I . am I B&B lt4PoRmikriom & IMAGE Mkm^=EMENT 300 @emoc D=Itucon wou@ Ulafmcot MA$ILSORMI P44^w@edo Z077Z 0 USA 0 (201) 24@l 10 D E P A R T M E N T 0 F H E A L T Hi E D U C A T I 0 N A N D W E L F A R E PUBLIC HEALTH SERVICE National Institutes of Health Division of Regional Medical Programs National Advisory Council an Regional Medical Programs Minutes of Meeting ,august 12-13, 1966 National Institutes of Health Conference Room "All Stone House DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Minutes of Fifth Meeting 1/ 2/ August 12-13, 1966 The National Advisory Council an Regional Medical Programs convened for its fifth meeting at 9:00 a.m., Friday, August 12, 1966, in Conference Room "A", Stone House, National Institute# of Health, Bethesda, Maryland. Dr. Robert Q. Marston, Associate Director, NIH, and Chief, Division of Regional Medical Programs, presided. The Council mmbers present were: Dr. Leonidas H. Berry Dr. J. Willis Hurst Dr.'Kary 1. Bunting Dr. Clark H. Millikan Dr. Michael E. DeBakey Dr. George E. Moore Dr. Bruce W. Everist Dr. William J. Peeples Dr. James T. Howell Dr. Robert J. Slater Public Health Service members attending some o.f the sessions included: Dr. William H. Stewart, Surgeon General, PHS Dr. James Shannon, Director, NIH Dr. Stuart Sessoms, Deputy Director, NIR I*. Bert Cole, OSG Liaison members: Dr. Sidney Farber, NCI Council Dr. A. B. Baker, NINDB Council (absent) Dr. Edward W. Dempsey, NIGHS Council'(absent) Dr. John B. Hickam, NRI Council (absent) 1/ Proceedings of meetings are restricted unless cleared by the Office of the Surgeon General, The restriction relates to all material submitted for discussion at the meetings, the agenda for the meetings, the supplemental materials, and all other official documents. For the record, it is noted that members absent themselves from the meeting when the Council is discussing applications: (a) from their respective institutions or (b) in which a conflict of interest might occur. This procedure does not, of course, apply to en bloc actions--only when the application is under individual discussion. -2- Others present were: Mr. Karl D. Yordy, Assistant Chief, DRMP Mr. Stephen Ackerman, Chief, Planning & Evaluation Branch, DRHP Mr. Jams A. Beattie, Chief, Grants Management Branch, DRMP Dr. Carl Brewer, Chief, Grants Review Branch, DRMP Dr. Margaret Sloan, Chief, Program Development & Assistance Branch, DRMP Mr. Edward Friedlander, Special Assistant for Communications and Public information, DRt4P Mr. Maurice Odoroff, Assistant to Chief for Systems and Statistics, DRMIP. RMP Mr. Storm Whaley, Associate Chief for Organizational Liaison, D Mr. Charles Hilsenroth, Executive Officer, DRMP Dr. William Mayer, Special Assistant to Director, DRMP Dr. Kenneth Endicott, Director, NCI Dr. Robert Grant, Director, NHI Dr. Clarence A. Imboden, BSS Dr. W. D. David, BSS Dr. Benjamin Wells, VA Mr. Ralph Mueller, BOB Dr. R. L. Ringler, NHI Dr. Jerome H. Green, NHI Dr. G. Howard Gowan, NCI Miss Pauline Stephan, NCI Dr. J. H., U. Brown, NIGHS Dr. 0. Malcolm Ray, KINDB Mr. Thomas McCarthy, DRG Mr. Frank Ehrlick, OD Mr. Bruce Carson, OD Miss Jane Fullerton, OD Mr. James Gregg, OD Miss Cecelia Conrath, DRMP Mr. Robert Anderson, DRMP Dr. James Mc A'Nulty, DRIIP Miss Leah Resnick, DRMP Mr. Daniel Zwick, DRMP Mr. 'Larry Coffin, DRMP Mrs. Mary Geisbert, DRMP Dr. Harry Roberts, DRMP Mrs. Jessie Salazar, DRMP Mr. Ira Alpert, DRMP Dr. John Hamilton, DRMP Dr. John Hazen, DRMP Dr. Robert O'Bryan, DRMP Miss Charlotte Turner, DRMP Mr. Harold 0"Flaherty, DRMP Mr. Art Hiatt, DRMP Mr. Stuart Yaffe, DRMP -3- I. CALL TO ORDER AND OPENING Dr. Marston called the meeting to order at 9:10 a.m. II. REGIONAL MEDICAL PROGRAMS PROGRESS AND PROSPECTS--Dr. Marston During this meeting we wish to direct attention to matters of policy and to seek assistance in the areas of the broad implications of the program. An evidence of the progress of the Regional Medical Programs is that there have been established throughout the nation groups representing the major health resources. These regional advisory groups have been meeting and discussing the health needs of their regions. Thus, we have now for the first time a national communication framework for regional medical programs. We will be utilizing this framework with less concern now than we did previously when we were concerned about the possibility of too much direction of the planning from the Federal level. In the future we will be able to obtain information in a way thatwas not possible prior to the local identification of the appropriate organization to approach in seeking such information. Mr. Edward Friedlander will soon be on our staff as Assistttnt to Chief, DIRMP (Communications & Public Information). He has already begun planning ways in which he can work in terms of communication with the existing or planned Regional Medical Programs. We are scheduled to give major speeches to several National organizations within the next few months. Our staff in the Development and Assistance Branch is making visits to all approved regions every 90 days. Some of the early grantees are even now scheduled to have a second visit. Within the Government, we have expanded the distribution of our progress reports to the Surgeon General and are meeting with those agencies directly involved in interests related to research and development (R&D). A summary article has been submitted to "PHS Reports" for broad distribution. Another item that we discussed at the last Council meeting is, "Continuing Education". Dr. Mayer is currently expanding his program markedly, and he will discuss this further during the meeting. Dr. Shannon presented his views regarding the Division of Regional Medical Programs. He stated that this is a very complex program, and needs flexibility in the mechanism by which objectives are attained, -4 because there are ro guidelines that we have conventionally used in the application of this program in its relation to others. This program is the direct outgrowth of the President's Commission on Heart, Cancer, and Stroke, the entire thrust of which is to provide a scientific base for the practice of medicine. This is complex also because one has to move the scientific base out of the university, university hospital, and actually into centers of activity that perhaps are beat characterized as the, ficommunity hospital." This type of hospital might have a budget of around $200,000, and a flow of patients of sufficient magnitude that a whole variety of highly specialized services can be built in. We have to develop mechanisms for translation of both fundamental and applied knowledge from the point of origin to the point of use, and to recast the role of the scientist into two functions, the first of which is to develop new knowledge, and the second is to make it applicable, not as an individual, but as a scientific body. The scientist has to participate in some sort of core program upon which peripheral excellence can develop. This is the realistic program of continuing education. This program can only be in a community hospital, and will involve the base'of a good deal of the continuing education process. In order to have a good system of continuing education we have to modify the process of education at the medical school, since the present educational process prepares the person for specialty training in the university hospital, but riot for the task of a continuously learning process throughout his entire career. To have excellent medicine in this Nation, it is necessary to have a public education program which would begin in gra@r school and carried through all levels of our educational process. This will not be the concern of the Regional Medical Programs, but one of the new Bureaus of the Public Health Service. The logistical problem of developing a framework for the transference of knowledge and making it easily accessible to the physicians at large constitutes the primary problem about which this Council is to be concerned. Thus, this casts the community hospital in a completely different role than ever before. In this program, we are aiming at excellence in a profession that, if too far separated from the source of new knowledge, becomes mediocre and obsolete. It is in this light that one should approach the problem, One of the difficult areas in this program will be that of the big city with all of its'scientific excellence and the tendency of institutions to isolate themselves from the social problems in the geographic area within which they reside. 111. DISCUSSION OF "SURGEON GENERAL'S REPORT TO CONGRESS"--Mr. Ackerman P. L. 89-239, Section 908, states that, "On or before June 30, 1967., the Surgeon General, after consultation with the Council, shall submit to the Secretary for transmission to the President and then to the Congress, a report of the activities under this title together with (1) a'stateme'nt of the relationship between Feder@l financing and financing from other sources of the activities undertaken pursuant to this title, (2), an appraisal of the activities assisted under this title in the light of their effectiveness in carrying out the purposes of this title, and (3) recommendations with respect to extension or modification of this title in the light thereof." The following are certain things that raise questions to which the Council must address itself: a) To what extent is the lack of construction authority an inhibition in achieving the fundamental purpose? b) How should the funding policy under the Division of Regional Medical Programs be delineated, i.e., what things should be funded under this program in relationship to other program authorizations? These are difficult questions which relate very directly to the policy In regard to the determination of Federal support with relationship to other supports. c) What is to be the Federal role? Regarding the timetable for this report, we have set a rough timetable that we would complete our work proiram within a matter of weeks, that the ad hoc advisory group would meet in mid-September; we would have a progress report at the November Council meeting; that we would expect to have a first draft at the end of November. A National Conference with the people involved in this program is contemplated for January. Another progress report will be made at the February Council meeting, and we expect to have a final draft in March. The intramural review resources will be used with regard to the evolution of the report. It is contemplated that Council review of the final draft would be at the May Council meeting. We hope to have the report ready by May 30. Dr. Stewart said that normally, in legislation which expires in the second session of the Congress, we would introduce the legislation in the first session. Sincelwe have this report which is perhaps halfway through the first session, he has not decided at what point legislation would be introduced in the next Congress. It seems rather cumbersome to introduce it before the report is made. It would get no consideration -6- before the report is made. Because of this, we must have, by the end of November, estimates of certain sizes and shapes as to what this might be in order to include it in the President's legislative package even though it may go up later. So this first draft in November probable will be far enough along and show us where the gaps are to give us this kind of guideline. The policy and determination of Federal support and the clarification of relationships of the Regional Medical Programn to other Federal programs in the construction area and every other area will be the most sensitive issues. IV. ANNOUNCEMENTS Dr. Marston made general announcements about the Service Desk and luncheon arrangements. Also, he read the statement on, t'Confidenti- ality of Meetings." He followed up on the discussion at the last Council meeting concerning, "Conflict of Interest" about (a) how long after one has an active attachment with an institution is he considered a representative of that institution; and (b) what are the potential conflicts of interest where there is borderline of overlap of regional programs. Regarding item (a), there is no legislative restraint as far as consultants and council members are concerned. If either-of these kinds of members are involved in the actual writing or development of an application, then he should leave the room during the discussion of that application. With regard to item (b), members who happen to be in an adjacent State where there is not a direct and obvious involvement in the development of the application would not absent themselves from the discussions. These items have been discussed with the General Counsel who concurs with the above. V. CONSIDERATION OF FT3TURE HEETING DATES The Council approved the following dates for future meetings; November 27, 1966 (8:00 p.m.) November 28-29, 1966 (9:00 a.m.) February 19,_1967 (8:00 p.m.) February 20-21, 1967 (9:00 a.m.) May 22-23, 1967 VI. CONSIDERATION OF MINUTES OF JUNE 1966 MEETING The Council unanimously recommended approval of the Minutes of the June 20-21, 1966, meeting as written. -7- VII. COMMENTS FROM LIAISON MEMBERS Dr. Farber had no comments to make for the National Advisory Cancer Council. Dr. Marston extended appreciation to Dr. Farber, who will be retiring from the Cancer Council on September 30. His replacement as a liaison representative to this Council will be: Dr. Murray M. Copeland Associate Director (Education) M. D.' Anderson Hospital and Tumor Institute Texas Medical Center Houston, Texas VIIT. REPORT ON ALL APPLICATIONS WHICH WERE CONSIDERED AT JUNE COUNCIL MEETING Application No. 1-SO2-RM-00019-01, California Coordination Agency for Training, Research, Education and Demonstratton in the Field of Heart Disease, Cancer, Stroke, and Related Diseases; Dr. Nemat 0. Borhani, Program Coordinator At the meeting on June 20-21, 1966, the Council recommended that .this application be deferred pending (1) a project site visit with members of the Council and the Division staff to explore in greater depth the relationship of the proposed planning activities to other planning activities 'already ongoing within the State on the regional level, and (2) clarification of the legality of support of this application under the provisions of Title IX of the Public Health Service Act., and exploration of possible alternative means of supporting this type of planning and coordinating activity if the importance and nature of this function is established. As recommended by the Council,. a project site visit was made to Berkeley, California. This application was revised, and upon consideration of the additional information, the Council unanimously recommends approval with the -deferral of the subcontract portion of the application of $2,500,000. The applicant anticipates requesting supplemental support for the-subcontract portion at a future date. These supplements will be reviewed by the California Coordinating Committee and also receive the dual review by our Review Committee and Council. The amounts requested were: $2,723,400, $2,709,970, and $2,716,968. The Council recommends that the following direct costs be awarded: $223,400 first year; $209,970 second year; and @216,968 third year, plus appropriate indirect costs. Application No. I-SO2-RM-00016-01, Health Research, Inc.,, on behalf of the New York State Department of Health; Dr. Hollis S. Ingraham, Program Coordinator In accordance with the Council's recommendation at the June meeting, a project site visit was made by some Council and staff members to Albany, New York. However, the additional information-which is needed prior to further action by the Council has not beer. received, and the Council, therefore,, again recommends deferral. Application No. I-SO2-RM-00012-01, Planning Committee on Oregon Regional Medical_Programs, Portland, Oregon; Mr. Roscoe K. Miller Program Coordinator Application No. 1-SO2-RM-00014-01, Boston University, Boston, Massachusetts; Dr. Thomas R. Dawber, Program Coordinator Application No. 1-SO2-RM-00021-01, Minnesota State Medical Foundation, St. Paul, Minnesota; Dr. J. Minott Stickney, Pro?,ram Coordinator Application No. 1-SO2-RM-00022-01, Ohio State University' College of Medici4e, Columbus, Ohio; Dr. Ricbard L. Meiling, Program Coordinator The Council reaffirmed its recommendations for deferral of the four applications listed above, pending receipt of further information from the applicants. T-X. CONSIDERATION OF APPLICATIONS- The Council made the following recommendations on each application, and suggested that the staff of the Division of Regional Medical Programs meet with each applicant-ohose application has been recommended for approval or deferral prior to making an award to clarify any questions raised by the Council: Application No. 1-SO2-RM-00023-01, University of Oklahoma Medical Center, Oklahoma City, Oklahoma; Dr. Ben I._Heller, Program Coordinator The Council recommends approval in the amounts and time requested of $143,250 and $137,168, plus Appropriate indirect costs. Application No. 1-SO2-RM-00024-01, The Florida_Advisory Council on Heart Disease, Cancer, and Stroke, Inc.; Dr. Richard P. Schmidt,, Acting ogram Coordinator The Council recommends that the application be disapproved because of the necessity to delete the major systems analysis support, the Program Coordinator is serving in an acting capacity and other staff members are yet to be named, and the planning arrangements and tasks are poorly defined. Application No. 1-SO2-RM-00025-01, University of Rochester, School of Medicine @ Dentistry, Rochester, N.Y@. Dr. Ralph C. Parker, Jr., ProgEam Coordinator. The Council recommends approval in the amounts and time requested of $299,394, $329,364, and $343,867, plus appropriate indirect costs. ApRlicatiou No. 1-SO2-RM-00026-01, TJniversity City Science Center, Philadelphia, Pennsylvania; Dr. William C. Spring, Program Coord@*,or The Council recommends that this application be returned for revision because it contains too many operational-components, the 20 members of the advisory group did not appear to have functioned extensively in the planning to date, there has been no appointment of hospital administrators for the program for planning, and the public officials of UCSC have not entered the planning phase in any evident way in a protocol. Application No. I-SO2-RM-00027-01, University of Iowa, Iowa Ci@ Iowa; Dr. Robert C. Hardin, Program Coordinator The Council recommends that this be deferred for staff consultation for clarification on the responsibilities ard organization of the liaison group, the lack of more representatives of the consumer public of some of the other hospitals in the State and practicing physicians. After this information is obtained, a mail ballot should be made of the Council for a final recommendation. Application No. 1-SO2-RM-00028-Ol.-University of Alabama Medical Center, Birmingham, Alabama; Dr. Joseph F. Volker, Program Coordinator The Council recomends that the application be returned for revision. The concerns of the Council should be transmitted to the applicant regarding: strengthening the advisory c7 -ittee, elimination of certain of the operational components of the program,, clarification of the specifics of planning and phasing@to justify the budget timing, and a more effective definition of community regional planning to include a broader involvement of the population. Application No. 1-902-RM-00029-01, State Universit-y of New York Downstate Medical Center, Brooklyn, N. Y.; lir. Robert A. Moore, Program Coordinator The Council recommends approval after assurance, through staff contact, that the award of the grant would not impede the development of cooperative arrangements elsewhere in the New York metropolitan area. The amounts requested were: $137,980, $134,277, and $133,557, plus appropriate indirect costs. lo- Ap,plication7No. I-SO2-RM-00030-01-University of California at Los Angeles; Dr. Donald-Brayton, PrRgram Coordinator Administratively withdrawn. @plication No. 1-SO2-RM-00031-01, Medical Society.of the District of Columbia, Washington, DO_C.; Program Coordinator to-be named The Council recommends approval after the staff meets with the applicant to discuss the problems raised concerning: (a) the vagueness of the application; (b) the reason for the lack of a representative of the consumer public on the Advisory Group; (c) the fact that the coordinator was not named; (d) clarification of the role of the @ical schools; (e) involvement of the community hospitals; and (f) to seek clarification on the planning activities relevant to adjacent areas of Maryland and VirgiAia. The amounts requested were: $188,708,, $169,658, and $169,658, plus appropriate indirect costs. Dr. Peeples abstained from voting. Application No. I-SO2-RM-00032-0@ Western Interstate Commission for Higher Educatioa, Bouldikr. Colorado; Dr. Kevin P. Bunnell, Program Coordinator The Council recommends approval in the amounts and tixw requested of $774,038 and $761,983, plus appropriate indirect costs. - ApRlication No. 1-SO2-RM-00033-0l,'Louisiana State Department of Hospitals, Baton_Rouge, Louisiana; Mr. E. Lee_Agerton, Acting Program Coordinator The Council recommends that this application be returned for revision. It was the opinion of the Council that that application as submitted was more in the nature of a pre-planning rather than a planning proposal. It would appear that the applicant has assembled numerous opinions about what might go Into a planning grant application, but that they now need to assemble these opinions and put them in some form which can be identified and clearly assessed by the reviewers. 1/ Dr. Everist absented himself. Application No. 1-SO2-RM-00634-01, The University of New Mexico, Alburgiiergue, New Mexico; Dr. Reginald-_H. Fitz, Prdgram Coordinator The Council recomends approval with staff contact to assure compliance with conditions. The amounts requested were: $508,400, and $729,285, plus appropriate indirect costs. I/ Dr. Moore opposed. A22lication No. I-SO2-RM-00035-01, Medical College of South Carolina, Charleston, South Carolina; Dr. Charles P. Summerall, TIT, Proaam Coordinatc:,r I The Council recommends that this application be returned for revision with the suggestion that: (a).they start with three or four larger regions and subdivide them later rather than divide the State into nine regiona; (b) they should be encouraged to seek the services of a full-time coordinator; (c) there is no indication of adequate representation in the Negro population and; (d) there is no evidence of involve=nt of the other educational institutions in the State. Dr. Moore abstained from voting. ARplication No. I-SO2-RM-00036-01, Coordinating Committee of Medical Schools and Teaching Hos2itals of Illinois, Chicago, Illinois; Dr. Leon 0. Jacobson, Program Coordinator The Council recommends that this application be disapproved because there was no real description of the advisory group, their-methods of procedure.. the local problems to be faced, or the positions to be filled. There seemed to be total involvement of the medical schools =W their related teaching hospitals.. and practically no involvement of c nity medical facilities. Dr. Barry absented himself during this discussion. Application No. 1-SO2-RM-00037-01, Wisconsin Regional Medical Ogram, Inc., Milwaukee, Wisconsin,, Dr. John S. Hiro'chboeck Pr6gaam @inator The Council recomends approval with staff contact to assure co."Iiance with conditions. The amounts requested were: $319,458 and $341,000, plus appropriate indirect costs. Application No. I-SO2-RM-00038-01, University of Washinitton, Seattle, Washi@,qton; Dr. Donal R. Sparkman, Program Coordinator The Council recommends approval in the amounts and time requested of $213,998, @230,934, and $241,795, p lus appropriate indirect costs. ApElication No. I-SO2-IU4-0 0039-01, New York Medical College,- Dr. Harold S. Cole, Program Coordinator Administratively withdrawn. ITEM OF POSSTBLE CONCERN Salary Scales on Applications Dr. Robert M. O'Bryan, of the Development and Assistance Bran(*, Division of Regional Medical Programs, presented a report an this subject. Copies of the -12- report were distributed to the Council, and there was a general discussion. However, no firm policy decisions were reached. EDUCOM (Inter-University Communications Council) Dr. William D. Mayer, Associate Director (Continuing Education), Division of Regional Medical Programs,,reported on activities in this area. The EDUCOM meeting,was held in July to discuss various kinds of activities that- are going on in the country in terms of handling science information. The EDUCOM staff, working with others from the outside, expect to submit a proposal to a Government agency, presumably the Department of Health, Education, and Welfare, (DHEW), to set up a prototype in an area. The question is yet to be evolved of how broad an area they will be involved in to begin a network of commmications between universities. Because of this, some of our staff has attended a meeting with DHEW staff to discuss this issue. It appeared that DHEW is Interested in pursuing this concept further with'EDUCOt4., and that the Office of Education will become involved in the program. Status of Contracts to study, "Systems Analysis" Mr. Maurice Odoroff, Assistant to Chief, DRMP (Systems and Statistics), reported that we are exploring the possibility of getting competent help in the area of "Systems Analysis." One of the things we would be interested in is that such a person should have the ability to train a staff and to give technical adviee concerning iufluences of technological advances on further capabilities in terms of this program. Problems of making grants to newly created, non-profit corporations for the purpose of Regional Medical Programs Mr. James A. Beattie, Chief, Grants Management Branch, DRMP, discussed this topic. Section 903 of the Public Law permits the Surgeon General to make the grants to non-profit, private agencies and institutions. Of the .applications which have been considered by this Council to date, 12 have been from private, non-profit corporations. Since these corporations are not large, established organizations, there is a certain financial risk involved in making awards to them. One possible way to eliminating this risk is to require that the nonprofit agency provide a surety bond, which guarantees compliance with written- agreements. Many other problems arise with these types of situations, at which time the advice of the General Counsel is sought. It was suggested that we should attempt to develop a reasonable set of articles 6f incorporation, by-laws, standards for fiscal accountability, etc. With regard to bonding, perhaps the Federal Government might be its own insurance carrier. -13- XII. ADJOURNMENT The meeting was adjourned at 12:40 p.m., August 13, 1966. I hereby certify that, to the best of my knowledge, the foregoing minutes and attachments are accurate and complete. Robert Q. Marston, M.D. Associate Director, NIH, and Chief, Division of Regional Medical Programs Eva M. Handal, Recording Secretary Council Assistant, DREP REGIONAL MEDICAL PROGRAMS COUNCIL MMERS 10/21/66 Dr. Leonidas R. Berry Dr. John Willis Hurst Professor 9 Cook County Graduate Professor and Chairman School of Medicine, and Department of Medicine Senior Attending Physician Emory University School Michael Reese Hospital of Medicine 412 E. 47th Street Atlanta, Georgia -30303 Chicago, Illinois 60653 Dr. Clark H. Millikan Dr. Mary I. Bunting Consultant in Neurology President, Mayo Clinic Radcliffe College Rochester, Minnesota 55902 Cambridge, Massachusetts 02138 Dr. George E. Moore Mr. Gordon R. Cumming Director Administrator, Roswell Park Memorial Institute Sacramento County Hospital 666 Elm Street 2315 Stockton Boulevard Buffalo 3, New York 14203 Sacramento, California 95817 Dr. William J. Peeples Dr. Michael E. DeBakey C-r,,tlissioner of Health Professor and Chairman State Department of Health Department of Surgery State Office Building College of Medicine 301 West Preston Street Baylor University Baltimore, Maryland 21201 Houston, Texas 77025 Dr. Robert J. Slater Dr. Bruce W. Everist Dean, College of Medicine Green Clinic University of Vermont 709 South Vienna Street Burlington, Vermont 05401 Ruston, Louisiana 71270 Dr. Cornelius H. Traeger Dr. James T. Howell 799 Park Avenue Executive Director New York, New York 10021 Henry Ford Hospital Detroit, Michigan 48202 Ex Officio Member Dr. William H. Stewart (Chairman) Surgeon General Public Health Service Bethesda, Maryland 20014