The Founding of the Institute of Medicine1
In 2011, The New York Times described the Institute of Medicine (IOM) as one of “the nation’s most esteemed and authoritative advisors on issues of health and medicine” (Harris, 2011) with the power “to transform medical thinking around the world” (Ince, 2015, p. 15). Such a ringing endorsement may have come as a surprise to the charter members of the IOM in 1970, although it was a perfect match for their ambition.
The roots of the organization can be traced to the 1960s, when highly politicized debates over the prospect of national health insurance in the United States revealed the need for an unbiased, evidence-based source of advice to guide health policy and its implementation. The IOM, which began as the Board on Medicine and Public Health within the National Academy of Sciences (NAS), set out to meet that need. The IOM’s association with the prestigious NAS, as well as an influential public statement it made on the safety of heart transplantation (described later in this chapter), garnered almost immediate visibility for the fledgling organization. Yet, it faced formidable challenges in establishing its infrastructure and governance in its early years.
Nevertheless, elements of the organization The New York Times would later deem capable of changing the world were already evident. From the beginning, the IOM’s founding leaders and members determined that it would be a working organization, rather than solely honorific, and be dedicated to solving pressing health and medical challenges. Because such challenges required a multidisciplinary approach, the IOM established a requirement that one-quarter of its members should represent disciplines outside medicine and the biomedical sciences. The IOM’s early leaders also demonstrated a keen understanding of the influence of social factors on health, as well as a commitment to an active agenda that serves the needs of the public. These elements continue to be critical to the mission and approach of the organization, which was reconstituted as the National Academy of Medicine (NAM) in 2015.2
1 Except where otherwise noted, historical facts presented in this chapter are drawn from a 1998 history of the Institute of Medicine authored by Edward Berkowitz (IOM, 1998a).
2 At the same time the IOM was reconstituted as the NAM, a new Health and Medicine Division (HMD) was created within the National Research Council. All of the IOM’s boards and many of its convening activities were moved to HMD. See Chapter 3 for more on the 2015 reorganization.
THE NEED FOR INDEPENDENT ADVICE IN HEALTH AND MEDICINE
In 1964, Irvine Page (see Figure 1-1), a prominent physician who would later become a founding member of the IOM, wrote an editorial in the journal Modern Medicine titled “Needed—A National Academy of Medicine.” At the time, the notion of national health insurance preoccupied health policy makers, but faced opposition from private physicians who feared it would stifle their businesses. The future of the National Institutes of Health (NIH) was also the subject of spirited debate, as politicians advocated for the funding of pet issues and scientists contended that priorities should be set by experts in accordance with the most critical needs in health and medicine.
For Page, a leading expert on hypertension and heart disease at Cleveland Clinic, such disputes illustrated the need for a national organization that could speak with independent, nonpartisan authority on questions of health policy. In his 1964 editorial, Page argued that government required the advice of a group of physicians who were “truly representative of excellence in all branches of medicine” and who could provide “decisions of wisdom” (Page, 1964).
The American Medical Association and Academic Medicine
The largest medical association at the time, the American Medical Association (AMA), was a grassroots organization founded in 1847 to represent the interests of practicing physicians across the nation. Its goals included professionalizing the practice of medicine and instilling science as the foundation of medical education and practice. In 1883, the AMA established the Journal of the American Medical Association (JAMA) as a vehicle to distribute peer-reviewed research and encourage the practice of evidence-based medicine among its members. The AMA was a broad-based organization that brought all medical specialties inside its tent. However, because of its demo-
cratic structure, the AMA’s policy positions reflected the influence of the majority of its physician members, who worked in private practice settings.
Page and his colleagues had a different perspective. Doctors on the faculty of medical schools often had teaching, clinical, and research responsibilities. External funding was crucial to their endeavors. As tertiary care settings receiving patients with the most critical medical problems, medical schools relied on specialists in a wide range of fields. At some academic institutions, physicians were paid on a salaried basis, in contrast to doctors working in private practice, or relied on grants from the NIH and private foundations. Academic physicians and medical researchers, in Page’s estimation, had fundamentally different concerns than did doctors engaged in general practice in their communities.
Many private doctors opposed the passage of Medicare, for example, believing it was in effect the first step toward the socialization of medicine. They worried in particular about the possibility that government would set prices and enforce national standards that violated the norms of local medical practice. Reflecting these concerns, the AMA, beginning in the late 1930s and the 1940s, had become the leading opponent of proposals for national health insurance, frequently testifying on the subject before Congress. Despite efforts by the Truman administration (1945–1953) and liberal members of Congress, proposals had failed in every congressional session after 1949. Medical researchers and academic physicians such as Page, on the other hand, had a much more collaborative relationship with the federal government (e.g., through work with the NIH), and therefore less apprehension about federally funded health care (Chapin, 2015).
It was in this context that Page and other prominent academic physicians began to explore the idea of an “academy of medicine,” an organization that could represent the views of the academic medical community and balance the influence of the AMA.
Health Policy Priorities of the 1960s
The future of the NIH was at the center of Page’s concerns. The agency enjoyed a wide base of political support; throughout the 1950s, Congress had consistently allocated more money for the NIH than the Eisenhower administration requested. However, some believed it was a fragile organization of relatively recent vintage that could be easily misdirected.3 The NIH had extensive programs of intramural and extramural research, with work being done across the nation in medical schools as well as the sprawling Bethesda headquarters. It was commonplace for politicians to try to secure funding for their local institutions and for members of Congress to urge that research into a disease of particular interest to them be brought to the forefront of the NIH’s priorities.
Page and others wanted to protect the NIH from what they considered to be harmful political influences. They advocated for policies to ensure that the NIH’s funding decisions reflected an expert understanding of the most critical research needs in health and medicine—not the political flavor of the week. They insisted, for example, that grant proposals submitted to the NIH undergo peer review by leading medical experts, rather than government officials. (In 2020, this issue would come full circle as the presidents of the NAS, the NAM, and the NAE spoke out against the political review of scientific proposals under the Trump administration; see Chapter 7.)
President John F. Kennedy (1961–1963), unlike his predecessor President Dwight D. Eisenhower (1953–1961), supported a socially progressive agenda with significant implications for the practice of medicine. Medicare, long a subject of contention, finally gained traction during the Kennedy administration and was ultimately signed into law in 1965. It was clear that the legislation would fundamentally alter the relationship between the medical profession and the federal govern-
3 The NIH was established in 1949 with the creation of the National Institute of Mental Health.
ment. Page believed that government needed the best possible independent advice to implement this complicated new program and that such advice should come from leaders of academic medicine.
Other elements of Kennedy’s political agenda had relevance to Page’s effort. Federal aid to education (including aid to medical schools) continued to be a hotly contested issue. By expanding existing medical schools and creating new ones, the federal government could insure against an anticipated doctor shortage that might cripple the nation and put it at a disadvantage in the Cold War. The Civil Rights Act of 1964 also had broad ramifications for health care, bringing about the desegregation of health facilities and setting the stage for efforts to build a more diverse clinical workforce. In this period of complex and sweeping change, Page believed that an independent medical advisory organization would serve the nation well.
Irvine Page Convenes Founding Members of the Institute of Medicine
In a March 1965 follow-up editorial, Page argued for an academy of medicine that, unlike the AMA, would not be a grassroots organization lobbying for change from the bottom up. Instead, he envisioned an academy that would draw its membership from the “upper, relatively thin layer of the best medical and scientific talent” and would adapt continuously as medical science evolved (Page, 1965). The academy would be a “working organization” positioned at the forefront of medical research and science. However, the “upper layer” described by Page did not necessarily reflect the makeup of U.S. society or the challenges faced by its diverse population. As the photo of Page’s group (see Figure 1-2) illustrates, leaders of the medical field in the 1960s and 1970s were almost overwhelmingly White and male. Yet, the civil rights and women’s movements in the era of the IOM’s founding demanded equity and access to positions of influence for women, Black people and other people of color. This tension endured for decades, even as the IOM issued reports that highlighted the crisis of racial and other health disparities. Diversification of the IOM/NAM membership across dimensions of demographics and expertise remained both a challenge and a priority for the organization in 2020, when the NAM launched a membership diversity task force (Dzau, 2020).
On January 17, 1967, with the help of a $6,000 grant from the Cleveland Foundation, Page convened a group of 16 leading physicians and scientists in Cleveland, Ohio, to refine his idea of
an academy of medicine. The attendees were well connected in political and philanthropic networks. Nearly all of them worked in medical schools or for the NIH; the group included the NIH’s then current director, James Shannon, an influential malaria researcher who had advised the U.S. Secretary of War on tropical diseases during World War II (NASEM, 1967a; NIH, n.d.a). Other attendees included Ivan Bennett, Deputy Director of the Office of Science and Technology Policy under President Lyndon B. Johnson (1963–1969). Colin MacLeod, a scientist who discovered the hereditary properties of DNA, served as Vice President for Medical Affairs at The Commonwealth Fund, an important source of support for public health and medical research. Shannon and McLeod were also elected members of the NAS.
The NAS enjoyed a strong reputation as an unbiased, independent advisor to the nation on complex scientific and technical questions, as it had for more than a century. Its membership included physicians such as Shannon who worked in academic medical centers and made outstanding scientific contributions. However, the large majority of the NAS’s membership hailed from fields such as physics, biology, or mathematics.
Before Page’s group met for a second time in March 1967, Shannon and Bennett arranged a meeting in Washington, DC, with Frederick Seitz, a prominent physicist who was then president of the NAS. Seitz was receptive to the Cleveland group’s ideas. He offered to move its meetings to the NAS headquarters in Washington, DC, and establish a Board on Medicine and Public Health under the auspices of the academy. The board would not only contemplate the formation of an academy of medicine, perhaps as an offshoot of the NAS, but would also meet with foundations and government agencies to discuss issues of concern, including urban health challenges and the complexities of national health insurance. Members of the Cleveland group agreed to the move (NASEM, 1967b).
ESTABLISHMENT OF THE NATIONAL ACADEMY OF SCIENCES’ BOARD ON MEDICINE AND PUBLIC HEALTH
In June 1967, the NAS Council approved the creation of a Board on Medicine and Public Health charged to “formulate recommendations on matters of policy related to medicine and public health” (IOM, 1998a, p. 10). Seitz indicated that the Board could “possibly lead to the formation of a National Academy of Medicine somewhat analogous to the NAE [National Academy of Engineering]” (IOM, 1998a, p. 10). The NAE had been established in 1964 under the charter of the NAS to honor eminent engineers and tap engineering expertise for the nation’s most important scientific projects (NAE, n.d.). During this time of transition for the Cleveland group, Page continued to advocate for the creation of an academy of medicine that would not be a purely honorific organization like the NAS. However, on June 2, 1967, Page suffered a heart attack. Although he remained active in the discussions of the Board on Medicine and Public Health, he no longer took the lead.
As an NAS activity, the new Board on Medicine and Public Health (ultimately shortened to the Board on Medicine) required an NAS member as its leader. Seitz made the appointment, setting a precedent for NAS involvement in IOM leadership decisions that would remain until the IOM’s reconstitution as an independent academy in 2015. Seitz chose Walsh McDermott, a professor at Cornell Medical School known for his contributions to the development of antibiotics and anti-tuberculosis drugs, to serve as the board’s first chair (see Figure 1-3). McDermott had served as the head of the Division of Infectious Diseases at New York Hospital, where he performed important clinical trials on penicillin, streptomycin, and the other “wonder drugs” of the era. In the 1950s, he shifted his focus to the task of bringing medical treatment to underserved populations, and organized a successful effort to treat tuberculosis among members of the Navajo Nation living in Arizona and New Mexico. He had served as a member of the NIH’s National Advisory Health Council as well New York City’s Board of Health.
Under the banner of the Great Society in the 1960s,4 the federal government attempted to confront large-scale societal challenges facing the nation, including poverty and health disparities, physician shortages related to the Vietnam War and the implementation of Medicare, ensuring access to affordable health care, and the need to increase government support for medical research. Culturally, there was a sense of optimism that progress was possible on all of these fronts in an increasingly prosperous America with a developing commitment to civil rights. McDermott’s strong interest in public health was a contributing factor in developing the portfolio of the Board on Medicine, and subsequently the IOM. Even more so than Page, McDermott envisioned an organization of working members who were actively engaged by the most pressing medical and health concerns for society.
Together, McDermott and Seitz selected the original members of the Board on Medicine, with Page, Bennett, and MacLeod among them (see Box 1-1). The membership also included non-physicians deliberately selected for the expertise they could bring to social problems. Adam Yarmolinsky, for example, was a lawyer with experience in the Kennedy and Johnson administrations who had helped to organize the Johnson administration’s war on poverty. Yarmolinsky became an active member of the IOM, eventually writing the organization’s charter bylaws and serving on its governing council. Rashi Fein, another non-physician member, had served on the staff of President Kennedy’s Council of Economic Advi-sors, making him an expert on what would soon become the field of health economics.
Representation of a wide range of medical specialties and social expertise became an explicit objective of the board—a criterion that would extend to membership in the IOM and NAM. Lucile Leone, a nurse who had led the U.S. Cadet Nurse Corps during World War II, was a charter member of the board and the only woman in the group (Thurber, 2000). Just two of the Board’s original 21 members were African American (see Figure 1-4). Samuel Nabrit, a marine biologist and the first African American to receive a PhD from Brown University, was a member of President Johnson’s Atomic Energy Commission (Brown University, n.d.). Alonzo Yerby, a physician who served as the first African American Commissioner of Hospitals in New York City, had helped the Johnson
4 The “Great Society” refers to a series of socially progressive policies and initiatives under the Johnson administration. See https://www.washingtonpost.com/wp-srv/special/national/great-society-at-50 (accessed September 7, 2022).
administration to draft Medicare and Medicaid legislation (Harvard T.H. Chan School of Public Health, n.d.). Diversification of the IOM/NAM membership (across race/ethnicity, age, gender, and geography) would be an ongoing challenge for the IOM/NAM (discussed further in Chapter 7).
The Board on Medicine held its first formal meeting on November 15, 1967. Its formation garnered national attention, including a front-page story in The New York Times titled “Medical Board Set Up to Speed Benefits of Research to Public.” Walsh McDermott was quoted in the article, describing the board as a “good balanced mix of people who could be counted on for dispassionate and expert judgments about a broad range of problems” (Clark, 1967). From its earliest days, the organization’s determination to engage the nation’s current concerns resonated with the public.
The Board on Medicine Issues Its First Public Statement
In December 1967, less than 1 month after the first meeting of the Board on Medicine, news broke that Christiaan Barnard, a South African surgeon, had completed the world’s first heart transplant (see Figure 1-5). Interest in the procedure skyrocketed among Americans, who welcomed a bit of good news at a moment when the United States appeared to be losing the Vietnam War and race riots had broken out in many cities. Although many viewed heart transplants as a medical miracle in the company of penicillin or polio vaccinations, the Board on Medicine responded more warily. Outcomes data for the heart transplants were lacking, and operations were proceeding in an ad hoc manner across the United States. Members of the board understood that a successful transplant depended as much on immunology—the question of whether the body would reject the donor heart—as it did on the skill of the surgeon. The board concluded that there was insufficient scientific evidence to support the widespread adoption of heart transplants.
On February 28, 1968, the Board on Medicine issued a public statement titled “Cardiac Transplantation in Man,” in which it argued that heart transplants should not yet “be regarded as an accepted form of therapy, even as a heroic one” (Board on Medicine, 1968). Rather, the statement read, heart transplants should be viewed as scientific experiments for which reliable results were still pending, and should only be conducted by institutions “in which the total array of scientific expertise necessary for the proper conduct of the whole experiment (can) be brought to bear on every case” (Board on Medicine, 1968). This expertise included an experienced surgical team, a
supporting team of immunologists, and meticulous efforts to record the long-term outcomes of transplant patients.
The Board on Medicine’s statement was covered by almost every major U.S. newspaper. An article in The New York Times noted that five of the six people who had received heart transplants in recent weeks had died. The article quoted McDermott as saying that, while the statement was intended to inform the medical community, “the issues are of such importance to the lay public as well that it is hoped they will take notice” (Clark, 1968). But not all of the attention was favorable. Francis Moore, a prominent Harvard surgeon, questioned the board’s expertise in heart transplants, claiming in a letter to McDermott that it would “have been prudent … to seek some consultation from those who have been intimately concerned with these problems for almost twenty years” (IOM, 1998a, p. 19). McDermott countered that the statement exemplified the board’s mission of acting as a “disinterested group.” The Board on Medicine, he wrote, “sought to be helpful on the more important issues as they arise considering both medicine itself and its relationship to our society.” For McDermott, the statement exemplified the board’s utility (IOM, 1998a, p. 19).
Publicity from the heart transplant statement, along with the board’s well-connected membership and association with the prestigious NAS, paved the way for preliminary funding discussions with foundations. MacLeod and fellow board member Robert J. Glaser fostered a relationship between the board and the Commonwealth Fund, ultimately securing $150,000 in support. The Commonwealth Fund, in turn, arranged a meeting between the board and five other large foundations. The Rockefeller Foundation, the Milbank Memorial Fund, the Carnegie Foundation, and the Association for the Aid of Crippled Children also became early funders of the Board on Medicine.
PROPOSAL FOR A NATIONAL ACADEMY OF MEDICINE
In July 1968, McDermott asked a committee of Board on Medicine members to prepare a report evaluating the prospect of creating an academy of medicine. After about 8 months of
deliberation, the committee reached consensus and recommended the creation of an academy that would remain affiliated with the NAS but would initiate its own studies and activities. This decision represented a compromise between McDermott, who sought the continuation of the Board on Medicine, and Page, who favored an independent academy. On March 12, 1969, the full Board on Medicine accepted the committee’s recommendation.
NAS leadership, however, greeted the proposal with skepticism. The NAS, which largely served as an honorific membership organization, had an operational arm called the National Research Council (NRC), which was tasked with responding to requests from the federal government for studies and advice on scientific policy. The NRC had a Division of Medical Sciences, which had advised the Surgeons General of the Navy and Army on medical research and medical care during World War II (NAS, 1947). When McDermott met with the Executive Committee of the NAS Council at the end of March 1969, the members expressed concern that an independent academy of medicine might create competition with the NRC and fragment the organization.
The debate highlighted issues that would become fundamental to the mission of the IOM and eventually the NAM. For example, the board’s stated commitment to examining and responding to important social challenges, such as health disparities and the social determinants of health, did not fit neatly into the scientific method. Some NAS members believed that such topics should not fall under the purview of the Academy. Supporters of this view contended that the role of the NAS should be to honor achievement and promote academic discussion, rather than take positions in what they viewed as social concerns with political undercurrents and implications.
A five-person delegation5 from the Board on Medicine met with the full NAS Council on June 7, 1969. When the group presented the board’s proposal, NAS Councilors cemented the Executive Committee’s doubts about an academy that could initiate its own studies. Such an arrangement, they felt, ran counter to the organization, operation, and tradition of the NAS, which relied on the NRC to conduct studies (and then only at the request of the federal government). Ultimately, however, the Council deferred a decision on the proposal.
Around this time, the NAS underwent a leadership transition that would influence the debate over an academy of medicine. Philip Handler, Chair of the Department of Biochemistry at Duke University, succeeded Seitz as NAS President on July 1, 1969. Determined to provide strong leadership and uphold the NAS’s high scientific standards, Handler was less sympathetic to the idea of an academy of medicine than his predecessor. He made it clear that he did not support the establishment of an academy during his tenure, preferring instead to expand the NAS’s Medical Sciences Section and the NRC’s Division of Medical Sciences. In a letter to the NAS Council, Handler voiced his concern that proponents of an academy of medicine wanted to “undertake a type of lobbying activity which is not in keeping with the history of the Academy” (IOM, 1998a, p. 31). Finally, on July 19, 1969, the Executive Committee of the NAS Council formally rejected the idea of an academy of medicine, although it expressed support for the board’s stated goals.
ESTABLISHMENT OF THE INSTITUTE OF MEDICINE
The floundering of the Board on Medicine’s proposal to create an academy of medicine under the NAS charter reinvigorated Page’s campaign to create a fully independent organization. Some members of the board urged McDermott to inform Handler that they would proceed with the formation of an academy, even if it meant disengaging entirely from the NAS. Both McDermott and Handler hoped to avoid this outcome, however, and worked for nearly 1 year to engineer a
5 The delegation consisted of McDermott, Adam Yarmolinsky, James Shannon (the retired head of the NIH who served as a consultant to the Board), Robert Glaser, and Irving London, who chaired the Department of Medicine at the Albert Einstein College of Medicine and had chaired the subcommittee to consider the formation of an academy of medicine.
compromise. By May 1970, members of the Board on Medicine had come to agreement around the notion of an institute of medicine that—although lacking the stature of an academy and reporting to the NAS Council—would nevertheless have the freedom to set its own agenda and conduct studies with the support of an independent staff.
Yarmolinsky took the lead in drafting a charter for the new Institute of Medicine. The IOM would aim for an initial membership of approximately 100, with plans to grow to 250. Members of the IOM, like their counterparts in the NAS and the NAE, would be people of merit and achievement. In a continuation of the multidisciplinary focus that defined the Board on Medicine, at least 25 percent of the IOM’s members would come from fields outside medicine and the biomedical sciences. “The problems posed in provision of health services are so large, complex and important as to require, for their solution, the concern and competences not only of medicine but also of other disciplines and professions,” the charter read (IOM, 1998a, p. 40).
On June 5, 1970, McDermott presented the IOM’s proposed charter to the NAS Council. The following day, the NAS Council authorized Handler “to take the necessary steps to create an Institute of Medicine.” On June 10, the NAS made a formal announcement that it would establish an Institute of Medicine “to address the larger problems of medicine and health care” (IOM, 1998, p. 39).
With approval in place, the Board on Medicine began its metamorphosis into the IOM. The new institute would operate under multiple organizational restraints because of its relationship to the NAS. For example, the NAS Council retained the right to review IOM publications using NRC procedures and to add or remove individuals nominated for IOM membership. In effect, the NAS Council would assume responsibility for quality control and high-level oversight of the IOM.
Members of the Board on Medicine orchestrated the organizational transition. One early decision touched on the institute’s leadership structure. The typical institute, such as those found in universities, had a director who reported to the university president. According to this model, the IOM director would report to the NAS president. Members of the Board on Medicine found such an arrangement unacceptable, because it would not reflect the IOM’s independent authority to initiate and conduct studies, and proposed that a president rather than a director lead the institute.
The NAS Council acquiesced to the notion of an IOM president, and Handler appointed Glaser, then dean of the Stanford University School of Medicine, to act in the role. The IOM officially launched its operations on December 21, 1970.
The Institute of Medicine Selects Its First Members
The IOM’s first task was to delineate the terms of membership and select its first members. As a starting point, members of the Board on Medicine were grandfathered into the IOM and reconstituted as its Executive Committee (see Box 1-2). A membership subcommittee then set about identifying a list of nominees to expand the IOM membership to its initial target of 100 eminent leaders. The 1971 inaugural class was nominated by the membership subcommittee, approved by the IOM Executive Committee and the NAS president, and invited to join the organization. In addition, members of the NAS’s Medical Sciences Section automatically received invitations. In subsequent years, new classes of IOM members would be elected by the existing membership.
In June 1971, 77 new members of the IOM were announced. Among them, Glaser identified at least 19 different fields, including administration, basic sciences, engineering, community medicine, dentistry, nursing, and nutrition. Notably, the inaugural class also included two future IOM presidents: Donald Fredrickson, then general director of the National Heart Institute, and David A. Hamburg, then a psychiatrist at Stanford University.
Despite its long and occasionally contentious path to creation, the IOM found a fruitful home within the NAS complex, where it would remain for the next 45 years. In the story of its founding are themes that would color its journey for the next five decades. The organization’s emphasis on a multidisciplinary, action-oriented membership would endure, with IOM (and later NAM) members regularly posting higher rates of volunteerism in studies and advisory activities than their peers in the NAS and the NAE. The statement on heart transplants, too, with its “outsider” perspective, began to define the IOM and the NAM’s unique value as an advisor to government and the public. The organization would soon develop a firm reputation for independence and objectivity, even and especially when its recommendations were unpopular or controversial. Finally, the debate over creating an academy of medicine was far from settled. The IOM would continue to both benefit from the NAS’s influence and chafe under its restrictions. In the ensuing decades, IOM leadership would fail repeatedly to advance the notion of an academy of medicine, until finally finding success in 2015 (see Chapter 3).
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