3
The Hamburg Era

On May 3, 1977, President Jimmy Carter read an article in the Washington Post and jotted down a note for Joseph Califano, his Secretary of Health, Education, and Welfare (HEW). The President wanted Califano to read the story on an Institute of Medicine (IOM) study of computed tomography (CT) scanners. The thrust of the study was that hospitals and physicians should not overuse the beneficial yet costly new technology. Only after the local health planners approved should a new CT scanner be installed; these local planners should make sure that each scanner operated at maximum efficiency, performing a minimum of 2,500 tests a year. Hospitals, not private doctors' offices, should be the setting for scanners. "Let's take similar action—stronger if possible—and include other devices as well," the President urged his Secretary of Health, Education, and Welfare.1

If the Institute of Medicine wanted evidence of its influence, the note from Carter to Califano provided it. In 1977, the IOM knew that the President of the United States and his chief minister for health both took an interest in its activities. The moment marked the realization of Walsh McDermott's aspirations by proving that the IOM could have an enduring effect on the nation's health policy. It also demonstrated the dramatic results of David Hamburg's management. Hamburg, who had taken over from Donald Fredrickson in the fall of 1975, provided the IOM with five years of inspirational leadership.

Despite these considerable achievements in the Hamburg era, the embrace of the Carter administration failed to heal all of the IOM's maladies. Even at the end of five years of steady activity, old problems continued to nag at the organization. These included the lack of a secure financial base, troubled relations with the National Academy of Sciences (NAS), and an often less than clear focus for the IOM's activities.



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To Improve Human Health: A History of the Institute of Medicine 3 The Hamburg Era On May 3, 1977, President Jimmy Carter read an article in the Washington Post and jotted down a note for Joseph Califano, his Secretary of Health, Education, and Welfare (HEW). The President wanted Califano to read the story on an Institute of Medicine (IOM) study of computed tomography (CT) scanners. The thrust of the study was that hospitals and physicians should not overuse the beneficial yet costly new technology. Only after the local health planners approved should a new CT scanner be installed; these local planners should make sure that each scanner operated at maximum efficiency, performing a minimum of 2,500 tests a year. Hospitals, not private doctors' offices, should be the setting for scanners. "Let's take similar action—stronger if possible—and include other devices as well," the President urged his Secretary of Health, Education, and Welfare.1 If the Institute of Medicine wanted evidence of its influence, the note from Carter to Califano provided it. In 1977, the IOM knew that the President of the United States and his chief minister for health both took an interest in its activities. The moment marked the realization of Walsh McDermott's aspirations by proving that the IOM could have an enduring effect on the nation's health policy. It also demonstrated the dramatic results of David Hamburg's management. Hamburg, who had taken over from Donald Fredrickson in the fall of 1975, provided the IOM with five years of inspirational leadership. Despite these considerable achievements in the Hamburg era, the embrace of the Carter administration failed to heal all of the IOM's maladies. Even at the end of five years of steady activity, old problems continued to nag at the organization. These included the lack of a secure financial base, troubled relations with the National Academy of Sciences (NAS), and an often less than clear focus for the IOM's activities.

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To Improve Human Health: A History of the Institute of Medicine David Hamburg Arrives The departure of Donald Fredrickson put a strain on the IOM, which had gone through two presidents in less than five years. Most of the effort to pick up the pieces fell to Julius Richmond, the distinguished child psychiatrist who acted as vice chairman pro tem of the IOM Council. Much as Robert J. Glaser had filled the void between Walsh McDermott and John Hogness, so Richmond, ably assisted by Roger Bulger, kept things together in the spring and summer of 1975. He quickly constituted the Executive Committee of the Council as a search committee and set it to work finding a new IOM president. The fact that the IOM had searched for a president less than two years earlier facilitated the process. The same short list that had been developed in the summer of 1973 could also be used in the spring of 1975. Although Richmond encouraged members to submit nominations and generated a list of more than 60 names, he and his committee concentrated from the first on a few, select candidates. On June 19, the IOM Council culled through the names and designated David Hamburg as its first choice. The NAS Council moved quickly to confirm the selection, although Philip Handler objected to being given only one name to consider. Richmond explained that although the Council had other candidates in mind, it had not "ranked them as clearly as we had Dr. Hamburg." Handler acquiesced, in part because Hamburg had been the second choice less than two years before and would, in effect, be filling Fredrickson's unexpired term. On June 26, 1975, Handler wrote to Hamburg and offered him the job.2 David Hamburg's acceptance of the offer depended on a set of circumstances as bizarre as the IOM had ever encountered. Because Hamburg was in Dar es Salaam, Handler's letter reached him very slowly. Hamburg had gone there to negotiate the release of four Stanford students who had been kidnapped by Zairian rebels. On July 19, 1975, Hamburg reported to Handler that three of the four students had been freed without harm, "but the negotiating process for the fourth is very difficult." In the meantime, he and his wife were discussing Handler's offer.3 The kidnapping incident delayed the recruiting process and meant that Roger Bulger effectively ran the IOM from the beginning of July until the beginning of November. Formal announcement of Hamburg's appointment came only at the end of October. Born in 1925, David Alan Hamburg spent his childhood and received much of his education in Indiana, graduating from the University of Indiana Medical School in 1947. After taking three

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To Improve Human Health: A History of the Institute of Medicine years off for military service, he went to Michael J. Reese Hospital, where he had taken much of his postgraduate training, and worked at the Institute for Psychosomatic and Psychiatric Research and Training. In 1958, he began a three-year stint as chief of the adult psychiatry branch at the National Institute of Mental Health in Bethesda. Then, in 1961, he took over as the chairman of Stanford's Department of Psychiatry. In the summer of 1975, he held the appointment as Reed-Hodgson Professor of Human Biology in Stanford's medical school. In his research, Hamburg analyzed the links between biology and behavior, examining such things as the behavioral, endocrine, and genetic aspects of stress and the biologic basis for aggressive behavior. He had more than 93 scientific papers to his credit. The appointment of Hamburg continued the IOM tradition of selecting distinguished researchers and administrators from the field of academic medicine as president. 4 On November 6, 1975, David Hamburg delivered his inaugural remarks to IOM members who attended the annual meeting. He was far from a stranger in IOM circles, having been selected as an initial member in 1971, served on the Council from 1971 to 1974, and chaired the Program Committee between 1972 and 1973. In his inaugural remarks, he described what he considered the key features of the IOM. The organization made a "serious, thoughtful attempt to face" difficult issues and to do so in a way that cut "across traditional specialties and perspectives." Unlike other organizations, the IOM held "no over-riding doctrine, no party line, no cow too sacred to be examined," and its views reflected ''deeper analysis and reflections" than those of others in the health field. After listing the organization's assets, Hamburg pondered its liabilities. He wondered how the IOM could coax sufficient time from its busy members to examine the key issues, how a Washington-based staff could relate to a geographically dispersed membership, how the IOM could preserve its independence and be of use both to the government and to private institutions, and how the IOM could achieve cross-specialty collaboration ''to tackle the policy problems of health care, prevention, education and the science base underlying it all." These problems, Hamburg observed, deserved "thoughtful attention. And I intend to get it—by quiet, respectful inquiry if possible; by relentless harassment if necessary."5 Speaking to the members, Hamburg revealed an almost pastoral style. Almost alone among the previous IOM presidents, he spoke and wrote with an inspirational eloquence with which he exhorted the members to contribute to the organization. At the same time, he realized that he and the organization faced many problems, not the least of which were his own logistical difficulties. He told the IOM

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To Improve Human Health: A History of the Institute of Medicine Council, for example, that he would not be able to move to Washington on a full-time basis until June 1976. Until then, he would take up the IOM presidency to the "maximum extent that circumstances would permit."6 Ruth Hanft and the Social Security Studies Hamburg would also have to build up his own team. At the end of 1975, Adam Yarmolinsky ended his term on the IOM Council, severing one of the last links between the Institute's founders and the inner circles of IOM policymaking. In the case of Yarmolinsky, the Council thought so highly of his services that it took steps to preserve a role for him, designating him as a special counselor to the IOM. He continued to provide the organization with legal and practical advice until, accepting a position in the Carter administration, he suspended his close IOM ties for the duration of his government service. Another key departure, that of Roger Bulger, took place early in 1976. He became chancellor of the University of Massachusetts at Worcester and dean of the University of Massachusetts Medical School. No doubt part of his appeal to the university was the fact that he had served so effectively as interim head of the IOM and had gotten to know so many leading figures in academic medicine through his service as the IOM's executive officer. Still another departure that took place in 1976 involved Ruth Hanft. With Hanft went the large data-gathering studies. As David Hamburg took hold of the IOM, another such study reached completion. This second study followed from the first one, which had concerned the costs of medical education. After the IOM had submitted the earlier study, Congress asked it to consider the related problem of how the Medicare and Medicaid programs should pay physicians in teaching hospitals for their treatment of elderly (Medicare) or indigent (Medicaid) patients. Congress also wanted to know how much federal money went into the support of foreign medical school graduates and how Medicare reimbursement could be used to avoid gluts of physicians in some areas and shortages in others. Finally, the study request asked the IOM to consider how Medicare reimbursements might be structured so as to encourage a greater number of physicians to enter primary care fields. Adam Yarmolinsky chaired the steering committee, and Ruth Hanft directed a large staff, which eventually grew to 45 people, for what became a very elaborate effort. This second large data-gathering study raised many of the same problems as the first. The Medicare

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To Improve Human Health: A History of the Institute of Medicine law, passed in 1965, made a distinction between payments for medical services provided by physicians and payments for medical services provided by hospitals. In the case of teaching hospitals, however, it was difficult to separate physician and hospital services. Medical students, interns, and residents all treated patients, yet these practitioners often received salaries from hospitals or medical schools as part of the hospital staff. Furthermore, it was difficult to separate the costs of treatment from the costs of education. To address these problems, the staff designed a survey that was sent to 1,400 teaching hospitals; it made site visits to 96 teaching hospitals, 15 medical schools, and 2 osteopathic schools and ascertained how the more than 100 intermediaries and carriers who administered Medicare on behalf of the Social Security Administration defined teaching physicians and teaching hospitals. The collaboration between Yarmolinsky's steering committee and Hanft's staff often grew strained. In the final version of the report, Yarmolinsky attributed classical virtues to Hanft and her staff. They were "heroic," "stoic," and ''Socratic in [their] dialogue with the steering committee." At the same time, staff and steering committee faced different and often conflicting tasks. The staff wanted to collect as much data as accurately as possible and be responsive to Congress. Although the steering committee shared this goal, it also sought to draw larger policy implications from the data. The process of combining these different outlooks and missions into a coherent document, on a subject technical enough to require a seven-page glossary just to make the report accessible to medical experts, proved difficult. In the end, the IOM issued 99 pages of findings and recommendations and many more pages of what were described as resource papers. Despite Yarmolinsky's insistence on clarity, the study's recommendations were so inward and technical as to be beyond most people's comprehension. For example, the group recommended that "under the cost payment regulations issued under Section 15, Public Law 93-233, inclusion of payment of the imputed value of volunteer services should be continued; under the same cost regulations, the ceiling of $30,000 on the imputed value of a volunteer teaching physician's services should be changed to the average salary for full-time physicians in the area or the VA [Veterans Administration] compensation for full-time physicians if an area average is unavailable." In general, however, the group recommended that an interim solution to the problem of Medicare reimbursement in teaching hospitals, adopted by Congress in 1972, be discontinued and that other payment methods, which the group specified, might be

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To Improve Human Health: A History of the Institute of Medicine appropriate. In addition, the group came out in favor of providing more funds for ambulatory care services so that teaching hospitals could more easily support primary care training programs. Going even further, the study recommended elimination of the immigration law incentives for importing foreign physicians. According to Yarmolinsky, the most controversial recommendation of all was one that would permit the Secretary of HEW to withhold Medicare and Medicaid funds from residency programs in specialties that a "permanent, quasi-independent physician manpower commission" determined to be in excess supply. 7 The IOM held a press conference to release the report. Questions dealt with the recommendations favoring ambulatory care services because, as Ruth Hanft conceded, the proposals in this area were easier to understand than the others. Hanft also briefed congressional staffers on the report; they tended to share some of her dissatisfaction with the IOM study process. The report recommendations, the congressional staff members believed, confused the interests of the medical schools with the public interest, even if the study itself had produced valuable data. Expressing unhappiness with the composition of the steering panel, the congressional staff members thought it was weighted, like IOM membership itself, in favor of academic medical centers.8 Most IOM members never had a chance to read the Medicare reimbursement report. Because it was large, bulky, and expensive to mail, it went only to members of the steering committee and the Council. When David Hamburg learned about this situation, it made him think more about how to engage members in the work of the IOM. His experiences with the Medicare reimbursement study also caused Hamburg to consider what role, if any, large data-gathering studies should play in the IOM program. Ruth Hanft, for her part, pushed Hamburg to accept other, technical assignments from Congress that did not require issuing recommendations and could be done by staff alone. Concerned about the separation of staff and membership, Hamburg and the IOM Council grew wary of Hanft's requests, and she eventually left the IOM staff. 9 The Institute Recharts Its Course Although Hamburg wished to encourage member participation, he realized how important it was to maintain good relations with the congressional staffs who were interested in using the IOM to create and maintain data bases. The mid-1970s marked a period of

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To Improve Human Health: A History of the Institute of Medicine resurgence in congressional activism that followed the Watergate investigations. In this era, the bipartisan spirit that had prevailed between the Republican President and the Democratic Congress began to break down, and Congress began to insist on developing its own analytical capacity rather than accepting the advice of executive agencies. Congressional subcommittees, staffs, and agencies such as the Congressional Budget Office and the Congressional Research Service all began to grow. Health, particularly the costs of health care, was a major preoccupation of congressional and executive branch policymakers in this era of concern for rising prices and stagnant wages. Although Hamburg wanted to make the IOM relevant to this new policymaking structure, he hesitated to do so in a way that would turn the IOM into a staff-driven Washington think tank or consulting firm. Like his predecessors, Hamburg grappled with the issue of the IOM's identity during his first year in office. He initiated a major review of the IOM's progress that lasted from the fall of 1975 through the fall of 1976. The review, extending to all levels of the IOM's operation—from the staff, to the IOM Council, to the IOM membership—provided Hamburg with a means of learning about the organization, forging a consensus as to its future direction, and reshaping the organization to reflect this consensus. In a more personal sense, it enabled Hamburg to fill in the awkward period during which he commuted to Washington from California. The process began at the staff level with regular staff discussions and with the work that Roger Bulger had commissioned Larry Lewin to do in the summer of 1975. At Bulger's suggestion, Lewin, a noted management consultant in the health care field, questioned a wide range of people on a broad range of topics about the IOM and presented his results in the form of a staff seminar that took place on March 19, 1976.10 After he told the staff some of what people had said to him about the IOM, he led a structured discussion designed to expose problems and suggest possible solutions. As Lewin's report made clear, people in the Washington community held differing opinions of the IOM's capabilities. Jay Constantine, a plain-speaking member of the Senate Finance Committee staff, said that the IOM should perform "neutral" studies for Congress, unlike the costs of education study on which the IOM had "whored" by ignoring the evidence and coming out in favor of capitation. Stuart Altman of the Department of Health, Education, and Welfare thought that the IOM was needed, but not for large data-gathering studies because others could do them better. Jim Mongan, a colleague of Constantine's, agreed and said that the federal

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To Improve Human Health: A History of the Institute of Medicine government should develop its own analytic capacity, through agencies such as the congressional Office of Technology Assessment, rather than depend on the IOM. The weight of opinion, therefore, seemed to be against the IOM's doing large data-gathering studies. As for what the IOM should do, one public health official believed that conferences should be its main activity; others urged the IOM to do quick-response studies, perhaps without using a steering committee. The discussion then turned to the management of the IOM. One lingering problem was an undertone of antagonism between staff members assigned to specific projects and members of the permanent core staff. Project staff perceived that the core staff all too readily identified with the IOM membership rather than with their fellow staff members. The problems were particularly acute on steering committees. Many staff members felt that such committees were a "resource to be managed," rather than the ultimate arbiters of a particular study or project. Listening to the discussion, David Hamburg realized that he would have to clarify the expectations that project staffs and steering committees had of one another. Although the discussion was diffuse, it did produce four tentative conclusions. First, the IOM, the staff now believed, should work on some big issues but not at the expense of monopolizing IOM money or staff talent. Second, the IOM staff should develop the ability to perform policy analysis on a quick-response basis. Third, the organization should work hard to alter the "wrong but strong" perception that the IOM was dominated by officials from academic health centers. Fourth, the IOM should use the broad-based interests of its members to expand the Institute from a Washington-oriented operation to a national operation. More than anything else, however, the discussions demonstrated that no one had a firm fix on the IOM's mission. Adjectives such as "rudderless," "drifting," and ''floundering" came up in Lewin's discussion with government and foundation officials. According to one foundation officer, "the IOM had not yet decided what its mission should be.'' Furthermore, the IOM did not function well enough "to free its president to chart a course and to harness available resources to pursue that course." Staff tried to follow up on the Lewin session by posing their own questions about IOM's organization and management. In effect, staff members prepared a "wish list" for Hamburg to consider. High on the list was the desire to clarify the relationship between the staff and the steering committees. Staff wanted steering committee members to receive a document that, among other things, explained the staff role, exhorted committee members to meet deadlines, educated the committee on basic research methodology, and admonished steering

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To Improve Human Health: A History of the Institute of Medicine committee members to attend meetings. The staff also pressed for studies that its members could do on their own, with only an advisory, not a steering, committee to assist them.11 Hamburg made few commitments and turned next for advice from the IOM Council and from IOM members. Council member Dorothy Rice, director of the National Center for Health Statistics, gave one of the most thoughtful replies. She wrote that most members felt the IOM had not lived up to its great potential, spending too much time on large studies that did not address the nation's most important health problems. Rice told Hamburg that the IOM had to decide how much of its efforts should be devoted to "major studies, policy statements, background papers and conferences and seminars." She then asked how the IOM should operate. Should it be like Brookings, which turned a talented staff loose on important problems; the Committee on Economic Development, which issued policy statements that reflected the views of enlightened businesspeople on policy issues; or the Urban Institute, which performed contract research for the federal government? As the IOM grappled with this issue, Rice cautioned that Hamburg would have to consider the important issue of staff morale. "To keep good staff," she advised, "you need to provide a mechanism for close identifications of the individual and the research product." This led her to the issue of steering committees. Was their purpose to act as an advisory group or ''to provide actual directions to staff in the conduct of the study"? When studies were completed, it often took a great deal of time to disseminate the results. Rice said that the delays relating to project approval that were built into the system required examination, as did the question of how the membership might be involved in the entire process.12 A major motif of the members' responses to Hamburg was that the IOM was not the organization they wanted it to be. Ernest Saward, former director of the Permanent Clinic in Portland, Oregon, and an original member of the Board on Medicine, told Hamburg that he was frustrated with the IOM. "It was to be a working group, not an honorific one," he explained, and "while there was to be staff, it hardly was imagined that the staff did all the work and the members were more or less judicial." Saward complained that unless one were a member of the Council, it was hard to keep up with IOM activities. The Board's original vision for the IOM "seems very distant to us now."13 Robert Petersdorf, the head of the Department of Medicine at the University of Washington, agreed with Saward that "the Institute is not fulfilling the high hopes which many had for it," but he disagreed on the nature of the failure. In Petersdorfs opinion, the IOM was

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To Improve Human Health: A History of the Institute of Medicine wanting because it had failed to act as Irvine Page had hoped it would. "The IOM has not really become the collective spokesman for medicine," he told Hamburg. The problem lay in the fact that social scientists had taken over the IOM, in part because they had worked harder at it. Although Petersdorf conceded that social scientists were necessary, he worried that many had made their reputations by "taking anti-medicine stands. In fact, a number of people have begun to call the IOM the 'Institute of Anti-Medicine.'" It was up to Hamburg to set things right. "No organization,'' Petersdorf advised, could prosper "unless there is strong direction from the top and in a relatively continuous fashion."14 Before Hamburg provided this direction, he wanted a mandate from the Council and the members. Toward this end, he scheduled a series of retreats for the IOM Council that took place in July 1976. Julius Richmond presided over the first one in which five IOM Council members held a long and unstructured discussion of IOM priorities, deciding that the IOM should devote more of its time to "short-term, quick-response kinds of activities" that allowed the organization to react to public policy developments.15 Hamburg seemed to affirm this point at a meeting of the Program Committee that took place a week later. He said that the Institute would not be doing so many "responsive" studies in the style of the Medicare-Medicaid reimbursement project. Instead, it would turn more toward private foundations and corporations to support smaller studies.16 At the end of July, Council members held a two-day retreat at Woods Hole, Massachusetts, at which they contemplated the IOM's future. Setting the tone for the discussion, Julius Richmond said that the IOM could "no longer offer promissory notes; it must begin to influence public policy more substantially." In support of this proposition, Richmond said that the IOM should begin to attack major problems such as national health insurance and biomedical research policy. Although Richmond did not know it, his priorities were exactly those of the Board on Medicine, which had singled out the same two problems for attention. Listening to the discussion, Hamburg floated an idea that he had been considering for a long time. He would ask the staff to "map out the terrain" in five major policy areas, giving staff a definite role in the "new IOM" and staking out the major issues that should be addressed. Hamburg thought that the five areas should be (1) health services, with special attention to national health insurance; (2) health sciences policy; (3) prevention of disease; (4) education for the health professions; and (5) mental health. This proved to be the major idea that emerged from the meeting.17

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To Improve Human Health: A History of the Institute of Medicine In a communication from Hamburg to IOM members in September 1976, he synthesized the staff, committee, and Council discussions of the IOM's mission. Here again, he announced his intention "to map the terrain of health by means of the multiple perspectives so distinctively available in IOM." In the past, IOM studies had been initiated by Congress and the executive branch, but the terrain maps would make it easier for the IOM to initiate its own studies. Although Hamburg did not believe that the IOM's five principal benefactors would continue to provide the sort of flexible money that would make such initiatives possible, the IOM might be able to obtain foundation grants in "particular program areas."18 Reorganization The upshot of the long discussions was a reorganization. In March 1977, the Institute of Medicine created six operating divisions, each with its own staff director and its own advisory board of IOM members and other experts. The divisions corresponded to the categories in which the Program Committee had considered proposals and the subjects of the terrain maps. Before the reorganization, staff had worked on projects of the moment without a permanent assignment. The new plan made it possible for staff members to develop specialties and for the entire IOM program to have more coherence from one year to the next. The titles of the divisions and their areas of responsibility underwent constant change as the health care policymaking environment, available staff, and available funds changed. In the original six-division scheme, the Division of Health Care Services focused on topics related to health services research, such as the financing of health care and issues of health care quality. The Division of Health Manpower and Resources Development concentrated on such issues as education and the proper distribution of medical specialists. Elena Nightingale, who was both a Ph.D. and the only M.D. among divisional directors, headed the Division of Health Promotion and Disease Prevention, which examined the impact of biological and social factors on disease and disability. The Division of Health Sciences Research was responsible for projects that related to "the conduct and support of biomedical and behavioral research." The Division of International Health worked on projects that related to health and economic development, and the Legal, Ethical, and Educational Aspects of Health Division was a catchall category to cover everything else.19

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To Improve Human Health: A History of the Institute of Medicine Richmond managed to restore order. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention appeared in August 1979, and Joseph Califano signed it as one of his last official acts as Secretary of HEW. As Hamburg explained, the book drew heavily on the material that IOM had prepared but that, "naturally, DHEW has put its stamp on the material." A second volume of the Surgeon General's report consisted entirely of the background papers that the IOM had commissioned.57 During the summer of 1979, Jimmy Carter delivered his famous homily on the nation's wavering sense of purpose that the press dubbed the "malaise" speech. In the wake of this speech, the President announced a shakeup of his cabinet, which led to the dismissal of Joseph Califano. According to a predetermined schedule, the Surgeon General's report was released just after Califano had been fired. As a result, it received little of the fanfare that Califano might have brought to it. The bold call for a "second public health revolution" to prevent all disease tended to go unheeded. In fact, the Surgeon General's report revealed an important fault line in the nation's political ideology. In the past, Democratic administrations had emphasized measures that the government could take to improve the nation's health, such as the creation of Medicare or increased investment in medical education and research. The Carter administration inherited many of these projects from past administrations, in particular the desire to shore up the financing of health care through national health insurance. Unlike the other administrations, Carter and Califano started with the primary goal of cost containment as a necessary precondition for guaranteeing universal access. Prevention was a key to cost containment, and Carter administration officials tended to see prevention as an individual, rather than a governmental, responsibility. The Surgeon General's report seemed to confirm the fact that, as the Washington Post reported, "people can do far more to improve their health by acting themselves than they can by waiting for symptoms and then going to doctors."58 The IOM committee in charge of advising the surgeon general was not prepared to push the prevention line this far Committee members continued to see an important role for government in disease prevention and health promotion. The dental study and the Surgeon General's report on prevention revealed that, however much the IOM wanted to be of service, it was removed from politics. It could get only so close to a particular administration before the differences between its style of operation and those of a more politicized organization became apparent. In the case of the Carter administration, the departure of Califano,

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To Improve Human Health: A History of the Institute of Medicine combined with the demise of many of the items on the administration's agenda, led to an increased separation between it and the IOM. Hamburg hoped that the IOM could be as helpful to Patricia Roberts Harris, Califano's replacement, as it had been to Califano. As David Hamburg later noted, Califano early saw the IOM's value and sought to work with it. As Califano came to see the increasing importance of health as an area of social policy, he developed an attachment to the IOM that continued after he left office. Califano became an IOM member and served on the IOM Council during the 1990s. Patricia Harris, for her part, held many fruitful discussions with Hamburg and proved to be very supportive of the IOM's international health efforts. Still, her time in office was brief and the possibilities of collaboration were fewer during her tenure than during Califano's. Riddles of Power Being close to power was exhilarating but not without its problems. To preserve its reputation, the IOM always had to fend off blatantly political requests. A good example in the Carter era concerned a request from Senator Daniel Inouye (D-Hawaii) that the IOM study the health effects of tourism. Staff members from the senator's Subcommittee on Tourism of the Senate Commerce Committee visited IOM staff member Karl Yordy and explained that they wished to explore ways in which the effective use of leisure might lead to improvements in health. If a link between leisure and good health were established, the government might mandate vacations in the same way that the Fair Labor Standards Act limited the standard working week to 40 hours. Yordy listened as politely as he could and talked of the many difficulties that an IOM study might pose, such as the problem of conceptualizing leisure. Undeterred, Senator Inouye sent David Hamburg a formal letter, noting that hearings in his subcommittee "raised the possibility of linkages between stress ... one's ability to relax and various physiological and psychological symptoms." He even suggested that the government might want to promote four-day work weeks and mandatory paid vacations as part of its public health responsibility. Calling the IOM's academic and professional expertise "second to none," Inouye asked the IOM to help the subcommittee develop policy recommendations.59 The self-interest in this request was obvious. Inouye represented a state whose economic well-being depended on the health of its tourism industry. What he wanted, in effect, was to use the federal

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To Improve Human Health: A History of the Institute of Medicine government to subsidize the economy of Hawaii on the recommendation of the IOM. The press had already begun to investigate this matter. Yordy told Hamburg that Newsweek had almost put the study in its "golden fleece" category, certifying it as a boondoggle. Wary of offending an important senator, Hamburg bowed out as gracefully as he could. He thanked Inouye for his letter and said that he personally wanted the IOM to do the study but it would require review by the Program Committee. In this way, he let the matter drop.60 Even on a project that the IOM and government officials both wanted, complications related to politics sometimes developed. A good example concerned an IOM conference on the subject of the care of terminally ill patients. At first, the National Cancer Institute (NCI) expressed an interest in funding such a conference. In a few months, however, it became apparent that the NCI would not do anything to help the project; IOM officials suspected that priorities within the NCI had changed. Then Joseph Califano gave a speech in which he embraced the hospice concept and announced plans for a national conference on the care of dying patients. National Cancer Institute officials immediately got in touch with the IOM and stopped work on the contract they had been negotiating. The IOM then began discussions with Califano's staff to see if it could play a role in his conference. As discussions progressed, IOM officials realized that HEW envisioned a grandiose conference, attended by more than 1,000 people, that would serve as a platform for Califano to follow up on his earlier speech. The IOM wanted no part of organizing such a conference and proposed instead that the IOM provide "credibility, objectivity, and intellectual input" by convening a committee to advise on the conference agenda and speakers. HEW rejected this idea, and the negotiations ended. 61 In this case, the IOM could not maneuver between its desire to study an issue and Califano's desire to publicize the case for hospice care. Just after Joseph Califano was fired, an exasperated Karl Yordy wrote to his counterpart at the Kellogg Foundation that "obtaining HEW support during the last year has been such a struggle, in spite of great goodwill for the Institute at all of the policy levels within the Department, that it is difficult to imagine the situation being any worse."62 Fund-Raising Karl Yordy and David Hamburg realized that government funds and government projects would never take the place of private

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To Improve Human Health: A History of the Institute of Medicine foundation support. During Hamburg's presidency, the core foundations continued to finance the Institute, and the IOM managed to add new patrons to the list. When Donald Fredrickson announced his intention to leave the IOM, a program officer at the Robert Wood Johnson (RWJ) Foundation hastened to assure Karl Yordy that the RWJ staff intended "to continue to support IOM regardless of the leadership change." This proved to be the case. The Kellogg Foundation told the IOM in 1975 that Kellogg would support only "specific project activities," yet Kellogg continued its generous support, as a 1978 award of $375,000 to "help underwrite the Institute's annual program plan" demonstrated. In 1978 the IOM also received a check for $750,000 from the Andrew Mellon Foundation to "address policy issues critical to the nation's use of finite resources for health care.'' During the next year, a $105,000 check arrived from the Richard King Mellon Foundation for the ''leadership and initiative functions of IOM."63 Even as David Hamburg hastened to reassure these foundations that the IOM was still worth supporting, he also courted new ones. A notable success came with the Charles H. Revson Foundation. Using IOM Council member Lisbeth Bamberger Schorr as an intermediary, Hamburg set up a meeting with Revson Foundation Director Eli Evans. "I think our interests overlap in many ways," Hamburg wrote to Evans after the meeting. Three months later, Hamburg learned that the Revson board had appropriated $200,000 for the IOM to conduct four Revson seminars on biomedical research.64 Although these donations helped, they still could not free the IOM from debt. In July 1979, for example, the IOM Council learned that the fiscal year would end with a budget deficit of $210,000. The National Academy of Sciences offered to bail out the IOM but at the cost of reducing its support for fiscal year 1980. This meant that the IOM would have to cut back on its 1980 expenses.65 A major part of the problem stemmed from a ruling made by government auditors in 1978 that the IOM had to include overhead costs for private foundation grants in its budget. In other words, if the IOM received money from Robert Wood Johnson, part of this money would have to go toward indirect costs or overhead. Not all of the money could be spent on things such as salaries, meetings, or conferences; part of it would have to go toward general upkeep of the Institute. This ruling had the effect of reducing the amount of the foundation grants and upsetting the IOM budget so that the IOM suddenly found itself with a $750,000 debt. Although IOM staff members hoped that President Handler would appeal the auditors' ruling, he preferred, in the

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To Improve Human Health: A History of the Institute of Medicine privately spoken words of one IOM staffer, "to chastise the IOM for its profligate and careless ways." Hamburg thought about compensating for the loss of income by obtaining what he described as "flexible kinds of support from federal quarters."66 Such support proved very hard to obtain because federal agencies insisted on contracts for specific projects and the government did not make flexible grants in the manner of foundations. Defining the Institute's Mission The oversight that the National Academy of Sciences exercised over the Institute complicated any efforts to resolve the IOM's funding difficulties. Although relations between the NAS and the IOM tended to be calm in the Hamburg years, sharp differences of opinion did arise over such issues as the report review function. When John Hogness was IOM president, he developed a good working relationship with NAS Vice President George Kistiakowsky. As a result, the review of IOM reports by the Academy became routine. "We never had any difficulties," Hogness recalled.67 This changed during the Hamburg years. In March of 1978, for example, Philip Handler sent Hamburg a long memo in which he pointed out his "vaguely negative" initial reaction to a report on medical technology, the disastrous history of the steering committee for the project, and the "undocumented assertions" that abounded in the report. He asked if Hamburg could regard the study as IOM's ''best effort."68 Hamburg hastened to make changes and thanked Handler for making the report "sounder.''69 Such chastisement from Philip Handler rankled, as did the criticism of IOM reports by Saunders Mac Lane, who was a University of Chicago mathematician and NAS vice president, and chairman of the Academy's Report Review Committee. In 1980, Mac Lane told the IOM Council that the reports had run into difficulties because the IOM sometimes started "with the view of influencing policy rather than conducting a dispassionate assessment of fact." The resulting reports did not make explicit which of the findings stemmed from "informed judgment" and which rested on "hard evidence." At times also, conclusions reflected the opinion of the staff, not the results of investigations undertaken by the steering committee. In a similar spirit, Vincent P. Dole, vice chairman of the NAS Report Review Committee, cautioned the IOM not to become too involved in the political process when dealing with health policy problems.70

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To Improve Human Health: A History of the Institute of Medicine In response to this criticism, Hamburg pointed to the differences between basic and applied science. The social problems of the sort that the IOM addressed had a scientific content, "but all also entail uncertainty in the knowledge of factors that can influence outcome." If the IOM wished to tackle "the truly large, difficult issues of health and disease," as Walsh McDermott had hoped it would, it could not adopt the attitude of the pure scientist. Instead, the IOM had to consider the gray areas that lay beyond scientific certainty. As Fred Robbins, who succeeded Hamburg as IOM president, stated bluntly, "The Institute could not limit its study to the hard evidence and still carry out its mission.''71 At the end of the Carter administration, it was still difficult to discern this mission. It was clear that the IOM walked a fine line between the scientific concerns of the National Academy of Sciences and the political preoccupations of policymakers. It also tried to sort out the most appropriate projects from those that its members suggested and those that the government brought to it. The fact that it could filter these proposals through separate divisions, each with its own advisory committee, helped lend coherence to the effort. Even so, Renee Fox, a University of Pennsylvania sociologist and member of the IOM Council, called the program plan for 1980 a "diffuse set of projects." Margaret Mahoney, head of the Commonwealth Fund and an IOM Council member who had done much to encourage philanthropic support for the Institute, said that "the time has come when [IOM] should think with some continuity so that people will associate certain kinds of activities with the Institute and no other organization." In this sense, the IOM, although it had discovered important themes such as primary care, health education, quality assurance, and prevention, had not yet found its niche.72 Conclusion At the beginning of 1979, David Hamburg appeared before the IOM Council and made a special announcement. He had been reflecting on his three years as head of the IOM. Some Council members had suggested that he serve another five-year term beyond his present one. Hamburg told the Council members that he had decided not to do so. He would complete his term and then leave the IOM. Hamburg announced his intention to establish "valuable, long-term directions for the Institute" during the remainder of his term. In the meantime, the IOM would have plenty of time to search for his successor.73 Council members greeted Hamburg's decision with

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To Improve Human Health: A History of the Institute of Medicine genuine disappointment; they wanted him to stay, continue his inspirational leadership, and finish the job of establishing the IOM as an independent organization that was not afraid to engage questions that were close to the surface of the nation's political life. David Hamburg left office only a month before the presidential election that would chase Jimmy Carter from town. Their simultaneous departures marked the start of a new and very different era in IOM history. At the end of Hamburg's tenure, Philip Handler wrote him a graceful letter that eloquently captured his contributions to the IOM: Under your leadership, the Institute of Medicine has been brought to maturity. It has earned a place in the Washington scene and become the instrument to which we aspired when it was created. Our country has yet a long way to go in the development of an accepted philosophy which will enable us to frame a consistent national health policy. Thanks to you, I am confident that the Institute of Medicine will make cardinal contributions to that process. We have enjoyed your boundless good humor, basked in the warmth of your compassion, and been stimulated by the keenness of your intellect. All of us are richer for your stay among us.74 Notes 1.   Clipping with White House note and Lawrence Meyer, "Panel Urges Curb on Use of Costly X-Ray Device," Washington Post, May 3, 1977, in Yordy Files, Accession 91-051, Institute of Medicine (IOM) Records, National Academy of Sciences (NAS) Archives. 2.   "Steps Taken in the 1975 Search," Presidential Search Committee Files, 1975–1980, Accession 93–192, IOM Records; Philip Handler to Julius Richmond, June 26, 1975; Richmond to Handler, July 10, 1975; and Handler to David Hamburg, June 26, 1975, all in IOM-1975 File, NAS Records, NAS Archives. 3.   David Hamburg to Philip Handler, July 19, 1975, NAS Records. 4.   NAS Press Release, October 30, 1975, NAS Records; Curriculum Vitae for David Hamburg, March 1975, IOM Records. 5.   "Remarks by David A. Hamburg on the Occasion of His Inauguration as President of the Institute of Medicine, November 6, 1975," Yordy Files, Accession 91-051, IOM Records. 6.   IOM Council Meeting, Minutes, November 6 and 7, 1975, IOM Records. 7.   Institute of Medicine, Medicare-Medicaid Reimbursement Policies , (Washington, D.C.: National Academy of Sciences, 1976), pp. 5, 9–10. 8.   IOM Council Meeting, Minutes, March 18, 1976, IOM Records. 9.   See, for example, the discussion in IOM Council Meeting, Minutes, May 20, 1976, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 10.   The discussion of the Lewin report that follows is drawn from "Summary of Lewin Report on Major Issues Confronting the New IOM President," IOM Records, and "Notes on Report to Institute of Medicine Staff by Larry Lewin, March 19, 1976," both in Yordy Files, Accession 91-051, IOM Records. 11.   Jim Lewis to Program Director's Group, April 2, 1976, and Lewis to Program Director's Group, April 26, 1976, both in IOM Records. 12.   Dorothy Rice to David Hamburg, July 1, 1976, Yordy Files, Accession 91-051, IOM Records. 13.   Ernest W. Saward, M.D., to Dr. David Hamburg, June 28, 1976, Yordy Files, Accession 91-051, IOM Records. 14.   Robert Petersdorf to David Hamburg, June 18, 1976, Yordy Files, Accession 91-051, IOM Records. 15.   IOM Council Meeting, Minutes, July 15, 1976, IOM Records. 16.   IOM Program Committee Meeting, Minutes, July 22, 1976, Program Committee Files, Accession 81-006, IOM Records. 17.   IOM Council Meeting, Minutes, July 29–30, 1976, IOM Records. 18.   David Hamburg, "Institute of Medicine, 1976, Current Status and Future Prospects," IOM Records. 19.   "Institute of Medicine Divisional Structure," Yordy Files—Second Series, Accession 94-111, IOM Records. 20.   IOM Program Committee Meeting, Minutes, February 1977, April 1977, and July 1977, all in Program Committee Files, Accession 81-006, IOM Records. 21.   W.A. Lybrand, IOM Staff, to Division Directors, June 22, 1979, Accession 81-006, IOM Records. 22.   David Hamburg to IOM Staff, December 22, 1978, Yordy Files, Accession 91-051, IOM Records. 23.   IOM Council Meeting, Minutes, November 1976 and January 1978, IOM Records. 24.   Institute of Medicine, Division of Health Manpower and Resources Development, A Manpower Policy for Primary Health Care: A Report of a Study (Washington, D.C.: National Academy of Sciences, 1978), pp. 3–9. 25.   Richard M. Schleffer, Neil Weisfield, and E. Harvey Estes, "A Manpower Policy for Primary Health Care," New England Journal of Medicine, 298 (May 11, 1978), pp. 1058–1062. 26.   Summary of "Evaluation of Health Care Quality Assurance Programs," July 5, 1977, Yordy Files—Second Series, Accession 94-111, IOM Records; Institute of Medicine, Assessing Quality in Health Care: An Evaluation (Washington, D.C.: National Academy of Sciences, 1976). 27.   This account is based on Guido Calabresi to John Hogness, July 29, 1977, and other materials, including summaries of steering committees and grant proposals, in Medical Injury Compensation Study Files, Accession 80-010, IOM Records. 28.   Institute of Medicine, Beyond Malpractice: Compensation for Medical Injuries (Washington, D.C.: National Academy of Sciences, 1978), p. 65.

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To Improve Human Health: A History of the Institute of Medicine 29.   IOM Council Meeting, Minutes, November 1976 and January 1977, IOM Records. 30.   Elena Nightingale to Bernard Greenberg, January 27, 1977, Polio Vaccine Study Files, Accession 91-007, IOM Records. 31.   "Evaluation of Poliomyelitis Vaccines: Report of the Committee for the Study of Poliomyelitis Vaccines," Polio Vaccine Study Files, Accession 81-007, IOM Records. 32.   Elena Nightingale to the Committee for the Study of Poliomyelitis Vaccines, October 7, 1977, Polio Vaccine Study Files, Accession 84-007, IOM Records. 33.   "An Appraisal of Computed Tomography," in "Activities of the Division of Health Care Services," July 1977, Yordy Files—Second Series, Accession 94-111, IOM Records; IOM Council Meeting, Minutes, January 1977, IOM Records. 34.   Institute of Medicine, Controlling the Supply of Hospital Beds (Washington, D.C.: National Academy of Sciences, 1976). 35.   IOM Council Meeting, Minutes, March 23, 1977, IOM Records. 36.   IOM Council Meeting, Minutes, March 23, 1977, and May 18, 1977, IOM Records; Edward M. Kennedy, Paul Rogers, Richard Schweicker, Tim Lee Carter, and Jacob Javits to David Hamburg, January 28, 1977, Yordy Files, Accession 91-051, IOM Records. 37.   IOM Council Meeting, Minutes, May 17,1978, IOM Records. 38.   IOM Council Meeting, Minutes, July 20, 1977, IOM Records. 39.   IOM Council Meeting, Minutes, September 28, 1977, IOM Records. 40.   Institute of Medicine, Strengthening U.S. Programs to Improve Health in Developing Countries (Washington, D.C.: National Academy of Sciences, 1978), pp. ix, ES7, ES18. 41.   Steering Committee Meeting, Minutes, November 29, 1979, Files of Health and Behavior Study, Accession 82-076, IOM Records. 42.   Institute of Medicine, Health and Behavior: A Research Agenda, Interim Report Number 1, Smoking and Behavior (Washington, D.C.: National Academy of Sciences, 1980), p. 11. 43.   Institute of Medicine, Health and Behavior: A Research Agenda, Interim Report Number 2, Combining Psychosocial and Drug Therapy (Washington, D.C.: National Academy of Sciences, 1981), p. 8. 44.   Institute of Medicine, Health and Behavior: A Research Agenda, Interim Report Number 6, Behavior, Health Risks, and Social Disadvantage (Washington, D.C.: National Academy of Sciences, 1982), p. 5. 45.   Institute of Medicine, Health and Behavior: A Research Agenda Interim Report Number 5, Health, Behavior, and Aging (Washington, D.C.: National Academy of Sciences, 1981), p. 1. 46.   Institute of Medicine, Health and Behavior: A Research Agenda, Interim Report Number 4, Infants at Risk for Developmental Dysfunction (Washington, D.C.: National Academy of Sciences, 1982), p. 3. Other conferences covered the subjects of bereavement and sudden cardiac death.

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To Improve Human Health: A History of the Institute of Medicine 47.   Institute of Medicine, David A. Hamburg, Glen R. Elliott, and Delores L. Parron, eds., Health and Behavior (Washington, D.C.: National Academy of Sciences, 1982), pp. 2, 5, 7, 16, 18. 48.   Fred Robbins to Robert Rubin, M.D., Assistant Secretary of Planning and Evaluation, Health, Education, and Welfare, November 5, 1981, Research on Stress and Human Behavior Files, Accession 82-077, IOM Records. 49.   Steering Committee Meeting, Minutes, November 26, 1979, "Research on Stress in Health and Disease," Accession 82-077, IOM Records; Institute of Medicine, Research on Stress and Human Health (Washington, D.C.: National Academy of Sciences, 1981), p. xi. 50.   Glen Elliott, Study Director, and Fred Solomon, Division Director, to Steering Committee Members, August 7, 1981, and Elliott and Solomon to Fred Robbins, August 6, 1981, both in Accession 82-077, IOM Records; Research on Stress and Human Health, pp. 6, 20. 51.   Institute of Medicine, Annual Report, Year Ended June 30, 1979 (Washington, D.C.: National Academy Press, 1980). 52.   Chester W. Douglass to David Hamburg, September 7, 1976, and "The Possible Inclusion of Dental Care Under National Health Insurance," December 10, 1976, both in Dental Care Study Files, Accession 81-064, IOM Records. 53.   Steering Committee Meeting, Minutes, May 25 and 26, 1978, Study of Dentistry in National Health Insurance, Accession 81-064, IOM Records. 54.   Steering Committee Meeting, Minutes, Study of Dentistry in National Health Insurance, September 13, 1978, and Walter McNerney to Lester Breslow, July 25, 1978, both in Accession 81-064, IOM Records. 55.   David Hamburg to Ben Barker, September 12, 1979; Karl Yordy to Lou Cranford, December 19, 1978; Linda Demlo to Yordy, March 27, 1979; and "Public Policy Options for Better Dental Health," December 1980, all in Accession 81-064, IOM Records. 56.   David Hamburg to Anne R. Somers, October 4, 1978, "US Plans a Major Health Report," New York Times, July 13, 1978, and other materials in Surgeon General's Report Files, Accession 86-064-06, IOM Records. 57.   David Hamburg to Robert F. Murray, Jr., August 27, 1979, Accession 86-064-06, IOM Records. 58.   Victor Cohen, "New Health Report Stresses Prevention Through Diet, Habits," Washington Post, July 29, 1979, p. 1; Joseph Califano, Governing America: An Insider's Report from the White House and the Cabinet (New York: Simon and Schuster, 1981). 59.   Karl Yordy to David Hamburg, April 1, 1976; Yordy to Patrick DeLeon, Senate Commerce Committee, April 29, 1976; and Senator Daniel Inouye to David Hamburg, July 13, 1977, all in Program Committee Files, Accession 94-111, IOM Records. 60.   David Hamburg to Senator Daniel Inouye, June 30, 1977, Program Committee Files, Accession 94-111, IOM Records. 61.   See materials in the Palliative Care Conference File, Accession 94-111, IOM Records.

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To Improve Human Health: A History of the Institute of Medicine 62.   Karl Yordy to Robert Sparks, Program Director, W. K. Kellogg Foundation, July 30, 1979, Funding Files, Accession 91-045, IOM Records. 63.   Karl Yordy to Donald Fredrickson, February 11, 1975; Walter Unger to Roger Bulger and Karl Yordy, May 14, 1975; John Sawyer to Philip Handler, October 5, 1978; Robert Sparks to John Coleman, October 27, 1978; and George Taber, Director, Richard King Mellon Charitable Trusts, to David Hamburg, June 19, 1979, all in Funding Files, Accession 91-045, IOM Records. 64.   Eli Evans to "Lee" Schorr, March 24, 1978; David Hamburg to Evans, January 30, 1979; and Evans to Philip Handler, June 12, 1979, all in Funding Files, Accession 91-045, IOM Records. 65.   IOM Council Meeting, Minutes, July 1979, IOM Records. 66.   IOM Council Meeting, Minutes, May 17, 1978, IOM Records. 67.   John Hogness to Wallace Waterfall, June 20, 1990, IOM Records. 68.   Philip Handler to Dr. Courtland Perkins and Dr. David Hamburg, March 16, 1978, Yordy Files, Accession 91-051, IOM Records. 69.   Courtland D. Perkins and David Hamburg to Philip Handler, July 17, 1978, Accession 91-051, IOM Records. 70.   IOM Council Meeting, Minutes, May 29, 1980, IOM Records. 71.   Executive Session of the IOM Council, Minutes, July 16, 1980, IOM Records. 72.   In David Hamburg's original scheme there had been six divisions, but one had been "deactivated" during fiscal year 1979. IOM Council Meeting, Minutes, November 28, 1979, IOM Records. 73.   IOM Council Meeting, Minutes, January 1979, IOM Records. 74.   Philip Handler to David Hamburg, September 22, 1980, NAS Records.