To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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3 The Hamburg Era
3 The Hamburg Era
Pages 95-133
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From page 95... ...
It also clemonstrated the dramatic results of David Hamburg's management. Hamburg, who had taken over from Donald Fredrickson in the fall of 1975, provided the TOM with five years of inspirational leadership.
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From page 96... ...
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 Handier objected to being given only one name to consider.
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From page 97... ...
He had more than 93 scientific papers to his credit. The appointment of Hamburg continued the lOM 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 TOM members who attended the annual meeting.
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From page 98... ...
With Hanft went the large data-gathering studies. As David Hamburg took hold of the TOM, another such study reached `;omp~e~on.
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From page 99... ...
For example, the group recommended that "under the cost payment regulations issued under Section IS, 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 fulltime physicians in the area or the VA EVeterans 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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From page 100... ...
When David Hamburg learned about this situation, it made him think more about how to engage members in the work of the TOM. 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.
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From page 101... ...
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 TOM and presented his results in the form of a staff seminar that took place on March 19, 1976.~° After he told the staff some of what people had said to him about the TOM, he led a structured discussion designed to expose problems and suggest possible solutions.
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From page 102... ...
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.
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From page 103... ...
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 TOM grappled with this issue, Rice cautioned that Hamburg would have to consider the important issue of staff morale.
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From page 104... ...
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 TOM Council members held a long and unstructured discussion of TOM priorities, deciding that the TOM should devote more of its time to "short-term, quick-response kinds of activities" that allowed the organization to react to public policy developments.~5 Hamburg seemed to affirm this point at a meeting of the Program Committee that took place a week later.
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From page 105... ...
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.~9
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From page 106... ...
As Cecil Sheps, a public health specialist from the University of North Carolina, put it, every proposal had some value, but the "maps" would guide the committee in choosing among the proposals. David Hamburg himself chaired the group in charge of writing the terrain maps in health science policy and in prevention.
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From page 107... ...
Not only would members be able to serve on the Program Committee, they also would be able to serve on or make suggestions for an advisory board in their particular specialty area. Second, the new structure simultaneously expanded the role of the staff, because staff would have to guide the advisory boards and help in the creation of terrain maps.
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From page 108... ...
All medical schools should direct, or have an affiliation with, at least one primary care residency program. When medical schools admitted students, they should favor those who wanted to go into primary care fields, and all medical schools should provide undergraduates with clinical experience in a primary care setting as well as training in epidemiology and other aspects of the behavioral and social sciences that were relevant to patient care.
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From page 109... ...
Even as Hamburg presided over the dissemination of the study on quality assurance, however, he hoped that the TOM would be able to break free of this mold and initiate its own studies.26 The Malpractice Stucly and the Polio Study The medical malpractice project exemplified the sort of study that the TOM had wished to do for a long time. First discussed in the era of John Hogness, it came to fruition during the presidency of David Hamburg.
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From page 110... ...
John Hogness agreed to chair the steering committee, which met for the first time in August 1976, in part because he wanted to show his continuing interest in TOM affairs and in part because the subject was one about which he knew little and wanted to learn more. The committee contained an interesting mix of medical practitioners, such as Jeremiah Barondess, a professor of medicine at Cornell University Medical College; social scientists, such as Stanford sociologist Richard Scott and Wisconsin economist Burton Weisbrod; and legal scholars, such as Guido Calabresi of the Yale Law School (who later became its dean)
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From page 111... ...
Theodore Cooper, the Ford administration's Assistant Secretary of Health (and later, head of the TOM Program Committee) , approached David Hamburg about responding to a request from Senators Edward Kennedy and Jacob davits (R-N.Y.~: Would the TOM look into the relative merits of live (Sabin)
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From page 112... ...
It also provided the committee with an opportunity to assemble working groups on practical questions, such as how to be obtain informed consent from those who received polio shots, and on the safety and efficacy of polio vaccines in the United States. After these groups departed, the committee assembled in executive session and reached decisions on the major public policy questions.
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From page 113... ...
The study, noted Nightingale, "has aroused quite of bit of positive interest in poliomyelitis vaccination" and, she might have added, in the Institute of Medicine.32 The Embrace of the Carter Administration The computed tomography scanning project resembled the polio vaccine study. It was to be a "rapid, yet incisive appraisal of the ~ u~;~ Emu of `;umpu~er~zea tomography scanners in medical practice." The Blue Cross Association, which served as the umbrella organization for the many local Blue Cross hospital insurance plans across the country, sponsored the study because of its desire, as study director Judith Wagner delicately put it, for the "judicious use of technological innovations in medicine."33 In other words, Blue Cross hoped to put appropriate limits on an expensive procedure.
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From page 114... ...
In the Nixon and Ford eras, TOM staff eventually developed and maintained many close ties to administration officials, such as HEW Secretary Elliott Richardson and Assistant HEW Secretary Merlin DuVal. During the Ford administration, in particular, David Hamburg worked closely with Theodore Cooper, the Assistant Secretary of Health, and Guy Stever, the President's science adviser.
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From page 115... ...
In TOM Council meetings, David Hamburg reported on the latest developments in the Carter administration and encouraged TOM participation in them. He also invited administration officials to give presentations at Council meetings, a practice that Hogness had followed but that had lapsed in more recent years.
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From page 116... ...
It heard from Peter Bourne, a Carter White House staffer and former student of David Hamburg's, that health was a "pivotal concern in the administration's strategy for improving relations with other countries." Bourne said that in the President's human rights policy, "problems in food supply, health care, and shelter were likely to receive as much emphasis in dealings with other countries as civil rights."38 Congress mirrored the President's interest. Aware that the TOM was doing work in the field, members of the Senate Committee on Human Resources attached an amendment to a public health bill that provided for an TOM study "to determine opportunities, if any, for broadened Federal program activities in areas of international health."39 This study became the first formal product of the TOM Division of International Health.
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From page 117... ...
So you end up with that kind of funny mosaic of our agenda and theirs." Hamburg, Julius Richmond, Donald Fredrickson, and the heads of the various NTH and Alcohol and Drug Abuse and Mental Health Administration (ADAMHA) institutes created the mosaic that became the TOM project "Health and Behavior: A Research Agenda."4t The project consisted of a series of IOM conferences, each of which generated its own report, on specific questions in the field of health and behavior, followed by a volume that synthesized the conference results, suggested promising research leads, and integrated "available information into a perspective of the frontiers of the biobehavioral studies." As one indication of David Hamburg~s personal interest in this project, he decided to chair the steering committee, which met for the first time in November 1979.
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From page 118... ...
The idea emerged that "behavioral science has a powerful role to play in conjunction with traditional biologic research at the levels of both the individual patient and of society if we are to improve the nation's health."43 In a subsequent conference, participants tried to bring the concept of "social disadvantage" into the mix. They noted, for example, that rates of severe mental illness were higher among members of the lower social classes and argued, in the manner of social scientists from the 1960s, that "inadequate resources, low status jobs, social stigma and inadequate education interact with differential immunity, nutrition, environmental risks and coping styles to create a 'circle of disadvantage'."44 As the social scientists had learned earlier, this was tricky terrain, invoking memories of Daniel Moynihan's "tangle of pathology,' in the black ghetto.
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From page 119... ...
An elaborate undertaking, the stress study involved the use of many panels and consultants; as many as 100 scientists participated.48 On November 26, 1979, when David Hamburg greeted the members of the steering committee, headed by Car} Eisdorfer, president of Montef~ore Hospital and professor of psychiatry and neurosciences, he told them that they faced an arduous process. They had to do more than simply denounce stress as a contributor to mortality and morbidity; instead, they had to try to uncover some of the linkages between stress and ill health and to report on those areas in which more research was required.
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From page 120... ...
Although three of the TOM reviewers approved the report, two had strong reservations. They believed that the report failed to support its recommendations and complained that it was full of"tautolog~es, nebulous notions, and old research." "All of these statements are true," conceded the TOM staff members in charge, "the committee was not in a position to remake the stress field, which has been characterized by just those problems for many years." What the report tried to do was present results that "transcended those limitations" and replace "tautologies with insights, old research with new and well-designed studies, and vague ideas with hard data." The final report suggested that investigators move "beyond questions about whether stress can affect health and explore more fully the mechanisms through which stressors might produce such consequences." They should clo so even though the stress response was a "complex, interactive process."50 The process of collaborating with and advising the Carter administration extended well beyond the area of health and human behavior.
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From page 121... ...
As the project proceeded, the Carter administration began to formulate and Congress to consider a national health insurance bill. On May 25, 197S, Stan Jones, the lOM's program development officer and former Hill staffer, reported that President Carter would issue a statement of principles on health insurance in June.
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From page 122... ...
The project stemmed from Surgeon General and Assistant Secretary of Health Julius Richmond's desire to issue a report on prevention as a major theme of health policy. In February 197S, the TOM held a conference on health promotion and disease prevention, a subject that had received a great deal of attention from the Carter administration.
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From page 123... ...
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.
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From page 124... ...
Undeterred, Senator Inouye sent David Hamburg a formal letter, noting that hearings in his subcommittee "raised the possibility of linkages between stress .
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From page 125... ...
Just after Joseph Califano was Fred, 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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From page 126... ...
In 1978 the TOM 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 $106,000 check arrived from the Richard King Mellon Foundation for the "leadership and initiative functions of TOM."63 Even as David Hamburg hastened to reassure these foundations that the TOM was still worth supporting, he also courted new ones. A notable success came with the Charles H
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From page 127... ...
thanked Handier for making the report "sounder."69 Such chastisement from Philip Handier rankled, as did the criticism of TOM 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 TOM Council that the reports had run into difficulties because the TOM 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.
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From page 128... ...
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 TOM, 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 TOM Council and made a special announcement. He had been reflecting on his three years as head of the TOM.
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From page 129... ...
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.
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From page 130... ...
22. David Hamburg to IOM Staff, December 22, 1978, Yordy Files, Accession 91-051, IOM Records.
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From page 131... ...
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.
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From page 132... ...
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.
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From page 133... ...
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.
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