2
The Institute of Medicine Begins Operations

Early in 1971, Philip Handler, the president of the National Academy of Sciences (NAS), wrote one of his correspondents that ''the Institute of Medicine [IOM] is, at the moment, largely a paper organization, but the members of our Board on Medicine are busily engaged in fleshing it out."1 Four and a half years later, after two IOM presidents had come and gone, Roger Bulger, a key IOM staff member, noted that it had never "been our expectation that we would become a household word across the United States of America. We have never felt that we would become, at least in the first years, an opinion maker at the level of the individual citizen."2

As Bulger indicated, the Institute of Medicine attracted little national attention during its first five years of operations. This was because its work did not directly engage the questions that animated the public, such as the passage of national health insurance, nor did its leaders seek to become political celebrities who testified often before Congress. Instead, the IOM maintained a low profile and focused on relatively technical, but nonetheless important, questions related to health policy and conduct.

The new organization faced internal pressures that mitigated against its undertaking more ambitious projects. Members expected to shape the organization's agenda and participate in its activities, yet the IOM depended heavily on Washington-based staff, attuned to the nuances of public policy and accustomed to taking the lead on research projects, to guide its work. The action-oriented IOM formed part of the National Academy of Sciences and had to adapt to its culture. This meant an insistence on intellectual rigor attained by close peer review of Institute reports, combined with a relatively passive attitude toward obtaining grants and contracts. The National Academy of Science's leaders believed that Washington should come to them, an outlook that the Institute of Medicine, a younger, less established organization with a direct dependence on external funds,



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To Improve Human Health: A History of the Institute of Medicine 2 The Institute of Medicine Begins Operations Early in 1971, Philip Handler, the president of the National Academy of Sciences (NAS), wrote one of his correspondents that ''the Institute of Medicine [IOM] is, at the moment, largely a paper organization, but the members of our Board on Medicine are busily engaged in fleshing it out."1 Four and a half years later, after two IOM presidents had come and gone, Roger Bulger, a key IOM staff member, noted that it had never "been our expectation that we would become a household word across the United States of America. We have never felt that we would become, at least in the first years, an opinion maker at the level of the individual citizen."2 As Bulger indicated, the Institute of Medicine attracted little national attention during its first five years of operations. This was because its work did not directly engage the questions that animated the public, such as the passage of national health insurance, nor did its leaders seek to become political celebrities who testified often before Congress. Instead, the IOM maintained a low profile and focused on relatively technical, but nonetheless important, questions related to health policy and conduct. The new organization faced internal pressures that mitigated against its undertaking more ambitious projects. Members expected to shape the organization's agenda and participate in its activities, yet the IOM depended heavily on Washington-based staff, attuned to the nuances of public policy and accustomed to taking the lead on research projects, to guide its work. The action-oriented IOM formed part of the National Academy of Sciences and had to adapt to its culture. This meant an insistence on intellectual rigor attained by close peer review of Institute reports, combined with a relatively passive attitude toward obtaining grants and contracts. The National Academy of Science's leaders believed that Washington should come to them, an outlook that the Institute of Medicine, a younger, less established organization with a direct dependence on external funds,

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To Improve Human Health: A History of the Institute of Medicine could ill afford. These differences in institutional outlook between the NAS and the IOM often took the form of personal confrontations between I presidents John Hogness and Donald Fredrickson and NAS President Philip Handler. Even as Hogness and Fredrickson dealt with these constant pressures, they faced the more mundane task of running the IOM on a daily basis. The invention of routines that would guide the new organization through its first five years fell to them. Much of their work centered on the task of recruitment. They had to hire staff members who would set the tone for the Institute's subsequent development, select members who would initiate key committees such as the Program Committee, and make vital contacts with the foundation officers and public officials whose decisions on funding grant proposals held the key to the Institute's very survival. Neither of these presidents served for a long time. John Hogness spent three years in office before leaving to become president of the University of Washington; Donald Fredrickson stayed at the IOM for less than a year, much of it spent in distracting and ultimately successful negotiations with federal officials over whether he would become the head of the National Institutes of Health (NIH). The turnover made the difficult endeavor of starting the IOM that much harder. Because Hogness and particularly Fredrickson left so quickly, the organization failed to establish a sense of continuity. Those in the foundation and health policy communities in positions to fund the IOM and increase its visibility found it difficult to gain a "fix" on the organization's identity. Nonetheless, Hogness and Fredrickson both made enduring impressions on the Institute of Medicine's history. Under their leadership in the years between 1971 and 1975, the IOM perfected its form of governance through establishment of the IOM Council and experimented with different ways of influencing health policy. IOM leaders came to realize that the organization possessed the means of convening the nation's leading experts to consider important issues in health policy. As a result, the IOM influenced President Nixon's war on cancer and established an important methodology for estimating the costs of medical education. By the end of the period, the IOM, if not a household name, had become known to the Washington health policy community as an organization with the potential to serve as a useful and influential source of impartial advice.

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To Improve Human Health: A History of the Institute of Medicine Recruiting Members After Philip Handler declared the IOM open for business in December 1970, the first task was very basic: the members of the old Board on Medicine, now reconstituted as the IOM Executive Committee, had to pick the initial members of the new Institute of Medicine. This task, like many others in the period between the end of 1970 and the spring of 1971, fell on acting President Robert J. Glaser, a witty man and an accomplished physician, who proved quite adept at the delicate task of getting the organization started. He had been present at the first, tentative NAS meetings that had given birth to the Board on Medicine, and he was a veteran of the long discussions that had led to the Institute of Medicine. During the often contentious sessions that followed, he managed to retain the goodwill of Walsh McDermott, Irvine Page, and Julius Comroe. Like McDermott, Page, and Comroe, Glaser came from the world of academic medicine. Raised in St. Louis, he went to Harvard at a time when that school was just beginning to accept students from the Midwest and West who lacked a fancy prep school background. Graduating from a Harvard class that also contained John F. Kennedy, Glaser continued his studies at Harvard Medical School. This enabled him to embark on a career that included a series of distinguished academic appointments. At Washington University, he headed the Division of Immunology. In 1957, he moved to the University of Colorado, where he became one of the nation's youngest medical school deans. Six years later, he returned to Harvard, where he held the university's first chair in social medicine. Then, in 1965, he arrived at Stanford to become dean of the medical school. Five years later, Glaser accepted a job as vice president of the Commonwealth Fund, which enabled him to make occasional trips from New York to Washington to handle IOM business on a part-time basis.3 Glaser chaired what was known as the Initial Membership Committee. Ivan Bennett, Walsh McDermott, and Eugene Stead also served on the committee that began its work even before the formal creation of the Institute and made many of the important decisions about the terms of IOM membership. Discussions centered on the appropriate age, proper geographic distribution, and right mix of medical specialties, other health professionals, and nonmedical fields. Although the process went smoothly, disagreements with the Executive Committee (the old Board on Medicine) arose over how to treat people who were approaching age 60. The Membership Committee wanted to exclude them; the Executive Committee

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To Improve Human Health: A History of the Institute of Medicine disagreed, hoping to attract as much talent to the Institute as possible. 4 As a compromise, Glaser's committee decided to apply an age limit of 64. This meant that the IOM would not necessarily be an organization of young men, even though the Charter called for people to become senior members when they reached age 66. Nor would the IOM necessarily be an organization with many active members, although it did work out this way and willingness to work was defined as one of the conditions of membership. The initial Membership Committee decided not to consider whether a person was already overburdened with other commitments before asking him or her to become a member; those asked to join were allowed to make up their own minds about whether they could find time to serve.5 Having set the basic ground rules, the Membership Committee proceeded to generate a list that contained nearly twice as many people as necessary to bring the total membership to 100. Board on Medicine and NAS members who belonged to the Section on Medicine received automatic invitations. This left 77 positions to fill. In January 1971, the committee nominated 48 people for membership from a list of 85, and in March the committee selected the final 29 nominees. In contrast to later years when the Institute of Medicine would hold a formal membership election, in 1971 the nominees were selected by a committee, approved by the Executive Committee and Philip Handler, and then asked to join. Glaser presented the final list to Handler in April. Letters to newly selected members went out toward the end of May 1971, and the NAS made the formal announcement in June.6 The National Academy of Sciences protected the Institute of Medicine from the more overt forms of lobbying that accompanied the membership process. Ever since the formation of an Institute of Medicine had become a real possibility, Philip Handler had received a stream of letters from organizations arguing that they deserved representation in the IOM. Psychiatrists, pharmacists, toxicologists, veterinarians, dieticians, and rehabilitation doctors all wrote to Handler. To his credit, he kept these letters to himself and did not pressure the IOM to accept anyone merely as a representative of a particular profession or medical specialty. He preferred that merit predominate.7 To be sure, the IOM Executive Committee and the NAS Council did not agree completely on the criteria for membership. Although the NAS Council approved the list, some Council members complained that key scientific fields, such as demography and epidemiology, did not receive enough representation. The IOM, for its part, worried about the lack of practicing physicians, who constituted only 10

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To Improve Human Health: A History of the Institute of Medicine percent of the initial membership. In a variation of a discussion that had gone on since 1967, Glaser told Handler that practicing physicians were "essential for the Institute to carry out its obligations," even though their accomplishments could not be measured by publications or membership in prestigious professional societies. Glaser even admitted that in the absence of these academic criteria, the selection process for practicing physicians was less rigorous than for other members. Identifying physicians engaged in the private practice of medicine who had national reputations proved a difficult task. Some of the physicians who were chosen, such as one who practiced near the NAS's unofficial summer headquarters in Woods Hole, Massachusetts, owed their selection to the fact that key IOM and NAS officials knew them. In addition to the concern over finding enough private physicians with sufficient distinction to merit IOM membership, Glaser worried about the geographic tilt of the final list. A disproportionate number of members came from the Northeast, mid-Atlantic, and West Coast regions—a taint of elitism that bothered the IOM far more than it did the NAS.8 Charter Members of the Institute of Medicine Paul B. Beeson, M.D. Walsh McDermott, M.D.* Ivan L. Bennett, Jr., M.D.* Carl V. Moore, M.D.* Charles G. Child III, M.D.* Samuel M. Nabrit, Ph.D. Julius H. Comroe, Jr., M.D.* Irvine H. Page, M.D.* Jerome W. Conn, M.D.* Henry W. Riecken, Ph.D. Rashi Fein, Ph.D. Walter A. Rosenblith, Ing. Rad. Robert J. Glaser, M.D. Ernest W. Saward, M.D.* Robert A. Good, M.D., Ph.D. James A. Shannon, M.D., Ph.D.* Leon O. Jacobson, M.D.* Thomas H. Weller, M.D. Henry G. Kunkel, M.D.* Dwight L. Wilbur, M.D.* Lucile P. Leone, M.A. Bryan Williams, M.D. Irving M. London, M.D. W. Barry Wood, Jr., M.D.* Colin M. MacLeod, M.D.* Adam Yarmolinsky, LL.B. Maclyn McCarty, M.D. Alonzo S. Yerby, M.D.* * Deceased

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To Improve Human Health: A History of the Institute of Medicine The group did better in selecting members from a broad array of fields. Glaser identified 19 different fields in the initial membership group, including administration, basic sciences, engineering, community medicine, dentistry, nursing, and nutrition.9 It was, by any sort of measure, an impressive group. It contained two future IOM presidents, Donald Fredrickson and David Hamburg. It featured people who practiced medicine in very different settings: a family practitioner from Hampton Highlands, Maine, and the dean of the Harvard Medical School; the chairman of the Johns Hopkins Department of Pediatrics and a nurse-midwife from New York Downstate Medical Center. The physician-in-chief at Beth Israel Hospital, the general director of Massachusetts General Hospital, and the head of Blue Cross-Blue Shield all made their way to the Institute of Medicine. Only four people, who were not directly involved in health policy and had corporations or other large organizations to run, turned down the IOM's offer of membership.10 John Hogness At the same time that Robert J. Glaser orchestrated the talent hunt for IOM members, he also coordinated the search for the first permanent IOM president. In December 1970, Glaser himself was on a short list of eight candidates, but he made it known that he was not interested; he preferred to launch the organization and do his work at the Commonwealth Fund. Like Glaser, all of those on the list were white, male medical doctors who worked in an academic or a research setting; indeed, everyone who headed the IOM in its first quarter century fit this description. Because each person on the list held a prestigious position such as chief of medicine, chairman of a medical school department, or medical school dean, Glaser realized it would require salesmanship to interest one of these individuals in the IOM job. On January 20, 1971, Glaser reported to Philip Handler on a meeting with John Hogness, former dean of the Medical School at the University of Washington and current director of the university's Health Sciences Center. ''I got the feeling," Glaser noted, "that John is extremely interested and that the chances are very good that he will be interested in taking it on." Two months later, Handler made a formal offer to Hogness to serve a five-year term beginning on July 1, 1971. On March 30, 1971, the Academy announced Hogness's selection. "With the appointment of Dr. Hogness, the Institute of Medicine becomes a reality," said Handler.11

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To Improve Human Health: A History of the Institute of Medicine On the same day, the New York Times made John Rusten Hogness its "Man in the News," indicating a high level of interest in the IOM and its affairs. The piece featured a picture of Hogness, stethoscope around his neck, intently performing a medical examination. His hair slicked back, Hogness looked a bit like the television reporter Mike Wallace. The head and shoulders shot gave no indication of Hogness's height—6 feet, 4 inches—"the size of a tackle," according to the Times, nor did the grainy black-and-white photo capture the blondish cast of his hair. Physically imposing, Hogness related well to people and used his self-deprecating sense of humor to soften what the Times described as "his vigorous and innovative way of doing things."12 Although Hogness later wondered what factors played a role in his selection as IOM president, he was a natural enough choice. His selection helped to bridge some of the gaps between the McDermott and Page factions of the Board on Medicine. Although he came from an academic background at the University of Washington, he had maintained a private practice in Seattle for most of the 1950s. Leaving private practice in 1959, he plunged into the administration of the academic medical center at the University of Washington, serving first as medical director of the newly opened university teaching hospital, next as dean of the School of Medicine, and finally as executive vice president of the University of Washington at a time when the disruptions caused by the Vietnam War made it a trying proposition. He persevered and developed a reputation as an excellent university administrator, one who received regular offers from large research-oriented universities to serve as president. Not only had he been in private practice, he had served as secretary-treasurer of the local medical society. Not only had he done research in endocrinology, he had also chaired the Board of Health Sciences at the University of Washington and come to know the members of other health professions. He therefore had connections with both the nationally oriented academic and the locally oriented private practice sides of medicine and with its scientific and clinical aspects. In selecting Hogness, the IOM touched all bases.13 Born in 1922, Hogness was only 48 at the time of his appointment as IOM president, a young man to lead a young organization. He came from a distinguished scientific family. His father, a physical chemist, had taught at the University of Chicago and played a key role in the Manhattan Project that led to the development of the atomic bomb. His brother became a distinguished biochemist at Stanford, and John himself took his undergraduate degree in chemistry. This pedigree no doubt was reassuring to Philip Handler, who could assume that Hogness knew how to function in a community in which scientific

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To Improve Human Health: A History of the Institute of Medicine achievement was paramount. The physicians at the IOM, for their part, could take comfort in the fact that Hogness had received topflight training at the nation's best medical schools, including the University of Chicago and Columbia, before coming to Seattle in 1950 as a chief resident at King County Hospital, a teaching hospital for the newly formed University of Washington School of Medicine.14 "At last we have a pope," one waggish doctor remarked on learning of Hogness's selection.15 Even as Hogness spoke ex cathedra of the IOM and its mission, he realized that the new organization was far from becoming the "established church" in its field. The IOM resembled a movie set with a glossy front and the illusion of depth. Stripped of all the promises about what it would become, the IOM consisted only of a group of members and a president who had the services of one staff member. It would be up to Hogness to make something of an organization that had spent most of its time arguing about its role in the Academy and relatively little time on concrete projects that would, in the end, determine its reputation. Speaking to anyone who would listen, Hogness tried to interest people in the IOM. He described his new job as "one of the most important jobs in the health field," as head of an organization that "alone in the health field will speak ... without an axe to grind." Members, who were at the peaks of their careers, would marshal the scientific wisdom of the United States and make recommendations "widely recognized as authoritative."16 It was important that the organization not play politics, because it could not favor one side over the other and still speak with an impartial sense of authority. In this regard, the IOM would investigate and arbitrate far more than it would assert or advocate. At the same time, the IOM would not be passive and wait for disputes to come to it. Instead, it would seek out problems, looking for significant matters of national policy. "When there are major issues and concerns before the American public, we are more apt to be involved in those areas.... We will be able to foresee future problems, rather than deal with them after they have reached crisis proportions," said Hogness,17 who promised ''one hell of a show.''18 Staffing the Institute and Bureaucratic Routines Despite this bravado, Hogness told the Executive Committee at the end of 1971 that he had traveled widely in the past year and found few people who were even aware of the Institute's existence.19 In part, the IOM's anonymity resulted from Hogness's preference to

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To Improve Human Health: A History of the Institute of Medicine get his own house in order, by hiring the IOM's core staff and establishing its bureaucratic routines, before he reached out to the external community. In September 1971, Hogness announced his intention to hire a senior professional to serve as his deputy. He had in mind Roger J. Bulger, associate director of medical education for allied health at Duke University, with whom he had developed a rapport and who brought distinct skills to the job. If the IOM president came from the West Coast, his executive director would come from the East. 20 In fact, the careers of Bulger and Hogness were closely intertwined. Bulger, a major figure in IOM history from 1972 to 1976, received his undergraduate degree from Harvard in 1955. After a year in England, he returned to Harvard as a medical student. Bulger took much of his postgraduate training at the University of Washington, serving as chief resident in medicine in the 1964–1965 academic year and, significantly for the IOM, meeting John Hogness. His medical education and postgraduate training in science prepared the way for an academic appointment at the University of Washington. In 1970, he left for Duke, where he held the title of professor of community health sciences and associate professor of medicine. Still only 38 years old, he came to the IOM with a wealth of experience. More importantly, he had a quiet competence and an easy manner that made the work of the IOM go smoothly. He served as the inside man who ran the store while the IOM presidents made outside appearances.21 After hiring Bulger, Hogness appointed the members of the IOM's standing committees. In September 1971, he announced the formation of a Program Committee, headed by Irving London, to oversee requests for studies and establish priorities among them. The work of this committee became so important that Hogness decided that it required its own staff. He hired Karl Yordy, the associate administrator for program planning and evaluation at the Health Services and Mental Health Administration, for this purpose. Yordy, who would remain in positions of authority at the IOM from the era of John Hogness until the era of Ken Shine, soon became indispensable not only to the Program Committee but to Hogness and Bulger as well. As for other committee assignments, Dr. Clifford Keene, president of the Kaiser Foundation hospitals, agreed to head a Finance Committee, and Hogness convinced Robert J. Glaser to continue as head of the Membership Committee.22 With the basic structure in place, Hogness, turning to the most important committee of all, decided that the Executive Committee was too large to function in this capacity. He renamed it the IOM

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To Improve Human Health: A History of the Institute of Medicine Council, and it became the organization's central governing body. From the IOM Council, Hogness drew members who would act as a Report Review Committee, once the IOM began to issue reports. The Executive Committee, meanwhile, was transformed into a much smaller group of only five members.23 Hogness realized that one of the most important tasks he and the Council faced was to make plans for the IOM's first annual meeting. The bylaws stipulated that there be such a meeting, and even without a specific mandate, the need for it was obvious. Members required a forum in which they could meet one another, discuss the IOM's program, and become a part of the organization. Hogness set the meeting date for the middle of November and put Samuel Nabrit, Irvine Page, and Eugene Stead in charge of coming up with a program. They devised panels on the founding of the IOM and on "medical care as related to scientific research." In an offhand comment that said a great deal about gender relations at the time of the IOM's founding, the program planners announced that "there will be no special program for wives, and no plans for their attendance at the banquet."24 Science reported with some optimism that "the institute seemed to be satisfactorily en route toward establishing an identity of its own" at the November 1971 meeting. The journal reported, however, that the IOM was new and had practically no business to transact. It filled the void with speeches. Walsh McDermott recounted the founding of the IOM. Victor Sidel, head of the Department of Social Medicine at Montefiore Hospital in New York, discussed his recent trip to China. In a concluding speech, John Knowles, general director of Massachusetts General Hospital, offered what was described as an "iconoclastic" analysis of health policy, urging the Institute to get involved in modern problems and not become a "status organization." 25 For Hogness, the main objective was to keep the members active and involved. Without much of a scientific product "to offer the membership," he thought it important "to put on a good program and have an outstanding reception." So Hogness and his staff laid on an "very elaborate, excellent buffet." In the years that followed, the IOM fall reception, which attracted a unique crowd of researchers, practitioners, members of Congress and their staffs, and health policy officials, became a key social, professional, and political gathering. With tongue only slightly in cheek, Hogness later wrote that ''if, in the first years of our existence, we were not yet too well known, at least we ate well."26

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To Improve Human Health: A History of the Institute of Medicine Cancer Wars If the IOM were to succeed, it had to do more than host a pleasant cocktail party. It required a substantive program, something that had largely eluded the Board on Medicine. One of the organization's first opportunities to contribute to medical policy came during the "cancer wars" that dominated the medical news in 1971. President Richard Nixon's decision to declare war on cancer shook up the medical research establishment. Senators Edward Kennedy (D-Mass.) and Jacob Javits (R-N.Y.), neither of whom enjoyed warm relations with the administration, introduced a bill to create a National Cancer Authority, which received wide support from such organizations as the American Cancer Society. The potential issue for the IOM was not whether the federal government should support cancer research but rather how to organize this research. Kennedy and Javits hoped to separate the cancer effort from the rest of the National Institutes of Health in an effort to give it more visibility and free it from the red tape that supposedly hindered NIH efforts. Many IOM members and their colleagues in universities and medical centers felt that such a separation would seriously undermine the NIH and medical research in general. Each special disease or cause would ask to be elevated above the rest of NIH, and soon the entire organization, which had put so much money in medical school coffers, would disintegrate. Nor did creation of a separate National Cancer Authority appear to be conducive to good science. As several IOM members noted in March, "there is the mistaken belief that equates a separate agency with curing cancer." 27 Philip Handler, whose own background was in biological research that took place in a medical school, felt strongly enough about the issue to write Kennedy and Javits a letter advising against the National Cancer Authority. Handler urged the IOM to move on the issue, but with the organization still so new and eager not to make a mistake in handling its first big political issue, IOM leaders hesitated to make a public stand.28 When the political action shifted from the Senate to the House, John Hogness received a request to testify before Congressman Paul Rogers (D-Fla.) and his Subcommittee on Public Health and Welfare. Hogness also was wary of establishing a bad precedent, in this case by testifying as an individual. He preferred to reserve his congressional appearances for times when he would be able to present the results of an IOM report or study.29 In this case, however, he decided to break his own rules. The cancer agency, he told a reporter, was "a little different because it went to the nature of health research." On

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To Improve Human Health: A History of the Institute of Medicine Donald Fredrickson When John Hogness reaffirmed the soundness of the IOM structure, he did so as someone who was about to leave the organization. Appearing before the IOM Council on May 10, 1973, he announced that he would assume the presidency of the University of Washington, the one job he felt he could not refuse, in the late spring of 1974. A search committee headed by Walsh McDermott moved quickly to select a successor. The committee chose Donald Fredrickson, who had the distinction of being a member of both the Institute of Medicine and the National Academy of Sciences.96 Two years younger than Hogness, Fredrickson had followed a different route in his career. He began his undergraduate studies at the University of Colorado, but the war interrupted them. After serving in the U.S. Army, he finished his undergraduate degree at the University of Michigan and remained in Ann Arbor for his medical degree. Between 1949 and 1953, he completed his training in hospitals and laboratories that were associated with Harvard. Beginning in 1953, he worked at the National Heart Institute, serving as its director from 1966 to 1968. In 1973, when the IOM search committee approached him, he was the director of intramural research at the National Heart and Lung Institute. Of all the IOM founders, his career resembled most closely that of James Shannon: the focus was on research, rather than on clinical practice. Fredrickson had joined the IOM with the initial membership group in 1971, quickly becoming involved in it activities. In the fall of 1971, he received a phone call from Julius Comroe, who wanted another basic scientist to serve on the IOM Council and asked Fredrickson to run. Agreeing, Fredrickson became a Council member in 1972 and found it to be an engaging experience. "There was a rich mixture of the dialects and ethics operative in the world outside the laboratory walls," he recalled, that offered "an unparalleled view of the complex field of human health." When the search committee approached him in the fall of 1973, he was interested. On November 20, 1973, Philip Handler invited Donald Fredrickson to his office. "The Council of the IOM thinks I ought to talk to you about John's job," Handler said. Fredrickson told him that the prospect of becoming president of the IOM was not unattractive but that he worried about how the NAS reorganization would affect the Institute. He defended the IOM practice of mixed membership, saying that "ecumenism" was important in such a complicated area as health. He announced that he would not consider the job unless the disagreements between the NAS and the IOM were settled. This

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To Improve Human Health: A History of the Institute of Medicine provided a spur to Handler and Hogness and accounted in large measure for Handler's acquiescence to the IOM position. After some hesitation, Fredrickson accepted the offer of the IOM presidency on January 18, 1974. The members' meeting in the spring of 1974 served as an inauguration of sorts for Donald Fredrickson. He spoke of bridging the worlds of science and medical practice, arguing that the IOM's commitment was to "lend the scientific method to the direction of a whole social movement." Noting that the IOM's success rested upon the "essence, not merely the appearance, of nonpartisan objectivity," he predicted that the same sort of satisfaction he had found in the laboratory could also be found at the Institute of Medicine. However, Fredrickson faced a rude sort of culture shock. Perhaps the most jarring element was the need to visit the IOM's major funders, reassure them that the organization remained strong, and initiate the process of reapplying for support. As an official of NIH, Fredrickson had given away, not requested, money. Fund-raising in the federal government took the form of appealing to the Bureau of the Budget and Congress, a far different exercise than going to New York and meeting with foundation officials. One exercise that the leadership of NIH and the IOM held in common was the need to provide sufficient office space for staff. The IOM staff was simply too large to be housed in IOM headquarters, nor could it secure enough space in an auxiliary building on Pennsylvania Avenue. Therefore, the IOM rented space in the Watergate office complex that had previously been occupied by the Democratic party. Indeed, Fredrickson's office turned out to be the same one used by Lawrence O'Brien, the very site of the Watergate break-in, which monopolized the headlines during this period surrounding President Nixon's resignation. As a consequence, IOM staffers often found their work interrupted by curious tourists seeking out the "stuff of history." Fredrickson never had time to sink his teeth into the job as president of the IOM. Almost as soon as he arrived in the late spring of 1974, he began to receive phone calls from federal officials warning of dissension in the upper ranks at NIH. Some of these officials wanted to know if he would be willing to return to Bethesda as head of the National Institutes of Health. Early in January 1975, Fredrickson learned that he was on a short list of candidates for both Assistant Secretary of Health and director of NIH. He met with administration officials on January 9, 1975, a year to the day after he had received a phone call from Handler offering him the job as IOM president. On January 24, he told the IOM Council that he had been approached by the administration to serve as head of NIH and that he

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To Improve Human Health: A History of the Institute of Medicine "would not refuse to consider this position" if it were offered to him. That morning, over breakfast, Adam Yarmolinsky had tried to dissuade Fredrickson from considering the position, arguing that he could do more good as head of the IOM. Fredrickson explained that as he had told Philip Handler, the NIH was "not a job; it's a cause." Realizing that something had to be done, the IOM Council moved to designate a vice chairman pro tem who would take over in Fredrickson's absence. It eventually selected Julius Richmond for the post.97 On April 19, 1975, HEW Secretary Caspar Weinberger announced the nomination of Donald Fredrickson as director of the National Institutes of Health. On May 5, Fredrickson addressed a letter to all members of the IOM telling them he had accepted President Ford's offer and that he would be leaving IOM in June. He said that the choice was difficult but he had chosen NIH because its needs seemed more critical. He realized that although changing presidents twice in four years created great potential for harm, he was confident that the IOM would "survive its president." He owed his confidence to his faith that Julius Richmond and Roger Bulger would preside effectively over the Institute during the transition period. He also took solace in the fact that the Robert Wood Johnson and Kellogg Foundations had renewed their core grants to the IOM and that the IOM would be able to maintain a budget of from $3.5 million to $4 million in fiscal year 1976.98 "In retrospect the time you have spent with us now seems to have been extraordinarily short," Handler wrote to Fredrickson.99 Indeed, Fredrickson had only a few months to concentrate on the IOM. The rest of his short tenure was spent in negotiations with administration officials over the state of the National Institutes of Health. This left him with too little time to change the IOM's basic direction or to infuse the IOM with the funds that would make it truly self-sustaining. Of six major projects that the IOM had hoped to initiate during Fredrickson's tenure, only two had received any sort of outside funding.100 Conclusion During the traditional August lull in 1975, Roger Bulger, who had been running the IOM on a daily basis since Fredrickson's departure, dictated a thoughtful letter to Larry Lewin, a Washington consultant who had worked on the IOM's costs of education study. The letter provided Lewin, who was hired to make recommendations on how the

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To Improve Human Health: A History of the Institute of Medicine IOM should be structured and managed, with an overview of the IOM's four-year history. It was an exceptionally candid look at the organization. Bulger noted that the problems of the IOM began with its name. People mistook it for the National Institutes of Health. When the IOM did something newsworthy, its activities became confused with those of the National Academy of Sciences. As for the IOM's program, the organization had often been concerned with issues that were "very philosophic, sometimes ethical, often quite political, and frequently not as quantitative or analytical as may people would like." Still, most people knew of the organization only because of the large, data-collecting studies, such as the costs of education study. The problem was that it was possible just to collect data, without getting at underlying policy issues. Hogness and Fredrickson had both believed that much of the valuable activity at the IOM took place outside the formal studies. If nothing else, the IOM served to "broaden the horizons of each of its members." Many of its best conversations and activities took place in Council meetings and meetings of the Membership Committee. These discussions were themselves contributions to health policy. Although the IOM had its headquarters in Washington, D.C., it was not a typical Washington organization. The IOM president did not make regular appearances on Capitol Hill or serve as a sort of "health policy guru." In this regard, the IOM differed from the American Association of Medical Colleges, whose president, John Cooper, had become a major player on the national scene. Some people thought that the IOM should try to play a more visible role in the policy process. Part of what inhibited the IOM was the inability to distribute the results of its studies. Bulger thought it sad that the IOM could not provide copies of its costs of education studies to every medical school in the country. Nor did the IOM spend much on publicity, depending on the "kindness of strangers" to let the world know of its accomplishments. As a way to overcome some of these problems, John Hogness had "utilized the development of a staff as a combination of acquiring expertise and analytic abilities with extending the points of contact for the Institute throughout the health establishment." The members of the staff complemented one another. Bulger had experience with the allied health professions, Karl Yordy with the government, and Ruth Hanft with health services researchers. The IOM used its visiting scholars and residents to fill in the gaps. Every such request was scrutinized with an eye toward the potential "contribution to the general environment of the Institute and its possible contribution to

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To Improve Human Health: A History of the Institute of Medicine the staff." The result, according to Bulger, was a "reasonable level of staffing." "We have a very wholesome interdisciplinary thing going,'' he added, "such that I am comfortable as a health professional with the whole range of staff people.'' Bulger concluded his long letter by saying that "as we have developed more of track record and more people have taken notice of us, we have also attracted our share of jealousies and legitimate concerns. It is important that in this city of Washington, those people who might look to us for advice and who might be able to use us should think of us as competent and able to deal with the problems."101 Hogness and Fredrickson had made a start in this direction, in particular by raising funds from foundations and establishing the basic routines of IOM governance and IOM studies. Still, as Bulger had noted, the organization remained invisible to mainstream Washington and the general public. By the time Jimmy Carter became president in 1977, this condition would change. Notes 1.   Philip Handler to Dr. Ward Darley, January 20, 1971, Institute of Medicine, 1971, General, National Academy of Sciences (NAS) Records. 2.   Roger Bulger to Larry Lewin, August 6, 1975, Yordy Files, Accession 91-051, Institute of Medicine (IOM) Records, NAS Archives. 3.   Oral interview with Robert Glaser, Menlo Park, Calif., November 1, 1997. 4.   Meeting of Executive Committee, December 17, 1970, Institute of Medicine, NAS Records. 5.   Minutes of Initial Membership Committee, January 28, 1971, Robert Glaser Papers, Menlo Park, Calif. 6.   Initial Membership Committee, March 10, 1971; Robert J. Glaser to Philip Handler, April 16, 1971; and Inger Herman to Handler, June 21, 1971, all in IOM Records, NAS Archives; Glaser to Julius Comroe, April 5, 1971, Glaser Papers. 7.   Raymond Waggoner, immediate past President of the American Psychiatric Association, to Philip Handler, June 15, 1970; Isidore Greenberg, Director of Graduate Studies, Brooklyn College of Pharmacy, to David Hamburg, June 15, 1970; Eric Comstock, Executive Director, American Academy of Clinical Toxicology, to Handler, July 18, 1970; R. L. Kitchell, Dean of the College of Veterinary Medicine, Iowa State University, to Handler, July 21, 1970; and Joseph Goodgood, Professor of Rehabilitation Medicine, New York University, to Handler, August 13, 1970, all in IOM Membership, 1970, NAS Records. 8.   Robert Glaser to Philip Handler, April 16, 1971, IOM Membership, 1971, NAS Records.

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To Improve Human Health: A History of the Institute of Medicine 9.   Robert Glaser to Institute of Medicine, April 27, 1971, Glaser Papers. 10.   Robert Glaser to Philip Handler, April 16, 1971, and Inger Herman to Handler, June 21, 1971, IOM Membership, 1971, NAS Records. 11.   Robert J. Glaser to Philip Handler, January 20, 1971; Handler to Dr. John Hogness, March 24, 1971; and NAS Press Release, March 30, 1971, all in Institute of Medicine, Administrative, President, 1971, NAS Records. 12.   Harold M. Schmeck, Jr., "President of the Institute of Medicine: John Rusten Hogness," New York Times, March 30, 1971. 13.   John R. Hogness to Wallace K. Waterfall, June 20, 1990, Waterfall Materials, Institute of Medicine; Oral interview with John Hogness, Mazama, Wash., October 1, 1997. 14.   Curriculum Vitae for John R. Hogness, NAS Records. 15.   Clipping from Medical World News, May 7, 1971, in Institute of Medicine, Administrative, President, 1971, NAS Records. 16.   Ibid. 17.   "Institute's Goal: 'Fresh, Unbiased' Look at Medicine," American Medical News, September 20, 1971, p. 13. 18.   "Hell of a Show Promised by Hogness for Institute of Medicine: Organizational Work Finished, Funds Promised, He Tells Meeting," Drug Research Reports, May 24, 1972, Irvine Page Papers, National Library of Medicine, Bethesda, Md. 19.   IOM Executive Committee Meeting, Minutes, December 21, 1971, NAS Records. 20.   IOM Executive Committee Meeting, Minutes, September 16, 1971, IOM General, 1971, NAS Records. 21.   Oral interview with Roger Bulger, June 11, 1997, Baltimore, Md. 22.   IOM Executive Committee Meeting, Minutes, December 21, 1971, NAS Records. 23.   IOM Executive Committee Meeting, Minutes, September 16, 1971, IOM General, 1971, NAS Records. 24.   IOM Executive Committee Meeting, Minutes, June 21, 1971, NAS Records. 25.   John Walsh, "Institute of Medicine: Broad-Spectrum Prescription," Science 74 (November 26, 1971), pp. 929–933. 26.   John Hogness to Wallace Waterfall, June 20, 1990, Waterfall Materials. 27.   IOM Executive Committee Meeting, Minutes, March 11, 1970, NAS Records. 28.   IOM Executive Committee Meeting, Minutes, June 10, 1971, NAS Records. 29.   IOM Executive Committee Meeting, Minutes, September 16, 1971, IOM General, 1971, NAS Records. 30.   "Hogness Testified Against National Cancer Authority at Executive Committee's Direction," Drug Research Reports 14 (October 27, 1971), p. 6, in Page Papers; Stephen P. Strickland, Politics, Science, and Dread Disease: A Short History of Medical Research Policy (Cambridge, Mass.: Harvard University Press, 1972), p. 287; see also James T. Patterson, The Dread

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To Improve Human Health: A History of the Institute of Medicine     Disease: Cancer and Modern American Culture (Cambridge, Mass.: Harvard University Press, 1987). 31.   IOM Council Meeting, Minutes, September 14, 1972, IOM Records, NAS Archives. 32.   "The National Cancer Program Plan: A Report of the Ad Hoc Review Committee of the Institute of Medicine, National Academy of Sciences," December 15, 1972, in Materials for IOM Council Meeting, January 18, 1973, IOM Records. 33.   John Hogness to Philip Handler, November 29, 1972, in Materials for IOM Council Meeting, January 18,1973, IOM Records. 34.   Philip Handler to John Hogness, November 30, 1972, in Materials for IOM Council Meeting, January 18, 1973, IOM Records. 35.   John Hogness to Philip Handler, December 4, 1972, in Materials for IOM Council Meeting, 1972, IOM Records. 36.   IOM Program Committee Meeting, Minutes, May 1973, Accession 81-006, IOM Records. 37.   See Paul J. Sanazaro, "Federal Health Services R&D Under the Auspices of the National Center for Health Services Research and Development," in Sanazaro and E. Evelyn Flook, eds., Health Services Research and R&D in Perspective (Ann Arbor, Mich.: Health Services Press, 1973), pp. 150–183. 38.   Action Memorandum for Executive Committee of the Council of NAS, November 13, 1971, in Accession 86-064-04, IOM Records. 39.   Philip Handler to Robert Glaser, March 16, 1971, and Glaser to Handler, March 22, 1971, both in Glaser Papers. 40.   Leon White to John Hogness, June 18, 1971, and Hogness to White, June 23, 1971, both in Universal Entitlement Study Files, IOM Records. 41.   IOM Executive Committee Meeting, Minutes, September 16, 1971, IOM General, 1971, NAS Records. 42.   Action Memo for Executive Committee of the NAS, November 13, 1971. 43.   IOM Program Committee Meeting, Minutes, December 1971, IOM Program Committee Files, NAS Records. 44.   David Mechanic to John Hogness, December 17, 1971, Entitlement Study Files, IOM Records. 45.   "Minutes of Meeting of February 5, 1972," Boston, and Irving Lewis to John Hogness, February 9, 1972, both in Accession 86-064-04, Entitlement Study Files, IOM Records. 46.   Martin Feldstein to John Hogness, April 3, 1972, Accession 86-064-04, Entitlement Study Files, IOM Records. 47.   Leon White to John Hogness, September 16, 1971, Accession 86-064-04, Entitlement Study Files, IOM Records. 48.   John Hogness to Martin Feldstein, April 14, 1972, Accession 86-064-04, Entitlement Study Files, IOM Records. 49.   Barbara J. Culliton, "Institute of Medicine: Taking on Study of Cost of Medical Education," Science 176 (June 1972), pp. 998–999; David Kessner to Panel on Health Services, March 20, 1969, Accession 95-050, IOM Records;

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To Improve Human Health: A History of the Institute of Medicine     Helen C. Chase, David M. Kessner, et al., eds., "Infant Death: An Analysis by Maternal Risk and Health Care: Contrasts in Health Status, Volume 1," 1973, Accession 95-050, IOM Records. 50.   See Minutes of IOM Meeting, January 18, 1973, IOM Records. 51.   M. Mitchell-Bateman, M.D., to John Hogness, March 14, 1974, Records of the Study on the Health Effects of Legal Abortion, Accession 81-008, IOM Records (hereafter, Abortion Study Files). 52.   See, for example, Donald Fredrickson to Dr. Leslie W. Dunbar, Executive Director, Field Foundation, December 19, 1974, Abortion Study Files, IOM Records. 53.   See, for example, Martha Blaxall to Steering Committee, August 29, 1974, Abortion Study Files, IOM Records. 54.   Institute of Medicine, "Report of a Study, Legalized Abortion and the Public Health," May 1975, Abortion Study Files, IOM Records. 55.   Jason Douglas, Director, Center for the Study of Moral Order, to Donald Fredrickson, June 6, 1975, Abortion Study Files, IOM Records. 56.   Roger J. Bulger to Mr. S. G. Landfather, Executive Director, Sunnen Foundation, September 29, 1975, Abortion Study Files, IOM Records. 57.   Materials for Action, January 18, 1972, IOM Records; Institute of Medicine, Disease by Disease Toward National Health Insurance (Washington, D.C.: National Academy of Sciences, 1973), p. 10. 58.   John Hogness to Paul Ward, November 21, 1972, Statement on Health Maintenance Organization Files, Accession 95-021, IOM Papers, (hereafter, HMO Files). On the HMO Act of 1973, see Lawrence D. Brown, Politics and Health Care Organization: HMOs as Federal Policy (Washington, D.C.: Brookings Institution, 1983). 59.   Institute of Medicine, "Health Maintenance Organizations: Toward a Fair Market Test: A Policy Statement by a Committee of the Institute of Medicine," May 1974, HMO Files, IOM Records. 60.   Anne Somers to J. F. Volker, D.D.S., Ph.D., January 14, 1974, and Harold F. Newman, M.D., to Karl Yordy, April 19, 1974, both in HMO Files, IOM Records. 61.   Merlin K. DuVal to Dr. John R. Hogness, November 17, 1971, Materials for IOM Council Meeting, IOM Records. 62.   See "Interim Report to Congress: Costs of Education of Health Professionals," March 15, 1973, Accession 86-064-03, Files of the Study on Costs of Educating Health Professionals, IOM Records (hereafter, Costs of Education Files). 63.   IOM Council Meeting, Minutes, March 16, 1972, IOM Records; John Hogness oral interview; Oral interview with Ruth Hanft, June 10, 1997, Washington, D.C.; Testimony of Roger J. Bulger before Subcommittee on Health and Environment of the House Interstate and Foreign Commerce Committee, May 20, 1974, Costs of Education Files, IOM Records. 64.   See John Ingle, Senior Staff Officer, to Harold Helms, Dean, School of Pharmacy, University of Colorado, March 27, 1973; Ruth S. Hanft, "Notes for a Speech to Association of Health Professional Schools," September 19, 1972;

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To Improve Human Health: A History of the Institute of Medicine     Memorandum by Eli Ginzberg, September 11, 1972, and other materials, all in Costs of Education Files, IOM Records. 65.   IOM Steering Committee Meeting, Minutes, September 18–19, 1973, Costs of Education Files, IOM Records. 66.   "Costs of Education in the Health Professions, Summary," January 1974, and "Costs of Education in the Health Professions, Parts I and II," January 1974, both in Costs of Education Files, IOM Records. 67.   Ruth Hanft, "Testimony of the Institute of Medicine, National Academy of Sciences before the Subcommittee on Health and Environment of the House Interstate and Foreign Commerce Committee," May 20, 1974, Costs of Education Files, IOM Records. 68.   IOM Council Meeting, Minutes, September 19, 1974, IOM Records. 69.   John Hogness to Richard Raring, September 20, 1971, NAS Records. 70.   "Annual Report for the Year Ending June 30, 1972," p. 6, in Materials for IOM Council Meeting, January 18, 1973, IOM Records. 71.   IOM Council Meeting, Minutes, July 20, 1972, IOM Records. 72.   "Program Evaluation Groups," in IOM Council Meeting, Minutes, March 16, 1972, IOM Records; James A. Shannon to Roger Bulger, March 28, 1972; Philip Handler to Shannon, April 4, 1972; and Bulger to Shannon, April 3, 1972, all in Yordy Files, Accession 94-111, IOM Records. 73.   "The Development of the Program of the Institute of Medicine," draft November 8, 1972, in agenda items for IOM Council Meeting, November 16, 1972, IOM Records. 74.   John Hogness to Wallace Waterfall, June 20, 1990, IOM Records. 75.   Figures come from "Draft Annual Report for the Year Ending June 30, 1972," in Materials for IOM Council Meeting, January 18, 1973, IOM Records. 76.   Ibid. 77.   John Hogness to Gustav Lienhard, President, Robert Wood Johnson Foundation, December 16, 1971; Hogness to David E. Rogers, January 26, 1972; Walter J. Unger to Donald S. Fredrickson, January 10, 1975; and Rogers to Philip Handler, June 2, 1972, all in Funding Files, Accession 91-005, IOM Records. 78.   Roger Bulger to David E. Rogers, September 13, 1972, Accession 91-045, IOM Records. 79.   John Hogness to David Rogers, June 20, 1973, Funding Files 1972-1981, Accession 90-074, IOM Records. 80.   John Hogness to Frederick W. Featherstone, M.D., Program Director, W. K. Kellogg Foundation, February 28, 1972; Hogness to Featherstone, April 26, 1972; Featherstone to John Coleman, Executive Officer, NAS, June 28, 1972; News Release, "Institute of Medicine Receives Kellogg Foundation Grant," July 31, 1972; and Hogness to Featherstone, August 3, 1973, all in Funding Files, Accession 91-045, IOM Records. 81.   Robert J. Glaser to John Hogness, March 22, 1972; Hogness to George Taber, June 7, 1972; Richard P. Mellon to Hogness, December 15, 1972; and Hogness to George Taber, September 29, 1973, all in Funding Files, Accession 91-045, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 82.   John Hogness to Quigg Newton, February 5, 1974; Roger Bulger to Aaron Rosenthal, NAS Comptroller, April 9, 1974; Walter Unger to David Hamburg, February 1, 1977; Hogness to Nathan Pusey, January 7, 1974; "Proposal to Andrew W. Mellon Foundation," November 18, 1974; and Pusey to Philip Handler, December 20, 1974, all in Funding Files, Accession 91-045, IOM Records. 83.   Memorandum for the Files, "New York Trip Report," October 29, 1975, Funding Files, Accession 91-045, IOM Records. 84.   Adam Yarmolinsky to McGeorge Bundy, January 21, 1974; Bundy to Yarmolinsky, January 31, 1974; Bundy to Roger Bulger, March 22, 1974; and Harold Howe to Walter Unger, November 21, 1974, all in IOM Funding Files, Accession 91-045, IOM Records. 85.   William Danforth, Chancellor, Washington University to Donald Fredrickson, April 7, 1975, Funding Files, Accession 91-045, IOM Records. 86.   John Hogness to Philip Handler, June 1, 1972, and Irvine Page to Hogness, August 22, 1972, both in IOM Membership, 1972, NAS Records. 87.   John Hogness to Irvine Page, September 19, 1972, IOM Membership, 1972, NAS Records; Philip Handler to Hogness, June 13, 1973, and David Mechanic to Roger Bulger, both in Materials for IOM Council Meeting, July 1974, IOM Records; IOM Council Meeting, Minutes, March 20, 1975, IOM Records. 88.   Institute of Medicine, Annual Report, year ended June 30, 1975 (Washington, D.C.: National Academy of Sciences, 1976) p. 10. 89.   IOM Council Meeting, Minutes, March 15, 1973, IOM Records. 90.   David Rogers to John Hogness, March 29, 1973, Funding Files, Accession 91-045, IOM Records. 91.   Robert Marston to David Rogers, June 27, 1974, Funding Files, IOM Records; Barbara J. Culliton, "Johnson Health Policy Fellows: Joining the Scientific and Political," Science, September 19, 1973, pp. 977–980. 92.   David Rogers to Philip Handler, April 5, 1976, Funding Files, Accession 91-045, IOM Records. 93.   John Hogness to Wallace Waterfall, June 20, 1990, IOM Papers. 94.   Executive Committee Meeting, Minutes, November 18, 1971, and December 21, 1971; John Hogness to Philip Handler, August 18, 1971; Hogness to Handler, September 22, 1971; and Hogness to Handler, November 30, 1971, all in Yordy Files, Accession 91-051, IOM Records. 95.   Philip Handler to John Hogness, November 7, 1973, Yordy Files, Accession 91-051, IOM Records; Special Meeting of the IOM Council, Minutes, December 19, 1973, attached to Hogness to Handler, January 4, 1974, IOM Records; and Handler to Hogness, February 13, 1974, Yordy Files, Accession 91-051, IOM Records. 96.   Much of what follows is based on Donald S. Fredrickson, "I.O.M.: Mémoires à l'Accouchement," an essay on his IOM experiences that he prepared for the Institute's 20th anniversary, in the IOM Records. 97.   Memorandum for the Record, January 24, 1973, IOM Council Minutes, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 98.   Donald Fredrickson to Members, Institute of Medicine, May 5, 1975, Attachment to IOM Council Meeting, Minutes, May 15, 1975, IOM Records. 99.   Philip Handler to Donald Fredrickson, June 25, 1975, IOM-1975 File, NAS Records. 100.   Walter J. Unger to Donald Fredrickson, Julius Richmond, and Nathan Start, May 12, 1975, attachment to IOM Council Meeting, Minutes, May 15, 1971, IOM Records. 101.   Roger Bulger to Larry Lewin, August 6, 1975, Yordy Files, Accession 91-051, IOM Records.