Organizational History, 1970–1995

by Enriqueta C. Bond, Ph.D.*

President, The Burroughs Wellcome Fund, Morrisville, N.C.

BEGINNINGS AND THE FIRST FIVE YEARS: 1970–1975

The idea for an organization such as the Institute of Medicine (IOM) probably arose in the mid-1960s. Early in December 1960, then-President-Elect John Kennedy appointed a seven-person preinaugural Task Force on Health and Social Security under the chairmanship of Wilbur Cohen, a professor at the University of Michigan. Its mission was “to review from among the most pressing and significant health and welfare proposals those which should have priority in the initial phase of the new Administration.” The report had considerable influence upon public policy decisions in the ensuing years. One of the less noted recommendations read as follows:

The President should take the necessary steps to arrange for the establishment of a National Academy of Health comparable to the National Academy of Sciences. The purpose of such a non-governmental, independent Academy would be two-fold:

  1. To recognize and honor the significant achievements of leaders in health research, teaching, care, and administration, and

*

Dr. Bond was executive officer of the Institute from 1989 to June 1994.



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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Organizational History, 1970–1995 by Enriqueta C. Bond, Ph.D.* President, The Burroughs Wellcome Fund, Morrisville, N.C. BEGINNINGS AND THE FIRST FIVE YEARS: 1970–1975 The idea for an organization such as the Institute of Medicine (IOM) probably arose in the mid-1960s. Early in December 1960, then-President-Elect John Kennedy appointed a seven-person preinaugural Task Force on Health and Social Security under the chairmanship of Wilbur Cohen, a professor at the University of Michigan. Its mission was “to review from among the most pressing and significant health and welfare proposals those which should have priority in the initial phase of the new Administration.” The report had considerable influence upon public policy decisions in the ensuing years. One of the less noted recommendations read as follows: The President should take the necessary steps to arrange for the establishment of a National Academy of Health comparable to the National Academy of Sciences. The purpose of such a non-governmental, independent Academy would be two-fold: To recognize and honor the significant achievements of leaders in health research, teaching, care, and administration, and * Dr. Bond was executive officer of the Institute from 1989 to June 1994.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 To ensure a continuing body of recognized integrity, responsibility of purpose, and breadth of competence for advice to the Government and the public on questions affecting health. Dr. Irvine Page is given credit for stimulating the development of the Institute of Medicine. In 1964 he wrote an article called “Needed, a National Academy of Medicine.” He believed that increasing governmental involvement in medicine and lack of communication among researchers, health care professionals, and the business community were leading to conflicting viewpoints on future directions for medicine. Page wrote: As a beginning, I propose establishment of a National Academy of Medicine, located in Washington, [that would be] truly representative of excellence in all branches of medicine, scientific and administrative, [and] large enough to fulfill the requirements of representation and to meet the protean demands of the modern world of science. . . . The institute . . . [should] be quasi-governmental, [and] carefully structured to provide [the] means of effectively using a working membership. I would envision such an organization as democratic to the point that status is not the prime objective of membership, but rather that it is used as a symbol of excellence, coupled with paying the price [for membership] by active work for an earned respect. . . . I would hope that a National Academy could provide a platform around which some harmony could develop, while concurrently providing the scaffolding for medicine to probe its intellectual, economic, and administrative future[s]. We have already spent too much time and effort either in retrospect or in living for the moment. Now is the time for prospect. Dr. Page obtained a grant from a private source, assembled a group of about 25–30 people, and held meetings to consider the wisdom of creating a national institution for medicine. Dr. Colin MacLeod, Dr. James Shannon, and Dr. Ivan Bennett were deputized by the group to visit Dr. Frederick Seitz, then president of the National Academy of Sciences (NAS), to propose that the NAS consider establishment of a National Academy of Medicine, just as the National Academy of Engineering had been set up in 1964. Dr. Seitz, who was trying to change his own institution, was receptive to the idea that something should be done and proposed the establishment of a Board on Medicine, which was the highest organizational level in the Academy structure. In 1967, the formation of the Board on Medicine was authorized by the NAS Council, with a mandate to explore the issues and problems presented by the further evolution of medical education, medical sciences, and health services in the context of rapidly changing social, economic, and scientific settings. The Board was to study, analyze, and evaluate these issues and problems as a basis for developing a body of findings and recommendations that could contribute to their resolution, provide guidance for public policy and

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 action, and further the development of medicine and its institutions, broadly conceived. Dr. Walsh McDermott was appointed the first chairman of the Board on Medicine. Joseph Murtaugh served as its executive secretary. The ideas and procedures first introduced in the Board of Medicine continue to shape the IOM today. Dr. Seitz convened a small group of people, only a few of them NAS members, to advise him on the formation and composition of the Board. Members of the group included Dr. Irvine Page, Dr. Colin MacLeod, Dr. James Shannon, Dr. Ivan Bennett, Dr. Robert Glaser, Dr. Eugene Stead, Dr. Irving London, and Mr. Kermit Gordon. The Board was considered an end unto itself, not just an organizing body or an Academy of Medicine. Most importantly, because the Board needed to be accepted as being objective and free from the influence of special interests, it was to be composed of people representing all of the health professions, as well as knowledgeable persons in related areas such as economics, law, and political science (see Box 1). Singled out for initial examination were the complex issues surrounding the further development of medical education; the improvement of health services, particularly the health status of the urban and rural poor; and the establishment of a National Academy of Medicine. Box 1. Members of the Board on Medicine, June 1969 Walsh McDermott, M.D., Chairman Ivan L. Bennett, Jr., M.D. Charles G. Child III, M.D. Julius H. Comroe, Jr., M.D. John T. Dunlop, Ph.D. Rashi Fein, Ph.D. Robert J. Glaser, M.D. Lucile P. Leone, M.A. Irving M. London, M.D. Colin M. MacLeod, M.D. Samuel M. Nabrit, Ph.D. Irvine H. Page, M.D. Henry W. Riecken, Ph.D. Walter A. Rosenblith, Ing.Rad. Eugene A. Stead, Jr., M.D. Dwight L. Wilbur, M.D. Bryan Williams, M.D. Adam Yarmolinsky, LL.B. Alonzo S. Yerby, M.D. Joseph S. Murtaugh To address the establishment of an Academy of Medicine, an Ad Hoc Panel on Further Institutional Forms chaired by Irving London was set up to develop a plan. The panel recommended “that the Board on Medicine take the steps necessary to secure the creation, under the Charter of the National Academy of Sciences, of an autonomous National Academy of Medicine.” The

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 panel believed “that there was a need for an institutional framework in medicine in which distinguished thoughtful and concerned individuals from medicine and other fields could work effectively on the solutions of problems confronting medicine and could exert a constructive influence on public and private action in these areas.” In a nutshell, as crisply laid out by Walsh McDermott, the institution would speak about medicine, not for medicine. Although all Board members were solidly for the nature of the institution as outlined (but there were some questions about the wisdom of using the word “academy”), some division of views existed on the specific direction for the organization. Drs. Shannon, Comroe, and Page wanted the primary function to be defense of the role of science in medicine, while others believed the broader social concerns of medicine and health should guide the institution's work. This dichotomy of views resurfaced later in tensions with the NAS. Most agreed that science and policy needed to be closely linked, and that an organization that addressed only one dimension was not able to carry out the vision as articulated by Walsh McDermott. Unfortunately, the NAS Council turned down the proposal at its June 1969 meeting. When this news was relayed to the Board, Dr. McDermott reports, “I could describe what occurred as a violent eruption. They were simply wild, even those who had been less enthusiastic than others about certain parts [of the plan].” Nevertheless, recognizing that there was value in being part of the tradition and heritage of the NAS and that if a free-standing academy outside the NAS were set up, links to science would be lost, a middle ground was sought. Dr. Philip Handler, the new president of the NAS, set up a committee (of which Dr. McDermott was a member) chaired by Franklin Long to look at the whole question of reorganizing the National Research Council (NRC). The Long committee's report included a minor recommendation that drew little attention at the time, that one of the instruments that might be created in reorganizing the NRC to deal with medical issues was something called an “institute. ” This time the NAS Council approved the establishment of such a body, subject to the development of acceptable bylaws and a charter. At an August 24, 1970, meeting, Dr. London, Dr. McDermott, and Mr. Yarmolinsky submitted the institute's bylaws and charter prepared by Mr. Yarmolinsky to the NAS Council. On June 10, 1970, Dr. Handler announced that NAS would create an “institute on medicine” to address the larger problems of medicine and health care, using the Board on Medicine as the nucleus of the new organization. On December 17, 1970, the Institute was activated, and the Board on Medicine went out of existence. In a letter recollecting the early years of IOM, Dr. Hogness, the first president of the IOM, pointed out that the “Institute of Medicine was created [in] a somewhat hostile environment that existed between the National Academy of Sciences and the National Academy of Engineering [NAE] relating to disa-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 greements over membership and program [and the harmonization of science and technology under one roof]. One of the major reasons that the Institute of Medicine was not called an Academy of Medicine was because of this unresolved conflict between the two other academies and the unwillingness of Phil Handler and other members of the Academy of Sciences to take on another unknown entity called an academy.” As Dr. Donald Fredrickson, the second president of the IOM recalled, the factors that led to his recruitment included an uneasy accommodation of the NAS to the IOM. It [IOM] wished to run some studies with its own staff, contrary to the new thrust for all programs to be overseen by the NRC Governing Board. The failure of the IOM to submit its studies to the supervision of the Board was considered a serious threat to the “symmetry” of the newly-constructed Academy structure. This also meant that the NAS Council must go through the arithmetic again of apportioning representation of another partner to the Board [of the NRC]. The outcome had to appeal to the sensitivities of all the groups at interest, while assuring retention of an executive majority by the NAS. To add to the potential for conflict, an Assembly of Life Sciences was chartered in 1973–74 to oversee the NRC action in the biological sciences—including the fractious, quasi-independent Division of Medical Sciences. The sentiment of the NAS leadership was thoroughly dis-inclined to hand over to the IOM the sciences most relevant to its work, and there was a general feeling that the Institute ought to be content with a residual, collectively called “health.” Despite this stormy beginning, the first 5 years of IOM saw the basic framework of its later potential, both organizational and programmatic, carefully crafted on the vision of the Board on Medicine. A membership and staff were built, reasonable operating procedures were devised, its place in the Academy began to be worked out, credibility in the health community and the government were established, and its first activities got under way. The Charter of the Institute of Medicine, adopted in August 24, 1970, stated the purpose of the Institute in the following terms: The growth of knowledge in the health sciences has greatly expanded the capabilities of medicine. Rising expectations of better health and of improved quality of life for all members of our society now include good health care as a universal human right and a goal of this society. The provision of such care places increasingly heavy demands on health services and their complex relations with other sectors of society. The resulting expansion of requirements for health manpower and the continuing need to provide for further scientific progress present grave challenges to our medical and social institutions. These developments have generated the need for a national institution, composed of

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 individuals of distinction and achievement, committed to the advancement of the health sciences and education and to the improvement of health care. The membership was to consist of persons selected from fields in health and medicine and from other fields such as social and behavioral sciences, law, administration, government service, and engineering. The charter stipulated that no more than three-quarters of the members could be drawn from health and medicine. Members had to be willing to be active participants in the Institute's work. The members of the Board on Medicine became the charter members of the IOM (see Box 2). They then elected the first class of new members in 1971—about 100 people. Key Individuals During 1970–1975 As noted above, there were a number of people associated with the creation of the IOM (see the list of members of the Board on Medicine), with Dr. McDermott and Dr. Page as key leaders among them. Dr. Robert Glaser was acting president of IOM until Dr. John Hogness, the founding president of IOM, could arrive in 1971. Dr. Hogness left in the spring of 1974 to become the president of the University of Washington. He was succeeded by Dr. Donald Fredrickson, who departed in June 1975 to assume the directorship of the National Institutes of Health. Dr. Roger Bulger was the first IOM executive officer. Members of the first IOM Council included William O. Baker, Clifton Dummett, Loretta Ford, Julius Richmond, Lewis Thomas, Adam Yarmolinsky, Donald Fredrickson, John Hogness (who was its chairman), Robert Glaser, David Hamburg, and Rozella Schlotfeldt. Staff members identified in the 1972–1973 annual report included Martha Blaxall, Lou Cranford, Jean George, John Ingle, Paul Rettig, Gloria Ruby, Laurence Trancredi, and Wallace Waterfall. Scholars and fellows in residence included Clark Havighurst, Robert Ball, Robert Marston, and Don Detmer. Karl Yordy, a central source of institutional memory, leadership, and knowledge for the IOM, arrived as a senior program officer and staff to the program committee charged with developing the initial IOM program. Karl later became executive officer of IOM and served in many different capacities. Jana Surdi was one of the early staff members who remains to this day (as does Lou Cranford). Ruth Hanft came on board to run the first, and to this day the largest, study at IOM—on Medicare–Medicaid Reimbursement Policies, published in 1975. The 29 charter members of IOM included 20 members of the Board on Medicine and 9 others who were invited to join. Walsh McDermott functioned as the first IOM foreign secretary, succeeded by Ivan Bennett in July of 1975.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Box 2. Charter Members of the Institute of Medicine Paul B. Beeson, M.D. Ivan L. Bennett, Jr., M.D.* Charles G. Child III, M.D. Julius H. Comroe, Jr., M.D.* Jerome W. Conn, M.D.* Rashi Fein, Ph.D. Robert J. Glaser, M.D. Robert A. Good, M.D., Ph.D. Leon O. Jacobson, M.D. Henry G. Kunkel, M.D.* Lucile P. Leone, M.A. Irving M. London, M.D. Colin M. MacLeod, M.D.* Maclyn McCarty, M.D. Walsh McDermott, M.D.* Carl V. Moore, M.D.* Samuel M. Nabrit, Ph.D. Irvine H. Page, M.D.* Henry W. Riecken, Ph.D. Walter A. Rosenblith, Ing.Rad. Ernest W. Saward, M.D.* James A. Shannon, M.D., Ph.D.* Thomas H. Weller, M.D. Dwight L. Wilbur, M.D. Bryan Williams, M.D. W. Barry Wood, Jr., M.D.* Adam Yarmolinsky, LL.B. Alonzo S. Yerby, M.D.* * Deceased as of September 15, 1995. Program Efforts During 1970–1975 The IOM program built on the work of the Board on Medicine, which had produced a white paper laying down principles to guide cardiac transplantation, conducted a study on biomedical education for the future, and appointed a panel to work on a study of contrasts in health status to better understand the breakdown of health services in rural and urban areas. The Institute's early program was directed toward the following six areas: policies affecting biomedical research; education in the health professions, and the distribution of personnel among fields and specialties; definition and measurement of health care quality; organization and financing of health care; social and behavioral influences on health, and minimum requirements of a program designed to prevent disease and disability; and ethical and legal aspects of medicine and health care. Among the programmatic activities and reports issued in the first 5 years were the following:

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 National Cancer Program Plan (1972)—A special Institute committee undertook a review of the 5-year plan for a “targeted” program of research against cancer. Requested by the National Cancer Institute, this report was delivered in December 1972 with the understanding that it would be made public after the final draft of the National Cancer Program was presented to the president and Congress. Months passed, during which changes were made to the cancer plan that obviated some of IOM's criticisms of it. Senator Gaylord Nelson finally entered the entire IOM report-in the Congressional Record of April 18, 1973. The report, which then received widespread attention, warned that cancer research had not accumulated enough knowledge to be turned into a moon-shot program, and that the mainstay of a “war on cancer” would have to be basic biomedical research. Conference on Education (1972)—More than 120 educators in medicine, dentistry, nursing, and allied health fields met to explore curricular collaboration toward preparing students to function as members of a health care “team.” Contrasts in Health Status (1972)—This large-scale study was initiated to determine the differences in health status of distinct population groups and, insofar as possible, to relate these differences to medical care and social, biological, and behavioral characteristics. It provided methods that proved useful in further research to develop standards of health care quality. It formed the basis for a policy statement by the IOM Council in 1974. Costs of Education in the Health Professions (1974)—Congress mandated this study after it had introduced capitation grants as a new method of federal aid to education in the health professions. Most of the eight professions studied cited this report as a public policy justification for maintaining direct federal payments to schools on the basis of their enrollments. Disease by Disease Toward National Health Insurance (1973)—This report examined the consequences of federal payments for the treatment of particular catastrophic diseases after federal funding of treatment for end-stage renal disease went into effect. The panel concluded that coverage of discrete categories of catastrophic disease would be an inappropriate course to follow for the foreseeable future. Legalized Abortion and the Public Health (1975)—This study concluded that easing of restrictions on abortion would lead to fewer deaths and complications from the procedure and suggested that laws, medical practices, and educational programs should enable and encourage women who have chosen abortion to obtain it in the first 3 months of pregnancy. In 1973 a health policy fellowships program was established by the IOM with a 3-year grant of $710,000 from the Robert Wood Johnson Foundation. The first class of six fellows included David Banta, Johnnie Gallemore, Fre-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 derick Glaser, David Sanchez, Robert Schlegel, and Arthur Viseltear. The program continues to this day as the longest continuously running activity at the Institute. By 1975, a new emphasis on program development led to the establishment of processes for enunciating longer-range goals in the various categories of program activities. An annual program plan was begun in 1972, and the IOM Council and the NRC Governing Board generally were satisfied that the Institute's program reached into most major segments of national health policy. Less satisfying, however, was the program 's piecemeal growth. The IOM Program Committee and staff undertook a methodical assessment of options for changes in the U.S. health care system and issues that the Institute should explore to improve public understanding of these options. International health affairs also began to receive greater attention at this time, and relationships were developed with the National Council for International Health, the NRC Board on Science and Technology for International Development, and the Royal Society of Medicine. The NRC Governing Board replaced the NAS Council as the locus of review of all programs in the Academy, including all Institute projects. Membership of the Governing Board changed to consist of seven representatives from the NAS, four from the National Academy of Engineering, and two from the IOM. Finances During these early years the IOM budget grew from approximately $200,000 in 1971 to $2,541,067 in 1975. Support from private foundations was absolutely essential to the Institute's development. The Robert Wood Johnson Foundation, the Commonwealth Fund, the W. K. Kellogg Foundation, the Andrew W. Mellon Foundation, and the Richard King Mellon Foundation were among those providing substantial support. The goal was to achieve an approximately equal tripartite funding stream: one-third from the government; one-third from foundations; and one-third from industry. There was an explicit objective to have funds available to support the evolution of projects initiated by IOM members rather than have the Institute solely respond to government needs. This guiding philosophy would reach fruition only with the endowment secured during the presidency of Sam Thier. THE SECOND FIVE YEARS: 1975–1980 By the second 5 years of its existence the IOM was well positioned to carry out its fundamental mission to improve the health of the public. As iden-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 tified by Dr. David Hamburg in his recollections concerning the institution on its 20th anniversary in 1990, the assets included the following: the distinction, diversity, and breadth of its members; its position in the NAS, allowing it to share the Academy's long and distinguished tradition; independence from, yet close contact with, the federal government; the commitment of the members to work in IOM activities; the broad mandate of the IOM's charter and early history encompassing the whole range of interests pertinent to the health of the public—rather than simple recognition of individual accomplishment or preoccupation with any particular profession or science; and a dedicated, competent staff experienced in health policy analysis and governmental processes as well as the health sciences. By 1980 the membership numbered 374, approaching the maximum of 400 stipulated in the original charter. Membership committees had worked diligently to ensure the diversity required to recruit and identify a membership that could contribute to the Institute's work. The charter had stipulated that more than one-quarter of the membership be elected from professions other than health and medicine, and by 1980, more than one-quarter of IOM members came from law, economics, engineering, and basic sciences. With the arrival of a new president, David Hamburg, there was a careful examination made of the Institute's mission and activities in the study of health policy. The membership increasingly expressed the concern that a steady preoccupation with large-contract studies would detract from IOM's ability to initiate policy investigations, to direct its efforts toward perceived needs, and to assess the long-range prospects for the nation's health enterprise. To respond to such concerns, in 1977, IOM's program activities were organized around six program divisions, which allowed the Institute to recruit advisory committees for each program area to provide advice on potential activities beyond those the government requested. This ability to think in the long term and to initiate studies was unique within the Academy complex and resulted from the expression of the philosophical perspective of the membership, but was enabled by the critical support provided by the private sector. The Institute received more private-sector support through this period than any other part of the Academy complex. Prior to the formation of the divisions, there was essentially no organizational structure for the Institute's activities except for the ongoing projects themselves. Dr. Hamburg's vision was that “the divisional structure [would] provide for continuity of program, expertise, delegation of administrative opportunities for membership participation and an improved mechanism for internal and external communication about IOM program activities.”

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 The Program Committee's responsibility changed from detailed review of each proposed project to concern with the program's comprehensiveness, continuity, and change. A survey of members was carried out during this time to help identify program interests (more than 100 were noted) to be considered by the IOM. Four basic methods were used to examine an issue: (1) background papers were solicited or commissioned to organize and review the available information on a subject; (2) conferences were held to elicit new data and concepts relevant to policy considerations; (3) policy statements were written by expert committees after an examination of alternative courses of action on an issue; and (4) major studies were conducted that researched and analyzed health policy matters of national concern. These approaches added flexibility and extended the Institute's study capability. Offices for IOM program staff were rented in the Watergate office building on the sixth floor—the same offices that were the scene of the Watergate break-in during the Nixon presidency. The Institute's ability to anticipate problems in the health field and negotiate for studies that would have optimal significance for policymakers depended upon having a stable base of core funding. Therefore, efforts were put in place to assess fund-raising prospects, and a Special Resources Committee was established to advise the president on development matters. New attention was given to dissemination of the IOM's work to ensure its impact so that study reports and publications would reach the audiences that could implement their findings. The first derivative paper from a study (on sleeping pill prescribing practices) was published in the New England Journal of Medicine. Key Individuals During 1975–1980 David Hamburg was installed as IOM's third president in November 1975. At the start of the 1976 program year, Roger Bulger, IOM's first executive officer, resigned to become chancellor of the Medical Center and dean of the School of Medicine of the University of Massachusetts. He was succeeded by Karl Yordy. Stanley Jones joined the staff in 1977 and served as program development officer, with Richard Seggel functioning as program operations officer. During these years the divisions developed gradually. The first division directors deserve mention because they were instrumental in the “terrain mapping” exercise that defined the span of interest of IOM program efforts. These included Elena Nightingale, Division of Health Promotion and Disease Prevention (HPDP); Linda Demlo, Division of Health Care Services (HCS); David Tilson, Division of International Health (IH); Richard Scheffler, Division of Health Manpower and Resources Development (HMRD); Michael

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 knowledged that if IOM did not exist, a similar organization would need to be invented. Recognizing that an overlap with CLS's program would continue despite IOM's stable financial base, Thier requested that the NAS revisit the overlap after his arrival. Historically underfunded and unendowed, the Institute began in calendar year 1986 to plan a course toward financial independence for its central function, including program development, governance, and project cost-sharing when necessary. By the end of 1987, core funds amounted to $19.7 million, of which $15.8 was endowment. This first phase of the Institute's campaign began with a solicitation of funds from philanthropic foundations, many of which had been longtime supporters. The campaign was enlarged during the year to include pharmaceutical firms and hospital systems and other components of the health industry. By 1990 the endowment approached $20 million. Increased financial stability contributed to an appreciable increase in project activity as staff had more time to develop program initiatives. Administrative functions were centralized to increase efficiency and decrease costs. The roles of the IOM Council and the Program Committee were reexamined. The mission and charter were reviewed and reaffirmed—IOM was committed to the advancement of the health sciences and education and to the improvement of health care. Program objectives were set to assess health care with respect to quality, access, and needs; foster research and manpower to meet the health needs of society; and exploit new and existing knowledge for the health of society. The IOM Council was restructured, and its schedule of meetings and its agenda were altered to allow the 21 members to concentrate more on policy, not on details. Working committees were formed to consider program, finance, development, and dissemination. Board chairs were added to the Program Committee to link together the program direction capability of the organization. True to his word, Frank Press convened another committee chaired by James Ebert, the vice-president of the NAS, to once more examine the overlap of CLS's and IOM's programs. This time the missions of the two units were further refined, and in 1988 the Food and Nutrition Board (FNB) and the Medical Follow-Up Agency (MFUA) were transferred from CLS to the IOM, adding about $3.5 million in program dollars and about 40 staff members. Increased numbers of studies and similar activities afforded increased opportunities for involvement of IOM members; about 46 percent of the membership ended up working in some capacity on an IOM project. By 1990, there were 462 active members and 397 senior members. A new membership category was added in these years—foreign associates. Growing appreciation of the value of international cooperation in resolving health problems led to the

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 appointment in 1990 of James Wyngaarden as IOM foreign secretary, a post that had not been filled for a number of years. In addition to its studies of 1- to 3-years' duration, the Institute developed other ways of working. Several short-term studies of approximately 6 months' duration were conducted. Continuing forums on drug development, AIDS research, and the future of children and families were under way, and IOM's convening function was used in many ways to advance discourse on and to examine issues relating to health. The many new activities meant the Institute needed more space, and the IOM program staff moved to a larger facility. During this era the IOM began to be a fully functioning partner within the Academy complex, with the president participating actively in governance and development activities of the entire complex and in promoting engagement by the entire complex on self-initiated issues such as the AIDS epidemic and misconduct in science. Key Individuals During 1985–1990 Sam Thier was inaugurated as the fifth president of the IOM in October 1985, departing in 1991 to become the president of Brandeis University. Charles Miller retired as executive officer at the end of 1988, to be replaced by Enriqueta Bond at the beginning of 1989. The division directors during this era included Ruth Bulger in HSP, Gary Ellis in HPDP, Herman Diesenhaus in Biobehavioral Sciences and Mental Disorders (the newly renamed MHBM), Karl Yordy in HCS, Catherine Woteki in FNB, William Page in MFUA, Polly Harrison in IH, and Marion Ein Lewin in the fellowships office. Robin Weiss led the AIDS activities (which had been given programmatic status to emphasize their priority), Lou Cranford continued to lead the administrative functions, and Wallace Waterfall directed the Office of Communications. The program committee was now chaired by the president; Floyd Denny chaired HPDP; Jack Barchas, BSMD; Walter McNerney, HCS; Claude Bennett replaced Al Fishman in HSP; William Foege chaired IH; Richard Havel, FNB; Richard Remington, MFUA; Edward Brandt, the RWJ Health Policy Fellowships Board; and Robert Lawrence, the Committee on Health and Human Rights. Program Efforts During 1985–1990 By 1990, although still growing in number and total expenditures, the IOM program activities began to show signs of steadying after several years of breakneck expansion. The Institute's portfolio could be classified in several different ways. Six cross-cutting themes were used to describe programmatic

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 emphases in addition to the organizational structure of the divisions. These included quality, access, organization, and financing of preventive and clinical services; role, education, and supply of health professionals; research opportunities and resources; development and application of appropriate technologies for health; critical issues in the health of special populations; and information needs, sources, and uses. The program continued to evolve and change. For example, the Council on Health Care Technology was phased out in 1990 and transformed into a Committee on Clinical Evaluation. Many collaborations with other units in the NRC were established to conduct work jointly. New mechanisms were invented to address issues in more timely and less costly ways. Programmatic efforts by IOM began to have enormous impact over these 5 years. The October 1985 annual meeting was devoted to the subject of AIDS. The information presented at that meeting was summarized in a nontechnical volume Mobilizing Against AIDS: The Unfinished Story of a Virus. That annual meeting was not intended to develop recommendations about the best course of action for dealing with the problems it surveyed, but the IOM realized that recommendations were needed and that, to develop them, national leadership was essential. As a result, in early 1986, the presidents of the NAS and IOM, with the approval of their councils, decided to initiate a special effort to assess the extent of the problems arising from AIDS and to propose a national response. A major study was mounted using internal funds, and by the end of the year the report Confronting AIDS: Directions for Public Health, Health Care, and Research had been issued. The New York Times described the report as having “provided a benchmark by which many members of Congress and analysts judged the effectiveness of the Nation's effort to combat AIDS.” The magnitude of federal budget increases during this time was credited as reflecting the findings in this and its successor report, Confronting AIDS: Update 1988. The report's immediate impact reaffirmed the value of IOM as an organization and its mission. Other reports also had a significant impact. Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders guided the NIMH program. Prenatal Care: Reaching Mothers, ReachingInfants, built on preventing low birthweight, made a case for reaching mothers who do not receive adequate prenatal care. Improving the Quality of Care inNursing Homes was translated into law almost immediately after its release. The Future of Public Health, released in 1988, documented the disarray that public health had fallen into and the steps to be taken toward revitalizing the

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 system to meet the new challenges. The Future of Public Health has become the new rationale for public health in the future. Academic Geriatrics for theYear 2000 guided legislation and private-sector support for building a cadre of geriatrics teachers to serve the aging population. A report on the intramural program at NIH followed up the examination of the extramural program conducted in 1984. This report was revisited on the arrival of (IOM member) Harold Varmus as director of the National Institutes of Health in 1993. Varmus commented that, had the IOM recommendations been followed, there would not have been a need for a new study. The impact of the overall program began to be systematically evaluated with surveys to document the value of IOM's work and to improve programmatic efforts. Division boards were setting priorities and reviewing their activities with the Program Committee to fill gaps and identify new directions. Finances As noted above, this 5-year period was notable for the remarkable development of a nearly $20 million endowment. A matching challenge from the W. K. Kellogg Foundation to both the IOM and the NAS provided $4 million with no stipulation for matching and then agreed to match up to $16 million, dollar for dollar. Income from the challenge grant could go to self-initiated programs in agriculture, education, or health. By 1990, good progress was being made toward raising the matching dollars. The IOM program was in excess of $13 million. Members were beginning to worry that perhaps we were doing too much rather than too little. THE PRESENT: 1990–1995† During 1990–1995, the IOM entered into a period of considerable stability in program level and efforts. Membership continued to grow slowly. In 1990 the charter was changed to permit election of up to 600 members, and by 1993 there were 479 regular members, 510 senior members, and 33 foreign associates. A new discovery process designed to increase the diversity and excellence of the membership was implemented in 1993. In 1990 the IOM celebrated its 20th anniversary and its history of “making a difference in the nation's health.” There was general agreement by those attending the 1990 annual meeting that the organization had realized the promise envisioned by its founders. As stated by IOM President Sam Thier in his comments on the eve of the anniversary: † This section has been updated by IOM's current executive officer, Karen Hein.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 It may seem unimaginative to expect the next 20 years of IOM activities to resemble strongly those of the past two decades. But, although the specifics may change, the nature of the problems will persist. Of course, the context into which they fit will broaden as health is viewed from a more international perspective with population growth and environmental change as leading concerns. Infectious diseases were on the wane with better hygiene, vaccines, and antibiotics. Then came AIDS [HIV] to remind us that we must still contend with new and old microbes. Child survival could be enhanced now with preventive strategies such as better nutrition and immunization, but we are probably years from an internationally concerted effort. Populations everywhere are aging, but how to address aging still confounds us. It is realistic to believe that within the next two decades all Americans will be insured for at least basic health care, but who will deliver what care and how technology, quality, and practice will be evaluated will continue to challenge us. Research will still undergird sensible policy, but even a broad acceptance of that concept will not ensure the provision of stable support for research and training. In all these matters, we can only be certain that the IOM will continue its efforts and improve its capacity to find the answers. In 1991, Sam Thier departed to become president of Brandeis University. Dr. Stuart Bondurant, a member of the IOM Council, was appointed to serve as acting president while a search committee was established jointly by IOM and NAS. Kenneth Shine, dean of the UCLA School of Medicine, was appointed president-designate of IOM in January 1992 and assumed his full-time duties in July 1992. By 1994, IOM's activities were organized in eight program units—seven divisions and one program initiative. Given the growth in the program of the Medical Follow-Up Agency and the hiring of a permanent director, Richard Miller, Dr. Shine requested council approval for transforming this program into a division. On other fronts, the base of support and sources of requests for IOM projects continued to broaden; the audiences for IOM's work expanded; and the variety of ways in which program activities were conducted widened to include roundtables and forum activities, workshops, traditional studies, and more narrowly focused, short-term studies. With the arrival of Dr. Shine in 1992, the Institute embarked on an evaluation and planning process. The Program Committee guided this process, which was brought to fruition at a retreat. There the mission statement was revised, and goals, objectives, and strategies were laid out to guide work in the future. The IOM's mission is to advance scientific knowledge and the health and well-being of all people of this nation and the world consistent with the role conferred by its congressional authority. It accomplishes this mission by providing objective, timely,

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 and authoritative information to government, the professions, and the public through its elected membership and access to the best expertise. The arrival in 1994 of a new NAS president, Bruce Alberts, portended new opportunities and relationships with the rest of the Academy complex. His priority became the development of science and math education standards, providing a unique opportunity to focus on the next generation of scientists. A drop in the program of the Academy complex (though not in the IOM) necessitated cost-cutting across the board. Further cuts required structural changes and potentially a change in the way the complex did business. Because IOM had already pioneered a variety of approaches to its work, and in its planning process had met with its users, close work with the Academy complex fostered efficient and cost-effective ways of operating. Fortunately, the drop in program level was temporary and merely reflected a change in administration; it did, however, provide the opportunity to institute efficiencies and streamline operations. By mid-1995, the IOM program had rebounded and increased by 25 percent as compared to 1991. Hardly a major topic in human health has not been touched by the Institute over the past 25 years, and its published reports suggest the limitlessness of the domain. A current publications list has well more than 120 titles, and those only for reports of studies, the principal method employed by the IOM for a detailed examination of a problem. Nearly 100 more titles describe workshop reports, collections of scholarly papers, proceedings of symposia, and staff analyses of such concerns as the federal budget for health. In addition, our work now appears in journals such as JAMA. In an effort to improve continually the quality of IOM reports, the Program Committee continues to assess the impact of IOM reports in a systematic fashion to determine what factors may lead to more or less “successful” reports. This information is used to inform potential supporters, members, and other interested parties about the value of IOM's work and, for program management purposes, to improve the conduct of our studies and design better ones in the future. According to the responses to the three surveys that have now been completed, the activities evaluated had substantial and varied impacts, ranging from direct effects on legislation, to agency research programs, to the actions of professional societies, to changing industry labeling practices. Anticipating the 25th anniversary of the IOM in 1995, Dr. Shine established a Steering Committee to assist in planning activities to expand knowledge of IOM and its work, to celebrate the establishment of the IOM, and to use the occasion for raising additional resources. A series of regional symposias and lectures were held around the country through the summer of 1995—in Chicago, Palo Alto, Raleigh-Durham, and Seattle —with more planned for

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Ann Arbor, Boston, New York, and Washington, D.C. in the fall of 1995 and on into 1996. Key Individuals During 1990–1995 As noted above, Sam Thier, Stuart Bondurant, and Kenneth Shine all served as president during this period. In 1994, Enriqueta Bond departed to become president of the Burroughs Wellcome Fund, and Joe Cassells became interim executive officer until Karen Hein was recruited early in 1995. Wallace Waterfall retired, and the newly reorganized Reports and Information Office was managed by Mike Edington. Karl Yordy, present from nearly the beginning of IOM, became an off-site study director for the study on the future of primary care. Kathy Lohr became director of the Division of Health Care Services. Robert Cook-Deegan came to head a newly revitalized Division on Biobehavioral Sciences and Mental Disorders (BSMD), and was succeeded by Constance Pechura when he transferred to the NRC to be the staff director of a major study on priority-setting in science. The work of BSMD has been strengthened and has grown dramatically. Also during this time, Mike Stoto became the director of the Division of Health Promotion and Disease Prevention when Gary Ellis departed for NIH. In Health Sciences Policy, Valerie Setlow replaced Ruth Bulger, who left to become vice-president for scientific affairs at the Henry Jackson Foundation. Chris Howson became the director of the Board on International Health when Polly Harrison asked to become study director of a new activity on contraceptive development. When Cathy Woteki left for the Office of Science and Technology Policy, Allison Yates came to head the Food and Nutrition Board. Richard Miller now directs the Medical Follow-Up Agency. Changes in board chairs also took place. Claire Fagin chaired HPDP; Don Detmer, HCS; Joe Coyle and Ellen Frank, BSMD; Janet King took over FNB from M. R. C. Greenwood; Jack Stobo replaced Claude Bennett at HSP; Norman Breslow chaired MFUA; and Ed Brandt and William Foege remained in place as chairs of the fellowships program and IH, respectively. Senior scholars continued to spend time at IOM. For example, Connie Curran, Henry Foster, and Neal Vanselow were scholars in 1994. With the retirement of James Wyngaarden as foreign secretary of the NAS and IOM in 1994, David Rall became the IOM foreign secretary. Program Efforts The election of President Bill Clinton, and the subsequent introduction of the Health Security Act, created a strong mandate for major health care re-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 form. To inform the dialogue surrounding policy options, IOM initiated a series of colloquia on issues such as basic benefit packages, the roles of states, measurement of quality, and mental health services. Assessing Health Care Reform laid attributes for measuring good health care reform efforts. In its review of the mission and development of a strategic plan to guide IOM's work, the IOM Council and the Program Committee recommended in 1994 that the IOM also establish a special initiative on quality of care in this era of transition in the health care system. A white paper, “America's Health in Transition: Protecting and Improving Quality, ” was released by the IOM Council, and a series of other program activities on quality was planned to span all the divisions. Several short-term studies demonstrated the ability of IOM to complete projects to meet policy deadlines. These included the report Strategies forManaging the Breast Cancer Research Program (1993), which laid out programmatic investment strategies and peer-review mechanisms through which allocation decisions for the $210 million granted to the U.S. Army Medical Research and Development Command could be made; a report on RU 486 and other antiprogestins to guide research on this compound and advance its consideration by the Food and Drug Administration; a 1995 review of the fialuridine clinical trials at NIH in which five people died; and an evaluation of the NIH Women's Health Initiative. The ability to complete studies on time and on budget has made IOM a reliable and sought-after source of advice. Progress toward a healthier America will depend substantially on improvements for certain populations that are at especially high risk. For that reason, some segments of the population have been singled out by the IOM for particular attention because the higher mortality and morbidity experienced by these groups may require alternative strategies to solve specific problems. These population groups include mothers and infants, the elderly, women, the disabled, and underserved minorities. Among the studies released were The Best Intentions: Unintended Pregnancy and the Well-Being of Children andFamilies (1995), which explored the issues surrounding the approximately 57% of pregnancies that are unintended each year in the United States; and HIV and the Blood Supply: An Analysis of Crisis Decisionmaking, also released in 1995, which took an in-depth look at the contamination of the U.S. blood supply during the early 1980s that left about 8,000 hemophiliacs and 12,000 blood transfusion patients infected with HIV. Other studies focused on immunization practices and control of sexually transmitted diseases. To recognize and emphasize these population groups, a new board, the Board on Children and Families, jointly administered by the IOM and the Commission on Behavioral and Social Sciences and Education of the NRC, was established to build on the past work of these two units and create a locus where health, education, and welfare issues affecting children and families could be considered together. Sheldon White chairs the Board and Deborah

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Phillips is its director. In addition to singling out subpopulations for attention, several health care problems such as AIDS, alcohol and substance abuse, and health care of the poor are very much a part of the program currently under way at IOM. For example, Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths, released in 1994, examined and made recommendations on further research needed on the biology of addiction, the social and behavioral factors in the initiation of smoking behaviors and the addiction process, and prevention strategies that are developed specifically for children and adolescents. The report was cited by David Kessler, director of the Food and Drug Administration, when he proposed regulations aimed at reducing smoking among children and youths. Ultimately, the provision of high-quality, appropriate health care depends on the availability of an adequate number of well-trained professionals of the types appropriate to a reformed system. Dental Education at the Crossroads: Challenges and Change (1995) identified measures for strengthening dental education in response to challenges posed by changes in health status, demographic trends, scientific and technical developments, and shifts in federal and state funding and university priorities. There is a growing consensus that an imbalance exists between primary care and specialized care and that more primary care practitioners, nurses, and physician assistants are needed (as had been pointed out in the 1978 IOM report, A Manpower Policy for PrimaryHealth Care, which is now being revisited in a new study on primary care as well as in the Roundtable on Academic Health Centers in an Era of Health Care Reform). High-quality care also depends on having an adequate research base properly translated to clinical practice. An unprecedented array of research opportunities, which outstrips the resources available, continues to emerge. The environment and resources required for research have been and continue to be integral to a number of studies and activities that will generate research agendas and commentary on training needs and the financial investments needed to realize the promise of science. For example, a major study on research opportunities in the nutrition and food sciences was released at a symposium in December 1993. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (1994) assisted the NIMH and other agencies in developing a strategic plan for research to promote mental health and prevent disorders. Heightened concern for the environment, the globalization of the world's economy, and transborder movements of disease will all require new international arrangements and cooperation amidst competition. Over the years, adequate resources to sustain a program in international health have not been easy to secure, limiting the IOM's ability to mount the program needed to address international concerns. The government locus for international health issues is once more in flux, so IOM has mainstreamed the IH program throughout the divisions while keeping a strong Board in place to continue program develop-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 ment. At the same time, a formal relationship with the Mexican National Academy of Medicine has been established to facilitate joint studies and convening activities. A first effort on the North American Free-Trade Agreement provided an opportunity for issues concerning the Mexican, Canadian, and U.S. health care systems to be discussed. This activity was so successful that the program will become a model for further activities with other countries. The Institute also has fostered joint study capabilities in the Middle East under the umbrella of the relevant scientific academies in the region. Finances The IOM endowment has grown to over $21 million and is a crucial resource to support core activities and new program initiatives. Additional endowment is required to support future program efforts, especially issues that are not of interest to government in the short term. A new goal for the program endowment will be set in conjunction with the 25th anniversary activities. The NAS/IOM Kellogg Matching Endowment Campaign was successfully completed on March 31, 1993. Contributions by IOM members to the campaign totaled approximately $290,400, with 53 percent of the membership participating. The Presidents' Circle of the NAS and IOM, a group of influential players drawn predominately from the private sector, has been established, and an IOM committee was appointed to assist in resource development on special projects and to advise Dr. Shine on the Institute's agenda. Overall, President's Circle members serve as advocates for the Academy and Institute, promulgating a better understanding of these organizations and how their work benefits the nation. The IOM program ranges from $12 million to $16 million each year and continues to grow at a slow pace.

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