Mr. Chairman, and members of the Subcommittee, my name is Barbara Iglewski and I am a Past President of the American Society for Microbiology (ASM). My testimony today on the Fiscal Year 2000 appropriation for the National Institutes of Health (NIH) is presented on behalf of the American Society for Microbiology, the largest single life science society in the world with more than 42,000 members. The ASM appreciates the opportunity to provide the following comments and recommendations on funding for the NIH.
National Institutes of Health
First, I would like to thank the Chairman and members of this Subcommittee for their strong support of the NIH. Your financial investment in biomedical research in the past has resulted in successes against many diseases. Your continued generous support will translate into even greater public health advances in the future. With increasing emphasis on interdisciplinary approaches to medicine, we are poised on impressive technical advances incorporating molecular biology and computer technology. As a result, in the next century the nation will benefit from the economic prosperity stimulated by new technologies and related industries.
It also will save considerable health care costs through more effective prevention. As an example of the wide-ranging effects of a scientific success, last fall the Food and Drug Administration approved a vaccine to protect young children against rotavirus infections. Rotavirus, which was not identified until the early 1970s, is the principal cause of life-threatening diarrhea in infants worldwide. Here in the United States each year, the virus is responsible for an estimated 50,000 hospitalizations and 500,000 physician visits, at a cost of over $1 billion. Vaccinations against rotavirus will lead to considerable savings in our health care system. Such successes are gratifying, but there are too many reasons we must not become complacent in the face of infectious disease.
The ASM concurs with Congressional leaders that the United States is not spending enough on scientific research. It is particularly disappointed in the 2 percent increase in NIH funding proposed in the Administration's FY 2000 budget request. Not only will this small increase fall far short of meeting the perpetual need for new medical research, it does not even counterbalance the medical inflation rate of 3.5 percent and thus will undermine current research of proven importance. Such serious financial shortcomings would unquestionably have negative effects on both this nation's public health and its scientific leadership worldwide.
Therefore, the ASM supports the recommendation of the Ad Hoc Group for Medical Research, which calls for an FY 2000 appropriation of $18 billion for the NIH. A 15 percent increase over FY 1999, the proposed level would represent the second step towards the bipartisan goal of doubling the NIH budget by FY 2003. Long range-indeed, visionary-strategies for strong, sustained research investment into the next century are critical to both U.S. and world-wide health and well-being.
The Benefit of Medical Research
We are surrounded by the very real benefits of our traditionally strong federal commitment to medical research, successes which remind us of the importance of the NIH as the world's preeminent medical research enterprise. At present, only 3 percent. of all money spent on health care in this country supports biomedical research, yet each year, through the dedication of scientists and clinicians and the judicious use of research funding, this nation achieves new victories against threats to our public health. For example, the age-adjusted death rate from HIV infection in the United States dropped an estimated 47 percent from 1996 to 1997, in large part due to new therapeutics arising from basic medical research. As another example, with funding from the NIH's National Institute of Allergy and Infectious Diseases (NIAID), during FY 1996, scientists described the entire genetic sequence of the microorganisms that cause the sexually transmitted diseases syphilis and chlamydia. This "genetic medicine" facilitates the discovery of potent antibiotics against some of our most worrisome infectious diseases. Another recent success is the identification of the protein which makes the malaria microorganism resistant to the drug normally used against this elusive, global killer.
The Challenge for Medical Research and Global Health Issues
Despite such positive news, there remain too many disturbing challenges to the health of an aging and increasingly diverse American population, as well as to health throughout the world. With a society that is more and more global, there are fewer barriers to the spread of disease, as humans move easily from region to region. The NIH works broadly across scientific disciplines to counter these challenges.
Diseases due to microorganisms cost this nation more than $120 billion each year; that is one of every six health care dollars spent. Worldwide, infectious diseases remain the leading cause of death and they are the third leading cause of death in the United States. However, loss of life is not the only cost of infection. Foodborne illnesses, some of which were unrecognized 20 years ago, are estimated to cause up to 33 million cases and to cost an estimated $22 billion a year. On each and any day, news reports recount the human cost of infectious disease, whether an outbreak of food poisoning in a day care center or the recently released evidence that microorganisms may play a significant role in heart disease.
The problems associated with infectious diseases cover the medical, social, and geographic spectrum. At present the ASM is particularly alarmed over several areas of both national and global importance: new and reemerging infectious diseases, antibiotic resistance in pathogenic microorganisms, bioterrorism, and infectious causes of chronic inflammatory diseases and cancer. Overcoming each of these serious threats to public health has been and will remain part of the NIH mission, especially of the National Institute of Allergy and Infectious Diseases. But fluctuating and insufficient funding like that proposed in the FY 2000 budget will severely impede progress in these crucial areas, all of which rely on long-term research and an accumulation of scientific knowledge over time.
Bioterrorism is not simply an apocalyptic literary device used by science fiction writers as Congress has demonstrated in numerous hearings, particularly those focusing on the nation's public health infrastructure against epidemics and bioterrorism. Testimony provided by the ASM has given voice to the alarm felt by scientists and by political leaders over the chilling possibilities of any intentional release of microbial pathogens to harm humans, animals, or plants. National security measures against biological warfare must include control measures that are already under consideration by the NIH, that is, development of new vaccines, therapeutics, and diagnostic techniques for pathogens, in advance of an emergency need. The ASM has created its Task Force on Biological Weapons Defense to advise policy makers, and it appreciates the President's and the Congress' support of increased funding in this area. However, the immense complexity within both the microbial world and the scientific knowledge needed to overcome that world absolutely requires broadly based biomedical research that is not undercut by erratic appropriations or the redirection of resources from essential primary missions. Included in the NIH/NIAID's Bioterrorism Research Plan, which would complement the CDC's role of surveillance and investigation of disease outbreaks, is basic research on the mechanisms of pathogen replication and on the pathogenesis of related diseases. Such basic research cannot progress unless financially supported in a consistent and sufficient manner. The bioterrorism research plan will require the allocation of new resources for research, staffing and research infrastructure of about $30 million in FY 2000.
The Threat of Emerging Diseases
During his appearance at the National Academy of Sciences, President Clinton correctly stated that "cutting-edge [scientific research] efforts will address not only the threat of weapons of mass destruction, but also the equally serious danger of emerging infectious diseases." Some infectious diseases such as smallpox have been conquered by modern advances and indeed, during the first eight decades of this century, the infectious disease mortality rate in the United States declined significantly. But the emergence of new human pathogens such as hantavirus and the reemergence of those thought to be under control, such as the tuberculosis bacterium, remind us of the unpredictability of infectious diseases. Scientists have identified about 30 new human pathogens since 1976, and we fully expect these grim discoveries to continue.
The growing list of new and new-again pathogens causing public health problems includes those that very recently attracted a great deal of public and media attention, such as the hepatitis virus as a major reason for liver transplants and the pathogenic E. coli responsible for fast-food-related outbreaks of foodborne disease. More familiar are tuberculosis and HIV/AIDS as two new or reemergent infectious diseases that at present account for significant health care expenditures. Already, the scenario of HIV and AIDS is all too familiar to us at the end of the twentieth century. Worldwide there have been more than 29 million infected with the virus, at enormous emotional, social, and financial cost. As for the re-emergent tuberculosis, each year there are more than 8 million new cases globally and about 2 to 3 million deaths; at the same time, the tuberculosis bacterium is mutating into antibiotic-resistant forms.
The Growing Problem of Antibiotic Resistance
On behalf of the ASM, I participated last December in a round table discussion on antimicrobial resistance sponsored by Senators Frist and Kennedy. As ASM noted at that time, the emergence of drug-resistance among certain pathogens is absolutely alarming. Ten years ago medical workers first found enterococci in patients that were resistant to the antibiotic vancomycin. The most common cause of hospital-acquired infections in the United States, enterococci often could only be eliminated from a patient by prescribing vancomycin. But between January 1989 and March 1993 there was a twenty-fold increase in vancomycin-resistant enterococci. Unfortunately other commonly occurring bacteria are likewise becoming resistant to the antibiotics traditionally used against them. Pneumococci and staphylococci are two examples, both of which are leading causes of infection in this country and worldwide. In some parts of the United States, as many as 20 to 40 percent of pneumococci are found to be resistant to penicillin. Ninety percent of the strains of Staphylococcus aureus now are resistant to penicillin. Recently, the CDC reported four known cases worldwide of staphylococci that were of intermediate resistance to all known antibiotics; this very small number of cases inevitably will increase.
Microorganisms adapt to their environment and antibiotic resistance has been a consideration since antibiotics first were discovered more than 50 years ago. But the overuse of antibiotics by patients and physicians has contributed to the recent escalation of resistance. Between 1980 and 1992 the number of prescriptions written by office-based U.S. physicians jumped by 28 percent to an estimated 110 million. There were legitimate reasons for many of these prescriptions, as during the same period deaths due to infectious diseases rose 58 percent. From 1975 to 1997 the number of middle ear infectious in the United States more than tripled, as more children entered daycare centers. Diagnosis of these diseases often called for antibiotic treatments, but as many as 50 percent of prescriptions are inappropriate, according to experts. Some are ineffective because the real cause of disease is a virus, others are ineffective because an exact identification of the cause is not made. For some infectious diseases, there still are no rapid diagnostic tests available. All these factors, along with strong pressure from patients and from patients' parents, contribute to overuse of broad spectrum antibiotics. Among the several steps needed to counteract a growing number of antibiotic-resistant bacteria, there must be more support for NIAID research leading to improved diagnostics and better understanding of how bacteria become resistant and how disease spreads.
Infectious Causes of Chronic Inflammatory Diseases and Cancer
Powerful diagnostic technology, plus the realization that organisms of otherwise unimpressive virulence can produce slowly progressive chronic disease with a wide spectrum of clinical manifestations and disease outcomes, has resulted in the discovery of new infectious agents and new concepts of infectious diseases. The demonstration that final outcome of infection is as much determined by the genetic background of the patient as by the genetic makeup of the infecting agent is indicating that a number of chronic diseases of unknown etiology are caused by one or more infectious agents. One well-known example is the discovery that stomach ulcers are due to Helicobacter pylori. Mycoplasmas may cause chronic lung disease in newborns and chronic asthma in adults, and Chlamydia pneumoniae, a recently identified common cause of acute respiratory infection, has been associated with atherosclerosis. A number of infectious agents that cause or contribute to neoplastic diseases in humans have been documented in the past 6 years. The association and causal role of infectious agents in chronic inflammatory diseases and cancer have major implications for public health, treatment, and prevention.
The basic biology of agents implicated in chronic diseases and cancer, in contrast to many other infectious agents, is relatively unknown. With rare exception, the means by which pathogens suppress, subvert, or evade host defenses and establish chronic or latent infection have received little attention. Few areas of basic research compared with microbial latency hold greater promise of substantially contributing to our understanding of infectious diseases and the eventual relief of human suffering. Given that the diseases discussed are among the most common in the world, even if only some cases are proven to be of infectious origin and effective therapies or vaccines can be developed, the impact on reducing health-care costs would be substantial. Thus, further research to clarify the etiologic agents and pathogenic mechanisms involved in chronic diseases and cancer should be given the highest priority.
The Urgent Need to Address Microbial Dangers to Public Health
The long list of microbial dangers to public health cannot be fully described here today. Yet it is important to emphasize that complacency can be fatal when it comes to infectious disease. In 1996, infectious diseases in the United States were the third leading cause of death. Infectious diseases also account for one-fourth of all visits to medical offices in this country. To counter this deadly onslaught, the most effective approach is to improve the public health infrastructure in this country and expand our biomedical research capacity. The NIH is the principal research agency in the biology and pathology of infectious diseases. The NIH and U.S. public health are poised to begin the 21st century taking advantage of research opportunities opened by new technology and already accumulated knowledge.
The ASM encourages Congress to continue its strong support of biomedical research in the United States by rejecting the President's insufficient funding request and instead granting another 15 percent increase in NIH funding. This is an investment in not only our scientific leadership but also towards what each American desires-continued good health. Thank you for the opportunity to testify