Wrap-up

Kenneth I. Shine

Institute of Medicine

“A little over four years ago, a group of about a dozen of us gathered together on a Sunday to discuss with Harold Varmus what might happen in the course of a doubling of the National Institutes of Health (NIH) budget, and I raised a question about NIH’s investment in the social and behavioral sciences,” Dr. Shine began. “Harold’s response was: ‘I understand where the frontiers are in research in genomics. I don’t know where the frontiers are in research in the social and behavioral sciences.’ ”

His comment was not a hostile one, Dr. Shine recalled; he was simply asking for guidance. In response, several projects have since been undertaken to help enlighten such influential decisionmakers: the report titled Promoting Health: Intervention Strategies from Social and Behavioral Research supported by the Woodruff Foundation; the six National Research Council and Institute of Medicine reports, supported by NIH, Center for Disease Control (CDC), and the Robert Wood Johnson Foundation, that are the basis of this symposium; and continuing efforts by the National Research Council (NRC) and the Institute of Medicine (IOM) “in both the research and practice of what we need to do with regard to the social and behavioral sciences.”

IOM’s projects in these areas that are currently underway include a congressionally mandated study on racial disparities; a study on the vision of public health for the 21st century; a congressionally mandated study on the structure of the NIH with regard to existing institutes, their relation-



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Wrap-up Kenneth I. Shine Institute of Medicine “A little over four years ago, a group of about a dozen of us gathered together on a Sunday to discuss with Harold Varmus what might happen in the course of a doubling of the National Institutes of Health (NIH) budget, and I raised a question about NIH’s investment in the social and behavioral sciences,” Dr. Shine began. “Harold’s response was: ‘I understand where the frontiers are in research in genomics. I don’t know where the frontiers are in research in the social and behavioral sciences.’ ” His comment was not a hostile one, Dr. Shine recalled; he was simply asking for guidance. In response, several projects have since been undertaken to help enlighten such influential decisionmakers: the report titled Promoting Health: Intervention Strategies from Social and Behavioral Research supported by the Woodruff Foundation; the six National Research Council and Institute of Medicine reports, supported by NIH, Center for Disease Control (CDC), and the Robert Wood Johnson Foundation, that are the basis of this symposium; and continuing efforts by the National Research Council (NRC) and the Institute of Medicine (IOM) “in both the research and practice of what we need to do with regard to the social and behavioral sciences.” IOM’s projects in these areas that are currently underway include a congressionally mandated study on racial disparities; a study on the vision of public health for the 21st century; a congressionally mandated study on the structure of the NIH with regard to existing institutes, their relation-

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ships to one another, and additional kinds of programs; and a project on health communication. Today’s presentations are themselves important contributions to delineating the frontiers of research in the social and behavioral sciences, Dr. Shine said, and he proceeded to share some of his reactions to them. First, he agreed that multidisciplinary efforts—essential if the social and behavioral sciences are truly to have an impact on health—imply the need to learn a new vocabulary. Terms like social network, social ecology, norms, ecometrics, and allostatic loads can be confusing for those who are not experts in their respective fields of origin. Thus “one of the greatest challenges,” Dr. Shine said, will be in “making the language more explicit and more precise and to increase the amount of common understanding.” He observed that even in the course of producing the six NRC and IOM reports, “I was struck, in the deliberations of the committees, by the number of times in which there were either misunderstandings of language or unwillingness to accept particular uses of language—particularly among individuals coming to the problem from different disciplines.” That being the case, he added, imagine “the problem of how the public, or funders, or policymakers are going to understand what you’re talking about.” The need to simplify, clarify, and generally improve the quality of communication is particularly important at the interface between social/behavioral sciences and biology, Dr. Shine said. “There are major obstacles here, as we talk with each other, about what we mean in terms of hypotheses, methods, and research design.” And it’s essential that a sense of audience also pervade communication with potential patrons, he noted. For example, though the need for “multilayered comprehensive approaches”—a term that has appropriately come up at this symposium—is indisputable, “I hope that nobody tries to convince a congressional committee that there ought to be more funding for [studies] based on multilayered comprehensive approaches.” The challenge is to show that need, clearly and concretely. Other challenges mentioned at this symposium that we need to keep in mind include maintenance and scaling-up, Dr. Shine said. For example, “I’d like to know, in a weight reduction intervention in the community, how long that lasted” after the activities—often requiring an enormous investment of time, effort, and energy—were terminated. Similarly, he continued, we have a major problem with scaling-up—in generalizing—activities. “We do a very good job with isolated projects, usually around an enthusiastic or charismatic leader,” he said. But it’s strik-

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ing how often that leader’s presence determines the outcome, which we are then unable to duplicate. “We need to ask ourselves, in every case where we fund an activity: What is the essence of it that will allow it to be generalized? And what would be its requirements? And what would be required to maintain it?” There was some discussion today about the “magnitude of change,” Dr. Shine said, and “that is a very, very, very important concept.” If, for example, we wring our hands that certain interventions at reducing substance abuse—say, involving cocaine or heroin—have “only” increased the number of cures from 12 to 20 percent, that completely misses the social and individual value of having almost twice as many people who are now drug-free. Similarly, improving the vaccination rate for the nation by “only” 2 or 3 percent may seem marginal, “but in terms of the number of human lives that are affected, that is spectacular. And if it’s your kid, it’s your whole world. We need to address that issue and to communicate it much more effectively,” he said. Although Dr. Shine agreed that multiple interventions are often needed, there still has to be some sense of priority setting. “We don’t have the resources to do everything,” he said, so we need to distinguish the questions that can be answered from those that cannot. For example, at-risk populations often merit high priority not only for reasons of equity, morality, or compassion, but also because they provide a mechanism for asking clearer questions and getting clearer answers. Another illustration of priority setting: “You may be aware that 20 conditions account for 80 percent of health care expenditures in the United States,” Dr. Shine said; IOM has recommended 15 of those to be targets. Each of the targets should entail treatment and prevention approaches geared to individuals, along with public health, population-based strategies. And each orientation complements the other. “We believe that focusing on integrated care, care systems, and multidisciplinary care has the potential to create resonance with some of the things we are talking about in public health,” he said. Meanwhile, Dr. Shine noted, “our discussions with medical school deans, accrediting organizations, and others [who examine physicians] is that there ought to be increased training in population issues and prevention” because “clearly we are too far over on the individual side.” Still, he cautioned, “this is not about populations versus individuals. It is about populations and individuals. Figuring out how to balance that and where

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the resources are to go obviously requires a resetting, if you will, of the thermostat.” Another needed balance is between reductionism and integration. “The 20th century was, and maybe the first decade of the 21st century will be, a continuation of the biomedical reductionist approach,” he said. “But biomedicine is already beginning to turn the corner. Once you start talking about gene products, protein structure, the structure of cells, the structure of organs, the mind in terms of neuroscience, you will see serious integration beginning to take place.” There are some synergisms here that we should take advantage of, Dr. Shine said. “Those in public health need to piggyback to some extent on what happens in biomedicine and the health care delivery system, and those in biomedicine and the health care delivery system need to work with colleagues in public health, and not make this an either-or kind of a proposition.” But with regard to another trade-off mentioned at this symposium—of advocacy versus science—Dr. Shine urged researchers to stick with science. “An enormous problem in the entire field of the social and behavioral sciences arises from the notion that we mix everything into it—poverty, income redistribution, all kinds of stuff that has political connotations,” he said. “But the best way we can address these kinds of problems is by doing the very best science—objective, well-placed, evidence-based science.” Providing such solid analysis will in the long run be far more persuasive to the media, the public, and its leaders, he insisted, than when researchers complicate matters by inserting themselves into the political process. Mixing beliefs with facts can cause complications even closer to home. The six NRC and IOM studies we have talked about today were not easy to do, Dr. Shine noted. In fact, he considered them to be among the hardest studies he has been involved with during his nine and a half years at IOM. “As I look back at why they were hard, it wasn’t because the data were not sufficient,” he said, “but because many of the people on our committees—and God bless all of them, 104 plus the chairs; they did a splendid job—came with belief systems that may or may not have been based on data.” Referring to his point about language at the beginning of these remarks, Dr. Shine concluded, “It is very important that we enhance our understanding of each other, and that in our deliberations we work very hard to look at the data.”