Expansion of the Institute of Medicine
At the end of March 1987, the Wall Street Journal ran a story about the Institute of Medicine (IOM) on its Washington politics page. In contrast to the journalistic pieces on the IOM that had appeared during the confrontation over the Sproull report, this one had a decidedly upbeat tone. "After more than 15 years of comparative obscurity," wrote Journal reporter Alan Otten, "the Institute of Medicine ... seems to be gaining visibility and clout in Washington." The article cited the many problems that had previously characterized the IOM, such as the quick turnover in presidents, the constant scramble for money, and the ambivalent attitude of the foundations, and suggested that these problems had been remedied in the short period between the end of 1985 and the spring of 1987.1
No doubt, the newspaper overstated both the degree of the initial problems and the permanence of the solution. It was nonetheless the case that the IOM rebounded from the crisis of the Sproull report under the leadership of Samuel Thier. In a short time, Thier restored the confidence of foundations in the Institute of Medicine, leading to a more stable pattern of financing and ending the yearly struggle to make ends meet. Resolution of the financial issues strengthened the position of the Institute of Medicine within the National Academy of Sciences and paved the way for a major expansion of IOM responsibilities and staff. As a result, the years between 1985 and 1991 were ones of major growth for the Institute of Medicine.
Samuel Thier and the Outreach to Foundations
Thier, a comparatively young man of 48 when he became IOM president, had the sort of leadership style that inspired confidence. Refusing to become bogged down in details or to succumb to cynicism, he simply assumed that he would be able to meet his objectives,
projecting an air of competence that both reassured and energized people. Among many other positive attributes, Samuel Thier was a quick study. Even before he took over on a full-time basis, he realized the need to build a strong endowment that would allow the IOM to set its own agenda. Turning a disadvantage into an advantage, he used the Sproull Report as a form of leverage. Because the foundations had subjected the Institute of Medicine to such a probing and painful analysis and because the Institute of Medicine had begun to put its house in order, Thier argued that the foundations now had a moral obligation to come to the IOM's aid. He hastened to reassure these foundations that he had absorbed the many criticisms of the IOM and would take steps to remedy the problems. Under his leadership, he promised, the IOM would strive to complete its studies more quickly, with the goal of cutting in half the time necessary to complete studies. Using the IOM's convening power, he planned to bring together the parties interested in drug development and health technology assessment in order to facilitate communication among participants in these particular fields. Finally, Thier vowed to make the IOM more visible to the government, so that government agencies turned reflexively to it for advice.2
Like his predecessors, Thier was a respected academic doctor who had produced more than 80 research papers in his chosen field of kidney function. More importantly, however, he had early shown a penchant for medical administration and proved himself to be a superior clinician. The son of a physician, Thier decided to follow his father's profession. "My father was a general practitioner and loved what he was doing and I just thought it was an exciting life," he explained. Thier graduated from the State University of New York Upstate Medical Center at Syracuse in 1960 and then entered the elite echelons of the medical profession by taking his internship and residency at Massachusetts General Hospital in Boston. By 1966, he had earned the coveted position of chief resident at Massachusetts General, which prepared him for a career in academic medicine that included positions as chief of the renal service at Massachusetts General and vice chairmanship of the Department of Medicine at the University of Pennsylvania. In 1975, only 15 years removed from medical school, he became chairman of the Department of Medicine at Yale. Fellow doctors admired both his ability to respond to emerging trends in medicine and his clinical skills in diagnosis and treatment.3
By the time Thier arrived at the Institute of Medicine at the end of 1985, he had already played an active role in the organization's affairs and in medical affairs more generally. Elected to the IOM in 1978, Thier had chaired the Board on Health Sciences Policy and been a
member of two study committees. Just before coming to the IOM as president, Thier served as chairman of the American Board of Internal Medicine, the national body that set certification standards for doctors in internal medicine and its subspecialties. Under his and William Kelley's leadership, the board had established the subspecialty of geriatrics. In addition, Thier held many appointments related to his academic position, such as chief of medical service at the Yale-New Haven Hospital and member of the editorial board of the New England Journal of Medicine.4
When Thier presided over his first Council meeting on November 18, 1985, it immediately became apparent that the IOM would no longer be, in the words of a veteran IOM member, "Sleepy Hollow." Thier cut through much of the talk that tended to slow the organization down. Too much energy, he said, had been expended on determining whether the IOM should be involved in health policy or the health sciences. He believed that it was not an either-or proposition, but that instead, the Institute should be responsible for what he described as "the entire spectrum of activities within the National Academy of Sciences (NAS) complex that deal with human health." To make sure this was the case, Thier bargained with NAS President Frank Press to initiate a review of National Research Council (NRC) activities that should be transferred to the IOM. At the same time, Thier realized that if these units were to be transferred to the IOM, the IOM would have to improve its ability to provide oversight on basic science issues by increasing the number of scientists on the IOM Council. Thier also took immediate steps to address the IOM's financial problems. He got Press to agree to raise the amount of NAS support for the IOM from $596,000 to $800,000. With this additional money, no staff cutbacks would have to be instituted. More importantly, he convinced Press to grant the IOM a two-year grace period during which it would not be penalized for reasonable deficits.5
As soon as Thier took over on a full-time basis at the beginning of 1986, he made the rounds of foundations and appealed for core support. For many of the foundations, such as the Robert Wood Johnson (RWJ) Foundation, money for an endowment violated their action-oriented view of philanthropy. They wanted to solve specific, pressing problems at a time when people were increasingly turning to private charities, rather than to the government, for such solutions. They had less interest in endowing institutions and giving them a free rein to run their own affairs. With his usual optimism, Thier visited the Commonwealth Fund, the Carnegie Corporation, the Andrew W.
Mellon Foundation, the Dana Foundation, and the Kaiser Family Foundation and tried to convince them otherwise.6
Thier realized that the key to the effort was the Robert Wood Johnson Foundation because other foundations that specialized in health and medicine tended to follow RWJ's lead. Of all the foundations interested in medicine, RWJ had the most money at its disposal, enjoyed a close relationship with the Institute of Medicine, and played a key role in the formation of the Sproull committee. Of all the foundations, however, RWJ also had the most stringent rules for the accounting of funds and made very few grants to endow specific institutions. It preferred to run its own fellowship programs, often in conjunction with other institutions such as Johns Hopkins University and the Institute of Medicine, and to take a coordinated approach to the solution of a specific problem such as homelessness. Aware of these constraints, the IOM proceeded to make a request for a $5 million endowment that occasioned considerable controversy among members of the RWJ board and staff. The foundation asked Thier to meet with a small subcommittee of its board in the fall of 1986.7
The meeting proved a considerable success. At the end of October, the Robert Wood Johnson Foundation announced that it would make a special award to the Institute of Medicine. The award consisted of a $5 million grant that came with two conditions: The first was that the IOM raise its endowment goal to $20 million, and the second was that the IOM raise $2.00 for every $1.00 it received from Robert Wood Johnson. "The conditions of the grant are fully acceptable to us," Thier replied, noting that there was "no organization to which the Institute is as deeply indebted for its continuing support as it is to the Robert Wood Johnson Foundation."8
The IOM used the RWJ grant as the basis for a capital campaign announced in March 1987. By this time, the IOM already had in hand much of the money necessary to match the RWJ grant. By November 1986, for example, the IOM had received $500,000 from the Commonwealth Fund, $1 million from the Andrew W. Mellon Foundation, $1.5 million from the Kellogg Foundation, and even more impressively, $5 million from the MacArthur Foundation. For the first time, the Institute of Medicine would be able to enjoy the benefits of an endowment that would yield substantial income each year.9
These significant new sources of income did not exempt the IOM from the usual sort of confrontation with the foundations. The Robert Wood Johnson Foundation, in particular, proved to be a demanding patron. In 1988, for example, it reduced the IOM's budget request for the RWJ fellows in health care policy from a requested $300,000 to $200,000 and refused to contribute toward the indirect costs of
running the program. Becoming very angry, Thier accused the foundation of not honoring its previous commitments. As a compromise, foundation officials suggested that RWJ pay half of the indirect costs and that the IOM pay the other half from its endowment funds. As Marion Ein Lewin, the IOM staff member who ran the fellowship program, explained, foundation officials regarded the endowment money as an ''unusual, generous grant'' that had served as seed money for other grants. The foundation was also firmly against paying indirect costs. Hence, it seemed reasonable to foundation officials that the IOM use some of its RWJ money to help pay for the one IOM program directly associated with the Foundation. Thier refused to see it this way, insisting that the use of the endowment to defray indirect costs had never been a condition of the RWJ grant. IOM Council members expressed a reluctance to "disrupt relations" with a foundation that had been so generous to the IOM for so long. Thier, for his part, did not want to compromise on an important point "in order to placate a powerful donor."10 In the end, Thier secured an agreement that after a two-year period, the foundation would pay the full costs of the program.11
Despite these inevitable disagreements, the fact is that the IOM enjoyed unprecedented success in its outreach to foundations during the presidency of Samuel Thier. One factor in this success was the surge in the stock market and the economic boom that occurred in the mid-to late 1980s. After a sharp recession in the early 1980s, economic conditions brightened. This meant that the value of the securities that foundations held in their portfolios increased, and because the foundations were required by law to spend a certain percentage of their income, the amount of money they awarded also increased. For example, the Kellogg Foundation discovered at the end of fiscal year 1987 that it had "a significant overrun in income" that had to be spent by the end of the calendar year. This made it receptive to a proposal from Frank Press and Sam Thier for an additional $20 million endowment for the NAS and the IOM.12 The foundation eventually awarded the NAS and the IOM a $20 million challenge grant to support studies in health, education, and agriculture.13
Another factor in the IOM's fund-raising success was that the Reagan revolution appeared to have run its course. Because the foundations were no longer quite so panicked about defining their role in an era of shrinking government, they felt able to make grants to their traditional clients such as the IOM. A third factor was the persistence and confidence with which Thier approached the foundations. Unlike Fred Robbins, who tolerated the fund-raising process because he recognized its importance and knew it was
expected of him, Thier made fund-raising a priority and enjoyed the experience. He excelled at reassuring the foundations that their money would be well spent and proved adept at creating a bandwagon effect, urging one foundation not to get left behind by another.
Report Dissemination and Expansion of the Institute
One of the items on which Thier spent the IOM's newfound money was the dissemination of IOM reports. From the day he took over as IOM president, he vowed to make an effort to distribute IOM reports in an organized fashion, beginning with the original proposal and extending through the evaluation of the final report's impact.14 "Dissemination is our current buzz word," said communications director Wallace Waterfall in 1987,15 referring to such things as a videotape of the symposium on the medical effects of nuclear war that the IOM prepared for distribution to universities and the special efforts that the IOM made to publicize its study on prenatal care.16
The prenatal care study, designed to suggest ways of increasing the utilization of prenatal care by mothers early in their pregnancies, began in 1986. Headed by Joyce Lashof, dean of Berkeley's School of Public Health, it followed from the recommendations of the widely acclaimed report from the Fred Robbins's era that had cited increased prenatal care as a primary means of preventing low birthweight. Therefore, the very fact that the IOM undertook the second study indicated a new ability to achieve continuity in its program. To support the study on the utilization of prenatal care, the IOM secured funding from the Carnegie Corporation, the Ford Foundation, the March of Dimes, and the Rockefeller Foundation. To ensure wide dissemination of the final report, which appeared in October 1988, the IOM received additional money from Carnegie and Ford that enabled it to issue a separately bound summary of the report to more than 10,000 people and organizations. On the evening before formal release of the report, the IOM hosted a special dinner for 70 key leaders in the field of maternal and child health, and the following morning the IOM held a press conference. Forty reporters attended, leading to reports on the CBS Evening News and the MacNeil-Lehrer NewsHour and in the New York Times, the Wall Street Journal, USA Today, and many local newspapers.
The IOM next focused on giving speeches about the report to influential groups and on getting coverage in medical and scholarly journals. These efforts resulted in presentations in such settings as the U.S. Conference of Mayors, the Council on Foundations, and the
National Governors' Association and articles in such places as the Journal of the American Medical Association and the Journal of Social Issues. In the next phase of dissemination activity, the IOM sought to interest Congress in the report. In the summer of 1988, Sarah Brown, the staff study director, testified before both the House Committee on Government Operations and the Senate Finance Committee. 17
This sort of attention to dissemination became a key part of Thier's plan to improve the performance and influence of the IOM. As one document of the period stated, "The recommendations of a study can only be regarded as disseminated when they are acted upon by the health enterprise." Other components of the IOM's "new directions" included better targeting of health policy problems as they developed, greater versatility in responding to problems, and closer involvement of members in the creation of the program plan and the execution of IOM studies.18
Increased funds and more attention to dissemination brought positive results in the form of increased prominence within the National Academy of Sciences, growth of the IOM staff, and expansion of the IOM's organizational responsibilities. One sign of its increased clout within the larger organization was an agreement that increased the NAS funds that went to the IOM. These funds took the form of payments for the overhead costs of some of IOM's program activities. The more that the IOM contributed to the total pool of overhead funds, the more it could demand from the Academy.19 In fiscal year 1988, the IOM expended more than $6.5 million dollars in program activities, compared with $3.02 million in 1986. At the beginning of 1988, the IOM had 85 project staff members (compared with 20 in December 1986) and 20 core staff members. The staff was growing so rapidly that finding a place to house them in relative proximity proved a serious challenge.20
A key element of the IOM expansion involved the July 1, 1988, transfer of the Medical Follow-Up Agency and the Food and Nutrition Board from the National Research Council to the Institute of Medicine. These organizational changes marked the realization of plans that went at least as far back as the Ebert report in 1982, which had called for the IOM to assume more administrative responsibility for the components of the Commission on Life Sciences (CLS) that dealt primarily with medicine. When Thier took over, he asked Frank Press once again to investigate the organization of the NRC with an eye toward identifying those parts of the Commission on Life Sciences that more properly belonged in the IOM. Press assigned Walter Rosenblith, emeritus professor at MIT and former member of the
Board on Medicine, to head the group charged with this task. His primary recommendation was that the Medical Follow-Up Agency should be transferred to the IOM, and his secondary recommendation called for the Food and Nutrition Board to have part of its activities overseen by the National Research Council and part by the Institute of Medicine. The IOM Council preferred a simpler arrangement, in which the Institute assumed administrative responsibility for the Food and Nutrition Board, with an understanding that the IOM would "assign to CLS ... those activities that were recommended by [Rosenblith's] committee for retention under CLS oversight."21 In this case, unlike so many others in the past, the IOM got what it wanted. Both the Medical Follow-Up Agency and the Food and Nutrition Board came to the IOM.
Created in 1946, the Medical Follow-Up Agency brought an epidemiological focus to the Institute of Medicine. The agency's main purpose was to facilitate the use of federal records, primarily those of the armed forces and the Veterans Administration, for medical research. The agency also maintained a special data base on twins who had served in the armed forces. Among topics of interest to the agency, which contained a staff of six professionals, were the psychological and medical results of military captivity, the risk of cancer following exposure to a nuclear weapons test, and the natural history of various forms of hepatitis. An eight-person Committee on Epidemiology and Veterans Follow-Up Studies, headed by Richard Remington, vice president for Academic Affairs at the University of Iowa, supervised the agency's studies which were financed, at the rate of about $1 million per year, almost entirely from federal funds. Unlike the other parts of the Institute of Medicine, the Medical Follow-Up Agency engaged in the conduct of original research, often with statisticians and epidemiologists on the staff acting in collaboration with clinical investigators and epidemiologists from academic medical centers.22
The Food and Nutrition Board was a larger and more complex undertaking. Started during the Second World War, it addressed issues of critical importance that pertained to the adequacy and safety of the nation's food supply as well as matters that related to proper diet and nutrition. Among the questions it sought to address were ones of considerable political and economic sensitivity, such as the effects of chemical additives on the quality of the food supply or the nutritional qualities and harmful side effects of particular foods. Most of the members of the 12-person board were academic physicians or scientists concerned with the study of nutrition. Typical of the work of the Board was a large 1989 report on Diet and Health that
recommended the appropriate daily levels of fats and salt necessary to maintain health and prevent disease. Other aspects of the board's work concerned the international dimensions of nutrition, such as how to correct the deficiency of vitamin A in the diets of Third World children that led to blindness. Still other parts of the board's mission involved the maintenance of proper nutrition during pregnancy and lactation. In 1988, the board's disparate activities cost about $1.5 million to run and required the services of some 14 professional staff members.23
Not only did the IOM acquire new agencies as part of its newfound prosperity, it also revived components that had been moribund and invented new entities. The Board on International Health served as a good case in point. An important priority of David Hamburg's, international health had languished as an IOM activity during the 1980s, becoming the IOM division that encountered the most difficulty in attracting outside funds. To the proprietors of an increasingly troubled American health care system, international problems appeared remote, and the Reagan administration was reluctant to spend money on controversial forms of foreign aid such as advice on population control. As a result of these forces, the Board on International Health, which had struggled to come into existence in the first place, was effectively dissolved by the end of 1987. Thier and his staff set out to raise funds for a revived board and succeeded in gaining money from the Rockefeller Foundation, the Public Health Service, and the Agency for International Development. The IOM also contributed some of its newly gained endowment money. As a result, the new Board on International Health met for the first time in January 1989.24
In reconstituting the board, Thier vowed to avoid the mistakes of the past. The new board, unlike the old one, would have a firm funding base and be less susceptible to changing political fashions in which health shifted as a priority in economic development and foreign aid portfolios. It would be smaller and better focused than the previous board, and it would include foreign experts on health care policy. With this new outlook, Thier hoped that the new board would shape "a clear image of a distinctive role for itself' and convey this to the international health community.25 By 1990, the IOM's program in international health included a wide array of projects, such as a study of malaria prevention and control and another of female morbidity and mortality in Africa.26
This latter project ultimately resulted in the publication of a 1996 volume that showed how the IOM had changed over the years. Like other complicated projects, this one took a long time to complete. It
required almost six years to gather sufficient funding, find an appropriate focus, and perform the analysis. The final report covered sub-Saharan Africa and not the entire African continent. It was nonetheless an ambitious attempt to define the gender-related burden of health problems for females across the life cycle. As with all recent IOM reports, it began with an accessible summary that, for example, presented the main results in the form of two large tables. Furthermore, the book had an attention-getting main title, In Her Lifetime, and an arresting cover. Against a striking gold background, an impressionistic picture of an African woman, done in shades of red, orange, and black, appeared. It made quite a contrast to the utilitarian covers, in an institutional shade of yellowish gray, that had graced IOM reports through all of the 1970s and much of the 1980s. The old reports had consisted of photo-offset typescripts with jagged right margins; the new reports contained sleek type faces and crisp graphics that gave these publications a professional appearance and made them much easier to read.27
The chief drawback of studies such as the one on female morbidity in Africa was the length of time required to complete them. As part of the effort to respond more quickly to current concerns, the IOM started a number of informal forums. One was the Forum on Drug Development and Regulation, "a meeting ground for the exchange of ideas and information," that began in July 1986. The idea behind this effort, an experiment that soon evolved into a regular activity of the Institute's Board on Health Sciences Policy, was to provide "regular meetings in a nonadversarial environment for representatives from government, industry, and academia to discuss pharmaceuticals." Recognizing the value of such an institution, federal agencies concerned with drug development such as the Food and Drug Administration, professional organizations such as the American Medical Association, and private trade associations such as the Pharmaceutical Manufacturers Association all contributed to the forum's upkeep. The Forum on Drug Development, as the entity ultimately became known, involved little of the internal clearances and other hindrances that often delayed IOM initiatives. A unique use of the IOM's convening power, it made the IOM privy to the latest developments in the field and led to workshops on related topics, such as a 1990 workshop on the development of drugs for pediatric populations.28
A more ambitious effort to respond quickly to current health concerns began in the Fred Robbins's era with a 1983 report that recommended establishing a consortium for assessing medical technology. This idea attracted interest in Congress and led to the
passage of the Health Promotion and Disease Prevention Amendments of 1984, which included a provision for the Council on Health Care Technology. A subsequent law, passed a year later, made it possible for this council to be formed as an IOM activity. By the time the first meeting took place in April 1986, Samuel Thier, like Fred Robbins before him, had become an enthusiastic proponent of the concept. The council required a great deal of Thier's attention, because Congress appropriated money for it through the National Center for Health Services Research (NCHSR) and Health Care Technology Assessment (part of the Public Health Service) and made all money contingent on the receipt of private matching funds, at rates that changed over the course of the project. Thier organized a fund-raising campaign in which, for example, he solicited funds from the Medical Products Group at Hewlett-Packard and the Du Pont Medical Products Department, as well as numerous insurance companies. The need to raise funds in such a piecemeal fashion hampered the operations of the council, which was phased out in 1990 in favor of a Committee on Clinical Evaluation. "We believe that the requirements to raise private sector support and to spend it before it can be matched by NCHSR ... hindered the work of the Council," Enriqueta Bond of the IOM staff explained. 29
In its relatively short life, the 16-person council, chaired by William Hubbard, the former head of the Upjohn Company, and cochaired by Jeremiah Barondess, a professor of clinical medicine at Cornell University Medical College and later president of the New York Academy of Medicine, studied aspects of the use of technology in health care. Perhaps the most important of its projects, the 700-page Medical Technology Assessment Directory, illustrated its role as a clearinghouse of information in the field. Appearing in 1988, this directory provided a list of resources on which hospitals, insurers, and others in the health care field could rely to make difficult decisions related to medical technology. If, for example, a hospital wished to purchase a lithotriptor to destroy kidney stones, it could find listings that would direct it to the available information on this subject. Insurance executives, concerned about the proper use of magnetic resonance imaging, could use the directory to get a quick sense of studies designed to test the cost-effectiveness of such techniques. Clifford Goodman, the council program officer, described the directory as a volume "designed to get dog-eared" and as a step toward creating an effective network of practitioners in the field of health care technology assessment. The completion of such studies, as well as ones on computerized patient records, earned plaudits from Congress. In 1987, renewing the program for three additional years, the Senate
Committee on Labor and Public Welfare, praised the council for providing an "important forum for joint government and private cooperation to promote the development of methods of health care technology assessment." 30
Although this important council proved short-lived, it showed a new willingness of the IOM to experiment with entities other than study committees in order to influence health care policy—another sign that the IOM had come out of its early 1980s malaise. Indeed, by the end of the decade, many of the problems cited in the 1984 Sproull report had been resolved. The key factor was that the absence of a financial burden gave the IOM a new freedom to set its own agenda. Samuel Thier feared that the National Research Council, with its ethos of service, had become a "job shop" that responded to all requests for assistance. He preferred that the IOM take charge of its own activities, even at the expense of turning down some requests. In this spirit, the IOM began to scrutinize requests far more carefully than it had previously.31
At the same time, the IOM contemplated formulating its own requests. The Board on Health Care Services wanted to focus the attention of the Institute of Medicine on the broad question of access to health care services. This topic, with its breadth and complexity, resembled the sort that the Board on Medicine had once hoped to address. In the intervening years, the IOM had discovered, however, that few foundations or government agencies wished to finance studies that appeared to be diffuse and unrelated to political realities. Even though the IOM had managed to secure NRC approval for such studies, it had seldom been able to gather enough money to get them under way. In October 1988, the Board on Health Care Services tried again, proposing that the IOM develop a statement of objectives on this topic, issue an annual status report on health care access in the United States, sponsor a structured debate on critical policy issues, and perform in-depth studies that would generate policy recommendations. Thier, for his part, recognized that the topic was of interest to a broad segment of the IOM membership.32
Although the IOM never carried out the ambitious program suggested by the Board on Health Care Services, the theme of access became central to the IOM's operations in 1989. "The quality, access, organization, and financing of preventive and clinical services," emerged as the first of six cross-cutting themes that the IOM used to describe its program and identify its priorities. Identification of the themes by the Program Committee marked an explicit effort to "bind program efforts together and bring cohesion to disparate efforts." The annual report for 1989 included a chart that matched each of the
IOM's many projects with one or more of the cross-cutting themes. The Division of Health Promotion and Disease Prevention's project on a research agenda on aging, for example, matched theme number three, "research opportunities and resources." The Food and Nutrition Board's study of nutritional status during pregnancy and lactation fell under theme five, "critical health issues, including those of special populations, defined by gender, race, age and socioeconomic status."33
The formulation of cross-cutting themes indicated that by the end of the 1980s, the chief problems of the IOM had become controlling growth, not soliciting funds. At the end of 1987, Thier turned his attention away from fund-raising and toward strengthening the IOM program. Twenty million dollars was all the organization could reasonably be expected to raise, he told the IOM Council. With fund-raising no longer the top priority, Thier set four goals for himself. First, he wanted to develop a clear set of program objectives, as in the six cross-cutting themes. Second, he hoped to create a work plan that had a span of at least two years to enable the organization to address larger, more complicated problems. Third, he expected to continue his interactions with key officials in the executive branch and in Congress so as to ensure the continuing influence of the IOM on health care policy. Fourth, he sought to achieve one of the long-standing objectives of the IOM, which was to increase members' participation in the IOM's affairs.34
Even as Thier's focus began to shift, each year, it seemed, brought more staff and a larger endowment. When the Food and Nutrition Board and the Medical Follow-Up Agency became parts of the IOM, for example, they raised the number of staff members to 132. By July 1988, the Institute of Medicine had become the largest single budget item in the National Academy of Sciences complex. At the beginning of 1989, the IOM had more than 150 employees, project expenditures of $12.7 million, 60 projects under way, and 20 reports scheduled to be released that year. By the end of the year, it had raised more than $23.2 million from its capital campaign, including $18.9 million in endowment. 35 Whereas before the IOM Council had spent an inordinate amount of time trying to come up with a financial development strategy, it now thought of ways to control the consequences of growth. At one point, for example, Thier suggested the development of a computer program that would enable one division to track the activities of another through the use of key words.36
Samuel Thier credited his staff members with making much of the growth possible. When Charles Miller retired as executive officer at the end of 1988, Enriqueta Bond took his place. As Roger Bulger, Karl
Yordy, and Charles Miller had done before her, she managed the IOM's increasingly complex internal affairs, operating with an efficiency that enabled Thier to reserve his energies for the four goals he had set for himself. She received capable support from a team of administrators that included individuals who had worked at the IOM since the days of John Hogness, such as administrative officer Louis Cranford, membership services director Jana Surdi, and communications director Wallace Waterfall.37
The Institute's Program
Financial security and administrative efficiency defined means, rather than ends. Although they ensured the organization's survival, more money and tight management implied nothing about the organization's future direction. The IOM's identity continued to be bound up with its program. Even with the influx of money and the concentration on report dissemination, only a few studies issued by the IOM in the late 1980s or early 1990s, such as those on prenatal care and on nutritional guidelines, captured the attention or imagination of the general public. Instead, the organization continued to speak out on a wide variety of medical issues and to influence, in a limited way, the direction of public policy. Each project and each study committee had to balance the demands of responsible science and the exigencies of public relations in order to respect the limits of the evidence and still communicate a message.
The IOM functioned best when it used the technical expertise of its members to address a well-defined area of public policy. The best example concerned the development of vaccines, a topic that was a continuing concern of the organization at least since the era of David Hamburg and one to which Fred Robbins had devoted much time and attention. In 1985, as a result of Robbins's efforts, the IOM issued two important reports on this subject, Vaccine Supply and Innovation and New Vaccine Development: Establishing Priorities. Three years later, An Evaluation of Poliomyelitis Vaccine Policy Options appeared, which updated the work on this subject that the IOM had done in 1977. The 1988 polio report recommended the use of an injectable vaccine that could be given in combination with other childhood immunizations, a recommendation that was adopted by the Public Health Service's advisory committee on immunization practices.
The report on Vaccine Supply and Immunization, which appeared at the end of July 1985, had a definite effect on public policy. It contained a warning that the supply of vaccine was "precarious" and
posed a ''threat to the public's health.'' The problem was that manufacturers hesitated to make the vaccines for fear of being sued by someone who had been harmed by them and having to pay exorbitant damage claims. The solution, according to the group headed by Jay Sanford, dean of the Uniformed Services University of the Health Sciences, was the adoption of a new compensation system that would relieve the manufacturers of the uncertainty they faced and assure adequate compensation to victims of vaccine-induced injury. The commission also saw the need for a group that would continue to monitor the situation and recommended the creation of a national vaccine commission for this purpose.38
The IOM made sure that the report was distributed widely, particularly to the people who made public policy that affected vaccine development. It also commissioned a science writer to produce a nontechnical summary of the report that better enabled the media to understand and report on the study, and it briefed congressional staff members on the report. These efforts paid off in March 1986 when Representative John Dingell (D-Mich.), chairman of the House Committee on Energy and Commerce, and Senator Orrin Hatch (R-Utah), the chairman of the Senate Committee on Labor and Human Resources, requested that the IOM convene a workshop to refine the report's conclusions for possible use in the legislative process. Financing the workshop through special dissemination funds from the Carnegie Corporation, the IOM complied with the request. The workshop led to a bill that proposed a national vaccine program and an injury compensation system, which Congressman Henry Waxman (D-Calif.) introduced in July 1986. President Reagan signed a modified version into law on November 14, 1986, as part of a larger health measure. In this manner, the Institute of Medicine came to be the author, if such a thing were possible in the collaborative world of Congress, of the National Vaccine Program and the National Childhood Injury Act of 1986 that were contained in the law.39
The report on vaccine innovation and supply illustrated nearly all of the elements of Samuel Thier's strategy to increase the IOM's effectiveness. First, the IOM paid a great deal of attention to the process of dissemination, making sure the report came to the attention of key policymakers and journalists. Second, the IOM responded quickly to Congressman Dingell's and Senator Hatch's request for assistance. In addition, the IOM displayed a sense of flexibility throughout the process. In the past, the organization might simply have issued a report and left it for others to interpret. In the Thier era, the organization did not hesitate to get involved in the finer details of politics and, in effect, to collaborate with congressional staff
in writing the bill. Where John Hogness might have shied away from congressional testimony and direct involvement in the course of legislation from bill to law, Samuel Thier appeared to delight in these things. For him, passage of a law that bore the IOM's imprint represented an organizational triumph.
A less dramatic triumph came from the work done by the IOM on Reye's syndrome. Acting in an oversight capacity, the IOM issued a series of short reports, all highly technical in nature, on the Public Health Service's conduct of a study of the association between analgesics, such as aspirin, and Reye's syndrome. These reports appeared between 1984 and 1987, simultaneously with the formulation and the conduct of the study. Through these reports, the IOM called attention to an issue that required Food and Drug Administration (FDA) intervention. As a result, the FDA ordered that aspirin packages carry special warnings advising parents not to give the product to children with influenza or chickenpox. This public health measure might not have been undertaken without IOM's intervention. It was the sort of thing that the IOM listed in its annual reports under headings such as "making a difference" or "impact."40
Not everything worked so well, as IOM's experience with the Committee on Health Objectives for the Year 2000 demonstrated. This project was larger, more diffuse, less well-suited to the National Academy of Science's ethos of scientific investigation, and much closer to the surface of partisan politics than others that the IOM undertook. It involved a process that had begun in the Carter era and led to the 1979 publication of Healthy People. Issued by Surgeon General Julius Richmond, the book had established broad goals for improvement of the health of Americans. Around 1986, the Public Health Service began the long process of producing new goals for the year 2000 and requested the IOM's help in the procedure. The IOM's experience in the Carter years with this sort of exercise had been painful, leading to major disagreements over the relative emphasis on individual responsibility and government obligation in maintaining the nation's health. Nonetheless, the IOM consented to join the new effort. Unlike the Carter initiative, this one was supposed to come from the bottom up rather than the top down. Rather than convening a group of national experts in Washington, D.C., the Public Health Service hoped to hold hearings in locations across the nation, in order, in Enriqueta Bond's words, to "create a sense of ownership" by the local agencies and private-sector organizations that would have to implement the new objectives. The role of the Institute of Medicine was to help organize the process by holding regional hearings, summarizing the results in a form that would be useful to the Public
Health Service, forming a consortium of professional and voluntary organizations and soliciting its input to the process, and convening a conference to launch the new objectives.41
The Institute of Medicine appointed a steering committee for the project, which conducted regional hearings at the beginning of 1988. The idea was to hold the hearings before the presidential election distracted public attention from the process. The hearings produced a series of grassroots laments that were difficult to synthesize into a larger and more coherent list of objectives. In Birmingham, Alabama, an academic physician from the University of Tennessee testified on the subject of breast cancer, a disease that he characterized as "common, curable, and easily detectable." Despite this fact, people continued to die of breast cancer, most often because of a delay in diagnosis that was the result of "negative feelings about health care facilities, avoidance and denial and societal conditions that lead to a fatalism about the disease." A physician from Nashville, Tennessee, said that poor people delayed seeking treatment for high blood pressure because of financial barriers and also because of a "culturally determined belief that favors reliance on family, friends, and spiritualists over medical professionals." A member of the Washington State House of Representatives told the IOM study group in Seattle that the number one issue was health care financing. "Legislators,'' he testified, "see health dollars as a kind of pac man (a popular video game of the period) eating various bits of money ... we're seeing costs going up and access going down." Just how these problems could be addressed through the goal-setting process was not immediately evident.42
As the hearings took place, IOM staff sat in on discussions at the Public Health Service in which federal officials critiqued drafts of the health objectives for the year 2000. From the IOM perspective, the drafts often showed what one staff member described as "political accommodation rather than scientific rationale." The staff member questioned the need to add a category on the "safety of foods, drugs, and medical devices," which appeared to be a means of getting the FDA involved in the objectives process and nothing else. He claimed that the addition of category 22 for people with disabilities "seems to be the result of strong political pressure to do something for the disabled."43 In other words, the Institute of Medicine believed that setting health goals should be a scientific process, rather than one dominated by bureaucratic politics and the needs of minority groups to advance their political agenda. IOM staff members felt uncomfortable with the pluralism of the policy process, preferring instead to seek consensus among well-trained and experienced health
professionals. Holding such a view, the Institute of Medicine, or more properly its staff and steering committee concerned with this project, found it difficult to participate in the making of policy from the bottom up. Because such a policy model was antithetical to the National Academy of Science's very nature, any IOM reports that reflected this view would, in all likelihood, not be approved by the NRC.
The conference that was to be the culmination of the project took place in the spring of 1990. By this time, George Bush was President of the United States. Because the Public Health Service hoped the President would deliver the keynote address at the conference, planning for the conference became complicated and politically contentious. The Public Health Service, for example, invited the United Way to cosponsor the conference, providing a link between the health objectives and the private sector and enabling the United Way to raise funds for the conference. Saying that this arrangement violated National Academy of Sciences rules, Samuel Thier wanted the IOM to drop out as a cosponsor. To navigate around these difficulties, the Public Health Service and the Institute of Medicine negotiated an agreement under which the Year 2000 Health Objectives Consortium, created and managed by the IOM, became a cosponsor with the United Way. The wording of the objectives generated even more discussion. The White House wanted to keep the President away from controversial matters; hence, the objectives related to family planning and teenage parenthood were vague on the use of contraception by teenagers, the provision of sex education, and the subject of abortion. In the end, the President did not appear at the September 1990 conference, which featured the release of Healthy People 2000: Citizens Chart the Course, the IOM publication that summarized the testimony it received. Issuing a proclamation, President George Bush sent Secretary of Health and Human Services Louis W. Sullivan to speak in his absence. Although the surgeon general described the report as the "cornerstone" of the process, the collaboration between the IOM and the Reagan and Bush administrations involved considerable strain and misgivings. 44 In this case, it was not clear how much of a difference the IOM had made.
The IOM fared better when it had more control over the process, as in a 1988 study of the future of public health. This study resembled the one on setting goals for the year 2000 in that it consisted of predicting the future course of health policy and making suggestions to alter this course for the better. Both studies involved the process of seeking input from local health practitioners and professional organizations in order to arrive at some sort of consensus. The
difference was that in the public health study, the IOM did not have to reflect grassroots opinion but could rely instead on the advice of its steering committee, which contained such luminaries and IOM members as Richard Remington, vice president for academic affairs at the University of Iowa; David Axelrod, commissioner of health for the State of New York; Lester Breslow, a professor of public health at the University of California at Los Angeles; Melvin Grumbach, head of the Department of Pediatrics at the University of California at San Francisco; and Robert J. Haggerty, president of the William T. Grant Foundation. These individuals shared a set of assumptions, for example, that the maintenance of public health constituted an important mission of government at all levels and that public health officials should have the advantage of expert knowledge derived from fields such as epidemiology and biostatistics rather than being forced to make decisions on the "basis of competition, bargaining and influence." In other words, these people, experts themselves, believed that professional expertise should inform politics.
The report sought a reaffirmation of the nation's traditional public health mission. The committee found that the nation had "slackened [its] public health vigilance and the health of the nation is unnecessarily threatened as a result." Signs of disarray were everywhere. There was little agreement on the public health mission, with the result that public health activities had become fragmented and politicized. Mental and environmental health, for example, were often separated from the rest of a state's public health activities. Morale among public health officers was low and turnover high, with the increasing substitution of political appointees for public health experts. The committee believed that public health departments at the state and local levels should return to the activities they had let disintegrate, such as gathering statistics that described the health of the community. The committee recommended that every state should have a department of health, headed by a cabinet-level officer and distinct from the department of income maintenance, as well as a health council. Through these organizations, according to the report, states should put in place a series of disease control measures that responded to modern conditions such as AIDS, cancer, and heart disease. The report concluded with the message, "Public health is a vital function that is in trouble. Immediate public concern and support are called for in order to fulfill society's interest in assuring conditions in which people can be healthy."45
The ringing rhetoric demonstrated the desire of the Institute of Medicine to make itself heard. Most readers probably did not read the entire 217-page report, preferring instead to consult the 18-page
summary, which was attractively bound in a softcover booklet with a salmon and turquoise cover. In the past, IOM reports, written in bland and cautious prose with little regard for the felicities of language, had been dauntingly difficult to read. Only the most devoted could make their way through them. The essence of the recommendations mattered, not the language in which they were expressed. By way of contrast, The Future of Public Health read as though it had been written by a professional writer, although it was in fact the work of the IOM staff. At times, the recommendations were vague, as in the exhortation that "agencies must take a strategic approach, developed on the basis of a positive appreciation of the democratic political process." However, the report could always be understood.46
In a certain sense, clarity, aided by an orderly dissemination process, translated into influence. This report served as a basis for bills that were introduced in state legislatures. The bills sought to revamp the structure and responsibilities of state public health agencies to bring them in line with the IOM recommendations. The report also provided the impetus for a plan developed by the Public Health Service to strengthen public health in the United States. In other words, the project became the focal point for a generation of reform efforts in the field of public health.47
Serving as a catalyst for action was a congenial role for the IOM, not only on large global studies such as the future of public health, but on smaller, more specialized studies as well. Typical of these was a report entitled The Computer-Based Patient Record that appeared in 1991. The message of this report, the work of a 10-person study committee chaired by Don Detmer, a professor of surgery and vice president for health services at the University of Virginia, was contained in a seven-page summary. In keeping with the IOM's modern sense of style, the report summary came bound in an attractive booklet with a colorful cover, whose sheer cheerfulness tended to counteract the utilitarian nature of the subject under discussion. For harried readers who lacked the time for the summary, the essence of the report could be gleaned by reading the text box on page six that listed the report's seven major recommendations. The chief recommendation was that "health care professionals and organizations should adopt the computer-based patient record ... as the standard for medical and all other records related to patient care."48
Throughout this report, the study committee emphasized its vision of the future, rather than its reading of the present. Hence, the report, despite its prescient quality, had some of the "gee-whiz"
attitude common to studies that described future trends in technology. In the committee's view, the patient record of the future was a wondrous thing, complete with "links to administrative, bibliographic, clinical knowledge and research databases"; decision support systems; "video or picture graphics ... and electronic mail capability." For practitioners of health services research, such a record, with its rich sources of data that could be gathered and analyzed easily, was a particularly tantalizing prospect. Missing from the report, however, was a coherent sense of how to get from here to there because little in the report connected present-day realities to future possibilities. In the real world, computers broke down; proved incompatible from one part of a hospital to another; required constant maintenance, replacement, and updating; and demanded more knowledge of their operations than users often had. Faced with a new technology that took time to learn, many physicians responded by scribbling notes on charts for others to decipher or dictating reports for others to transcribe. The IOM report, in other words, described a future goal suggested by the potential of technology but did not offer much evidence to show that the goal would ever be reached. At issue was the ability of technology to change behavior, an issue that the report did not address. Nonetheless, it did spur further activity in the field, for example, through the founding of the Computer-Based Patient Record Institute to develop appropriate standards.49
As the IOM gained influence, it received numerous requests from Congress to examine controversial matters and help in the adjudication of contentious issues. In these instances, the organization did not have the luxury of simply rallying the health care establishment in support of future goals. Instead, it had to confront the limits of the influence of science on public policy.
A good case in point concerned the mandate of the 99th Congress that the IOM investigate the subject of the health care received by homeless people. As the report, issued during the fall of 1988, entered the NRC review process in the winter of 1987–1988, it encountered numerous objections and difficulties. At the heart of these objections was the concern of NAS President Frank Press that the committee had gone beyond the boundaries set by the evidence and strayed into areas not contained in the congressional mandate. Bruce Vladeck, chairman of the study group who later became the head of the Health Care Financing Administration during the Clinton presidency, told the committee that he saw himself as its advocate in the review process.50 After repeated delays and substantial NAS editing of the report, Vladeck complained that the edited report lacked "emphasis, strength, and passion." To counteract this impression, he drafted a
"Chairman's Message" that contained very strong language. It described homelessness as "a scandal and an outrage" that demanded not only "dispassionate analysis" but also "a more direct and less qualified scream of pain and anger." The report, according to Vladeck, contained ''lots of analysis but no poetry.... We tried to make our report as dispassionate as the IOM/NAS process requires, but the reality we experienced cries out for passion."51
In the end, little of Vladeck's passion seeped into the final report. Careful analysis triumphed over soaring poetry, even in an era in which dissemination of results and impact on the policy process were among the highest IOM values. The report appeared with no supplementary statement from Vladeck, who threatened to write about the matter in an op-ed piece for the New York Times. Instead, it contained the unexceptionable conclusions that a high level of mental illness characterized the homeless community and that the homeless required stable residences and sufficient incomes. In this regard, the report could be parodied in a manner similar to a sketch from Beyond the Fringe: What the homeless needed was not to be homeless. As for the health care received by the homeless, the report suggested that it was inadequate and formed part of a larger problem of providing access to health care for those unable to pay. In the meantime, public policies toward the homeless were fragmented and often ineffective.52 Perhaps homelessness, unlike the improvement of medical care records, was simply too large and amorphous a problem for the IOM to solve.
If Congress liked to present the IOM with issues for which no solution was imminent, it also requested the IOM's assistance in matters that were simply too controversial for politicians to handle. Such a case occurred during the early 1980s in the Social Security programs designed to pay benefits to people with disabilities. During the 1970s, Congress had grown concerned over the rapid growth of these programs and had sent signals to the bureaucracy to reduce the size of the rolls. When the Social Security Administration responded by removing many people from the rolls in the early 1980s, Congress shifted direction and expressed concern for people taken off the rolls in the midst of a severe recession. Congress passed a law in 1984 that made it more difficult to remove a person from the disability rolls. Certain issues, however, were too difficult for Congress to decide, such as how much credence should be given to complaints of pain among applicants for disability benefits. In response, Congress mandated the creation of the Commission on the Evaluation of Pain and directed the commission to work in consultation with the IOM. The commission, in turn, recommended further study by the IOM, an
assignment that the IOM accepted in 1985 and that led to the report Pain and Disability in 1987.53
An interesting blend of medical doctors and social scientists served on the committee, which was chaired by Arthur Kleinman, a professor of anthropology and psychiatry at Harvard, and David Mechanic, the Rene Dubos Professor of Behavior Sciences at Rutgers. From the beginning, this group recognized that the phenomenon of pain had both a physiological and a behavioral component. The report stated bluntly that "very little is known about the mechanisms underlying such common clinical problems as low back pain" and that "no direct, objective way to measure pain" existed. Rather than dismiss an applicant's protestations of pain, the group recommended that the Social Security Administration should instead assess what the experts called the ''functional capacity for work." At the same time, the committee suggested that such things as "chronic pain syndrome" not be added to the list of impairments that automatically qualified a person for disability benefits. The Social Security Administration took the IOM's advice and instituted an early functional assessment of claimants with a primary pain complaint. To be sure, the disability programs remained controversial, particularly during the tremendous surge in the rolls that occurred after 1984. Nonetheless, the IOM had successfully intervened in, and probably improved, a significant component of disability policy at a time when Congress was reluctant to become involved.54 Furthermore, it had done so by bringing together leading medical doctors and social scientists in ways that were unique to the IOM.
Even as the IOM undertook special assignments for Congress, it also tended to its traditional concerns. In 1990, for example, one of the cross-cutting themes of the Institute's work was "the role, education and supply of health professionals." In support of this theme, the IOM released a report on financing the graduate medical education (GME) of primary care physicians in ambulatory settings. This project came to the IOM not by way of the government but rather through the efforts of two professional organizations concerned with health, the Association of Program Directors in Internal Medicine and the Ambulatory Pediatrics Association. The IOM obtained support for the project not primarily through the government but rather from the Josiah Macy, Jr., Foundation.
The final report lacked the elegant writing and presentation that marked so many IOM reports during this period, in part because it concerned hard-core matters of interest only to those who understood the intricacies of health financing policy. In support of increasing the number of doctors who worked in primary care fields in outpatient
settings, the report recommended that technical adjustments be made in the way the Medicare program financed graduate medical education and the way it reimbursed the services of physicians. The report also urged medical schools to reorder their priorities so that primary care teaching and curriculum development were rewarded. As the report noted, physicians in primary care practice responded to community health needs in settings that ranged from solo practice to HMOs; the hospital was no longer a suitable principal focus for the GME experience of such physicians. The committee concluded that "the care provided by future generations of primary care physicians would be enhanced if the GME experience placed greater emphasis on training in primary care outpatient settings." Although the report's effect on public policy was scant, it helped call attention to the need to match the educational system with the realities of medical practice. It received attention from medical schools that were in the process of revising their primary care residency programs, if not from the Congress.55
The Institute of Medicine produced a dizzying array of reports and studies in the Thier years. In the field of health manpower and education, for example, the work of the Institute extended beyond primary care to include multiple studies in the fields of geriatrics, allied health services, and occupational and environmental medicine.56 Often, one study exposed gaps in knowledge or highlighted opportunities that led to the IOM's being asked by a sponsoring agency to do a follow-up study.
At the same time, the IOM responded to numerous requests for assistance from government agencies on studies or projects that the agencies were undertaking themselves. To cite one example, the Institute of Medicine provided scientific advice and oversight for several Centers for Disease Control (CDC) studies of the health of Vietnam veterans. In particular, the CDC wanted to know if exposure to Agent Orange and other herbicides in South Vietnam led to a greater risk of such cancers as Hodgkin's disease and non-Hodgkin's lymphoma. In 1990, the IOM issued a summary report in which it concluded that the CDC Selected Cancers Study made a "useful and important contribution to understanding the relationship between the Vietnam experience and the cancers under study." Such validation was important because an earlier study that had been canceled led to a charge from Representative Ted Weiss (D-N.Y.) that the Reagan administration had deliberately obstructed the study. In such a contested area of public policy as the effects of Agent Orange, with millions of dollars in damages at stake, the public had to be reassured that scientists who performed the investigations were above political
suspicions. The IOM helped to supply this reassurance and improve the conduct of the study.57
Despite the fact that the IOM did so many studies on such widely disparate topics, the organization moved with considerable caution. If anything, the IOM moved more cautiously in the Thier years than before, in part because of the realization that its actions had real policy consequences and in part because of a new financial independence that made it less dependent on external funders. When, for example, the IOM convened a group to consider what projects, if any, the organization should pursue in the area of medically assisted technology, Thier warned that it should not become enmeshed in the ''sociopolitical arguments" that had arisen over medically assisted conception. Instead, the IOM could maintain its neutrality by focusing on the "science base" of this matter. As a result, the Institute decided to sponsor a conference on reproductive biology. The Board on Medicine and the early IOM, one might surmise, would have engaged the question differently. 58
In these various ways then, the IOM conducted its activities in the years between 1986 and 1991. At times it responded to congressional mandates and, at other times, generated its own funds for studies that had been suggested by the IOM members. Some studies came at the request of government agencies and others at the request of private foundations or professional groups. In some instances, the IOM tried to condition future practices; in others, it sought to redress past grievances. It handled large and amorphous topics such as the future of public health, as well as smaller and more select topics such as the role of pain in Social Security disability determinations. At times, the IOM acted as an agent of reform. At other times, it functioned as an arbiter of public policy or an entity that validated the actions of others. Always, however, the IOM used its special prestige and status, its membership drawn from a wide variety of medical fields and disciplines, and its ties to the National Academy of Sciences to convene an appropriate and distinguished panel to examine the particular question under discussion. In these regards, the Thier era was not unlike the eras that preceded it; the difference came primarily in the increased scope of the IOM's activities.
Despite all that happened between 1986 and 1991, questions that dated back from the founding of the IOM still preoccupied the staff and the Council. The issue that most animated the IOM staff concerned the overlap between the missions of the IOM and the National Research Council. Even with the transfer of new agencies from the NRC to the IOM, the boundary between these two parts of the Academy complex was unstable. In November 1989, Samuel Thier complained, as had his predecessors, that the overlap was "not well controlled" and that such topics as animal research, radiation effects research, and environmental studies and toxicology led to duplication and competition between the Institute of Medicine and the Commission on Life Sciences. Potential for conflict on behavioral topics also existed with the NRC's Commission on Behavioral and Social Sciences and Education.59
The question that appeared to be of most interest to the IOM Council involved who should be elected to the IOM in a given year, because each year the longest discussions concerned membership criteria. In January 1988, for example, David Challoner appeared before the Council to discuss the final ballot for the 1988 election and the proposed ballot for the 1989 election. At this point in the organization's history, membership elections had become quite structured, with quotas in seven different categories. The largest of these categories was the one broadly based in the medical disciplines; the smallest included physical scientists, mathematicians, and engineers. In 1988, the Membership Committee arranged the quotas to yield a total of 40 new members. To assist voters, the Membership Committee, with the help of IOM members themselves, ranked the nominees in each of the categories. Those ranked highest usually gained membership. In addition, the IOM hoped to elect 10 people directly to senior membership. For the 1989 election, the IOM Council decided to elect 40 new members, as well as 5 senior members and no more than 10 foreign associates. Apportioning quotas among the categories always created disagreements. In 1988, for example, Alexander Capron, a lawyer from the University of Southern California and a Council member, expressed concern that the number of members in the social sciences category was decreasing. Thier replied bluntly that the IOM was "not a representative group and some disciplines and areas of expertise would not be as well represented as others." The idea was not to spread the membership across fields but rather to identify "outstanding people who can contribute to the Institute's task."60
As the Institute added new members each year, it bumped up against the limit of 500 members that was contained in the Charter, which increased the pressure to include individuals from specialties not well represented and made the competition across membership categories even more intense. The trouble stemmed in part from the composition of the various membership sections that suggested new members. These sections were narrower in scope than the membership categories. Section Eight, for example, represented family medicine, primary care specialties, emergency medicine, physical medicine and rehabilitation, and osteopathy. It contributed suggestions for those nominated under Category Three, medical disciplines, in the general election. Although family medicine was well represented in this section, it contained few practitioners from the other medical fields it was designed to include. If a section was dominated by people from one field, it was difficult for someone from another field to get nominated or, if nominated, to receive a high ranking from the section and the Membership Committee. This feature of the election process limited the organization's ability to face new problems that demanded the expertise of people in fields that were not well represented in the membership. In addition to these questions related to discipline, the Institute faced other concerns related to the composition of its membership, such as ensuring the election of women and minorities. In a setting in which the organization received 200 nominations for only 40 places, achieving diversity proved difficult. Members tended to rely on what one described as "the old-boy, old-girl network."61
To ease these problems, the Council decided in November 1989 to raise the ceiling on membership from 500 to 600. This would permit the Institute to elect 45 rather than 40 members each year. The rationale for the change was that in the past, it had been necessary to control the quality of the membership by limiting the size of the organization. Because of the rigorous procedures followed by the Membership Committee, however, the Council felt that quality concerns had become integral to the nominating process. Hence, the number of members could be expanded, although not without limit, and the quality of the membership could be maintained.62
If there was a major change in membership over the years, it concerned the increased medical, as opposed to public policy, expertise of members. There were fewer generalists, more specialists. When the Board on Medicine started, it included individuals such as Adam Yarmolinsky, who were distinguished in their own fields, lacked direct experience in medicine, and became quite interested in medical affairs in large part because of their involvement with the IOM. In the
IOM's first years, it also had members who were regarded as important to the ongoing discussion of national health insurance, people such as Robert Ball and Wilbur Cohen, two Social Security experts who had played major roles in the creation of Medicare. As national health insurance faded as a topic of concern, people similar to Ball and Cohen, who were neither physicians nor health care professionals working in an academic medical center, had more difficulty being elected to the IOM. With the tendency to more closely merge the medical professions and the IOM came the danger of losing sight of the connection between medical policy and larger social concerns.
Despite this danger, many IOM members insisted on preserving its social, as opposed to scientific, mission. In 1989, Samuel Thier noted with pride that Dr. Louis Sullivan had been nominated by President-elect George Bush to serve as Secretary of Health and Human Services. Sullivan became the first person to serve as Secretary of Health and Human Services while already an IOM member. It gave the organization a sort of "in" with the department most concerned with social policy that it had not enjoyed since the days of Joseph Califano. It increased the chances that the department and the IOM could act in concert in facing such issues as AIDS, homelessness, and crack and cocaine addiction. With each of these social problems, it was the IOM that showed the most interest in them among the components of the National Academy of Sciences. Even as the IOM increased its science component, therefore, it remained the branch of the National Academy of Sciences most dedicated to bringing research to bear on modern social problems.
What most distinguished the years between 1985 and 1991 was not a change in the IOM program as much as the experience of phenomenal growth. No longer could the IOM be regarded as marginal to the NAS, an experiment that could be suspended with cause. Instead, the IOM became the branch of the NAS with the most financial resources at its disposal and, in many respects, the most active membership. The Thier years assured the IOM of its survival and made it a permanent entity in the NAS and on the larger national scene.
It even looked for a time as though Samuel Thier would become the first two-term president of the NAS. When his first term ended in the fall of 1990, he began a second. In May of 1991, however, he announced that he had received an offer to be president of Brandeis University that he felt he could not refuse. When Thier left for Brandeis in the fall of 1991, Stuart Bondurant, dean of the University of North Carolina Medical School at Chapel Hill, became the acting
president of the IOM. Once again, the IOM awaited a new leader. Unlike Samuel Thier, for whom expectations were low in the face of threats to the IOM's very existence, the new IOM president would lead a large, complex, and growing institution that was expected to play a major part in the nation's health policy. As the Wall Street Journal reported in 1987, the Institute of Medicine had achieved considerable clout on the Washington scene, and Samuel Thier had played no small part in this.