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4. NUMERICAL RECOMMENDATIONS TRAINING DATA FOR 197 8 In fiscal year 1978, Congressional appropriations for the training programs of the NIH and ADAMHA were $16 9 mill ion ~ up 15 percent from the $146 million appropriated in FY1977, which was somewhat below the normal level of recent years (NRC, 1975-1978: 1978 Report, p. 19~O The augmented ap- propriation led to a 7 .6 percent increase in the number of traineeships and fellowships awarded by these agencies from 12, 261 in FYI977 to 13, 204 in FY1978 ~ Thus, in percentage terms, only about half of the increase in appropriations was used for increasing the number of trainees, while the rest was absorbed by increases in the costs of training such as tuition, salaries, and equipment. The increases in training appropriations, however, were not shared equal ly be tween NIH and ADAMHA o The NIH appro- priation for training in FYI978 increased by almost IB per- cent, while that for ADANHA decreased by ~ percent. Cor- respondingly ~ the number of NIH-supported trainees increased almost 10 percent, while ADAMHA's declined by almost 5 per- cent . There were al so ~ i f ferences among the various broad fields of training. Awards in the field of nursing research showed the largest percentage increase, up almost 34 percent ~13 1 awards in FYI978 versus 98 in FYI977 ) . The cl in ical sciences also had a large increase ~16 percent) over FYl977 level s . Awards in the teas ic b homed ical sc fences showed a moderate increase (9 percent), while those in the behavioral sciences declined by 12 percent. In the latter case, most of the decl ine occurred in NIH training awards and wa s primaries y due to a phasing out of behavioral science predoctora~ training programs formerly author ized under the PHS Act. The complex situation with regard to training in the behavioral sciences is discussed more ful ly on p. 58. Health Services Research awards also showed a sl ight 61e- crease from 1977 to 1978. Table 4 e ~ shows the number of training post Lions ~ traineeships and fellowships) made available by the agencies from FYI978 funds. The overall level of 13, 204 awards is j ust sl ightly under the 13 ~ 775 recommended by the Committee. Tabs e 4.2 presents the Committee' s numerical recommendations for NIH/ADAMHA and the Heal th Resources Administration (HRA) training programs in FY1980-1982. These recommendations appeared in the 1978 Report and are reef f irmed here . Since 1974, the training stipends paid under the NRSA Act have been fixed at the base levels of $3,900 for predoc- toral trainees, and $10, 000 for postdoctoral trainees. But from 1974 to 197S, the Consumer Price Index has risen by 34 percent, resul ting in a decl ine of more than ~ percent 50

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per year in the real stipend level. The agencies have an- nounced that a one-time increase in stipends will be made in FYI980, equivalent to a 5 percent increase per year since 1974. An additional 5 percent increase has been included in the budget requested for FYI981. The Committee, having recommended such stipend increases in its 1977 and 1978 Reports, readily agrees wi th this action . The stipend schedules starting on July I, 1980, and planned for 1981 are as follows (Appendix C): Starting July I, 1980 FYI981 Predoctorals $ 5,040 $ 5,202 Pos tdoc toral s Years of prior experience 0 13,380 14,040 1 14,040 14,736 2 14,736 15,468 3 15, 468 16, 236 4 16,236 17,040 5 17, 040 17, 892 6- 17,892 18,780 7 and over 18,780 19,716 The insti tutional allowances have al so been changed under the new plan . For training grants, the 25 percent 1 imit for institutional allowances on NESA grants has been replaced by a plan that allows a maximum of $3,000 for each pretloctoral trainee and $5, 000 for each postdoctoral trainee. Indirect costs of ~ percent and trainee tuition may al so continue to be requested. For postdoctoral fellowships, the maximum institutional allowance will be $5, 000 per 12-month period at nonfederal institutions and $2, 000 at federal institutions. These new allowances will apply to awards made after Ju1 y I, 1980. Table 4.3 shows the estimated cost of the Committee's recommended training ~ easels using the new stipend levels and assuming a 5 percent annual increase in other training costs . BASIC BIOMEDICAL SCIENCES Tra in ing Level s In its 1976 and ~ 977 Reports (NRC, 1975-1978 ), the Committee recommended cutbacks amounting to 30 percent In the number of predoctorals supported annually between EYI975 and FYI979 from 6, 000 to 4, 250 and a ~ eveI support of 3, 200 postdoctor- a's. These recommendations were made in view of evidence of a reduction in the growth in the overa1 ~ demand for biomedi- cal scientists, while affirming the vital role played by the 53

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- - - - u ~ I e u u u c, O u O O ~ 0 ~ ~ O s ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 0 u ~ O ~ O ~ O O ~ O 46 ~ ~ 1~ 04 E ~ P~ ~ ~ Cl. . c, . ~ . u u 0 u 0 u O 0 ~e ~ 0 ~ ~ O e E. ~ O O ~ O O ~ O o S ~ e. ~o ~ 5 ~ ~ x ~ 1 ~ ~ o a 54 ~ ~ ,` . e u ~ u O u O ~ O u 0 l 0 ~t ~ o ~ 0 e~ ~ ~ ~ 111 ~ ~ ~ ~ ~ a. ~ ~ O O ~ O O ~ O E~ 1~ ~ ~ a4 0~ P lib tlo O o~e ~ c x 3 lie' al ~ z: a, ~ ~c u " - 4' 4, s ~ x u e~e ~ ~ u u u' ~ o 9 1 . .~ ko = Z O C~ ~ ~ ~ c ms C r h C U ~ ~c 3. 4~ ~ s ~ ~ ~ Oe ~ ~ c=~ ~; ~ ~ t ~ ~ ~ u ..., o o 4J o o ~ ,- .- 0 ~ ~ o P. ~U: o G O 4 0 ~ ~ _ a' U C ,4 C O? ~ ~4 ~ o S~ C U O C C ~4 C ~4 U C U C Oc S dP U1 C 01 ~ e -

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training grant and fellowship programs in training high- qual ity researchers . The 1978 Report reiterated these recommended level s and suggested that time was needed to evaluate the effects of these cutbacks and further develop- ments in the 1 abor market before new recommendations could be made. The Committee now feels that, by the time of f it ing its next Report, suff icient time will have clasped since its 1976 employment survey to permit such a new eve, uation of the labor market. A survey of recent Ph.D. ' s is current, y being completed and wil l yield up- to-date information on em- ployment patterns . In addi t ion, the Commi thee pi ens during the months immediately ahead to conduct a series of site visits, based upon its 1977 survey of basic biomedical sci- ence departments, in order to evaluate the impact of cut- backs in training support on enrollments and program qual i ty . Therefore, whit e the Commi thee af f irms i ts pre- viously recommended levels of 4,250 predoctorals and 3,200 postdoctorals, it does anticipate having sufficient informa- tion this coming year to reevaluate the conditions on which these earl ier recommendations were based . BEHAVIORAL SCI ENCES Pr edoc tor al/Po s tdoc tora1 ~ uppor t In its 1976 Report, the Commi t tee recommended a gradual shift in training emphasis in the behavioral sciences from a program of predominantly predoctoral support to one of predominantly postdoctoral support wi th a ratio ul t imately of 30 percent predoctoral/70 percent postdoctoral awards (NBC, 1975-1978: 1976 Report, p. 10 ~ . The proposed shift in training emphasis seeks to promote the emergence of special- ized investigators in innovative areas of behavioral re- search, such as research in heal th and behav for ( NRC, 1975-1978: 1977 Report, p. 106 ~ . The Committee recommended that this change in training emphasis be carried out gradually over a 6-year period ~ see, for example, Table 4.4), while maintaining total program costs at FYI975 rev-Is, ad justed per-io<3ically for cost- of-] iv ing increases ~ of ., Tab, e 4 . 3 ~ . Thus , the Commi ttee cat culated the total number of awards avail able each year by costing out the number of predoctoral and postdoctoral awards that could be supported g iven a constant level of funding and an average stipend cost for these awards (NRC, 1975-1978: ~ 976 Report, p. 10) . The Committee recognized, of course, that the total number of NRSA awards in the behavioral sciences would ~ decrease owing to the greater cost involved in training postdoctorals. 55

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On the basis of those calculations, then, the Committee recommended that no fewer than I, 300 awards be made in the behavioral sciences at any time, with approximately 390 predoctora, awards and 910 pos tdoctorals when the 30/7 0 ratio was in pi ace. Information provided by NIH and ADAMHA reveals ~ however, that the proposed shif t to predominantly postdoctoral sup- port has been occurring more slows y than recommended by the Committee . In FYI97S, the ratio of awards was 77 percent predoctoral/23 percent postdoctoral, essential ly unchanged from the ratio of 78 percent predoctoral/22 percent post- doctora~ reported by the agencies in FY~ 977. (A ratio of 55 percent predoctoral/4 5 percent postdoctoral was recommended by the Committee for FY'978. ~ The failure to move more quickly to predominantly postdoctoral support may also be partly a function of the s:1 ow expansion in the number of postdoctoral app] ications in this area. Tab] e 4 . 4 below reveals that the actual number of postdoctoral awards made in FY1978 is less than half the recommended number. Table 4.4 Committee Recommendations and Actual Awards by NIH and ADAMHA in the Behav ioral Sc fences . Agency Award s and Conun i ttee Recommendations 1975 ~ 976 t 977 1978 1979 1980 1981 1982 F iscal Year Ac tual awards Total Predoc . Postdoc . Committee recommendat ions 1966 1801 1738 1514 1754 1401 1352 1160 212 400 386 354 Total 1860 1740 1590 1490 1390 1300 1300 Predoc. 1500 1200 850 745 575 390 390 Postdoc. 360 540 740 745 815 910 910 In a recent memorandum to the Institute Directors of ADAMHA, Dr. Gera1 d Klerman, Administrator, acknowledged that 1 ittle shift had occurred toward the goal of 30 percent predoctoral/70 percent postdoctoral support in the be- haviora~ sciences. Dr. Klerman proposed the establ ishment of a schemed e for ADAMHA to reach the ratio of awards recom- mended by the Commi t tee by FYl 9 ~ 3 2: 56

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Because of the evidence of on' y ~ imi ted achievement in shifting the emphasis in behavioral science research training to postdoctoral support, I feel that a strong commitment from you and your staff is necessary in order for us to meet this goal. While it is not possible for us to reach the NAS-recommended goal by 1981 ~ based on current program distri- bution), ~ am establishing a schedule of goals for achieving the NAS recom- mended distr ibution in f iscal year 1983. . . . The Committee reiterates its view that if the goal of reaching a 30/70 ratio is to be achieved, and the desired specialized training in heal th and behavior at the postdoc- tora~ level provided, it must be done by markedly increasing the number of pos tdoc toral awards and an orderly decrease in the number of predoctorals, rather than by meres y reducing predoctoral support. Recognition of this point appears in a more recen t memorandum from Or . Klerman deco ADAMHA research training program directors 3: ADAMHA is giving special attention to increas- ing the number of postdoctoral trainees --and f el lows supported under the Na t tonal Research Service Award (NRSA) program. Accordingl y the number of awards for predoctora, training in the behavioral sc fences wi 11 decl ine progre s- sively to achieve, by 1983, a distribution of 70% postdoctoral trainees and 30% predoctoral trainees. In order to achieve this goal, only a 1 imited number of new and competing extension (renewal) awards wil ~ be made each year for pre- doctoral training grant programs and predoctora~ f el lowsh ips . Because patterns of postdoctoral research training have not been as common in the behavioral sc fences as in other areas, rapid expansion of the number of postdoctoral pro- grams may be difficul t. However, data from the MRC Commit- tee on a Study of Postdoctoral Research S tat f in Sc fence and Engineering suggest that the number of behavioral scientists on postdoctoral appointments of al ~ kinds almost doubt ed be- tween 1973 and 1977--from 365 to 684 (NRC, 1978 ~ . Further- more, a recent follow-up of graduates of NIMH research training programs in psychology reveal s a sharp increase in the proportion of research postdoctoral s--from 4 percent of those completing their training between ~ 968 and 1972 to over 11 percent of the 1973-1976 cohort. 4 57

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Together these data suggest that a trend toward post- <3octoral train ing was underway even as the Commi t tee formu- lated its recommendations in this area, and that there may be a larger opportunity for postdoctoral programs than ADAMHA is now supporting. Institutions and training directors interested in providing post<3octoral research training support will be challenged to adapt existing patterns of education and to create new training experiences. However, the Committee be- lieves this can be accomplished, and welcomes the commi tment of.ADAMHA and other agencies to this goal. Traineeships/Fellowships Each year the Committee has endorsed the existing ratio of approximately 80 percent traineeships/20 percent fellowships as a suitable mixture for research training in the behav- ioral sciences. Data reveal that this ratio shifted to almost 90 percent traineeships/IO percent fellowships in FYI978. This change appears to be linked to a decline in FYI978 appropriations for ADAMHA (see p. 50~. While this may be a temporary perturbation in the system, the situation merits monitoring during the coming year. The institutional training grant has become the primary mechanism of support over the years in the behavioral sciences. However, in fields such as anthropology and ethology, the research training fellowship provides opportunities for important predoctoral field work. It also assures opportunity for postdoctoral training for some investigators in new or emerging areas for which insti tutional training programs <30 not yet exist. Hence, i t is important that the opportunity -for training through NRSA fel lowship awards not be subs tan tial ly cur ta il ed . The Committee, therefore, continues to recommend support for research training in the behavioral sciences through fellowships as well as institutional traineeships, and affirms its recommendation that the ratio of traineeships to fellowships be maintained at approx imately 80 percent/20 percent through FYI983. Reduction in Behavioral Science Awards As noted ear] ier in this chapter, the number of awards made by NIH in the behavioral sciences deal ined substantial ~ y between 1977 and 1978. Whereas the number of behavioral science awards made by ADAMElA decl ined by about 5 percent between 1977 and ~ 978, the total number of predoctoral and postdoctoral awards made by NIH in the behavioral sciences declined by almost 30 percent during that time. The reasons for this sharp drop are not completely clear. Most of the 58

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reductions occurred in the predoctoral training grants sponsored by NIGMS under the former ~ pre-NRSA) PHS author- ity. Some of the decl ine may be attr ibutable to changes in classif ication. However, the extent to which such behavior- al sciences training is counted in other areas remains to be cl ar i f fed by the Commi ttee in the coming year . CLINICAL SCIENCES In its 1978 Report (NBC, 1975-1978, p. 103), the Committee forecast a need for an annual increment of approximately I, 800 persons to meet requirements created by expansion and attrition of cl inical facul ties in medical schools over the next few years. Postulating a 3-year length of research training experience In the clinical disciplines, the nation- wide pool of postdoctoral research trainees would have to be approximately 5,400 to achieve the described annual in- crement. For purposes of its f unding recommendation, the Committee selected 50 percent of the total pool as the ap- propriate number of persons to be supported under the NRSA Act. The resulting calculations were subsequently adjusted to reflect two additional factors. First, the pool includes doctorate holders other than M.D.'s, such as individuals with the D.V.M., D.D.S., and Ph.D. degrees. Second, demand emanates from employment sites other than medical schools. On the basis of the foregoing, federal support was recommended for 2, 800 postdoctoral trainees and fellows. Since pubI ication of its last report, no new data have be- come available that would lead the Commi ttee to change i ts prey ious recommendat ion . HEALTH SERVICES RESEARCH For over 3 years the Committee has identified health ser- vices research as an emerging area of national need and has described the importance of federal support for research training in this area (NRC, 1975-1978: 1977-1978 Reports). The Committee notes that in his FYI980 budget proposal to Congress, President Carter emphasized two priorities in the health area, which probably require more emphasis on health services research and perhaps additional trained HSR person- ne] (Office of Management and Budget, 1979, pp. 231-232~: Expanded ass istance to improve access to heal th serv ices for those mos t in need . Increased efforts to control ~nf~ ationary growth in health care costs and to e] iminate waste, fraud, and abuse in f ederally suppor ted programs . 59

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The FYl980 budget specifies that $62 mill ion of the proposed $3. 4 billion for heal th research is to be availab~ e for Serb vices research through the Health Care Financing A<3ministra~ tion and NCHSR. It is expected that these funds will be used for research "in the area of technology assessment, cost containment and health planning, regulation and health [and for] survey work essential for some of the decisions to be made for the national health insurance plan" (Office of Management and Budget, 19791. These figures do not include' however, that portion of the ADAMEA research budget that will support an expanded mental health services research ef- fort in keeping with the recommendations of the Report of the President's Commission on Mental Health (1978) e While there is, then, a clearly expressed national com- mitment to improve health care and health services re- search, a comparable commitment to the training of needed health services research personnel is generally racking O The only explicitly identifiable health services re- search training currently under the NRSA authority is that supported by ADAMHA for training in research on mental health, drug abuse, and alcoholism services. In 1978, 136 awards were made for such training ~ see Table 4. ~ ~ O NIH sponsors training under the NRSA authority in basic fields related to health services research ~ such as biosta- tistics r epidemiology, and public health) O However, the present system of recording specialty fields of training has not allowed the Committee to determine the extent to which health services research training actually is being provided through these awards (NRC, ~ 975-1978: 1978 Report, pp. 116-117) .5 Finally, as mentioned earlier, the recent extension of the NRSA authority to permit the use of these awards by the NCHSR makes pass ible a greater commi tment of research training funds to the production of investigators in this area. It is the Committee's hope that a program of general health services research training wit ~ now be established in keeping with this legislative action. In the past 2 years the Committee Cal ~ ed for a 10 per- cent per annum increment in the number of NRSA awards made by ADAMHA in the area of health services research training (NRC, ~ 975-1978: 1977 Report, p. 144) . The Committee notes that this recommendation has not been followed and that, in fact, the number of awards has declined from ~64 in FYI976 to 136 in FYI978. This makes the Committee's former recommenda t ions ou tmoded . Yet the Committee does not cons ider i ts earl ier goals undesi rable. The Committee affirms its recommendation that ADAMBA expand its training in health services research at a rate of ~ O percent per annum from present levels, thus achieving the recommended program levels (Table 4.2 ~ by the mid-1980 's. 60

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NURS ING RESEARCH The research capably ities of many of the schools of nursing mus ~ be improved be fore s bong doctoral tra ining progr ems can be es tabI ished . Hence, the Commi ttee has recommended that NRSA institutional training grants be awarded to schools of nursing primarily to assist in the establishment of interdiscipl inary programs that involve the close co- operation of university departments in the biological, physical, or behavioral sciences. However r where a strong research environment already exists in "well-qua! if led" schools of nurs ding, the Committee has also recommended that a ~ imited number of these institutional grants be provided for doctoral research training. The Committee notes that this recommendation has generated a great deal of controversy wi th in the nurs ing profess ion . This appears to stem in part from a bel ief that interdiscipl inary approaches to training of ten lack strong institutional support (Hansen and Williams, 1979), or will produce investigators without c' ear professional affil ia- tions (Barritt, 1979~. The Committee be' ieves a serious need now exists to provide ample opportunity for nurses to obtain scientific training in relevant basic science disciplines. This need will continue to exist even as schools of nursing bolster the ir programs of research and develop sound nursing educa- Lion programs at the doctorate level. Hence, the Committee affirms its concl usion that opportunities for scientific tra in ing mus ~ be fos tered through ins ti but iotas arrangements that con tr ibute to the advancement of ours ing research . The Committee is aware that its recommendation to ~ imi t training grants to "well-qualifiec]" schools of nursing is perce ived by the nurs ing profess ion as a doubled-edged sword. A majority of nurses endorse the criterion of "ex- cellence" as a prerequisite to NRSA support (Gortner, 1979; Murphy, ~ 979) . Others, however, find that many schools are unable to enhance their research capabilities owing to capricious federal budget pol icies (NRC, 1975-1978: 1978 Re- port, p. 137 ~ . The pr imary concern of the Commi ttee, of course, is that the qual ity of research training in nursing be high. For this reason, the primary need is, and will continue to be, to train nursing researchers in the basic sciences even as the research capabilities of schools of nursing improve. Predoctoral/Pos tdoc tora1 Awards In its 1977 and 1978 Reports (NRC, 1975-1978 ), the Committee recommended an expans ion of the NRSA program from a total of 61

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240 awards in FYI980 to 300 awards in FYl9820 The 'dRA Division of Nursing has made substantial strides in expand- ing the MRSA awards in FYI9 78 . The curren t rate of program growth would suggest that the Division will meet the Com- mittee' s recommended level of NRSA support by the early 1980' s if funds are made avail able. The Committee notes that the bulk of awards have been made for predoctoral supper t in accordance wi th the recommendat ion s of the Committee. In light of these Revel opments, the Committee has concluded that the size of the program and rate of growth recommended in ear] ier reports continue to be appropr late . Fellowsh ips The Commi ttee has suggested in earl ier reports that a ma jor reorientation in fed lowship support provided by the BRA D iv is ion of Nurs ing should occur so that there would be a substantial reduction in training support for study in non- science departments (NRC, 1975-1978 0 1977 Report, p. 164 ~ . Recent data from the Divis ion of Nursing reveal that the proportion of individuals receiving fell owship support in Conscience areas has indeed been reduced. 6 The Committee app] auds these efforts and will continue to monitor the development of this program by the Division. In the meantime, the Committee aff irms its recommendations of previous years. Senior Investigators In its 1978 Report (NRC, 1975-1978, p. 142), the Committee acknow, edged the need to give serious consideration to the recruitment of midcareer investigators whose research ski' Is may need to be upgraded in view of the recent advances in nursing research. The Committee has learned that the HRA Division of Nursing is exploring a program of Senior Investigator Awards that wou, d provide such midcareer opportunities under the auspices of the NRSA authority. The Committee regards its recommendation for fellowship support as adequate to implement such a program on an exper- imental basis at the postdoctoral level. The Committee urges the Division to consider implementing a model program of senior investigator awards within the scope of fellowship support descr ibed by the Commi ttee, and to keep the Commi t- tee informed of progress in this area. 62

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NOTES 1. The Committee has examined cl osely the training grants awarded by NIH in epidemiol ogy and biostatistics and has concluded that these grants do not fall within the Pane' 's definition of HSR (see NRC, 1975-1978: 1978 Report, p. 113). These awards, therefore, are shown in Table 4.l under the biomedical sciences. Similarly, awards made by the NIH in the fields of community and environmental health are also shown under the biomedical sciences, although NTH would define these as HSR. The Panel on HSR is in the process of examining these latter awards , and will report the results of their analysis to the Committee in future reports. ADAMHA provides training in these areas but was not asked to supply data in this format. ADAMHA also provides support for research training of clinicians, but these persons are not considered to be training in the clinical sciences and are reported in other areas depending on the disciplinary focus of their training. 2. Dr. Gerald Klerman, Administrator, ADAMHA, memorandum to Institute Directors, June 29, 1979. 3. Administrator, ADAMBA, memorandum to ADAMHA NRSA Re- search Training Program Directors and Potential Research Training Grant and Fell owship Applicants, December 19, 1979. 4. Dr. Stanley Schneider, Chief, Psychology Education Branch, NIMH, in an unpubI ished report transmi tted to Dr . Pamela Ebert-Flattau, July 24, 1979. 5. The manner in which NTH reports its NRSA awards for the area of health services research training has been discussed extensively between NIR and Committee staff. The Committee has concluded that a two-dimensiona~ matrix, simi' ar to the one developed by ADAMHA, is the best means for the Committee to determine the extent to which these NIH awards are ori- ented toward the research problems that characterize health services research and set it apart from the other biosci- ences (see NRC, 1975-1978: 1978 Report, pp. Il3-~17~. 6. In FYI97B, 26 fellowships were awarded in the behavior- al sciences: 27 in nursing, 10 in education, 4 in health services administration, 2 in the biomedical sciences, and 3 in other fields. Dr. Marie Bourgeois, HRA, Division of Nursing, per sonar communication to Dr. Pamela Ebert-Flattau, April 12, 1979. 63

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