2020 VISION

Health in the 21stCentury

Institute of Medicine 25thAnniversary Symposium

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS

Washington, D.C.

1996



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2020 Vision: Health in the 21st Century 2020 VISION Health in the 21st Century Institute of Medicine 25th Anniversary Symposium INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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2020 Vision: Health in the 21st Century National Academy Press 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Institute of Medicine's Council. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The Institute gratefully acknowledges the generous support of the following organizations toward its 25th anniversary activities: Albert Einstein College of Medicine of Yeshiva University; Carnegie Corporation of New York; Columbia University College of Physicians and Surgeons; The Commonwealth Fund; Kaiser-Permanente; Memorial Sloan-Kettering Cancer Center; The Mount Sinai Hospital/Mount Sinai School of Medicine; The New York Hospital; The Pew Charitable Trusts; Times Mirror Company; University of California, Irvine; University of Florida Health Science Center; University of Medicine and Dentistry of New Jersey; University of Rochester Medical Center; University of Southern California; and Yale University School of Medicine. Corporate benefactor: Bristol-Myers Squibb. Corporate patrons: The Hoffmann-La Roche Foundation; Merck & Co., Inc.; and Pfizer, Inc. Corporate sponsors: Amgen, Inc.; Eli Lilly and Company; Marion Merrell Dow, Inc.; Procter and Gamble; Sandoz Pharmaceuticals Corporation; Schering-Plough Corporation; G.D. Searle and Company; and The Upjohn Company. International Standard Book Number: 0-309-05488-5 Library of Congress Catalog Card Number: 96-68279 Additional copies of this publication are available from: National Academy Press, Lock Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 in the (Washington metropolitan area), or visit the NAP on-line bookstore at http://www.nap.edu/nap/bookstore/. Call (202) 334-2352 for more information on the other activities of the Institute of Medicine, or visit the IOM home page at http://www.nas.edu/iom/. Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. COVER: Plate #753 by Robert Sperry. Stoneware, white slip over black glaze, 1987. Courtesy of the National Museum of American Art, Smithsonian Institution; gift of the James Renwick Alliance. This and other of Mr. Sperry's works were shown at the National Academy of Sciences through Arts in the Academy, a public service program of the National Academy of Sciences. Cover design by Linda Humphrey.

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2020 Vision: Health in the 21st Century INSTITUTE OF MEDICINE 25TH ANNIVERSARY SYMPOSIUM PLANNING COMMITTEE KENNETH I. SHINE, M.D. (Chair), president, Institute of Medicine, Washington, D.C. JORDAN J. COHEN, M.D., president, Association of American Medical Colleges, Washington, D.C. SR. ROSEMARY DONLEY, S.C., executive vice president, The Catholic University of America JOHN M. EISENBERG, M.D., chairman and physician-in-chief, Department of Medicine, Georgetown University Medical Center RUTH S. HANFT, Ph.D., consultant, Alexandria, Virginia BARBARA C. HANSEN, Ph.D., director, Obesity and Diabetes Research Center, and Professor, Department of Physiology, School of Medicine, University of Maryland at Baltimore MICHAEL M. E. JOHNS, M.D., vice president and dean of the Medical Faculty, The Johns Hopkins University School of Medicine ELAINE L. LARSON, Ph.D., dean, Georgetown University School of Nursing CLAUDE LENFANT, M.D., director, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland FITZHUGH MULLAN, M.D., director, Bureau of Health Professions, and assistant surgeon general, U.S. Public Health Service, Rockville, Maryland ROBERT F. MURRAY, JR., M.D., professor of pediatrics, medicine, and genetics, Howard University College of Medicine BARBARA STARFIELD, M.D., University Distinguished Service Professor, Division of Health Policy, The Johns Hopkins University School of Hygiene and Public Health DONALD E. WILSON, M.D., dean, School of Medicine, University of Maryland at Baltimore Staff KAREN HEIN, M.D., executive officer JANA H. SURDI, director, Office of Council and Membership Services JOAN SIEBER, administrative assistant, Office of Council and Membership Services DON TILLER, administrative assistant, Division of Health Care Services (until February 1996)

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2020 Vision: Health in the 21st Century Preface After about a decade of planning, consultation, and negotiation, 30 people received a charter on December 17, 1970, to establish the Institute of Medicine (IOM). As part of the National Academy of Sciences (NAS), the IOM's mission is to advance scientific knowledge and the health and well-being of all people of this nation and the world consistent with the roles conferred upon it by its congressional authority. That congressional authority extends back to the 1863 NAS charter authorized by the Congress and signed by President Abraham Lincoln, in which the Academy was asked to advise the government on issues related to science and the arts and to do so without a fee. Thus, all of our work is done by committees of experts who work without honoraria, pro bono, with the support and assistance of an outstanding staff. The Institute is greatly indebted to its many members and others who have worked on these committees over the years. This list of people, through whose service the nation and world have benefited, is long and distinguished. We deeply appreciate their efforts and commitment. The Institute accomplishes its mission by providing objective, timely, and authoritative information to government, the health professions, and the public through both its elected membership and through its access to people with the insight and expertise needed to tackle major issues of the day. The results of IOM's work are exemplified by the variety of reports and other activities produced over the years and the impact we have had on society. As part of the ongoing celebration of the IOM's 25th anniversary over the last year, we have already touched upon our past accomplishments, both at the 25th Anniversary Annual Meeting and in the publication For the Public Good: Highlights from the Institute of Medicine, 1970–1995.

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2020 Vision: Health in the 21st Century Therefore, we thought it fitting to dedicate the 25th Anniversary Symposium to a look ahead at the next 25 years. The title of the symposium, "2020 Vision," was not selected to satisfy our members who are ophthalmologists, but in recognition of the fact that IOM will then be 50 years old. What challenges will we face in the years to come, and what forces will affect our lives, our health, and our health care system in 2020? If we can take a clue from the past, the challenges are likely to be significant and, at least to some degree, unpredictable. In December 1970, at the time of IOM's founding, Hodgkin's disease was essentially uniformly fatal, childhood leukemias were largely fatal, bone marrow transplants were a highly experimental activity, and many kinds of organ transplants were only hopeful dreams in the minds of researchers. Thanks to technological advances and research breakthroughs, that picture has changed considerably in the intervening years. However, we also have witnessed the emergence of HIV/AIDS and the reemergence of old enemies such as tuberculosis—serious reminders that we should not take too much comfort in the battles we've won, as we still have far to go. Therefore, we look to the future grounded in a rich past, and confident that whatever lies ahead, the Institute of Medicine will be there to play its part in finding solutions, answering questions, and guiding policymakers in the effort to improve the public health, both in the United States and worldwide. Kenneth I. Shine President, Institute of Medicine

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2020 Vision: Health in the 21st Century Acknowledgments As with all endeavors such as this, "2020 Vision: Health in the 21st Century"—both the symposium itself and this volume containing its proceedings—would not have been possible without the efforts and energy of a large group of dedicated people. These include the members of the symposium planning committee: Jordan J. Cohen, Sr. Rosemary Donley, John M. Eisenberg, Ruth S. Hanft, Barbara C. Hansen, Michael M. E. Johns, Elaine L. Larson, Claude Lenfant, Fitzhugh Mullan, Robert F. Murray, Jr., Barbara Starfield, and Donald E. Wilson; the Institute of Medicine staff who helped organize and carry off the event: Joan Sieber, Jana Surdi, and Don Tiller; IOM's executive officer, Karen Hein; our distinguished speakers: Baruch S. Blumberg, Robert M. Carey, Lincoln C. Chen, Don E. Detmer, John M. Eisenberg, Richard G. A. Feachem, Jeff Goldsmith, Paul F. Griner, Michael M. E. Johns, Lawrence S. Lewin, Edward H. O'Neil, the Honorable John E. Porter, the Honorable Donna E. Shalala, and Donald E. Wilson. In addition, we appreciate the work of Claudia Carl and Mike Edington from the Institute's Reports and Information Office, Dawn Eichenlaub and Sally Stanfield from the National Academy Press, and our graphic designer, Linda Humphrey, for their help in the production and publication of this volume. Kenneth I. Shine President, Institute of Medicine

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2020 Vision: Health in the 21st Century Contents     OVERVIEW AND INTRODUCTION Donald E. Wilson   1     OPENING ADDRESS The Honorable John E. Porter   4 PART I: THE BIG PICTURE         WORLD POPULATION AND HEALTH Lincoln C. Chen   15     INFORMATION AND COMMUNICATIONS Don E. Detmer   24     GLOBAL HEALTH Richard G. A. Feachem   37 PART II: IMPLICATIONS FOR HEALTH         INTRODUCTION TO AFTERNOON SESSION John M. Eisenberg   47

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2020 Vision: Health in the 21st Century     RISK AND RESPONSIBILITY: THE EVOLUTION OF HEALTH CARE PAYMENT Jeff Goldsmith   49     Response John M. Eisenberg   58     INSTITUTIONS AND HEALTH Lawrence S. Lewin   65     Response Robert M. Carey   74     NEW KNOWLEDGE FOR HEALTH Baruch S. Blumberg   81     Response Michael M. E. Johns   89     THE WORKFORCE FOR HEALTH Edward H. O'Neil   93     Response Paul F. Griner   102     25TH ANNIVERSARY KEYNOTE ADDRESS The Honorable Donna E. Shalala   108     CONCLUDING REMARKS Kenneth I. Shine   114     CONTRIBUTORS' BIOGRAPHIES   117

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2020 Vision: Health in the 21st Century 2020 VISION Health In the 21st Century

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