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2020 Vision: Health in the 21st Century 25th Anniversary Keynote Address Honorable Donna E. Shalala, Ph.D. Secretary, U.S. Department of Health and Human Services Let me begin by reading a letter that the White House just sent over to me. Greetings and congratulations to all of those gathered to celebrate the Institute of Medicine's 25 years of devoted public service. Since 1970, the Institute of Medicine has contributed thoughtful and wise health policy analyses covering an extraordinary range of issues from mental health to Medicare, from nutrition to new vaccines, that are of great interest and importance to us all. As we continue to work towards a high-quality, fully accessible health care system for all of our people, your work is essential to maintaining the finest possible care. I am pleased to commend the Institute for its efforts day in and day out to improve the health of the American people. Best wishes for every success in the years to come. [signed] Bill Clinton. I want to thank the Institute of Medicine—not only for inviting me here for this special occasion, but also for lending our administration a team of truly remarkable health care leaders—from Phil Lee to Harold Varmus, from Shirley Chater to David Kessler, from Ruth Kirschstein to Claude Lenfant, and from Bruce Vladeck to Jo Ivey Boufford. In 1971, one of your charter members, Dr. Irvine Page, challenged this Institute to "maintain its integrity, exhibit courage in its decisions, and willingly undertake study of problems that others prefer to shun." For 25 years, with passion and perseverance, you have met that great challenge: 25 years of calling the health care problems facing our most vulnerable citizens by their true name: America's problems;
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2020 Vision: Health in the 21st Century 25 years of rejecting politics and focusing our country's spotlight on critical issues like drug use, vaccines, AIDS, and breast cancer; 25 years of helping this country improve the way it delivers health care and educates our workforce; and 25 years of showing the world how sustained victories in basic science can help us win the ultimate war against some of our greatest enemies, such as stroke, cancer, and heart disease. That has never been more important than right now, because from kitchen tables to the halls of Congress, we are engaged in a historic debate about the role of the federal government. This debate is about much more than the size of our budget and the way we allocate our precious resources. At its heart, this debate is about our values. It's about who we are; it's about what values mean to American children; and, as we peer into the future, it's about the kind of legacy we want to leave our children. Fifty-five years ago, when President Roosevelt dedicated the NIH campus, he summed up our national commitment to biomedical research in this way. He said: "I dedicate it to the underlying philosophy of public health. To the conservation of life. To the wise use of the vital resources of the nation. I voice for America and for the stricken world our hopes, our prayers, our faith in the power of . . . humanity." Since World War II, our historic commitment to biomedical research has spawned a steady march of progress—from the breaking of the DNA code to the mapping of the human genome. Since World War II, through years of Republican and Democratic leadership, that hope—that vision and that commitment to science—has not wavered. It must not waver today. Like war and peace, revolutions in science have defined the ages, transformed our lives, and altered the very course of global history. Like war and peace, investments in science guarantee our national security—and must remain a national priority. That's why, at the Department of Health and Human Services, we recruited the most brilliant scientific minds in the country to lead our national effort—leaders like Phil Lee, Harold Varmus, Bill Paul, Rick Klausner, Francis Collins, and Zack Hall. That's why the president created the National Science and Technology Council to give us an integrated research and development budget that focuses on key national goals. That's why, under the remarkable leadership of David Kessler, we've slashed drug approval times by 50 percent since 1987. That's why we've supported the new science education standards from day one—so that all Americans are introduced to science from the time they start crawling. Finally, that's why, in a time of zero growth across government, our administration has fought—and will continue to fight—for steady increases in research.
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2020 Vision: Health in the 21st Century These efforts have paid off—time and time again. In just the last few years, we saw a team of researchers discover BRCA1, a gene linked to hereditary breast cancer. We helped discover the first drug treatment for severe cases of sickle cell anemia. We sponsored a clinical trial that demonstrated that AZT (azidothymidine) can reduce the risk of perinatal transmission of AIDS by 67 percent. In addition, recently, researchers demonstrated the first treatment ever for the most common type of stroke. Have we made a serious commitment to science and research? Yes, we have. Yet, as we approach the 21st century, is it enough? No, it isn't. We are not even close. In the classic novel, Alice in Wonderland, the Queen of Hearts gives some sage advice to Alice. The Queen explains that every morning, before she eats breakfast, she makes herself believe in the impossible. In fact, she makes herself believe six impossible things. Taking my cue from Lewis Carroll, I believe there are six impossible things that must become possible—that we must make possible—to ensure that America continues to lead the world in research into the next century and beyond. First, let's ensure that the culture of research not only survives—but thrives. We know that research cannot survive with the uncertainty of seven-year budgets and the certainty of evaporating discretionary funding. To create real security for research itself, as well as for our scientists and their students, we must find new ways—more stable ways—of financing research in the future. We all know why this must be our top priority. Because it is only with real security that we can nourish the seeds of research. It is only with real security that we can create an atmosphere in which young investigators are pulled into science, inspired to stay there, and ultimately train the next generation of researchers. We have built a magnificent scientific infrastructure, but it is extremely fragile. Like many of our most cherished treasures, it is hard to build and easy to tear down. One caution—as we search for financial stability and security, we must ensure that we are making every dollar count: That's why, at NIH, we are conducting top-down reviews of our intramural research, so we can spend our money wisely and effectively. That's why we are fine-tuning the peer-review process to ensure that it continues to serve us well in funding the best science. That's why we must focus on prevention. The fact is, about 50 percent of all deaths have their roots in personal behavior. We must invest in all the science that holds the potential to prevent disease and help Americans to live healthier lives—from environmental research to occupational research to behavioral research. Second, we must look beyond the bottom line of profits to the bottom line of progress. I don't have to tell any of you about the impact that cost-
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2020 Vision: Health in the 21st Century cutting is having on some of our most fundamental missions and most cherished institutions. It's not easy or inexpensive to run an academic health center—I know, I ran one. Yet our academic health centers are the envy of the world. They are the places where we unlock our greatest scientific mysteries. They are the places where we educate and train the next generation of scientists. They are often the places where we care for our neediest citizens. Their mandate is unique, and their goals will not survive in the marketplace. Together, we must address the complex—and potentially devastating—pressures squeezing academic health centers today. At our department, we are forming a working group—led by Phil Lee—to do just that. We want to reach out to leaders of academic health centers and help find innovative ways to safeguard the irreplaceable—the absolutely irreplaceable—contributions that these great institutions make. At the same time, we must ensure that we do not punish progress. Therefore: It is time to tackle the perverse economic incentives that discourage experimental studies and other attempts to expand the frontiers of knowledge. It is time to train a health care work force that can respond to and thrive in the next century. Moreover, it is time to protect and strengthen the treasure of clinical research. That's why Harold Varmus has convened a panel to build upon the IOM's recent report on patient-oriented research. Under the leadership of Dr. David Nathan, a group of experts will ask some fundamental questions about how we can protect the critical role—the ''translational role''—of clinical research. We need to know how we can reinforce the link between the laboratory of basic science and the living rooms of our citizens—and how we can ensure that the best science in the world ultimately pays off for all Americans. That brings me to the third impossible thing: Let us ensure that our bioethics are as sophisticated as our science. For every great scientific breakthrough—whether in genetics or in medicine—ethical questions will emerge, and those questions must be addressed carefully and immediately because we must not create a world in which our genetic map is used to deny jobs or health insurance; we must not create a world in which the worthy goal of science eclipses our fundamental sense of humanity, fairness, and values; and we must not create a world in which discoveries of the future widen the chasm between the haves and the have-nots—and send us backward. Fourth, we need to take the long view of basic science. The promise of gene therapy, although awe inspiring, is still far from being realized. That's
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2020 Vision: Health in the 21st Century the tough wake-up call we received recently from a panel of experts, and from it, we were reminded of some important lessons. We were reminded that we must invest more in the foundation of our scientific universe—in the incremental gifts of basic science that will help us unleash blockbuster discoveries over time. We were reminded that we must do a better job of educating the public about what is really possible right now and what is not. We were reminded of the importance of honesty and self-criticism—the importance of being willing to change directions, even in midsentence—if it will help us reach our common goals. Fifth, we cannot move forward by falling back. We cannot even begin to plan for the future of research unless we stop policies that will move this country and its health care infrastructure—public or private—in the wrong direction. When the Republicans in Congress try to take hundreds of billions of dollars out of our health care system and out of the hands of our citizens, that's not progress. When they try to take away the Medicaid guarantee of health coverage for 37 million vulnerable Americans—and replace it with an underfunded, ill-conceived block grant—that's not progress. When they ask us to tear a big loophole in the nursing home standards that the IOM helped create—and allow us to go back to the days when citizens in nursing homes went without vital protections—that's not progress. When they try to slash Head Start, Earned Income Tax Credits, student loans, and other engines that help move people out of poverty—and toward healthier lives—that's not progress. If we allow ourselves to take giant steps backward, we may never catch up again. That's why we believe we must balance the budget without breaking our historic promises to science, our citizens, and our country. That's why, in this budget climate, it is not enough for the American people to simply appreciate science. This brings me to my sixth and final challenge. Sixth, every citizen must be an active constituent of science. Whenever science has leapfrogged over the general public's knowledge, we have been catapulted into confusion, stagnation, and even darkness. Just ask Galileo. To succeed in the 21st century, our obligation must go beyond answering our most perplexing scientific questions. We must hop onto the information superhighway and ensure that critical information about science and health is only a keystroke away for our citizens. Most important, we must write the poetry of science in prose that the American people can understand. We need a sophisticated electorate that has the context and intellectual discipline to absorb the great breakthroughs; an electorate that understands
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2020 Vision: Health in the 21st Century the historical, social, and economic urgency of investing in science; an electorate that cares deeply about science because it understands how science touches and benefits its lives; and an electorate willing to nourish and enhance our investments in good times and—at the very least—to safeguard them from the kinds of indiscriminate budget cuts we are seeing today in Washington. That—above all else—is the key to our collective future. So, let us ask ourselves the following questions: When we are long gone and history books of our time have been written, what will they say about our contributions to the future of science and the future of our country? At a time of great revolutions in both biology and information, did we rise to the challenge? Did we keep our historical promises to our most vulnerable citizens? Did we maintain our strong commitment—our international commitment—to basic science and clinical research? Did we attract, train, and sustain new generations of brilliant scientists—women and men? Did we give the American people the tools they needed to make the right choices with the only lives they will ever have? Did we embrace our common vision and move forward on our common ground? Quite simply, did we do the right thing? Like the dying woman who plants a tree for her grandchildren to enjoy, every seed of science that we plant today, every plot of soil that we cultivate tomorrow, has the potential to open doors and enrich the lives of this generation and of every generation to come.
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