5
Expansion of the Institute of Medicine

At the end of March 1987, the Wall Street Journal ran a story about the Institute of Medicine (IOM) on its Washington politics page. In contrast to the journalistic pieces on the IOM that had appeared during the confrontation over the Sproull report, this one had a decidedly upbeat tone. "After more than 15 years of comparative obscurity," wrote Journal reporter Alan Otten, "the Institute of Medicine ... seems to be gaining visibility and clout in Washington." The article cited the many problems that had previously characterized the IOM, such as the quick turnover in presidents, the constant scramble for money, and the ambivalent attitude of the foundations, and suggested that these problems had been remedied in the short period between the end of 1985 and the spring of 1987.1

No doubt, the newspaper overstated both the degree of the initial problems and the permanence of the solution. It was nonetheless the case that the IOM rebounded from the crisis of the Sproull report under the leadership of Samuel Thier. In a short time, Thier restored the confidence of foundations in the Institute of Medicine, leading to a more stable pattern of financing and ending the yearly struggle to make ends meet. Resolution of the financial issues strengthened the position of the Institute of Medicine within the National Academy of Sciences and paved the way for a major expansion of IOM responsibilities and staff. As a result, the years between 1985 and 1991 were ones of major growth for the Institute of Medicine.

Samuel Thier and the Outreach to Foundations

Thier, a comparatively young man of 48 when he became IOM president, had the sort of leadership style that inspired confidence. Refusing to become bogged down in details or to succumb to cynicism, he simply assumed that he would be able to meet his objectives,



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To Improve Human Health: A History of the Institute of Medicine 5 Expansion of the Institute of Medicine At the end of March 1987, the Wall Street Journal ran a story about the Institute of Medicine (IOM) on its Washington politics page. In contrast to the journalistic pieces on the IOM that had appeared during the confrontation over the Sproull report, this one had a decidedly upbeat tone. "After more than 15 years of comparative obscurity," wrote Journal reporter Alan Otten, "the Institute of Medicine ... seems to be gaining visibility and clout in Washington." The article cited the many problems that had previously characterized the IOM, such as the quick turnover in presidents, the constant scramble for money, and the ambivalent attitude of the foundations, and suggested that these problems had been remedied in the short period between the end of 1985 and the spring of 1987.1 No doubt, the newspaper overstated both the degree of the initial problems and the permanence of the solution. It was nonetheless the case that the IOM rebounded from the crisis of the Sproull report under the leadership of Samuel Thier. In a short time, Thier restored the confidence of foundations in the Institute of Medicine, leading to a more stable pattern of financing and ending the yearly struggle to make ends meet. Resolution of the financial issues strengthened the position of the Institute of Medicine within the National Academy of Sciences and paved the way for a major expansion of IOM responsibilities and staff. As a result, the years between 1985 and 1991 were ones of major growth for the Institute of Medicine. Samuel Thier and the Outreach to Foundations Thier, a comparatively young man of 48 when he became IOM president, had the sort of leadership style that inspired confidence. Refusing to become bogged down in details or to succumb to cynicism, he simply assumed that he would be able to meet his objectives,

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To Improve Human Health: A History of the Institute of Medicine projecting an air of competence that both reassured and energized people. Among many other positive attributes, Samuel Thier was a quick study. Even before he took over on a full-time basis, he realized the need to build a strong endowment that would allow the IOM to set its own agenda. Turning a disadvantage into an advantage, he used the Sproull Report as a form of leverage. Because the foundations had subjected the Institute of Medicine to such a probing and painful analysis and because the Institute of Medicine had begun to put its house in order, Thier argued that the foundations now had a moral obligation to come to the IOM's aid. He hastened to reassure these foundations that he had absorbed the many criticisms of the IOM and would take steps to remedy the problems. Under his leadership, he promised, the IOM would strive to complete its studies more quickly, with the goal of cutting in half the time necessary to complete studies. Using the IOM's convening power, he planned to bring together the parties interested in drug development and health technology assessment in order to facilitate communication among participants in these particular fields. Finally, Thier vowed to make the IOM more visible to the government, so that government agencies turned reflexively to it for advice.2 Like his predecessors, Thier was a respected academic doctor who had produced more than 80 research papers in his chosen field of kidney function. More importantly, however, he had early shown a penchant for medical administration and proved himself to be a superior clinician. The son of a physician, Thier decided to follow his father's profession. "My father was a general practitioner and loved what he was doing and I just thought it was an exciting life," he explained. Thier graduated from the State University of New York Upstate Medical Center at Syracuse in 1960 and then entered the elite echelons of the medical profession by taking his internship and residency at Massachusetts General Hospital in Boston. By 1966, he had earned the coveted position of chief resident at Massachusetts General, which prepared him for a career in academic medicine that included positions as chief of the renal service at Massachusetts General and vice chairmanship of the Department of Medicine at the University of Pennsylvania. In 1975, only 15 years removed from medical school, he became chairman of the Department of Medicine at Yale. Fellow doctors admired both his ability to respond to emerging trends in medicine and his clinical skills in diagnosis and treatment.3 By the time Thier arrived at the Institute of Medicine at the end of 1985, he had already played an active role in the organization's affairs and in medical affairs more generally. Elected to the IOM in 1978, Thier had chaired the Board on Health Sciences Policy and been a

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To Improve Human Health: A History of the Institute of Medicine member of two study committees. Just before coming to the IOM as president, Thier served as chairman of the American Board of Internal Medicine, the national body that set certification standards for doctors in internal medicine and its subspecialties. Under his and William Kelley's leadership, the board had established the subspecialty of geriatrics. In addition, Thier held many appointments related to his academic position, such as chief of medical service at the Yale-New Haven Hospital and member of the editorial board of the New England Journal of Medicine.4 When Thier presided over his first Council meeting on November 18, 1985, it immediately became apparent that the IOM would no longer be, in the words of a veteran IOM member, "Sleepy Hollow." Thier cut through much of the talk that tended to slow the organization down. Too much energy, he said, had been expended on determining whether the IOM should be involved in health policy or the health sciences. He believed that it was not an either-or proposition, but that instead, the Institute should be responsible for what he described as "the entire spectrum of activities within the National Academy of Sciences (NAS) complex that deal with human health." To make sure this was the case, Thier bargained with NAS President Frank Press to initiate a review of National Research Council (NRC) activities that should be transferred to the IOM. At the same time, Thier realized that if these units were to be transferred to the IOM, the IOM would have to improve its ability to provide oversight on basic science issues by increasing the number of scientists on the IOM Council. Thier also took immediate steps to address the IOM's financial problems. He got Press to agree to raise the amount of NAS support for the IOM from $596,000 to $800,000. With this additional money, no staff cutbacks would have to be instituted. More importantly, he convinced Press to grant the IOM a two-year grace period during which it would not be penalized for reasonable deficits.5 As soon as Thier took over on a full-time basis at the beginning of 1986, he made the rounds of foundations and appealed for core support. For many of the foundations, such as the Robert Wood Johnson (RWJ) Foundation, money for an endowment violated their action-oriented view of philanthropy. They wanted to solve specific, pressing problems at a time when people were increasingly turning to private charities, rather than to the government, for such solutions. They had less interest in endowing institutions and giving them a free rein to run their own affairs. With his usual optimism, Thier visited the Commonwealth Fund, the Carnegie Corporation, the Andrew W.

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To Improve Human Health: A History of the Institute of Medicine Mellon Foundation, the Dana Foundation, and the Kaiser Family Foundation and tried to convince them otherwise.6 Thier realized that the key to the effort was the Robert Wood Johnson Foundation because other foundations that specialized in health and medicine tended to follow RWJ's lead. Of all the foundations interested in medicine, RWJ had the most money at its disposal, enjoyed a close relationship with the Institute of Medicine, and played a key role in the formation of the Sproull committee. Of all the foundations, however, RWJ also had the most stringent rules for the accounting of funds and made very few grants to endow specific institutions. It preferred to run its own fellowship programs, often in conjunction with other institutions such as Johns Hopkins University and the Institute of Medicine, and to take a coordinated approach to the solution of a specific problem such as homelessness. Aware of these constraints, the IOM proceeded to make a request for a $5 million endowment that occasioned considerable controversy among members of the RWJ board and staff. The foundation asked Thier to meet with a small subcommittee of its board in the fall of 1986.7 The meeting proved a considerable success. At the end of October, the Robert Wood Johnson Foundation announced that it would make a special award to the Institute of Medicine. The award consisted of a $5 million grant that came with two conditions: The first was that the IOM raise its endowment goal to $20 million, and the second was that the IOM raise $2.00 for every $1.00 it received from Robert Wood Johnson. "The conditions of the grant are fully acceptable to us," Thier replied, noting that there was "no organization to which the Institute is as deeply indebted for its continuing support as it is to the Robert Wood Johnson Foundation."8 The IOM used the RWJ grant as the basis for a capital campaign announced in March 1987. By this time, the IOM already had in hand much of the money necessary to match the RWJ grant. By November 1986, for example, the IOM had received $500,000 from the Commonwealth Fund, $1 million from the Andrew W. Mellon Foundation, $1.5 million from the Kellogg Foundation, and even more impressively, $5 million from the MacArthur Foundation. For the first time, the Institute of Medicine would be able to enjoy the benefits of an endowment that would yield substantial income each year.9 These significant new sources of income did not exempt the IOM from the usual sort of confrontation with the foundations. The Robert Wood Johnson Foundation, in particular, proved to be a demanding patron. In 1988, for example, it reduced the IOM's budget request for the RWJ fellows in health care policy from a requested $300,000 to $200,000 and refused to contribute toward the indirect costs of

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To Improve Human Health: A History of the Institute of Medicine running the program. Becoming very angry, Thier accused the foundation of not honoring its previous commitments. As a compromise, foundation officials suggested that RWJ pay half of the indirect costs and that the IOM pay the other half from its endowment funds. As Marion Ein Lewin, the IOM staff member who ran the fellowship program, explained, foundation officials regarded the endowment money as an ''unusual, generous grant'' that had served as seed money for other grants. The foundation was also firmly against paying indirect costs. Hence, it seemed reasonable to foundation officials that the IOM use some of its RWJ money to help pay for the one IOM program directly associated with the Foundation. Thier refused to see it this way, insisting that the use of the endowment to defray indirect costs had never been a condition of the RWJ grant. IOM Council members expressed a reluctance to "disrupt relations" with a foundation that had been so generous to the IOM for so long. Thier, for his part, did not want to compromise on an important point "in order to placate a powerful donor."10 In the end, Thier secured an agreement that after a two-year period, the foundation would pay the full costs of the program.11 Despite these inevitable disagreements, the fact is that the IOM enjoyed unprecedented success in its outreach to foundations during the presidency of Samuel Thier. One factor in this success was the surge in the stock market and the economic boom that occurred in the mid-to late 1980s. After a sharp recession in the early 1980s, economic conditions brightened. This meant that the value of the securities that foundations held in their portfolios increased, and because the foundations were required by law to spend a certain percentage of their income, the amount of money they awarded also increased. For example, the Kellogg Foundation discovered at the end of fiscal year 1987 that it had "a significant overrun in income" that had to be spent by the end of the calendar year. This made it receptive to a proposal from Frank Press and Sam Thier for an additional $20 million endowment for the NAS and the IOM.12 The foundation eventually awarded the NAS and the IOM a $20 million challenge grant to support studies in health, education, and agriculture.13 Another factor in the IOM's fund-raising success was that the Reagan revolution appeared to have run its course. Because the foundations were no longer quite so panicked about defining their role in an era of shrinking government, they felt able to make grants to their traditional clients such as the IOM. A third factor was the persistence and confidence with which Thier approached the foundations. Unlike Fred Robbins, who tolerated the fund-raising process because he recognized its importance and knew it was

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To Improve Human Health: A History of the Institute of Medicine expected of him, Thier made fund-raising a priority and enjoyed the experience. He excelled at reassuring the foundations that their money would be well spent and proved adept at creating a bandwagon effect, urging one foundation not to get left behind by another. Report Dissemination and Expansion of the Institute One of the items on which Thier spent the IOM's newfound money was the dissemination of IOM reports. From the day he took over as IOM president, he vowed to make an effort to distribute IOM reports in an organized fashion, beginning with the original proposal and extending through the evaluation of the final report's impact.14 "Dissemination is our current buzz word," said communications director Wallace Waterfall in 1987,15 referring to such things as a videotape of the symposium on the medical effects of nuclear war that the IOM prepared for distribution to universities and the special efforts that the IOM made to publicize its study on prenatal care.16 The prenatal care study, designed to suggest ways of increasing the utilization of prenatal care by mothers early in their pregnancies, began in 1986. Headed by Joyce Lashof, dean of Berkeley's School of Public Health, it followed from the recommendations of the widely acclaimed report from the Fred Robbins's era that had cited increased prenatal care as a primary means of preventing low birthweight. Therefore, the very fact that the IOM undertook the second study indicated a new ability to achieve continuity in its program. To support the study on the utilization of prenatal care, the IOM secured funding from the Carnegie Corporation, the Ford Foundation, the March of Dimes, and the Rockefeller Foundation. To ensure wide dissemination of the final report, which appeared in October 1988, the IOM received additional money from Carnegie and Ford that enabled it to issue a separately bound summary of the report to more than 10,000 people and organizations. On the evening before formal release of the report, the IOM hosted a special dinner for 70 key leaders in the field of maternal and child health, and the following morning the IOM held a press conference. Forty reporters attended, leading to reports on the CBS Evening News and the MacNeil-Lehrer NewsHour and in the New York Times, the Wall Street Journal, USA Today, and many local newspapers. The IOM next focused on giving speeches about the report to influential groups and on getting coverage in medical and scholarly journals. These efforts resulted in presentations in such settings as the U.S. Conference of Mayors, the Council on Foundations, and the

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To Improve Human Health: A History of the Institute of Medicine National Governors' Association and articles in such places as the Journal of the American Medical Association and the Journal of Social Issues. In the next phase of dissemination activity, the IOM sought to interest Congress in the report. In the summer of 1988, Sarah Brown, the staff study director, testified before both the House Committee on Government Operations and the Senate Finance Committee. 17 This sort of attention to dissemination became a key part of Thier's plan to improve the performance and influence of the IOM. As one document of the period stated, "The recommendations of a study can only be regarded as disseminated when they are acted upon by the health enterprise." Other components of the IOM's "new directions" included better targeting of health policy problems as they developed, greater versatility in responding to problems, and closer involvement of members in the creation of the program plan and the execution of IOM studies.18 Increased funds and more attention to dissemination brought positive results in the form of increased prominence within the National Academy of Sciences, growth of the IOM staff, and expansion of the IOM's organizational responsibilities. One sign of its increased clout within the larger organization was an agreement that increased the NAS funds that went to the IOM. These funds took the form of payments for the overhead costs of some of IOM's program activities. The more that the IOM contributed to the total pool of overhead funds, the more it could demand from the Academy.19 In fiscal year 1988, the IOM expended more than $6.5 million dollars in program activities, compared with $3.02 million in 1986. At the beginning of 1988, the IOM had 85 project staff members (compared with 20 in December 1986) and 20 core staff members. The staff was growing so rapidly that finding a place to house them in relative proximity proved a serious challenge.20 A key element of the IOM expansion involved the July 1, 1988, transfer of the Medical Follow-Up Agency and the Food and Nutrition Board from the National Research Council to the Institute of Medicine. These organizational changes marked the realization of plans that went at least as far back as the Ebert report in 1982, which had called for the IOM to assume more administrative responsibility for the components of the Commission on Life Sciences (CLS) that dealt primarily with medicine. When Thier took over, he asked Frank Press once again to investigate the organization of the NRC with an eye toward identifying those parts of the Commission on Life Sciences that more properly belonged in the IOM. Press assigned Walter Rosenblith, emeritus professor at MIT and former member of the

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To Improve Human Health: A History of the Institute of Medicine Board on Medicine, to head the group charged with this task. His primary recommendation was that the Medical Follow-Up Agency should be transferred to the IOM, and his secondary recommendation called for the Food and Nutrition Board to have part of its activities overseen by the National Research Council and part by the Institute of Medicine. The IOM Council preferred a simpler arrangement, in which the Institute assumed administrative responsibility for the Food and Nutrition Board, with an understanding that the IOM would "assign to CLS ... those activities that were recommended by [Rosenblith's] committee for retention under CLS oversight."21 In this case, unlike so many others in the past, the IOM got what it wanted. Both the Medical Follow-Up Agency and the Food and Nutrition Board came to the IOM. Created in 1946, the Medical Follow-Up Agency brought an epidemiological focus to the Institute of Medicine. The agency's main purpose was to facilitate the use of federal records, primarily those of the armed forces and the Veterans Administration, for medical research. The agency also maintained a special data base on twins who had served in the armed forces. Among topics of interest to the agency, which contained a staff of six professionals, were the psychological and medical results of military captivity, the risk of cancer following exposure to a nuclear weapons test, and the natural history of various forms of hepatitis. An eight-person Committee on Epidemiology and Veterans Follow-Up Studies, headed by Richard Remington, vice president for Academic Affairs at the University of Iowa, supervised the agency's studies which were financed, at the rate of about $1 million per year, almost entirely from federal funds. Unlike the other parts of the Institute of Medicine, the Medical Follow-Up Agency engaged in the conduct of original research, often with statisticians and epidemiologists on the staff acting in collaboration with clinical investigators and epidemiologists from academic medical centers.22 The Food and Nutrition Board was a larger and more complex undertaking. Started during the Second World War, it addressed issues of critical importance that pertained to the adequacy and safety of the nation's food supply as well as matters that related to proper diet and nutrition. Among the questions it sought to address were ones of considerable political and economic sensitivity, such as the effects of chemical additives on the quality of the food supply or the nutritional qualities and harmful side effects of particular foods. Most of the members of the 12-person board were academic physicians or scientists concerned with the study of nutrition. Typical of the work of the Board was a large 1989 report on Diet and Health that

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To Improve Human Health: A History of the Institute of Medicine recommended the appropriate daily levels of fats and salt necessary to maintain health and prevent disease. Other aspects of the board's work concerned the international dimensions of nutrition, such as how to correct the deficiency of vitamin A in the diets of Third World children that led to blindness. Still other parts of the board's mission involved the maintenance of proper nutrition during pregnancy and lactation. In 1988, the board's disparate activities cost about $1.5 million to run and required the services of some 14 professional staff members.23 Not only did the IOM acquire new agencies as part of its newfound prosperity, it also revived components that had been moribund and invented new entities. The Board on International Health served as a good case in point. An important priority of David Hamburg's, international health had languished as an IOM activity during the 1980s, becoming the IOM division that encountered the most difficulty in attracting outside funds. To the proprietors of an increasingly troubled American health care system, international problems appeared remote, and the Reagan administration was reluctant to spend money on controversial forms of foreign aid such as advice on population control. As a result of these forces, the Board on International Health, which had struggled to come into existence in the first place, was effectively dissolved by the end of 1987. Thier and his staff set out to raise funds for a revived board and succeeded in gaining money from the Rockefeller Foundation, the Public Health Service, and the Agency for International Development. The IOM also contributed some of its newly gained endowment money. As a result, the new Board on International Health met for the first time in January 1989.24 In reconstituting the board, Thier vowed to avoid the mistakes of the past. The new board, unlike the old one, would have a firm funding base and be less susceptible to changing political fashions in which health shifted as a priority in economic development and foreign aid portfolios. It would be smaller and better focused than the previous board, and it would include foreign experts on health care policy. With this new outlook, Thier hoped that the new board would shape "a clear image of a distinctive role for itself' and convey this to the international health community.25 By 1990, the IOM's program in international health included a wide array of projects, such as a study of malaria prevention and control and another of female morbidity and mortality in Africa.26 This latter project ultimately resulted in the publication of a 1996 volume that showed how the IOM had changed over the years. Like other complicated projects, this one took a long time to complete. It

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To Improve Human Health: A History of the Institute of Medicine required almost six years to gather sufficient funding, find an appropriate focus, and perform the analysis. The final report covered sub-Saharan Africa and not the entire African continent. It was nonetheless an ambitious attempt to define the gender-related burden of health problems for females across the life cycle. As with all recent IOM reports, it began with an accessible summary that, for example, presented the main results in the form of two large tables. Furthermore, the book had an attention-getting main title, In Her Lifetime, and an arresting cover. Against a striking gold background, an impressionistic picture of an African woman, done in shades of red, orange, and black, appeared. It made quite a contrast to the utilitarian covers, in an institutional shade of yellowish gray, that had graced IOM reports through all of the 1970s and much of the 1980s. The old reports had consisted of photo-offset typescripts with jagged right margins; the new reports contained sleek type faces and crisp graphics that gave these publications a professional appearance and made them much easier to read.27 The chief drawback of studies such as the one on female morbidity in Africa was the length of time required to complete them. As part of the effort to respond more quickly to current concerns, the IOM started a number of informal forums. One was the Forum on Drug Development and Regulation, "a meeting ground for the exchange of ideas and information," that began in July 1986. The idea behind this effort, an experiment that soon evolved into a regular activity of the Institute's Board on Health Sciences Policy, was to provide "regular meetings in a nonadversarial environment for representatives from government, industry, and academia to discuss pharmaceuticals." Recognizing the value of such an institution, federal agencies concerned with drug development such as the Food and Drug Administration, professional organizations such as the American Medical Association, and private trade associations such as the Pharmaceutical Manufacturers Association all contributed to the forum's upkeep. The Forum on Drug Development, as the entity ultimately became known, involved little of the internal clearances and other hindrances that often delayed IOM initiatives. A unique use of the IOM's convening power, it made the IOM privy to the latest developments in the field and led to workshops on related topics, such as a 1990 workshop on the development of drugs for pediatric populations.28 A more ambitious effort to respond quickly to current health concerns began in the Fred Robbins's era with a 1983 report that recommended establishing a consortium for assessing medical technology. This idea attracted interest in Congress and led to the

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To Improve Human Health: A History of the Institute of Medicine passage of the Health Promotion and Disease Prevention Amendments of 1984, which included a provision for the Council on Health Care Technology. A subsequent law, passed a year later, made it possible for this council to be formed as an IOM activity. By the time the first meeting took place in April 1986, Samuel Thier, like Fred Robbins before him, had become an enthusiastic proponent of the concept. The council required a great deal of Thier's attention, because Congress appropriated money for it through the National Center for Health Services Research (NCHSR) and Health Care Technology Assessment (part of the Public Health Service) and made all money contingent on the receipt of private matching funds, at rates that changed over the course of the project. Thier organized a fund-raising campaign in which, for example, he solicited funds from the Medical Products Group at Hewlett-Packard and the Du Pont Medical Products Department, as well as numerous insurance companies. The need to raise funds in such a piecemeal fashion hampered the operations of the council, which was phased out in 1990 in favor of a Committee on Clinical Evaluation. "We believe that the requirements to raise private sector support and to spend it before it can be matched by NCHSR ... hindered the work of the Council," Enriqueta Bond of the IOM staff explained. 29 In its relatively short life, the 16-person council, chaired by William Hubbard, the former head of the Upjohn Company, and cochaired by Jeremiah Barondess, a professor of clinical medicine at Cornell University Medical College and later president of the New York Academy of Medicine, studied aspects of the use of technology in health care. Perhaps the most important of its projects, the 700-page Medical Technology Assessment Directory, illustrated its role as a clearinghouse of information in the field. Appearing in 1988, this directory provided a list of resources on which hospitals, insurers, and others in the health care field could rely to make difficult decisions related to medical technology. If, for example, a hospital wished to purchase a lithotriptor to destroy kidney stones, it could find listings that would direct it to the available information on this subject. Insurance executives, concerned about the proper use of magnetic resonance imaging, could use the directory to get a quick sense of studies designed to test the cost-effectiveness of such techniques. Clifford Goodman, the council program officer, described the directory as a volume "designed to get dog-eared" and as a step toward creating an effective network of practitioners in the field of health care technology assessment. The completion of such studies, as well as ones on computerized patient records, earned plaudits from Congress. In 1987, renewing the program for three additional years, the Senate

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To Improve Human Health: A History of the Institute of Medicine "Chairman's Message" that contained very strong language. It described homelessness as "a scandal and an outrage" that demanded not only "dispassionate analysis" but also "a more direct and less qualified scream of pain and anger." The report, according to Vladeck, contained ''lots of analysis but no poetry.... We tried to make our report as dispassionate as the IOM/NAS process requires, but the reality we experienced cries out for passion."51 In the end, little of Vladeck's passion seeped into the final report. Careful analysis triumphed over soaring poetry, even in an era in which dissemination of results and impact on the policy process were among the highest IOM values. The report appeared with no supplementary statement from Vladeck, who threatened to write about the matter in an op-ed piece for the New York Times. Instead, it contained the unexceptionable conclusions that a high level of mental illness characterized the homeless community and that the homeless required stable residences and sufficient incomes. In this regard, the report could be parodied in a manner similar to a sketch from Beyond the Fringe: What the homeless needed was not to be homeless. As for the health care received by the homeless, the report suggested that it was inadequate and formed part of a larger problem of providing access to health care for those unable to pay. In the meantime, public policies toward the homeless were fragmented and often ineffective.52 Perhaps homelessness, unlike the improvement of medical care records, was simply too large and amorphous a problem for the IOM to solve. If Congress liked to present the IOM with issues for which no solution was imminent, it also requested the IOM's assistance in matters that were simply too controversial for politicians to handle. Such a case occurred during the early 1980s in the Social Security programs designed to pay benefits to people with disabilities. During the 1970s, Congress had grown concerned over the rapid growth of these programs and had sent signals to the bureaucracy to reduce the size of the rolls. When the Social Security Administration responded by removing many people from the rolls in the early 1980s, Congress shifted direction and expressed concern for people taken off the rolls in the midst of a severe recession. Congress passed a law in 1984 that made it more difficult to remove a person from the disability rolls. Certain issues, however, were too difficult for Congress to decide, such as how much credence should be given to complaints of pain among applicants for disability benefits. In response, Congress mandated the creation of the Commission on the Evaluation of Pain and directed the commission to work in consultation with the IOM. The commission, in turn, recommended further study by the IOM, an

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To Improve Human Health: A History of the Institute of Medicine assignment that the IOM accepted in 1985 and that led to the report Pain and Disability in 1987.53 An interesting blend of medical doctors and social scientists served on the committee, which was chaired by Arthur Kleinman, a professor of anthropology and psychiatry at Harvard, and David Mechanic, the Rene Dubos Professor of Behavior Sciences at Rutgers. From the beginning, this group recognized that the phenomenon of pain had both a physiological and a behavioral component. The report stated bluntly that "very little is known about the mechanisms underlying such common clinical problems as low back pain" and that "no direct, objective way to measure pain" existed. Rather than dismiss an applicant's protestations of pain, the group recommended that the Social Security Administration should instead assess what the experts called the ''functional capacity for work." At the same time, the committee suggested that such things as "chronic pain syndrome" not be added to the list of impairments that automatically qualified a person for disability benefits. The Social Security Administration took the IOM's advice and instituted an early functional assessment of claimants with a primary pain complaint. To be sure, the disability programs remained controversial, particularly during the tremendous surge in the rolls that occurred after 1984. Nonetheless, the IOM had successfully intervened in, and probably improved, a significant component of disability policy at a time when Congress was reluctant to become involved.54 Furthermore, it had done so by bringing together leading medical doctors and social scientists in ways that were unique to the IOM. Even as the IOM undertook special assignments for Congress, it also tended to its traditional concerns. In 1990, for example, one of the cross-cutting themes of the Institute's work was "the role, education and supply of health professionals." In support of this theme, the IOM released a report on financing the graduate medical education (GME) of primary care physicians in ambulatory settings. This project came to the IOM not by way of the government but rather through the efforts of two professional organizations concerned with health, the Association of Program Directors in Internal Medicine and the Ambulatory Pediatrics Association. The IOM obtained support for the project not primarily through the government but rather from the Josiah Macy, Jr., Foundation. The final report lacked the elegant writing and presentation that marked so many IOM reports during this period, in part because it concerned hard-core matters of interest only to those who understood the intricacies of health financing policy. In support of increasing the number of doctors who worked in primary care fields in outpatient

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To Improve Human Health: A History of the Institute of Medicine settings, the report recommended that technical adjustments be made in the way the Medicare program financed graduate medical education and the way it reimbursed the services of physicians. The report also urged medical schools to reorder their priorities so that primary care teaching and curriculum development were rewarded. As the report noted, physicians in primary care practice responded to community health needs in settings that ranged from solo practice to HMOs; the hospital was no longer a suitable principal focus for the GME experience of such physicians. The committee concluded that "the care provided by future generations of primary care physicians would be enhanced if the GME experience placed greater emphasis on training in primary care outpatient settings." Although the report's effect on public policy was scant, it helped call attention to the need to match the educational system with the realities of medical practice. It received attention from medical schools that were in the process of revising their primary care residency programs, if not from the Congress.55 The Institute of Medicine produced a dizzying array of reports and studies in the Thier years. In the field of health manpower and education, for example, the work of the Institute extended beyond primary care to include multiple studies in the fields of geriatrics, allied health services, and occupational and environmental medicine.56 Often, one study exposed gaps in knowledge or highlighted opportunities that led to the IOM's being asked by a sponsoring agency to do a follow-up study. At the same time, the IOM responded to numerous requests for assistance from government agencies on studies or projects that the agencies were undertaking themselves. To cite one example, the Institute of Medicine provided scientific advice and oversight for several Centers for Disease Control (CDC) studies of the health of Vietnam veterans. In particular, the CDC wanted to know if exposure to Agent Orange and other herbicides in South Vietnam led to a greater risk of such cancers as Hodgkin's disease and non-Hodgkin's lymphoma. In 1990, the IOM issued a summary report in which it concluded that the CDC Selected Cancers Study made a "useful and important contribution to understanding the relationship between the Vietnam experience and the cancers under study." Such validation was important because an earlier study that had been canceled led to a charge from Representative Ted Weiss (D-N.Y.) that the Reagan administration had deliberately obstructed the study. In such a contested area of public policy as the effects of Agent Orange, with millions of dollars in damages at stake, the public had to be reassured that scientists who performed the investigations were above political

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To Improve Human Health: A History of the Institute of Medicine suspicions. The IOM helped to supply this reassurance and improve the conduct of the study.57 Despite the fact that the IOM did so many studies on such widely disparate topics, the organization moved with considerable caution. If anything, the IOM moved more cautiously in the Thier years than before, in part because of the realization that its actions had real policy consequences and in part because of a new financial independence that made it less dependent on external funders. When, for example, the IOM convened a group to consider what projects, if any, the organization should pursue in the area of medically assisted technology, Thier warned that it should not become enmeshed in the ''sociopolitical arguments" that had arisen over medically assisted conception. Instead, the IOM could maintain its neutrality by focusing on the "science base" of this matter. As a result, the Institute decided to sponsor a conference on reproductive biology. The Board on Medicine and the early IOM, one might surmise, would have engaged the question differently. 58 In these various ways then, the IOM conducted its activities in the years between 1986 and 1991. At times it responded to congressional mandates and, at other times, generated its own funds for studies that had been suggested by the IOM members. Some studies came at the request of government agencies and others at the request of private foundations or professional groups. In some instances, the IOM tried to condition future practices; in others, it sought to redress past grievances. It handled large and amorphous topics such as the future of public health, as well as smaller and more select topics such as the role of pain in Social Security disability determinations. At times, the IOM acted as an agent of reform. At other times, it functioned as an arbiter of public policy or an entity that validated the actions of others. Always, however, the IOM used its special prestige and status, its membership drawn from a wide variety of medical fields and disciplines, and its ties to the National Academy of Sciences to convene an appropriate and distinguished panel to examine the particular question under discussion. In these regards, the Thier era was not unlike the eras that preceded it; the difference came primarily in the increased scope of the IOM's activities.

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To Improve Human Health: A History of the Institute of Medicine Organizational Routines Despite all that happened between 1986 and 1991, questions that dated back from the founding of the IOM still preoccupied the staff and the Council. The issue that most animated the IOM staff concerned the overlap between the missions of the IOM and the National Research Council. Even with the transfer of new agencies from the NRC to the IOM, the boundary between these two parts of the Academy complex was unstable. In November 1989, Samuel Thier complained, as had his predecessors, that the overlap was "not well controlled" and that such topics as animal research, radiation effects research, and environmental studies and toxicology led to duplication and competition between the Institute of Medicine and the Commission on Life Sciences. Potential for conflict on behavioral topics also existed with the NRC's Commission on Behavioral and Social Sciences and Education.59 The question that appeared to be of most interest to the IOM Council involved who should be elected to the IOM in a given year, because each year the longest discussions concerned membership criteria. In January 1988, for example, David Challoner appeared before the Council to discuss the final ballot for the 1988 election and the proposed ballot for the 1989 election. At this point in the organization's history, membership elections had become quite structured, with quotas in seven different categories. The largest of these categories was the one broadly based in the medical disciplines; the smallest included physical scientists, mathematicians, and engineers. In 1988, the Membership Committee arranged the quotas to yield a total of 40 new members. To assist voters, the Membership Committee, with the help of IOM members themselves, ranked the nominees in each of the categories. Those ranked highest usually gained membership. In addition, the IOM hoped to elect 10 people directly to senior membership. For the 1989 election, the IOM Council decided to elect 40 new members, as well as 5 senior members and no more than 10 foreign associates. Apportioning quotas among the categories always created disagreements. In 1988, for example, Alexander Capron, a lawyer from the University of Southern California and a Council member, expressed concern that the number of members in the social sciences category was decreasing. Thier replied bluntly that the IOM was "not a representative group and some disciplines and areas of expertise would not be as well represented as others." The idea was not to spread the membership across fields but rather to identify "outstanding people who can contribute to the Institute's task."60

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To Improve Human Health: A History of the Institute of Medicine As the Institute added new members each year, it bumped up against the limit of 500 members that was contained in the Charter, which increased the pressure to include individuals from specialties not well represented and made the competition across membership categories even more intense. The trouble stemmed in part from the composition of the various membership sections that suggested new members. These sections were narrower in scope than the membership categories. Section Eight, for example, represented family medicine, primary care specialties, emergency medicine, physical medicine and rehabilitation, and osteopathy. It contributed suggestions for those nominated under Category Three, medical disciplines, in the general election. Although family medicine was well represented in this section, it contained few practitioners from the other medical fields it was designed to include. If a section was dominated by people from one field, it was difficult for someone from another field to get nominated or, if nominated, to receive a high ranking from the section and the Membership Committee. This feature of the election process limited the organization's ability to face new problems that demanded the expertise of people in fields that were not well represented in the membership. In addition to these questions related to discipline, the Institute faced other concerns related to the composition of its membership, such as ensuring the election of women and minorities. In a setting in which the organization received 200 nominations for only 40 places, achieving diversity proved difficult. Members tended to rely on what one described as "the old-boy, old-girl network."61 To ease these problems, the Council decided in November 1989 to raise the ceiling on membership from 500 to 600. This would permit the Institute to elect 45 rather than 40 members each year. The rationale for the change was that in the past, it had been necessary to control the quality of the membership by limiting the size of the organization. Because of the rigorous procedures followed by the Membership Committee, however, the Council felt that quality concerns had become integral to the nominating process. Hence, the number of members could be expanded, although not without limit, and the quality of the membership could be maintained.62 If there was a major change in membership over the years, it concerned the increased medical, as opposed to public policy, expertise of members. There were fewer generalists, more specialists. When the Board on Medicine started, it included individuals such as Adam Yarmolinsky, who were distinguished in their own fields, lacked direct experience in medicine, and became quite interested in medical affairs in large part because of their involvement with the IOM. In the

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To Improve Human Health: A History of the Institute of Medicine IOM's first years, it also had members who were regarded as important to the ongoing discussion of national health insurance, people such as Robert Ball and Wilbur Cohen, two Social Security experts who had played major roles in the creation of Medicare. As national health insurance faded as a topic of concern, people similar to Ball and Cohen, who were neither physicians nor health care professionals working in an academic medical center, had more difficulty being elected to the IOM. With the tendency to more closely merge the medical professions and the IOM came the danger of losing sight of the connection between medical policy and larger social concerns. Despite this danger, many IOM members insisted on preserving its social, as opposed to scientific, mission. In 1989, Samuel Thier noted with pride that Dr. Louis Sullivan had been nominated by President-elect George Bush to serve as Secretary of Health and Human Services. Sullivan became the first person to serve as Secretary of Health and Human Services while already an IOM member. It gave the organization a sort of "in" with the department most concerned with social policy that it had not enjoyed since the days of Joseph Califano. It increased the chances that the department and the IOM could act in concert in facing such issues as AIDS, homelessness, and crack and cocaine addiction. With each of these social problems, it was the IOM that showed the most interest in them among the components of the National Academy of Sciences. Even as the IOM increased its science component, therefore, it remained the branch of the National Academy of Sciences most dedicated to bringing research to bear on modern social problems. What most distinguished the years between 1985 and 1991 was not a change in the IOM program as much as the experience of phenomenal growth. No longer could the IOM be regarded as marginal to the NAS, an experiment that could be suspended with cause. Instead, the IOM became the branch of the NAS with the most financial resources at its disposal and, in many respects, the most active membership. The Thier years assured the IOM of its survival and made it a permanent entity in the NAS and on the larger national scene. It even looked for a time as though Samuel Thier would become the first two-term president of the NAS. When his first term ended in the fall of 1990, he began a second. In May of 1991, however, he announced that he had received an offer to be president of Brandeis University that he felt he could not refuse. When Thier left for Brandeis in the fall of 1991, Stuart Bondurant, dean of the University of North Carolina Medical School at Chapel Hill, became the acting

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To Improve Human Health: A History of the Institute of Medicine president of the IOM. Once again, the IOM awaited a new leader. Unlike Samuel Thier, for whom expectations were low in the face of threats to the IOM's very existence, the new IOM president would lead a large, complex, and growing institution that was expected to play a major part in the nation's health policy. As the Wall Street Journal reported in 1987, the Institute of Medicine had achieved considerable clout on the Washington scene, and Samuel Thier had played no small part in this. Notes 1.   Alan L. Otten, "When Institute of Medicine Speaks, People Listen, Because Newest President Won't Let It Be Ignored," Wall Street Journal, March 31, 1987. 2.   Gina Kolata, "New Directions for the IOM," Science, 230 (November, 1985), pp. 524–525. 3.   "Executive Profile: Samuel Thier," Pharmaceutical Executive, August 1988, pp. 28–40. 4.   "Thier to Become Fifth President of the Institute of Medicine," IOM Press Release, September 30, 1985, Yordy Files, Accession 91-051, Institute of Medicine (IOM) Records, National Academy of Sciences (NAS) Archives. 5.   IOM Council Meeting, Minutes, November 18, 1985, IOM Records. 6.   IOM Council Meeting, Minutes, March 17, 1986, IOM Records. 7.   IOM Council Meeting, Minutes, July 21–22, 1986, IOM Records. 8.   Samuel Thier to Leighton Cluff, October 21, 1986, and Cluff to Thier, October 21, 1986, both in Yordy Files, Accession 91-051, IOM Records. 9.   "Institute of Medicine, Aiming for Endowment, Gets Johnson Foundation Pledge," IOM Press Release, March 31, 1987, IOM Records; IOM Council Meeting, Minutes, November 17–18, 1986, IOM Records. 10.   IOM Council Meeting, Minutes, April 18–19, 1988, IOM Records. 11.   IOM Council Meeting, Minutes, July 21–22, 1988, IOM Records. 12.   IOM Council Meeting, Minutes, July 23–24, 1987, IOM Records. 13.   IOM Council Meeting, Minutes, July 21–22, 1988, IOM Records. 14.   IOM Council Meeting, Minutes, November 18, 1985, IOM Records. 15.   Alan L. Otten, "When Institute of Medicine Speaks," op. cit. 16.   IOM Council Meeting, Minutes, April 20–21, 1987, IOM Records. 17.   Sarah S. Brown, "Final Report of Dissemination Activities for Prenatal Care: Reaching Mothers, Reaching Infants," Yordy Files, Accession 91-051, IOM Records; Institute of Medicine, Annual Report 1987, Program Plan 1988 (Washington, D.C.: National Academy Press, 1988). 18.   "New Directions for the Institute," June 1986, Yordy Files, Accession 91-045, IOM Records. 19.   IOM Council Meeting, Minutes, January 27, 1987, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 20.   Samuel Thier to Members of the Institute of Medicine, December 9, 1987, Yordy Files, Accession 91-051, IOM Records; IOM Council Meeting, Minutes, April 20–21, 1987, IOM Records. 21.   "Minutes of the Discussion of the Report of the Study Committee to Review the Programs of the Institute of Medicine and the Commission on Life Sciences," January 26, 1988, IOM Records. 22.   IOM Council Meeting, Minutes, January 9–10, 1989, IOM Records; Institute of Medicine, Annual Report 1988 (Washington, D.C.: National Academy Press, 1989), pp. 62, 81, 89–92. 23.   IOM Council Meeting, Minutes, November 14–15, 1988, and July 24–26, 1989, IOM Records; "Food and Nutrition Board: Goals and Objectives," July 1989, Yordy Files, Accession 91-051, IOM Records; Institute of Medicine, Annual Report 1988, pp. 35–38, 62; Institute of Medicine, Catherine E. Woteki and Paul R. Thomas, eds., Eat for Life: The Food and Nutrition Board's Guide to Reducing Your Risk of Chronic Disease (Washington, D.C.: National Academy Press, 1992). 24.   IOM Council Meeting, Minutes, July 21–22, 1988, IOM Records; Board on International Health Meeting, Minutes, January 17–18, 1989, Yordy Files, Accession 91-051, IOM Records. 25.   Ibid. 26.   Institute of Medicine, Annual Report 1990 (Washington, D.C.: National Academy Press, 1991), p. 41. 27.   Institute of Medicine, Christopher P. Howson, Polly F. Harrison, Dana Hotra, and Maureen Law, eds., In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa (Washington, D.C.: National Academy Press, 1996). 28.   "New Directions for the Institute," June 1986, Yordy Files, Accession 91-045, IOM Records. 29.   "Council on Health Care Technology: Chronology," in "The Council on Health Technology at the Institute of Medicine," April 1986; "Council on Health Care Technology, Interim Report, June 1987"; and Enriqueta Bond to J. Michael Fitzmaurice, Ph.D., Director, Department of Health and Human Services, October 2, 1989, all in Funding Files, Accession 91-045, IOM Records. 30.   Glenn Kramon, "Guide Assesses New Technology," New York Times, May 17, 1988, p. D2; "Action Memo," October 22, 1988, Yordy Files, Accession 91-051, IOM Records. 31.   IOM Council Meeting, Minutes, July 21–23, 1987, and April 20–21, 1987, IOM Records. 32.   IOM Council Meeting, Minutes, November 14–15, 1988, IOM Records; "Access to Health Services," October 22, 1988, Yordy Files, Accession 91-0513, IOM Records. 33.   Institute of Medicine, Annual Report 1989 (Washington, D.C.: National Academy Press, 1990), pp. 65–67. 34.   IOM Council Meeting, Minutes, November 16–17, 1987, IOM Records; Samuel Thier to IOM Members, December 9, 1987, Yordy Files, Accession 91-051, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 35.   IOM Council Meeting, Minutes, January 9–10, 1989, IOM Records; Institute of Medicine, Annual Report 1989, p. 3. 36.   IOM Council Meeting, Minutes, July 23–24, 1987, IOM Records. 37.   IOM Council Meeting, Minutes, January 9–10, 1989, IOM Records. 38.   Philip M. Boffey, "Experts Warn of 'Precarious' Vaccine Supplies," New York Times, July 30,1985. 39.   Samuel Thier to David Hamburg, December 5, 1986, Funding Files, Accession 91-045, IOM Records. 40.   See, for example, Institute of Medicine, Annual Report 1988, p. 5. 41.   Samuel Thier to Anne E. Hubbard, November 25, 1987, and "Proposal Draft," May 1987, both in Records of the Committee on Health Objectives for the Year 2000, Accession 90-067, IOM Records. 42.   Testimony of Alvin Mauer, University of Tennessee, Osman Ahmed, Meharry Medical College, and William Hagens, Member of the Washington State House of Representatives, in transcripts of regional hearings, Birmingham, Alabama, January 14–15, 1988, and Seattle, Washington, February 5–6, 1988, in Records of the Committee on Health Objectives for the Year 2000, 1987–1990, Accession 90-067, IOM Records. 43.   Mike Stoto to Committee on Health Objectives for the Year 2000, April 8, 1988, in Records of the Committee on Health Objectives for the Year 2000, Accession 90-067, IOM Records. 44.   Mike Stoto to Committee on Health Objectives for the Year 2000, May 31, 1990, and Stoto to Committee on Health Objectives for the Year 2000, March 20, 1989, both in Records of the Committee on Health Objectives for the Year 2000, Accession 90-067, IOM Records; Institute of Medicine, Healthy People 2000: Citizens Chart the Course (Washington, D.C.: National Academy Press, 1990). 45.   Institute of Medicine, The Future of Public Health (Washington, D.C.: National Academy Press, 1988), pp. 1–18. 46.   Institute of Medicine, The Future of Public Health: Summary and Recommendations (Washington, D.C.: National Academy Press, 1988), p. 7. 47.   On the importance of the report, see, for example, Institute of Medicine, Annual Report 1988, p. 4. 48.   Institute of Medicine, Richard S. Dick and Elaine B. Steen, eds., The Computer-Based Patient Record: An Essential Technology for Health Care (Washington, D.C.: National Academy Press, 1991), p. 6. 49.   Ibid., p. 3. 50.   Bruce Vladeck to Members of the Committee on Health Care for Homeless People, February 29, 1988, Homelessness Study Records, Accession 90-047-4, IOM Records. 51.   IOM Council Meeting, Minutes, January 25–26, 1988, and July 21–22, 1988, IOM Records; Bruce Vladeck to Members of the Committee on Health Care for Homeless People, Homelessness Study Records, Accession 90-047-4, IOM Records. 52.   IOM Council Meeting, Minutes, July 21–22, 1988, IOM Records; IOM Annual Report 1988, p. 5.

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To Improve Human Health: A History of the Institute of Medicine 53.   For background on this issue, see Edward Berkowitz, Disabled Policy (New York: Cambridge University Press, 1987). 54.   Institute of Medicine, Marion Osterweis, Arthur Kleinman, and David Mechanic, eds., Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives (Washington, D.C.: National Academy Press, 1987), pp. 2, 3, 8, 9; Edward Berkowitz and Richard Burkhauser, "A United States Perspective on Disability Programs," in Leo J.M. Aarts et al., eds., Curing the Dutch Disease: An International Perspective on Disability Policy Reform (Alderstot, U.K.: Avebury Press, 1996), pp. 71–91. 55.   Institute of Medicine, Annual Report, 1989, p. 5; Jessica Townsend, Study Director, to David Nexon, Committee on Labor and Human Resources, October 10, 1989, and Townsend to Frank Press, November 8, 1988, both in Records of the Committee for Supporting Graduate Medical Training in Primary Care, Accession 91-007-5, IOM Records; Institute of Medicine, Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings (Washington, D.C.: National Academy Press, 1989), pp. 10–11. 56.   Relevant IOM reports included Academic Geriatrics for the Year 2000 (1987); Strengthening Training in Geriatrics for Physicians (1993); Extending Life, Enhancing Life: A National Research Agenda on Aging (1991); Allied Health Services: Avoiding Crises (1988); Role of the Primary Care Physician in Occupational and Environmental Medicine (1988); and Meeting Physician Needs for Medical Information on Occupational and Environmental Medicine (1991), all published by the National Academy Press, Washington, D.C. 57.   "Summary Report: Selected Cancers Study, Advisory Committee on the Centers for Disease Control, Study of the Health of Vietnam Veterans," April 25, 1990, Accession 90-068, IOM Records; Keith Scheider, "Agent Orange Study Was Obstructed," New York Times, August 12, 1990, p. A-12. 58.   IOM Council Meeting, Minutes, July 21–22, 1986, IOM Records. In fairness, it should be pointed out that the IOM returned to this topic in its 1990 annual meeting. 59.   IOM Council Meeting, Minutes, November 13–14, 1989, IOM Records. 60.   IOM Council Meeting, Minutes, January 26, 1988, IOM Records. 61.   IOM Council Meeting, Minutes, January 9–10, 1989, and April 10–11, 1989, IOM Records. 62.   IOM Council Meeting, Minutes, November 13–14, 1989, IOM Records.