To Improve Human Health

A History of the Institute of Medicine

Edward D. Berkowitz

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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To Improve Human Health: A History of the Institute of Medicine To Improve Human Health A History of the Institute of Medicine Edward D. Berkowitz NATIONAL ACADEMY PRESS Washington, D.C. 1998

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To Improve Human Health: A History of the Institute of Medicine NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 Additional copies of To Improve Human Health: A History of the Institute of Medicine, are available for sale from the National Academy Press, 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’s online bookstore at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www2.nas.edu/iom. International Standard Book No. 0-309-06188-1 Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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To Improve Human Health: A History of the Institute of Medicine Preface In this first formal history of the Institute of Medicine (IOM), Professor Edward Berkowitz describes many of the important events and individuals associated with this institution. Many more decades may have to pass before we can fully appreciate or understand the significance of the Institute's work in the larger context of American life. However, the opportunity for Dr. Berkowitz to interview so many of the people who were part of the Institute's creation including each of its presidents warranted a scholarly appraisal at this time. Memories alone are not necessarily history. Many of those who have been active in the Institute during its short life may have different perspectives about the people and events described in this book. My own view, however, is that Dr. Berkowitz has done an admirable job of capturing both the spirit and substance of the events of the past three decades.* As I read this history, I was struck by two characteristics of the Institute. Despite many ups and downs, successes and near misses, intellectual disagreements, and financial concerns, certain core values have persisted, as has a pervasive sense of optimism that these values can contribute to better health for all people, nationally and internationally. Those core values and that optimism are clearly reflected in this text. From its creation, IOM has been committed to: knowledge and policies that improve health for present and future generations; objective, impartial evidence-based decision-making; anticipating and confronting difficult issues; *   People with additional information, documents, pictures, or perspectives relevant to the history of the Institute are encouraged to send them to the Institute's Reports and Information Office, where they will be collected and transmitted to our archives to benefit future historians.

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To Improve Human Health: A History of the Institute of Medicine interdisciplinary, multifaceted perspectives; self-assessment and continuous improvement of its operations; and the joining of scientific and humanistic values.* Many of the issues that seemed to have imminent solutions when the Institute was founded in 1970 continue to challenge us. There still remain uncompleted agendas for the Institute to tackle, such as access to quality health care for all Americans, the strength of the public health infrastructure, the availability of appropriate care for children and the elderly, America's role in international health, issues of nutrition and food safety, the appropriate training and use of the health care work force, and adequate support for the development of new knowledge in these—and other—areas. As this history documents, the Institute has made important contributions in most of these areas and significant progress in others. With a recollection of the past, we rededicate ourselves to making further progress on these issues in the future. Acknowledgments The Institute has a wonderful tradition that members share in the work instead of delegating it. That tradition is exemplified by the diligent efforts of the IOM History Oversight Committee in guiding the progress of this project, for which I am deeply grateful. They worked with and advised Dr. Berkowitz as he researched and wrote the manuscript, then provided critical comments and suggestions about the draft and its revision. The committee members were Adam Yarmolinsky, LL.B. (Chair), Regents Professor of Public Policy in the University of Maryland System; Gert H. Brieger, M.D., Ph.D., William H. Welch Professor and chairman of the Department of the History of Science, Medicine, and Technology, Johns Hopkins University School of Medicine; Roger J. Bulger, M.D., president, Association of Academic Health Centers, Washington, D.C.; and Elaine L. Larson, R.N., Ph.D., professor in pharmaceutical and therapeutic research, Columbia University School of Nursing. *   From the 1997 Institute of Medicine strategic plan, available on line at: www2.nas.edu/iom/stratplan.pdf.

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To Improve Human Health: A History of the Institute of Medicine I also appreciate the assistance provided by the individuals who reviewed the manuscript: Enriqueta C. Bond, Ph.D., president, Burroughs Wellcome Fund, Durham, N.C.; Barbara J. Culliton, correspondent-at-large, Nature Medicine, Washington, D.C.; Donald S. Fredrickson, M.D., scholar, National Library of Medicine, National Institutes of Health, Bethesda, Md.; Robert J. Glaser, M.D., independent consultant, Menlo Park, Calif.; David A. Hamburg, M.D., President Emeritus, Carnegie Corporation of New York, New York City; John R. Hogness, M.D., President Emeritus, University of Washington; June E. Osborn, M.D., president, the Josiah Macy, Jr., Foundation, New York City; Frederick C. Robbins, M.D., University Professor Emeritus, Department of Epidemiology and Biostatisties, Case Western Reserve University; Samuel O. Thier, M.D., president and chief executive officer, Partners HealthCare System, Inc., Boston; and Karl Yordy, health policy consultant, Tucson, Arizona. Other persons—some of whom are already acknowledged here—gave generously of their time and knowledge through interviews conducted by Dr. Berkowitz. They are Stuart H. Altman, Ph.D.; Roger J. Bulger, M.D.; James D. Ebert; Rashi Fein, Ph.D.; Donald S. Fredrickson, M.D.; Robert J. Glaser, M.D.; David A. Hamburg, M.D.; Ruth S. Hanft, Ph.D.; Karen Hein, M.D.; John R. Hogness, M.D.; Irving M. London, M.D.; David Mechanic, Ph.D.; Henry W. Riecken, Ph.D.; Frederick C. Robbins, M.D.; Samuel O. Thier, M.D.; and Adam Yarmolinsky, LL.B. The long association of each of the above named individuals with the Institute, and their understanding of its triumphs, as well as of its trials and tribulations, make them an invaluable source of knowledge and guidance in the completion of this project I am also grateful for the help provided throughout the project by a number of IOM staff, including Conrad Baugh, Mike Edington, Karen Hein, Sandra Matthews, Janet Stoll, and Jana Surdi. Further, I appreciate the generous grant provided by the Burroughs Wellcome Fund, which has partially supported the publication of this book.

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To Improve Human Health: A History of the Institute of Medicine Most of all, I thank Dr. Edward Berkowitz for the splendid job he has done in writing this history. Although the IOM produces many, many reports each year, this publication is unique: It is a book about the Institute, not from the Institute. This is Dr. Berkowitz's contribution to the institution and to each of us. He has performed this task carefully and well, and he did it on time and on budget, setting an example for all future IOM activities. Kenneth I. Shine, M.D. President Institute of Medicine

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To Improve Human Health: A History of the Institute of Medicine Foreword It is a pleasure for me to have this opportunity to introduce this detailed history of the first 25 years of the Institute of Medicine. My involvement with this institution is of relatively recent origin. I assumed office as president of the National Academy of Sciences on July 1, 1993, some 22 years after the Institute was founded. Since that time, I have had the pleasure of collaborating closely with the Institute's current president, Dr. Kenneth 1. Shine, as well as with many outstanding members and staff. As described in this fine volume, the statutory relationships between the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine are complex ones, overladen with history. By law, our Academy occupies a special position as the original chartering organization. However, from the beginning of my term, I have tried to ignore these complexities as much as possible. Instead, I like to speak of the Institute of Medicine, the National Academy of Engineering, and the National Academy of Sciences as sister organizations, which work together to provide the expertise that our nation badly needs in the areas of health, engineering, and science. These three "academies" oversee our operating arm, the National Research Council. Our extremely active organizations carry out many important policy studies at the request of the U.S. government. Altogether, we publish nearly one report dealing with matters of public policy every working day. We are private entities, and the studies that produce these reports are carried out with complete independence from their sponsors. Indeed, it is precisely this independence that gives our judgments their credibility and great value. Modern technologies have recently allowed us to use these reports to produce a large electronic archive of valuable wisdom based on science, engineering, and health that will remain freely available to all through the Worldwide Web at: www.nap.edu. As the importance of science and technology to our society increases, so does the importance and influence of the four organ-

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To Improve Human Health: A History of the Institute of Medicine izations that make up the "Academy complex." Ours are not merely honorary membership associations: They are instead service organizations with major responsibilities for directing our nation's future. Our forefathers were indeed wise in keeping medicine, engineering, and science so tightly knit together. Increasingly, we find that the problems we are asked to deal with cannot be answered by any single group of disciplines. Instead, the most important problems must often be addressed by the combined efforts of health professionals, engineers, and scientists. Thus, the close collaboration of the Institute of Medicine, the National Academy of Engineering, and the National Academy of Sciences through the National Research Council allows each of us to serve the nation in ways that are much more powerful than could be achieved by any one institution alone. The current leaders of our three institutions—Ken Shine at the Institute of Medicine, William A. Wulf at the National Academy of Engineering, and I—owe a great debt to the many dedicated people who have gone before us. They have created a truly extraordinary set of institutions that are unique in the world. In closing, it has been a privilege for me to work so closely with the Institute of Medicine for the past 5 years. The next 25 years will certainly be even more productive, and I look forward with excitement and great expectations to the Institute's many future contributions to the vitality of our nation and the world. Bruce Alberts, Ph.D. President National Academy Of Sciences

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To Improve Human Health: A History of the Institute of Medicine Author's Acknowledgments A number of people helped make this project a reality: Mark Santangelo, as chief researcher, did admirable work and provided considerable assistance; at George Washington University, Cyndy Donnell typed the transcripts of the many interviews I conducted and Michael Weeks performed a variety of useful tasks; Harry Marks, of Johns Hopkins University, made many helpful sugestions during the course of the project and passed along many valuable documents; Janice Goldblum and Daniel C. Barbiero, of the Archives of the National Academy of Sciences and National Research Council, went out of their way to make Institute of Medicine records accessible. The IOM History Oversight Committee, particularly its chair, Adam Yarmolinsky, gave both me good advice and helpful encouragement. Edward D. Berkowitz, Ph.D.

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To Improve Human Health: A History of the Institute of Medicine Contents 1   Creating the Institute of Medicine   1     The Page Discussion Group   2     Walsh McDermott and the Board on Medicine   8     The Heart Transplant Statement   16     Business of the Board   20     Debate over a National Academy of Medicine   23     Rejection by the National Academy of Sciences   28     The Diplomacy of Reconciliation   33     The Institute of Medicine   38     Conclusion   41 2   The Institute of Medicine Begins Operations   50     Recruiting Members   52     John Hogness   55     Staffing the Institute and Bureaucratic Routines   57     Cancer Wars   60     Entitlement and Health Contrasts   63     Health Effects of Abortion   67     Policy Statements   69     The Costs of Education Study   71     The Program Committee   75     Fund-Raising   76     Organizational Routines   80     Relations with the National Academy of Sciences   82     Donald Fredrickson   84     Conclusion   86 3   The Hamburg Era   95     David Hamburg Arrives   96     Ruth Hanft and the Social Security Studies   98     The Institute Recharts Its Course   100     Reorganization   105     Clearing the Pipeline   107

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To Improve Human Health: A History of the Institute of Medicine     The Malpractice Study and the Polio Study   109     The Embrace of the Carter Administration   113     Working for the Carter Administration on International and Mental Health   115     Working with the Carter Administration: The Dental Study and the Surgeon General's Report   120     Riddles of Power   124     Fund-Raising   125     Defining the Institute's Mission   127     Conclusion   128 4   Fred Robbins and the Sproull Report   134     Searching for Frederick Robbins   135     Backlist of Projects   138     The Ebert Report   145     Advent of the Reagan Administration   148     Studies During the Reagan Era   151     Fund-Raising   160     The Sproull Report   162     Defending the Institute of Medicine   168     Conclusion   172 5   Expansion of the Institute of Medicine   179     Samuel Thier and the Outreach to Foundations   179     Report Dissemination and Expansion of the Institute   184     The Institute's Program   192     Organizational Routines   204 6   The Institute of Medicine and AIDS   211     Facing Up to the Problem   212     Toward the 1986 Report   215     The 1986 Report   220     AIDS Workshops   224     Toward the 1988 Report   227     The 1988 Report   230     Advice for the President   232     The Institute's AIDS Activities   233     Continuing Interest in AIDS   237     The Institute and AIDS   243 7   The Institute of Medicine at Twenty Five   249     Kenneth Shine Arrives   249     The Inner Details of Health Care Policy   250

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To Improve Human Health: A History of the Institute of Medicine     The Institute as Public Health Crusader   252     Science and Politics   258     The Institute's Audience   260     Strategic Planning and the Health Security Plan   263     The National Academy of Medicine?   267     Summing Up   268     Index   277

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