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Harvey V. Fineberg, M.D., Ph.D.

President’s Address at the Institute of Medicine Annual Meeting, 13 October 2008

ASK THE BIG QUESTIONS
 

I take this energetic set of conversations as a good sign that people are glad to see one another, happy to share ideas and to have the opportunity for the fellowship that we enjoy at each of our annual meetings.

 

Challenging Times for the Nation

We gather today in turbulent times. America is sliding into recession. We lost a net 150,000 jobs last month, and businesses are just starting to cut back.  The credit markets remain frozen.  This past week witnessed a fall in stock prices that was greater than in any previous week in history.

Oh, by the way, I learned over the weekend that there was actually an easy way to make a small fortune in the stock market last week.  The key was you had to start with a large fortune.

And that's not all.  Our nation is engaged in two wars.  The war in Iraq is costing $10 billion a month.  The war in Afghanistan is not going all that well.  The cost of oil, while gyrating, is at levels that would seem exorbitant except for the stratospheric heights that the price of oil had previously reached, and our nation still lacks a coherent, comprehensive, long-term energy policy. 

The risks of climate disruption and increased frequency of extreme weather events—on habitation of coastal areas, on productivity of agriculture, on the emergence of infections, and on other adverse consequences—remain to be played out.  Terrorism is a continuing threat.  Iran is on a path toward nuclear weapons capability.  And the on-again, off-again, on-again nuclear inspection regime in North Korea does not provide a high measure of comfort. 

Our nation’s public education system seems to be in a state of perpetual crisis. And every once in awhile, when a bridge collapses or a highway sinks, the country is reminded about the sorry state of our physical infrastructure.  Fundamentally, we need more innovation across the board—in biomedicine, in renewable energy, in promising science and engineering from nanotechnology to regenerative medicine.

This is quite a collection of challenges for whoever will be elected president three weeks from tomorrow. In this historic election for America, ageism, sexism, and racism are all on the line.

And what about health in America?

The United States is the only industrialized country without a satisfactory national health insurance system. We have 47 million uninsured and millions more underinsured, shortages of nurses and primary care doctors, and persistent disparities in access and outcomes for racial and ethnic minorities.

More than one out of every six dollars in the U.S. economy flows through the health care system. On a per capita basis, the U.S. lavishes on health more than twice the average spent by other countries in the OECD (www.oecd.org/dataoecd/29/52/36960035.pdf).

In international comparisons of health system performance, the United States is now surpassed by dozens of countries in such measures as life expectancy at birth and infant mortality.  As previous IOM studies have documented, those without insurance tend to delay care and suffer worse health outcomes than those with insurance (Care Without Coverage: Too Little, Too Late, 2002). Too often, our doctors and hospitals fail to rely on the best evidence and do not consistently deliver the right care to the right patient at the right time, as every patient deserves.

One telling study appeared earlier this year, sponsored by the Commonwealth Fund and reported by Ellen Nolte and Martin McKee from the London School of Tropical Medicine and Hygiene (E Nolte and CM McKee. Measuring the health of nations: updating an earlier analysis. Health Affairs, January/February 2008; 27(1): 58-71.) The investigators reprised a study they had done in 1997-98 comparing 19 countries in terms of mortality from conditions that are in principle amenable to medical intervention. In 1997-98, the U.S. ranked 15th out of the 19 comparison countries.  Over the next five years, the U.S. improved by four percent.  However, other countries, on average, improved by 16 percent, and by 2002-2003, the U.S. dropped to 19th out of 19 comparison countries.  If the U.S. had achieved the outcomes of the three best-performing countries, we would have experienced 101,000 fewer deaths per year by the end of the study period. 

At a time when economic turmoil and war preoccupy our nation’s attention, what should we, as a community concerned about the long-term and enduring values of health, attempt to accomplish? 

Before turning to answer this question, I want to reflect with you on the work and contributions of the Institute of Medicine (IOM) since the time of our last annual meeting. 

 

The IOM over the Past Year

Over the past twelve months, the IOM has done a number of projects aimed directly at improving the quality and character of health care.  Cancer Care for the Whole Patient was a very important analysis looking at the psychosocial health needs of patients and reestablishing the fundamental importance of healing relationships between physicians and patients.  We conducted a timely and important study, Treatment of Posttraumatic Stress Disorder, examining the treatments available, their effectiveness, and what can be done to meet a growing need for care among our nation’s returning veterans.  We issued a number of publications based on workshops, from Diffusion and Use of Genomic Innovations in Health and Medicine to Standardizing Medication Labels: Confusing Patients Less. Medication errors remain the leading cause of errors in medical practice, and the final common pathway of how patients take their medicine can be greatly enhanced by clarity in medication labeling. 

A lot of our work this year was directed at guiding research for the nation.  A number of publications from our Forum on Drug Discovery, Development, and Translation focused, for example, on improvements in testing, monitoring, and managing the safety of drug products. Others were directed at the special challenges of drug development for the pediatric population. 

In our Forum on Neuroscience and Nervous System Disorders, the work done this year included a very important meeting on lines of research into possible environmental factors in the cause of autism. Two other valuable products that emerged from workshops of that Forum dealt with ways to improve our understanding of neuroscience and of mental disorders. 

We continued the series of studies that was requested specifically by the National Institute on Occupational Safety and Health (NIOSH) to examine its programs and advise the agency how it to improve its research activities. And this past year, we reported on ways to improve both cancer clinical trials and HIV prevention trials. 

Among the most important things I believe the IOM can contribute in the course of a year is to elevate the visibility of health problems and opportunities for solutions that would otherwise go unnoticed by the public, the profession, and policymakers, or fail to receive the level of interest and attention that they deserve.

In this past year, we continued work on reducing health disparities, a problem that requires continued attention.  We also shed light on specific health needs during adolescence, that awkward period between childhood and adulthood when youngsters have their own peculiar mix of health needs and requirements. 

We held a workshop that opened up the possibilities and the challenges of the effect of climate change and extreme weather events on the emergence of infectious diseases. We also highlighted the problem of violence and its prevention in low- and middle-income countries—a problem which, in the global burden of disease and illness and premature mortality, is shockingly high. 

The IOM aspires to inform and to influence policy. We have had a direct impact this past year on legislative proposals, on enacted legislation, on the actions of federal agencies, on state policy, on professional practices, and on public understanding and action for health. (A summary of ten illustrative examples of impact are included in the separate supplement to my Annual Report.)  We raised attention to needs and strategies for infectious disease surveillance and preparation for pandemic influenza. We extended our work on health risks that apply to returning veterans from the Gulf War and attended to the safety and well-being of those in active-duty military service. 

As an example of the global reach of the IOM, I want to mention a study that I believe contains very important messages for the use and deployment of malaria treatment, Assessment of the Role of Intermittent Preventive Treatment for Malaria in Infants. This report represents an interesting complement to the study that was done several years ago by the IOM on making anti-malarial medication more inexpensively available around the world—a study whose principal recommendations have yet to be fully adopted and acted upon.

Among the most fundamental activities of the IOM is our effort to look with clear eyes and careful scrutiny at some of the most fundamental needs for improvement in health and health care in our nation. 

This past year, for example, our Roundtable on Evidence-based Medicine laid out a marvelous set of principles that are going to be very important, I believe, not only in guiding the work of the Roundtable, but in influencing the way many will think about the role of evidence in medical practice, value-based decision-making, and creating a learning health system. One report released during the course of this last year, Knowing What Works in Health Care, describes how the nation can learn routinely and effectively what actually works in health care, for exactly which patients, and how we can translate that knowledge into action. 

One of the most profound efforts of this year dealt with a crucial long-term challenge for our health system and society:  What do we need to do to prepare a health workforce for an aging society?  The IOM report, Retooling for an Aging America, shows the way forward. At a time when the number of geriatrically-trained physicians is in decline, this is a major problem for the country and one key part of a larger challenge on human resources for health and health care. 

 

Speaking to the Public

I want to remind IOM members about our efforts to reach out to the public and to other specific audiences whose understanding of health and science are fundamental to the quality of decisions that our nation and our leaders will make. 

When the National Academy of Sciences turned its attention to the new edition of its report, Science, Evolution, and Creationism, President Ralph Cicerone invited the IOM to join in cosponsoring this effort and to participate in its preparation. This readable report, lays out in clear and unequivocal terms the abundant evidence for evolution in biology.  It cites and quotes many religious leaders from different faiths who wholeheartedly accept biological evolution.  It is important for the public to know and understand the facts of evolution and not to feel that this contradicts other deeply held beliefs. This was a very important part of the core message of this succinct report, one that has been requested and read by thousands of people over the course of this last year, and I think will be a lasting credit to the Academies. 

I also want to share with you a very special effort over this last year that was initiated by the Council for Excellence in Government (CEG), led by Patricia McGinnis. She brought to us the idea that in addition to speaking to the public in the course of the year about science and about health, how important it would be for us to listen to the public and to engage in dialogue about what's on the minds of people in everyday life about health, especially in the context of the myriad other concerns that I mentioned earlier. 

The idea was to engage in a series of three town hall meetings around the country, the first of which was held in Miami, hosted by Donna Shalala, President of the University of Miami, former member of the IOM Council and former Secretary of Health and Human Services.  The second was held in Detroit; among our members who participated was Gail Warden. And the third was held in San Francisco.  These meetings were very revealing in many ways, and they were complemented by a set of surveys that were incorporated into a report prepared by CEG that is going to be released publicly tomorrow.

I learned many things in the course of listening and participating in this project. Perhaps not surprisingly, when the public is asked what its number one concern is about health, the answer was the cost of care.  But here's a key insight:  When members of the public talk about the cost of care, they're talking about the out-of-pocket payments that they cannot afford.  They're not talking about the total costs that economists and health analysts worry about, and that's a very important message to understand. 

One other insight that I gained was the large number of people who are more than willing to have their medical information shared if it will contribute to better learning about what works and how we can make progress in health, and that was a very encouraging part of the message from this exercise.  I urge you to look at the whole report and see what insights you can garner that are relevant to your thinking about what needs to be done in health reform. 

Given how important it is to have two-way communication with the public in an ongoing way, we are making an effort to revisit, reconsider, and reconstruct our website, a principal tool by which the public, as well as our members, can interact and reach the IOM, its programs, and its products. Over the course of the next year, and with luck, by the end of next summer, we hope to go live with a revised, more usable, more accessible, more relevant website that will inform and engage the public in more effective ways.

While I'm talking about reconstruction, I also want to mention to our membership that the National Academy of Sciences building in which we meet today is going to undergo a massive renovation and restoration process starting next spring.  For the next two annual meetings of the IOM, we will not gather in this auditorium.  We realize how important historically this building is, designed by the renowned architect Bertram G. Goodhue, constructed in the Art Deco style of the 1920s, resonant with the Lincoln Memorial situated nearby on the National Mall, and one of the very few buildings on the Mall still in nongovernmental hands.  This building is going to absorb forty, fifty or more millions of dollars and be reconstructed to look essentially just the way it looks now.

But it will work a lot better.  And indeed, for some of the less historic portions of the building, we can make it more functional.  We can improve the technological underpinning.  We can make the meeting rooms more agreeable and useful, and we can establish better public access and movement, all of which is going to get underway next spring. 

 

Collaborating with Other Nations’ Academies

I want to remind our membership about the continuing efforts of the IOM to reach out to other academies in other countries.  When I spoke yesterday with the class of 2007, the members newly elected in this past season, whom I'll be introducing later in the day, I reminded them about the fact that other national academies are often more honorific in their character compared to the service ethos that we have.  But one thing I have discovered in meeting with, talking to, and interacting with academicians around the globe is that they do embrace and aspire to a service mission.  They want to make a difference for their countries in just the same way that we try to make a difference in the U.S.  And there are a number of important ways that we are reaching out to try to work together with others. 

I might mention, in this connection, that during this past year, we had a wonderful regional meeting in London, co-hosted at the King’s Fund by IOM Foreign Associate Sir Cyril Chantler.  I had the experience this past winter of participating in a review of the Netherlands Health Council, which carries out advisory functions analogous to those that we perform.  We've also had meetings of the Inter-Academy Medical Panel board in Mexico, and interactions with the Mexican Academy and others. 

Today I want to highlight two particular regions of the world.  The first is the African Science Academies Development Initiative (ASADI). This project has been under way for the last four years at the National Academies, with the IOM in the lead for now. We have been working with our counterpart academies in Africa, especially with the academies in Nigeria, Uganda, and South Africa, but also with four other countries in a developmental phase, as well as some of the Africa-wide academies, attempting to help them provide strategic advice to policy makers.  Last summer, the South African Academy presented its findings and its report on HIV in South Africa, and put forward, in no uncertain terms, the importance of recognizing HIV as the cause of AIDS and the foolishness of looking to garlic or African herbs to treat HIV infection. This was a very important step forward that was a direct outgrowth of the developmental collaboration accomplished by ASADI. 

In April of this year, representatives from the African Academies joined us for a week in Washington to immerse themselves in the procedures and activities of the IOM and to participate in a valuable dialogue with the IOM Council that met at the same time. We hope to extend these very promising developments with our African colleagues in the years to come. 

One troubled part of the world where collaboration can be problematic is in the Middle East. The IOM’s work there began about a decade ago, and then went into a quiet phase exacerbated by the second intifada when it was impossible for the Academies to meet.  But in January of this year, hosted by the Jordanian Council (its Academy equivalent) we were able to bring together representatives from the Jordanian, Israeli, and Palestinian Academies to begin again to focus on their common needs and interests.  Five different areas of future work were identified, and a commitment was made to develop, particularly, a Board on Nutrition. Nutrition was an area where all of the academicians felt they both have something to offer and something to gain from the interaction.  At that meeting, I saw first-hand how important it can be for the U.S. to sit at the table. Without our participation, it would have been much more difficult for the representatives of those three academies to assemble on their own. 

In the course of this last year, we produced a workshop summary on Foodborne Disease and Public Health, done jointly with colleagues in Iran.  I believe it is especially important when international relations are confounded that we maintain scientific and health collaboration and remain connected at the human level, even when there are so many difficulties at political and governmental levels.  Later this fall, if all goes according to plan, we will visit Iran to follow up on a meeting last year, led by another group from our National Academies, attempting to build and develop continuing interactions and collaboration, something that I believe can contribute positively in a troubled world. 

 

Supporting Young Talent

Now, I would like to bring some good news to you about one very exciting development over the course of this past year. As a lifelong educator, I have always loved the fact that the web address for the Institute of Medicine is a “dot edu.” Through our work, we are in fact in the business of education.  And one way in which we participate in education, in addition to our outreach, our publications, our programs of interaction, is by bringing fellows to the IOM and to the rest of the National Academies. 

At the IOM, we host the venerable Robert Wood Johnson Foundation fellows whom I'll be introducing at the end of the day.  This program dates back almost to the founding of the IOM, and it represents a vital opportunity for senior leaders in the health arena to engage in policy. The resident Nurse Scholar program has become a valued component of our fellowship activities, and we also participate in an Academies-wide program of doctoral and immediate postdoctoral fellows training, the Mirzayan Fellows program. 

You may recall I spoke to you recently about an idea that emerged from the Council following our 35th anniversary celebration, about a special type of fellowship that would concentrate on rising scholars, young faculty at an early stage of their careers, who regardless of their particular disciplinary interest—in the laboratory, in the clinic, in scholarship, or in the field—would find a part of their career fulfilled by more active engagement in the policy and analytic processes of the IOM.  We developed a pilot program that would attach these rising young faculty for a period of two years to the IOM. Rather than bringing them full-time to Washington, they remain in residence at their home institutions so that they can continue to progress in their laboratory or in their clinical or professional work and their teaching. Like expert volunteers, the Fellows become engaged in IOM committees, in our boards, in our forums, in our annual meetings, and in other activities, so that they become part of the learning experience and contribute to the work of the IOM.  The Fellowship offers every fellow a flexible stipend of $25,000 to help them pursue their professional development, and we also assign each fellow a senior, local member of the IOM to serve as a mentor during the two years of their fellowship. 

Today, I am very pleased to announce that we recently received the first gift to endow a fellowship in this Anniversary Fellows program. This fellowship was endowed by the American Board of Obstetrics and Gynecology (ABOG) in honor of Norman F. Gant, who has served as Executive Director of the Board for many years. The ABOG/Gant Fellowship is endowed in perpetuity with a gift of $650,000.  Most of you in universities will know that a gift of $650,000 for a permanently endowed fellowship of this special character, has to be a best buy in anybody's terms, and I'm very hopeful that we will find a way to make this efficient, productive, and very rewarding program a much more widely-supported endeavor of the IOM. 

 

Ask Big Questions

Now let me turn back to the key question I posed earlier.  In this time of crisis, with so much besetting our nation, what should the IOM do?  My answer to that question is that we should ask big questions.  At a time when the nation is concerned, oppressed, distracted and otherwise beset with so many troubles, it is more important than ever that we together focus on those challenges that will really make a difference for the health of people in this country and around the world.  What are those kinds of questions and what are the things that we should do?  You may have some in mind.  I hope you do, and I want to know what they are.  Let me give you three examples. 

Both presidential campaigns are talking about increasing the level of access to insurance, by very different mechanisms to be sure, but let us suppose for a moment that our nation does progress toward universal access.  The big question I would pose is:  Access to what?  What is it that should be included in the basic entitlement that we believe is the right of every resident of the U.S. to receive in health care? The IOM is as well positioned as any to answer this basic and deceptively complex question.

Let me give you a second example that relates to the difference between what people focus on in terms of personal medical expenses and the larger challenge of cost for the U.S. healthcare system.  As you are all aware, we in the U.S. now spend annually more than $2 trillion on health.  If health costs continue to grow at eight percent a year on average, in nine years we'll be over $4 trillion in annual health expenditures.  If you think economic conditions are hard now, consider the foreshadowing of a Pete Peterson and a David Walker and others who warn that the combination of United States’ deficit spending, lack of savings, and growing entitlements will make the current economic difficulties look like a small pothole in a road going over a cliff. 

What can we do about it? One answer I would submit is that we can figure out how to reduce by $30 - $50 billion a year cumulatively the rise in health costs so that in nine years, instead of $4-plus trillion health budget, it will be $3.5 trillion, and to obtain these savings at the same time as we enhance the quality, value, and outcomes for health in the United States.  That's a big question and a big challenge: save substantial sums of money while improving performance. 

Another big question is an outgrowth of the study I mentioned earlier on preparing a health workforce for an aging population. Overall, we have a very serious health workforce challenge in the U.S.  We have chronic shortages of nurses, and the nursing crisis is a fundamental problem.  We have diminishing numbers now entering the primary care specialties, and that is going to present a growing challenge.  We have distributional problems still in our rural and inner-city areas.  We have many, many health needs that cannot be fulfilled without an adequately prepared, deployed, and utilized workforce.  But the human resource problem cannot be solved in crisis mode at the last minute.  You cannot magically create a new workforce.  You must prepare and take action a decade and more before the results are available in the field.  What set of policies and incentives do we need to assure a future health workforce that will meet the health needs of the American people? That is another big question. 

These are the kinds of questions that I think we need to pose and to answer.  While we want to be true to our service ethic and respond as best we can to requests for advice from any government agency, we also need to raise the most fundamental challenges to health. And then—with the resources of our members and volunteers, with the credibility that is earned by virtue of your stature and the procedures that protect the integrity of our process, with the kind of reliance on evidence and science that are the hallmark of what we do—we at the IOM need to answer the big questions.

 

In Memoriam

We are going to have a harder time moving ahead than we might have because of the loss of more than two dozen distinguished members over this past year.  Reflect with me for a moment on these extraordinary individuals—pioneers in science, in surgery, in medicine, in public health, in healthcare practice, and in public policy. These are leaders who have garnered every prize, medal, accolade and recognition ever conjured by human beings. They made a huge difference in our lives, in the lives of Americans, and in the lives of people all over the world. Let us take a moment of silence in memory of these illustrious lives and dear friends.

 

A Final Note

In the course of today’s meeting, we will examine one of the most fundamental conundrums at the intersection of biology, health and society: Is Biology Destiny? This is a discussion that I'm looking forward to, I know as much as you.  For now, let me conclude my report by simply expressing my own sense of deep appreciation for the privilege of working with you, the members of the IOM, with our dedicated staff, with our leaders on the Council, with all who serve as volunteers for our standing committees, our boards, and our forums, with those who participate in our workshops, and serve in reviews, and who respond so unselfishly to the call of service.  You are the ones who make all the difference.  Thank you very much.