Afterword

by Karen Hein, M.D.

Executive Officer, Institute of Medicine

What now? The Institute of Medicine (IOM) at 25 is well established, successfully integrated into the Academy complex, financially stable, and productive. Yet the ways in which the IOM promotes the health and well-being of Americans and people throughout the world could be improved. Looking ahead to the next 25 years, three questions are germane:

  1. How can we reach the public in new and better ways?

  2. What changes should be made to make the IOM a more diverse, flexible, responsive, and timely organization?

  3. How can we assemble the most relevant thinkers, players, and change agents to reflect and shape the direction of health and science policy?

Serving the public first entails defining who the “public” is. Our main constituents have traditionally been Congress, government agencies, and academia. Our reports have typically been deliberative, technical, and lengthy, both in the time they take to complete and in substance. Although the IOM is a public institution, we serve the people indirectly, through a filter of policymakers, academics, and health professionals. This detachment, especially given the current climate in which scientists and the organizations they represent are increasingly subject to intense scrutiny and criticism, is less than ideal. The head of NASA laments, “why is it so hard for the science and technology community to understand [that] their customer is the American public?”1



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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Afterword by Karen Hein, M.D. Executive Officer, Institute of Medicine What now? The Institute of Medicine (IOM) at 25 is well established, successfully integrated into the Academy complex, financially stable, and productive. Yet the ways in which the IOM promotes the health and well-being of Americans and people throughout the world could be improved. Looking ahead to the next 25 years, three questions are germane: How can we reach the public in new and better ways? What changes should be made to make the IOM a more diverse, flexible, responsive, and timely organization? How can we assemble the most relevant thinkers, players, and change agents to reflect and shape the direction of health and science policy? Serving the public first entails defining who the “public” is. Our main constituents have traditionally been Congress, government agencies, and academia. Our reports have typically been deliberative, technical, and lengthy, both in the time they take to complete and in substance. Although the IOM is a public institution, we serve the people indirectly, through a filter of policymakers, academics, and health professionals. This detachment, especially given the current climate in which scientists and the organizations they represent are increasingly subject to intense scrutiny and criticism, is less than ideal. The head of NASA laments, “why is it so hard for the science and technology community to understand [that] their customer is the American public?”1

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 There is also an increased tension between reliance on and mistrust of technology. This is not a new phenomenon. Nearly 200 years ago, reacting to the economic disruptions caused by the Industrial Revolution, Ned Ludd led a band of cottage handweavers through the countryside of Northern England smashing power looms and burning textile mills. In 1813, 24 Luddites were hanged.2 Similarly, but, we hope, with less dire consequences, we are now experiencing what has been described as “a widespread, powerful, corrosive hostility toward science.”3 In the words of one congressman, “the science community seems to think that as long as the money is flowing, I'm okay, you're okay, we're all okay and [it] doesn't get involved in setting priorities. . . . I wish science studies could work to the same rhythm that legislatures have to. . . .”4 But what form would such an arrangement take? As Avedis Donabedian queries in his chapter, “would the next step be an actual partnership with consumers as equals in serving the public interest?” Forging new partnerships with the public will require changes at the IOM. Shorter reports, less technical versions aimed at the lay public, fast-track studies, and electronic access to IOM reports or information about the Institute via the Internet and the World Wide Web are four possible ways to increase timeliness and accessibility to the public. It has been said that journalism is the first draft of history.5 In this volume, we have identified six themes that capture some of the work of the IOM's first 25 years. Through the chapters written by staff members and the accompanying commentaries by IOM members, we can look back on the Institute's first two and one-half decades and put its work into historical context with the issues and problems the country faced during that time. This is an important exercise, because looking back gives us a solid footing for looking ahead. Looking ahead requires that we keep in mind that we will always be a reflection of our times. Looking ahead also means that we must examine both the structure and the function of the IOM. Balance and breadth are key elements of IOM's success and are attributes that we must maintain. In contrast, a senior policy advisor has described the involvement of the scientific community in shaping public policy as “a combination of arrogance and ignorance.”6 To avoid distortion, irrelevance, or prejudice, we should be vigilant in maintaining and, where necessary, increasing diversity in the Institute's membership and committees, in the selection of studies, in the peer-review process, and in dissemination activities. In addition, keeping an open mind means keeping our processes as open to outsiders as possible and putting together committees in such a way that we balance intellectual biases while avoiding conflicts of interest. One important role of the IOM over the years has been to elevate emerging issues to greater public attention and scrutiny. Some of the studies with the greatest impact (e.g., Confronting AIDS and Growing Up Tobacco Free) have been initiated within the IOM itself. The balance between being reactive and

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 proactive is one tipped by available funding and sponsor support. Putting an issue on the map has sometimes even meant creating a division to highlight a neglected area, such as occurred with the Division of Biobehavioral Sciences and Mental Disorders (formerly Mental Health and Behavioral Medicine). One result of this was to help move mental health and substance abuse from being “often-forgotten” to “sometimes-forgotten” orphans of health and science policy, as Connie Pechura states. Indeed, these are not the only fields to have suffered neglect. In his commentary, David Hamburg notes that biochemistry was once viewed as “weak chemistry or weak biology.” Looking ahead can also mean looking at the ways in which the IOM could play a central role in defining and focusing attention on new fields. Environmental justice, risk assessment and communication, intellectual property rights, and the relation of health to sustainable development are examples of terms and concepts that did not even exist several years ago, but help to define the critical issues of our times. Where does the IOM fit in the global village? Human health and illness know no political boundaries, as the emergence and reemergence of infectious diseases has proven. Developing and developed nations alike are grappling with a growing disparity of wealth and health between rich and poor people. Rural-to-urban migration, ethnic conflicts, and the proliferation and dispersal of highly destructive technologies such as land mines threaten the stability, health, and productivity of all people. Scientific organizations such as the National Academy of Sciences, National Academy of Engineering, the IOM, and others around the world can play a central role in bringing nations together around a nonpolitical table to discuss mutual concerns and their potential solutions. In 1994, President Clinton described the rationale for investing in science in the national interest, and this theme has been reiterated by many in the scientific community.7 Elements of such support might include funding for basic research, long-term capital investment, a lowering of the government-generated risk associated with innovation, protection of intellectual property, and support of industry cooperation on research and development. In the United States, a new rationale for federal support of science and technology has been countered by a sense that government should withdraw, rather than increase its involvement in applied research and technology. In the health policy arena, a remarkable reversal has occurred. During the past year, efforts to pass comprehensive health care reform legislation failed. In its place, market forces are fueling a firestorm of change in the U.S. health care system. In fact, the system is undergoing such rapid evolution that some describe it as a revolution. Other nations have also recently focused governmental resources in health and science according to explicitly stated priorities. For example, France has created a superministry for research, the United Kingdom has declared that the primary goal of research should be on the creation of wealth,8

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 and South Africa has tied its research resources to improving public health, education, and welfare. In the next 25 years, the IOM will have a much wider public to serve, a host of new ways to reach people electronically, and the chance to shape as well as reflect the world in which we live. The question now is not whether or not the Institute should exist, but what difference can—and will—it make? NOTES 1. Daniel Goldin, as quoted by Andrew Lawler in “Is Science Lobbying an Oxymoron?” Science 269:20, 1995. 2. Kevles, D. J. 1995. E Pluribus Unabomber. New Yorker August 14:2–3. 3. Paul R. Gross, as quoted by Franklin Huke in “Scientists See Broad Attack Against Research and Reason.” The Scientist 9(14):1, 1995. 4. Robert Walker, as quoted by Andrew Lawler in “Robert Walker: The Speaker's Right Hand on Science.” Science 269:750, 1995 5. Altman, L. K. 1993. Bringing the News to the Public: The Role of the Media. Annals of the New York Academy of Sciences 703:200–9. 6. Alan Bromley, as quoted by Andrew Lawler in “Is Science Lobbying an Oxymoron,” op. cit. 7. Institute for the Future. 1995. The Future of America's Research-Intensive Industries. Menlo Park, California: Institute for the Future. 8. Balter, M. 1995. Research is Absorbed into Superministry. Science 268: 1127–8.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995