1962. 436 REPORT TO THE PRESIDENT (36) Hepner, Savt. Methods of organizing informs, tion for storage and searching. Amer. Dog 18: 8-14, 1962. (37) Mutter, J. G. Toward a general theory for th, behavioral sciences. Amer. Psychologist 19. 518-531, 1955. (38) Couen, M. R. A preface to logic. New York, Holt, 1944. (39) U.S. National Library of Medicine. Medical snp. ject headings. 2d ed. Washington, U.S. Publiy Health Service, 1963. (40) U.S. National Institutes of Health. Division o¢ Research Grants. Medical and health relateq sciences thesaurus. Washington, 1963. (PHS Publication No. 1031.) (41) International Conference on Scientific Informa. tion. Proceedings. Washington, National Academy of Science-National Research Coun. cil, 1959. t (42) Apatr, W. C. Citation indexes for scientific literature. Amer. Doc. 6: 31-82, 1955. (43) Garrierp, E. and Suer, J. New factors fn the evaluation of scientific literature through cita- tion indexing. Amer. Doc. 14: 195-201, 1963 (44) Necratu, Otro and others, eds. International encyclopedia of unified science. Chicago, Uni- versity of Chicago Press, 1938. (45) GaRFrIeLp, EUGENE. A unified index to science. In: International Conference on Scientific In- formation. Proceedings. Washington, Nation- al Academy of Sciences-National Research Council, 1959. p. 461-469. (46) Perez, Vierorta, A. Document UNESCO/NS/ 177-A. Code of good practice for scientific pub- Heations, Amer. Doc. 14: 241-245., 1963. (47) U.S. National Heart Institute. A handbook of 3 heart terms. Bethesda, Md., 1964. (PHS Pub lication No. 1073.) 4 (48) Frater, P. C. and others. Third Annual report | Leonia, N.J., Council for the ‘Advancement of . Science Writing. 1962. (49) Handbook for press rooms at scie Port Washington, New York, Nation tion of Science Writers, 1962. (50) Conference of Biological Editors. for biological journals. 2d ed. American Institute of Biological Sciences, (51) U.S. National Science Foundation. Office of 5: entific Information Service. Federal policy the standardization of microforms for Gover ment research and development documen™ Washington, 1963. ie (52) Krxe, G. W. and others. Automation an brary of Congress. Washington, Li Congress, 1964. ; (53) Apants, Scott, MEDLARS and the library oor munity. Symposium, Apr. 5, 1963, Nation?” brary of Medicine, Bethesda, Ma, 1964 nice (54) Terry, L. L. The crisis in health commu tions. Hospitals 38: 49-51, June 16, “: nrific meetings a] Associa Style manual s Washingtom .2 1962 nd the ue prary of bg Info; peBaxey, M. E. and others. The film and medi- Ame ore cal communication. Atlanta, Ga., U.S, Com- municable Disease Center (undated). cory for U.S. Department of Health, Education, and Wel- aologist fare. Program plans for science information, 1963-65. Washington, 1963. 'S. National Institutes of Health. Dtviston of Research Grants. A guide to the Public Health Service grants and awards. Washington, 1964. (PHS Publication No. 1067) cuveIeER, J. H. Survey of projects related to the published literature, supported by grants and contracts from the Public Health Service. Bethesda, Md., National Library of Medicine, 1964. (59) SHIBEE, Writus. Rise and fall of the Third Reich. New York. Simon and Schuster, 1960. 60) U.S. Public Health Service. Office of the Surgeon “gn 58) 5 General. Conference on health communica- or sete tions. Held, Nov. 5-8, 1962. Washington, 1955. 1963. . setors in ($1) U.8.Government Organization Manual, 1963-64. through ° Washington, Office of the Federal Register, 1064. {62) U.S. Federal Council for Science and Technology. Committee on Scientific Information. Scien- tific and technical communication in the Gov- Internation Yhicago, Uk: 763-310 0-65-29 COMMUNICATIONS (63) (64) (65) (66) (67) (68) (69) (70) 437 ernment, by James Crawford, Jr., and others. Washington, 1962. American Institute of Biological Sciences. In- formation handling and science, ed. by P. C. Janaske. Washington, 1962. U.S. Congress. Senate. Interagency coordina- tion of information hearings. 87th Congress. 2a Session. Sept. 1, 1962. Washington, 1963. p. 21. U.S. Office of Education. Library statistics of colleges and universities, 1959-60. Part 2. Washington, 1963. Murtaugh, J. S. Long-range planning for an analysis of medical research and training needs. U.S. Public Health Service. Washington, 1964. Broomevist, HaRotp. The status and needs of medical school libraries in the United States. J. Med. Educ. 38: 145-163, 1968. U.S. Publie Health Service. Medical education facilities. Washington. 1964. (PHS Publica- tion No. 1180-A-Ib. ) RCA-ETC Information Bulletin, No. 1~K-1. Camden, N.J., Radio Corp., of America (un- dated) U.S. Congress. House. Select Committee on Gov- ernment Research. Study 1V. Documentation and dissemination of research and development results. Washington, 1964.