4
Fred Robbins and the Sproull Report

On March 19, 1980, David Hamburg informed the Institute of Medicine Council that Frederick C. Robbins, dean of the Case Western Reserve University School of Medicine, had accepted the offer of the National Academy of Sciences (NAS) to become the IOM's next president. The appointment, he said, had been welcomed "enthusiastically" by all and constituted the "most positive response" that he had ever seen to a change in organizational leadership.1 The leaders of the IOM realized that Robbins would need all the goodwill he could muster. If nothing else, raising funds would be difficult in an economy that was suffering from stagnant employment and sharply rising prices. A week later, Theodore Cooper, head of the IOM Program Committee and former Assistant Secretary for Health in the Ford administration, elaborated on the problems that Robbins would have to solve. Cooper said that the IOM could not let the "somewhat depressing overall economic picture in the country'' lower the level of creativity at the IOM, nor could it let "funding sources control its program" during a period of fiscal constraint.2

As things turned out, Robbins did face many trials. Some of these challenges came from external conditions, such as the state of the economy and the change in administration from Democratic to Republican. Others stemmed from internal conditions, such as the change of administration at the National Academy of Sciences. The Robbins era culminated at the end of 1984 with a report from an NAS committee that seriously questioned whether the IOM should continue to exist as an entity of working members who engaged questions of social importance. The report implied that the IOM designed by Walsh McDermott should come to an end and a new National Academy of Medicine should take its place. Ultimately, Robbins managed both to expand upon the work of David Hamburg and to reaffirm the concept of the IOM. Child health became an important area of concern for the IOM during the Robbins years; so did studies related to vaccine supply and medical technology. Still, there were always distractions. Just as organizational questions had



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To Improve Human Health: A History of the Institute of Medicine 4 Fred Robbins and the Sproull Report On March 19, 1980, David Hamburg informed the Institute of Medicine Council that Frederick C. Robbins, dean of the Case Western Reserve University School of Medicine, had accepted the offer of the National Academy of Sciences (NAS) to become the IOM's next president. The appointment, he said, had been welcomed "enthusiastically" by all and constituted the "most positive response" that he had ever seen to a change in organizational leadership.1 The leaders of the IOM realized that Robbins would need all the goodwill he could muster. If nothing else, raising funds would be difficult in an economy that was suffering from stagnant employment and sharply rising prices. A week later, Theodore Cooper, head of the IOM Program Committee and former Assistant Secretary for Health in the Ford administration, elaborated on the problems that Robbins would have to solve. Cooper said that the IOM could not let the "somewhat depressing overall economic picture in the country'' lower the level of creativity at the IOM, nor could it let "funding sources control its program" during a period of fiscal constraint.2 As things turned out, Robbins did face many trials. Some of these challenges came from external conditions, such as the state of the economy and the change in administration from Democratic to Republican. Others stemmed from internal conditions, such as the change of administration at the National Academy of Sciences. The Robbins era culminated at the end of 1984 with a report from an NAS committee that seriously questioned whether the IOM should continue to exist as an entity of working members who engaged questions of social importance. The report implied that the IOM designed by Walsh McDermott should come to an end and a new National Academy of Medicine should take its place. Ultimately, Robbins managed both to expand upon the work of David Hamburg and to reaffirm the concept of the IOM. Child health became an important area of concern for the IOM during the Robbins years; so did studies related to vaccine supply and medical technology. Still, there were always distractions. Just as organizational questions had

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To Improve Human Health: A History of the Institute of Medicine preoccupied the Board on Medicine, so structural matters consumed the time of Fred Robbins. Although the IOM survived the challenges that arose between 1980 and 1985, the ordeal sapped some of the organization's energy that could otherwise have gone into its expansion. Searching for Frederick Robbins In picking David Hamburg's successor, the IOM knew it had a reasonable amount of lead time. Hamburg announced his resignation at the beginning of 1979, and a new IOM president would not have to be in place until the fall of 1980. In March 1979, the IOM created a search committee, composed of members of the Executive Committee, two other members of the IOM Council, and one former Council member. This group selected William Danforth, the chancellor of Washington University in St. Louis, to be its chairman. At its first meeting, the search committee elaborated on the desirable qualities for an IOM president. Some of the characteristics, such as "leadership ability" or a "knack for institution building," were self-evident, but others revealed a great deal about the culture of the IOM. Membership in the National Academy of Sciences was "desirable but not essential"; an M.D. degree was "preferable but not decisive." The committee noted that a ''research scientist" might be acceptable if he or she had ''good rapport with" and "recognized stature in" the health professional community, implying that it was unlikely the search committee would select, for example, an economist. The IOM was about medicine and would, in all likelihood, be lead by a medical doctor, preferably one who knew something about health policy, who had gained an international perspective on the issues, and who had an "appreciation of the need for constant attention to fund-raising."3 The search committee looked for help from two individuals. One was Walsh McDermott, who had been active in all of the previous searches and was the resident expert on the IOM's original mission. The other was Julius Richmond, who had chaired the previous search, which was widely regarded as a great success, and who was in touch with the latest developments in health policy through his government post as Assistant Secretary of Health. The committee's choice of advisers reflected its desire to keep the selection process within the IOM family and not to broaden the search much beyond the IOM and the world of academic medicine. The committee decided, for example, not to advertise the position in a widely circulated publication such as the New York Times. Instead of putting an ad in a newspaper or

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To Improve Human Health: A History of the Institute of Medicine journal, William Danforth solicited nominations from medical school deans, the presidents of 50 colleges, and IOM members.4 Despite the closely held nature of the process, the search yielded more than 140 nominations. The search committee interviewed eight candidates and submitted a final list of four to the IOM Council. By the end of 1979, the search committee and the Council had put Frederick Robbins at the top of the list. "Fred Robbins is clearly our first choice," William Danforth told NAS President Philip Handler, "we recommend that all efforts be made to secure his services."5 Robbins's career path resembled that of other IOM presidents. After receiving his undergraduate degree at the University of Missouri, he went first to the University of Missouri Medical School and then to Harvard, where he completed his M.D. During the war, Robbins did important laboratory work for the army, identifying the agent that caused a certain form of pneumonia. After the war, Robbins returned to Harvard and continued his work as a pediatrician with a strong research interest in infectious diseases, joining John F. Enders' laboratory and participating in the studies of viruses that caused mumps and polio. The work that Enders, Thomas Weller (who was a charter member of the Institute of Medicine), and Robbins did in cultivating the polio virus earned them the Nobel Prize in medicine in 1954. By this time, Robbins had already left Harvard to become director of pediatrics and contagious diseases at Cleveland's City Hospital and professor of pediatrics at Case Western Reserve University. News of Robbins's Nobel Prize caused quite a stir in Cleveland, although Robbins's wife Alice claimed to be unimpressed, because her father, as it turned out, had also won a Nobel Prize.6 Robbins spent the bulk of his career at Case Western. In 1966, he became dean of the Medical School and succeeded in making this school one of the most exciting places to study medicine in the nation. As dean, Robbins fostered the creation of new departments of Community Health and Family Medicine, and he made sure that students received a solid grounding in primary care. Presiding over turbulent times in a calm and unflappable manner, he was, according to his Case Western colleagues, a capable leader, willing to compromise, rather than a firebrand or an innovator. "I'm not going to revolutionize things," he told a reporter at the time of his appointment as IOM president. He sought at first simply to continue the program that David Hamburg had begun.7 Robbins was already an IOM insider. Like David Hamburg and Donald Fredrickson at the time of their selection as IOM president, he had served on the IOM Council. Unlike these two, Robbins had

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To Improve Human Health: A History of the Institute of Medicine also been in residence at the IOM as a senior scholar. Taking a sabbatical during 1977–1978, he came to the IOM and chaired the steering committee for the studies of saccharin and food safety policy. As a member of the IOM's Executive Committee, Robbins might be thought of as part of the Hamburg administration, in a manner analogous to a federal cabinet officer. With perfect justification, Hamburg could tell the members of the IOM that "Fred has been deeply committed to the tasks of the Institute." His accomplishments as physician, scientist, educator, administrator, and government adviser matched "the breadth of the Institute's mission."8 Robbins was accomplished, in a sense that set him apart from those who had already served as IOM presidents. At the time of his appointment, Robbins was 63, only three years away from being designated a senior member. He had already been a dean, already become a member of the National Academy of Sciences, and already won the Nobel Prize. Walsh McDermott hoped that the IOM would be led by young and vigorous men and that its ranks would constantly be replenished by younger men. Hogness, Fredrickson, and Hamburg were all young men on the rise, and each went on to greater prominence after having served as IOM president. Hogness became a university president; Fredrickson served as head of the National Institutes of Health (NIH) and head of a foundation; Hamburg took a job at Harvard and then became the head of the Carnegie Corporation. It was unlikely that Robbins, who would be 68 at the end of his term, would follow a similar path. Unlike the personable and energetic Hogness, the intensely intellectual Fredrickson, or the charismatic Hamburg, Fred Robbins, an affable and highly competent man, would maintain what others had created. From the very beginning, he faced an uphill fight. The first thing that NAS President Philip Handler told him was that Handler should never have allowed the IOM to get started. The 1980 annual meeting, held in the middle of October, marked the formal beginning of the Robbins era. The program that year featured a look at health in the new decade and included speeches by Robert Wood Johnson Foundation head David Rogers, Nobel laureate geneticist Joshua Lederberg, future Nobel laureate economist Kenneth Arrow, and distinguished jurist David Bazelon. Much of the program was celebratory in nature. On the first day, the Institute held a special symposium in honor of David Hamburg in which five distinguished scientists gave papers on "Adaption, Stress, and Coping." The inauguration of Frederick Robbins came on the second day. The audience heard a message from John Enders who reminisced

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To Improve Human Health: A History of the Institute of Medicine about Robbins's days at Harvard and a speech by Philip Handler on Robbins's scientific and medical contributions.9 Backlist of Projects As Robbins settled in as head of the IOM, he administered a series of projects that began in the Hamburg era and came to a conclusion during his presidency. The situation resembled that of the new head of a Hollywood studio, who had first to market his predecessor's films before he could promote his own. Robbins found a backlist of at least five projects that, in a manner typical of the Institute of Medicine, covered a wide range of subjects. Some, such as the airline pilot study, were narrow in focus yet of vital interest to the groups involved. The study stemmed from a controversy that had arisen over a Federal Aviation Administration (FAA) rule prohibiting commercial aviation carriers from allowing anyone over 60 to pilot or copilot a plane. As the generation of pilots trained in World War II and Korea aged, they began to feel that the FAA rule was discriminatory and unnecessary. They formed groups such as the Pilots' Rights Association and petitioned Congress to pressure the FAA to change the rule. Congress responded, as it did in many controversial situations, by calling for a study of the matter.10 At the beginning of 1980, Donald Fredrickson, the head of NIH, contacted David Hamburg about having the IOM do the congressionally mandated study. Although the IOM Council reacted with enthusiasm, it took many months for federal officials to decide if they wanted to enter into a contract with the IOM or whether they preferred to do the study in-house. Not until June was a contract signed and a study group appointed. The IOM panel would confine itself to objective medical findings on the subject of pilot performance and age, and the National Institute of Aging would use the data as part of its formal response to Congress. 11 The IOM decided to form a series of task forces to examine the effects of aging on various bodily systems, for example, one that focused on the cardiovascular system. The group made site visits to places such as the American Airlines Flight Academy in Dallas, Texas, where it hoped to acquire a sense of the physical skills involved in flying a plane. The final report, a product of the IOM's Division of Health Sciences Policy and a steering committee headed by Robert F. Murray, chief of the Division of Medical Genetics at Howard, appeared in 1981, about five months after Fred Robbins's inauguration.

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To Improve Human Health: A History of the Institute of Medicine The report was decidedly tentative in tone. On the one hand, the group noted that for significant acute events, such as a heart attack or stroke, age 60 did not mark the beginning of a period of special risk. On the other hand, the group concluded that "subtle changes that may adversely affect pilot performance" increased with age. A pilot's skills deteriorated with age, yet there was great variation among individuals in any particular age group. The committee implied that tests of individual acuity should be developed that could take the place of a blanket exclusionary rule. In the end then, the report called, as did nearly every IOM report, for further research that would make such tests possible.12 Another study on the backlist concerned nursing education and marked a throwback to the large data-gathering studies that had been done by Ruth Hanft. Just as the IOM was asked to investigate how the federal government should subsidize medical education at the beginning of the 1970s, so it received a similar request to investigate nursing education at the end of the decade. In the Nurse Training Amendments, passed in 1979, Congress sought the IOM's help in resolving a controversy over whether there should be continued federal support of nursing education. Although the study would not involve the data-gathering efforts that had marked the earlier study supervised by Hanft, it was nonetheless a large and ambitious undertaking that was scheduled to take two years to complete.13 The Institute of Medicine asked Arthur Hess to head the steering committee that included some truly distinguished practitioners in the field of health services research. Hess was a veteran bureaucrat from the Social Security Administration who had helped launch the Medicare program. Other members included Otis Bowen, a medical doctor from Indiana who later became governor of Indiana and Secretary of Health and Human Services; Stuart Altman, dean of the Heller School of Social Welfare at Brandeis; Saul Farber, head of the Department of Medicine at New York University; John Thompson, a professor of nursing education at Yale; Isabel Sawhill, a specialist in manpower policy at the Urban Institute; and Linda Aiken, a nurse with a Ph.D. in sociology who worked for the Robert Wood Johnson Foundation. This panel plunged into the complexities of federal subsidies for nursing education. The tone of the 1983 report, a product of the IOM's Division of Health Care Services, revealed some of the differences that had occurred over the course of a decade in the field of social policy. The nursing report, unlike the IOM's earlier report on federal support for medical education, did not reflexively call for more federal spending or regulation. On the contrary, the group concluded that "no specific

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To Improve Human Health: A History of the Institute of Medicine federal support is needed to increase the overall supply of registered nurses, because estimates indicate that the aggregate supply and demand for generalist nurses will be in reasonable balance during this decade." Despite this finding, the study group had no intention of abandoning the IOM's earlier efforts at social reform, arguing, for example, that states and private employers should facilitate the actions of nurses who wished to upgrade their skills, particularly those nurses who wished to pursue clinical, rather than administrative, careers. In a similar vein, the group believed that the federal government should cosponsor, with states and private foundations, demonstration projects designed to alleviate nursing shortages in medically underserved areas and that the federal government should institute a "competitive" program to provide scholarships for members of minority and ethnic groups who wanted to be educated as nurses. Nurse practitioners also received the study group's endorsement, as in the recommendation that the federal government should continue to support the training of nurse practitioners who were needed in medically underserved areas and in programs caring for the elderly. Words such as "competitive" and public-private or federal-state "partnerships'' reflected the new conservative tone of the era. One could no longer simply assume that health professions education was a public good deserving of federal support or that an increase in the number of health care practitioners was socially desirable. At the same time, the report made it clear that the study group and, one might infer, the Institute of Medicine believed in a strong federal presence in the field of health manpower.14 The government's proper role in maintaining an adequate supply of doctors also figured in a study the IOM carried out for the Department of Defense on graduate medical education in the military. A doctors' draft, meant to handle the contingencies of the Vietnam War, ended in June 1973. Without a ready supply of doctors, who were needed to provide care to servicemen stationed around the world and to be prepared for the onset of another war, all three branches of the military faced a crisis. One way around this problem was to pay for a person's medical education in return for a period of military service. Another way was to allow a medical doctor to take his or her internship and residency while on active duty. By the late 1970s, a substantial number of active-duty military physicians were interns, residents, or fellows, and the Department of Defense ordered the services to limit the fraction of military physicians in graduate medical education to not more than 20 percent of their authorized physician strength. All three of the uniformed services protested this

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To Improve Human Health: A History of the Institute of Medicine ruling. So the Assistant Secretary of Defense for Medical Affairs asked the IOM to undertake a study of graduate education in the military services.15 The IOM complied. Using its remarkable ability to assemble experts in a given area of medical policy, the IOM put together a strong steering committee. Leonard Cronkhite, who was both president of the Medical College of Wisconsin and a major general in the U.S. Army Reserves, agreed to chair. The group decided that the policy question of how large the Uniformed Services University of the Health Sciences, which was essentially a military medical school, should be could not be "answered objectively and unambiguously." Nonetheless, the group recommended that the Department of Defense withdraw its directive to limit the percentage of military physicians in graduate medical education assignments to 20 percent. Instead, each military medical department should be permitted to adjust its graduate medical education programs "to meet the changing manpower circumstances and requirements that it faces." In order to do this, the Department of Defense should produce a set of "planning guidelines, programs, and personnel policies" for each of the services.16 In this manner, the report, done quickly and with rather cursory analysis, contained a variant on the usual ''more research is needed" recommendation. It also showed just how reluctant the members of the IOM steering committee were to part with an important federal subsidy to medical education. For many influential IOM members, including every one of its presidents, military service had been an important part of their medical and research training. Of course, they had had little choice about the matter, and their service sometimes stretched into a long period that interfered with their careers. These doctors wanted future generations of physicians to enjoy the opportunities that military service provided, without being disadvantaged in comparison to their civilian peers. Differences in generational outlook also figured in another of the IOM studies that Fred Robbins inherited from David Hamburg. This study, on the health-related effects on marijuana use, reflected the IOM's role as an arbiter of public health. The National Institutes of Health initiated the request for the study, perhaps because federal officials understood just how controversial a topic marijuana use was and wished to have it investigated by an external authority.17 For the IOM, the study resembled the one it had done on the health effects of legalizing abortion. Although in both cases the subject was controversial, the IOM restricted its investigations to the health aspects, not the morality, of the subject under investigation. In both cases, the IOM discovered that the subject was so emotional that it

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To Improve Human Health: A History of the Institute of Medicine was difficult to conduct a dispassionate inquiry. In both cases, the IOM faced a dissonance between the ambiguity of the data and the almost religious certainty of people on opposing sides of the issue. The study fell into the domain of the Health Sciences Division at the IOM. Enriqueta Bond, a talented scientist who would become an increasingly important part of the IOM's history, did much of the staff work for the project. She had arrived at the Academy complex as a study director in the Division of Medical Sciences of the National Research Council (NRC). IOM staff member Elena Nightingale recruited her to come over to the IOM and work on studies related to genetic screening in the workplace. According to Bond's later recollection, "the IOM was the new kid on the block doing innovative things and having substantial impact in the policy world." On the marijuana study, Arnold Relman, editor of the New England Journal of Medicine, played a prominent role as chairman of a large steering committee that was divided into many subpanels that examined such aspects of the problem as reproductive and fetal issues and behavioral and psychosocial issues. When Relman met with the group for the first time on April 15, 1981, he told members that their task was to write a report that could "be used a guide to policy but which itself is not required to suggest policy—thank God." He noted that the group operated in "the context of a very polarized social and political scene" and that its work would be "watched and prodded and ... criticized by many contending forces.'' He suggested that the members be "totally indifferent to these social and political forces and just do our jobs as scientists and physicians and evaluators, dispassionate evaluators of the evidence."18 Even as Relman spoke, the IOM began to receive scores of letters from grassroots proponents and opponents of marijuana use. For example, Robert L. Mitzenheim urged that marijuana be used by people with glaucoma or undergoing chemotherapy. "After seeing people go through these things without even the chance to try the THC [an abbreviation of the chemical name for the active ingredient in marijuana], my feelings have become stronger in opening new doors for them; I personally would use it, law or no law," he wrote. Thomas E. Campbell reported that he smoked marijuana three or four evenings a week and found that it relaxed him and enabled him to sleep. With regular marijuana use, Campbell said, he could reduce his alcohol consumption below his previous level of six drinks per day and his use of tobacco from his previous pack-a-day habit. The steering committee also received mail from a Martha Stone, who offered testimony of how her child's marijuana use produced four years of "absolute chaos in our home." A writer from Celeste, Texas, told the

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To Improve Human Health: A History of the Institute of Medicine lamentable tale of her nephew Rick who was sitting in jail awaiting trial. When he was in elementary school, he was the ideal child, "smart, handsome, active, enjoyable." Then he discovered girls and marijuana, and paradise was lost. After that, "instead of bringing home those straight A report cards, he brought home misery."19 The IOM ignored these letters and probed the facts. Relman pressed steering committee members who brought him anecdotes on the detrimental effects of marijuana to bring him the facts. When one member told him that marijuana could produce an "acute brain syndrome," Relman asked if the phenomenon was well documented in the literature. Told that it was not, Relman replied, "We have to be very careful. We cannot cite our own clinical experience in this."20 The reality was, however, that facts could take the group only so far. As a steering committee member pointed out, "the ultimate decision about the question may be nonscientific, maybe more a political, social, cultural, moral kind of thing." One member went so far as to suggest that the IOM get some "young people to read some of the report and see if it has verisimilitude.''21 The final report, which came out at the end of 1981, took a very cautious approach to the subject. It pointed out, for example, that smoking marijuana produced "acute changes in the heart and circulation that are characteristic of stress" but concluded there was no evidence "to indicate a permanently deleterious effect on the normal cardiovascular system occurs." Marijuana produced acute effects on the brain, but there was simply not enough evidence to determine "whether prolonged use of marijuana causes permanent changes in the nervous system or sustained impairment of brain function and behavior in human beings." Although marijuana might possibly be useful in the treatment of glaucoma, the control of nausea and vomiting, and the treatment of asthma, the group could not say this for sure and thought that other, already approved therapeutic agents made more biological sense than THC. The antidote to all of this ambiguity was more research—the IOM's universal antidote. "The explanation for all these unanswered questions is insufficient research," the report noted.22 For all of its caution, the report could be read as an indictment of marijuana use. "Our major conclusion," the steering committee wrote, "is that what little we know for certain about the effects of marijuana on human health—and all that we have reason to suspect—justify serious national concern."23 The committee worried particularly about the effects of marijuana on child development. In these ways, the marijuana study resembled the abortion study. In both cases, the fundamental beliefs of the steering committee were clear: in the one

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To Improve Human Health: A History of the Institute of Medicine instance, prochoice, and in the other, antimarijuana. Both reports left the impression that further research would buttress these basic beliefs. Not everything that the IOM studied in the areas of public health and health sciences concerned subjects of long-standing duration. Just as Fred Robbins took over from David Hamburg, the IOM became involved in the emerging concern over toxic shock syndrome. This term first came into currency in 1978 and drew a large amount of attention in the spring and summer of 1980. At that time, epidemiologists discovered a link between cases of toxic shock, which could produce dangerous fevers and even death, and young women's use of tampons. A particular brand of tampon, known as Rely and manufactured by Procter and Gamble, appeared to produce a disproportionate number of cases. In response, Procter and Gamble withdrew Rely from the market in September 1980. A few weeks later, Johnson and Johnson, also a manufacturer of tampons, approached the IOM about doing a study of toxic shock syndrome. Very aware of the need to protect the IOM's reputation for objectivity, Fred Robbins told Johnson and Johnson that the IOM would like to do the study but would require a broader base of funding. In the end, four government agencies, Johnson and Johnson, and Procter and Gamble all helped to finance the project. It proved to be an interesting collaboration between the IOM and private industry. When the steering committee met for a second time on September 21, 1981, for example, it heard from both of the manufacturers under an elaborate set of guidelines. The representatives of one company agreed to leave the room when representatives of the other spoke, in an effort to protect proprietary information.24 The report on toxic shock syndrome was highly technical in tone. The steering committee, chaired by Sheldon Wolff, head of the Department of Medicine at Tufts and physician-in-chief of the New England Medical Center, noted that cases of toxic shock were rare but severe. It therefore seemed prudent to give women enough information to allow them to make informed decisions about tampon use. At the same time, the committee felt that the available information indicated that women who had had toxic shock syndrome, who were postpartum, or both should not use tampons. Women between 15 and 24 years of age who used tampons needed to understand that they were at higher risk than older women, and all women should minimize their use of high-absorbency tampons of the Rely type.25 The toxic shock syndrome project showed that the disease environment changed with time. The very conditions of modern life

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To Improve Human Health: A History of the Institute of Medicine prepare a quick response to the Sproull report when it appeared in November.75 A short and relatively informal document, the Sproull report, or more properly the "Final Report of the Study Committee on the Institute of Medicine," contained recommendations that, simply put, were devastating to the IOM. "In general," the committee wrote, "we propose a strengthening of the Institute of Medicine that amounts to a rebirth.'' In its second life, the Institute of Medicine would be resurrected as the National Academy of Medicine. The IOM's studies would be transferred to the National Research Council and in their place would come a "policy-oriented core program, flexibly and imaginatively attacking the great health and medical problems and making better use of an even more distinguished membership." The committee referred to this core program as a "health policy center that would serve as a crucible for national and international health policy discussions." In order to move from an Institute of Medicine to a National Academy of Medicine, the committee proposed that a new emphasis be placed on ''professional distinction as judged by professional peers," rather than on "the visibility and influence of a candidate's position." In its initial phase, the National Academy of Medicine would have about 150 members, chosen by the NAS Council. Those IOM members not selected for the new academy would become senior members of the National Academy of Medicine for a limited term.76 If the Sproull committee's recommendations were adopted, it would mean the end of the Institute of Medicine. Walsh McDermott's experiment would end in failure, and something more compatible with the other parts of the National Academy of Sciences would take its place. The basic idea of moving the IOM's studies to the National Research Council was not new. It had been proposed when the IOM was first founded and again in a different way by the Ebert report at the beginning of the 1980s. The difference with the Sproull committee was that it had the eyes and ears of the foundation community. Defending the Institute of Medicine Members of the IOM community reacted with concern. Karl Yordy called the report a "key event in the history of the IOM" and urged Robbins "to set a new course, not give up the ship." Using a different military metaphor, Yordy argued the need to "move rapidly to develop a defense" against the "blitzkrieg" of NAS President Frank Press before he conquered the IOM. Press wanted to disarm his opposition

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To Improve Human Health: A History of the Institute of Medicine in the same manner that Hitler conquered Poland. "I think the IOM must become like Switzerland," Yordy asserted, "too well armed to be worth the effort for a Kaiser or a Hitler to conquer." Yordy accused Press of acting in bad faith by outmaneuvering the foundations and twisting ''their original intent toward his own internal organizational objectives'' and by "cynically" using the Sproull committee "to generate an occasion for the action he wanted to take all along." The IOM would now have to play Winston Churchill to Sproull's Neville Chamberlain. 77 Although other IOM insiders did not put the matter in such graphic terms, many agreed with Karl Yordy. Alan Nelson, a Council member who specialized in internal medicine and endocrinology, took exception to the study committee's implication that "health policy is not anything that good scientists would want to mess with." William Bevan, a vice president of the MacArthur Foundation and a Council member, said he was disappointed in the report and believed it had the "capacity for great mischief." Philip Leder, head of the Department of Genetics at Harvard, reacted with "shock, surprise, and amazement at the weaknesses in concept and structure alleged by the report and the radical scope of the proposed solutions." Ruth Gross, a professor of pediatrics at Stanford found the report "difficult to evaluate" and "quite confusing," and Ben Lawton, a surgeon from the Marshfield Clinic, reported that his "initial reaction was outrage! From our briefing by Dr. Sproull, I knew we could expect considerable negative comment. I did not expect a frontal attack and proposal to abolish the Institute of Medicine and emasculate its proposed successor."78 If Lawton expressed the feelings of the majority, this still left room for a considerable minority. Gilbert Omenn, dean of the School of Public Health and Community Medicine at the University of Washington and head of the IOM Task Force on Mission, Structure, and Finances, found the Sproull report "very supportive of the IOM" because their "crucial finding was that the IOM (or something very much like it) is, indeed, needed." On the matter of the plan to create a National Academy of Medicine, Omenn, who had worked with Frank Press in the Carter White House, said he would keep an open mind. Agreeing with Omenn, Robert Butler, a Council member and the former head of the National Institute of Aging, thought the Sproull committee did "a good job and came up with some respectable conclusions."79 This set up the major lines of division for an IOM Council meeting in January 1985 devoted to formulating the IOM response to the Sproull report. In general, those who wished to defend the IOM

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To Improve Human Health: A History of the Institute of Medicine outnumbered those who thought the IOM should react sympathetically to the report. The Council objected in particular to the notion that the IOM had an incompatible mission of trying to combine scientific objective analysis on the one hand and subjective policy judgments on the other. In the view of many IOM members, such distinctions perpetuated the nineteenth century notion that science was an empirical, value-free endeavor and ignored the realities of both the scientific and the policy processes. Rejecting this central premise of the Sproull report, the Council went on to argue that there was no need to move the IOM's studies to the National Research Council. The idea of a health policy center had merit, but it could easily be accommodated within the existing IOM structure. This was something that the IOM hoped to explore, just as it pledged to improve the quality of its reports and refine its criteria for membership. The Council noted that although other things could be done to improve the way in which the IOM functioned, substantive changes should await the arrival of the next president. In summary then, the IOM argued that the Sproull report was based on a misperception of the IOM's work, and it opposed the transfer of IOM projects to the NRC.80 Based on the Council's discussion and the ongoing work of its task forces, the IOM Council composed a formal statement in response to the Sproull report that appeared at the end of January. In this statement, the Council tried to be deferential toward the Sproull committee—"a distinguished group which addressed its task sincerely and thoughtfully" and positive about the IOM—we "want to build on the accomplishments of the past 14 years." For all of this deference, the IOM Council felt compelled to "disagree with many of their recommendations and some of their findings.'' The statement proceeded to object to the report's basic premise, to argue against moving the IOM's studies to the NRC, and to oppose the creation of a National Academy of Medicine. The IOM gave ground only in the areas of membership, in which it conceded that improvements could be made, and finances, in which it admitted that although it always balanced its books by the end of the year, each year was a struggle. Despite the considerable effort to be conciliatory yet firm, the Council still could not contain all of its members. Ronald W. Estabrook, a biochemist from the University of Texas at Dallas and a member of the National Academy of Sciences, felt compelled to write a dissent in which he said that he was "not disturbed" by the prospect of transferring the IOM's studies to the NRC and that membership in the IOM should be based on ''evidence of scholarly achievement." The

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To Improve Human Health: A History of the Institute of Medicine notion of a mixed membership, with practicing physicians and public policy practitioners, held little appeal for him.81 The NAS Council served as the final arbiter on the matter, and in this forum the IOM did quite well. Remembering the difficulties with the National Academy of Engineering, the NAS Council had little inclination to create a new academy of medicine within the NAS complex and quickly dismissed the idea. As it had at the time of the IOM's creation, the NAS Council conceded that there was a need for a "membership organization directed toward medicine and health policy"—something, in other words, like the IOM. The NAS Council also approved of many of the IOM's recent decisions, such as its willingness to examine its membership criteria closely and its decision not to elect new members in 1984 but instead to put in place a new system that emphasized achievement and not merely position. On other matters, however, such as the crucial question of whether to move the IOM's studies to the NRC, the NAS Council resolved to hold off its decision until it met in February.82 At this February 1985 meeting, Frederick Robbins, in a rare display of emotion, vented his feelings. He told the NAS Council that the last few months had been particularly difficult. Although he had started as an enthusiastic supporter of the process, he was dismayed to receive a "highly critical" report that contained "drastic recommendations for change" and indicated "a true lack of support for the concept of the IOM.'' The report put him and his organization in a "defensive posture which is not a pleasant situation to be in." Robbins did not say so, but it rankled him in particular that the report cast aspersions on the IOM staff. Of all the people in the NAS complex, Robbins, who held important IOM and NRC posts, was in the best position to compare the NRC and IOM staffs, and in his opinion, the quality of the IOM staff exceeded that of the NRC staff.83 Whether or not the NAS Council was moved by Robbins's presentation, it rejected the recommendations of the Sproull committee and decided not to recommend that the IOM be disbanded and its studies transferred to the NRC. Instead, it opted to take a wait-and-see approach. It issued a statement announcing that it "continued to be strongly supportive of the Institute of Medicine" but recognized the issues and problems raised by the Sproull committee. In response, it proposed to join the search for the new IOM president and, together with this new president, to "further examine" the issues. At a minimum, the IOM had won a reprieve without making a major concession. All it had to do was disband its presidential search committee and replace it with one jointly chosen by Frank Press and Fred Robbins. "As is the case with any organization under new

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To Improve Human Health: A History of the Institute of Medicine leadership," Frank Press explained to John Sawyer of the Mellon Foundation, "the opportunity for self-analysis and charting new directions is one that should coincide with the inauguration of the next IOM president." 84 The action shifted to the presidential search committee. On March 20, 1985, Paul Marks, president of the Sloan-Kettering Cancer Center, agreed to chair the committee. Eight others joined him, including four medical doctors, two distinguished Ph.D. scientists, a public health expert, and a hospital administrator. Five of the committee members, including the chairman, were selected by the National Academy of Sciences, giving the NAS the majority of the appointments. It was this committee's job to come up with a new president of the IOM by the time of Robbins's departure on October 1, 1985.85 The wait stretched through the summer and into the fall. The IOM Council meeting on September 23 proceeded as usual, the chief item of business being the usual distressing news about IOM finances. The staff predicted a quarter of a million dollar shortfall in operating expenses for fiscal year 1986, which would mean that division directors and division secretaries could not be carried on the general operating budget and would instead have to be shifted to specific projects. As the meeting wound down, Frank Press walked into the room and announced that Samuel Thier, the head of the Internal Medicine Department at Yale, would become the next president of the Institute of Medicine. 86 Conclusion Although IOM members could not have known it at the time, the organization had weathered the crisis. During the era of Fred Robbins, the IOM managed to survive two threats to its existence in the form of two NAS reviews of its structure and accomplishments. The Sproull report represented the most profound assault on the concept of the IOM that the organization had ever faced, calling for the rebirth of the IOM. As it worked out, the IOM was reborn, not as a National Academy of Medicine but as an Institute that would rededicate itself to speaking out on health policy issues in scientifically and socially responsible ways. The Robbins era might be compared to the Board on Medicine period. In both instances, leaders of the organization spent the bulk of their time attempting to define the IOM's basic mission and negotiating with the National Academy of Sciences over the degree of

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To Improve Human Health: A History of the Institute of Medicine autonomy the IOM would enjoy. Because the Board on Medicine and the Robbins-era IOM devoted so much time to these endeavors, they accomplished less in the way of completing studies than they might otherwise have. In both eras, the country stood on the cusp of social and political change. The Board on Medicine began during the Great Society and concluded its work during the presidency of Richard Nixon. Robbins's tenure started at a time when the IOM enjoyed a tight relationship with the Carter administration and ended when the Reagan administration was at the height of its powers. It was to Fred Robbins's credit that he adjusted to changes in the external environment without succumbing to despair. He learned to work with the Reagan administration, sometimes as a collaborator and sometimes as an adversary. The results were highly acclaimed studies on such topics as the organization of the National Institutes of Health and low birthweight babies. Although the course of the Sproull committee's work disheartened him, he kept the IOM on course, like the leader of a nation during a civil war. If Fred Robbins left many problems with which his successor would have to deal, he also started many projects, such as one on the future of public health, that would come to fruition under his successor. Because of Robbins's perseverance, his successor would also deal with a foundation community that was somewhat chastened by its experience with the Sproull report and more predisposed than before to consider providing the IOM with an endowment. Of all of Robbins's achievements, however, perhaps the very fact that there was an IOM to pass on to Sam Thier constituted the greatest accomplishment of all. Notes 1.   IOM Council Meeting, Minutes, March 19, 1980, Institute of Medicine (IOM) Records, National Academy of Sciences (NAS) Archives. 2.   "Summary of Discussion, IOM Program Committee Meeting, March 26, 1980," Yordy Files—Second Series, Accession 94-111, IOM Records. 3.   "Meeting of the Presidential Search Committee, July 18, 1979," Search Committee Files, Accession 93-192, IOM Records. 4.   "Steps Taken in the 1979 Search," Search Committee Files, Accession 93-192, IOM Records. 5.   William Danforth to Philip Handler, December 21, 1979, Search Committee Files, Accession 93-192, IOM Records. 6.   "Nobel Laureate Named New President of Institute," IOM Press Release, March 7, 1980, Search Committee Files, Accession 93–192, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 7.   Marjorie Sun, "Institute of Medicine Gets New President," Science , 210 (November 7, 1980), p. 616. 8.   David Hamburg to Members, Institute of Medicine, March 3, 1980, Search Committee Files, Accession 93-192, IOM Records. 9.   Annual Meeting Program, 1980, in Institute of Medicine, 1981 Annual Program Plan (photo-offset), 1981. 10.   Public Law 96-171 was passed in December 1979. 11.   IOM Council Meeting, Minutes, January 16, 1980, IOM Records; William Lybrand to Robert M. White, NRC Administrator, April 15, 1980, Yordy Files, Accession 94-111, IOM Records; Karl Yordy to David Hamburg, January 22, 1980, and Draft Minutes of Meeting, July 15, 1980, both in Airline Pilot Study Files, Accession 81-065, IOM Records. 12.   See materials in Airline Pilot Study Files, Accession 81-065, IOM Records; Institute of Medicine, Airline Pilot Age, Health, and Performance, (Washington, D.C.: National Academy of Sciences, 1981). 13.   "Development of Study Plan for Two-Year Study of Nursing Education," n.d., Yordy Files, Accession 94-111, IOM Records. 14.   Institute of Medicine, Nursing and Nursing Education: Public Policies and Private Actions (Washington, D.C.: National Academy Press, 1983), pp. 2, 7, 11–13, 16, 17, 19. 15.   William A. Lybrand to Dr. John H. Moxley III, Assistant Secretary of Defense for Health Affairs, February 15, 1980, Graduate Medical Education in the Military Files, Accession 81-063A, IOM Records. 16.   Institute of Medicine, Graduate Medical Education and Military Medicine (Washington, D.C.: National Academy of Sciences, 1981), pp. 2, 13. 17.   Dr. William A. Lybrand to Paul L. Sitton, Executive Officer, NAS, June 12, 1980, Health Effects of Marijuana Files, Accession 86-064-13, IOM Records. 18.   "Committee Meeting Transcript," April 15, 1981, Health Effects of Marijuana Files, 86-064-13, IOM Records. 19.   Robert L. Mitzenheim to Dr. Linda Dujack, March 30, 1981; Martha Stone to Dujack, April 30, 1981; Thomas E. Campbell to Dujack, March 19, 1981; and Sarah Swingell, Celeste Texas, to Dujack, May 27, 1981, all in Health Effects of Marijuana Files, IOM Records. 20.   Transcript of Committee Meeting, April 15, 1981, Health Effects of Marijuana Files, IOM Records. 21.   Transcript of Committee Meeting, June 2, 1981, Health Effects of Marijuana Files, IOM Records. 22.   Institute of Medicine, Marijuana and Health (Washington, D.C.: National Academy Press, 1981), pp. 2–3, 5. 23.   Ibid., p. 6. 24.   Vicki Weisfeld, Acting Director, Division of Health Promotion and Disease Prevention, to Members of the Council, November 3, 1980, and Minutes of the Committee on Toxic Shock Syndrome, September 11–12, 1981, both in Toxic Shock Files, Accession 86-064-11, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 25.   Institute of Medicine, Toxic Shock Syndrome—Assessment of Current Information and Future Research Needs (Washington, D.C.: National Academy Press, 1982). 26.   IOM Council Meeting, Minutes, March 19, 1980, IOM Records. 27.   Frederick Robbins to IOM Membership, November 4, 1981, in Wallace Waterfall Materials; IOM Council Meeting, Minutes, September 16, 1981, IOM Records. 28.   IOM Council Meeting, Minutes, September 17, 1980; March 18, 1981; and June 2, 1980, all in IOM Records. 29.   IOM Council Meeting, Minutes, June 2, 1981, IOM Records. 30.   "Interim Report of IOM Task Force on Structure," IOM Records. 31.   IOM Council Meeting, Minutes, September 16, 1981, IOM Records. 32.   Frederick C. Robbins to Frank Press, October 14, 1981, Yordy Files, Accession 91-051, IOM Records. 33.   "A Report to Frank Press on Matters of NRC Organization and Procedures," February 18, 1982, Yordy Files, Accession 91-051, IOM Records. 34.   IOM Council Meeting, Minutes, March 17, 1982, IOM Records; Frederick Robbins to Frank Press, March 23, 1982, Yordy Files, Accession 91-051, IOM Records. 35.   Frank Press to the Staff of the National Research Council, March 2, 1982, and "The Organization of the National Research Council," n.d., both in Yordy Files, Accession 91-051, IOM Records; IOM Council Meeting, Minutes, July 1982, IOM Records. 36.   "Report to the Council: Task Force on Membership Issues," May 5, 1983, IOM Records; IOM Council Meeting, Minutes, January 20, 1981, IOM Records. 37.   IOM Council Meeting, Minutes, January 16, 1980, IOM Records; Karl Yordy to David Hamburg, September 2, 1980; Fred Robbins to Fred Abby, Health Care Financing Administration, December 4, 1980; and Yordy to Arnold S. Relman, December 23, 1980, all in Yordy Files—Second Series, Accession 94-111, IOM Records. 38.   IOM Council Meeting, Minutes, November 17, 1982; January 19, 1983; and September 23, 1985; and IOM Annual Report for 1984, draft copy in IOM Council Meeting, Minutes, all in IOM Records. 39.   IOM Council Meeting, Minutes, March 18, 1981; May 19, 1982; and July 20, 1983, all in IOM Records. 40.   IOM Council Meeting, Minutes, January 15, 1981, and July 21, 1982, IOM Records. 41.   IOM Council Meeting, Minutes, July 21, 1982, and November 18, 1981, IOM Records. 42.   IOM Council Meeting, Minutes, January 19, 1983; May 18, 1983; and September 21, 1983; Draft Copy of Annual Report, 1984, and IOM Council Meeting, Minutes, March 19, 1984, and July 21, 1982, all in IOM Records. 43.   IOM Council Meeting, Minutes, November 18, 1961, IOM Records; and Bradford Gray to John T. Dunlop, April 8, 1983; Fred Robbins to Kingman Brewster, March 9, 1983; "Draft Proposal to the Pew Foundation," n.d.; and Gray to Thomas F. Frist, Jr., M.D., President and CEO, Hospital

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To Improve Human Health: A History of the Institute of Medicine     Corporation of America, December 15, 1982; March 14, 1983; and June 14, 1983, all in For-Profit Enterprise in Health Care Files, Accession 91-007-4, IOM Records. 44.   "Minutes of Meeting," July 29–31, Airlie House, For-Profit Enterprise in Health Care Files, IOM Records. 45.   Ibid. 46.   Committee Meeting, Minutes, October 1–2, 1984, For-Profit Enterprise in Health Care Files, IOM Records. 47.   Bradford Gray and Walter J. McNerney, "For-Profit Enterprise in Health Care: The Institute of Medicine Study," New England Journal of Medicine 314 (June 5, 1986), pp. 1525, 1526, 1528. 48.   Form letter from Samuel Thier to financial contributors to the For-Profit Enterprise in Health Care Study, August 1, 1986, For-Profit Enterprise in Health Care Files, IOM Records. 49.   Institute of Medicine, Responding to Health Needs and Scientific Opportunity: The Organizational Structure of the National Institutes of Health (Washington, D.C.: National Academy Press, 1984). 50.   Ibid., pp. 5, 10, 20. 51.   Ibid., p. 26; IOM Council Meeting, Minutes, September 17, 1984, IOM Records. 52.   Fred Robbins to Thomas W. Moloney, Commonwealth Foundation, May 29, 1985, Low-Weight Birth Files, Accession 86-064-07, IOM Records. 53.   Richard E. Behrman, Frederick C. Robbins, and Sarah S. Brown, "Preventing Low Birthweight," mimeo dated May 1985, Low-Weight Birth Files, IOM Records. 54.   Ibid. 55.   Fred Robbins to Wallace K. Waterfall, March 20, 1990, Waterfall Materials. 56.   IOM Council Minutes, July 20, 1983, IOM Records; "Proposal to Study the Regulation of Nursing Homes," September, 1983, Nursing Home Regulation Files, Accession 91-007, IOM Records. 57.   Steering Committee Meeting, Minutes, December 7, 1983, Nursing Home Regulation Files, IOM Records. 58.   Steering Committee Meeting, Minutes, February 20–21, 1986, Nursing Home Regulation Files, IOM Records. 59.   Institute of Medicine, Annual Report, 1986, Program Plan, 1987 (Washington, D.C.: National Academy Press, 1987), p. 21. 60.   Fred Robbins to Robert Derzon, July 31, 1984, Development Office Files, Accession 91-045, IOM Records; financial data from IOM Annual Report, 1984. 61.   James M. Furman, Executive Vice President, MacArthur Foundation, to Fred Robbins, November 14, 1984, Development Office Files, Accession 91-045, IOM Records; Robert I. Smith, President, Glenmede Trust Company, to Robbins, August 16, 1979; Smith to Robbins, November 30, 1979; David Hamburg to Smith, July 3, 1980; Smith to Robbins, November 24, 1981; and Glenmede Trust Company to Robbins, May 7, 1985, all in Development Office Files, Accession 91-029, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 62.   "Membership Dues and Annual Meeting Registration Fees," n.d., but probably November 1984, Accession 91-051, IOM Records. 63.   IOM Council Meeting, Minutes, March 19, 1982; January 19, 1983; March 9, 1983; January 16, 1985; and July 16, 1984, all in IOM Records. 64.   Fred Robbins to Robert Ebert, January 19, 1984, Yordy Files, Accession 91-051, IOM Records. 65.   "Minutes of NAS Staff Meeting," March 22, 1984, Waterfall Materials; Frank Press to Dr. Robert J. Buchanon, March 30, 1984, Yordy Files, Accession 91-051, IOM Records; Fred Robbins to IOM Members, March 30, 1984, Waterfall Materials; Margaret E. Mahoney to Frank Press, July 9, 1984, Sproull Committee Files, Accession 89-013-05, IOM Records. 66.   IOM Council Meeting, Minutes, May 13–14, 1984, IOM Records; Charles Miller to IOM Professional Staff, May 25, 1984, Waterfall Materials. 67.   Staff Summary, Committee Meeting, June 5, 1984, Sproull Committee Files, Accession 89-013-05, IOM Records. 68.   R. L. Sproull, "Interview with David Rogers, Robert Blendon, Margaret Mahoney, and Thomas Maloney," July 10, 1984, Sproull Committee Files, IOM Records. 69.   Robert L. Sproull, Confidential Memorandum of a Conversation with Dr. John Sawyer, President, Andrew Mellon Foundation, August 9, 1984, Sproull Committee Files, IOM Records. 70.   Harvey Sapolsky, Interview with Alvin Tarlov, August 22, 1984, Sproull Committee Files, IOM Records. 71.   Harvey Sapolsky, Interview with Stuart Altman, July 27, 1984; Sapolsky, Interview with John Ball, July 11, 1984; Sapolsky, Interview with Larry Brown, n.d.; Sapolsky, Interview with E. Langdon Burwell, July 15, 1984; Sapolsky, Interview with John Cooper, July 11, 1984; Robert Sproull, Interview with Loretta Ford, n.d.; Sapolsky, Interview with Victor Fuchs, September 7, 1984; Sapolsky, Interview with William Gorham, July 20, 1984; and David Calkins, M.D., Interview with Walter McNerney, October 30, 1984, all in Sproull Committee Files, IOM Records. 72.   Harvey Sapolsky, Interview with Rashi Fein, June 29, 1984; Sapolsky, Interview with James Shannon, September 6, 1984; Minutes of Committee Meeting, June 16, 1984, in David Calkins to Study Committee on the Institute of Medicine; Larry McCray, Interview with Robert Rubin, July 2, 1984; and Sapolsky, Interview with Karl Yordy, July 25, 1984, all in Sproull Committee Files, IOM Records. 73.   Harvey Sapolsky, Interview with John Ball, July 11, 1984; Sapolsky, Interview with Enriqueta Bond, July 12, 1984; Sapolsky, Interview with Robert Derzon, September 6, 1984; Stuart Bondurant to Robert Sproull, August 7, 1984; Vincent Dole to Sproull, August 31, 1984; and S. Marsh Tenney to Sproull, August 14, 1984, all in Sproull Committee Files, IOM Records. 74.   Karl Yordy to Charles Miller, August 23, 1984, Yordy Files, Accession 91-051, IOM Records; Miller to Members of the IOM Council, August 28, 1984, Waterfall Materials; Meeting of the IOM Council, Executive Session, September 16–17, 1984, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 75.   Fred Robbins to Robert Sproull, October 3, 1984, Waterfall Materials; IOM Council Meeting, Minutes, November 19, 1984, IOM Records. 76.   "Final Report of the Study Committee on the Institute of Medicine," National Academy of Sciences, Washington, D.C., November 1984, pp. 3, 9. 77.   Karl Yordy to Fred Robbins, December 20, 1984, and Yordy to Robbins, February 4, 1985, Yordy Files, Accession 91-05 1, IOM Records. 78.   William Bevan, "Comments on Sproull Report," January 13, 1985; "Memorandum to File, Conversation with Dr. Phil Leder," January 2, 1985; Frederic Solomon to Charles Miller, January 3, 1985; "Transcribed Phone Call, Ben Lawton's Reaction to Sproull Committee Report," January 7, 1985; and Fred Solomon to Charles Miller, January 2, 1985, all in Yordy Files, Accession 91-051, IOM Records. 79.   Gil Omenn to Fred Robbins, December 19, 1984, and "Comments Dictated 1/3/85 by Bob Butler," both in Yordy Files, Accession 91-051, IOM Records. 80.   IOM Council Meeting, Minutes, January 13–14, 1985, IOM Records. 81.   "Statement of the Council of the Institute of Medicine to the Council of the National Academy of Sciences," January 29, 1985, and Ronald W. Estabrook to Members of the National Academy of Sciences, January 25, 1985, both in Waterfall Materials. 82.   Philip M. Smith to Members of the Council, National Academy of Sciences, January 30, 1985, Waterfall Materials. 83.   Frederick Robbins, "Statement Before the Council of the National Academy of Sciences," February 8, 1985, Waterfall Materials. 84.   Fred Robbins to Members of the Institute of Medicine, February 11, 1985, and Frank Press to John Sawyer, February 11, 1985, both in Waterfall Materials. 85.   Frank Press and Fred Robbins to Paul A. Marks, March 20, 1985, Waterfall Materials. 86.   Minutes of IOM Council Meeting, July 15, 1985, and September 23, 1985, IOM Records. Irvine H. Page's group to discuss the formation of a National Academy of Medicine met for the first time on January 17, 1967, at the Cleveland Clinic Foundation. Although Page never realized his ambition to create such an academy, this group supplied the impetus that eventually led to the founding of the Institute of Medicine. Top, left to right: Fay H, Lefevre, M.D., J. Englebert Dunphy, M.D.; Carleton B. Chapman, M.D.; Francis D. Moore, M.D.; William B. Bean, M.D.; John B. Hickam, M.D.; E. Cowles Andrus, M.D.; Robert A. Aldrich, M.D.; Ivan L. Bennett, Jr., M.D.; and Stuart M. Sessoms, M.D. Bottom, left to right: James A. Shannon, M.D.; Frederick C. Robbins, M.D. (who would later become the Institute's fourth president, in 1980); Irving S. Wright, M.D., Irvine H. Page, M.D., Douglas D. Bond, M.D.; and Robert H, Williams. Photograph courtesy of The Cleveland Clinic Foundation. Frederick Seitz, Ph.D., a distinguished physicist, created the Board on Medicine in 1967 during his tenure as president of the National Academy of Sciences (1962–1969). Photograph by Harris and Ewing, Washington, D.C., courtesy of the National Academy of Sciences. Walsh McDermott, M.D., a professor of medicine and public health at Cornell Medical School, chaired the Board on Medicine and played a leading role in the creation of the Institute of Medicine. Photograph courtesy of The New York Hospital-Cornell Medical Center Archives. Irving M, London, M.D., who was chairman of the Department of Medicine at Albert Einstein College of Medicine in 1967, was a key ally of Walsh McDermott on the Board on Medicine. Photograph courtesy of Irving London. Julius H. Comroe, Jr., M.D., director of the Cardiovascular Research Institute of the San Francisco Medical Center, tended to side with Irvine Page in the debates over the creation of the Institute of Medicine. Photograph courtesy of the University of California at San Francisco. James A. Shannon, M.D., director of the National Institutes of Health from 1955 to 1968, believed that the primary purpose of the Institute of Medicine should be to support the government's role in medical research. Photograph by Ralph Fernandez, courtesy of the History of Medicine Division, National Library of Medicine. Robert J. Glaser, M.D., who was dean of Stanford's School of Medicine in 1967, wrote the Board on Medicine's heart transplant statement and chaired the Institute's Initial Membership Committee. He also served as acting president of the Institute until John Hogness took office in the spring of 1971. Photograph courtesy of Robert Glaser. Irvine H. Page, M.D., who was head of the Research Division at the Cleveland Clinic from 1945 to 1967 and a leading expert on hypertension and heart disease, was a strong advocate for the creation of a National Academy of Medicine. He and Walsh McDermott engaged in spirited debates within the Board on Medicine. Photograph courtesy of The Cleveland Clinic Foundation. Philip Handler, Ph.D., a well-known biomedical researcher at Duke University who was president of the National Academy of Sciences from 1969 to 1981, played a key role in the creation of the Institute of Medicine and in its early development. His constant goal was to maintain the integrity of the Academy. Photograph courtesy of the National Academy of Sciences Archives. Presidents of the Institute of Medicine John R. Hogness, M.D. (1970-1974), was the Institute of Medicine's first president. He started the IOM Council and initiated many of the routines that governed the Institute's development. Donald S. Fredrickson, M.D. (1974–1975), a distinguished biomedical researcher, stayed only a short time at the Institute before leaving to become director of the National Institutes of Health. Presidents of the Institute of Medicine David A. Hamburg, M.D. (1975–1980), helped to bring the Institute to national prominence. He established the divisions that still underlie the basic organizational scheme of IOM. Frederick C. Robbins, M.D. (1980-1985), a Nobel laureate, brought his knowledge of medical research to the Institute, helping the organization to overcome the challenge posed by the Sproull report. Samuel O. Thier, M.D. (1985–1991), energized the Institute and led a successful fund-raising effort. As a result of his work, IOM reached parity with the other components of the Academy complex. Kenneth I. Shine, M.D. (1992–present), ushered the Institute into its second quarter century. Now in his second term, he is IOM's longest-serving president. Karl Yordy (left), a durable and valuable member of the Institute's staff, served the IOM from the era of John Hogness into the era of Ken Shine, both as executive officer after Roger Bulger and as director of the Division of Health Care Services. Charles Miller (right) succeeded Yordy as executive officer, serving from 1983 to 1988-years that encompassed threats associated both with possible insolvency and the Sproull report, and then increasing financial security and expansion of the Institute's program. Photograph courtesy of Jana Surdi. The Institute's first executive officer, Roger J. Bulger, M.D., was a close associate of John Hogness. He guided the daily operations of the Institute in its early years and went on to a distinguished career in medical administration, most recently as president of the Association of Academic Health Centers. Photograph courtesy of the Association of Academic Health Centers. Enriqueta C. Bond, Ph.D. Samuel Thier relied heavily on Queta Bond to manage the day-to-day affairs of the Institute. She served in different capacities under a number of IOM presidents before assuming the presidency of the Burroughs Wellcome Fund in 1994. Photograph courtesy of the Burroughs Well-come Fund. Karen Hein, M.D., a former Robert Wood Johnson Health Policy Fellow, served as the Institute's executive officer from 1995 until 1998 before leaving to become president of the William T. Grant Foundation. Photograph courtesy of Karen Hein. Susanne Stoiber, M.S., M.P.A., was named IOM executive officer in 1998, She came to the Institute from the Department of Health and Human Services, where she was deputy assistant secretary for planning and evaluation. In a previous stint at the Academy, she directed the Division of Social and Economic Studies. Photograph courtesy of Susanne Stoiber. An M.D.-Ph.D. with a background in cardiovascular surgery and long a major figure at the Institute, Theodore Cooper chaired the study that produced Confronting AIDS: Update 1988. Photograph courtesy of Pharmacia & Upjohn. Robert A, Derzon, M.B.A., a distinguished hospital administrator, followed his service as the first head of the Health Care Financing Administration with a period as a scholar in residence at the Institute. He was an IOM Council member during Fred Robbins's tenure and helped recruit Samuel Thier. Photograph courtesy of Robert Derzon. Robert M. Ball, M.A., head of the Social Security Administration from 1962 to 1973, became a scholar in residence at the Institute and served as a confidante of IOM presidents from Hogness through Robbins. ''Watergate''—a national preoccupation from 1972 to 1974, and a word that became synonymous with political scandal— originated with a burglary that took place on the night of June 17, 1972, in this fashionable Washington, D.C., office complex. In 1974, the Institute moved into the 6th-floor offices that the Democratic National Committee had recently vacated. Its offices attracted tourists and others interested in the "stuff of history." Photograph courtesy of Elena Nightingale. In one of the more unusual circumstances to affect the Institute, before David Hamburg could accept the presidency of IOM in 1975, he needed to negotiate the release of some of his Stanford students who had been kidnapped by rebels in Zaire. He is shown here back in Stanford with (from left) Carrie Hunter, Steven Smith, and Emilie Bergman after their release in the fall of 1975. Photograph courtesy of David Hamburg. Joseph A. Califano, Jr., LL.B., President Jimmy Carter's Secretary of Health, Education, and Welfare, worked closely with the Institute in the Hamburg era, and ultimately was elected an IOM member and a member of the IOM Council. Photograph courtesy of the History of Medicine Division, National Library of Medicine. Robert Sproull, Ph.D., a well-known physicist and president of the University of Rochester, chaired a committee whose 1984 report advocated the transformation of the Institute into an academy of medicine and led to some particularly painful moments for the young organization. Photograph courtesy of the University of Rochester. In early May 1977, a Washington Post article on the recently released IOM study Computed Tomogrophic Scanning caught President Jimmy Carter's eye. The study urged that hospitals and physicians should not overuse the new technology and that local health planners should approve the installation of new scanners, as well as ensure that they operated efficiently. Carter wanted Secretary of Health, Education, and Welfare Califano to read the article as well. Confronting AIDS (1986) commanded public attention and urged the nation to do more to combat this deadly epidemic. A follow-up report, Confronting AIDS, Update 1988, was used by President George Bush to help formulate government policy toward AIDS. Preventing Low Birthweight attracted a great deal of attention in part because of the dramatic way in which it was released in the spring of 1985 during hearings conducted by Representative Henry Waxman (D-Calif.). In recent years, the Institute has produced reports that grab a reader's attention visually as well as engaging them with substantive issues, as the covers of these reports show—Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (1994, top left), Eat for Life: The Food and Nutrition Board's Guide to Reducing Your Risk of Chronic Disease (1992, top right), and In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa (1996, below). Such covers are strikingly different from the more ultilitarian documents that the Institute produced during its early years. Current National Academy of Sciences President Bruce Alberts, Ph.D. (left), joins past NAS President Frederick Seitz, Ph.D. (right), at the April 1995 dedication of a portrait of Frank Press, Ph.D. Press, a noted physical scientist from the Massachusetts Institute of Technology, had been President Carter's science advisor prior to taking over as NAS president in 1981. Alberts, a well-known biochemist and molecular biologist from the University of California at San Francisco, succeeded Frank Press in 1993. Photograph courtesy of the National Academy of Sciences. A letter from President Bill Clinton commemorated the Institute's 25th anniversary in December 1995.