Creating the Institute of Medicine
In the summer of 1964, Dr. Irvine Page, who edited a journal that was widely distributed to members of the medical profession, wrote an editorial on the need for a National Academy of Medicine. With the appearance of this editorial, Irvine Page began a concerted campaign to create the National Academy of Medicine (NAM). Although he was ultimately unsuccessful in creating an entity with this name, he set in motion the forces that would lead to the creation of the Institute of Medicine (IOM) in 1970.
Between 1964 and 1970, key government officials and leaders of academic medicine agreed on the need for an organization concerned with health policy but disagreed over what form that organization should take. Irvine Page had the idea of an advocacy group that would represent the best collective wisdom of the medical profession. In his mind, such a group should be composed primarily of physicians. James Shannon, director of the National Institutes of Health (NIH), thought that the organization's primary mission should be to support scientific research in medicine. Walsh McDermott, a prominent practitioner of academic medicine with a deep interest in public health, believed that the organization should serve as a forum where physicians and other professionals concerned with health policy could work toward the solution of health-related social problems.
Although profound differences divided these three men, they concurred in the belief that the organization should do more than bestow an honor on its members. Each favored an entity composed of working members. Each also realized that the primary reason for forming a new organization lay in the changed relationship between the federal government and medicine. They understood that the federal government, the nation's primary source of funds for the conduct of medical research and the payment of medical care, could not be ignored as a factor in health policy.
The discussions in which Page, Shannon, and McDermott engaged took place in two main settings. Beginning in 1967, Irvine Page organized a series of meetings in Cleveland to discuss the formation of
a National Academy of Medicine. These gave way in November 1967 to the activities of the Board on Medicine, a group convened in Washington by the National Academy of Sciences. What emerged in 1970 was the Institute of Medicine. An institute not an academy, the new organization nonetheless reflected the ideas of all three men.
The Page Discussion Group
Between 1964 and 1967, Irvine Page had the field pretty much to himself, although he was not alone in proposing a National Academy of Medicine. In the fall of 1960, a six-person task force, which contained no fewer than four future members of the Institute of Medicine, advised President-elect Kennedy of the need to establish a National Academy of Medicine ''comparable to the National Academy of Sciences.'' President Kennedy showed little interest in this recommendation, preferring to concentrate instead on the creation of Medicare, as the expansion of Social Security to pay the hospital bills of Social Security recipients became known. When Irvine Page wrote his editorial on the need for a National Academy of Medicine in 1964, Medicare was a hotly contested issue. On September 2, 1964, within weeks of the appearance of Page's editorial, the Senate approved a version of the measure.
It was no wonder, then, that Page led his editorial by calling attention to the "important trend linking medicine to government." A group from the medical profession was needed to provide the government with the impartial yet expert advice necessary to make "decisions of wisdom" on questions of medical policy. The American Medical Association, according to Page, approached the federal government with a "grumbling hostility" that limited its effectiveness. The Association of American Medical Colleges, a similarly venerable organization that was in the process of transforming itself from a "congenial 'deans' club' into a powerful lobby for academic medicine," represented the interests of academic health centers, not the medical profession. Few other organizations were large or influential enough to speak for the profession. Page believed that the solution was a National Academy of Medicine, located in Washington, D.C., that would be "truly representative of excellence in all branches of medicine."1
Irvine Page was the logical leader of a campaign to create a National Academy of Medicine. Like nearly everyone who helped found the Institute of Medicine, he came from the fields of academic medicine and scientific research. He combined a high academic
pedigree (degrees from Cornell and the Cornell Medical School) and scientific prowess with a talent for organization that enabled him to publicize his causes effectively. Born in 1901, he was older than most of the Institute of Medicine's other founding mothers and fathers, more than 65 years of age by the time serious discussions began. His career reflected many of the major developments in American academic medicine. He began by studying the chemistry of the brain and in 1928 received an invitation from the prestigious Kaiser Wilhelm Institute in Munich to begin a department in brain chemistry. After the rise of Hitler made working in Germany uncomfortable, he secured a position at the Rockefeller Institute for Medical Research in New York. These aspects of Page's career illustrated the influence of German models on American science and demonstrated that in the prewar era, support for medical research came as much from private philanthropy as from government grants.
Working at the Rockefeller Institute between 1931 and 1937, Page became interested in the phenomenon of high blood pressure. He both demonstrated the harmful effects of hypertension and showed that the disease could be treated effectively. In 1937, moving to the Lilly Laboratory for Clinical Research, he continued his efforts to "identify and isolate the compounds that affected blood pressure." After the Second World War, he started a research division at the Cleveland Clinic that attracted many topflight doctors and scientists. Not content to limit his work to the laboratory, Page also made rounds at the clinic and became a public health advocate, stressing the importance of exercise and diet in the prevention of heart disease. To further his goals, he helped create such organizations as the American Foundation for High Blood Pressure and the American Society for the Study of Arteriosclerosis.2
Irvine Page, then, was far from a typical physician engaged in the full-time practice of clinical medicine; rather, he was a representative of a branch of the profession that enjoyed close relations with academia. Not surprisingly, Page communicated the results of his research by publishing, writing textbooks on the chemistry of the brain, editing books on treatment techniques for stroke and high blood pressure, and producing scientific papers and laboratory reports. Because of his academic prominence and ability to communicate his ideas, he received opportunities to serve in advisory capacities for influential organizations, such as NIH. If he obtained support from the Rockefellers at the beginning of his career, he, in common with many of his colleagues, switched to the National Institutes of Health, whose budget grew from $3 million to $400 million between 1941 and 1960, in the postwar era. Over the course of
a long career, therefore, Page had observed the changing relationship between government and medicine at close hand.3
At the end of the summer of 1964, Page wrote a letter to his many contacts in the medical profession and in the world of science and asked for their reactions to his proposal to create a National Academy of Medicine. In the letter, he noted that the National Academy of Sciences (NAS) did a good job in representing the interests of science and that engineers appeared well on their way to establishing a National Academy of Engineering within the larger NAS. He wanted to know if a National Academy of Medicine would serve a similarly useful purpose.
Page's correspondents presented him with a bewildering variety of views. Some wanted to wait to see how the National Academy of Engineering turned out. Others expressed skepticism about finding an exact purpose for the organization. Some advocated a close alliance with the National Academy of Sciences, but others felt just as strongly that the new organization should have nothing to do with the NAS. They criticized the NAS as a "self-perpetuating" body. It was a great honor to join, and the "main function ... is to decide who deserves the honor." "Let us proceed slowly and thoughtfully, but let us proceed," Page concluded.4 In private, he told a colleague that no one needed to be pushed ''but if the thinking about it is open and moves along, the whole thing will gel."5
In public, he wrote another editorial for Modern Medicine that appeared in March 1965. In this piece, Page again cited the gap between the American Medical Association, which at the moment was leading a last-gasp effort to prevent the passage of Medicare, and the various federal agencies concerned with medicine. Something had to be done to close this gap, because "no serious-minded person denies the role that medicine must play if we plan to have a 'Great Society'." Summarizing the letters that he had received, he wrote that they demonstrated a need for a National Academy of Medicine and indicated that the material was "certainly there to form it."
In July 1965, Page refined his ideas about the proper membership for a National Academy of Medicine and once again solicited the views of his colleagues. He had no doubt that unlike the democratic and relatively ineffectual American Medical Association, the new organization should draw "from the upper, relatively thin layer of the best medical and scientific and lay talent." There should, however, be no limit on the number of members because the subject of medicine was "constantly growing." Further, membership should depend on a person's capabilities, without regard to degrees or titles. These
capable members would be expected to work, not just to participate in "an honorary society for the greater glory of the individual."
For the most part, his correspondents agreed, Dr. Julius H. Comroe, Jr., director of the Cardiovascular Research Institute of the San Francisco Medical Center and later an influential figure in the creation of the Institute of Medicine, argued for the importance of "real working committees picked from individuals best able to give advice on specific problems." Fred Robbins, a Nobel laureate in medicine who worked up the road from Page at Case Western Reserve University and would later be president of the Institute of Medicine, emphasized the need to choose people who commanded respect at the national level and suggested that practitioners of the biological, behavioral, and social sciences be represented. Each of these ideas would influence the subsequent development of the Institute of Medicine.6
External events motivated Page to go from ideas to action. Signing Medicare into law on July 30, 1965, President Lyndon Johnson set in motion forces that would lead to a rise in medical expenditures—from 6.2 to 7.6 percent of gross national product between 1965 and 1970—and a fall in the percentage of these expenditures paid by the private sector—from 75 to 63.5 percent in the same five years. Although these trends created opportunities for collaboration between the medical profession and the federal government, they also produced tensions. Similarly, federal support of medical research, although lavish, bred its share of problems among members of Congress, the executive branch, and representatives of medical schools. In June 1966, President Johnson convened a meeting of his top health policy officials and asked them whether "too much energy was being spent on basic research and not enough on translating laboratory findings into tangible benefits for the American people." The mere fact that the President posed the question, according to Stephen Strickland, "fell like a bombshell" on NIH officials and created a ripple of panic among the scientists in medical schools.7 Not long after this meeting, Science printed an item in which it attributed a desire to create a National Academy of Medicine to "reform-minded top officials of the Department of Health, Education, and Welfare." The new organization "would supply the profession with another set of spokesmen and provide the government with a more congenial source of authoritative advice.''8
Only a short time after President Johnson's meeting with his science advisers, Page used his local connections to secure a grant of $6,000 from the Cleveland Foundation that enabled a group of leading physicians to travel to Cleveland, Ohio and discuss strategy. The
meeting took place on January 17, 1967. In addition to Page, 15 physicians, nearly all of whom were on the faculties of medical schools or attached in some capacity to the National Institutes of Health, attended the meeting.9
It was Page's show. He set the agenda, hosted the meeting, chaired the sessions, and gave an opening talk, to which he devoted substantial preparation, on the need for a National Academy of Medicine. The new organization, Page said, should be the "voice of moderation, wisdom, and integrity," and it should be "free and beholden to no one" as it ''provided advice ... to any who want to listen." Above all, Page stressed the fact that advice on medical questions could no longer be left to amateurs: medicine's growing scientific base and its increasingly complicated relationship with the government necessitated the creation of a group that could mobilize the best professional opinion in the country.10
Although Page dominated the meeting, James Shannon also made his presence felt. Only three years younger than Page, James Augustine Shannon was something of a Washington legend because of his extraordinary success at running the National Institutes of Health. Like Page, Shannon combined interests in science and medicine. He received a medical degree from New York University (NYU) and a Ph.D. in physiology. During the war, he became the director of an NYU research service at Goldwater Memorial Hospital and did work on malaria that led to a Presidential Medal of Merit. After flirting with private industry after the war, Shannon arrived at the National Institutes of Health in 1949 as associate director for intramural research of the National Heart Institute. On August 1, 1955, he became the director of the National Institutes of Health. In this position, he held what Donald S. Fredrickson, himself an NIH director and an IOM president, described as an "uncomplicated philosophy of science" that consisted of "unfettered support of good science and rejection of the bad." Good science tended to mean basic research, rather than research targeted on finding a cure for a particular disease. He blended this uncomplicated philosophy with a sophisticated understanding of congressional relations and of the policy process.11 Shannon, whose career bore so many similarities to Page's, was just the sort of person whom Page hoped to interest in a National Academy of Medicine.
Addressing the group in Cleveland, Shannon said that a National Academy of Medicine should be able to speak to government and to conduct sound studies. It should be highly professional and not be formed unless it could isolate four or five broad areas of inquiry, because its initial studies would determine its reputation. An
overarching purpose of the organization, according to Shannon, would be to "define, enunciate, and promote the health sciences." As a practical matter, Shannon advised that representatives of the group should sit down with Fred Seitz, the physicist who served as president of the National Academy of Sciences, and with Harvey Brooks, a Harvard academic who chaired the Academy's influential Committee on Science and Public Policy, and gauge the NAS's level of interest in a National Academy of Medicine.12
A second meeting, held on March 7, 1967, satisfied Page that the need existed for a National Academy of Medicine. Still, he wondered, as had James Shannon, whether the group should proceed on its own or whether it should "come under the umbrella of a chartered organization such as the NAS." In fact, the Cleveland group was already in contact with the NAS. After the first meeting, Shannon and Ivan Bennett had arranged a Washington conference with Frederick Seitz, president of the NAS. They had no trouble getting an appointment. An NAS member, Shannon was one of the federal government's most influential bureaucrats concerned with science. Although a generation younger than Shannon or Page, Ivan Bennett was an academic physician with impressive Washington connections, who had worked at Yale and as the Baxley Professor of Pathology at Johns Hopkins before accepting an appointment as deputy director of the Office of Science and Technology in the Johnson White House.
Talking with Shannon and Bennett, Seitz had offered the possibility of establishing a "board" within the Academy that could begin to do the sorts of studies the Cleveland group wanted and, according to Shannon, "give us a base from which we could begin to operate and to study what sort of organization should emerge." Shannon believed that Page's group should take advantage of the NAS's generosity, even though he thought that there ultimately should be a National Academy of Medicine that was independent of the National Academy of Sciences. Bennett pointed to the advantages of working with a group as prestigious as the Academy. If things turned out badly, the doctors could always back out gracefully and form their own group.
Colin MacLeod, who played a key role in discussions at the second meeting of Page's group, agreed with this assessment, and like the others in attendance, he spoke with considerable authority on the subject of medical policy. He came from an academic and scientific background that was far removed from the daily practice of clinical medicine. A doctor with a strong interest in science, MacLeod had worked at the Rockefeller Institute during the 1930s, just as Page had. From there he had gone on to chair the Microbiology
Departments at New York University and the University of Pennsylvania. In 1963, he took a job in the White House at the Office of Science and Technology, which he later yielded to Ivan Bennett. In 1967, he served as the vice president of medical affairs at the Commonwealth Fund, an important dispenser of funds for medical research and public health. Highly regarded as a scientist, MacLeod, like James Shannon, was a member of the National Academy of Sciences.13
Walsh McDermott and the Board on Medicine
As Ivan Bennett noted, the prestige of the National Academy of Sciences, with its federal charter and its proud history that stretched back to the presidency of Abraham Lincoln, was beyond dispute. In 1967, it consisted of about 800 members, each of whom had undergone rigorous nomination and election procedures. Almost all of the members owed their selection to the quality of their published research in the "hard sciences." Upon election to the Academy, a member voluntarily joined one of 18 discipline-specific sections. Physics and chemistry formed the two largest sections. Attempts to increase the number of physicians in the Academy had met with repeated failure. In 1941, for example, Ross Harrison of the Yale Medical School called attention to the "urgent need for the Academy to have in its membership a larger proportion of the distinguished clinicians of the country than at present." He was told that creating a section of medical scientists would result in attracting people who were "merely clinicians,'' and the idea was dropped for the next 27 years.14 In the interim, the few medical doctors elected to the Academy were found in the microbiology, physiology, and biochemistry sections. It was not a young crowd; the median age of the microbiologists was 66.5. Very few social scientists belonged to the Academy, and those who did were concentrated in the anthropology and applied mathematics sections. Beyond the prestige that came from joining the Academy, members also enjoyed the benefit of two yearly meetings at which they discussed NAS governance, awarded medals to one another, and listened to scientific papers.
The Academy also contained what observers called an "operational arm" in the form of the National Research Council (NRC). Established in 1916 during the period of mobilization before the country's entry into the First World War, it responded to requests for studies or advice from Congress, the executive branch, and a variety of other
private and public sources. The periods of greatest activity for the NRC came during the two world wars. In the Second World War, for example, the NRC's Division of Medical Sciences had advised the surgeons general of the Army and Navy on medical research and other matters related to wartime care. Between 1940 and 1946, the division's advisory committees on war services held more than 700 meetings and 243 conferences and played an important role in shaping the nation's wartime medical policy.15 In 1946, however, the National Research Council contemplated an end to these emergency activities. The advent of the cold war once again increased the demand for the NRC's services, yet the Division of Medical Sciences initiated little work of its own. As a result of the policy to respond to requests from others, the division contained a bewildering variety of committees, offices, research boards, and panels such as an Office of Tropical Health, an advisory committee to the Federal Radiation Council, the Atomic Bomb Casualty Commission, and the Committee on Radiology. To do its work, the National Research Council drew on the resources of large numbers of scientists in academia and private industry; its reach extended well beyond that of the Academy itself.16
Beyond the formal Academy and the National Research Council, the National Academy of Sciences also housed the National Academy of Engineering (NAE). Established in 1963, it marked an outgrowth of the engineering section within the NAS. Engineers felt that the scientists in the Academy failed to accord the engineering profession the respect it deserved. After the engineers received a grant from the Sloan Foundation, the NAS agreed to form what Fred Seitz called "a sister academy under the original NAS Charter." The possibility remained that the National Academy of Engineering would eventually split away from the NAS. By the end of the decade, however, the NAE remained entrenched within the Academy, and the exact relationship between the National Academy of Engineering and other parts of the NAS was a matter of constant negotiation. Engineers continued to feel that they were not first-class citizens of the NAS. Officers of the NAS believed that the engineers elected people to their Academy who were better known as executives of large private firms than as scientists. 17
Although NAS leaders who served on the Academy's governing council regarded the National Academy of Engineering as less than a hopeful precedent, they nonetheless listened to Colin MacLeod, who reported to them in April 1967 on the events in Cleveland, with considerable sympathy. Seitz told the Executive Committee of the NAS Council that he had already talked with Bennett and Shannon and suggested the creation of an advisory board on medicine. Such a
board, Seitz felt, could provide advice on policy questions related to medicine and health and consider the question of whether to form a National Academy of Medicine. For the NAS, it was a way of bringing discussion about a National Academy of Medicine in-house. Furthermore, an ad hoc advisory board of the sort Seitz proposed would involve a minimum of bureaucratic disruption and avoid the time-consuming and often contentious matter of a vote by the membership. Council members agreed with Seitz. If nothing else, creation of an advisory board on medicine would prevent the Carnegie Corporation and the Commonwealth Fund from taking independent action on the matter, as they threatened to do. Seitz felt confident enough about the matter to inform NAS members at their 1967 spring meeting that it appeared "fairly clear" that an advisory board on medicine would be created. 18
Early in June, the NAS Council approved a motion to establish this advisory Board on Medicine and Public Health. The new Board, charged with the responsibility to "formulate recommendations on matters of policy related to medicine and public health," would report directly to the Council. Seitz told the division heads of the National Research Council that the Board could "possibly lead to the formation of a National Academy of Medicine somewhat analogous to the NAE."19 The Page group hoped this would be the case and made plans to hold a third meeting.
These plans received a serious setback on June 12, 1967, when Irvine Page suffered what his secretary described as a "mild coronary." Page, the expert on heart disease, now found himself looking at the condition "from inside out." After his heart attack, Page, despite his relative vigor, occupied a less prominent place in the movement to create a National Academy of Medicine. His role changed from that of primary advocate to chief critic of the Board on Medicine.20
Seitz realized that the chairman of the Board on Medicine and Public Health would have to be a physician who was also a member of the National Academy of Sciences. His choice was Walsh McDermott, a 56-year-old professor of medicine and public health at Cornell Medical School who recently had been elected to the Academy. McDermott belonged to Page's discussion group, although he had missed both meetings and told Page of his ambivalence toward a National Academy of Medicine. 21 The appeal of his selection lay not only in his familiarity with the movement to create a National Academy of Medicine but also in his unquestioned prominence as a doctor and a public health official.
McDermott was an American aristocrat—"white shoe," in the words of one of his colleagues. The son of a New Haven physician, he attended Andover, Princeton, and Columbia Medical School. During his residency at New York Hospital in 1935, he developed tuberculosis and had to go to the tuberculosis sanitarium in Saranac Lake, New York. Over the course of the next few years he eased his way back into work until he accepted an appointment in 1942 as the head of the Division of Infectious Diseases at New York Hospital. In this post, he performed important clinical trials on penicillin, streptomycin, and other so-called wonder drugs. He also engaged in laboratory work on the effects of antimicrobial therapy on animals, despite the fact that he had never had formal training in either microbiology or experimental pathology. In the 1950s, he shifted directions and became interested in bringing medical treatment to underserved populations, earning substantial fame for organizing a successful tuberculosis treatment program for the Navajos living in Arizona and New Mexico. This experience sparked a continuing interest in public health and led him to become involved in other public health projects both in the inner-city neighborhoods of New York and the developing nations of the world. In the course of these activities, McDermott acquired a plethora of contacts and honors. He served, for example, as a member of the NIH's National Advisory Health Council between 1955 and 1959 and of New York City's Board of Health.22
McDermott accepted the appointment as head of the NAS Board on Medicine and Public Health at the end of June. Both he and Seitz hoped that the Board would develop into "a widely respected voice of American medicine." He proceeded to negotiate with Seitz over other members of the Board. They agreed that Ivan Bennett, Colin MacLeod, James Shannon, and Irvine Page, the prime movers behind Page's efforts to launch a National Academy of Medicine, should all be members. Seitz suggested other names, making it a point not to limit membership to physicians. For example, he mentioned Rashi Fein, an economist at Brookings, who had served as a staff member on the President's Council of Economic Advisors and, according to Seitz, "has a deep interest in the social problems connected with medicine," as a potential member of the Board.23
Despite Page's illness and the preemptive action of the NAS, the Page group held a third and final meeting on June 28. Colin MacLeod chaired the meeting in Page's absence. Some of the nine physicians present wondered if the Board on Medicine and Public Health would really be able to do anything constructive, because it started from the narrow base of doctors within the NAS. The participants conveyed a sense of regret that Page's group no longer controlled the action on a
National Academy of Medicine. MacLeod urged the group to develop a list of people who should be involved in the Board on Medicine. Those present obliged by coming up with no fewer than 41 names.24
The business of constructing a Board on Medicine and Public Health began in earnest on September 13, 1967, at a meeting called by Fred Seitz. Those present included McDermott, Colin MacLeod, Ivan Bennett, and Page. Joseph Murtaugh, chief of the Office of Program Planning at NIH, represented the interests of Jim Shannon. Keith Cannan, who worked for the Division of Medical Sciences of the National Research Council, attended as an NAS staff member. Irving London, chairman of the Department of Medicine at Albert Einstein College of Medicine; Eugene Stead, a professor of medicine at Duke; and Robert J. Glaser, dean of Stanford's School of Medicine, completed the group. All of the people in the room, with the exception of Seitz and NAS staffers, were medical doctors, and each had connections with an academic medical center. It was their task to complete the list of Board members. As Page put it, ''Each one of the members appointed to the Board will represent different aspects of social and scientific medicine, such as economics, poverty, etc."
As a practical matter, members of the group agreed on themselves and on Dwight Wilbur, a San Francisco physician who was president-elect of the American Medical Association, and then got bogged down. In the social science fields, for example, the group had only the most cursory knowledge of current practitioners. James Tobin, Milton Friedman, and Carl Kaysen were suggested as economists, even though none of the people in the room was familiar with their work. As for a sociologist, someone in the room offered the name of Daniel Bell, not because of his work in the field of medicine but because he was well known. For the most part, the group concentrated on occupational and demographic categories, such as dentists or people who worked in the pharmaceutical industry, and it acknowledged the need for "at least two Negroes." 25
The group agreed to ask 22 people to serve, and by the end of September, Seitz reported to the Council that the Board on Medicine "was taking shape." McDermott told Seitz that it was a good list but that it was weighted toward the two coasts and contained almost no private practitioners. Given the people doing the selecting, this was a natural bias. In addition, the Academy had trouble recruiting people from outside the medical profession. A string of distinguished economists declined the offer, as did sociologist Daniel Bell who cited "a lack of competence" on questions related to medicine. Pure scientists approached by the group also were reluctant to become involved with the Board. When Kermit Gordon, the economist from
the Brookings Institution declined to be named to the Board, he quickly suggested Rashi Fein of the Brookings staff, whom Seitz had mentioned earlier, as a logical substitute. As Fein recalled, Gordon urged him to accept the position, and he did so with alacrity, pleased to join a "disinterested group that would be able to examine ... the issues facing the American medical system."26
The National Academy of Sciences made a public announcement of the new Board, now called simply the Board on Medicine, on November 13, 1967. In its final form, the Board contained 21 men and one woman (Lucile Petry Leone of the Texas Woman's University's School of Nursing). Two of the Board members were black. Although a majority of Board members were physicians, the group also included two economists, one of whom later resigned, a nurse, a lawyer, an engineer, and at least two people identified primarily as social scientists. Only two of the physicians devoted the bulk of their time to private practice, and one was something of a "ringer." The son of Ray Lyman Wilbur, Herbert Hoover's Secretary of Commerce and a Stanford University president, Dwight Wilbur, although a clinician engaged in private medical practice, nonetheless knew many of the leaders of academic medicine. The rest of the Board on Medicine members either served as medical administrators, did research in academic settings, or both. Twelve held formal academic appointments.
Members of the Board on Medicine, June 1969
The appointment of the group made a large splash in the media. The New York Times ran a page one story that featured quotations from Seitz and McDermott. Seitz cited the need to apply biomedical knowledge to "critical human needs." He specifically mentioned experimentation on human beings, the role of medicine in attacking rural and urban slum problems, improvement of the quality of medical care, and the reform of medical education as matters that the Board might investigate. McDermott spoke of the "good balanced mix of people who could be counted on for dispassionate and expert judgments about a broad range of problems."27
Despite the high hopes, the Board on Medicine faced the difficult task of simultaneously undertaking scientific studies and exploring the feasibility of a National Academy of Medicine. McDermott hoped to build the Board's reputation on the scientific studies it would undertake. For Irvine Page and Julius Comroe, however, the National Academy of Medicine was a constant preoccupation that demanded the Board's total attention. From the beginning, Page worried that the Board would somehow, as he put it, prevent "the evolvement of a freestanding NAM." Although he often contemplated dropping out of the Board on Medicine, he never disbanded his own group of physicians and scientists interested in a National Academy of Medicine, writing reports for them on Board on Medicine activities that, by their mention of confidential discussions, often annoyed McDermott.
"Don't think for a moment that our original group is disbanded," Page told one of his medical acquaintances soon after the creation of the Board on Medicine. He urged fellow Board member Jim Shannon to keep "our ultimate objectives in mind" and informed Shannon that Walsh McDermott ''is an extremely capable and nice person but I do not think he is in a class with you." Indeed, Page hoped Shannon would become the first president of a National Academy of Medicine. As these sentiments implied, Page had many criticisms of the way in which the National Academy of Sciences handled the Board on Medicine. He objected to the lack of clarity in the Board's objective and to the mixed nature of its membership. "I am not sure if as unhomogeneous a board as we now have can even begin to fulfill the promises a NAM can make,'' he wrote Colin MacLeod.28
Beyond the matter of a medical academy, the Board faced the problem of meeting high expectations with a group of only 22 people and one professional staff member. He was Joseph Murtaugh, a former staff member at NIH, who had agreed to leave the government and come to work for the National Academy of Sciences. To be successful, the group had to make recommendations that commanded the respect of both government officials and practicing doctors. Yet
the group itself contained only one full-time clinician and a few people with recent government experience. Furthermore, the Board hoped to look at the social aspects of medical problems, despite the fact that only four of its members had training in social sciences. Many of the problems on which the Board hoped to focus, such as the plight of inner cities, were large and complex; it would be difficult to define the Board's contributions to their solution.
The Board on Medicine held its first formal meeting on November 15, 1967. All but four of the members attended. Fred Seitz greeted the group and expressed his hope that it might address some of the problems caused by the growing complexity of medicine. Page added his wish that the Board be a place to consider complex problems in a setting free from emotion, professional politics, and other forms of distortion and bias. For all that the Board was supposed to be a professional tribunal whose members were guided only by the facts, the members inevitably brought their own preferences, formed by their unique experiences, to the discussion. Dr. Dwight Wilbur, whose primary institutional experience was with the American Medical Association, wanted the group to consider the problems caused by the importation of foreign physicians. James Shannon noted the profusion of groups already concerned with medical care and policy and compared the result to a "floating crap game." The Board on Medicine should bring institutional stability to this situation and should make it less of a game of chance and more a matter of putting the best minds in contact with the hardest issues. Adam Yarmolinsky, a lawyer by training with a strong interest in problems related to poverty, noted that his prior contacts with medicine were primarily those of a patient, yet he hoped the Board would address the distribution of medical care in the inner cities. Samuel Nabrit, executive director of the Southern Fellowships Fund who was very involved with questions related to civil rights, agreed that the Board should consider how "to meet immediately and directly the ghetto's needs." The meeting ended with agreement only on the need for more discussion of the types of problems the Board should address.29
When the Board reconvened in December, it adopted a seminar format. Board members lectured to one another on such topics as the personal physician delivery system, the functions of the modern hospital, medical education, and the funding of medical research.30 McDermott believed that these sorts of sessions served the useful purpose of establishing a common language and arriving at a consensus about current conditions that would lead to policy recommendations.31 Reporting to the members of his group, Page described the tone of the meetings as "pedagogic." "At the moment we
are all trying to get our breath, get used to one another, and in due course come to grips with these major organizational problems." Page worried, however, that the nonmedical members of the panel did not share his concerns about forming a National Academy of Medicine. 32 It was clear that the Board on Medicine had not yet found its rhythm.
The Heart Transplant Statement
Then, in the second month of 1968, the Board caught a break.33 On February 2, McDermott brought up the matter of organ transplantation. All of the Board members were aware that only a few months before, the first heart transplant operation had been performed by Dr. Christian Barnard in South Africa. The operation, quickly followed by others performed in the United States, captured public interest at a time when much of the other news, such as the beginnings of the Tet Offensive in South Vietnam, was depressing. Eugene Stead, the Board on Medicine member from Duke, called McDermott and told him that the American Heart Association was prepared to issue a guideline on the use of heart transplants. Stead said that the Board on Medicine would be a much more appropriate organization to issue such a guideline. McDermott reminded Board members that they had already been attacked in the popular press for being inactive. If the Board came up with a statement on heart transplants, it could counter its image. No one appreciated the need for slow deliberation on weighty topics more than McDermott, but as he put it, "we are trying to establish an institution" and certain issues should be seized.
The group held a brief discussion on the subject. McDermott emphasized the fact that heart transplants were experimental procedures that required a careful recording of the operation and its results. Informed consent of the patient should be obtained, and the procedure should be done only on people who would otherwise die. It followed that not all hospitals should undertake heart transplants. When Christian Barnard performed his heart transplant, he lacked, according to Julius Comroe, a proper team of immunologists to assist him. Robert J. Glaser, the dean of the Stanford Medical School that had performed a heart transplant only weeks before, claimed that Barnard had no background in, and little appreciation of, the immunological aspects of heart transplantation, in contrast to Stanford's Dr. Rose Payne, who was a topnotch immunologist. As a result, the radiation in Barnard's operation, according to Glaser, was
"given ineptly and in excess." Such practices, the Board agreed, should not be allowed to occur. The Board should therefore caution the medical profession that heart transplants should be done only as an experiment in a proper setting. The public should know that heart transplants were not a therapy that could be relied on until more data had been gathered. Such a statement, Glaser hoped, might serve as a deterrent to adventurous surgeons who wanted to be on the cutting edge of medical practice yet knew little about how to prevent rejection of the transplanted heart. McDermott then turned to Glaser and asked him to draft a statement, with an emphasis on the experimental nature of heart transplants.34
Working with Joseph Murtaugh and Walsh McDermott, Glaser prepared a short statement that was ready for circulation by February 20. Instead of waiting for the next Board meeting to discuss the statement, McDermott decided to solicit members' opinions by phone. As he saw it, the statement hinged on two basic principles. Heart transplants could not yet be justified as therapy because no one knew their relative advantages over other forms of therapy. In other words, controlled experiments had not yet been performed, and the public should understand that in the absence of these experiments, heart transplants could not be regarded as a miracle cure. As a second basic principle, McDermott believed that heart transplants should be conducted only in institutions "in which the total array of scientific expertise necessary for the proper conduct of the whole experiment can be brought to bear in every case." In other words, heart transplants were more than a matter of surgery; they also involved complicated issues related to immunology. If McDermott's two principles were implemented, the total number of transplants would be small.35
Moving with incredible speed, the Board issued what was billed as its first public statement on February 27. The statement polished the rhetoric of the previous discussions. "Cardiac transplantation raises new, complex issues that must be faced promptly," the Board asserted. It could not yet "be regarded as an accepted form of therapy, even as a heroic one." Instead, "it must be clearly viewed for what it is, a scientific exploration of the unknown, only the very first step of which is the actual surgical feat of transplanting the organ.'' The procedure, in other words, required much more than a surgeon with good hands. Instead, it demanded a "surgical team" that ''should have extensive laboratory experience in cardiac transplantation." Furthermore, the "overall plan of study should be carefully recorded in advance and arrangements made to continue the systematic observations throughout the whole lifetime of the recipient."36
The media gave the statement prominent play. Walsh McDermott told the New York Times that the Board felt comfortable with the statement because heart transplants were "a more clear cut example of all the problems involved in human experimentation" than medicine usually afforded. McDermott said that the Board realized that there were many surgeons who had the necessary skill to perform the operation and who faced a "terrible temptation ... to embark on the avant garde with ... the tremendous satisfaction of exercising one's skill." With its statement, the Board hoped to discourage such surgeons. McDermott said that the statement illustrated the Board's mission to consider situations in which medical knowledge outstripped its application to critical human needs.37
If the Board wanted to publicize its work, heart transplantation served as the perfect vehicle. The Board used clear and concise language that any layperson could understand to address a pressing matter in a timely fashion. As a consequence, word of the Board's actions spread not just to centers of elite opinion, such as New York and Washington, but also to smaller cities across the nation. Nearly every major newspaper in the country carried a story about the Board's stance on heart transplants. "Don't Try Heart Transplants too Soon, Scientists Warn," read a typical headline.38
The statement made a deep impression on intellectuals who followed the transplantation debate and on government officials responsible for funding medical research. In April 1968, the Saturday Review printed the statement in full.39 Senator Lister Hill (D-Ala.), who both authorized and appropriated money for medical research programs, inserted the Board's statement into the Congressional Record. In the White House, Joseph Califano, the staff member most responsible for President Johnson's domestic policy, read and commented on the statement. In the Department of Health, Education, and Welfare (HEW), Dr. Philip Lee, Assistant Secretary for Health, called the statement "timely and very appropriate." Wilbur Cohen, about to become HEW Secretary, praised the Board for "bringing a sense of reality and caution into a very complex set of matters." The statement even received international recognition. The State Department's Office of International Scientific Affairs sent the statement to major embassies across the world in the "Friday bag.'' The United States Information Agency interviewed McDermott for the Voice of America.40
Not everyone, even at the elite medical schools, approved of the statement. Some saw it casting doubt on a promising area of medical inquiry. Francis D. Moore, a prominent surgeon at Harvard Medical School, said he was shocked to see such a statement coming from a
Board that contained not a single surgeon or any immunologists who had experience with heart transplantation. He also could not understand why the Board chose to single out heart transplants from the transplantation of other organs. At Brigham and Women's Hospital, a Harvard teaching hospital, surgeons had done their first kidney transplant in 1951, although the procedure had involved identical twins and posed no immunological problems. Ignoring the fact that Glaser had contacted the members of his faculty who had performed heart transplant surgery, Moore thought it would have been prudent "for the National Academy of Sciences to seek some consultation from those who have been intimately concerned with these problems for almost twenty years." He felt that the Board did not make it sufficiently clear that heart transplants could "rest secure in the scientific, ethical and moral climate which has already been characteristic of the transplantation of other organs in the United States."41
In a sense, Moore accused McDermott of exploiting the interest in heart transplants in an opportunistic manner. In reply, McDermott argued that the statement was intended to be a positive one, not meant to eliminate heart transplants but rather to make sure that such procedures were performed in places that had the "capability to make all the relevant observations." Most of the cardiac surgeons with whom McDermott had discussed the statement regarded it as "sensible and helpful," setting down guidelines that they themselves followed. 42 The statement, according to McDermott, exemplified the Board's mission of acting as a "disinterested group'' that sought ''to be helpful on the more important issues as they arise considering both medicine itself and its relationship to our society."43
Still, the heart transplant statement, for all of McDermott's lofty ideals, possessed elements of self-interest that were difficult for members of the Board on Medicine to perceive. As a pragmatic matter, the statement counted as a great success. As Irvine Page noted, the Board was "well ahead of the game" and could only hope to do "as well next time."44 It did not trouble either Page or McDermott that the statement favored the types of institutions with which they were associated over other institutions; they simply assumed that their institutions were superior. Robert J. Glaser, chief author of the heart transplant statement, worked for a medical institution that had already performed such transplants, one whose scientific expertise, according to the Board on Medicine, should allow it to continue to do these operations. To put it more bluntly, the head of the Stanford Medical School had helped draft a statement saying that complicated operations such as heart transplants should be done only in places
like the Stanford Medical School. No one on the Board on Medicine was likely to challenge such a statement.
Business of the Board
The heart transplant statement gave a sense of momentum to the operations of the Board on Medicine. As if in direct response, the Commonwealth Fund announced that it would give $150,000 to the National Academy of Sciences to support the Board on Medicine. It marked the start of what would be a long-standing philanthropic relationship between the fund and the Institute of Medicine. In awarding the money, the head of the Commonwealth Fund spoke of the "urgent need for an institutional entity of authoritative standing to serve as an independent, objective resource for dealing comprehensively with the problems and decisions confronting medicine and health in American society."45 Even when the hyperbolic foundation rhetoric is discounted, such a statement showed the hope that the Board engendered in elite medical policy circles.
Although a lack of funds would become one of the Board on Medicine's and the Institute of Medicine's chronic problems, it looked at first as if raising money would be easy. The Board, unlike other voluntary organizations that served a social purpose, enjoyed the backing and prestige of the National Academy of Sciences. Its mission, although vague, appeared to be related to America's social problems at a time when the mid-1960s optimism about solving these problems through Great Society programs had begun to wane. The combination of pedigree and relevance was very attractive to private foundations. As if this were not enough, the Board had some direct connections to the foundation world. Colin MacLeod, the same person who pleaded the Board's case to the NAS Council, worked for the Commonwealth Fund, which became an early supporter of the Board. Many Board on Medicine members served on foundation boards, and some, such as Walsh McDermott and Robert J. Glaser, went on to play major roles in the foundations that supported medical research. In Jim Shannon, the head of NIH, the Board maintained a connection to the largest supporter of medical research in the world. Although Shannon left NIH in 1968, he nonetheless kept the Board abreast of NIH and other government activities.46
Colin MacLeod took a direct role in the Board's outreach to the philanthropic community. He arranged a meeting at the Commonwealth Fund in New York that allowed Seitz, McDermott, and Murtaugh to discuss the Board's work with representatives of five
large foundations. McDermott looked to the foundations represented at the meeting, such as the Carnegie Foundation and the Rockefeller Foundation, to provide core support for the Board. He wanted to increase the Board's staff by at least three professional staff members. At the end of the meeting, Margaret Mahoney of the Carnegie Corporation took McDermott aside and told him that her foundation would be very interested in participating in a study of urban health services. She also told McDermott that the foundations worried about the widespread dispersal of their funds, which limited their effectiveness. She advised McDermott to get several foundations to work in concert to support the Board on Medicine.47 The Board on Medicine followed her advice and secured initial backing from Commonwealth, the Rockefeller Foundation, the Milbank Memorial Fund, Carnegie, and the Association for Aid to Crippled Children.48
A good part of the attraction for these foundations was the fact that the Board worked on social, and not merely medical, problems. If the Board needed a reminder of the urgency of America's social problems, it received it during its April meeting. Originally scheduled for the downtown offices of the National Academy of Sciences, the meeting took place in the suburbs to avoid the disruptions caused by the riots that followed the death of Martin Luther King, Jr. At this meeting, the Board faced the fact that despite the heart transplantation statement, it had still not initiated any substantive studies. In partial response, members decided to create two study panels. One, on medical education, came at the urging of Jim Shannon, who sought nothing less than a major redesign of medical education to incorporate changes in science into the curriculum. McDermott asked Ivan Bennett to head a five-person subcommittee charged with developing a proposal. The other study panel, on health services, had the daunting task of examining "existing programs, mechanisms, and laws" that related to the delivery of health services and of somehow formulating "a creative diagnosis" of the issues in the field. McDermott chose economist Rashi Fein to head this five-person panel.49
Both panels made initial progress. In June, the Board gained NAS approval to enter into a $40,000 contract with the National Institutes of Health for the initial phase of a study of medical education.50 The Board also refined its proposal in the area of health services, concentrating on the topic of health and the poor. It proposed to define the problem by asking if the health conditions of the poor were different, to examine how the poor were being served, to analyze government health programs that served the poor, to project the future medical needs of center-city dwellers, to test the effect of
income transfers or vouchers on improving access to health care, and to design government programs that might better serve the poor. If the project lacked focus and appeared to be overly ambitious, it nonetheless represented a tangible product of the Board's long discussions.51 By the fall, a Board Panel on Health and the Disadvantaged, chaired by Samuel Nabrit and containing five other Board members and four outside experts, had met in Washington for further consideration of the study.52
Despite this semblance of progress, the Board faced many internal and external challenges. In the first place, it drew criticism from within the National Academy of Sciences. One epidemiologist, a member of the NAS since 1948, questioned whether the Academy was qualified to appoint a Board on Medicine. He noted that the Academy itself still did not have a functioning Section on Medicine (although one would be formed in 1968) and that Board members were not "primarily people who have been involved in the provision of medical care to the public." The Board's social mission, so attractive to outside funders, also drew criticism from inside the Academy.53 Second, the very attractiveness of the Board's mission, combined with the slow pace at which it moved, invited competition from other entities that claimed to speak in the public interest. Senator Walter Mondale (D-Minn.), for example, hoped to create a Commission on Health, Science, and Society to "study and evaluate research in medicine." Such a commission could provide competition for the Board.54 Third, the Board still had to deal with the question of forming a National Academy of Medicine.
Neither Julius Comroe nor Irvine Page would let go of this issue. Comroe argued that the Board was placing too much emphasis on its social mission and too little on forming a National Academy of Medicine. Suggesting that the Board change its name to the "NAS Board on Social Medicine," he thought another group should organize a National Academy of Medicine. Comroe was worried that the Board spent its time on large and intractable problems, such as the conditions in urban and rural slums, that required the entire nation's attention and to which the Board could contribute little. Comroe, a blunt man, did not hide his feelings from Walsh McDermott. "I think that it is very nice for 22 men in a wide variety of disciplines to meet once a month and move at a relatively slow pace toward solution of major problems," he told McDermott, "but the work could go very much faster ... if a large prestigious group, more representative of medicine were formed to do the work....'' Page agreed with Comroe. In Page's opinion, the Board had become "the McDermott Committee of the NRC" and he hoped that Comroe, Colin MacLeod, and Jim
Shannon could save the organization from "becoming a small, self-satisfied outfit which can never properly undertake the problems I think we all had in mind when we got the thing started."55
Debate over a National Academy of Medicine
By July 1968, McDermott believed that it was time to begin a serious discussion on whether to form a National Academy of Medicine. He arranged a special one-day meeting to consider the matter and asked Comroe and Page to lead the discussion. In a paper prepared for the meeting, Page critiqued the Board on Medicine as too small, too narrow, and too concerned with the socioeconomic dimension of medical problems. With the socially minded Board on Medicine and the scientifically minded National Research Council, medicine found itself in a "schizophrenic state," a "split appendage" of an organization in which it had "no voice." Page concluded that a National Academy of Medicine should be formed, with or without the help of the National Academy of Sciences. 56 Comroe, for his part, prepared for the discussion by asking the opinions of 20 prominent physicians. All 12 of those who responded believed that there should be a National Academy of Medicine, although they differed on whether it should be affiliated with the NAS. Comroe emphasized that his correspondents felt a National Academy of Medicine should be organized by people actively engaged in medical practice, education, research, or administration. As for his vision of a National Academy of Medicine, Comroe thought it should have a permanent home, a full-time president, and at least 20 members in full-time residence, many of whom would be on sabbatical.57 Not surprisingly, he saw the NAM as a place to which academics would come to write and do research.
From the moment of Comroe's and Page's presentations on a National Academy of Medicine, the Board on Medicine concerned itself with little else. At the end of six hours of conversation, McDermott said he detected neither a consensus in favor of an academy nor one against it. He decided to appoint a subcommittee to investigate the matter. Headed by Irving London, a summa cum laude graduate of Harvard and a Harvard-trained doctor who chaired the Department of Medicine at Albert Einstein College of Medicine, the group contained six other Board on Medicine members. Because the group included Shannon, Comroe, Wilbur, and Page, it was comprised, as Comroe conceded, of "a very clear majority dedicated to
the formation of an academy." McDermott served in an ex officio capacity. 58
This group, with the unwieldy title of the Ad Hoc Panel on Further Institutional Forms for the Board on Medicine, met at the end of September 1968. The political climate lent a sense of urgency to the proceedings. When the Board started its work, the Democrats were in firm control of the White House and Congress. It now appeared as if Republican Richard Nixon might win the election and federal support for medical research and for social welfare programs, such as Medicaid, might weaken. As Adam Yarmolinsky told the Board, "Whoever is President of the United States—Humphrey, Nixon, Wallace, it is less likely that the kind of advice that we have to offer which involves spending money and doing things will be accepted."59
Whatever the urgency of the political situation, the Ad Hoc Panel moved at a very deliberate pace. A first meeting served only to set the stage for a second. "The discussions were quite tentative," Joseph Murtaugh reported to Fred Seitz, "with a great deal of uncertainty being reflected by the members in respect to many important points." 60 One of Page's allies wrote that he sensed a "foot-dragging attitude" on the part of McDermott. He urged Page to act independently of the National Academy of Sciences. He suggested that if nothing happened in the next few months, Page's original committee should be reactivated and a National Academy of Medicine should be organized on an independent basis.61 The head of the Dartmouth Medical School told Page that he was "bullheadedly holding to my original bias'' in favor of a National Academy of Medicine. ''The more I have thought about it ... the more I feel the academy is the only position to take," Page replied. He attributed opposition to the NAM to "public health people" and those "concerned with economics" who believed that "if medicine had the upper hand, we would all revert to our antediluvian days of which they are so highly critical."62
Walsh McDermott, whom Page would have classified as one of the public health people, refused to be stampeded. In a letter to London he tried to set the intellectual tone for the discussion. He began by pointing out that everyone agreed on the need for an institution, free of special interest, that included nonphysician professionals as well as physicians. The disagreement came over what purpose the institution should serve. The Page and Comroe faction favored an organization that spoke for medicine; McDermott wanted one that spoke about medicine. The first concept involved a group that addressed problems within medicine and expressed the medical viewpoint. The second concept addressed the need for an entity that "would speak to the
issues from the position of all-round competency rather than one that would speak from within medicine." This concept reflected McDermott's belief that the major problems facing medicine extended beyond the professional boundaries of medical doctors. Because McDermott admitted that he favored the second concept, he came down on the side of expanding the number of people on the Board on Medicine without changing its basic shape or character, rather than creating a National Academy of Medicine. It seemed to him that the Board represented the best hope of interdisciplinary collaboration, in which physicians could work with social scientists on such problems as the reform of medicine and medical education. An Academy of Medicine would develop a tendency to be overprotective of the medical profession and to shy away from the most critical problems.63
In a rebuttal to Walsh McDermott, Page charged that McDermott had stacked the intellectual deck. McDermott assumed that physicians would act in a biased and defensive manner without any evidence to support those assertions. Page argued that McDermott's was "the counsel of timidity" that expressed a "lack of faith in the competence of selected physicians." Physicians, according to Page, must have a "strong voice in determining the destiny of medicine," and anything less was ''a weak compromise for which interest will soon flag."64
The next meeting of London's committee took place in the midst of considerable confusion. First, the presidential election turned out as many Board on Medicine members had feared. Second, the National Academy of Sciences was undergoing its own change of administration. Fred Seitz would leave at the end of the fiscal year (July 1969), and the Board would have to deal with a new NAS president. In addition, the NAS was forming a section on medical sciences that could conceivably sap some of the energy from the campaign to create the National Academy of Medicine. Because these changes made the future seem less than clear, the second meeting of London's committee, like the first, ended with little substantive agreement except that each member would write down his preferences about a new institutional form for the Board on Medicine and send the results to Dr. London.65
When the full Board on Medicine convened on November 20, 1968, London could offer his colleagues only a status report on the deliberations of his subcommittee. Despite the uncertainty, some ideas appeared to be taking shape. Membership in whatever organization evolved should be on a short-term basis. Each of the members would be expected to work; no one wanted a purely honorific organization. There should be a full-time staff, headed by a full-time
officer or officers. The majority of the people on the Ad Hoc Panel appeared to be heading toward the use of the word "academy" in the organization's title. Most people agreed that the Board on Medicine in its present form had failed to meet the expectations generated by Page's discussion group and other advocates of a National Academy of Medicine. Still, profound differences remained between the Page-Comroe faction and McDermott. As Comroe put it, "Some of us believe very strongly that if it is to be a Board on Medicine or an Academy of Medicine, then it must be predominantly made up of medical people." If such a board or an academy were to be accepted, it had to be accepted among medical practitioners. This meant it had to overcome the stereotype that physicians always acted in their self-interest, desired nothing more than a trade union, and exhibited no concern for the country's future.66
Irvine Page aptly summarized the situation at the end of 1968. In an unguarded moment, he wrote that "there have been many, many arguments over the past year and a great deal of soul searching going on and there is no way of knowing how it is going to come out." To Dwight Wilbur, Page's friend and ally on the Board, it appeared that Walsh McDermott was "doing his best to fan the flames in his direction or on his behalf."67
As Wilbur's comment suggested, the Page faction spent much of the next year and a half in a state of frustration. One source was the inevitable delay. Another, more enduring source of frustration came with the announcement that Philip Handler, chairman of the Department of Biochemistry at Duke, would become president of the National Academy of Sciences on July 1, 1969. Unlike Seitz, Handler held no particular brief for a National Academy of Medicine. High on his list of priorities was a desire to strengthen the life sciences within the Academy. As part of this agenda, he hoped to elect more practitioners of medical sciences to the Academy and to strengthen the management of the National Research Council. None of this meshed with Page's plans.68
McDermott, too, experienced his share of aggravation. As the meetings of the Board on Medicine became more contentious, his job became more difficult. His finely honed sense of obligation did not permit him to retire from the Board until he had settled its future. This commitment forced him to attend endless rounds of meetings with Board members and NAS officials. Because McDermott regarded it as his duty to serve as an honorable intermediary between the Board and the NAS, he was often the bearer of bad news.
Nor did the Board's research projects bring much encouragement to Page, McDermott, or anyone else. The project to reform medical
education gradually unraveled. It had been tacitly agreed with Jim Shannon that the National Institutes of Health would support the project. On the strength of the initial $40,000 from NIH, the Board recruited a study director and assembled a number of panels. By the beginning of 1969, it had become clear that NIH had developed different priorities since Shannon's departure. The study director resigned, and efforts began to secure funds from other sources. The project on medical services for the poor experienced a similarly rocky start. 69
London's panel to decide on a National Academy of Medicine appeared to be the only Board on Medicine activity that mattered. The group met for a third time at the end of February in Palo Alto, California. 70 This time the group managed to get past its previous impasse and reach a decision. The group had already decided on the need for an "institutional framework in medicine" that could confront medicine's problems. The questions centered on what form such an institution should take. The panel debated three options: (1) continuation of the Board on Medicine, (2) transformation of the Board on Medicine into a National Academy of Medicine under the Charter of the NAS, and (3) creation of a free-standing National Academy of Medicine. In the end, the panel decided on the second alternative. It 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 panel even included a timetable that culminated in the formal creation of the National Academy of Medicine by July 1, 1970.71 Joseph Murtaugh hastily drew up a proposal for a National Academy of Medicine that included members who would serve for no more than 10 years; it would have an initial membership of 250 people, a balance of three to one between medical professionals and others, and a full-time elected president.72 Although Murtaugh could not have known it, he had, in fact, written the first draft of a plan for the Institute of Medicine.
At first glance the London panel's report appeared to be a victory for Irvine Page, who favored the creation of a National Academy of Medicine, and a defeat for Walsh McDermott, who opposed it. As always, however, it was the details that mattered. If London's group had its way, the National Academy of Medicine would be part of the National Academy of Sciences, a prospect more congenial to NAS member McDermott than to Page. Nor did the panel specify how much of a social, as opposed to a medical, content the new academy would have. Therefore, although Page felt a cautious sense of optimism, he warned Dwight Wilbur that "our troubles aren't over."73
The Board on Medicine debated London's report on March 12, 1969. In his presentation to the Board, London emphasized the advantages in terms of prestige and financial support that would come from linking the NAM to the established National Academy of Sciences. When Philip Handler dropped in on the meeting, he too argued against what he described as a free-standing academy. "I am afraid it would be thought of in the world at large as a guild of some sort," and it would be encumbered with the "stigma that guilds have in the world," he said. McDermott agreed that "the greatest single trap in which this campaign can be caught is guildism.''
Listening to the discussion with relative complacency, Board members voted to accept the panel's main recommendation. With a unanimous vote, the Board put itself on record as favoring an autonomous National Academy of Medicine under the National Academy of Sciences. In Comroe's account of the meeting to the absent Irvine Page, "there were only a few feeble arguments opposing the proposal for a National Academy of Medicine and these were dealt with very ably by those around the table." During the rest of the meeting, the Board attended to some of the details. If the Council of the National Academy of Sciences approved the proposal, then the president of the NAS would appoint an organizing committee to write what amounted to a constitution for the new organization. The Board on Medicine would then be expanded to 50 members who would select the first members of the National Academy of Medicine. Within three years of the founding of the National Academy of Medicine, three-quarters of the members would come from medicine and the medical sciences, and one-quarter would come from the social sciences, administration, law, and engineering.74
Rejection by the National Academy of Sciences
Once again, the campaign to create a National Academy of Medicine accelerated. Walsh McDermott presented the Board's plan to the Executive Committee of the NAS Council at the end of March. The NAS officers asked him a lot of pointed questions. They wondered just how members would be chosen, how the new academy might develop a working relationship with the National Research Council, and whether the NAM might take positions on public controversies that would put it at odds with the impartial National Academy of Sciences. In the end, the Executive Committee "accepted in principle the concept of a National Academy of Medicine" and agreed that the full NAS Council would take up the matter in June. However,
preliminary discussions in the Council, conducted behind closed doors, showed that many NAS Council members remained skeptical of the venture. They questioned the need for a new academy's autonomy. As far as Philip Handler and the NAS Council were concerned, the matter was far from settled.75
In the course of the May discussions of the Board, Walsh McDermott confided that he was having his own crisis of confidence. Although he would do his best to argue the case for a National Academy of Medicine to the Council in June, he still had doubts about the wisdom of this approach. Two things were essential to him—that the NAM not be solely honorific and that it contain a mixture of disciplines. "I have serious questions that anything that is called an academy is the proper instrument to meet these two purposes," he said. Irving London, who sympathized with McDermott's position, explained why he nonetheless favored a national academy. If the Board followed McDermott's advice and established something like a "National Medical Council" or the "National Board on Medicine," then "quite another group in this country would come along calling itself the National Academy of Medicine and would create enormous confusion in the public mind."76
Setting his doubts aside, McDermott issued the final assignments for the presentation to the NAS Council. He, London, and Adam Yarmolinsky would draft a document that would be presented to the Council. A delegation from the Board on Medicine comprised of McDermott, Glaser, London, and Yarmolinsky would make the formal presentation. There was nothing surprising about these assignments, except perhaps for the inclusion of Yarmolinsky. His selection reflected the Board's growing dependence on Yarmolinsky as a draftsman and, because he was quick thinking, as a spokesman. Yarmolinsky became the Board's informal counselor, advising the group on legal matters and matters of organizational design. His experiences in the Kennedy and Johnson administrations made this Harvard law professor the closest thing the Board had to a Washington insider.77
Jim Shannon, the Board's consultant and other certified Washington insider, took the case for a National Academy of Medicine to the public. Speaking in Chicago, Shannon told the American College of Physicians that the National Academy of Medicine would be a super agency that would reorganize America's "nonsystem" of health care. It would do for medicine what the National Academy of Sciences had done for science and technology. Addressing a Travelers Research Corporation seminar in Hartford, Connecticut, Shannon said that the members of the National Academy of Medicine would be
broadly informed and "objective enough to give true leadership." Nature reported that there was a good chance that a National Academy of Medicine would exist by 1970 and that Shannon "seems to have been the chief instrument in planning the new academy."78
Shannon joined the Board's representatives when they made their pitch to the NAS Council on June 7, 1969. The two-hour session resembled a Supreme Court hearing, with NAS Council members taking the part of judges. Scientists on the Council peppered the physician and lawyer who stood before them with questions. Would it not be better to expand the Board on Medicine? How could the National Academy of Medicine ensure that its members would be of high stature? Would the inclusion of medical practitioners debase the status and prestige of the new academy?
Although Shannon and the others did their best to respond, the answers seemed only to create more questions. The Council should not look on an Academy of Medicine as a threat or as competition, argued Shannon, but rather as a "complementary institution necessary for the further evolution of science." It would be a source of disinterested advice. This led George Kistiakowsky, the Harvard chemist and NAS vice-president, to wonder if offering such advice would make the new academy a lobbying organization and threaten the NAS Charter. Phil Handler also stressed the differences between the two sorts of academies. The National Academy of Medicine would initiate views on public policy rather than limiting itself, in the traditional NAS manner, to responding to requests for advice. The broad scope of the NAM mission also troubled the scientists, who wanted the disciplinary borders of the new academy to be clearly drawn. At the end of the discussion, Alvin Weinberg, an applied physicist who worked at the Oak Ridge National Laboratory, said that he would have a difficult time voting for the proposal because of what he called a substantial "impedance mismatch" between "some of the concepts set forth for the NAM and those which have been traditional for the NAS."79
When the Board on Medicine representatives left the room, Council members expressed serious misgivings about establishing a National Academy of Medicine. Handler said that demands to create separate academies would proliferate and soon the social scientists would ask that they too have an academy. The National Academy of Sciences might then become so diluted that its prestige would disappear. Wallace Fenn, a physiologist who worked at the University of Rochester's medical school, thought it would be much better to expand the Academy's Medical Sciences Section and the NRC's Division of Medical Sciences than to create a new academy. Council
members agreed that the Board's proposal should be examined with "great care and deliberation." Handler, who was about to take over as NAS president, proposed—and the Council agreed—that action on the proposal be put off until the Executive Committee meeting in July.80
Soon after the June meeting, Handler wrote the NAS Council a letter that further revealed his doubts about a National Academy of Medicine. He realized that there was a mismatch between the qualifications of the distinguished scientists elected to the NAS and the practical expertise needed to respond to requests for advice on policy questions related to science. The Academy had too few clinical medical scientists, applied agricultural scientists, engineers, and social scientists. This put many pressures on the Academy, such as the request to form the National Academy of Medicine. The advocates of an NAM wanted to "undertake a type of lobbying activity which is not in keeping with the history of the Academy" and to have a "mixed membership which would, in effect, make them independent of this Academy for advisory functions." If the federal government turned to the NAM and similar entities for advice, the NAS would "be left with only minor advisory functions. Its role in our national life will have been very markedly diluted and its prestige very significantly eroded." Handler proposed to create a Division of Medical Sciences, one of five such divisions in a reorganized NAS, that could elect its own members. Such a division might preempt the campaign to create a National Academy of Medicine.81
Although Joseph Murtaugh called the Council's reception of the Board on Medicine "cordial," the proposal for a National Academy of Medicine came at a sensitive time in NAS history.82 The resulting dispute reflected in part the differences in outlook between the hard and applied sciences. The physicists, chemists, and mathematicians who made up the bulk of the National Academy of Sciences regarded most social problems as too imprecise to define in a meaningful way. Because social problems did not lend themselves to the formulation and testing of hypotheses, they could not be solved through the scientific method and hence were not the legitimate business of the National Academy of Sciences. The economists and sociologists who might have disagreed with this proposition were too few in number in the NAS to influence its outlook.
Both McDermott and the Page contingent differed in their views from NAS scientists. For McDermott, the social aspects of medicine were the most important things for a National Academy of Medicine to address. Shannon, Page, and Comroe, each of whom became NAS members, were closer to the outlook of pure scientists. They, too, had doubts about the social aspects of the Board on Medicine's work—in
part because they came from the world of medical research, rather than the fields of public health, health services, or health care financing. Still, they believed that an effective National Academy of Medicine required participation from a broad cross-section of the medical profession. This put them at odds with the scientists who regarded an academy as a place for researchers, not mere clinicians; for thinkers, not policy activists. Furthermore, the scientists at the National Academy of Sciences, led by Handler, were protective of the Academy as a place where merit alone secured membership. In the Nixon era, with both academia and the undirected nature of scientific research under attack, preserving the Academy as a sanctuary from ephemeral politics seemed all the more important.
When the Executive Committee of the NAS Council met on July 19 in the Academy's facilities at Woods Hole, Massachusetts, to make a final decision on the Board's proposal, Handler's views prevailed. Although the NAS was generally sympathetic to the objectives of the Board proposal, it objected to the issuance of policy statements on political questions and to the "variable criteria" for membership. The Executive Committee hoped to work toward increasing the number of NAS members and, in doing so, to meet many of the Board's objectives. If the Board wished to proceed with an independent NAM, it should feel free to do so but without the help of the NAS. Finally, the fact that engineers had gained their own academy should "not be followed as a precedent."83
On the following day, McDermott and his group met with the NAS Executive Committee and learned of its decision: the NAS Council had rejected the concept of a National Academy of Medicine. Any hope of achieving the Board's objectives would have to occur in a reorganized NAS. In the meantime, the Executive Committee advised the Board to continue with its activities and to have faith in the committee's goodwill. Somewhat stunned, Yarmolinsky and London asked how the movement to create an independent National Academy of Medicine could be contained as the NAS reorganization process proceeded. There could be no way of preventing this from happening, Handler replied. He thought that in the long run, however, the prestige and status of the NAS would prevail.84
Handler tried to put a positive spin on the Council's actions. He emphasized that the NAS Council "warmly" approved of the Board's objectives. The Council's differences with the Board came over the mechanism of a National Academy of Medicine, which was "not welcomed by the Council at this time." Rather, the Council proposed to restructure the NAS, and whatever structures emerged would involve "increased membership of clinical investigators and of
individuals in other disciplines related to the problems of health care." Handler hoped that the process could be completed by the following spring. He concluded by thanking the Board for its proposal, which "has heightened our consciousness of the need for early reforms of our structure and mechanisms."85
The Diplomacy of Reconciliation
At a July postmortem meeting of the Board, Page said that the movement to start an independent National Academy of Medicine could no longer be contained. Dr. London believed that the group was the victim of timing. If Fred Seitz were still the NAS president, things would have turned out differently. McDermott tried to move beyond the anger and get the Board to decide on what to do now. Should the Board continue, or should its energy be put into forming an independent National Academy of Medicine? Dr. Bryan Williams, the physician from Dallas, said he did not want to wait any longer; it was time to form a National Academy of Medicine. Dr. Comroe urged the group to go back to Page's original conception of a National Academy of Medicine. Ivan Bennett agreed that the group had lost both time and money by working with the National Academy of Sciences. For all of the anger, however, the group could still not make a clean break from the NAS. Instead, McDermott was instructed to tell Philip Handler that it looked as though "the road is going to be that of an Academy of Medicine, that it is our hope that this can be done in a way that represents a natural disengagement from NAS with a lot of help from NAS." McDermott, meanwhile, clung to his hope that something could be worked out with the National Academy of Sciences.86
The situation had turned out as Page had thought. "It looks now as though the NAM is going to be formed independent of the NAS," he told a friend, "We are wiser but just about where we left off when the meetings were transferred to Washington." It was time to reunite the Cleveland group and get down to business. On August 15, Page sent a form letter to the leaders of his original Cleveland discussion group in which he announced tentative plans for another small meeting. The whole experience, he explained to Jim Shannon, demonstrated that a "chairman unsympathetic with the purposes of a group can really hamstring the progress of a committee."87
It was not a good time for the Board on Medicine. Within a week, it became clear that the study of medical education, which had received a final rejection from the National Institutes of Health,
would be disbanded. The staff hired for this study began to put their resumes in the mail. With the loss of this project, the rationale for continuing the Board on Medicine looked even weaker.88
In this deteriorating situation, Handler and McDermott engaged in a confrontational form of diplomacy. McDermott advised Handler that at least 14 members of the Board doubted whether an accord could be worked out with the Academy. Some of these, however, still believed that it would be more worthwhile to maintain some sort of link with the Academy. Handler informed his executive board that the Board on Medicine had decided to go ahead with the initial planning for a National Academy of Medicine and wondered what, if anything, the NAS should do in response. Members of the Council's Executive Board told him to hold firm. George Kistiakowsky recommended that the NAS do nothing to oppose the creation of a National Academy of Medicine. It should, however, insist that the Board undertake this activity on its own time or through other organizations. Wishing the Board well, the NAS should go about its business of increasing the number of physicians in the Academy and restructuring the National Research Council. Encouraged by this advice, Handler did not appear willing to make many concessions to the Board. ''I feel rather strongly that, in the end, creation of an independent National Academy of Medicine is not in the national interest," he told Joseph Murtaugh. The National Academy of Sciences would not be blackmailed by the threat of an independent National Academy of Medicine. At this point, the situation resembled the sorts of power struggles that scientists were beginning to witness over such things as the creation of black studies programs on their campuses.89
As the summer continued, both sides retreated from their harsh positions and began to engage in pragmatic bargaining. Walsh McDermott did all he could to soften Handler's position through a series of phone calls and telegrams. Working closely with McDermott, Handler drafted a letter in which he offered McDermott a chance to participate actively in the NAS committee charged with reorganizing the National Research Council. He also raised the possibility that a series of what he called "institutes" might be formed within the National Academy of Sciences, "one of which might well be an institute on medicine or health affairs." As he made these suggestions, Handler, along with the Executive Committee of the Council, urged that "the Board not take precipitate action at this time with respect to the planning of an external Academy of Medicine." Instead, all alternative plans should be examined and an "acceptable accommodation" found. In this manner, health affairs could assume "a suitable, highly visible, and decidedly dignified position within this
total body" and the fragmentation of the NAS could be avoided. "Your ... letter to me was splendid," McDermott replied.90
In September 1969, negotiations continued at a 12-hour meeting attended by Handler and all the principal players from the Board on Medicine, a sort of executive committee. Board on Medicine participants tried to determine which of their conditions were nonnegotiable. Merely adding members to the Board, they agreed, was unacceptable. At a minimum, they required a large institution with freedom to develop its own program, a diverse membership, and the word "academy" in the title. Handler, for his part, tried to be as conciliatory as he could, yet he admitted that the issue of a title for the new medical organization still presented considerable difficulties. He once again mentioned the possibility of an institute and hoped that this might provide "a sufficiently prestigious image." He also speculated that the entire NAS might be reorganized to contain five different subacademies, including the Academy of Medicine. Because such an academy (or subacademy) would maintain the NAS's membership standards, only scientists would be allowed to join. This left no room for the mixed membership coveted by McDermott. As for a completely independent National Academy of Medicine within the NAS, Handler saw no possibility of this. "If the Board insists on going down that road, we are at an impasse," he said.
After listening to Handler, the exhausted group identified three options, each of which meant giving up something. One was to proceed with an independent NAM and abandon the discussions with the NAS (the Page solution). Another was to find a place for medicine within a reorganized NAS structure and abandon McDermott's notion of a group with a mixed membership (the Handler solution). A third involved creating a new institution within the NAS, with a mixed membership, and abandoning the title "National Academy of Medicine" (the McDermott solution). These would be the options that the smaller group would present to the full Board on Medicine when it met in September.91
Page and Comroe were less than enthusiastic about the chances for progress. Page described Handler's mood as "flippant" at some times and "fairly harsh" at others. McDermott, he felt, sparred with the Board and represented it "very poorly indeed." Julius Comroe thought that "we are witnessing a last-ditch struggle to retain Walsh McDermott in the leadership (or controlling) position in the affairs of a Board on Medicine or its successor." Page agreed that "most of us have had enough of this cat-and-mouse game, so the field is again wide open, and I am not at all sure that anything profitable will come out of the meeting at the end of the month.''92
Not much did. Nearly all of the Board members were weary of the long struggle to create a National Academy of Medicine. As one put it, "We have all lost that pleasant little glow ... because we are haggling over what we are going to call ourselves." "The words are becoming very stale" because "we have not been doing anything for quite some time," London said. To stir things up, the Board agreed that it should return to its program of studies. Even as it tried to get back into the substance of medical policy, however, it kept stumbling over lingering antagonisms. Ivan Bennett mentioned that the Board had failed to advance the torch that the Page group had handed it, and Comroe placed the blame on Walsh McDermott. If the Board had not taken over, Comroe believed, a National Academy of Medicine would have been formed two years earlier.93
McDermott told Handler that little of substance had emerged from the meeting, except for a request that the Board meet with the NAS Council, a desire that the Board return to its substantive studies, and a commitment to continue to work with the NAS as the reorganization process progressed. Some Board members, McDermott emphasized, wanted to go further and draw up articles of incorporation for an Academy of Medicine. McDermott thought that support for this action was waning, yet the sentiment persisted. Handler replied that there was little point in the NAS Council meeting with the Board. The Council preferred to wait for the report of the Reorganization Committee, chaired by Franklin Long of Cornell University, before such a meeting.94
At this point, neither group knew if it could trust the other. Handler and the NAS Council regarded the creation of a National Academy of Medicine as a real threat to the integrity of the NAS. Ivan Bennett, who was becoming increasingly militant in his quest for a National Academy of Medicine, believed that the NAS had always been "reserved and academic in making studies and proposals," with little "activism in trying to see to it that these proposals are heard in the proper circles and that measures are taken to insure their implementation." Irvine Page thought that there was "little hope of coming to any sensible agreement with NAS without sacrificing the larger objectives of a National Academy of Medicine. I have no enthusiasm whatever to be dominated by Phil Handler and Walsh McDermott, who insist on treating us as second class citizens." The notion of trying to get back to the substantive work of the Board was only a "ploy" to silence Page and his allies.95
If so, it worked. For a time in late 1969, the Board concentrated on such substantive issues as the movement to pass national health insurance and the increased use of physician's assistants. A spurt of
renewed 1960s optimism attended this phase of the Board's work. It appeared likely that Congress would approve some form of national health insurance and that troop reductions in Vietnam would create a peace dividend that could be spent on social programs. At a time of fears of a shortage of physicians, nurses, and other key health professionals, de-escalation of the war also had the salutary effect of increasing the number of medical doctors and nurses at home. Caught up in the spirit, one Board member talked of opening "up for this nation and our society a whole new vista of progress."96 Buoyed by this optimistic feeling, the members made a crucial concession to the NAS and agreed to wait for the report of the Long Reorganization Committee before taking action on an independent National Academy of Medicine. "In my judgment," a relieved McDermott told Handler, "the immediate crisis has been weathered." For his part, Handler believed that "our problems are not solved and that we have simply bought time to bring the house in order. But that is all that I had hoped to accomplish at this period."97
Some of the fallout from the protracted struggle began to appear in early 1970 in the form of critical articles in the professional press. The standard line was that the Board had failed to live up to its expectations, as demonstrated by the rejection of its plan to investigate medical education. The rebuff of the academy idea by the NAS had "shattered the morale of many board members and staff." As further evidence of the low morale, the press pointed to the fact that both Shannon and his protégé Joseph Murtaugh were planning to leave the National Academy of Sciences. Shannon, who had been acting as an NAS consultant since his 1968 departure from the Academy, took a job with former NAS president Fred Seitz at Rockefeller University. Murtaugh, who had done a heroic amount of staff work for the Board, accepted a position with the Association of American Medical Colleges. 98
Despite bad press notices, the Board made real progress toward the resolution of its issues in January 1970. For one thing, Ivan Bennett met with the members of the Long committee and came away impressed. Although he had been an outspoken critic of Walsh McDermott, he began to believe that some sort of accommodation with the NAS might be possible. For another, Handler, stressing that the NAS had not vetoed the idea—as opposed to the title—of a National Academy of Medicine, worked at selling the concept of what McDermott called an "Institute of Health Sciences" to Board members.
Page began to give ground. If there could be a broadly based organization that "subtended all of medicine in its broadest sense"
and if money could be raised for such an organization, he ''would see no reason particularly for starting anything outside" of the Board on Medicine. To be sure, Page remained skeptical, yet he felt he had no alternative but to give the initiative a chance.99 When he left the January Board meeting, Page told Comroe that he had the strong impression he "would have to play along with it," in part because Robert J. Glaser and Irving London had gone "over to the other side completely." "I suppose in common decency that we have to wait," Page advised.100
As Joseph Murtaugh cleared off his desk before leaving the Board on Medicine, he too detected some progress. The Board had decided to turn its energy toward examining the implications of national health insurance for medicine, medical education, and health services. It was the usual broad and diffuse Board inquiry, yet it indicated that at least some members were beginning to think of something other than a National Academy of Medicine. In addition, Dr. Eugene Stead had started a small study of the role of the physician's assistant in medicine. Even better, Murtaugh thought that Page would call off a planning meeting of his "Cleveland group."101
In May, the Board on Medicine received a full briefing on the Long committee report. Although the report contained many suggestions about dividing the NAS membership among several subacademies, it also included the idea of creating institutes within the NAS structure. Most of the committee's recommendation required approval of the membership, which could take at least a year. McDermott stressed, however, that the Board could proceed with the creation of an institute immediately. Much like the old Board on Medicine, the new institute would survey the field, generate its own agenda, and undertake its own studies with its own staff. If the Board wished to go this route, "we are in a position to pretty much carve it out the way we want it," said McDermott. Adding his support, London noted that if Page gave his approval and the members approached the task with enthusiasm, the necessary money could be raised to make a go of this institute. McDermott persuaded the Board to put together a proposal for an institute that he could bring to the NAS Council.102
The Institute of Medicine
Once again, the Board on Medicine dusted off a proposal and presented it to the Council of the National Academy of Sciences. In this proposal, the Board asked that it be converted to an Institute of Medicine, reporting directly to the NAS Council. It would be
"qualitatively similar to the Board but sufficiently expanded ... to meet the great needs revealed by 2.5 years of Board experience." The Institute would conduct its own studies, provided they were less than a year in duration. Longer studies would be conducted jointly by the NRC and the Institute. As in the previous proposals for an academy, the Institute would have fixed terms of membership and be able to select its own members, most of whom would not be NAS members. At least 25 percent of the members would have degrees in fields other than medicine or biomedical sciences. All members would be selected for their personal attributes, not because they represented a particular constituency. Soon after the Institute started, it would have about 100 members, and ultimately it might grow to 250 members.103
Walsh McDermott and a delegation from the Board on Medicine presented this "draft charter" to the NAS Council on June 5, 1970. Yarmolinsky, the principal writer, hastened to reassure Council members that the Charter marked a revision of, but not a departure from, the Board on Medicine. It would not establish a propaganda body, as some Council members feared. On the contrary, it represented the culmination of long years of discussion and established a workable relationship with the NAS. If the Academy rejected this approach, McDermott warned, it would lose "the medical constituency."
The following day, the Council voted to authorize the president of the National Academy of Sciences "to take the necessary steps to create an Institute of Medicine." The Council specified that it would have final authority over the Institute, including the right to review publications and the right to add or delete names of those nominated for membership. It also asked to see a "specific detailed plan describing the organization and operation of the Institute." It regarded this plan as little more than a formality, however, because it authorized Handler to announce the Council decision to the public.104
On June 10, 1970, the National Academy of Sciences made a formal announcement that it would create an Institute of Medicine "to address the larger problems of medicine and health care." In a letter to McDermott, Handler cited the design of the health care delivery systems, the role of university medical schools, the mechanisms for funding medical care, and the support and nature of biomedical research as the types of problems the Institute might address. He also requested McDermott to prepare a document containing the bylaws of the organization in time for the NAS Council meeting in August.105
Appearing before the Board on Medicine in June, Handler assured the group that the NAS Council had given the Board on Medicine the
"broadest kind of hunting license" to establish the new Institute. The head of the Institute would be "someone of stature who would command a commensurate salary." The Board envisioned such a person to be about 45 years old. ''If you find the best man for it, we are just going to be delighted," Handler said, using the conventional sexist language of the era. He added that he did not foresee any problems with NAS Council approval.106
A draft of the constitution and bylaws received the Board's approval on July 22. The next step was for Irving London, Adam Yarmolinsky, Walsh McDermott, and James Shannon to present these documents to the NAS Council on August 24. In the meantime, Handler offered his suggestions. Among other things, he changed the title of the president of the IOM to the director, and the name "executive council" to "executive committee." In making these suggestions, Handler hoped to avoid confusion between the IOM and the NAS itself.
The August 24 meeting of the NAS Council went smoothly. On nearly all matters of dispute between the Board and the NAS, the Council yielded. The Council wanted to restrict the total number of members, but McDermott assured them that the Institute's work required more than 200 people. The Council agreed that the IOM should have a president, not a director. Both sides concurred in the provision that all members of the Medical Sciences Section of the National Academy of Sciences would receive an invitation to join the Institute.
On September 9, 1970, Walsh McDermott wrote that he, Adam Yarmolinsky, and Irving London were all quite pleased with the final version of the Institute of Medicine's Charter and Bylaws. The Charter contained a ringing statement that reflected McDermott's point of view: "The problems posed in provision of health services are so large, complex and important as to require, for their solution, the concern and competences not only of medicine but also of other disciplines and professions."107 In the terms of the earlier debate with Irvine Page, the Institute would speak about, not for, medicine.
Irvine Page retreated as gracefully as he could. In an editorial that appeared in October, he stated that he had once believed that only a freestanding National Academy of Medicine would do. Recently, however, he had been persuaded that the "N.A.S sincerely wishes to fulfill those needs through an Institute of Medicine. The immediate plans have taken more than two years to evolve, and the institute deserves a fair trial." Robert J. Glaser called Page's statement "excellent.... I believe we are now well on our way to creating the kind of organization you and others envisioned from the start."
Although Glaser warned that much would depend on securing financial backing, the initial signals from the foundation community were encouraging. Independently of Glaser, Page learned that foundation money for the sort of national academy he had wanted to form was no longer obtainable. As Page put it, the Carnegie Foundation and Commonwealth Fund planned to let the Institute "have a try and fail before big money will be available for NAM."108
Between 1967 and 1970, the Board on Medicine spent most of its time trying to reconcile the conflicting points of view of its members and negotiating with the National Academy of Sciences. As a consequence, it completed few studies and gained fame only for a short statement that it issued on heart transplants. An initial round of enthusiasm for the venture went largely unexploited, because the members of the Board could never quite agree on its final form. An almost superhuman form of patience was required on Walsh McDermott's part to bring the process to conclusion.
In the end, however, the Institute of Medicine reflected McDermott's vision as much as anyone else's. When Irvine Page wrote the 1964 editorial launching the process that ultimately led to the Institute of Medicine, he did not envision that the result would be an organization in which a quarter of the membership would be composed of people from outside the health sciences. Nor did he foresee an entity concerned not only with the problems of medical research but also with the larger social problems surrounding health. The Institute of Medicine was created at a time when health policy experts and even some of those in the realm of heath sciences research, such as McDermott, emphasized the social aspects of medical problems and people thought these problems were amenable to solution. The optimism of the era was stamped on the Institute of Medicine's Charter and Bylaws and on its initial agenda.
So were the organizational tensions that had developed in the National Academy of Sciences. These tensions created ambiguities that would continue to plague the Institute. Exactly how much autonomy did the Institute have? How did the Institute relate to the rest of the Academy structure? Few people wished to probe these questions too deeply for fear of upsetting the delicate set of understandings on which the IOM rested.
On December 17, 1970, Philip Handler appeared before the Board on Medicine, functioning as the Executive Committee of the Institute of Medicine, and announced that Dr. Robert J. Glaser would serve as acting president of the Institute. He would volunteer his time and keep his regular job. Until recently the dean of Stanford's School of Medicine, Dr. Glaser currently worked as a vice president of the Commonwealth Fund in New York, a position previously held by Board member Colin MacLeod. Four days later, the NAS issued a press release announcing the "formal activation of the Institute of Medicine."109 The Institute of Medicine was launched.