The Hamburg Era
On May 3, 1977, President Jimmy Carter read an article in the Washington Post and jotted down a note for Joseph Califano, his Secretary of Health, Education, and Welfare (HEW). The President wanted Califano to read the story on an Institute of Medicine (IOM) study of computed tomography (CT) scanners. The thrust of the study was that hospitals and physicians should not overuse the beneficial yet costly new technology. Only after the local health planners approved should a new CT scanner be installed; these local planners should make sure that each scanner operated at maximum efficiency, performing a minimum of 2,500 tests a year. Hospitals, not private doctors' offices, should be the setting for scanners. "Let's take similar action—stronger if possible—and include other devices as well," the President urged his Secretary of Health, Education, and Welfare.1
If the Institute of Medicine wanted evidence of its influence, the note from Carter to Califano provided it. In 1977, the IOM knew that the President of the United States and his chief minister for health both took an interest in its activities. The moment marked the realization of Walsh McDermott's aspirations by proving that the IOM could have an enduring effect on the nation's health policy. It also demonstrated the dramatic results of David Hamburg's management. Hamburg, who had taken over from Donald Fredrickson in the fall of 1975, provided the IOM with five years of inspirational leadership.
Despite these considerable achievements in the Hamburg era, the embrace of the Carter administration failed to heal all of the IOM's maladies. Even at the end of five years of steady activity, old problems continued to nag at the organization. These included the lack of a secure financial base, troubled relations with the National Academy of Sciences (NAS), and an often less than clear focus for the IOM's activities.
David Hamburg Arrives
The departure of Donald Fredrickson put a strain on the IOM, which had gone through two presidents in less than five years. Most of the effort to pick up the pieces fell to Julius Richmond, the distinguished child psychiatrist who acted as vice chairman pro tem of the IOM Council. Much as Robert J. Glaser had filled the void between Walsh McDermott and John Hogness, so Richmond, ably assisted by Roger Bulger, kept things together in the spring and summer of 1975. He quickly constituted the Executive Committee of the Council as a search committee and set it to work finding a new IOM president.
The fact that the IOM had searched for a president less than two years earlier facilitated the process. The same short list that had been developed in the summer of 1973 could also be used in the spring of 1975. Although Richmond encouraged members to submit nominations and generated a list of more than 60 names, he and his committee concentrated from the first on a few, select candidates. On June 19, the IOM Council culled through the names and designated David Hamburg as its first choice. The NAS Council moved quickly to confirm the selection, although Philip Handler objected to being given only one name to consider. Richmond explained that although the Council had other candidates in mind, it had not "ranked them as clearly as we had Dr. Hamburg." Handler acquiesced, in part because Hamburg had been the second choice less than two years before and would, in effect, be filling Fredrickson's unexpired term. On June 26, 1975, Handler wrote to Hamburg and offered him the job.2
David Hamburg's acceptance of the offer depended on a set of circumstances as bizarre as the IOM had ever encountered. Because Hamburg was in Dar es Salaam, Handler's letter reached him very slowly. Hamburg had gone there to negotiate the release of four Stanford students who had been kidnapped by Zairian rebels. On July 19, 1975, Hamburg reported to Handler that three of the four students had been freed without harm, "but the negotiating process for the fourth is very difficult." In the meantime, he and his wife were discussing Handler's offer.3 The kidnapping incident delayed the recruiting process and meant that Roger Bulger effectively ran the IOM from the beginning of July until the beginning of November. Formal announcement of Hamburg's appointment came only at the end of October.
Born in 1925, David Alan Hamburg spent his childhood and received much of his education in Indiana, graduating from the University of Indiana Medical School in 1947. After taking three
years off for military service, he went to Michael J. Reese Hospital, where he had taken much of his postgraduate training, and worked at the Institute for Psychosomatic and Psychiatric Research and Training. In 1958, he began a three-year stint as chief of the adult psychiatry branch at the National Institute of Mental Health in Bethesda. Then, in 1961, he took over as the chairman of Stanford's Department of Psychiatry. In the summer of 1975, he held the appointment as Reed-Hodgson Professor of Human Biology in Stanford's medical school. In his research, Hamburg analyzed the links between biology and behavior, examining such things as the behavioral, endocrine, and genetic aspects of stress and the biologic basis for aggressive behavior. He had more than 93 scientific papers to his credit. The appointment of Hamburg continued the IOM tradition of selecting distinguished researchers and administrators from the field of academic medicine as president. 4
On November 6, 1975, David Hamburg delivered his inaugural remarks to IOM members who attended the annual meeting. He was far from a stranger in IOM circles, having been selected as an initial member in 1971, served on the Council from 1971 to 1974, and chaired the Program Committee between 1972 and 1973. In his inaugural remarks, he described what he considered the key features of the IOM. The organization made a "serious, thoughtful attempt to face" difficult issues and to do so in a way that cut "across traditional specialties and perspectives." Unlike other organizations, the IOM held "no over-riding doctrine, no party line, no cow too sacred to be examined," and its views reflected ''deeper analysis and reflections" than those of others in the health field. After listing the organization's assets, Hamburg pondered its liabilities. He wondered how the IOM could coax sufficient time from its busy members to examine the key issues, how a Washington-based staff could relate to a geographically dispersed membership, how the IOM could preserve its independence and be of use both to the government and to private institutions, and how the IOM could achieve cross-specialty collaboration ''to tackle the policy problems of health care, prevention, education and the science base underlying it all." These problems, Hamburg observed, deserved "thoughtful attention. And I intend to get it—by quiet, respectful inquiry if possible; by relentless harassment if necessary."5
Speaking to the members, Hamburg revealed an almost pastoral style. Almost alone among the previous IOM presidents, he spoke and wrote with an inspirational eloquence with which he exhorted the members to contribute to the organization. At the same time, he realized that he and the organization faced many problems, not the least of which were his own logistical difficulties. He told the IOM
Council, for example, that he would not be able to move to Washington on a full-time basis until June 1976. Until then, he would take up the IOM presidency to the "maximum extent that circumstances would permit."6
Ruth Hanft and the Social Security Studies
Hamburg would also have to build up his own team. At the end of 1975, Adam Yarmolinsky ended his term on the IOM Council, severing one of the last links between the Institute's founders and the inner circles of IOM policymaking. In the case of Yarmolinsky, the Council thought so highly of his services that it took steps to preserve a role for him, designating him as a special counselor to the IOM. He continued to provide the organization with legal and practical advice until, accepting a position in the Carter administration, he suspended his close IOM ties for the duration of his government service. Another key departure, that of Roger Bulger, took place early in 1976. He became chancellor of the University of Massachusetts at Worcester and dean of the University of Massachusetts Medical School. No doubt part of his appeal to the university was the fact that he had served so effectively as interim head of the IOM and had gotten to know so many leading figures in academic medicine through his service as the IOM's executive officer. Still another departure that took place in 1976 involved Ruth Hanft.
With Hanft went the large data-gathering studies. As David Hamburg took hold of the IOM, another such study reached completion. This second study followed from the first one, which had concerned the costs of medical education. After the IOM had submitted the earlier study, Congress asked it to consider the related problem of how the Medicare and Medicaid programs should pay physicians in teaching hospitals for their treatment of elderly (Medicare) or indigent (Medicaid) patients. Congress also wanted to know how much federal money went into the support of foreign medical school graduates and how Medicare reimbursement could be used to avoid gluts of physicians in some areas and shortages in others. Finally, the study request asked the IOM to consider how Medicare reimbursements might be structured so as to encourage a greater number of physicians to enter primary care fields.
Adam Yarmolinsky chaired the steering committee, and Ruth Hanft directed a large staff, which eventually grew to 45 people, for what became a very elaborate effort. This second large data-gathering study raised many of the same problems as the first. The Medicare
law, passed in 1965, made a distinction between payments for medical services provided by physicians and payments for medical services provided by hospitals. In the case of teaching hospitals, however, it was difficult to separate physician and hospital services. Medical students, interns, and residents all treated patients, yet these practitioners often received salaries from hospitals or medical schools as part of the hospital staff. Furthermore, it was difficult to separate the costs of treatment from the costs of education. To address these problems, the staff designed a survey that was sent to 1,400 teaching hospitals; it made site visits to 96 teaching hospitals, 15 medical schools, and 2 osteopathic schools and ascertained how the more than 100 intermediaries and carriers who administered Medicare on behalf of the Social Security Administration defined teaching physicians and teaching hospitals.
The collaboration between Yarmolinsky's steering committee and Hanft's staff often grew strained. In the final version of the report, Yarmolinsky attributed classical virtues to Hanft and her staff. They were "heroic," "stoic," and ''Socratic in [their] dialogue with the steering committee." At the same time, staff and steering committee faced different and often conflicting tasks. The staff wanted to collect as much data as accurately as possible and be responsive to Congress. Although the steering committee shared this goal, it also sought to draw larger policy implications from the data. The process of combining these different outlooks and missions into a coherent document, on a subject technical enough to require a seven-page glossary just to make the report accessible to medical experts, proved difficult. In the end, the IOM issued 99 pages of findings and recommendations and many more pages of what were described as resource papers.
Despite Yarmolinsky's insistence on clarity, the study's recommendations were so inward and technical as to be beyond most people's comprehension. For example, the group recommended that "under the cost payment regulations issued under Section 15, Public Law 93-233, inclusion of payment of the imputed value of volunteer services should be continued; under the same cost regulations, the ceiling of $30,000 on the imputed value of a volunteer teaching physician's services should be changed to the average salary for full-time physicians in the area or the VA [Veterans Administration] compensation for full-time physicians if an area average is unavailable." In general, however, the group recommended that an interim solution to the problem of Medicare reimbursement in teaching hospitals, adopted by Congress in 1972, be discontinued and that other payment methods, which the group specified, might be
appropriate. In addition, the group came out in favor of providing more funds for ambulatory care services so that teaching hospitals could more easily support primary care training programs. Going even further, the study recommended elimination of the immigration law incentives for importing foreign physicians. According to Yarmolinsky, the most controversial recommendation of all was one that would permit the Secretary of HEW to withhold Medicare and Medicaid funds from residency programs in specialties that a "permanent, quasi-independent physician manpower commission" determined to be in excess supply. 7
The IOM held a press conference to release the report. Questions dealt with the recommendations favoring ambulatory care services because, as Ruth Hanft conceded, the proposals in this area were easier to understand than the others. Hanft also briefed congressional staffers on the report; they tended to share some of her dissatisfaction with the IOM study process. The report recommendations, the congressional staff members believed, confused the interests of the medical schools with the public interest, even if the study itself had produced valuable data. Expressing unhappiness with the composition of the steering panel, the congressional staff members thought it was weighted, like IOM membership itself, in favor of academic medical centers.8
Most IOM members never had a chance to read the Medicare reimbursement report. Because it was large, bulky, and expensive to mail, it went only to members of the steering committee and the Council. When David Hamburg learned about this situation, it made him think more about how to engage members in the work of the IOM. His experiences with the Medicare reimbursement study also caused Hamburg to consider what role, if any, large data-gathering studies should play in the IOM program. Ruth Hanft, for her part, pushed Hamburg to accept other, technical assignments from Congress that did not require issuing recommendations and could be done by staff alone. Concerned about the separation of staff and membership, Hamburg and the IOM Council grew wary of Hanft's requests, and she eventually left the IOM staff. 9
The Institute Recharts Its Course
Although Hamburg wished to encourage member participation, he realized how important it was to maintain good relations with the congressional staffs who were interested in using the IOM to create and maintain data bases. The mid-1970s marked a period of
resurgence in congressional activism that followed the Watergate investigations. In this era, the bipartisan spirit that had prevailed between the Republican President and the Democratic Congress began to break down, and Congress began to insist on developing its own analytical capacity rather than accepting the advice of executive agencies. Congressional subcommittees, staffs, and agencies such as the Congressional Budget Office and the Congressional Research Service all began to grow. Health, particularly the costs of health care, was a major preoccupation of congressional and executive branch policymakers in this era of concern for rising prices and stagnant wages. Although Hamburg wanted to make the IOM relevant to this new policymaking structure, he hesitated to do so in a way that would turn the IOM into a staff-driven Washington think tank or consulting firm.
Like his predecessors, Hamburg grappled with the issue of the IOM's identity during his first year in office. He initiated a major review of the IOM's progress that lasted from the fall of 1975 through the fall of 1976. The review, extending to all levels of the IOM's operation—from the staff, to the IOM Council, to the IOM membership—provided Hamburg with a means of learning about the organization, forging a consensus as to its future direction, and reshaping the organization to reflect this consensus. In a more personal sense, it enabled Hamburg to fill in the awkward period during which he commuted to Washington from California.
The process began at the staff level with regular staff discussions and with the work that Roger Bulger had commissioned Larry Lewin to do in the summer of 1975. At Bulger's suggestion, Lewin, a noted management consultant in the health care field, questioned a wide range of people on a broad range of topics about the IOM and presented his results in the form of a staff seminar that took place on March 19, 1976.10 After he told the staff some of what people had said to him about the IOM, he led a structured discussion designed to expose problems and suggest possible solutions.
As Lewin's report made clear, people in the Washington community held differing opinions of the IOM's capabilities. Jay Constantine, a plain-speaking member of the Senate Finance Committee staff, said that the IOM should perform "neutral" studies for Congress, unlike the costs of education study on which the IOM had "whored" by ignoring the evidence and coming out in favor of capitation. Stuart Altman of the Department of Health, Education, and Welfare thought that the IOM was needed, but not for large data-gathering studies because others could do them better. Jim Mongan, a colleague of Constantine's, agreed and said that the federal
government should develop its own analytic capacity, through agencies such as the congressional Office of Technology Assessment, rather than depend on the IOM. The weight of opinion, therefore, seemed to be against the IOM's doing large data-gathering studies. As for what the IOM should do, one public health official believed that conferences should be its main activity; others urged the IOM to do quick-response studies, perhaps without using a steering committee.
The discussion then turned to the management of the IOM. One lingering problem was an undertone of antagonism between staff members assigned to specific projects and members of the permanent core staff. Project staff perceived that the core staff all too readily identified with the IOM membership rather than with their fellow staff members. The problems were particularly acute on steering committees. Many staff members felt that such committees were a "resource to be managed," rather than the ultimate arbiters of a particular study or project. Listening to the discussion, David Hamburg realized that he would have to clarify the expectations that project staffs and steering committees had of one another.
Although the discussion was diffuse, it did produce four tentative conclusions. First, the IOM, the staff now believed, should work on some big issues but not at the expense of monopolizing IOM money or staff talent. Second, the IOM staff should develop the ability to perform policy analysis on a quick-response basis. Third, the organization should work hard to alter the "wrong but strong" perception that the IOM was dominated by officials from academic health centers. Fourth, the IOM should use the broad-based interests of its members to expand the Institute from a Washington-oriented operation to a national operation. More than anything else, however, the discussions demonstrated that no one had a firm fix on the IOM's mission. Adjectives such as "rudderless," "drifting," and ''floundering" came up in Lewin's discussion with government and foundation officials. According to one foundation officer, "the IOM had not yet decided what its mission should be.'' Furthermore, the IOM did not function well enough "to free its president to chart a course and to harness available resources to pursue that course."
Staff tried to follow up on the Lewin session by posing their own questions about IOM's organization and management. In effect, staff members prepared a "wish list" for Hamburg to consider. High on the list was the desire to clarify the relationship between the staff and the steering committees. Staff wanted steering committee members to receive a document that, among other things, explained the staff role, exhorted committee members to meet deadlines, educated the committee on basic research methodology, and admonished steering
committee members to attend meetings. The staff also pressed for studies that its members could do on their own, with only an advisory, not a steering, committee to assist them.11
Hamburg made few commitments and turned next for advice from the IOM Council and from IOM members. Council member Dorothy Rice, director of the National Center for Health Statistics, gave one of the most thoughtful replies. She wrote that most members felt the IOM had not lived up to its great potential, spending too much time on large studies that did not address the nation's most important health problems. Rice told Hamburg that the IOM had to decide how much of its efforts should be devoted to "major studies, policy statements, background papers and conferences and seminars." She then asked how the IOM should operate. Should it be like Brookings, which turned a talented staff loose on important problems; the Committee on Economic Development, which issued policy statements that reflected the views of enlightened businesspeople on policy issues; or the Urban Institute, which performed contract research for the federal government? As the IOM grappled with this issue, Rice cautioned that Hamburg would have to consider the important issue of staff morale. "To keep good staff," she advised, "you need to provide a mechanism for close identifications of the individual and the research product." This led her to the issue of steering committees. Was their purpose to act as an advisory group or ''to provide actual directions to staff in the conduct of the study"? When studies were completed, it often took a great deal of time to disseminate the results. Rice said that the delays relating to project approval that were built into the system required examination, as did the question of how the membership might be involved in the entire process.12
A major motif of the members' responses to Hamburg was that the IOM was not the organization they wanted it to be. Ernest Saward, former director of the Permanent Clinic in Portland, Oregon, and an original member of the Board on Medicine, told Hamburg that he was frustrated with the IOM. "It was to be a working group, not an honorific one," he explained, and "while there was to be staff, it hardly was imagined that the staff did all the work and the members were more or less judicial." Saward complained that unless one were a member of the Council, it was hard to keep up with IOM activities. The Board's original vision for the IOM "seems very distant to us now."13
Robert Petersdorf, the head of the Department of Medicine at the University of Washington, agreed with Saward that "the Institute is not fulfilling the high hopes which many had for it," but he disagreed on the nature of the failure. In Petersdorfs opinion, the IOM was
wanting because it had failed to act as Irvine Page had hoped it would. "The IOM has not really become the collective spokesman for medicine," he told Hamburg. The problem lay in the fact that social scientists had taken over the IOM, in part because they had worked harder at it. Although Petersdorf conceded that social scientists were necessary, he worried that many had made their reputations by "taking anti-medicine stands. In fact, a number of people have begun to call the IOM the 'Institute of Anti-Medicine.'" It was up to Hamburg to set things right. "No organization,'' Petersdorf advised, could prosper "unless there is strong direction from the top and in a relatively continuous fashion."14
Before Hamburg provided this direction, he wanted a mandate from the Council and the members. Toward this end, he scheduled a series of retreats for the IOM Council that took place in July 1976. Julius Richmond presided over the first one in which five IOM Council members held a long and unstructured discussion of IOM priorities, deciding that the IOM should devote more of its time to "short-term, quick-response kinds of activities" that allowed the organization to react to public policy developments.15 Hamburg seemed to affirm this point at a meeting of the Program Committee that took place a week later. He said that the Institute would not be doing so many "responsive" studies in the style of the Medicare-Medicaid reimbursement project. Instead, it would turn more toward private foundations and corporations to support smaller studies.16
At the end of July, Council members held a two-day retreat at Woods Hole, Massachusetts, at which they contemplated the IOM's future. Setting the tone for the discussion, Julius Richmond said that the IOM could "no longer offer promissory notes; it must begin to influence public policy more substantially." In support of this proposition, Richmond said that the IOM should begin to attack major problems such as national health insurance and biomedical research policy. Although Richmond did not know it, his priorities were exactly those of the Board on Medicine, which had singled out the same two problems for attention. Listening to the discussion, Hamburg floated an idea that he had been considering for a long time. He would ask the staff to "map out the terrain" in five major policy areas, giving staff a definite role in the "new IOM" and staking out the major issues that should be addressed. Hamburg thought that the five areas should be (1) health services, with special attention to national health insurance; (2) health sciences policy; (3) prevention of disease; (4) education for the health professions; and (5) mental health. This proved to be the major idea that emerged from the meeting.17
In a communication from Hamburg to IOM members in September 1976, he synthesized the staff, committee, and Council discussions of the IOM's mission. Here again, he announced his intention "to map the terrain of health by means of the multiple perspectives so distinctively available in IOM." In the past, IOM studies had been initiated by Congress and the executive branch, but the terrain maps would make it easier for the IOM to initiate its own studies. Although Hamburg did not believe that the IOM's five principal benefactors would continue to provide the sort of flexible money that would make such initiatives possible, the IOM might be able to obtain foundation grants in "particular program areas."18
The upshot of the long discussions was a reorganization. In March 1977, the Institute of Medicine created six operating divisions, each with its own staff director and its own advisory board of IOM members and other experts. The divisions corresponded to the categories in which the Program Committee had considered proposals and the subjects of the terrain maps. Before the reorganization, staff had worked on projects of the moment without a permanent assignment. The new plan made it possible for staff members to develop specialties and for the entire IOM program to have more coherence from one year to the next.
The titles of the divisions and their areas of responsibility underwent constant change as the health care policymaking environment, available staff, and available funds changed. In the original six-division scheme, the Division of Health Care Services focused on topics related to health services research, such as the financing of health care and issues of health care quality. The Division of Health Manpower and Resources Development concentrated on such issues as education and the proper distribution of medical specialists. Elena Nightingale, who was both a Ph.D. and the only M.D. among divisional directors, headed the Division of Health Promotion and Disease Prevention, which examined the impact of biological and social factors on disease and disability. The Division of Health Sciences Research was responsible for projects that related to "the conduct and support of biomedical and behavioral research." The Division of International Health worked on projects that related to health and economic development, and the Legal, Ethical, and Educational Aspects of Health Division was a catchall category to cover everything else.19
The creation of program divisions and the initiation of terrain maps transformed the way in which the Program Committee did business. What before had been an unstructured discussion of disparate projects became a much more disciplined conference on the six program areas. As Cecil Sheps, a public health specialist from the University of North Carolina, put it, every proposal had some value, but the "maps" would guide the committee in choosing among the proposals. David Hamburg himself chaired the group in charge of writing the terrain maps in health science policy and in prevention. Karl Yordy coordinated the committee working on health services policy. Drafts of these documents sparked spirited discussion within the Program Committee on an appropriate IOM role. In the area of health sciences policy, for example, the IOM might assess public participation in the field and ways in which the distribution of research dollars hampered interdisciplinary research. In the area of health promotion and disease prevention, the IOM might study the cultural factors that provided incentives for people to behave in healthful ways.20
By 1979, Dr. Theodore Cooper, the head of the Program Committee, could envision an entirely new role for this committee. No longer would it focus on specific studies. Instead, it would take a long-range view of health developments in the United States and identify "broad policy issues of high significance." Meanwhile, the division advisory boards would focus on specific projects that should be addressed in a particular year.21
By the time Cooper spoke, the division structure had already been altered. At the end of 1978, David Hamburg announced that the catchall division for medical ethics and other concerns would be abolished. In its place would come a new Division of Mental Health and Behavioral Medicine, an appropriate enough choice given the interests of the current administration and of David Hamburg himself. Another change came in IOM's management structure. As before, the president would be assisted by an executive officer. Since the departure of Roger Bulger, Karl Yordy had assumed this role. Just below Yordy in the organizational structure would come two program operations officers: Stan Jones, who had once worked for Senator Edward Kennedy (D-Mass.), would focus on program development and serve as principal staff to the Program Committee; Richard Seggel would focus on program operations and serve as principal staff to the Finance Committee. The division directors, in turn, would function as staff to the advisory boards in their particular areas.22
The new organizational structure achieved at least three separate goals. First, it increased the participation of members in IOM activities. Not only would members be able to serve on the Program Committee, they also would be able to serve on or make suggestions for an advisory board in their particular specialty area. Second, the new structure simultaneously expanded the role of the staff, because staff would have to guide the advisory boards and help in the creation of terrain maps. Finally, it enabled outside funders and other interested parties to observe what areas of inquiry the IOM regarded as most important and hence what projects most deserved to be funded.
Clearing the Pipeline
Before the new system could go into full effect, the IOM had to absorb the old studies that were in the pipeline. Perhaps the most important of these concerned the formulation of a manpower policy for primary care, a subject that would become a recurrent motif in the Institute's program. Begun in 1975 with funds from both the Robert Wood Johnson and the Kellogg Foundations and released in 1978, the study experienced many of the tensions that were evident in the IOM during this period. It fell somewhere in the middle on the scale between a large data-gathering study and a policy pronouncement. About a year into the project, Harvey Estes, the head of Duke's Department of Community and Family Medicine, who chaired the steering committee, asked the Council to increase the funds for the project so that the committee could develop estimates of the manpower required to supply an appropriate amount of primary care. The Council, wary of large data-gathering efforts, balked at the request and instructed the steering committee to reach conclusions based on the available evidence. When the completed study came before the Council for review, some Council members questioned whether the recommendations were internally consistent. They ordered the steering committee to change the order in which it presented its recommendations so as to convey "continuity of thought."23
The final report took as its objective the development of an "integrated" primary care manpower policy, although the steering committee admitted that it had undertaken no original research. Instead, the committee relied on staff papers, an open meeting at which interested organizations presented their positions, and steering committee members' "own expertise." The basic approach was to
develop a working definition of primary care—"accessible, comprehensive, coordinated continual care delivered by an accountable provider of health services"—and then suggest ways in which to create an adequate supply of such care. The committee stressed that the answer was not to increase the number of medical school students but rather to alter the incentives for physicians and other health care practitioners to enter primary care fields. Payment differentials between primary care and other services should be reduced. The national goal for the percentage of first-year residents in primary care fields should be increased. All medical schools should direct, or have an affiliation with, at least one primary care residency program. When medical schools admitted students, they should favor those who wanted to go into primary care fields, and all medical schools should provide undergraduates with clinical experience in a primary care setting as well as training in epidemiology and other aspects of the behavioral and social sciences that were relevant to patient care. What distinguished the report from a laundry list of recommendations was that it included a checklist of the steps that medical schools could take to implement the changes advocated by the committee.24
Aware of the need to distribute the results of its studies, the IOM made efforts to place a summary of the study in a good journal. The article appeared in the New England Journal of Medicine, which is read by doctors in many different specialties, soon after the formal release of the report. It carried the names of three authors. The first two were members of the project staff and the third was Harvey Estes. In this way, the IOM not only disseminated the results of its study but also provided an outlet for the creative energy and professional advancement of the staff.25
Another IOM study of this period stemmed from a congressional request to investigate quality assurance programs. The programs reflected Congress's desire to make sure that Medicare and Medicaid patients received appropriate services from health care providers, as well as an interest in using the Medicare and Medicaid programs to contain health care costs. In 1972, Congress authorized the establishment of professional standards review organizations, and in 1973, it mandated a study of alternative mechanisms for health care quality assurance. Long negotiations between the IOM and the Department of Health, Education, and Welfare ensued, with the result that the study did not appear until 1976. The steering committee, under the direction of Dr. Robert Haggerty, a professor of health services and child health at Harvard, concluded that there simply was not enough available information to demonstrate the effectiveness of quality assurance programs. The committee offered
suggestions, such as targeting reviews on "questionable patterns of care," to increase the effectiveness of existing review programs. As part of the same project, the IOM also studied the reliability of information on abstracts of hospital discharge records, finding wide discrepancies between the results obtained by an IOM team of researchers and the results in the hospital discharge records.
This study focused on the inner mechanics of health policy and the technical aspects of health care and answered questions posed by Congress, rather than by IOM members themselves. Within a very limited circle, such as the National Standards Review Council and professional conferences on disease classification, the study received wide play. The study fit the traditional NAS and National Research Council (NRC) model in which the Academy advised the government on technical and scientific issues. Indeed, Philip Handler welcomed competition between the NRC and the IOM in responding to requests to the Academy from the government. Even as Hamburg presided over the dissemination of the study on quality assurance, however, he hoped that the IOM woul be able to break free of this mold and initiate its own studies.26
The Malpractice Study and the Polio Study
The medical malpractice project exemplified the sort of study that the IOM had wished to do for a long time. First discussed in the era of John Hogness, it came to fruition during the presidency of David Hamburg. Like many IOM studies, it took a great deal of time to complete and involved a considerable amount of turmoil within the staff and the steering committee. The final study, for all of the effort that went into it, turned out to be a brief report with few policy recommendations.
The project began when John Hogness appointed an Ad Hoc Committee on Medical Malpractice, which met for a few months in 1973, at the time the HEW Secretary's Commission on Medical Malpractice was about to issue its report. This commission recommended that a uniform body of legal rules governing medical malpractice be created for courts to use throughout the country. The IOM Ad Hoc Committee found many deficiencies in the report, such as its failure to address the deterioration of the physician-patient relationship and the creation of conditions in which patients might well bring a tort action against their doctors. The committee asked that there be an IOM policy statement on this subject. The project then languished for lack of funds. When David Hamburg arrived in
1975, he found the project moribund but the subject compelling and asked IOM staff to find out what had happened in the field of medical malpractice between 1973 and 1975. Staff members Barbara Cohen, who had both Capitol Hill and White House connections, and Michael Pollard, who had both a law and a public health degree, made a round of Washington visits and came up with a new proposal for a study in the area of medical injury compensation. The Henry J. Kaiser and the William and Flora Hewlett Foundations contributed the money to fund the project.
John Hogness agreed to chair the steering committee, which met for the first time in August 1976, in part because he wanted to show his continuing interest in IOM affairs and in part because the subject was one about which he knew little and wanted to learn more. The committee contained an interesting mix of medical practitioners, such as Jeremiah Barondess, a professor of medicine at Cornell University Medical College; social scientists, such as Stanford sociologist Richard Scott and Wisconsin economist Burton Weisbrod; and legal scholars, such as Guido Calabresi of the Yale Law School (who later became its dean). The group also included Jonathan Spivak, the Wall Street Journal correspondent who followed events in the health care field closely.
Like nearly all IOM studies of this era, the work of the Medical Malpractice Committee became delayed. Barbara Cohen, the staff director, left the IOM, and Michael Pollard stepped in to take her place on the study. The budget for the project was tight, and Hamburg had to ask the sponsors for another $30,000 to complete it. Guido Calabresi received the staff draft of the final report in July 1977 and objected so strongly to it that he decided to resign from the steering committee. He complained about the report's loose grasp of economic theory, as in the statement that the cost of rising insurance premiums was passed along to customers.27
The final report, dated March 1978, stated at the end of 64 closely reasoned and heavily annotated pages, that "the focus of public policy and research that relate to medical injury should not be unduly restricted to instances of medical malpractice." Instead, policymakers should concentrate on "the incidence of medically related injury, possible techniques for preventing injury, and financially sound methods for compensating injured patients." In other words, the emphasis should not be on fault, as it was in the present tort system, but rather on prevention and on outcomes. The system should strive to prevent disability and alleviate its consequences, not encourage the deterioration of the physician-patient relationship. Beyond these important insights, the report offered few specific suggestions for
preventing or compensating medical injuries. The report was best read as a primer on compensation for medical injuries, not as a statement of policy or a research report.28
The medical injury report cast the IOM in the role of student rather than teacher. When the organization assumed the part of an expert arbitrating a dispute, it obtained better results. The polio vaccine study, another of the studies completed before David Hamburg's new organizational scheme took hold, illustrated how the IOM could use its expertise to resolve public policy disputes.
Polio vaccinations were one of America's greatest public health triumphs. After the introduction of the Salk vaccine in 1954, new cases of the disease virtually disappeared. By the 1970s, the number of new cases each year could be counted in single digits. Public health officials worried as much about people not getting vaccinated as they did about the safety of the vaccine itself. For greater ease of administration, authorities substituted the use of an oral vaccine for the injected vaccine in 1962. All a person had to do to prevent polio was swallow a sugar cube. Unlike the Salk vaccine, the Sabin oral vaccine was prepared with what scientists called "attenuated live virus." That meant that although the oral vaccine was very safe, it did lead to very occasional cases of polio, perhaps 44 cases between 1969 and 1976, among people who took it or came into contact with someone who had taken it.
The problem acquired more visibility in 1976 in the wake of the effort to prevent an epidemic of swine flu. A number of people who were vaccinated against the flu suffered adverse reactions, creating a major public scandal and raising questions about whether the government or the vaccine manufacturer was liable for damages. In September 1976, an HEW official testified before a Senate subcommittee that the government was having trouble entering into contracts with private companies for the manufacture of vaccines of all types, including those against measles, rubella, and polio. A public health crisis loomed, as officials worried about a shortage of vaccine.
Against this background, Dr. Theodore Cooper, the Ford administration's Assistant Secretary of Health (and later, head of the IOM Program Committee), approached David Hamburg about responding to a request from Senators Edward Kennedy and Jacob Javits (R-N.Y.): Would the IOM look into the relative merits of live (Sabin) versus killed (Salk) polio vaccines? Because of the short congressional deadlines, the job would have to be done quickly; Senator Kennedy wanted the report in the spring of 1977.29
The IOM responded with alacrity. In less than two months, Elena Nightingale of the IOM staff made arrangements for two committee
meetings and a two-day workshop. She and Hamburg persuaded Bernard Greenberg, dean of the School of Medicine at the University of North Carolina at Chapel Hill, to chair the study and recruited a steering committee that contained Fred Robbins, a Nobel laureate for his research on polio and a future IOM president, and Byron Waksman, a professor of pathology at Yale. The time line for the report was exceedingly tight. The committee would meet for the first time on February 10, 1977, and deliver its report on April 15.30
The committee met its deadlines. It convened in February to develop a working plan and to organize an international workshop that would take place in March. The workshop gave the committee the chance to consult with authorities from countries such as the Netherlands, which had not switched from the dead to the live vaccine. It also provided the committee with an opportunity to assemble working groups on practical questions, such as how to be obtain informed consent from those who received polio shots, and on the safety and efficacy of polio vaccines in the United States. After these groups departed, the committee assembled in executive session and reached decisions on the major public policy questions. On April 6, 1977, the committee presented its findings at a scientific conference devoted to immunization; nine days later, exactly on schedule, it delivered its report to the Department of Health, Education, and Welfare.
The committee recommended that the United States continue the use of the Sabin oral vaccine as its principal means of preventing polio. It added a number of caveats. Those with heightened susceptibility to infection or adults who were being vaccinated for the first time should continue to take polio shots. The committee also advised that there be a new round of immunizations, to be given orally to all children as they entered seventh grade. The committee hoped that this practice would protect the children in their later years when they became parents and, in this manner, eliminate cases in which parents contracted polio from their immunized children. The committee noted that the country could achieve a higher rate of immunization against polio. As of 1974, for example, only 45 percent of all nonwhite children had been vaccinated against polio. The committee hoped that the nation could reach a 90 percent immunization rate within a few years. To help obtain this goal, the committee advised that all liability from the immunizations, except in cases of gross negligence, be assumed by the government.31
The polio vaccination study attracted a great deal of attention. The New England Journal of Medicine ran an article that summarized the study, as did the widely circulated Scientific American. Elena
Nightingale reported that she had been besieged by requests for copies of the study from groups around the world, including the Belgian government and the World Health Organization. Perhaps the greatest achievement, according to Nightingale, was that the study helped to allay the hysteria that had followed the swine flu vaccine debacle. The study, noted Nightingale, ''has aroused quite of bit of positive interest in poliomyelitis vaccination" and, she might have added, in the Institute of Medicine.32
The Embrace of the Carter Administration
The computed tomography scanning project resembled the polio vaccine study. It was to be a "rapid, yet incisive appraisal of the proliferation of computerized tomography scanners in medical practice." The Blue Cross Association, which served as the umbrella organization for the many local Blue Cross hospital insurance plans across the country, sponsored the study because of its desire, as study director Judith Wagner delicately put it, for the "judicious use of technological innovations in medicine."33 In other words, Blue Cross hoped to put appropriate limits on an expensive procedure. The IOM study helped establish these limits.
The subject of cost containment also figured prominently in a statement about controlling the supply of hospital beds, which the IOM released just before the 1976 presidential election. As with other IOM studies, a long time was needed to acquire the necessary funding and to find an appropriate focus for the project. The completed report stated unequivocally that "significant surpluses of short-term general hospital beds exist or are developing in many areas of the United States and that these are contributing significantly to rising hospital care costs." The study panel, headed by Robert Heyssel, director of the Johns Hopkins Hospital, recommended that within five years there be a reduction of at least 10 percent in the ratio of short-term hospital beds to the population. The statement provoked a dissent from Harold Cross, a general practitioner from Hampton Hills, Maine. He argued that "to cap the process at some arbitrary bed limit before assuring minimal care is irresponsible and gives the appearance of having provided a solution."34
Among those who very much wanted to see a solution to the problem of health care cost containment was Jimmy Carter. The President realized that any campaign to create national health insurance would have to be accompanied with measures to reduce the rate of growth of health expenditures. It was for this reason that the
article in the Washington Post about the CT study had caught his attention.
President Carter and HEW Secretary Joseph Califano already had the full attention of the Institute of Medicine. David Hamburg and the IOM staff greeted the return of a Democratic administration with enthusiasm. Although the organization tried hard not to favor one party over another, it nonetheless had more in common with the Democrats than the Republicans. The Board on Medicine had been created in the shadow of the Great Society and in the expectation that the social experimentation of the 1960s would continue into the 1970s. Richard Nixon's election stunted the hopes of many Board on Medicine members and staff for such things as federally administered national health insurance.
In the Nixon and Ford eras, IOM staff eventually developed and maintained many close ties to administration officials, such as HEW Secretary Elliott Richardson and Assistant HEW Secretary Merlin DuVal. During the Ford administration, in particular, David Hamburg worked closely with Theodore Cooper, the Assistant Secretary of Health, and Guy Stever, the President's science adviser. After Cooper was fired by Califano, he received an invitation from Hamburg to come to the IOM as a visiting scholar. As these examples illustrated, party affiliation almost seemed not to matter in the health care field: professional identity often superseded partisan loyalty. In this spirit, the Ford administration named Donald Fredrickson director of the National Institutes of Health (NIH), and a similar bipartisan spirit prevailed in Congress. Nonetheless, IOM officials realized that a Democratic administration offered more chances for collaboration than did a Republican. David Hamburg said as much in March 1977, when he told the IOM Council that he and his staff had been approached for advice by the new administration. He thought that such contacts might give the IOM more chances to become involved in the formulation of health policy.35
The embrace of the Carter administration sent the IOM off in two different directions. On the one hand, the IOM wanted to be of service to an administration that appreciated its advice. On the other, the IOM wanted to use its divisional structure, which had just been put in place, to generate its own agenda. Just as the Hamburg reorganization took hold, the arrival of the Carter administration upset its workings.
At the time, few people saw any problems in the IOM maintaining a close relationship with the Carter administration. The opportunity to be on the inside track only increased the chance for the IOM to play an important role in health policy at a time when this policy appeared
to be at a point of momentous change. According to this view, the IOM would maintain its integrity even as it stepped closer to the center of power. As Hamburg had stated in his final president's report to the IOM, ''We must take a sympathetic interest in government efforts and try to be helpful where we can. But the Institute can be most helpful in the long run if our actions have the degree of insight and objectivity." So the IOM would continue to speak truth to power, only now power would listen.
In IOM Council meetings, David Hamburg reported on the latest developments in the Carter administration and encouraged IOM participation in them. He also invited administration officials to give presentations at Council meetings, a practice that Hogness had followed but that had lapsed in more recent years. In March 1977, for example, Hamburg told the Council that an ad hoc group had been convened to offer suggestions to the Presidential Commission on Mental Health. Even though the commission had not yet been formally appointed, Hamburg—whom one staff member described as "psychiatrist to Washington, D.C."—to whom everyone, even cabinet members, turned for inspiration, already knew that the IOM would be asked to prepare a study for the commission. Hamburg also reported on a bipartisan congressional request that the IOM review promising leads in the field of international health. Senator Edward Kennedy and his congressional colleagues from both parties expressed an interest in how America's "medical research capacity" and its "experiences in organization and delivery of primary and preventive care" might benefit other nations, an interest in the international dimensions of health that the Carter administration shared. In May, members of the IOM Council had dinner with Secretary Califano and met with Donald Kennedy, commissioner of the Food and Drug Administration (FDA), and Hamburg's former colleague at Stanford. In the same month the Council learned that Julius Richmond, who had served as an interim head of the IOM between Fredrickson and Hamburg, was the Carter nominee for the position of Assistant Secretary of Health.36
Working for the Carter Administration on International and Mental Health
Each of these administration ties led to work for the IOM. Already interested in the field of international health after his experiences in Africa, Hamburg urged the IOM Council to accept the congressional invitation to do research on this subject. At its own expense, the IOM
convened an International Health Committee that prepared a report on research opportunities in the field of international health. The field became integral to the IOM's basic activities, with a program division devoted to it. In 1978, for example, Hamburg made international health a major focus of the IOM's annual meeting. Although he was not sure how much interest members had in the topic, he believed that "gravity of disease conditions in other parts of the world" merited "serious attention from the Institute."37
In July 1977, the IOM Council learned how important international health activities were to President Carter. It heard from Peter Bourne, a Carter White House staffer and former student of David Hamburg's, that health was a "pivotal concern in the administration's strategy for improving relations with other countries." Bourne said that in the President's human rights policy, "problems in food supply, health care, and shelter were likely to receive as much emphasis in dealings with other countries as civil rights."38 Congress mirrored the President's interest. Aware that the IOM was doing work in the field, members of the Senate Committee on Human Resources attached an amendment to a public health bill that provided for an IOM study ''to determine opportunities, if any, for broadened Federal program activities in areas of international health."39 This study became the first formal product of the IOM Division of International Health.
The study itself appeared in April 1978. With the steering committee chaired by John Bryant, director of Columbia's School of Public Health, the report reflected the work of four subcommittees that, taken together, provided a panoramic view of the field. One group looked at the major diseases of low-income countries. A second investigated the ecological, socioeconomic, and cultural factors involved in health. A third studied environmental control programs and health education possibilities, and a fourth attempted to ascertain the feasibility of U.S. involvement in international programs to meet the problems identified. The resulting report identified the "major policy and organizational problems and constraints which currently hamper the U.S. government's international health activities." The committee concluded that "the current base of knowledge and experience provides the possibility of ameliorating many [health] problems by commitments of realistic amounts of resources by both developing countries and economically advanced countries." If some of the rhetoric was self-serving, as in a recommendation that the Agency for International Development (AID) enter into relationships with U.S. academic institutions to undertake research and development activities in the field of
international health, the report nonetheless marked a credible IOM entry into a new field of endeavor. This case was one in which the interests of the Carter administration combined with those of David Hamburg to shape the IOM's development.40
Something similar happened in the area of mental health. Once again, the interests of the Carter administration coincided with those of David Hamburg to produce a series of IOM studies. These concentrated on the links between health and behavior, which had long been a focus of Hamburg's research. Before he left Stanford to take the IOM job, Hamburg told his colleagues that one of his top priorities was to try to get the IOM "to look at behavioral aspects of health over the whole range of health." The work done by IOM for the President's Commission on Mental Illness presented Hamburg with an opening to pursue this interest. He used this work as a base from which to negotiate with Carter administration officials for an expanded IOM role in the field of behavioral medicine. As Hamburg described the process, the government and the IOM mixed and matched interests. The IOM had things that it viewed as "central to our agenda and the government may buy some of that, at least in modified form. On the other hand, they may come at us with questions that are salient to them and that don't particularly fit our agenda and yet, within the mandate of this institute, we pretty much have to take up because they're not farfetched, they're not disreputable, they're difficult and so on. So you end up with that kind of funny mosaic of our agenda and theirs." Hamburg, Julius Richmond, Donald Fredrickson, and the heads of the various NIH and Alcohol and Drug Abuse and Mental Health Administration (ADAMHA) institutes created the mosaic that became the IOM project "Health and Behavior: A Research Agenda."41
The project consisted of a series of IOM conferences, each of which generated its own report, on specific questions in the field of health and behavior, followed by a volume that synthesized the conference results, suggested promising research leads, and integrated "available information into a perspective of the frontiers of the biobehavioral studies." As one indication of David Hamburg's personal interest in this project, he decided to chair the steering committee, which met for the first time in November 1979. Other committee members were leading figures in the fields of psychology, psychiatry, and psychobiology. Because so many different federal agencies were involved in the task, the contract for the project was not signed until after the project had begun. The final report did not appear until the summer of 1982.
The first conference volume, on the links between smoking and behavior, followed an interest shared by Surgeon General Julius Richmond and HEW Secretary Joseph Califano. It featured an introduction by Richmond in which he noted that the volume supplemented the work he had undertaken for a 1979 report on smoking and health. Both the conference volume and Richmond's report emphasized the disparity between the large amount of biological research that showed the deleterious effects of smoking and the small amount of behavioral research on what caused people to smoke and what might encourage them to Stop.42
Five more conferences, each on a topic of interest to one or more federal agencies, followed the conference on smoking. Robert J. Haggerty, president of the William T. Grant Foundation, chaired the Conference on Combining Psychosocial and Drug Therapy. The idea emerged that "behavioral science has a powerful role to play in conjunction with traditional biologic research at the levels of both the individual patient and of society if we are to improve the nation's health." 43 In a subsequent conference, participants tried to bring the concept of "social disadvantage" into the mix. They noted, for example, that rates of severe mental illness were higher among members of the lower social classes and argued, in the manner of social scientists from the 1960s, that "inadequate resources, low status jobs, social stigma and inadequate education interact with differential immunity, nutrition, environmental risks and coping styles to create a 'circle of disadvantage'." 44 As the social scientists had learned earlier, this was tricky terrain, invoking memories of Daniel Moynihan's "tangle of pathology'' in the black ghetto. Indeed, the boundary between the personal and the social realms was difficult for participants in all of the conferences to define. In the field of aging, for example, researchers had to distinguish among events that were biologically determined, culturally determined, and personally determined.45 In a similar vein, Leon Eisenberg, summarizing the results of the Conference on Infants at Risk for Developmental Dysfunction, said that efforts "to understand ... the various risk factors experienced by both mothers and children during pregnancy ... and early infancy make sharply evident the need for research that integrates sociobehavioral with biomedical paradigms.'' 46
The conferences yielded a plethora of information that made for a fascinating final report. Within the Academy complex, furthermore, only the IOM could produce such a report, because of its ability to engage in interdisciplinary work and combine biology with behavior. The organization of the National Research Council, by way of contrast, resembled the traditional departments in a university, with
all the attendant problems of producing interdisciplinary work. The IOM study found that as much as half of the mortality from the 10 leading causes of death in the United States could be traced to a person's life-style. In the typical hospital population, one encountered a disproportionate number of people who had engaged in alcohol abuse, cigarette smoking, or overeating to obesity. Pregnant mothers spread the problems to the next generation. Cigarette smoking, for example, doubled the risk of having a low-birthweight infant; mothers who drank heavily faced a far greater chance that their babies would suffer from fetal alcohol syndrome. All in all, "relationships among the stress of life events, social supports, and various styles of coping" offered a "rich area of research opportunity." Such research would be informed by the knowledge that "for many chronic diseases, drugs alone are not enough." Through this research, health care practitioners would come to understand just how ''social and psychological influences affect the disease course and prognosis." The project amply demonstrated that "the leading causes of illness and death have substantial behavioral components, so approaches to preventing or managing them must include a strong biobehavioral perspective."47
Specifying the exact links between behavior and disease presented many difficulties, as the IOM discovered when it responded to a request from the Office of Science and Technology (OST) in the White House that it study the relationship between stress and behavior. White House staff members had identified stress as, in the jargon of the day, a cross-cutting issue that related both to mental health and to the subject of illness prevention. The White House brought together the National Science Foundation (NSF), the National Institute of Mental Health, and the National Institute of Aging to fund the study, which ran concurrently with the one on health and behavior. An elaborate undertaking, the stress study involved the use of many panels and consultants; as many as 100 scientists participated.48
On November 26, 1979, when David Hamburg greeted the members of the steering committee, headed by Carl Eisdorfer, president of Montefiore Hospital and professor of psychiatry and neurosciences, he told them that they faced an arduous process. They had to do more than simply denounce stress as a contributor to mortality and morbidity; instead, they had to try to uncover some of the linkages between stress and ill health and to report on those areas in which more research was required. He cautioned that interest in this subject was high. Indeed, he later wrote "no aspect of health and disease elicited more interests among leaders of the United States government" than the subject of stress. Hamburg was tempted to
elevate stress into a metaphor for the Carter years, with their series of wrenching events such as the radiation accident at Three Mile Island and the Iran hostage crisis. The press would therefore seize on the report and be eager to find a simplistic theme with which to characterize it, but the IOM and NSF committees that reviewed the report would demand more. Describing this review process, Hamburg said that "there's a lot of feedback ... and some of it is jarring. I mean it is quite difficult.... [T]o retain a high degree of consensus in the face of a stiff critique is not simple, but I think it is very important."49
As Hamburg had predicted, the report ran into difficulties in the review process that delayed its release until the end of 1981. Although three of the IOM reviewers approved the report, two had strong reservations. They believed that the report failed to support its recommendations and complained that it was full of "tautologies, nebulous notions, and old research." "All of these statements are true," conceded the IOM staff members in charge, ''the committee was not in a position to remake the stress field, which has been characterized by just those problems for many years." What the report tried to do was present results that "transcended those limitations" and replace "tautologies with insights, old research with new and well-designed studies, and vague ideas with hard data." The final report suggested that investigators move ''beyond questions about whether stress can affect health and explore more fully the mechanisms through which stressors might produce such consequences." They should do so even though the stress response was a "complex, interactive process."50
The process of collaborating with and advising the Carter administration extended well beyond the area of health and human behavior. In fiscal year 1979 alone, the Institute reviewed HEW's planning process, reported on food safety policy and on the health hazards of sleeping pills for the FDA, investigated the research agenda of the National Institute on Alcohol Abuse and Alcoholism, and studied health in Egypt for AID.51 It also tried to be of service in the legislative battle over national health insurance.
Working with the Carter Administration: The Dental Study and the Surgeon General's Report
A good example of such service concerned the study of dental care that the IOM started in 1976 before the Carter administration took office. From the beginning of this study, the IOM had national health
insurance in mind. It would be part of the general effort to examine "selected issues in national health insurance," which was featured in the IOM's 1976 program plan. Considered from this angle, dental care represented a neglected area of study. Most national health insurance bills included dental care for children up to age 13 on the theory that providing access of this sort would pay substantial dividends in the form of improved health. The IOM hoped to put this theory to the test and make other suggestions for just how dental care might be included in a national health insurance bill. Most of the analysis for the study was to be done by Chester W. Douglass, a professor of dentistry at the University of North Carolina at Chapel Hill and a former Robert Wood Johnson congressional fellow at the Institute of Medicine. The Kellogg Foundation agreed to support an 18-month study.52
Delays plagued the study from the start. On April 20, 1977, Hamburg invited Julius Richmond to chair the steering committee. When Richmond was nominated to be Assistant Secretary of Health, he had to resign and Dorothy Rice took over. As the project proceeded, the Carter administration began to formulate and Congress to consider a national health insurance bill. On May 25, 1978, Stan Jones, the IOM's program development officer and former Hill staffer, reported that President Carter would issue a statement of principles on health insurance in June. A benefit package would be specified in the fall. Jones advised the committee to release an interim report during the summer in an effort to influence the debate.53
The committee and its staff duly prepared such a report with very specific recommendations: for example, that national health insurance should provide individual preventive services for everyone, including routine prophylaxis. This report met with such strong disapproval from the IOM Council that it was never issued. The IOM Council reviewed the report as though it were a rigorous scientific study and wanted to see more evidence on such questions as whether a dental checkup on a regular basis would prevent health problems, fearing that, without such evidence, the report amounted to little more than a list of recommendations. Others questioned the economic logic of the report. Walter McNerney of the Blue Cross Association said, for example, that his experience showed that the removal of economic barriers contributed significantly to increases in utilization by the covered population. Hence he believed that the cost estimate of $1 billion for the coverage was unrealistically low. Faced with this criticism, the group decided to abandon the interim report and move on to the final report.54 Disagreements between Chester Douglass and the steering committee led to more delays. Money for the project ran
out and the IOM had to ask for more. The IOM brought in William Fullerton, a retired Social Security policy analyst and congressional staff member, and Stan Jones, who had left the IOM to become a private consultant, to act as "script doctors" and rewrite sections of the report. The final report did not appear until the end of 1980, long after the window for passage of national health insurance had closed. 55
It was clear that the rhythms of the IOM did not always mesh with those of Congress or others close to the political action in Washington. Part of the problem was that the IOM sought to be both an outside advocate and an inside collaborator in its relations with the Carter administration. In at least one instance, the IOM offered, in effect, to staff a major Carter administration effort. Differences in outlook between the IOM and HEW made for a strained collaboration.
The project stemmed from Surgeon General and Assistant Secretary of Health Julius Richmond's desire to issue a report on prevention as a major theme of health policy. In February 1978, the IOM held a conference on health promotion and disease prevention, a subject that had received a great deal of attention from the Carter administration. In May 1978, Richmond asked the IOM to prepare a report, based in part on the conference, that summarized the "state of the art." This led to a formal proposal from the IOM in July and a formal contract from HEW by the middle of August. In the meantime, Secretary Califano announced that Richmond would issue a major report in the autumn "to help Americans fight against obesity, alcoholism, and many other costly everyday health problems." The IOM staff, assisted by a special advisory committee, rushed to get something to Richmond by October. The IOM also commissioned a series of papers on particular aspects of the subject, such as reducing tooth decay in children or lowering the number of motor vehicle accidents. In this way, the IOM hoped to be ''as helpful as possible to the Surgeon General of the United States in writing a Surgeon General's Report on Prevention."56
As more units of the Department of Health, Education, and Welfare became involved in the project, the Surgeon General's report on health promotion and disease prevention became delayed. Serious disagreements arose between HEW and the IOM about how to handle the report. The IOM objected in particular to the way in which the surgeon general's staff "emphasized individual responsibility for health way out of balance with governmental and social responsibilities." The IOM contemplated withdrawing from the project and publishing the report it had prepared and the studies it had commissioned on its own. In the end, David Hamburg and Julius
Richmond managed to restore order. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention appeared in August 1979, and Joseph Califano signed it as one of his last official acts as Secretary of HEW. As Hamburg explained, the book drew heavily on the material that IOM had prepared but that, "naturally, DHEW has put its stamp on the material." A second volume of the Surgeon General's report consisted entirely of the background papers that the IOM had commissioned.57
During the summer of 1979, Jimmy Carter delivered his famous homily on the nation's wavering sense of purpose that the press dubbed the "malaise" speech. In the wake of this speech, the President announced a shakeup of his cabinet, which led to the dismissal of Joseph Califano. According to a predetermined schedule, the Surgeon General's report was released just after Califano had been fired. As a result, it received little of the fanfare that Califano might have brought to it. The bold call for a "second public health revolution" to prevent all disease tended to go unheeded.
In fact, the Surgeon General's report revealed an important fault line in the nation's political ideology. In the past, Democratic administrations had emphasized measures that the government could take to improve the nation's health, such as the creation of Medicare or increased investment in medical education and research. The Carter administration inherited many of these projects from past administrations, in particular the desire to shore up the financing of health care through national health insurance. Unlike the other administrations, Carter and Califano started with the primary goal of cost containment as a necessary precondition for guaranteeing universal access. Prevention was a key to cost containment, and Carter administration officials tended to see prevention as an individual, rather than a governmental, responsibility. The Surgeon General's report seemed to confirm the fact that, as the Washington Post reported, "people can do far more to improve their health by acting themselves than they can by waiting for symptoms and then going to doctors."58 The IOM committee in charge of advising the surgeon general was not prepared to push the prevention line this far Committee members continued to see an important role for government in disease prevention and health promotion.
The dental study and the Surgeon General's report on prevention revealed that, however much the IOM wanted to be of service, it was removed from politics. It could get only so close to a particular administration before the differences between its style of operation and those of a more politicized organization became apparent. In the case of the Carter administration, the departure of Califano,
combined with the demise of many of the items on the administration's agenda, led to an increased separation between it and the IOM. Hamburg hoped that the IOM could be as helpful to Patricia Roberts Harris, Califano's replacement, as it had been to Califano. As David Hamburg later noted, Califano early saw the IOM's value and sought to work with it. As Califano came to see the increasing importance of health as an area of social policy, he developed an attachment to the IOM that continued after he left office. Califano became an IOM member and served on the IOM Council during the 1990s. Patricia Harris, for her part, held many fruitful discussions with Hamburg and proved to be very supportive of the IOM's international health efforts. Still, her time in office was brief and the possibilities of collaboration were fewer during her tenure than during Califano's.
Riddles of Power
Being close to power was exhilarating but not without its problems. To preserve its reputation, the IOM always had to fend off blatantly political requests. A good example in the Carter era concerned a request from Senator Daniel Inouye (D-Hawaii) that the IOM study the health effects of tourism. Staff members from the senator's Subcommittee on Tourism of the Senate Commerce Committee visited IOM staff member Karl Yordy and explained that they wished to explore ways in which the effective use of leisure might lead to improvements in health. If a link between leisure and good health were established, the government might mandate vacations in the same way that the Fair Labor Standards Act limited the standard working week to 40 hours. Yordy listened as politely as he could and talked of the many difficulties that an IOM study might pose, such as the problem of conceptualizing leisure. Undeterred, Senator Inouye sent David Hamburg a formal letter, noting that hearings in his subcommittee "raised the possibility of linkages between stress ... one's ability to relax and various physiological and psychological symptoms." He even suggested that the government might want to promote four-day work weeks and mandatory paid vacations as part of its public health responsibility. Calling the IOM's academic and professional expertise "second to none," Inouye asked the IOM to help the subcommittee develop policy recommendations.59
The self-interest in this request was obvious. Inouye represented a state whose economic well-being depended on the health of its tourism industry. What he wanted, in effect, was to use the federal
government to subsidize the economy of Hawaii on the recommendation of the IOM. The press had already begun to investigate this matter. Yordy told Hamburg that Newsweek had almost put the study in its "golden fleece" category, certifying it as a boondoggle. Wary of offending an important senator, Hamburg bowed out as gracefully as he could. He thanked Inouye for his letter and said that he personally wanted the IOM to do the study but it would require review by the Program Committee. In this way, he let the matter drop.60
Even on a project that the IOM and government officials both wanted, complications related to politics sometimes developed. A good example concerned an IOM conference on the subject of the care of terminally ill patients. At first, the National Cancer Institute (NCI) expressed an interest in funding such a conference. In a few months, however, it became apparent that the NCI would not do anything to help the project; IOM officials suspected that priorities within the NCI had changed. Then Joseph Califano gave a speech in which he embraced the hospice concept and announced plans for a national conference on the care of dying patients. National Cancer Institute officials immediately got in touch with the IOM and stopped work on the contract they had been negotiating. The IOM then began discussions with Califano's staff to see if it could play a role in his conference. As discussions progressed, IOM officials realized that HEW envisioned a grandiose conference, attended by more than 1,000 people, that would serve as a platform for Califano to follow up on his earlier speech. The IOM wanted no part of organizing such a conference and proposed instead that the IOM provide "credibility, objectivity, and intellectual input" by convening a committee to advise on the conference agenda and speakers. HEW rejected this idea, and the negotiations ended. 61 In this case, the IOM could not maneuver between its desire to study an issue and Califano's desire to publicize the case for hospice care.
Just after Joseph Califano was fired, an exasperated Karl Yordy wrote to his counterpart at the Kellogg Foundation that "obtaining HEW support during the last year has been such a struggle, in spite of great goodwill for the Institute at all of the policy levels within the Department, that it is difficult to imagine the situation being any worse."62
Karl Yordy and David Hamburg realized that government funds and government projects would never take the place of private
foundation support. During Hamburg's presidency, the core foundations continued to finance the Institute, and the IOM managed to add new patrons to the list.
When Donald Fredrickson announced his intention to leave the IOM, a program officer at the Robert Wood Johnson (RWJ) Foundation hastened to assure Karl Yordy that the RWJ staff intended "to continue to support IOM regardless of the leadership change." This proved to be the case. The Kellogg Foundation told the IOM in 1975 that Kellogg would support only "specific project activities," yet Kellogg continued its generous support, as a 1978 award of $375,000 to "help underwrite the Institute's annual program plan" demonstrated. In 1978 the IOM also received a check for $750,000 from the Andrew Mellon Foundation to "address policy issues critical to the nation's use of finite resources for health care.'' During the next year, a $105,000 check arrived from the Richard King Mellon Foundation for the ''leadership and initiative functions of IOM."63
Even as David Hamburg hastened to reassure these foundations that the IOM was still worth supporting, he also courted new ones. A notable success came with the Charles H. Revson Foundation. Using IOM Council member Lisbeth Bamberger Schorr as an intermediary, Hamburg set up a meeting with Revson Foundation Director Eli Evans. "I think our interests overlap in many ways," Hamburg wrote to Evans after the meeting. Three months later, Hamburg learned that the Revson board had appropriated $200,000 for the IOM to conduct four Revson seminars on biomedical research.64
Although these donations helped, they still could not free the IOM from debt. In July 1979, for example, the IOM Council learned that the fiscal year would end with a budget deficit of $210,000. The National Academy of Sciences offered to bail out the IOM but at the cost of reducing its support for fiscal year 1980. This meant that the IOM would have to cut back on its 1980 expenses.65 A major part of the problem stemmed from a ruling made by government auditors in 1978 that the IOM had to include overhead costs for private foundation grants in its budget. In other words, if the IOM received money from Robert Wood Johnson, part of this money would have to go toward indirect costs or overhead. Not all of the money could be spent on things such as salaries, meetings, or conferences; part of it would have to go toward general upkeep of the Institute. This ruling had the effect of reducing the amount of the foundation grants and upsetting the IOM budget so that the IOM suddenly found itself with a $750,000 debt. Although IOM staff members hoped that President Handler would appeal the auditors' ruling, he preferred, in the
privately spoken words of one IOM staffer, "to chastise the IOM for its profligate and careless ways." Hamburg thought about compensating for the loss of income by obtaining what he described as "flexible kinds of support from federal quarters."66 Such support proved very hard to obtain because federal agencies insisted on contracts for specific projects and the government did not make flexible grants in the manner of foundations.
Defining the Institute's Mission
The oversight that the National Academy of Sciences exercised over the Institute complicated any efforts to resolve the IOM's funding difficulties. Although relations between the NAS and the IOM tended to be calm in the Hamburg years, sharp differences of opinion did arise over such issues as the report review function. When John Hogness was IOM president, he developed a good working relationship with NAS Vice President George Kistiakowsky. As a result, the review of IOM reports by the Academy became routine. "We never had any difficulties," Hogness recalled.67 This changed during the Hamburg years. In March of 1978, for example, Philip Handler sent Hamburg a long memo in which he pointed out his "vaguely negative" initial reaction to a report on medical technology, the disastrous history of the steering committee for the project, and the "undocumented assertions" that abounded in the report. He asked if Hamburg could regard the study as IOM's ''best effort."68 Hamburg hastened to make changes and thanked Handler for making the report "sounder.''69
Such chastisement from Philip Handler rankled, as did the criticism of IOM reports by Saunders Mac Lane, who was a University of Chicago mathematician and NAS vice president, and chairman of the Academy's Report Review Committee. In 1980, Mac Lane told the IOM Council that the reports had run into difficulties because the IOM sometimes started "with the view of influencing policy rather than conducting a dispassionate assessment of fact." The resulting reports did not make explicit which of the findings stemmed from "informed judgment" and which rested on "hard evidence." At times also, conclusions reflected the opinion of the staff, not the results of investigations undertaken by the steering committee. In a similar spirit, Vincent P. Dole, vice chairman of the NAS Report Review Committee, cautioned the IOM not to become too involved in the political process when dealing with health policy problems.70
In response to this criticism, Hamburg pointed to the differences between basic and applied science. The social problems of the sort that the IOM addressed had a scientific content, "but all also entail uncertainty in the knowledge of factors that can influence outcome." If the IOM wished to tackle "the truly large, difficult issues of health and disease," as Walsh McDermott had hoped it would, it could not adopt the attitude of the pure scientist. Instead, the IOM had to consider the gray areas that lay beyond scientific certainty. As Fred Robbins, who succeeded Hamburg as IOM president, stated bluntly, "The Institute could not limit its study to the hard evidence and still carry out its mission.''71
At the end of the Carter administration, it was still difficult to discern this mission. It was clear that the IOM walked a fine line between the scientific concerns of the National Academy of Sciences and the political preoccupations of policymakers. It also tried to sort out the most appropriate projects from those that its members suggested and those that the government brought to it. The fact that it could filter these proposals through separate divisions, each with its own advisory committee, helped lend coherence to the effort. Even so, Renee Fox, a University of Pennsylvania sociologist and member of the IOM Council, called the program plan for 1980 a "diffuse set of projects." Margaret Mahoney, head of the Commonwealth Fund and an IOM Council member who had done much to encourage philanthropic support for the Institute, said that "the time has come when [IOM] should think with some continuity so that people will associate certain kinds of activities with the Institute and no other organization." In this sense, the IOM, although it had discovered important themes such as primary care, health education, quality assurance, and prevention, had not yet found its niche.72
At the beginning of 1979, David Hamburg appeared before the IOM Council and made a special announcement. He had been reflecting on his three years as head of the IOM. Some Council members had suggested that he serve another five-year term beyond his present one. Hamburg told the Council members that he had decided not to do so. He would complete his term and then leave the IOM. Hamburg announced his intention to establish "valuable, long-term directions for the Institute" during the remainder of his term. In the meantime, the IOM would have plenty of time to search for his successor.73 Council members greeted Hamburg's decision with
genuine disappointment; they wanted him to stay, continue his inspirational leadership, and finish the job of establishing the IOM as an independent organization that was not afraid to engage questions that were close to the surface of the nation's political life.
David Hamburg left office only a month before the presidential election that would chase Jimmy Carter from town. Their simultaneous departures marked the start of a new and very different era in IOM history. At the end of Hamburg's tenure, Philip Handler wrote him a graceful letter that eloquently captured his contributions to the IOM:
Under your leadership, the Institute of Medicine has been brought to maturity. It has earned a place in the Washington scene and become the instrument to which we aspired when it was created. Our country has yet a long way to go in the development of an accepted philosophy which will enable us to frame a consistent national health policy. Thanks to you, I am confident that the Institute of Medicine will make cardinal contributions to that process. We have enjoyed your boundless good humor, basked in the warmth of your compassion, and been stimulated by the keenness of your intellect. All of us are richer for your stay among us.74