of what in fact are the proteins that are on the surface of various cells, including cancer cells. the trick is that every cancer is a little different and this is where the precision medicine part of this fits in and that's very much, i think, at the cutting edge of trying to bring immune yolg, genetics and cancer biology together to figure out how to make that strategy work not in a one size fits all but in a precision individualized way. >> shifting top picks completely in the last 30 seconds here. e-cigarettes, we've seen a tremendous growth and there has been studies that nih have funded about the high school students tripling their use in a single year and so forth. what do you see as the role of nih in terms of this new form of tone tobacco and tobacco addiction? >> thank you, senator. the nih is concerned about tobacco consumption because it

has such an impact on disease and in addition the issue of e-cigarettes where we do not know what either the short term or the long-term impact is from the cigarettes themselves, nor do we know what the implications are for behavior. and, therefore, the nih in conjunction with the fda is conducting research to investigate these critically important areas. >> thank you very much. >> thank you, senator. senator cassidy. >> thank you all so much. as a practicing physician sometimes still i am so aware of y'all's good work and i think we should double your budget because i understand the impact that would have upon my patients. among which when i did my residency in 1983 in los angeles the epi center of hiv, i'm very aware what was formally a death sentence is now something you live with. let me ask because dr. collins i

have been concerned that 20 years ago gia that nih rebalance its hiv spending from the 10% to diseases such as alzheimer's dementia which are more important now. if you receive the 7% increase that the chair and the ranking member aspire for, we all do, will 10% of that budget continue to go or roughly 9 1/2 to 10% of that will that go to hiv research? >> senator, you and i have discussed this on occasion and i think you are raising a good point about whether this makes sense to have a formula driven way in which we define how resources should be spent or should we focus that on what the public health needs are and scientific opportunities, the things that nih usually does. no, i do not think that if we had the wonderful good for tune to steve this increase that there shaut to be a lockstep 10% basis on which we should define the hiv research budget. we shouldn't take our foot off

the accelerator at a time when hiv aids a poised for major developments including a vaccine, but i think we should step away from the formula. >> in your directive, i don't know i don't have it in front of me, but you mentioned a ng no the focal points in terms of the hiv research would be an emphasis upon comorbidities. >> yes. >> when we hear from merkley and blunt and others about young researchers not having dollars this is a concern. we pulled the minutes from the 2013 national institute of heart, lung, blood and they are speaking about how the success rate of applications nonaids applications are 18%, but for aids applications they're 42%. meaning that it took a less quality project to be approved and they hope to encourage more submissions of aids projects and hope to understand the barriers of submission. then i see that the -- a project currently being done is looking

at the comorbidities, cardiovascular comorbidity in hiv and then i think we found out that of the 610,000 people who die every year from heart disease only roughly 1,800 of them have hiv as a determinative cause. but nonetheless the money we are spending on the study is 21% of the budget of the national heart, lung, blood institute. so we're spending 21% of a budget for .29% of those who die from hiv. now, if we're going to focus on comorbidities spending 21% of an institute's budget on the .29% who happen to be infected with hiv it seems we are going in the wrong direction. thoughts? >> so i'm not totally familiar with the detailed number you present, but i will certainly look at those. certainly we are in the process, senator, of trying to right size

the way in which our hiv research budget is being allocated and the office of aids research has the potential to move dollars around between institutes and between programs. >> but can we move it out of hiv so, for example, i have a studio here -- there has been a million dollars that has gn to study behavior of chinese men having sex with men in some city in china. $1 million over the last four years. it would have been great to put that to alds or to oregon where merkley's researcher would find -- i don't -- one of your predecessors said that we are not the international institute of health, we are the national institute of health. why are we spend ago million bucks on a behavioral health study in china? >> again, we have now identified, i think, the four areas of high priority and frankly i do not think that that study would necessarily fit those priorities. >> so i guess my question -- you mentioned the office of aids research moves dollars between institutes, but if this is the kind of study that -- if that

national heart lung it's 42% approval rate for the hiv/aids study, frankly they are getting too much money for hiv aids. they are having to find people to apply for something which is 21% of their budget. can we move money out of that area into neuro degenerative diseases, alzheimer's, parkinson's, als? >> i certainly agree that we should be making decisions across nih on the basis of public health needs, scientific priority. i would say there are scientific priorities eye merging in hiv aids that i would not want to see neglected particularly the opportunity to end this epidemic and the investment in the vaccine which is likely to be expensive. so taking your point i do not think we should in the process of rethinking this portfolio, which we are doing actually quite actively right now, we shouldn't neglect the potential of actually investing in different ways in hiv aids that will bring an end to this epidemic. >> there's something else i read and i will close with this and i've read so much about this i

have lost this quote, but if you decide to focus exclusively on the cure of one disease inevitably -- inevitably you end up ignoring other more pressing needs. we're spending $600 million right now on aids vaccine and domestically and i think $24 million on the international aids vaccine initiative. not that we couldn't spend more, but to justify 10% of the budget on the bases of that seems as if we will end up neglecting alzheimer's, dementia, mental health, thank you, i yield back. >> dr. collins, you may have mentioned but i don't know if i heard it if you did, the four target areas in hiv aids research. when did you announce that? that was a recent reevaluation of where you were headed and a recent announcement which was -- >> it was in august, senator. and i can quickly say those four priorities, reducing the incidence of hiv aids, research towards a cure for those who are infected who otherwise are doomed to lifelong treatment, a

next generation of therapies with better adherence and fewer i had effects and these hiv associated comorbidities recognizing there are many of people already infected who are having those comorbidities and we need to understand them better. >> thank you, mr. chairman, i thank all of you on the panel. i would like to thank dr. lorsch for coming to us and spending time in west virginia at west virginia university talking about a program that i learned so much about the idea program which is a smart successful program. so i thank you for that. it's doing -- you know, there's research with stroke and brain and also a collaborative effort with other universities, marshall university, west liberty and wheeling jesuit. so i thank you for that. i wanted to give you a chance to say if you had any take a ways from the visit there that you might be able to address. >> i want to thank you again senator. it was a fantastic visit that energized my staff and myself.

one thing we noticed about the idea program is it's full of best practices. i think we saw two there. the first was sharing, sharing of resources to create economies of scale, particularly in access to technologies, which we saw was very critical, especially to the young researchers. i think that model of creating economies of scale through sharing technology resources is something we should think about moving nationally because it can really get the taxpayers more science done for their money. the other area is training young investigators. we saw the cobri program, how it focuses on training young investigators and there was recently a paper just last week published by a group in nevada showing that investigators who participated in the cobri centers were three times more likely to succeed than investigators who did not participate in the cobri centers. in terms of getting r 1 grant

and publishing papers. again, i think given the importance of young investigators that taking that model from the idea program and thinking about how we can use it nationally is really important and i certainly give senator cochran a lot of credit for developing the idea program in the first place. so thank you again. >> thank you. no, i think the enthusiasm we saw with the young investigators and young researchers is something that is very inspiring for me and hopefully i've heard a lot about the programs of them moving to the next step. dr. koroshetz, the national institutes of age something partnered with the centers for disease control and prevention and the administration of community living in an initiative to create more older americans into research programs, the program has specific focus on alzheimer's patients. both my parents recently passed away from alzheimer's. can you talk to somebody like me who is 60 years old, how do you

get into these programs, how expansive are they, what are your expectations? i did hear, actually i went to an alzheimer's meeting just the other day and they were talking about the push for diversity in your research where you are researching minorities and other ethnic groups, women, men, to see what -- because it manifests itself differently possibly in different -- different types of groups. so that's a big question for a little bit of time. >> sure. well, so the national institute of neurological dis cords and stroke and the national institute of aging which is the point institute at nih are working hard on the alzheimer's projects and i think as you mentioned one of the stumbling blocks is the culture of research in this country. so as we develop new their piece our barrier is really the number of people that we can enroll into studies. the national action plan for alzheimer's research has a

number of milestones which are trying to expand how that happens. so in cancer, for instance, a large percentage of patients with cancer will enroll into trials. the neurologic disorders is much lower so we really need to push on that. i think we have good plans to do that. >> i'd like to help you with that. also it goes undiagnosed or un -- while they are getting old and that's just sort of the way it is and i'm really excited to hear about what you talked b the possibility of a vaccination or vaccine or something. >> yeah. >> quickly, dr. voluntarily could have, i'm from an latch cha, west virginia, we have a high incidence of prescription drug abuse and now heroin just on an astronomical rise, overdoses and just -- and deaths resulting from the use of heroin. i'm glad to see you read in the

huffington post to embrace the concept of addiction as a chronic disease. i think we are all with you there, not one of us probably has been untouched by this. i would like to ask what you are doing in terms of -- because rural america is really suffering from this, some of the smaller states, lower socio economics, they are going to heroin and other high unemployment areas. where do you see this, you know, your role here? >> well, the urgency and the tragedy of what's going on on the whole country but the appalachian region has made these one of our priority initiatives and it's also one of the priority initiatives for hhs. so we have been working with our sister agencies and brother agencies to actually integrate our projects to maximize the likelihood of success. so the hhs has three items, one of them better prescription practices for the proper management of pain. so nida, for example s very

invested on developing alternative treatments for the management of pain because we are very restricted by what we currently have which has resulted in the overreliance of opioids, greater access to nioxin. >> that was just legalized in our state. >> which is wonderful. we are partnering with pharmaceuticals to develop alternative ways of administering my ox inn that don't require an injection so anyone can administer them and the third one which is applying their piece which are shown to prevent overdoses and prevent infections. we are developing alternative medications that can increase compliance. what we want to do is to partner with cdc in order to develop a project that can target the appalachian region. i visited the place and i was struck by how minimal an infrastructure there were in many of these towns.

how does one address that. >> we have tools, how do we deploy them. >> right. thank you. thank you very much. >> senator moran. >> dr. collins and crew, welcome. thank you for the opportunity to have a conversation today. dr. collins, nih recently released its professional judgment budget for alzheimer's. in i correct in assuming that the president's budget request was the starting point for which you were going to build upon that presence request? that's true? >> that's true. we were building for fy 17 what a professional judgment budget would look like assuming that the president's budget was the fy 16 number. >> i want to give you the chance to tell us if we are successful in accomplishing what this committee did in regard to increases in funding over the president's request would it give us a greater opportunity to advance the success, the research necessary to address the issues of alz?

>> yes, senator, it would. some of the things that we imagined that we would fund in fy 17 could in fact be started earlier in '16. we would want to revise the number for the fy 17 professional judgment budget on that basis. >> so the subcommittee, senator blunt's subcommittee and the inclusion of a $2 billion increase at nih plus the specific issues related to brain and alz would have a significant consequence in the ability to advance the cure and treatment. >> i think we are not limited at the present time by ideas or talent, we are limited by resources. frp possible to have more resources in '16 we could start projects that otherwise would have to wait longer. yes, we could go faster. >> of course, dr. collins, i think you are a very bright intelligence person, but i have discovered that you also have the ability to say the same thing more than once.

perhaps you should be a senator. dr. koroshetz. >> i would say to go with what francis said, we have for the alzheimer's plan and for the brain as well we have serial projects that one depends on the other and we don't know at fy 16 what we will do, but we are ready to go. we have announcements ready, but we will not be ready to fund them unless additional money does come which would then put things off. >> let me make sure i understand that. you are prepared to expend the dollars that are included in the senate appropriations committee recommendations,our appropriate appreciation bill? >> we are shovel ready. >> good to hear. alz disease research summit occurred last february and nih is poised to revise the research milestones that it created in that national plan. when can we expect that? >> so the national plan is

actually a community plan that was developed with consultation from the scientific community, advocacy community, patient community, caregiver community and we are holding annual revisits to the plan so it's revised on an annual timeline. we alternate between n i & d s which covers the alzheimer's disease related like vascular disease that causes dementia, parkinson's disease which causes chem is that with the aging institute which runs the pure alzheimer's plan. so we are every year alternating between those two items and redoing the plan. >> thank you very much. dr. collins, in the budget hearing back in april you and i had a conversation in which you testified that -- something along these lines torques achieve our mission we must serve as effective stewards of the resources we have been given by the american public.

this is continuing to quote you, to support this focus on priority we are developing an overarching nih strategic plan and will be linking this with individual institute centers, strategic plans, that reflect the rapid current progress in bio science. my question is what are the details? tell me -- fill in the spaces about what's transpired since that conversation occurred. what are you doing that is new and that will mean that we're going forward? we have the latest opportunities because of that efficiency to achieve more. >> well, we are working very hard on developing this strategic plan that you mention and we are scheduled to deliver that to the congress in mid-december and it does try to lay out in a much more clear fashion across all of nih how it is that we set priorities, how do we make decisions about where the dollars are most efficiently

spent and also how are we being good stewards in terms of how the process of peer review and counsel review and director actions on what we fund is carried out as well as a number of other efficiencies that we are concerned about including what senator alexander was discussing earlier just in terms of the burden that is applied to investigators who are trying to get the research done as well as human subjects, oversight and so on. there will be a lot in this document that will lay out i think in greater detail than has been possible before how we have for the best benefit. >> mr. chairman and dr. collins, let me repeat myself. i have offered this admonition, if that's a safe thing to say, that we are often told as members of congress we don't want you meddling in the, quote, politics of deciding where research dollars should be spent and i share that view but it means it's incumbent upon nih to make the decisions that are

necessary as to where the dollars spent are the most likely to achieve the quickest, faste fastest, best and necessary results. >> and i welcome that responsibility as to do all of my colleagues. >> and i apologize for offending you to suggest that you could serve in the united states senate. >> there might have been a time when it was considered a complement but probably not right now. we do have time for a second round of questions. senator murray. >> dr. rodgers, you spoke earlier about the 29 million americans who have diabetes and the 86 million who are prediabetic. that sounds to me like we have a crisis on your hands as the number of americans with that disease continues to grow. you mentioned the work your institute has been on prevention programs that include regular exercise and reduce fat intake and the huge difference it makes. the cdcs program which our bill has forced to cut helped force

programs like one in my state that supported community health efforts through the ymca and other organizations that promote healthier living. what might taking that preventive program to scale mean for this country's diabetic epidemic? >> thank you, senator, for that question. the ymca that you are referring to and their ability to develop what we did in the clinical trial, the diabetes prevention program which is counseling this lifestyle intervention on an individual basis, they were able to take it to scale by doing the same lifestyle intervention but providing it in a group setting and in fact their results after the first year or two were quite similar to what we achieved in the individual program in terms of weight loss, et cetera. but more interestingly, the cost for patients involved in this clinical trial with the initial

instructions and the follow-up was about $6,000 per patient. in the group setting, in the ymca that cost was cut down to about $400 n terms of scaling this, for example, if we could expand this, we haven't done any economic analysis on this, but there is a private group called the urban institute that has recently looked at what happens if you can scale this. they estimate given those numbers about $191 billion over a ten-year period if this -- with some very conservative assessments or assumptions if this could go to scale. >> that's impressive. >> yes. >> dr. employed, let me ask you as dr. collins mentioned we have seen significant in terms of immunology in terms of treating liymphoma and lung cancer. there is support to find similar

break throughs for other cancers. what is nci doing to make that happen and where is the potential for new cures the greatest? >> we are investing in a number of different areas throughout the cancer spectrum and i think that there are opportunities in many different areas, for example, we are investing heavily in pancreatic cancer because this is a cancer where we have not had significant progress, despite long-term recognition of how serious this cancer is. we also are investing research in pediatric interventions and recently nci supported researchers developing two new interventions against pediatric leukemia and lymphoma and this was initially developed in the

academic sector and has been picked up by venture capital and is vapdly going forward for clinical trials. and we also have interacting with the pharmaceutical industry to try to identify new and important uses for drugs that are off the shelf, either because they have been approved for one intervention but not for another, for example, braf inhibitors in melanoma, trying them in other diseases. this is a potentially very important innovation because we recognize that a percentage of patients who have different kinds of cancers may actually have the same molecular abnormalities and therefore may benefit from targeted treatments initially developed in other areas. i could go on, but i think that given the time -- >> yeah. can you just tell me why immunotherapy is effective in

some patients but not in others who have the same cancer? >> yes. i think that this is a critically important issue and i think that what we are doing to support research to understand mechanisms are critically important because if we could understand why some patients are benefitting, whereas others are not, it should enable us to increase the -- that increased understanding should lead to better interventions for the people who currently are not responding or at the very least we would not be giving them treatment for which they are not going to benefit. >> so it's a question we need to answer with more research? >> yes. >> okay. thank you very much. >> i will go last in this second round. so senator shelby. >> i will be as fast as i can. thank you, mr. chairman. dr. collins, there has been

several articles regarding where biomedical study results including those funded by nih that appear in top peer-reviewed journals cannot be replicated or reproduced. the article cited -- one of the articles cited a buyer study describing how it had halted 64% of its early drug target projects because in-house experiments failed to match claims made in the publication. you've done a study on this. what is the problem here? why can't they replicate and is it rushing to print too fast? what is it? would you discuss that? >> senator, it was you who first brought this attention -- this issue to attention in a hearing like this about three years ago as it was just beginning to appear and i appreciate very much your having shined a light

on a situation that we are taking with great seriousness. this is a complicated multi-factor situation, i am actually showing up on the screen what nih has posted as far as a summary of all the things we are engaged in to try to address this and also to do things to improve the training of the next generation of scientists about these issues in terms of rigger and reproducibility. i would say of the factors that are involved certainly the hyper competitive atmosphere that currently exists much of it on the base us that funding is so tight causes people to try to get publications out as quickly as possible and that may result in circumstances where the replication study didn't quite get done and therefore somebody else finds out later it wouldn't have worked. we have an issue in terms of the journals also. in many instances not having been as thorough as they should be in evaluating manuscripts. happy to say through the leadership of dr. tabak we convened the journals to talk

about this and now more than 150 journals have signed off on a checklist that they use when papers come in to be sure the experimental details are there, the is that stis cal methods are described and so on. it's not something that touching many areas of science. dr. lorsch is looking at projects on cell lines, sometimes people public paper on work about a cell line that turns out those cell lines weren't what they thought they were. training is critical. we have training videos up on the site if you want to see what we are asking mentors to use in lab meetings and other group meetings to bring to the attention of trainees these critical issues about study design. how do you set up an experiment where you know you have done it rigorously. we are all over this and we are in fact pushing pretty hard to see this problem addressed. it will always be the case that science gives you results that later on you can't seem to make sense out of, but if that happens we want it to happen in

a way that was unavoidable not because people were actually cutling corners. i think we have the whole attention of the community now to this and you are going to see the problem get less than it had been, i hope much less. >> but this is a very important question because it goes right to the essence of investigation and replicating what you've found or discovered and what we benefit from, is that correct, doctor? do you want to comment on that? >> i will add one other point is that we've looked at this at our institute and there is another side to this which is some of these things if they are not -- it's not that you can't reproduce them, it's given the effort you've put in you didn't reproduce them. we have really interesting technologies within you first try to row produce it you can't do it but the people that developed the technology they open up their labs and people can go in, learn how to do it and then it works. >> some of them were on the right road but they didn't have the means to finish it? >> that's right.

>> thank you, mr. chairman. >> thank you, senator. let's go to senator casty and then senator moran. >> first i misspoke last time. $66 million is the 21% of nlrb, that was too much. nonetheless, the point taken. as best he can find out 1,800 people who die of hiv with cardiovascular disease we are spending $66 million on it. dr. volkow, i have heard people say that the addiction and mental health is a barron field. i am not a mental health provider but i am asking, do you feel as if there is -- if you had to take the question answered -- asked earlier, significant more resources, would you be able to do the clinical and basic science to make significant advances in the amount of addiction olg and could you people to that for mental health as well. >> definitely we could accelerate a lot of the discoveries but i'm going to --

and i apologize, senator, but i'm going to disagree because i wouldn't say that the research on mental health has been barron as it relates to over the past ten years i would say 15 years i really expanded understanding about what are the abnormalities in the brain of people that suffer from mental -- >> i accept that. actually did i not know enough to dis agree, but you would say there is great academic progress. >> there has been great academic progress, that has enabled us to identify potential treatment. >> dr. koroshetz, the issue on alzheimer's dementia i have heard people say in als and parkinson's that the promise is not there as it might nb other fields. i want to give you -- i also have parents with dementia and alzheimer's. i want to give you a lot of money. i'm hoping to convince my colleagues that's why they go ahead of me they have more swag than me to do so as well. would that be a worthy

investment? is there academic promise in those fields that you could do the research, clinical research, et cetera. >> i think the generation field in general is bringing lots of many smart people to try to solve these problems. we have the work force, i think with the resources we could really make hay. now, as i said before, there are a couple of things that are tantalizing now and that is that all the neuro degenerative diseases, parkinson's, alzheimer's, als, all have one common feature is that the cells that die have proteins that aggregate and get stuck in those cells and so people are really on the idea that maybe there is a unified theory and if we can stop this process for one disease we can stop it for all of them and so, i mean, it's a leap of faith right now, but there is evidence that this is not impossible. that we can make a big breakthrough. >> dr. collins. >> i'd just like to add to that -- and i have a question for you, dr. collins. >> this will be quick. basically the point here is that

you never are quite sure where the breakthroughs are going to come from and we have to be careful not to overly target research plans in the direction of a specific disease because the answer might come out of some very different investigation or from some very basic science as we are celebrating today with the nobel prizes. just a quick example, the biggest breakthrough i have heard about in the last month for als -- >> can i stop. i have a minute and 45 seconds. which top you for a second? you've got really -- you've got a bunch of bright aggressive people who they would not be who they are were it not for you being the pinnacle, believe me, i can a doc, i know you are the pinnacle of the docs. should mentioned earlier the academic promise, research promise of hiv aids as a rational to somewhat continue there. i guess what i was trying to figure out is is it lacking elsewhere? one of the excuses -- one of the reasons i should say to continue the funding in one area as

opposed to others is the apparent academic promise in the one as opposed to the others. how do you balance each of these folks who has such promise in their field as you make that decision? >> that's a great question and that's something we talk about every day around the table and it's certainly in every one of these institutes there are areas that are up and coming and others that perhaps are not quite as rapidly moving and we're constantly trying to adjust the decision making, but also not trying to be overly top down in making decisions because a lot of the great ideas come from our wonderful scientifi community out there and we can't always anticipate where they are going. it's a constant revision of where we want to put the emphasis. >> okay. and if dollars -- if my wish were pull filled and dollars were redirected from hiv aids into some of these other areas it sounds like there is fertile field that that ñ#p(v would fertilize and hopefully sew great benefits.

>> there's fertile fields all across our landscape. >> i yield back. >> senator moran. >> dr. collins, the most significant development that's occurred in the last 30 days is? on als? >> okay. thank you. it was -- and it sort of fits with the conversation we are having. it was an investigator who is actually studying hiv aids and trying to understand one of the comorbidities which is a neurological problem which resembles als in a way and he has discovered that there is a retro virus that we all carry around it starts making copies of itself and cause this is damage to the neurologic system, particularly those anterior horn cells. this looks very much like als and the publication that just came out suggested that this might be one of those missing clues to what's happening in lou gehrig's disease.

i don't know where that's going to go, probably dr. koroshetz could tell you a lot more about the details but it was an interesting example. you're studies this disease over here and learn something about that one over there and didn't expect that to happen. >> dr. lou ri welcome to this panel, i look forward to getting better acquainted with you. i wanted to give you the opportunity to express as the relatively new acting director your vision for the national cancer institute and i particularly wanted to highlight a program that has -- is being launched in pediatric clinical trials called pediatric match trial and have you tell me about that and where you see it going, what it may mean. >> the pediatric match trial, senator, is a trial that is currently under development and what it does is essentially do for pediatric cancer research what the adult match trial that started two months ago is doing

for adults who have advanced cancer for which there is no standard treatment. it puts the molecular abnormality of the patient front and center rather than the origin in the body of where it occurs and it takes drugs that are off the shelf either experimental drugs or that have been approved for other uses and it tests them in these other ways for cancers where they are not yet approved. the goal is to improve the outlook for these patients and this is a trial that, as i say, is under development. one of the -- one of the uses for the precision medicine initiative, the oncology portion that people have been talking abo about. the overall vision for nci is to

support basic research as we have done historically to invest in precision medicine, not just in the areas of cancer treatment as is occurring with the precision medicine initiative and the oncology portion, but also to emphasize precision medicine in the area of cancer prevention and cancer screening, understanding pert the causes of cancer, understanding better how cancer comes about. and in addition to put a focus on health disparities in cancer. unfortunately already many different kinds of cancer where certain underrepresented minorities have a much higher incidence of mortality and we need to treat these populations as we would any high risk population to understand the

biology, the lifestyle factors and the utilization of medical -- of medical utility. and in addition to try to mitigate these factors just as we do for any high risk population. these are some of the important areas that we are looking forward to making progress in. >> thank you very much. i wish you well. mr. chairman, thank you for this hearing. thanks to you and senator murray for your leadership in this area of medical research. >> thank you, senator moran. dr. lorsch, when senator moran was the ranking member on this committee they started an effort with the defense advanced research projects on high risk, i think it was an fy 2014. i'm not sure exactly whether we developed the same kind of category with nih yet, but you have mentioned high risk, high reward a couple of times. give a couple of examples of either things that did work out or things that didn't that you

would want to see as examples of the kinds of things we should be thinking about when we think about going to a high risk area as opposed to something that's more likely to produce a result but maybe not nearly as big a result. >> i think the recent developments in gene editing are an example of something that was an out of the box idea, could you use this bacterial system that allows rearrangements of genes and then use it to edit genes in a cell to possibly repair those genes in a disease state and that's something that as you may know has recently worked and has taken off and is really revolutionizing biotechnology and has the promise to revolutionize medicine in a variety of ways, i think that's a great example of that. >> i might mention the common fund at nih which the congress made into a permanent part of our budget back in 2006 is a place that specifically aims to try to support these high risk,

high reward projects that no single institute would probably be able to invest in but collectively we can. a couple examination there. the mime row biome. the effort to understand how the my robes play a role in our health and cause of disease. this has been a revolutionary set of insights coming about because of new technologies that allows you to find out what's there and how it changes over time. that was one of those high risk, high reward programs that has changed the whole landscape of how the institutes are doing research. you don't want to think of the human as an organism, it's super organisms, us and the microbes and interaction between the two. that's an kpafrl. another one which is closer to clinical medicine is to try to come one a standardized reliable way of patients reporting outcomes from their perspective. so much of clinical research is the researchers or the doctors saying, here is what we think happened to this patient who was

given this treatment. you want to hear what the patient thought, too, and sometimes it's not quite the same thing but we haven't had those majors. so a program called promise which many people thought this is going to be really hard has actually transformed that process and it makes it possible now for us to run more clinical trials where the patients are not really patients, they're partners, they're full participants. their input is fiegd our decision-making about what works and what doesn't. >> i think washington university is doing some of the microbial work. >> they are. jeff gordon your heroic figure is one of the main leaders in the world. >> unlike the genetic, your genetic structure the microbial structure is changing all the time and how do you impact that is the question here, is that right? >> that's right. as ware mountding this precision medicine initiative thinking about following a million americans over time to know what's happening to their micro biome as a consequence of

diet and exercise, the presence of illness or not, taking antibiotics we could find this out as a scale not previously imaginable once we get this up and going. >> senator murray mentioned that we had cut one -- i'm going to come to you, dr. coal could have, we thought the mock grant fund and lots of programs in this budget to reorient toward other priorities. i think we eliminated totally funding for 43 programs this year we're spending $1.25 billion all of which by the way had very good titles. there wasn't a tying single title that wasn't meritorious, but the process of prioritizing is exactly that. you really don't prior size if all you do is get more money and spend it on something more important than you were -- thought you were spending it on last year. that's not prioritizing, that's just adding more money on top for good things. what brought me to that when i

thought we did cut those block grants by 3% but the majority of that money in my view went into increasing the money to combat opioid abuse. which frankly a handful of years ago i hadn't heard of at all but in the committee hearings this year we heard about it all the time. do you want to talk a little bit about both opioid abuse and what research may be going on to come up with pain medicines that are lessees i will abused, lessees i will converted to other -- to other drugs to be used in other ways would be helpful. >> indeed unfortunately you are hearing about opioids because of their devastating consequences so on the one hand we have basically seen 16,000 in people dying from prescription opioid overdoses and over the past five

years we have seen a four fold increase in people dying from heroin. so it was stable for many years, 2000 and in the past five years it's 8,000. so we are seeing a really steep increase on deaths from prescription opioids and now from heroin and that has led us to realize what is the nature of the problem. so on the one hand we have the reality that there are many patients suffering from chronic pain, but we don't have sufficient alternatives as i was mentioning before, opioids. in partnership with obtained consortium at nih nida is trying to develop alternative medications that are effective for severe pain that are not addictive. we're trying to also partner with pharmaceutical industry to develop opioid medications that will not be diverted. we are partnering with funding agencies and the fda recently created a new indication that an opioid medication cannot be

diverted. we are also encouraging the better education of the healthcare providers on how to screen properly pain and how to manage opioids. and how to of course screen for substantial dis cords. so there is a multi-prong approach but from the perspective of nih with various institutes working together and at the same time with our sister agencies. >> and i would think one of those groups may be whatever is happening in defense department research on this topic because certainly service people in the service and veterans have a really high propensity to be -- to find themselves in that trap of becoming addicted to the pain medicines that they are given often because of their service-related industry -- injuries and that can't be a good thing. >> you are pointing on something that unfortunately not many people are aware. the prevalence of pain in military people returning is much higher and as a result of that they are much more likely

to be given prescription opioids, much higher than the rest of the public and so, therefore, the number of people that are dying from prescription opioids among td military is higher just by the fact that what you are saying, they are suffering from many and we don't have many pain alternatives so they receive opioid medications >> thank you for your help on this. senator shaheen. >> thank you, mr. chairman. you know, i would like to follow up on the concerns that you are raising about opioid abuse and also heroin. the fact that its led to a heroin epidemic. that is a huge challenge that we are facing in the northeast and across this country. i mean, i can tell you that in my little town of dover with a population of about 20,000 people that they had two recent

deaths just in one day from drug overdoses and i think it should rise to the level of the kind of cross agency -- it is a crisis and i appreciate that you all have a different mission in terms of research, but this is something that the medical community, the law enforcement community, the treatment community all need to be working on together and until that happens we are going to continue to see this crisis escalate. it is already out of control and it's only going to get worse. so when you can -- when you can buy in a small town in new hampshire you can buy a bag of heroin for less than you can get your prescription filled for $7 a bag, then we've got a real problem. so i just -- i want to make that point because i'm not sure if there are other ways in which

you all are looking at addressing this issue beyond just the challenge of opioids and what that -- the extent to which that gets people addicted. are there other things that add. are there other things that you're looking at respect to the opioid and heroin epidemic that's going on in the country right now? and i'm happy to direct that to whoever would like to take it. >> yes, indeed. again, one of the -- it's a devastating situation, but one of the reenforcing things, to me, has been how integrated the agencies have been together to come up with solutions and how these solutions are coming into very specific action items. like the da coming up with let's bring back all the opiate medications that are not being used.

the good news is that there are medications that we currently have that are effective for the treatment of people that become addicted to those opioid prescriptions. the challenge is they are not being implemented, so we're working with agencies to increase it so provide medications for the patients that are easier to take so they are compliant. >> sorry to interrupt. so does the nih have a view on whether narcan should be available over the counter to families, not to law enforcement or other people who actually do interventions, but to families who are concerned about drug overdoses and their families? >> i think we are extremely lucky to have narcan and we should make it as widely available as possible. >> thank you. i would just urge nih to think about all the ways in which you

can engage on this issue because it is, as you know, out of control and getting worse, not better, despite all the coordinated efforts. we see those in new hampshire and other states that are dealing with this issue, but we still haven't made it, i think, the kind of all hands on deck priority that it should be. >> just to add there is a lot of interagency work on this. there's an interagency pain research coordinating committee that meets with all the federal agencies. i think they're doing very good work. we have education programs -- >> can i just interrupt? so how are they coordinating the work they're doing at the state level with states that are dealing with this issue? >> yeah, i'd have to get back to you on the state level because that's something we haven't really approached, but there is a national pain strategy that we're working on through hhs to be cleared soon that addresses some of these problems. and there are education programs

that nih funds because one of the issues is educating the practitioners on the proper use. >> exactly. >> we have centers of education on how to mange pain. >> well, i don't know how we make sure that states are aware of the work that's going on, but certainly that seems to me one of the coordinating points that has to happen in order to better address the crisis. i would urge that you all think about and that if we can be helpful in thinking about how 20 make sure that kind of information and effort is available. >> congressman rodgers runs a summit every april and brings in

the states. the doctor and i have been at that summit each time for the last couple of years. it is an opportunity for states to hear what the opportunities are that are being thought about across the nation. it is probably not enough because we're still in the thick of a serious epidemic. i have to give congressman rodgers a lot of credit for being a convener. >> thank you. >> thank you. >> dr. collins, thank you. thank you for the fine representation of your team. as you suggested, there are more on the bench that you could call in at some future time and we might ask you to do that. over the next week, the record will stay open for questions. i know senator alexandra and others have already put some questions out there and i'm sure you'll get some. thank you for being here and the subcommittee stands in recess.

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this monday on c-span's new series "landmark cases," but 1830 the mississippi river around new orleans had become a breeding ground for cholera and yellow fever. to address this problem, the louisiana allowed only one

government-run slaughter house, crescent city, to operate in the city district and the other houses took them to court. follow the slaughter house cases of 1873. we're joined by a former solicitor general and author of "justice of shatters dreams." be sure to join the conversation as we take your calls, tweets, and facebook comments during the program using the hash tag landmark cases. live monday on c-span, c-span 3, and c-span radio. for background on each case while you watch, order your copy of the landmark cases companion book. it's available for 8.95 plus shipping at c-span.org/landmarkcases. tonight, on american history tv in primetime we'll take you

to archives, museums, and historic sites from across the country with programs from our american artifacts series. next, a look into the national gallery of arts portrait collection. then a tour of the national museum of health and medicine followed by the white house visitors' center and the frontier culture museum. american history tv airs all weekend every weekend on c-span 3 and in primetime on weeknights when congress is in recess. we cover all periods of american history and a wide diversity of topics. you can watch all of our programs, find our tv schedule, see youtube clips of upcoming shows, and connect with us on twitter and facebook. this is american history tv only on c-span 3. each week american history tv's american artifacts visits museums and historic