6

Advancing the Health of the Public in the United States and Globally

The goal of improving public health was a long-standing cornerstone of the Institute of Medicine (IOM) and was an essential legacy carried forward by the National Academy of Medicine (NAM) and the Health and Medicine Division (HMD). From the beginning, the IOM’s founders recognized that health outcomes were influenced by a complex array of social, economic, behavioral, and environmental factors, such as education, income, geography, housing, transportation, and family and social interactions. Over the years, the organization devoted a sizable portion of its portfolio to better understanding the interactions across these factors. “To improve health for all” by “accelerating health equity” was made a part of the NAM’s new mission statement in 2018, demonstrating the organization’s ongoing commitment to public health and ensuring greater health equity for all populations. As a “national academy with a global scope,” the NAM also expanded its reach to facilitate improvements for populations worldwide, acknowledging that the world was becoming more interconnected with each passing decade—a fact that was never more apparent than during the COVID-19 pandemic that swept the globe beginning in 2020. The reports and convening activities described in this chapter were led by staff from the IOM, the NAM, or the HMD with the help of NAM members and expert external volunteers.

DEFINING AND SHAPING PUBLIC HEALTH

Throughout its history, the IOM played a crucial role in defining and shaping the field of public health and public health programs in the United States. For example, in 1988 the IOM released a report called The Future of Public Health. The widely cited report defined public health as “what society does collectively to assure the conditions for people to be healthy” and sought to reaffirm the nation’s traditional public health mission (IOM, 2003f). The committee, which was chaired by external volunteer Richard D. Remington,¹ recommended “core functions in public health assess-

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¹ Richard D. Remington was the Vice President for Academic Affairs and the Dean of the Faculties at the University of Iowa at the time.

ment, policy development, and service assurances” that could reinvigorate the U.S. public health system and ensure better responses to ongoing and emerging public health threats (IOM, 1988a).

In 2002, the IOM released a follow-on report that revisited the state of the public health system. The Future of the Public’s Health in the 21st Century was drafted by a committee co-chaired by Christine K. Cassel² and Jo Ivey Boufford,³ who served as the NAM’s Foreign Secretary from 2006 to 2014 and on its Council from 2001 to 2006. The report concluded that the country continued to fall short in terms of population health despite having the largest health expenditures in the world. The report offered a conceptual framework designed to strengthen the public health infrastructure, build partnerships, emphasize accountability and evidence, improve communication, and account for the multiple determinants of health, going beyond factors related to the health care system. It also recommended the formation of a national commission to consider the benefits of a public health accreditation system (IOM, 2003f). As a result of the report, the Robert Wood Johnson Foundation (RWJF) funded the Exploring Accreditation Initiative, which brought together the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials, and other organizations to recommend a national framework for the voluntary accreditation of state and local public health departments.⁴

The IOM also explored opportunities to strengthen the public health workforce in its report Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century (IOM, 2003g), and options to integrate public health and primary care in its 2012 report Primary Care and Public Health: Exploring Integration to Improve Population Health (IOM, 2012g). This latter report is credited with inspiring the Practical Playbook website launched by the de Beaumont Foundation, Duke Community and Family Medicine, and the Centers for Disease Control and Prevention (CDC) in 2014. The Practical Playbook was designed to improve public health and primary care integration by providing resources for health care providers, including action steps for starting a collaborative project and case studies of successful projects. The website drew on a database of examples from a Primary Care and Public Health Collaborative, which had been established by ASTHO in response to the IOM’s report.⁵

Throughout its history, the IOM also played a valuable role in advising the Department of Health and Human Services (HHS) on its national public health priorities through a series of reports focused on health indicators. In 1978, the IOM released a paper that informed the first iteration of Healthy People (see Chapter 2), the government’s national agenda for improving the public’s health. Healthy People was updated regularly to set new 10-year objectives for 2000, 2010, and 2020, and the IOM provided input to each of those efforts. For example, the IOM released three reports—Healthy People 2000: Citizens Chart the Course (IOM, 1990d), Leading Health Indicators for Healthy People 2010: Final Report (IOM, 1999e), and Leading Health Indicators for Healthy People 2020: Letter Report (IOM, 2011)—each of which offered a set of health indicators and objectives for HHS to consider for inclusion in Healthy People.

The IOM also provided guidance on how communities and the nation could develop and implement quality measures to monitor progress against the leading health indicators in its report Toward Quality Measures for Population Health and the Leading Health Indicators (IOM, 2013o). In carrying on the IOM’s advisory role to HHS and in preparation for Healthy People 2030, the National Academies released Criteria for Selecting the Leading Health Indicators for Healthy People 2030 (NASEM, 2019l), and is expected to release a second report that will offer input on

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² Christine K. Cassel was the Dean of the School of Medicine at Oregon Health & Science University when this report was released.

³ Jo Ivey Boufford was the Professor of Health Policy and Public Service at the Robert F. Wagner Graduate School of Public Service at New York University during this time.

⁴ Impact of IOM Reports (Database), IOM/NAM Records.

⁵ Ibid.

specific leading health indicators for the 2030 national agenda. The IOM’s (and now the HMD’s) relationship with HHS exemplifies how the organization has informed the nation’s public health priorities over the last half-century.

To expand its role in advising the nation on topics related to public and population health, the IOM launched the Roundtable on Population Health Improvement in 2012. With sponsorship from nearly 20 foundations, government entities, academic institutions, and corporations, the roundtable’s members envisioned “a strong, healthful, and productive society which cultivates human capital and equal opportunity” (NASEM, n.d.r). Since its inception, the roundtable has created 2 Action Collaboratives, held more than 30 public meetings, and released numerous workshop summaries, commissioned papers, perspectives, and briefing documents. The roundtable’s work has explored topics related to the social determinants of health, including education and economic policy; opportunities to improve health equity; and collaboration across health care, education, and public health. The roundtable has continued its work under the auspices of the HMD but has also collaborated with the NAM on programs, such as the DC Public Health Case Challenge, with the intended goal of improving population health across the United States.

RESPONDING TO PUBLIC HEALTH PANDEMICS AND EPIDEMICS

In addition to its role as an advisor on identifying national public health priorities, the IOM and now the NAM and HMD have also delved into public health epidemics the nation and the world have faced throughout the organization’s existence. Some pandemics and epidemics are urgent and require an immediate response, including the development of short- and long-term strategies to mitigate the effects, such as the HIV/AIDS epidemic; tuberculosis, Zika, and Ebola outbreaks; the COVID-19 pandemic; and the opioid crisis in the United States (described in Chapter 7). Other epidemics represent persistent public health challenges that require decades of multi-faceted interventions to see shifts in prevalence, such as the tobacco use and violence epidemics. The organization also identified childhood obesity as an ongoing epidemic that warranted in-depth consideration.

HIV/AIDS Epidemic

During the HIV/AIDS epidemic the IOM demonstrated its ability to provide timely advice and active guidance to inform a national and international response to a novel disease. The IOM’s work on HIV/AIDS had a notable impact on public health decisions at the time and became the standard by which future IOM activities would be judged in terms of impact. Throughout its history, the IOM released nearly 30 consensus studies that reviewed various aspects of HIV/AIDS, including prevention, screening, and treatment; research and drug discovery; health policy and financing; and global health issues (see Box 6-1).⁶ The IOM’s work in the early years of the epidemic set the groundwork for later public health and policy responses to HIV/AIDS.

As the epidemic emerged in the early 1980s and fear among the public spread, Fred Robbins, the IOM’s fourth president, identified HIV/AIDS as a public health concern in which the IOM should be involved. In the summer of 1983, the IOM Council discussed possible roles for the IOM in responding to the crisis. The discussion at the time focused on the shortage of health care providers and facilities willing to care for the growing number of patients with AIDS. When Robbins contacted the Reagan administration about being part of the national response to the disease in 1983, Ed Brandt, the Assistant Secretary for Health at HHS, said there was little the IOM could or should do. Meanwhile, NAM member Anthony Fauci was appointed as director of the National

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⁶ The IOM’s AIDS-related activities are covered more fully in the 1998 history of the IOM authored by Edward Berkowitz (IOM, 1998a, Ch. 6). This section draws on that account.

Institute of Allergy and Infectious Diseases in 1984. Addressing a conference hosted by the National Institutes of Health (NIH) that year, Fauci spoke passionately about “the extraordinary advances in the evolution of this syndrome” (Newcott, 2021). By the spring of 1985, the Reagan administration’s position on the AIDS epidemic had shifted. James Mason, then the director of the CDC, said that the IOM could work on the issue of school admissions policies for HIV-positive students, as many parents feared that contact with an HIV-positive classmate would put their children at risk. The CDC wanted the IOM to confirm that “casual person-to-person contact” among schoolchildren “appears to carry no risk” (CDC, 1985).⁷ Under the direction of Robbins, the IOM dedicated its

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⁷ IOM Council Meeting, Minutes, July 20, 1985, IOM/NAM Records.

1985 annual meeting to the topic of HIV/AIDS. A summary of the annual meeting was published by the Harvard University Press in 1986 under the title Mobilizing Against AIDS: The Unfinished Story of a Virus. The publication provided a compendium of HIV/AIDS-related information and represented one of the first publications of this type from a reputable science authority (Nichols, 1986).

When Sam Thier became IOM President in November 1985, he encouraged the IOM’s continued engagement in HIV/AIDS work and suggested a collaborative Academy-wide response that included a joint National Academy of Sciences (NAS) and IOM committee. Thier kept Surgeon General C. Everett Koop updated on the committee’s work, which helped align the IOM’s recommendations with those of the Reagan administration.⁸ The committee’s report, Confronting AIDS: Directions for Public Health, Health Care, and Research, was released by the IOM in October 1986. The committee, which was co-chaired by NAM/NAS member David Baltimore⁹ and external volunteer Sheldon M. Wolff,¹⁰ recommended a National Commission on AIDS, a major public health campaign to help prevent the spread of HIV, and a scientific research program with the goals of preventing HIV and treating AIDS (IOM and NRC, 1986).

For the first time in the IOM’s history, the release of a report received notable media coverage that included front page stories in The New York Times and The Washington Post and follow-up stories in the days after the report release. On October 29, all three national television networks led their evening news broadcasts with stories about Confronting AIDS (Boffey, 1986; Russell, 1986; Network Television Evening News, 1986). According to The New York Times, the report “provided a benchmark by which many members of Congress and analysts judged the effectiveness of the nation’s effort to combat AIDS” (Boffey, 1988). The report spurred legislation that nearly doubled federal spending on AIDS. The media attention and political response to the report cemented the IOM’s position within the public health and health policy worlds. Following the release of the report, the mainstream media began to report routinely on the organization’s activities, and impact became an important internal measure of the efficacy of the organization’s work.

In November 1986, the IOM Council endorsed a continuation of the IOM’s HIV/AIDS-related work. The IOM held workshops on promoting drug development to treat HIV/AIDS, the epidemiology of HIV/AIDS in an international context, and the development of an HIV vaccine. In the spring of 1987, IOM President Thier and NAS President Frank Press joined forces to convene the NAS-IOM AIDS Activities Oversight Committee. This new committee was tasked with reviewing and updating the 1986 report and also coordinating HIV/AIDS activities across the National Academies. Confronting AIDS: Update 1988 was released in June 1988 and recommended that the HIV infection “itself should be considered as a disease” (IOM, 1988b, p. 37). The committee, which was chaired by external volunteer Theodore Cooper,¹¹ also affirmed the view, current at the time, that “virtually all [HIV-]infected individuals] will eventually develop AIDS” (IOM, 1988b, p. 2). The report stressed that “we are no closer now to having a licensed vaccine against HIV than we were two years ago” (p. 20) and that developing treatment options offered “the best hope of slowing the epidemic through research.”¹² Meanwhile, a grassroots movement to spur the development of treatments for HIV/AIDS gained momentum (see Figure 6-1).

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⁸ Oral Interview with Samuel Thier, November 2018, NAS-NRC Archives.

⁹ David Baltimore was at the Whitehead Institute for Biomedical Research and the Massachusetts Institute of Technology during this time.

¹⁰ Sheldon M. Wolff was at the Tufts University School of Medicine and the New England Medical Center Hospital when this report was released.

¹¹ Theodore Cooper was with the Upjohn Company in Kalamazoo, Michigan, during this time.

¹² “Panel Cites Remaining Deficiencies in National Effort to Combat AIDS,” IOM Press Release, June 1, 1988, IOM/NAM Records.

Like the first iteration of Confronting AIDS, the 1988 update garnered a sizable media response. Although the second report did not ultimately have the same level of impact as the original report, the 1988 report led to amendments to the Public Health Service Act that authorized $1.5 billion for HIV/AIDS research, public health programs, and an HIV/AIDS public information campaign. That same year, the IOM and NAS sent a jointly developed white paper to President-elect George H.W. Bush that argued that HIV/AIDS should be a key priority on his administration’s health agenda. The paper estimated that AIDS would claim more than 200,000 American lives during Bush’s term in office and advised the newly elected president to become involved in “an aggressive, unambiguous education program about behavior changes necessary to avoid HIV infection.”¹³

The AIDS Activities Oversight Committee continued its work after the release of the 1988 report by advising the National Academies on activities such as a government-requested evaluation of the NIH’s AIDS programs. A separate committee produced a report called The AIDS Research Program of the National Institutes of Health that was released in 1991. The report suggested that the NIH should increase its HIV/AIDS research activities in behavioral science, basic science, patient care research, and vaccine development. The committee supported the NIH’s organizational approach to its HIV/AIDS research activities, which leveraged a cross-cutting “institute without walls” model rather than creating a new institute (IOM, 1991d).¹⁴ The committee’s chair, NAM member William Danforth, testified before Congress indicating that the best way to increase the country’s understanding of HIV/AIDS was “to provide support for scientists studying how viruses work” (IOM, 1998a, p. 234).

Before the AIDS Activities Oversight Committee disbanded in June 1991, it advised on activities that involved nearly every board and division across the IOM, and HIV/AIDS became a

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¹³ Frank Press and Samuel Thier to George H.W. Bush, President-Elect of the United States, December 13, 1985, IOM/NAM Records.

¹⁴ William Danforth testimony before the Subcommittee on Human Resources and Intergovernmental Relations of the Committee on Government Relations, March 7, 1991, copy in IOM/NAM Records.

permanent item on the IOM’s agenda. For example, in 1989 the IOM established the Roundtable for the Development of Drugs and Vaccines against AIDS, which discussed the potential value of a consortium dedicated to overcoming challenges in developing HIV/AIDS treatments and vaccines such as an “acute shortage” of animals “to test potential preventive and therapeutic activities against AIDS.”¹⁵ Other HIV/AIDS-related activities included a collaborative meeting between the IOM and the Russian Academy of Medical Sciences that led to an international information exchange on HIV/AIDS and developed connections between American and Russian scientists.¹⁶ Additionally, the Medical Follow-Up Agency studied a group of HIV-positive servicemen who had previously been lost to follow-up after military discharge. During this timeframe, the NAS also convened its own HIV/AIDS-related activities that contributed to the National Academies’ response to the epidemic. For example, in 1987, citing the IOM’s “landmark” study, the NAS established the Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences. By February 1989, the committee had developed its report on AIDS, Sexual Behavior, and Intravenous Drug Use (NRC, 1989b). In 1990, the NAS released AIDS: The Second Decade, which indicated that the disease was nowhere near under control, noting that “morbidity and mortality from HIV infection will continue throughout the 1990s” (NRC, 1990, p. vii).

President’s Emergency Plan for AIDS Relief

In the late 1990s and early 2000s—as deaths from AIDS in the United States began to decline and new, more effective treatments for HIV such as antiretroviral drugs became more readily available in the United States—international organizations such as the World Health Organization (WHO) and the United Nations began calling for programs to make these new treatments available globally. In his 2003 State of the Union Address, President George W. Bush proposed the President’s Emergency Plan for AIDS Relief (PEPFAR), which was enacted by Congress on May 27, 2003, as part of the United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. PEPFAR was meant to provide “a comprehensive, integrated 5-year strategy to combat global HIV/AIDS” (IOM, 2007g, p. 3). The $15 billion initiative had goals related to preventing transmission of HIV, expanding access to treatment, and improving HIV/AIDS care with an emphasis on 15 countries that were identified as “focus countries.”

Around this time, the IOM began to turn its attention to HIV/AIDS outside of the U.S. borders. For example, in April 2005 the IOM released Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS, which indicated that 40 million people across the globe were infected with HIV and that 95 percent of them lived in resource-poor countries, such as the focus countries defined under the PEPFAR initiative (IOM, 2005b). The committee highlighted the critical need for health care professionals in these countries and reviewed options for overseas placement of U.S. health professionals. The committee, which was chaired by NAM member Fitzhugh Mullan,¹⁷ recommended the creation of a United States Global Health Service that would send health care professionals to the PEPFAR countries, functioning somewhat like the Peace Corps but with an emphasis on providing care for individuals with HIV/AIDS. In 2012, the Peace Corps announced a new Global Health Service Partnership (GHSP), which was funded through PEPFAR. The new program would deploy physicians and nurses to serve as faculty members tasked with helping

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¹⁵ “Roundtable for the Development of Drugs and Vaccines Against AIDS: Meeting Summary,” February 7, 1989, June 26, 1990, IOM/NAM Records; “The Potential Value of Research Consortia in the Development of Drugs and Vaccines Against HIV Infection and AIDS: Report of a Workshop,” 1989, IOM/NAM Records.

¹⁶ “Summary of the Institute of Medicine U.S.-USSR Aids Symposium, October 4–5, 1989,” February 28, 1990, IOM/NAM Records.

¹⁷ Fitzhugh Mullan was with Health Affairs/Project Hope and the Department of Prevention and Community Health of George Washington University School of Public Health and Health Services in Washington, DC, during this timeframe.

developing countries address health care provider shortages. Mullan advised GHSP Executive Director Vanessa Kerry in developing the program.¹⁸

Built into the legislation that authorized PEPFAR was a request for the IOM to conduct a short-term evaluation of the initiative 3 years after its launch. To prepare for this evaluation, the IOM released a letter report in October 2005, Plan for a Short-Term Evaluation of PEPFAR Implementation, that detailed the approach the committee would use to evaluate the program. The committee’s evaluation strategy included 1-week site visits to 13 of the 15 focus countries, which resulted in pre- and post-visit analyses for each country. In its deliberations the committee also reviewed budget and performance data, assessed available literature and documentation, and solicited input and feedback from a range of stakeholders and participants (IOM, 2006c). In 2007, the IOM released PEPFAR Implementation: Progress and Promise. The timing of the report release coincided with congressional deliberations related to reauthorization of the initiative. In its report, the committee, which was chaired by NAM member Jaime Sepúlveda,¹⁹ concluded that PEPFAR had “supported the expansion of HIV/AIDS prevention, treatment, and care services in the focus countries” (IOM, 2007g, p. 1). To promote continued progress toward PEPFAR’s goals, the committee recommended that the initiative needed to “transition from a focus on emergency relief to an emphasis on the long-term strategic planning and capacity building necessary for sustainability” (IOM, 2007g, p. 1). One year after the release of the IOM’s report, Congress reauthorized PEPFAR as part of Tom Lantos (D-CA) and Henry J. Hyde’s (R-IL) U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. The reauthorization legislation also included a provision requesting the IOM to conduct another evaluation of the initiative with an emphasis on its performance and its impact on health (IOM, 2013i).

On World AIDS Day in 2009, PEPFAR launched an international AIDS strategy for the next 5 years that drew from lessons learned since the program was launched in 2003 and heavily reflected the findings, conclusions, and recommendations of the 2007 IOM report. A press release from the Department of State spelled out the overarching goals for PEPFAR’s next phase, many of which were justified in the PEPFAR reauthorization legislation with references to the IOM report:

• Transition from emergency response to promotion of sustainable country programs;
• Strengthen partner government capacity to lead the response to this epidemic and other health demands;
• Expand prevention, care, and treatment in both concentrated and generalized epidemics;
• Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems; and
• Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.

These goals were well aligned with the IOM report’s emphasis on the importance of shifting the program’s focus from emergency relief to long-term strategic planning and capacity building; strengthening a country’s ownership and leadership of its response to the epidemic; and collecting and using data on the precise nature of the epidemic in each country to determine the most appropriate interventions and target them most effectively.²⁰

The IOM’s second report, Evaluation of PEPFAR, was published in February 2013. It noted that the reauthorization of the initiative had shifted priorities toward strengthening local health

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¹⁸ Impact of IOM Reports (Database), IOM/NAM Records.

¹⁹ Jaime Sepúlveda was the 2007 Presidential Chair and a Visiting Professor at the University of California, San Francisco.

²⁰ Impact of IOM Reports (Database), IOM/NAM Records.

systems with an emphasis on sustainability, while continuing to scale up services. The committee, which was chaired by NAM member Robert E. Black,²¹ concluded that

The committee offered recommendations to enhance and strengthen systems, capacity, and leadership in the partner countries in order to ensure sustainability that would allow them to manage their responses to HIV/AIDS (IOM, 2013i).

Tobacco and Marijuana Use

At one time, a high percentage of Americans smoked cigarettes and used other tobacco products (e.g., cigars, pipes, chewing tobacco, snuff), often becoming addicted and unknowingly causing harm to their health. As research demonstrated strong associations and eventually causal relationships between tobacco products and cancer, the evidence persuaded many people to quit using tobacco products and many others not to start in the first place. The prevalence of tobacco use remained high among teenagers and adults, however, and it was characterized as an epidemic by the WHO, the CDC, and public health researchers (CDC, n.d.d; Giovino, 2007; Slade, 1992; WHO, 2019). In the 1970s and 1980s, there was a growing belief among experts that the key to reducing tobacco use was to prevent young people from starting to use tobacco products. Under the direction of IOM President David Hamburg, the IOM began thinking about ways to decrease and prevent tobacco use. One of the IOM’s first reports on smoking cessation was released in 1979 as part of the IOM’s Health and Behavior series (see Chapter 2). Tobacco use was an area in which the IOM not only advised on public health and health policy, but also one in which it became involved in the underlying science with an emphasis on alternative tobacco products. The IOM was one of the few organizations with the necessary credibility and expertise to advise across multiple levels of the national discussion on the tobacco epidemic.

In the early 1990s, the IOM initiated a study focused on preventing addiction in children and youth. In 1994 the IOM released Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. The timing of the report release coincided with the release of a Surgeon General’s report on preventing tobacco use among young people (Elders et al., 1994). The Surgeon General’s report catalyzed additional public interest and media coverage related to the IOM report, including prominent newspaper articles and television news stories. The report identified tobacco-related deaths as “the leading cause of avoidable death in the United States,” resulting in more deaths than the combination of “AIDS, car accidents, alcohol, suicides, homicides, fires and illegal drugs” (IOM, 1994d, p. 1). According to Paul R. Torrens, an external volunteer who chaired the committee,²² “each year, decisions by more than 1 million youths to become regular smokers” take an average of 15 years off their lives and commit the health care system “to $8.2 billion in extra medical expenditures over their lifetimes” (p. 5). The report concluded that “in the long run, tobacco use can be most efficiently reduced through a youth-centered policy aimed at preventing children and adolescents from initiating tobacco use” (IOM, 1994d, p. 5).

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²¹ Robert E. Black was at Johns Hopkins University in Baltimore, Maryland, when this report was released.

²² Paul R. Torrens was a Professor of Health Services Administration in the Department of Health Services in the School of Public Health at the University of California, Los Angeles, during this time.

Growing Up Tobacco Free became one of the IOM’s best-selling reports of the 1990s.²³ The report was also the first in a series of IOM reports that evaluated the health risks of tobacco and made recommendations to quell tobacco use. In 1998, for example, the National Cancer Policy Board issued its first policy statement on tobacco control, Taking Action to Reduce Tobacco Use, which noted that tobacco had joined AIDS as “one of [the] two major growing health threats worldwide” (IOM and NRC, 1998a, p. 30). In a strongly worded statement, the board indicated that “the single most direct and reliable method for reducing consumption is to increase the price of tobacco products” (p. 30). With policy changes and new taxes, the market could aid in promoting public health. Following the release of its policy statement, the board released a summary of evidence related to the efficacy of state tobacco control programs, State Programs Can Reduce Tobacco Use (IOM, 2000f). The goal of the publication was to provide examples of successful state-level tobacco control policies and programs that could be implemented in other states.

By the start of the new millennium, it was widely understood that smoking caused cancer, chronic obstructive pulmonary disease, and stroke. Around this timeframe companies began developing alternative tobacco products that might reduce harm. In addition to exploring public health policy actions related to tobacco use and prevention, the IOM also explored the science of tobacco harm reduction. In 2001, the IOM released a report called Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction, which featured an examination of available literature on products that claimed to “preserve tobacco pleasure while reducing its toxic effects” (e.g., low-yield cigarettes, nicotine patches and gum). The committee, which was chaired by NAM member and Acting President (1991–1992) Stuart Bondurant,²⁴ concluded that “for many diseases attributable to tobacco use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible” (IOM, 2001f, p. 5). However, the products designed to reduce exposure had not “been evaluated comprehensively enough … to provide a scientific base to conclude that they reduced the risk of disease” (IOM, 2001f, p. 5). The report found a place for “strengthened federal regulation of all modified tobacco products,” including those designed to reduce risk (IOM, 2001f, p. 8).

Continuing its evaluation of public health policy and strategies to reduce tobacco use in the United States, the IOM released Ending the Tobacco Problem: A Blueprint for the Nation in 2007. During its deliberations, the committee, which was chaired by Richard J. Bonnie,²⁵ concluded that while progress had been made in tobacco control, approximately 44.5 million adults in the United States still smoked, with rates of cessation beginning to plateau. Additionally, tobacco-related morbidity and mortality continued to pose large burdens on the health care industry and society as a whole. In its report, the committee presented a blueprint that called for fortifying and expanding state-level control programs and community action, increasing taxes on tobacco products, strengthening bans and restrictions related to smoking, continuing efforts to prevent youth from using tobacco and helping users quit, and granting the Food and Drug Administration (FDA) additional regulatory authority over tobacco products (IOM, 2007h). In 2009, President Obama enabled FDA regulation through the Family Smoking Prevention and Tobacco Control Act, which granted the FDA “broad authority to regulate the manufacturing, distribution, and marketing of tobacco products, including ‘modified risk tobacco products’”—fulfilling recommendations from Clearing the Smoke (IOM, 2001f) and Ending the Tobacco Problem (IOM, 2007h) (IOM, 2012h; see Figure 6-2). In addition, Obama signed additional legislation that increased tobacco taxes by $0.62 per pack—from $0.39 to $1.01—the largest increase in history. The resulting revenue was

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²³ “IOM Bestsellers,” in IOM Council Minutes, January 1997, IOM/NAM Records.

²⁴ Stuart Bondurant was a Professor in the Department of Medicine at the University of North Carolina at Chapel Hill when this report was released.

²⁵ Richard J. Bonnie was the John S. Battle Professor of Law and the Director at the Institute of Law, Psychiatry, and Public Policy at the University of Virginia School of Law, Charlottesville, when this report was released.

used to fund the expansion of the Children’s Health Insurance Program.²⁶ Three years later, the IOM released a report called Scientific Standards for Studies on Modified Risk Tobacco Products. This report provided a minimum set of scientific standards that the FDA should use to confirm that a “product has the potential to reduce tobacco related harms as compared to conventional tobacco products” (IOM, 2012i).

In March 2015, prior to the creation of the NAM and the HMD, the IOM released Public Health Implications of Raising the Age of Legal Access to Tobacco Products. The committee, which was also chaired by Bonnie,²⁷ leveraged a strong scientific base, including developmental biology and psychology literature on tobacco use initiation, existing public health policies, and statistical modeling, to conclude that raising the age of legal access to tobacco would “likely lead to a substantial reduction in smoking prevalence” (IOM, 2015e, p. 3). The committee found that 90 percent of daily smokers had their first cigarette before the age of 19 and suggested that raising the nationwide minimum age of legal access to 21 years of age would lead to “approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019” (p. 4). Following the release of the report, cities and counties across the nation began changing local laws to increase the legal purchasing age for tobacco products to 21 years of age, which is commensurate with the legal age for buying alcohol.²⁸

Following the creation of the NAM and the HMD in 2015, the organization continued its tobacco-related work and its evaluation of the new products that claimed to reduce the harm associated with tobacco use. In the preceding years, companies had begun developing and sell-

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²⁶ Impact of IOM Reports (Database), IOM/NAM Records.

²⁷ Richard J. Bonnie was the Harrison Foundation Professor of Medicine and Law, the Professor of Psychiatry and Neurobehavioral Sciences, and the Director of the Institute of Law, Psychiatry, and Public Policy at the University of Virginia during this time.

²⁸ Impact of IOM Reports (Database), IOM/NAM Records.

ing electronic cigarettes (also known as e-cigarettes and vaping pens) despite contentious legal battles at the state and federal levels (CASAA, n.d.). The products quickly grew in popularity. However, safety evaluations and data on health effects were lacking. In 2018, the HMD weighed in on the debate over the health effects of e-cigarettes with its report Public Health Consequences of E-Cigarettes. The report reviewed existing scientific literature and made recommendations to guide future research efforts, identifying gaps and priority areas. Although the committee, which was chaired by NAM member David L. Eaton,²⁹ concluded that e-cigarettes potentially contained fewer toxicants than traditional combustible cigarettes and might promote cessation of traditional cigarettes, the committee urged caution, noting that the use of these devices was not without risk and the long-term health effects were not yet known. The committee also warned that evidence suggested that youth who began using e-cigarettes might subsequently transition to more harmful combustible cigarettes (NASEM, 2018f). One year after the report was released, the CDC linked an outbreak of severe lung injuries and several deaths to the use of e-cigarettes. The CDC reported that 38 percent of those with lung injuries were under the age of 21 (22 percent between the ages of 18 and 21; 16 percent under the age of 18). Preliminary findings from the outbreak indicated a potential association with marijuana-containing products that had been used in e-cigarettes and were possibly contaminated (CDC, n.d.e). The use of e-cigarettes with tobacco- and marijuana-containing products will require continued study to fully understand the risks and long-term health implications for users.

Marijuana

In addition to tobacco use, the IOM also explored the health effects of marijuana. In 1981, the IOM released Marijuana and Health in response to a request from the NIH (IOM, 1982). Although the report indicated that the public should be concerned about the health effects of marijuana, the committee, which was chaired by NAM member Arnold S. Relman,³⁰ also noted that there was currently little evidence that demonstrated that prolonged marijuana use had a permanent impact on the heart or brain. Due to the lack of available data, the committee called for further research and indicated that a definitive statement about the health effects of marijuana could not be made at the time.

Interest in marijuana persisted, and hypotheses about the potential therapeutic value of the drug began to emerge. The prospect of medicinal uses of marijuana was controversial, and political, legal, social, and religious debates often overshadowed available evidence (IOM, 1999d). In 1999, the IOM released Marijuana and Medicine: Assessing the Science Base. The purpose of the report, sponsored by the White House Office of National Drug Control Policy, was to review the available evidence on the risks associated with medical marijuana and the potential therapeutic value for conditions such as glaucoma, multiple sclerosis, chronic pain, nausea and vomiting associated with chemotherapy, and wasting associated with AIDS. The committee, which was chaired by NAM members John A. Benson, Jr.,³¹ and Stanley J. Watson, Jr.,³² described the available scientific evidence supporting the therapeutic properties of marijuana but also called for additional research and clinical trials to better understand safety and efficacy.

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²⁹ David L. Eaton was the Dean and the Vice Provost of the Graduate School at the University of Washington during this time.

³⁰ Arnold S. Relman was the Editor of the New England Journal of Medicine when this report was released. Relman also served as a member of the NAM Council.

³¹ John A. Benson, Jr., was the Dean and a Professor of Medicine Emeritus at the Oregon Health & Science University School of Medicine during this time.

³² Stanley J. Watson, Jr., was the Co-Director and a Research Scientist at the Mental Health Research Institute of the University of Michigan at the time of the report release.

In 2017, the HMD built on the IOM’s previous work with a report titled The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. In its report, the committee highlighted the rapid increase in the use of medical and recreational cannabis products as a result of shifting state laws and policies, with many states decriminalizing or legalizing marijuana use.³³ Despite the increase in use of cannabis products, the committee found that evidence related to the health effects—both harms and benefits—was still lacking. The report presented almost 100 research conclusions that were categorized based on the strength of the supporting data. For example, the committee found conclusive evidence supporting the efficacy of cannabis to treat chronic pain, nausea, and vomiting associated with chemotherapy, and patient-reported spasticity associated with multiple sclerosis. The committee developed four broad recommendations that could be used to fill research gaps, improve the quality of data and data collection efforts, and remove barriers to advancing research (NASEM, 2017f).

Violence

Violence as a broad public health concern became a recognized priority as early as 1979 with the publication of Healthy People. Violence is a complex public health challenge that encompasses a range of topics related to family and domestic violence, child abuse and neglect, elder abuse, suicide, and gun violence. Violence can have long-lasting effects on individuals and families and is often intertwined with mental health and/or substance use concerns (described later in this chapter), further complicating treatment and prevention strategies. One of the IOM’s early studies related to violence was a joint study with the National Research Council (NRC) that resulted in a report called Violence in Families: Assessing Prevention and Treatment Programs. The report was released in 1998 and covered topics such as child abuse, domestic violence, and elder abuse. The report served as a comprehensive review of the successes and shortcomings of interventions designed to eliminate violence in the family. The committee, which was chaired by NAM member and Councilor (1998–2000) Patricia A. King,³⁴ offered recommendations that provided “new strategies that offer[ed] promising approaches for service providers and researchers and for improving the evaluation of prevention and treatment services” (IOM and NRC, 1998b).

In 2002, the IOM revisited family violence, releasing Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. The report concluded that “family violence affects more people than cancer, yet it’s an issue that receives far less attention.” The committee, which was chaired by NAM member John D. Stobo,³⁵ highlighted the critical role of health care providers in identifying and treating abuse and neglect but found that there was an overall lack of education and training available. To better equip health care providers, the committee provided a set of recommendations to improve multidisciplinary curricula and training programs and to establish evidence-based core competencies related to family violence. The committee also noted that the recognition, treatment, and prevention of family violence cannot be solely managed by the health care system but rather are societal responsibilities that require a multi-faceted response from numerous stakeholders (IOM, 2002g).

Continuing its partnership with the NRC, the IOM released another joint report in 2014 called New Directions in Child Abuse and Neglect Research. This new report served as an update to a 1993 NRC report called Understanding Child Abuse and Neglect. Research indicated that the psychosocial and economic effects of child abuse and neglect could have long-term impacts on the

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³³ By 2019, only 11 states in the United States maintained laws that kept marijuana strictly illegal, while all of the other states allowed medical marijuana, had decriminalized marijuana, or had fully legalized it for recreational and medical purposes (Lopez, 2019).

³⁴ Patricia A. King was at the Georgetown University Law Center when this report was released.

³⁵ John D. Stobo was at the University of Texas Medical Branch at Galveston during this time.

individual, family, and societal levels. The report also highlighted the biological and psychological consequences of abuse on childhood development (see Chapter 4). The committee, which was chaired by NAM member Anne C. Petersen,³⁶ concluded that progress in child abuse and neglect research had been made in the two decades since the first report, but more work was needed. In its report, the committee offered an “actionable framework to guide and support future child abuse and neglect research” and called for the development of a “coordinated, national research infrastructure with high-level federal support” (IOM and NRC, 2014a).

Another form of violence that has long-lasting effects on families is suicide. In 2002, the IOM released Reducing Suicide: A National Imperative. The report indicated that suicide was the third leading cause of death in the United States, with more than 30,000 people dying annually and another 650,000 treated for attempted suicides in emergency departments each year (IOM, 2002c). Given that 90 percent of suicides are associated with mental health concerns and/or substance use (discussed below), the committee, which was co-chaired by NAM members William E. Bunney, Jr.,³⁷ and Arthur M. Kleinman,³⁸ concluded that more could be done to prevent suicides and treat suicidality. The committee’s recommendations focused on expanding research funding, improving data collection and surveillance, providing better training for health care providers, and developing and implementing suicide prevention programs. The committee also recommended legislation to restrict access to common means of suicide, including stricter gun control laws.

Firearm violence contributed to a large proportion of suicides (more than half) and homicides (approximately three-quarters) each year in the United States (IOM and NRC, 2013a). This sensitive topic involves advocates on both sides of the debate surrounding gun control and options for reducing gun violence. The December 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, reinvigorated the national discussion about gun control and prompted additional public health research on firearm violence (see Figure 6-3). In 2013, President Obama instructed the CDC to take up research related to firearm injuries after a 17-year hiatus that had resulted from a 1995 amendment, known as the Dickey Amendment, which eliminated CDC funding related to firearm violence as a public health concern (Kaplan, 2018).³⁹ To help set its research agenda, the CDC commissioned an IOM report. The IOM released its fast-track consensus study in June 2013: Priorities to Reduce the Threat of Firearm-Related Violence. The research agenda set forth by the committee, which was chaired by NAM member Alan I. Leshner,⁴⁰ included priorities related to “the characteristics of firearm violence, risk and protective factors, interventions and strategies, the impact of gun safety technology, and the influence of video games and other media” (IOM and NRC, 2013a).

Following the release of the report, the NIH announced new funding opportunities for research on violence, particularly firearm violence, citing the IOM’s call for research investment.⁴¹ However, the CDC’s research agenda remained stalled by the prevailing interpretation of the Dickey Amendment until fiscal year 2020, when a congressional appropriations bill included $25 million to fund gun violence research at the CDC and various NIH institutes (Weir, 2021). The funding was timely, as gun sales spiked during the COVID-19 pandemic (Tavernise, 2021) and the United

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³⁶ Anne C. Petersen was a Research Professor at the Center for Human Growth and Development at the University of Michigan in Ann Arbor during this time.

³⁷ William E. Bunney, Jr., was at the University of California, Irvine, when this report was published.

³⁸ Arthur M. Kleinman was at Harvard University in Cambridge, Massachusetts, at this time.

³⁹ Judith Salerno to IOM Council, January 22, 2013, IOM/NAM Records; IOM Council Minutes, February 6, 2013, IOM/NAM Records; Judith Salerno to IOM Council, June 28, 2013, IOM/NAM Records.

⁴⁰ Alan I. Leshner was at the American Association for the Advancement of Science in Washington, DC, when this report was published.

⁴¹ Impact of IOM Reports (Database), IOM/NAM Records.

States experienced a surge in mass shootings. In 2020, firearms surpassed vehicle accidents as the leading cause of death for children in the United States (Bendix, 2022).⁴²

In 2019, the HMD followed up on the IOM’s firearm violence report with a workshop summary called Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. The standalone workshop, which was organized by a planning committee chaired by NAM member George J. Isham,⁴³ evaluated the potential role of the health care system and health care professionals in preventing injuries and death associated with firearm violence. Workshop presenters and panelists considered the impact of firearm violence on individuals and communities, including the psychological and social burdens (NASEM, 2019i). The workshop participants also reviewed existing interventions and research related to identifying individuals at a higher risk of firearm violence, the prevention of firearm violence, the role of the health care industry, and developing a culture of health care professionals serving as interveners.

To address violence as an ongoing global public health epidemic, the IOM launched the Forum on Global Violence Prevention in 2010. With an overarching goal “to reduce violence worldwide by promoting research on both protective and risk factors and encouraging evidence-based prevention efforts” (NASEM, n.d.s), the forum provided experts and stakeholders from across the globe with “an ongoing, regular, evidence-based, impartial, scientific setting for the multidisciplinary exchange of information and ideas” (NASEM, n.d.s). The forum held 15 public meetings and workshops, released 14 publications, and engaged more than 1,400 individuals from 37 countries as contributors to its work. Through its work, the forum tackled topics such as violence against children and women, intimate partner violence, elder abuse, the social and economic costs of violence, and the neurocognitive and psychosocial impact of violence.

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⁴² In Spring 2022, two major mass shooting incidents again called attention to the crisis of gun violence in the United States: in Buffalo, New York, 10 people were killed while shopping at a grocery store in an incident motivated by anti-Black racism; and in Uvalde, Texas, 19 students and 3 teachers were killed at an elementary school (see https://nam.edu/statement-by-nam-president-victor-j-dzau-in-response-to-multiple-mass-shootings-in-may-2022).

⁴³ George J. Isham was a Senior Fellow at the HealthPartners Institute when this stand-alone workshop was held.

RESPONDING TO CHRONIC CONDITIONS

Over the past two centuries, advances in science, health care services, and public health have reshaped the health profiles of people across the globe. People are living longer, and diseases that were once fatal are now chronic conditions that can be managed (e.g., diabetes, heart disease, epilepsy). In the United States, nearly 70 percent of deaths are related to chronic conditions and almost a quarter of people live with more than one chronic condition (IOM, 2012i). In 2012 the IOM released Living Well with Chronic Illness: A Call for Public Health Action, which stated that “chronic disease has now emerged as a major public health problem and it threatens not only population health, but our social and economic welfare” (IOM, 2012i, p. 2). The report laid out “public health actions that can help reduce disability and improve functioning and quality of life” (p. 2) related to chronic conditions in the United States. Living Well was not the IOM’s first report to review topics related to chronic conditions; throughout its history, the organization recognized chronic conditions as serious public health concerns and reviewed topics related to cardiovascular diseases, epilepsy, obesity, mental health, and substance use either as standalone reports or in the context of broader issues related to the health care system, health care research, or public health in general.

Cardiovascular Disease

Cardiovascular disease (CVD) represents a set of chronic conditions (e.g., heart failure, coronary artery disease, vascular disease) that are risk factors for acute cardiovascular events such as myocardial infarction/heart attack, cardiac arrest, and stroke. Prevention and treatment of CVD were long-standing topics of concern for the IOM that were carried forward by the NAM and the HMD. Even before the creation of the IOM, the Board on Medicine, under the direction of Walsh McDermott, dedicated its first report in 1968 to the subject of heart transplants, indicating that the procedure was neither safe enough nor studied enough to play a major part in treating heart disease (see Chapter 1).

The IOM explored many risk factors related to CVD over the years, including three that the IOM studied as public health concerns in their own right: obesity, smoking, and oral health. Obesity, one of the largest risk factors associated with CVD, is discussed in the next section of this chapter. In addition to the IOM’s work related to primary tobacco use (e.g., smoking) (described above), the IOM also released a report in 2010 that connected secondhand smoke with CVD risks for nonsmokers. The report, Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence, indicated that there was a 25–30 percent increase in the risk of CVD that could be associated with exposure to secondhand smoke. The committee, which was chaired by NAM member and Councilor (2013–2019) Lynn R. Goldman,⁴⁴ identified gaps in existing data and provided research recommendations to better understand the health effects of secondhand smoke (IOM, 2010h). The IOM also released two reports in 2011 on oral health that highlighted possible connections between periodontal disease and heart disease and the need for better access to oral health services: Advancing Oral Health in America (IOM, 2011m) and Improving Access to Oral Health Care for Vulnerable and Underserved Populations (IOM and NRC, 2011b).

As obesity and smoking are risk factors for CVD, CVD is an underlying risk for sudden cardiac arrest—the focus of the final report that was released under the IOM brand in 2015. The report, Strategies to Improve Cardiac Arrest Survival: A Time to Act, noted that CVD, including coronary artery disease and structural heart disease, were more common risk factors in men than women in

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⁴⁴ Lynn R. Goldman was at the Johns Hopkins Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Maryland, when this report was published.

terms of cardiac arrest. In its report, the committee, which was chaired by NAM member Robert Graham,⁴⁵ stressed the importance of educating the public about recognizing and immediately responding to cardiac arrest, as well as differentiating cardiac arrest from heart attacks (e.g., myocardial infraction) and other types of cardiovascular events that might be associated with CVD (IOM, 2015j).

In terms of health care services and treatment related to CVD, the IOM’s portfolio on health disparities often identified CVD as a serious concern. For example, the IOM’s 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care stated that “some of the strongest and most consistent evidence for the existence of racial and ethnic disparities in care is found in studies of cardiovascular care,” noting that “differences in treatment are not due to factors such as racial differences in the severity of coronary disease” (IOM, 2003b, pp. 39–42). While not specific to CVD, the IOM’s goal to eliminate health disparities and the NAM’s continued work on health equity provided many opportunities to ensure equitable access to high-quality preventative, diagnostic, and treatment services for CVD.

Although CVD has long been considered a concern for industrialized nations, it has also been identified as an emerging public health concern on a global level, with increasing burdens in developing countries. In considering CVD from a global perspective, the IOM released Control of Cardiovascular Diseases in Developing Countries in 1998 (IOM, 1998c), which was followed by a 2010 report called Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. The 2010 report found that 30 percent of deaths in low- and middle-income countries were associated with CVD. Given the large burden of CVD in these countries, the committee, which was chaired by NAM member Valentín Fuster,⁴⁶ recommended that progress be made in two areas: “creating environments that promote heart healthy lifestyle choices” and “building public health infrastructure and health systems” that can effectively identify and manage CVD while also reducing risk factors associated with CVD. The committee concluded that “without better efforts to promote cardiovascular health, global health as a whole will be undermined” (IOM, 2010d). Following the release of the report, Barrio Sésamo, the Spanish version of Sesame Street, announced that it would feature a new character based on Fuster. “Dr. Valentine Ruster” was a Muppet doctor who promoted healthy eating, physical activity, and cardiovascular health to children.⁴⁷

Epilepsy

Epilepsy was the fourth most prevalent neurologic condition in the United States in the first decade of the 21st century, yet it remains one of the most misunderstood and misrepresented chronic health conditions across the globe. With more than 40 variants, epilepsy is a “complex spectrum of disorders … characterized by unpredictable seizures that differ in type, cause, and severity” (IOM, 2012j). Although the seizures can be managed with medication and other types of therapies for approximately two-thirds of people with epilepsy, living with the condition involves many challenges beyond the seizures, including those related to medication side effects, comorbid conditions (e.g., depression, CVD, migraine, sleep disorders), education and employment, driving and transportation, and family and social considerations. In 2010, 24 federal agencies and non-profit organizations came together to commission an IOM report on the public health dimensions of epilepsy with an emphasis on surveillance and data collection; population and public health research; health care, human services, health policy; and education for health care professionals, the public, and people with epilepsy and their families.

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⁴⁵ Robert Graham was at the Milken Institute School of Public Health at The George Washington University in Washington, DC, during this time period.

⁴⁶ Valentín Fuster was at Mount Sinai Heart during this time.

⁴⁷ Impact of IOM Reports (Database), IOM/NAM Records.

In 2012, the IOM released Epilepsy Across the Spectrum: Promoting Health and Understanding. In its report, the committee estimated that the medical costs associated with epilepsy care exceeded $9 billion per year, which did not capture the costs associated with community-based services, loss of productivity, decrements in quality of life, or higher rates of mortality for people with epilepsy. The committee, which was chaired by external volunteer Mary Jane England,⁴⁸ presented a vision and a list of research priorities. It also made 13 recommendations to encourage “a better understanding of the public health dimensions of the epilepsies and for promoting health and understanding” that resonated “with broad goals of chronic disease management” (IOM, 2012j, pp. 3–4). One year after the release of the report, the IOM hosted a meeting that allowed the sponsors of the report and other stakeholders to discuss progress and updates that had been made as a result of the report’s recommendations as well as plans for the future. Following the release of the report, the CDC also used the “IOM’s recommendations to guide research, program activities, and services in collaboration with partners such as nonprofit organizations, academic researchers, and communities” (CDC, 2017) and tracked progress made against the report’s recommendations for many years after its release. The National Institute of Neurological Disorders and Stroke (NINDS); the National Heart, Lung, and Blood Institute (NHLBI); and the CDC began work toward a sudden death registry that included a category for sudden unexpected death in epilepsy.⁴⁹

Obesity and Nutrition

Nutrition, and later obesity, were two major public health topics for which the IOM became known throughout its history. The IOM’s Food and Nutrition Board (FNB)—established just before World War II as part of the NRC and then transferred to the IOM in 1988—spearheaded the IOM’s efforts related to nutrient intake requirements, military nutrition, food safety (see Box 6-2), and childhood obesity. In the summary of the FNB’s 80th anniversary symposium, organizers noted that the board “studies issues of national and global importance on the safety and adequacy of the U.S. food supply; establishes principles and guidelines for good nutrition; and provides authoritative judgment on the relationships among food intake, nutrition, and health maintenance and disease prevention.”⁵⁰

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⁴⁸ Mary Jane England was at Boston University in Massachusetts when this report was published.

⁴⁹ Impact of IOM Reports (Database), IOM/NAM Records.

⁵⁰ Food and Nutrition Board: 80th Anniversary Symposium (IOM/NAM Records).

In 1989, the FNB produced a report called Diet and Health: Implications for Reducing Chronic Disease Risk that explored the connections between nutrition and chronic diseases (NRC, 1989a). In its report, the committee, which was chaired by NAM member and past Councilor Arno G. Motulsky,⁵¹ concluded that diet represented a risk factor for several noncommunicable and chronic conditions, including CVD and hypertension, some forms of cancer, chronic liver disease, obesity, and diabetes. Much of the FNB’s subsequent work considered the role of food and nutrition in chronic conditions including relationships between obesity and comorbid conditions connected with obesity, particularly CVD and diabetes. The IOM also provided advice on pregnancy weight gain and nutrition for women and children, which have direct linkages to childhood development and health over the lifespan.

Although the following sections emphasize the FNB’s work as it relates to nutrition, obesity, and chronic health conditions—topics selected to highlight prominent, ongoing public health challenges in the United States and in many other countries around the world in recent decades—the FNB also produced an extensive body of work that has contributed to broader food and nutrition policies and science across the globe during its 80-year history. One example of the breadth of the board’s work is the Food Forum, which was established in 1993 “to allow selected science and technology leaders in the food industry, top administrators in the federal government, representatives from consumer interest groups, and academicians to periodically discuss and debate food and food related issues openly and in a neutral setting” (NASEM, n.d.t). Since its launch nearly three decades ago, the Food Forum has become one of the National Academies’ longest running forums and engaged a diverse cross section of representatives from large, international corporations, such as Coca-Cola, ConAgra Foods, and Mars, Inc., along with representatives from U.S. federal agencies and non-profit organizations, such as the FDA, the NIH, the Department of Agriculture, the American Heart Association, the American Society for Nutrition, among many others. Through its work, the Food Forum has hosted numerous public meetings, fostered ongoing and open dialog across relevant stakeholders and interested parties, and produced a range of workshop summaries and publications that explored topics including sustainable diets, food safety, food literacy, food waste, nutrigenomics, nutrition and aging, and food technology.

One important and specialized area that the FNB explored during the second half of its history was military nutrition and health. The military’s physical fitness and performance requirements along with the sometimes extreme environments in which the military operates often necessitate nutritional considerations and guidance that may differ from those available for the general population. In 1982, the Assistant Surgeon General of the U.S. Army called on the National Academies, through the FNB, to establish a committee to advise the military on nutritional research and guidance for military personnel. The Committee on Military Nutrition Research was charged with “identifying nutritional factors that could critically influence the physical and mental performance of military personnel under environmental extremes, with identifying deficiencies in the existing relevant data base, with recommending approaches for studying the relationship of diet to physical and mental performance, and with reviewing and advising on nutritional standards for military feeding systems” (IOM, 1994e, p. 3). Over the years, the Committee on Military Nutrition Research, along the other consensus committees, provided the military with recommendations to meet the unique nutritional needs of military personnel so that they are ready for deployment and can fulfill military requirements (see Box 6-3).

Dietary Reference Intakes

The FNB has a long history in advising the nation on dietary intake recommendations that date back to its origins. In 1941, the FNB defined the first Recommended Dietary Allowances (RDAs) with the goal of providing advice for WWII food relief efforts and to recommend “allowances

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⁵¹ Arno G. Motulsky was at the Center for Inherited Diseases at the University of Washington in Seattle at this time.

sufficiently liberal to be suitable for maintenance of good nutritional status” (Yaktine and Ross, 2019). The RDAs, reviewed and occasionally updated, served as a source for dietary guidance in the United States for the next 40 years, bringing “together the concepts of a healthy diet while meeting essential nutritional requirements.”⁵² As the American diet evolved and rates of obesity and chronic diseases associated with obesity increased, the nutritional health challenges shifted (Yaktine and Ross, 2019). In the mid-1990s, Dietary Reference Intakes (DRIs), established by committees that worked under the auspices of the IOM, replaced the RDAs. The DRIs are a set of reference values that cover 40 nutrient substances that, “when adhered to, predict a low probability of nutrient inadequacy or excessive intake” (NASEM, n.d.u; Yaktine and Ross, 2019). Box 6-4 provides a list of the organization’s DRI reports released from 1997 through 2019. The DRI series contributed to the scientific basis for the 2005 Dietary Guidelines for Americans—the U.S. government’s nutrition policy document. As of 2019, the IOM’s DRI framework had been adopted by the governments of the Netherlands and China, the Australia-New Zealand Food Authority, and nutrition societies in Germany, Austria, and Switzerland.⁵³

The 2002/2005 report Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (IOM, 2005e) contributed to a 2003 decision by the FDA to require manufacturers to list trans fat on the Nutrition Facts Panel for foods and some

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⁵² Food and Nutrition Board: 80th Anniversary Symposium (IOM/NAM Records).

⁵³ Impact of IOM Reports (Database), IOM/NAM Records.

dietary supplements. The FDA estimated that removing trans fats from foods would prevent up to 1,200 cases of coronary heart disease and up to 500 deaths annually. In 2004, food manufacturers Frito Lay and Kraft Foods announced efforts to eliminate trans fats from their products, and in 2007, New York City banned the use of trans fats in restaurants—all three citing the IOM report as the basis for action. The report continued to have an impact more than a decade later, when the FDA, citing the IOM report, ruled that partially hydrogenated oils (PHOs)—the primary source of artificial trans fat in processed foods—were not safe for human consumption and ordered manufacturers to remove PHOs from their products within 3 years.⁵⁴

Over the years, the IOM and subsequently the HMD updated the DRIs based on the availability of new research and also modified its process for reviewing the nutrients. For example, nutrients were no longer grouped together, as was the approach in the beginning. In 2011, the IOM released Dietary Reference Intakes for Calcium and Vitamin D, which updated the calcium and vitamin D information originally found in its 1997 DRI report, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (IOM, 1997d, 2011n). In 2019, the HMD released Dietary Reference Intakes for Sodium and Potassium, which updated a portion of the IOM’s 2005 report, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (IOM, 2005f; NASEM, 2019l).

One of the DRI nutrients that the IOM returned to study frequently was sodium. Prior research, such as that undertaken by Board on Medicine member Irvine Page, had identified linkages between high sodium intake and elevated blood pressure, which increased the risks associated with chronic

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⁵⁴ Ibid.

illnesses and acute illnesses such as heart disease, congestive heart failure, stroke, and kidney disease. In 2010, the IOM released Strategies to Reduce Sodium Intake in the United States. The committee, which was chaired by NAM member, Home Secretary (2014–2020), and former FDA Commissioner Jane E. Henney,⁵⁵ concluded that sodium intake from processed foods and foods served in restaurants remained high, despite 40 years of initiatives and public health efforts to lower sodium intake. The committee called for “mandatory national standards for the sodium content of foods,” with an emphasis on strategies to reduce sodium in the food supply (e.g., pre-packaged and processed foods, food sold in restaurants) (IOM, 2010i). Following the release of the report, Walmart, a major food distributor, announced an effort to reduce the sodium content of the items on its shelves.⁵⁶ In 2011, Subway, the fast food restaurant chain, also committed to reducing the amount of sodium in its “Fresh Fit” sandwiches by 28 percent.⁵⁷

In 2013, the IOM released a second report focused on sodium called Sodium Intake in Populations: Assessment of Evidence. In its report, the committee conducted a review of available evidence related to sodium intake and the possible benefits and harms of reducing dietary sodium, with a focus on the design, methodologies, and conclusions of relevant research. Based on its review, the committee, which was chaired by NAM member Brian L. Strom,⁵⁸ reaffirmed connections between high sodium intake and risks for CVD but stated it could not find evidence to support further lowering sodium intake below 2,300 mg per day—the current recommended maximum—for the general population (IOM, 2013j).

Of all the public health topics covered by the IOM, the FNB reports arguably garnered the most public interest. For example, when the IOM released Dietary Reference Intakes for Calcium and Vitamin D in November 2010, more than 31,000 people visited the website (IOM, 2011o). As many as 5,000 of these visitors arrived via a link from The New York Times website, which included extensive coverage of the report. A few days later, content from the report became a question in The New York Times “Weekly Health Quiz”—an opportunity to reinforce the report’s message that Americans typically received adequate amounts of vitamin D without the need for supplements.⁵⁹

Nutritional Guidelines for Women and Children

In addition to providing nutritional guidance for the military and the general population, the IOM and the FNB also recognized the unique nutritional needs of women and children. In 1970, the FNB produced a report under the NRC called Maternal Nutrition and the Course of Pregnancy that served as a benchmark in pre- and perinatal nutrition. Twenty years later, the IOM revisited topics covered in the 1970 report when it released reports focused on the nutritional needs of pregnant and lactating women. For example, in 1990 the IOM issued Nutrition During Pregnancy: Part I: Weight Gain, Part II: Nutrient Supplements. Part I of the report called for a review and update to guidelines related to weight gain during pregnancy, and Part II focused on guidance related to nutritional supplements needed during pregnancy (e.g., folate, iron), as well as the effects of caffeine, tobacco, alcohol, and other drugs on maternal nutrition (IOM, 1990c). In 1991, the IOM released Nutrition During Lactation, which reviewed available data and examined how maternal nutrition affects milk composition and infant nutrition (IOM, 1991e).

Nearly two decades after the release of Nutrition During Pregnancy, the health and weight profile of women of childbearing age in the United States had changed (e.g., increased maternal

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⁵⁵ Jane E. Henney was at the College of Medicine at the University of Cincinnati, Ohio, when this report was published.

⁵⁶ Impact of IOM Reports, January–March 2011 in IOM Council Minutes, April 11, 2011, IOM/NAM Records.

⁵⁷ Impact of IOM Reports (Database), IOM/NAM Records.

⁵⁸ Brian L. Strom was the George S. Pepper Professor of Public Health at the University of Pennsylvania Perelman School of Medicine in Philadelphia when this report was released.

⁵⁹ Judith Salerno to IOM Council, “Overview of IOM Program Activity, September 10, 2011, IOM/NAM Records.

age, rates of chronic conditions, rates of maternal obesity), requiring modifications to the pregnancy weight guidelines the IOM had put forth in 1990. Weight Gain During Pregnancy: Reexamining the Guidelines was released in 2009. The committee, which was chaired by external volunteer Kathleen M. Rasmussen,⁶⁰ reviewed new data and research that had become available since the previous report and “updated target ranges for weight gain during pregnancy and guidelines for proper measurement,” adding guidelines for women with obesity (IOM and NRC, 2009c). When the report was released, the IOM created an online toolkit designed to provide information about healthy weight gain directly to pregnant women and women considering pregnancy. In 2013, the IOM, in coordination with the NRC, held a workshop to discuss strategies to promote behavior change aligned with the updated guidelines (IOM and NRC, 2013b). At this time, the IOM and the NRC jointly released two supplemental publications that synthesized the information from the 2009 report into consumer-friendly formats: Guidelines on Weight Gain and Pregnancy and Implementing Guidelines on Weight Gain and Pregnancy (IOM and NRC, 2013c,d).

Beyond pre- and perinatal nutritional guidelines for women, the IOM and the FNB also offered policy guidance for the Supplemental Nutrition Program for Women, Infants, and Children (WIC), which was established to provide “specific supplemental foods, nutrition education, and social service and health care referrals to low-income pregnant, breastfeeding, and postpartum women, infants, and children up to age 5 years” (IOM, 1996d, p. 1). Over the course of the IOM’s history, the organization provided guidance on nutritional risk assessment and eligibility requirements for the program (e.g., WIC Nutrition Risk Criteria: A Scientific Assessment [IOM, 1996d], Dietary Risk Assessment in the WIC Program [IOM, 2002h]) and also offered recommendations to update the WIC food packages—the allowable foods and beverages that could be obtained through the program (e.g., infant formula, fruits and vegetables, meat, dairy products). The IOM’s 2006 report, WIC Food Packages: Time for a Change, which was drafted by a committee chaired by NAM member Suzanne P. Murphy,⁶¹ offered recommendations to fulfill the goal of improving the “quality of the diet of WIC participants while also promoting a healthy body weight that will reduce the risk of chronic diseases” (IOM, 2006d). As a result of the committee’s recommendations, the WIC program was modified to align with the government’s Dietary Guidelines for Americans and applicable Healthy People 2020 goals and objectives (NASEM, 2017i). To fulfill a new congressional mandate to review the WIC food packages every 10 years, the HMD released an updated report in 2017 called Review of WIC Food Packages: Improving Balance and Choice: Final Report, which provided recommendations to encourage breastfeeding and offer greater variety and choice in the food packages (NASEM, 2017j).

Childhood Obesity

In 2002, the transition year between IOM Presidents Ken Shine and Harvey Fineberg, Congress charged the IOM with developing a prevention strategy to decrease obesity among children and youth in the United States. In 2004, the IOM released Preventing Childhood Obesity: Health in the Balance, which indicated that approximately 9 million children between the ages of 6 and 11 were obese. The report stated that the rate of obesity was approaching epidemic levels and constituted a critical public health threat, noting that obesity increased risks for a range of chronic illnesses such as diabetes, hypertension, and CVD. The committee, which was chaired by NAM

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⁶⁰ Kathleen M. Rasmussen was a Professor of Nutrition in the Division of Nutritional Sciences at Cornell University in Ithaca, New York, during this time.

⁶¹ Suzanne P. Murphy was at the Cancer Research Center of Hawaii at the University of Hawaii in Honolulu when this report was released.

member and Councilor (2003–2008) Jeffrey P. Koplan,⁶² developed a range of recommendations that highlighted actions for federal policy makers, private industry, states and local communities, schools, and parents, all with the goal of improving children’s diets and increasing physical activity (IOM, 2005c).⁶³

In 2007, the IOM released a follow-up report called Progress in Preventing Childhood Obesity: How Do We Measure Up?, which assessed progress since the release of the 2004 report. The committee found that although numerous initiatives and programs had been launched, they “generally remain[ed] fragmented and [were] small in scale” (IOM, 2007i). The committee, which was also chaired by Koplan, encouraged continued efforts with an emphasis on evaluating the initiatives, sharing best practices, and scaling up promising programs. In 2011, the IOM revisited childhood obesity with a focus on children under the age of 5 in its report Early Childhood Obesity Prevention Policies. The committee, chaired by external volunteer Leann L. Birch,⁶⁴ stressed that “the first years of life are important to health and well-being throughout the life span,” offering recommendations to health care professionals, parents, and child care providers to keep young children active, provide healthy diets, minimize screen time, and ensure that children get enough sleep (IOM, 2011p, p. 1).

In addition to high-level examinations of the childhood obesity epidemic, the IOM released targeted reports that were meant to provide guidance in specific areas. For example, the IOM released a report in 2006 called Food Marketing to Children and Youth: Threat or Opportunity?, which evaluated how current food marketing practices affected the nutritional status of children and youth and how marketing could be leveraged to promote healthier choices and diets. When the committee began its work in 2004, it found that products heavily marketed to children had low nutritional value and were high in calories, sugar, salt, and fat. The committee, which was chaired by NAM member and Leonard D. Schaeffer Executive Officer (2016–) J. Michael McGinnis,⁶⁵ concluded that “sustained, multisectoral, and integrated efforts” would be required to improve the diets of children and youth. In its recommendations, the committee called on companies in the food and beverage industry along with restaurants to use the resources and ingenuity they put into advertising to promote healthy diets in children. The committee also indicated that television networks, the federal government, and state and local education authorities should also be involved in promoting healthy foods and beverages for children (IOM, 2006e).

The release of this report was followed by a series of events that demonstrated the report’s reach and impact. One tangible sign of impact was a March 2006 letter signed by 10 Democratic senators and addressed to HHS Secretary Mike Leavitt. The senators cited the IOM report as proof of “scientific evidence that food marketing to children has a significant impact on children’s food preferences.” The senators agreed with the report’s call for the federal government to assume the lead role in solving the problem. They therefore urged Secretary Leavitt to take the necessary steps to begin monitoring progress toward the IOM’s recommendations.⁶⁶ The television industry also took immediate notice; between 2006 and 2007, Disney, Nickelodeon, and the Cartoon Network announced that they would no longer allow the use of their characters to market unhealthy food to children. Additionally, the British broadcast regulator Ofcom issued a ban on all junk food advertising in children’s programming. Major food and beverage companies including Burger King

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⁶² Jeffrey P. Koplan was at the Woodruff Health Sciences Center of Emory University in Atlanta, Georgia, when this report was released.

⁶³ Board Briefs, Food and Nutrition Board, IOM Council Minutes, July 11, 2011, IOM/NAM Records.

⁶⁴ Leann L. Birch was a Professor and the Director of the Center for Childhood Obesity Research at The Pennsylvania State University in University Park during this timeframe.

⁶⁵ J. Michael McGinnis was at the IOM when this report was released.

⁶⁶ Tom Harkin, Dick Durban, Ted Kennedy, Patty Murray, Chuck Schumer, and Hillary Rodham Clinton to Mike Leavitt, March 3, 2006, IOM/NAM Records.

and ConAgra also made commitments to promote healthier food to children. In line with a recommendation from the report, the Patient Protection and Affordable Care Act (ACA) required that all restaurants with 20 or more locations post the calorie content of their foods.⁶⁷

In 2009, the IOM provided specific guidance to community leaders in its report Local Government Actions to Prevent Childhood Obesity. The committee, which was chaired by external volunteer Eduardo J. Sanchez,⁶⁸ highlighted the important role that communities and local governments play in creating healthy environments for children—from grocery stores that offer healthy food options, such as fresh fruits and vegetables, to safe playgrounds where children can be physically active. The committee offered a set of strategies to improve diet and physical activity that could be implemented at the community level by mayors, city councils and managers, and country commissioners and boards (TRB et al., 2009).

In addition to providing recommendations related to food marketing and actions communities could take, the IOM also directed recommendations to schools in an effort to guide their food and physical activity policies. In 2007, the IOM released Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth, which stated that many children spend the majority of their day in school and the food consumed in schools can represent a large portion of children’s diets. The committee—chaired by NAM member Virginia A. Stallings⁶⁹—laid out “a set of guiding principles to support the creation of a healthful eating environment for children in U.S. schools” (IOM, 2007j, p. 2). The committee also organized foods and beverages that were offered outside of the federally reimbursable nutrition programs into two tiers to help schools develop policies regarding foods offered in vending machines, school stores, and concession stands. In 2010, the IOM released a complementary report called School Meals: Building Blocks for Healthy Children that was drafted by a committee also chaired by Stallings. The report evaluated nutritional standards and requirements for the School Breakfast Program and the National School Lunch Program (IOM, 2010e). Together, these two reports examined the various types of food and beverages offered in schools and provided recommendations “to better meet the nutritional needs of children, foster healthy eating habits, and safeguard children’s health” (IOM, 2010e, p. 2).

Many actions took place at the community, state, and national levels as a result of these reports. In 2010, President Obama signed into law the Healthy, Hunger-Free Kids Act, which directed the Secretary of Agriculture to propose updated regulations for nutrition standards for school breakfasts and lunches based on the School Meals report. Two years later, First Lady Michelle Obama and Secretary of Agriculture Tom Vilsack announced improved nutrition standards for school meals, including daily fruits and vegetables; fat-free or low-fat milk; whole grains; and less saturated fat, trans fat, and sodium—the first health-focused updates in 15 years (see Figure 6-4). School food service companies ARAMARK, Sodexo, and Chartwells also announced efforts to meet the IOM’s recommendations for fat, sugar, sodium, and whole grains within 5–10 years.⁷⁰

The IOM also considered physical activity in schools as another opportunity to prevent obesity and promote healthier lifestyles for children. In its 2013 report, Educating the Student Body: Taking Physical Activity and Physical Education to School, the IOM highlighted associations between physical inactivity and risks for chronic conditions such as diabetes, elevated blood pressure, CVD, certain types of cancers, osteoporosis, anxiety, and depression. As with healthy eating habits, habits related to physical activity are formed at a young age and affect health across the lifespan. The

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⁶⁷ Impact of IOM Reports (Database), IOM/NAM Records.

⁶⁸ Eduardo J. Sanchez was the Vice President and the Chief Medical Officer of Blue Cross and Blue Shield of Texas at the time.

⁶⁹ Virginia A. Stallings was at the Joseph Stokes Jr. Research Institute of the Children’s Hospital at the University of Pennsylvania Perelman School of Medicine in Philadelphia when this report was published.

⁷⁰ Impact of IOM Reports (Database), IOM/NAM Records.

committee, which was chaired by external volunteer Howard W. Kohl III,⁷¹ made recommendations that were designed to strengthen and improve physical activity policies and programs in schools (IOM, 2013k).

In 2012 the IOM once again revisited obesity and reviewed national progress since the release of its previous reports. In its report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation (IOM, 2012l), the committee concluded that while “many aspects of the obesity problem have been identified and discussed … there has not been complete agreement on what needs to be done to accelerate progress” (NASEM, n.d.d1). To drive progress, the committee—chaired by external volunteer Daniel R. Glickman⁷²—stated that broad societal changes using a systems approach would be required. According to the committee, there were five critical environments to address: physical activity, food and beverage, message, health care and work, and school. The committee developed goals that corresponded to these areas—for example, making “physical activity an integral and routine part of life” and making “schools the national focal point” for obesity prevention. Through its recommendations, the committee’s goal was to reshape the environments in which individuals and families “work, learn, eat, and play” (IOM, 2012k).

To further expand the reach of its work in obesity, the IOM entered into a collaboration with the CDC, the NIH, and HBO Documentary Films to produce a film series on the obesity epidemic under the title of The Weight of the Nation. The RWJF supported the project, and the Michael & Susan Dell Foundation and Kaiser Permanente contributed an additional $10 million. HBO made the films available to subscribers and non-subscribers alike, offering wide availability to anyone who

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⁷¹ Howard W. Kohl III was a Professor of Epidemiology and Kinesiology at the School of Public Health at the University of Texas Health Science Center-Houston and the Department of Kinesiology and Health Education at The University of Texas at Austin during this time.

⁷² Daniel R. Glickman was the Executive Director of Congressional Programs at The Aspen Institute in Washington, DC, when this report was released.

might be interested.⁷³ The reviews of the documentary were mixed, but generally acknowledged the importance of the topic and the content presented (Fryhofer, 2012; Lowry, 2012; Umstead, 2012). One review stated that the series “cast a very sobering light on the state of America’s health and the consequences of the continual expansion of our waistlines” (Umstead, 2012). As part of this series, the children’s film The Weight of the Nation for Kids: Quiz Ed! was nominated for a 2013 Emmy Award in the Outstanding Children’s Program category.

To continue its obesity work and create platforms to facilitate ongoing discussion, the IOM established the Standing Committee on Childhood Obesity Prevention in 2008 and the Roundtable on Obesity Solutions in 2014. The standing committee, which was sponsored by the RWJF, was designed to bring together leaders from government, academia, and corporate entities to have ongoing policy discussions and guide the selection of topics for future IOM workshops and consensus studies. Between 2009 and 2013, the standing committee held six meetings and workshops that covered topics related to food marketing, legal strategies, parents and children, and health equity in the prevention of childhood obesity. After the disbandment of the standing committee, the FNB formed the Roundtable on Obesity Solutions as a means of continuing the work of the standing committee (NASEM, n.d.v). With more than 30 sponsors and 50 members, the Roundtable on Obesity Solutions brought together leaders and stakeholders from multiple sectors in order to “view the problem of obesity from a systems perspective; achiev[e] health equity through focused action and research; develop and us[e] effective communication strategies; identify innovative financing mechanisms; and foster evaluation.” The roundtable worked toward fulfilling its mission by hosting workshops and public meetings, commissioning background papers, and operating four innovation collaboratives. Since its launch, the roundtable has released 20 publications that have reviewed topics such as the global obesity pandemic, obesity in the military, physical activity, and cross-sector responses to obesity.

Mental Health and Substance Use

Dating back to the IOM presidency of psychiatrist David Hamburg, mental health and substance use became ongoing priorities within the IOM’s portfolio and remained so for both the HMD and the NAM. During the IOM’s existence, the organization released an assortment of reports that covered topics related to preventing mental health disorders, quality of care, specific mental health needs of parents and children (see Chapter 4), substance use and addiction, and the mental health needs and concerns of military personnel and veterans. When the NAM was established in 2015, the NAM leadership carried forward the IOM’s legacy in mental health and substance use by elevating the U.S. opioid crisis to one of the organization’s top focus areas. The NAM identified the crisis as an urgent public health need that required a timely, united national response (see Chapter 7). While coordinating with and supporting the NAM’s opioid work, the HMD also continued the IOM’s mental health portfolio with work that cut across many of its boards and activities.

Approaching its 25-year anniversary, the IOM explored the possibility of preventing mental health disorders in a 1994 report called Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. The congressionally mandated study examined prevention as a possible mechanism to reduce the immense economic and social burdens of mental health disorders on individuals, families, and communities. The committee—chaired by NAM member and Councilor Robert J. Haggerty⁷⁴—estimated that approximately 20 percent of the U.S. population had one or more mental health or substance use condition (IOM, 1994f). Throughout its delibera-

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⁷³ The story of the HBO documentary can be followed through IOM Council Minutes, January 11, 2010, IOM Council Minutes, October 16, 2010, and Judith Salerno to IOM Council, February 8, 2012, all in IOM/NAM Records.

⁷⁴ Robert J. Haggerty was a Professor of Pediatrics Emeritus at the University of Rochester School of Medicine and Dentistry in Rochester, New York, during this time.

tions, the committee members considered successful public health prevention strategies that had been implemented to prevent CVD, injuries, and smoking, and they evaluated risk factors associated with mental health disorders such as Alzheimer’s disease, schizophrenia, alcohol use and addiction, depressive disorders, and conduct disorders (IOM, 1994f). The committee developed a research agenda and recommendations that focused on “develop[ing] effective intervention programs, creat[ing] a cadre of prevention researchers, and improv[ing] coordination among federal agencies” (NASEM, n.d.e1).

In 2005, as part of the IOM’s Quality Chasm Series (see Chapter 5), the organization took a special interest in the quality of care for individuals living with mental health and substance use conditions. Improving the Quality of Health Care for Mental and Substance-Use Conditions, which was authored by a committee chaired by Mary Jane England,⁷⁵ concluded that while effective treatments were available, care for mental health and substance use conditions was often fragmented, placing considerable burdens on individuals, families, and society (IOM, 2006h). In 2015, the IOM released a complementary study called Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards. More than two decades after the IOM’s 1994 report on prevention, this committee, which was also chaired by England,⁷⁶ reiterated that 20 percent of the population lived with one or more mental health conditions. The new report developed a framework that could be employed to ensure that available care was high-quality and evidence-based. The committee also offered recommendations to strengthen the evidence base and develop quality measures relevant to psychosocial programs and interventions (IOM, 2015f).

Recognizing the need for long-term, collaborative discussions regarding mental health and substance use conditions, the HMD established the Forum on Mental Health and Substance Use Disorders in 2019. With more than 20 sponsors and 30 members, the forum held its inaugural workshop in October 2019. Picking up on themes from previous IOM work, including the 2005 Quality Chasm report, the workshop focused on “key policy challenges to improve care for people with mental health and substance abuse disorders.” Speakers and panelists considered opportunities to promote person-centered care, better define adequate care, apply knowledge to practice, and encourage innovation and coordination across health care systems and the health care workforce (NASEM, n.d.w).

Substance Use and Addiction

Under the umbrella of mental health, the IOM and HMD also focused on topics related to substance use and addiction. The organization evaluated substance abuse in broad terms (e.g., Treating Drug Problems [Volume 1: IOM, 1990e; Volume 2: IOM, 1992c], Pathways of Addiction [IOM, 1996h]) and also evaluated specific topics related to the use of alcohol, opioids, tobacco, and marijuana. The organization reviewed evidence and provided recommendations related to quality of care, treatment and prevention options, and health care workforce needs. Box 6-5 provides a list of examples of the organization’s reports on substance use and addiction.

One of the subtopics the organization explored over the years was alcohol use. In 2003, the IOM investigated alcohol use among youth in its report Reducing Underage Drinking: A Collective Responsibility. The committee, which was chaired by Richard J. Bonnie,⁷⁷ identified underage drinking as a serious public health concern due to risks associated with “traffic fatalities, violence, unsafe sex, suicide, educational failure, and other problem behaviors.” In an effort to curb underage drinking and attempt to prevent it altogether, the committee described strategies that could be

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⁷⁵ Mary Jane England was President of Regis College in Weston, Massachusetts, when this report was released.

⁷⁶ Mary Jane England was a Professor of Health Policy and Management at the School of Public Health at Boston University when this report was published.

⁷⁷ Richard J. Bonnie was at the School of Law at the University of Virginia during this time.

implemented and expanded such as building partnerships with the alcohol and entertainment industries, modifying marketing practices, and enhancing the effectiveness of underage drinking laws by ensuring compliance and enforcement at the state level (NRC and IOM, 2004). In 2005, the Sober Truth on Preventing (STOP) Underage Drinking Act became the first major national legislation to address underage drinking. Based on the IOM’s 2003 report, the legislation called for investment in prevention coalitions, public marketing, and additional research. HHS Secretary Mike Leavitt launched a public service announcement campaign targeting parents and encouraging them to talk to their kids about drinking. Nickelodeon and the Century Council (financed by a number of distilling companies) (now known as the Foundation for Advancing Alcohol Responsibility) also created a $2 million ad campaign discouraging children from drinking.⁷⁸

In 2018, the HMD examined alcohol-impaired driving and opportunities to prevent injury and death in its report Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. The report, which was produced by a committee chaired by external

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⁷⁸ Impact of IOM Reports (Database), IOM/NAM Records.

volunteer Steven M. Teutsch,⁷⁹ included recommendations related to “increasing alcohol excise taxes, lowering state per se laws for alcohol-impaired driving to 0.05% blood alcohol concentration (BAC), preventing illegal alcohol sales to underage persons and to already-intoxicated adults, strengthening regulation of alcohol marketing, and implementing policies to reduce the physical availability of alcohol” (NASEM, 2018g, p. 1).

Mental Health and Substance Use Care in Military and Veteran Populations

Military and veterans’ health constituted another area of focus for the IOM and subsequently the HMD (see also Chapter 4). Through its work, the organization recognized the specific needs and challenges for these populations in terms of mental health—including posttraumatic stress disorder (PTSD) (see Box 6-6)—and substance use prevention and treatment. In 2010, after nearly a decade of war in Iraq and Afghanistan, the IOM released a report called Provision of Mental Health Counseling Services Under TRICARE, which assessed the mental health care needs of TRICARE⁸⁰ beneficiaries, including active duty personnel, reservists, military family members, and retirees. The committee—chaired by George J. Isham⁸¹—reviewed counseling options, TRICARE requirements, and determinants of high-quality care. In its report, the committee recommended that TRICARE

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⁷⁹ Steven M. Teutsch was an Adjunct Professor at the University of California, Los Angeles, Fielding School of Public Health; a Senior Fellow at the Public Health Institute; and a Senior Fellow at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California when this report was released.

⁸⁰ TRICARE is the Department of Defense’s health insurance program, which provides coverage for more than 9.4 million active duty military personnel, reservists, retired members of the military, family members, and other select individuals with military connections (Health.mil, n.d.).

⁸¹ George J. Isham was the Medical Director and the Chief Health Officer at Health Partners, Inc., in Bloomington, Minnesota during this time.

update its policies to allow autonomous practice for mental health counselors, removing the requirement that all counselors must practice under the supervision of a physician (IOM, 2010f).

The IOM followed up on the 2010 TRICARE report with a pair of reports in 2013 and 2014 that responded to the physical and psychosocial needs of military personnel returning from wars in Afghanistan and Iraq, as well as the needs of their families: Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families⁸² (2013) and Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs⁸³ (2014). In terms of mental health, the first report focused on the Department of Defense’s (DOD’s) and the Department of Veterans Affairs’ (VA’s) screening and treatment programs, whereas the latter report focused on prevention (IOM, 2014c). Specifically, the 2014 report evaluated the DOD’s “reintegration programs and prevention strategies for PTSD, depression, recovery support, and prevention of substance abuse, suicide, and interpersonal violence.” Together the reports made recommendations for the implementation of strategies at the “individual, interpersonal, institutional, community, and societal” levels to provide better support and mental health care to more than one million service members who were living with one or more psychological disorders and their families (IOM, 2014c).

The HMD produced a complementary report in 2018 called Evaluation of the Department of Veterans Affairs Mental Health Services. During its deliberations, the committee—chaired by NAM member Alicia L. Carriquiry⁸⁴—identified “a substantial unmet need for mental health services” among military personnel who had served in Afghanistan and Iraq. Although many veterans received high-quality mental health services through the VA, the committee identified a need to expand that care across all facilities and veteran populations. The report urged the VA to set “a goal of becoming a high-reliability provider of high-quality mental health services” within 5 years (NASEM, 2018h, p. 5). In doing so, the VA would have to adopt strategies to “engage veterans, expand outreach efforts …, and improve its transitional services” (NASEM, 2018h, p. 6).

Throughout its history, the VA has been the subject of intense public scrutiny that was often triggered by feedback from veterans and their encounters with the system—not limited to mental health services. For example, in 2014 the VA launched an investigation of the Phoenix VA health care system in response to concerns regarding serious scheduling problems and wait times. The investigation revealed that 1,700 veterans who needed care had not been included on the mandatory electronic waiting list, and 40 veterans who had been included on the list died while waiting for an appointment. In response to these findings, the VA asked the IOM to conduct a study and make recommendations to improve scheduling and access to the VA health system and throughout the U.S health care system more broadly. The IOM released its fast-track study—Transforming Health Care Scheduling and Access: Getting to Now—in 2015. The study examined systems-based engineering methods and various scheduling models, such as leaving openings in the schedule for same-day appointments. The committee, which was chaired by NAM member Gary Kaplan,⁸⁵ recommended that the VA and other health systems employ innovations such as queue streamlining and leverage non-physician clinicians and technology-based consultations in order to alleviate long wait times and improve access to needed care (IOM, 2015g).

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⁸² George W. Rutherford chaired this committee. At the time, he was the Salvatore Pablo Lucia Professor, the Vice Chair of the Department of Epidemiology and Biostatistics, and the Director of the Prevention and Public Health Group at the University of California, San Francisco.

⁸³ Kenneth E. Warner chaired the committee that drafted this report. During this time he was the Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan School of Public Health in Ann Arbor, Michigan.

⁸⁴ Alicia L. Carriquiry was at Iowa State University when this report was published.

⁸⁵ Gary Kaplan was the Chair and the Chief Executive Officer at the Virginia Mason Health System during this time.

In addition to the IOM’s work on mental health concerns among military and veteran populations, the organization also reviewed topics related to substance use in these populations. For example, in 2009, the IOM released a report called Combating Tobacco in Military and Veteran Populations. In its report, the committee, chaired by Stuart Bondurant,⁸⁶ concluded that the short- and long-term health and economic costs of tobacco use warranted DOD and VA investment in comprehensive tobacco-control programs that would encourage cessation and prevent initiation of tobacco use (IOM, 2009c). The committee recommended that the DOD take specific actions toward realizing its goal of becoming a tobacco-free military, including banning tobacco use on military installations and eliminating the sale of tobacco in commissaries. In 2013, the IOM conducted a broader review of substance use in the military with its report Substance Use Disorders in the U.S. Armed Forces. The report reviewed alcohol and other drug use, such as the misuse of prescription drugs including opioids, and concluded that substance use in the military was a public health crisis that threatened the readiness and psychological fitness of military personnel (IOM, 2013l). To reduce substance use and misuse, the committee, which was chaired by NAM member Charles P. O’Brien,⁸⁷ urged the DOD “to consistently implement evidence-based prevention, screening, diagnosis, and treatment services and take leadership for ensuring that these services expand and improve” (IOM, 2014d, p. 4).

U.S. overdose deaths saw a 30 percent increase during 2020, exacerbated by the opioid epidemic as well as the physical distancing restrictions and extreme stress imposed by the COVID-19 pandemic (CDC, n.d.f). Mental health concerns among adults and children also rose during the pandemic, and combating the overdose epidemic as well as ensuring the mental health and wellbeing of people across the globe was of critical importance (Panchal et al., 2021). In 2018, the NAM established an Action Collaborative on Countering the U.S. Opioid Epidemic (see Chapter 7).

Neglected Health Concerns and Chronic Conditions in Developing Countries

In addition to the IOM’s work on cardiovascular diseases globally, the organization also explored the impact of often neglected health concerns and chronic conditions, such as women’s health, brain disorders, and cancer in developing countries. For example, in 1996 the IOM released a report called In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa, which cut across a variety of neglected health concerns and chronic conditions. In sub-Saharan Africa, women’s health had largely been neglected due in large part to competing public health and social priorities. In its report, the committee, which was chaired by external volunteer Maureen Law,⁸⁸ reviewed the impact of specific diseases and conditions, such as HIV/AIDS, cancer, CVD, and mental health conditions, as well as broader concerns related to nutrition and obstetric care, on female populations. Highlighting the important role of women in the global economy, especially in sub-Saharan Africa, the report offered an agenda to promote research and health policies to improve women’s health in developing nations (IOM, 1996e).

In 2001, the IOM reviewed brain disorders and mental health challenges in developing nations in its report Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Focusing on developmental disabilities, epilepsy, schizophrenia, bipolar disorder, depression, and stroke, the committee highlighted “negative attitudes, prejudice, and stigma”

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⁸⁶ Stuart Bondurant was a Professor of Medicine and the Dean Emeritus at the University of North Carolina at Chapel Hill when this report was released.

⁸⁷ Charles P. O’Brien was the Kenneth E. Appel Professor of Psychiatry, the Vice-Chair of Psychiatry, and the Director of the Center for Studies of Addiction at the University of Pennsylvania Perelman School of Medicine in Philadelphia during this time.

⁸⁸ Maureen Law was the Director General of the Health Sciences Division at the International Development Research Centre in Ottawa, Ontario, Canada, when this report was published.

as barriers to ensuring adequate diagnosis, treatment, and care for these often neglected conditions. The committee, which was co-chaired by external volunteers Assen Jablensky⁸⁹ and Richard Johnson,⁹⁰ proposed specific strategies to reduce the burden of brain disorders and mental health, emphasizing the need for increased awareness among health care providers and the public (IOM, 2001g). In 2003, the Fogarty International Center of the NIH announced a new research program called Brain Disorders in the Developing World: Research Across the Lifespan. The program was designed to support international collaborations to study brain disorders in developing countries, and in its first decade, the program “awarded more than 150 grants totaling about $85 million” (Fogarty International Center, 2014).

Cancer—another often-neglected health concern in developing countries—was reviewed in the IOM’s 2007 report, Cancer Control Opportunities in Low- and Middle-Income Countries. In its review, the committee concluded that “more people die from cancer in [low- and middle-income] countries than from AIDS and malaria combined” and that cancer is often overlooked as a health concern by foundations, international health organization, and government aid agencies (IOM, 2007k). In the report, the committee, which was chaired by NAM member and Councilor (1990–1992) Frank A. Sloan,⁹¹ described opportunities to improve screening and treatment efforts for highly curable types of cancers such as leukemias, lymphomas, and retinoblastoma, which often occur in childhood. It also underscored the need for palliative care and reviewed options to prevent cancer in developing countries, such as suppressing increasing rates of smoking and increasing vaccination rates for hepatitis B and human papillomavirus.

ENVIRONMENTAL HEALTH

As defined by the American Public Health Association, environmental health is a broad sub-discipline within public health that considers the connections and interactions between humans and their environment. Programs and policies in environmental health are typically dedicated “to reduc[ing] chemical and other environmental exposures in air, water, soil and food to protect people and provid[ing] communities with healthier environments” (APHA, n.d.). Throughout its existence, the IOM recognized the importance of environmental health in ensuring and improving the health of populations in the United States and across the globe. Over the years, the organization studied topics related to occupational health and safety, including advising the military on hazardous exposures and advising the National Institute of Occupational Safety and Health on personal protective equipment (see Chapter 4). The IOM also examined lead in the environment, indoor air quality, environmental risk factors for cancer, climate change, and natural disasters.

In the early 1990s, the Board on International Health (later renamed the Board on Global Health) proposed an international symposium and series of workshops to examine lead in the environment and possible health risks in the Americas. Lead was selected as the area of focus because at the time lead poisoning was “thought to be one of the most serious diseases of environmental and occupational origin because of its high prevalence, environmental pervasiveness, and persistence of toxicity in affected populations” and it “is also an entirely preventable disease” (IOM, 1996f, p. 15). This topic was also selected, in part, due to increasing trade between the United States and Mexico and associated concerns related to transport of goods and waste across borders. The IOM came together with the National Institute of Public Health of Mexico to plan and execute work-

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⁸⁹ Assen Jablensky was a Professor in the Department of Psychiatry at the University of Western Australia, Perth, when this report was published.

⁹⁰ Richard Johnson was a Professor in the Department of Neurology and the Co-Chair of the Department of Microbiology and Neurosciences at the John Hopkins University School of Medicine in Baltimore, Maryland, during this time.

⁹¹ Frank A. Sloan was at the Center for Health Policy, Law & Management at Duke University in Durham, North Carolina, when this report was released.

shops in 1994 and 1995. The resulting workshop report, Lead in the Americas: A Call for Action, noted that symposium participants concluded that “for many populations in the Americas, human exposure to lead is excessive, produces disease, and must be reduced” (IOM, 1996f, p. 23). The report also provided a nine-step action plan and a series of recommendations designed to achieve primary prevention of lead poisoning wherever possible (e.g., removing lead from gasoline, limiting/eliminating workplace exposures), emphasize sustainable solutions, and implement surveillance strategies to monitor progress.

The IOM, and subsequently the HMD, also took an interest in how indoor air quality affected health due to the effects of allergens, microbes, and other chemical and biological substances that are found in indoor environments. In 2000, the IOM released Clearing the Air: Asthma and Indoor Air Exposures. Highlighting overall increases in the prevalence of asthma and asthma-related hospitalizations and deaths during the previous decades, the committee, which was chaired by NAM member Richard B. Johnston, Jr.,⁹² reviewed the possible influence of indoor exposure to irritants on asthma, including pests (e.g., dust mites, cockroaches), mold and moisture, pet dander, secondhand smoke (e.g., cigarettes), and other biological and chemical pollutants (IOM, 2000e). Indicating that “asthma mortality is disproportionately high among African Americans and in urban areas that are characterized by high levels of poverty and minority populations” (p. 1), the committee indicated that “identifying effective means to address prevalent exposure” (IOM, 2000e, p. 17) for these vulnerable populations should be a top priority.

In 2004 the IOM followed up on Clearing the Air with a related report called Damp Indoor Spaces and Health. The report included a comprehensive literature review that confirmed that there was sufficient evidence to support a linkage between “damp indoor environments and some upper respiratory tract symptoms, coughing, wheezing, and asthma symptoms” in sensitive populations (IOM, 2004f). The committee, which was chaired by external volunteer Noreen M. Clark,⁹³ called for additional research on limiting moisture and eliminating mold in indoor environments in order to aid in developing standardized assessment methods and a better understanding of potential impacts on health outcomes (IOM, 2004f). Following the release of the IOM’s report, the WHO issued a new public health guidelines document called Guidelines for Indoor Air Quality: Dampness and Mould, which heavily cited the IOM report and adopted the IOM committee’s health classification scheme (WHO, 2004).

Continuing its work on indoor air and indoor environments, the IOM released a report in 2011 called Climate Change, the Indoor Environment, and Health. In the report, the committee investigated how climate change could potentially reshape indoor environments and how those alterations could, in turn, affect human health. The committee, which was chaired by external volunteer John D. Spengler,⁹⁴ concluded that climate change could exacerbate existing indoor environmental concerns (e.g., air quality, dampness and moisture, thermal stress, ventilation, energy consumption, weatherization, existence of infectious agents and pests) and could also introduce new challenges (IOM, 2011i). The report urged the Environmental Protection Agency (EPA) and other government stakeholders to establish building codes that account for climate charge; to update testing standards for emissions from building materials and furnishings; and to better educate the public, health care providers, and building professionals on potential risks and how to mitigate them. In response, the

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⁹² Richard B. Johnston, Jr., was a Professor in the Department of Pediatrics at the University of Colorado School of Medicine and the National Jewish Medical and Research Center in Denver when this report was released.

⁹³ Noreen M. Clark was the Dean, the Marshall H. Becker Professor of Public Health, and a Professor of Pediatrics at the University of Michigan in Ann Arbor when this report was released.

⁹⁴ John D. Spengler was the Akira Yamaguchi Professor of Environmental Health and Human Habitation in the Department of Environmental Health at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, during this timeframe.

EPA issued a new request for applications for research addressing climate change, indoor environments, and health.⁹⁵

Following the creation of the NAM and the HMD in 2015, the HMD was involved in a report called Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings in 2017. The study, which was chaired by NAS member Joan Wennstrom Bennett,⁹⁶ was a collaborative effort across the National Academies that included several divisions and boards. The report estimated that people living in developed countries spend upward of 90 percent of their time indoors—from homes to cars and public transportation to workplaces and places of entertainment (e.g., restaurants, movie theaters, stores). Ever present in these environments are microorganisms (e.g., viruses, bacteria, fungi) that are spread by humans and animals, which contribute to indoor microbiomes. However, the committee concluded that little is known about how these microbiomes affect health, what constitutes a healthy indoor environment, or how improvements can be made to these environments (e.g., modifications to ventilation, building materials, furnishings) to ensure health (NASEM, 2017k). The report presented a 12-part research agenda to help better understand interactions across humans, microbiomes, and indoor environments and to help realize the committee’s “vision in which these interactions can be predicated and managed so as to design, operate, and maintain more healthful buildings” (NASEM, 2017l, p. 4).

In addition to its work on indoor environments, the IOM also considered how environmental factors can contribute to cancer risks. In May 2001, the IOM’s Roundtable on Environmental Health Sciences, Research, and Medicine (described below) held a workshop that resulted in a publication called Cancer and the Environment: Gene–Environment Interaction (IOM, 2002a). During the workshop, presenters and attendees examined how environmental factors such as chemicals, radiation and sun exposure, pollutants, and diet interact with an individual’s genes to determine their cancer risk profile. In 2012, the IOM followed up with a consensus study called Breast Cancer and the Environment: A Life Course Approach, which reviewed evidence related to specific environmental risk factors for breast cancer (e.g., radiation, smoking and alcohol use, postmenopausal hormone replacement therapy, weight gain, exposure to pesticides and other chemicals) over the life course (IOM, 2012b). The committee, chaired by external volunteer Irva Hertz-Picciotto,⁹⁷ presented 13 research-oriented recommendations that, if implemented, could lead to a better understanding of the underlying environmental risk factors for breast cancer and how these risk factors might be mitigated. As a result of the report, the Susan G. Komen organization announced $4.5 million in new research grants to examine environmental exposures and links to breast cancer.⁹⁸

In 1998, the IOM’s launch of the Roundtable on Environmental Health Sciences, Research, and Medicine created a long-term home for ongoing environmental health discussions among researchers, policy makers, government officials, industry partners, health care professionals, and other interested stakeholders. During its two decades of operation, the roundtable held nearly 70 meetings and released almost 30 publications with a recurring theme of sustainability and climate change. Through its work, the roundtable also responded to emergent environmental concerns (NASEM, n.d.x). For example, 2 months after Hurricane Katrina devastated New Orleans and the Gulf Coast region, the roundtable hosted a workshop to review the “status of the recovery effort …, consider the ongoing challenges in the midst of a disaster …, and facilitate scientific dialogue to understand the impacts of Hurricane Katrina on people’s health” (IOM, 2007l, pp. xi, 68; see Figure 6-5). The workshop resulted in a 2007 publication called Environmental Public Health Impacts of Disasters:

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⁹⁵ Impact of IOM Reports (Database), IOM/NAM Records.

⁹⁶ Joan Wennstrom Bennett was a member of the National Academy of Sciences who was affiliated with Rutgers University at the time.

⁹⁷ Irva Hertz-Picciotto was a Professor and the Chief of the Division of Environmental and Occupational Health at the University of California, Davis, when this report was published.

⁹⁸ Impact of IOM Reports (Database), IOM/NAM Records.

Hurricane Katrina: Workshop Summary. As the roundtable evolved, the focus of its work became more global, and included discussions related to “nanotechnology, the interrelationship between trade and health, and corporate social responsibility in environmental health” (NASEM, n.d.x).

In 2020, the effects of climate change on human health became a priority focus area for the NAM through its Grand Challenge on Climate Change and Human Health (see Chapter 7).

PROTECTING HEALTH IN AN INTERCONNECTED WORLD

The IOM’s early interest in population and public health beyond the borders of the United States led IOM President David Hamburg to include a Board on International Health in his operating structure for the IOM in 1978 (see Chapter 2). Despite intermittent funding challenges and varying levels of commitment across administrations—for example, the board, which was eventually renamed the Board on Global Health, was temporarily dissolved in 1987 and then reinstated in 1989—global health eventually became a mainstay within the IOM’s portfolio and was carried forward as part of the NAM’s mission in 2015. During a 2001 review of the Board on Global Health, Hamburg, who served on the review committee, noted that “the globalization of the economy, science, popular culture and other domains” reinforced the “importance of thinking about human health from a global perspective.”⁹⁹ The committee tasked with reviewing the board recommended that global health be infused throughout the work of all of the IOM boards and that the Board on Global Health be reconfigured to include expertise in infectious disease, vaccines for developing countries, and general global health.¹⁰⁰

U.S. Leadership and Investment in Global Health

One of the roles the Board on Global Health fulfilled over the years was developing reports to advise the federal government on the role of the United States and its investment strategies in global health. The first time the board stepped into this advisory function was during the Carter administration, when Congress requested an IOM study “to determine opportunities, if any, for broadened programs in areas of international health.” The board’s first report, Strengthening U.S.

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⁹⁹ “Report of the Visiting Committee on Global Health,” April 9, 2001, IOM/NAM Records.

¹⁰⁰ Board on International Health Meeting, Minutes, January 17–18, 1989, Yordy Files, IOM/NAM Records.

Programs to Improve Health in Developing Countries, was released in 1978. The report concluded that “the current base of knowledge and experience provides the possibility of ameliorating many [health] problems by commitments of realistic amounts of resources by both developing countries and economically advanced countries” (IOM, 1978).

Nearly two decades later the IOM released America’s Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests in 1997. In its report, the committee, which was co-chaired by NAM/NAS member and Councilor (1993–1998) Barry R. Bloom¹⁰¹ and future IOM President and NAM member Harvey V. Fineberg,¹⁰² concluded that the world was becoming more interconnected and that “distinctions between domestic and international health problems are losing their usefulness and are often misleading” (IOM, 1997c). Because diseases and health issues transcend borders, collaborative, international actions were needed. The committee recommended decisive action from the United States to promote global health. The committee indicated that supporting global health was necessary in order to sustain the population health, economic status, and security of the United States in the long term.

With a new administration arriving in the White House, the IOM released The U.S. Commitment to Global Health: Recommendations for the New Administration in 2009. The report was expressly developed to advise the Obama administration and Congress on future U.S. investments in global health. The committee, which was co-chaired by external volunteer Thomas R. Pickering¹⁰³ and NAM/NAS member Harold Varmus,¹⁰⁴ called on the administration to “highlight health as a pillar of U.S. foreign policy” and urged Congress to double funding for global health initiatives (IOM, 2009f). Following briefings from committee members, the Obama administration’s 2010 global health initiative strategy document reflected close adherence to the report’s recommendations.¹⁰⁵ In 2014, the IOM assessed U.S. investments in health systems abroad in a report called Investing in Global Health Systems: Sustaining Gains, Transforming Lives. In its review, the committee, which was co-chaired by external volunteers John E. Lange¹⁰⁶ and E. Anne Peterson,¹⁰⁷ concluded that “prompt and judicious investment in the management, financing, and infrastructure that support health could have a transformative effect on the lives of the world’s billion poorest people and build a more stable world for everyone” (IOM, 2014e). Through its recommendations, the committee outlined “an effective donor strategy for health.”

Continuing its tradition of providing guidance to incoming presidents, the IOM released Global Health and the Future Role of the United States as the Trump administration was set to take office in 2017. The report noted the benefits of international travel and trade, such as expanded access to goods, but also provided words of caution related to the spread of infectious diseases on a global scale. In light of the current global health landscape and the identified challenges, the committee, which was co-chaired by external volunteer Jendayi E. Frazer¹⁰⁸ and NAM member Valentín Fuster,¹⁰⁹ described four priority areas that offered the greatest potential for improving global

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¹⁰¹ Barry R. Bloom was at the Howard Hughes Medical Institute of the Albert Einstein College of Medicine during this time.

¹⁰² Harvey V. Fineberg was the Dean of the faculty of public health at Harvard University at the time.

¹⁰³ Thomas R. Pickering was the Vice Chair of Hills & Company, International Consultants in Washington, DC, at the time.

¹⁰⁴ Harold Varmus was the President and the Chief Executive Officer of Memorial Sloan Kettering Cancer Center in New York when this report was released.

¹⁰⁵ Impact of IOM Reports (Database), IOM/NAM Records.

¹⁰⁶ John E. Lange was a retired U.S. Ambassador and a Senior Fellow for Global Health Diplomacy at the United Nations Foundation at this time.

¹⁰⁷ E. Anne Peterson was the Director of the Public Health Program at the Ponce School of Medicine and Health Sciences when this report was released.

¹⁰⁸ Jendayi E. Frazer was with the Council on Foreign Relations in Washington, DC, during this time.

¹⁰⁹ Valentín Fuster was at the Mount Sinai Medical Center in New York when this report was published.

health: achieve global health security, maintain a sustained response to the continuous threats of communicable diseases, save and improve the lives of women and children, and promote cardiovascular health and prevent cancer (NASEM, 2017n).

During the first year of the COVID-19 pandemic, policies under the Trump administration limited international cooperation and ran counter to the recommendations of the studies described in this section, prompting NAM members and leadership to speak out more boldly on behalf of U.S. leadership in global health than they had in the past (see Chapter 7).

The Safety of Food and Medical Products

As global trade expanded, concerns regarding the safety of food and medical products that are imported into the United States increased. For example, much of the seafood consumed in the United States originates in Southeast Asian countries, and many of the active ingredients found in American medications come from other countries. Less stringent regulatory systems outside of the United States, combined with limitations in inspecting these products as they are imported, pose ongoing risks to U.S. consumers (IOM, 2012l). In 2012, the IOM released Ensuring Safe Foods and Medical Products Through Stronger Regulatory Systems Abroad, which was developed to help the FDA navigate these challenges. In its report, the committee, which was chaired by NAM member Jim E. Riviere,¹¹⁰ offered strategies and recommendations to bolster regulatory environments globally and ensure safer foods and medical products in the United States and worldwide. It encouraged the FDA to be a global leader “in the development and adoption of international standards for food and medical products” (IOM, 2012l, p. 238).

The IOM continued its review of medication safety in an interconnected world in its 2013 report, Countering the Problem of Falsified and Substandard Drugs. Substandard and falsified drugs can be sold in any country, but low- and middle-income countries with limited regulatory and safety standards and oversight are most vulnerable. The committee, which was chaired by NAM member Lawrence O. Gostin,¹¹¹ stated that “eradicating falsified and substandard drugs from the market will require strong national regulation and international cooperation.” The report provided a dozen recommendations for the United States to provide leadership in areas such as building global partnerships, adopting agreed-upon definitions, and establishing a code of practice; strengthening surveillance and detection efforts, including use of detection technologies; and ensuring compliance with international standards for manufacturing and quality control (IOM, 2013q). Implementing one of the recommendations from the report, the FDA launched an initiative in Ghana in 2013 to expand the availability of a handheld device used to detect falsified malaria drugs (CBS News, 2013).¹¹²

Infectious Diseases and Emerging Health Threats

The global spread of infectious disease has been a topic of interest for the IOM and many other international health organizations for decades. This threat has been amplified in recent years with the increasing prevalence of international travel; concerns regarding drug-resistant diseases (e.g., tuberculosis [TB], malaria); and outbreaks, epidemics, and pandemics of emerging infectious diseases without well-defined, effective treatments (e.g., Ebola, Zika, COVID-19). In the past 25 years,

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¹¹⁰ Jim E. Riviere was the Burroughs Wellcome Fund Distinguished Professor of Pharmacology and the Director of the Center for Chemical Toxicology Research and Pharmacokinetics at the College of Veterinary Medicine at North Carolina State University in Raleigh during this time.

¹¹¹ Lawrence O. Gostin was the Linda and Timothy O’Neill Professor of Global Health Law and the Director of the World Health Organization Collaborating Centre on Public Health Law and Human Rights at the Georgetown University Law Center in Washington, DC, when this report was released.

¹¹² IOM Council Minutes, July 8, 2013, IOM/NAM Records.

the IOM, and subsequently the NAM and the HMD, leveraged its reputation for providing reliable evidence-based advice and expanded its presence in global health policy by focusing a subsection of its work on preventing and responding to these emerging health threats in a timely manner.

In 1989, the IOM initiated a study to “assess the interactions between etiologic agents, environmental effects on disease, and host defenses to understand factors related to emergence of microbial disease.”¹¹³ In 1992, the resulting report, Emerging Infections: Microbial Threats to Health in the United States, was released (IOM, 1992b). It explored the spread of infectious diseases such as HIV/AIDS, Lyme disease, malaria, TB, and dengue in context of “human demographics and behavior, technology and industry, economic development and land use, international travel and commerce” (IOM, 1992b). The committee, which was co-chaired by NAS member Joshua Lederberg¹¹⁴ and external volunteer Robert E. Shope,¹¹⁵ cautioned against complacency and provided recommendations related to “disease surveillance; vaccine, drug, and pesticide development; vector control; public education and behavioral change; research and training; and strengthening of the U.S. public health system” (NASEM, n.d.f1).

The release of the report was met with considerable media attention, in part, due the fear-based messaging associated with the report. In conjunction with the report’s release, the IOM hosted a press conference, and the co-chairs and members of the committee participated in numerous interviews with the media to communicate the report’s findings and recommendations, indicating that microbial “threat[s] will continue and may even intensify in coming years” (IOM, 1992b, p. 1). A feature article in The New Yorker called the IOM report “frightening,” noting that “new diseases will emerge, although it is impossible to predict their individual emergence in time and place” (Preston, 1992). A New York Times article called the report a “wake up call” and highlighted the inadequacy of public health surveillance systems “to detect threats from new diseases and the reemergence of old ones” (Altman, 1992).

The 1992 report ultimately led to the establishment of a new section within the U.S. military’s Armed Forces Health Surveillance Branch called the Department of Defense–Global Emerging Infections Surveillance. In a 1996 directive announcing the new section, President Bill Clinton stated that “the mission of the DoD will be expanded to include support of global surveillance, training, research, and response to emerging infectious disease threats. DoD will strengthen its global disease reduction efforts through: centralized coordination, improved preventive health programs and epidemiologic capabilities; and enhanced involvement with military treatment facilities and overseas laboratories” (IOM, 2001h, p. 2). Several years later, the IOM, through its Medical Follow-up Agency (see Chapter 4), was asked to conduct a review of the program. In response, the IOM released a report in 2001, Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review, which concluded that “substantial progress has been made toward achieving system goals” (IOM, 2001h).

In 2003, nearly a decade after the release of the first Microbial Threats report, the IOM released a follow-up report titled Microbial Threats to Health: Emergence, Detection, and Response. Reassessing the state of research and international policy, the report described a recent SARS outbreak to illustrate the potential hazards of the global transmission of infectious diseases. The committee, which was co-chaired by NAM member and Foreign Secretary (2014–2020) Margaret A.

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¹¹³ Board on Health Sciences Policy, “Microbial Threats to Health,” September 12, 1989, IOM/NAM Records.

¹¹⁴ Joshua Lederberg was a University Professor and a Sackler Foundation Scholar at The Rockefeller University in New York during this time.

¹¹⁵ Robert E. Shope was a Professor of Epidemiology and the Director of the Yale Arbovirus Research Unit at the Yale University School of Medicine in New Haven, Connecticut, when this report was published.

Hamburg¹¹⁶ and Joshua Lederberg,¹¹⁷ offered recommendations designed to enhance the global capacity to detect and respond to threats. Reinforcing recommendations from previous reports, the committee called for the development of new vaccines and treatments for infectious diseases and emphasized the need to strengthen the domestic public health and surveillance infrastructure (IOM, 2003i). Shining a light on another form of microbial threat, the IOM released a report called Sustaining Global Surveillance and Response to Emerging Zoonotic Diseases in 2009. Zoonotic diseases—those that can be transmitted between animals and humans (e.g., SARS, HIV/AIDS, H1N1 [swine flu], mad cow disease)—present unique challenges as they are generally “novel and unpredictable,” they can “emerge anywhere and spread rapidly,” and they tend to have a “major economic toll” (IOM and NRC, 2009b). In its report, the committee, which was co-chaired by NAM member Gerald T. Keusch¹¹⁸ and external volunteer Marguerite Pappaioanou,¹¹⁹ reviewed existing surveillance systems that could detect zoonotic diseases and provided recommendations to improve early identification and response, while encouraging greater collaboration and coordination across human and animal health researchers and policy makers. The report was cited as an influence for a new Emerging Pandemic Threats program that was launched by the U.S. Agency for International Development program in 2009.¹²⁰

Following the release of the IOM’s 1992 Microbial Threats report, the IOM launched the Forum on Emerging Infections in 1996 (later renamed the Forum on Microbial Threats) at the request of the CDC and the NIH. The forum was established “to provide a structured opportunity for discussion and scrutiny of critical, and possibly contentious, scientific and policy issues related to research on and the prevention, detection, surveillance, and responses to emerging and reemerging infectious diseases in humans, plants, and animals, as well as the microbiome in health and disease.” With the support of its nearly 20 sponsors, the Forum on Microbial Threats held more than 45 public meetings and workshops on a wide variety of topics that built on the themes and recommendations from the previous reports. In 2008, for example, the forum hosted a workshop on “Infectious Disease Movement in a Borderless World.” Because of the ongoing nature of the forum and its ability to set its own agendas, the forum was also able to respond to emerging global concerns in a timely manner. For example, the forum hosted a discussion meeting and workshop on the H1N1 influenza pandemic in 2009 and a workshop on the Ebola epidemic in West Africa in 2015 (NASEM, 2016j). In 2015, the forum collaborated with the NAM to host a workshop that resulted in a summary called Global Health Risk Framework: Governance for Global Health: Workshop Summary (NASEM, 2016l), which contributed to the NAM’s Global Health Risk Framework Program (see Chapter 7).

In addition to its broad review of infectious diseases and emerging global health threats, the IOM also concentrated a segment of its work on specific mosquito-borne diseases such as malaria and Zika, and other infectious diseases, such as TB. The evolution and transmission of drug-resistant variants of these diseases have complicated global public health strategies to contain and treat them. In 1991, the IOM released its first report on malaria—Malaria: Obstacles and Opportunities—which described a resurgence of the disease with cases identified in more than 100 countries. The report indicated that malaria had become the top health challenge for sub-Saharan Africa, with more than 1 million deaths per year and rapidly increasing rates of drug-resistant cases. The com-

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¹¹⁶ Margaret A. Hamburg was the Vice President for Biological Programs at the Nuclear Threat Initiative during this time.

¹¹⁷ Joshua Lederberg was a Professor Emeritus and a Sackler Foundation Scholar at The Rockefeller University when this report was released.

¹¹⁸ Gerald T. Keusch was at Boston University at the time.

¹¹⁹ Marguerite Pappaioanou was at the Association of American Veterinary Medical Colleges in Washington, DC, at the time this report was published.

¹²⁰ Impact of IOM Reports (Database), IOM/NAM Records.

mittee, which was chaired by external volunteer Charles C. J. Carpenter,¹²¹ provided a comprehensive review of the state of malaria research, prevention, and control efforts, highlighting concerns with increasing rates of drug-resistant strains of the parasites that cause malaria (P. falciparum and P. vivax) and insecticide-resistant strains of mosquitoes. The committee recommended increased support for research and surveillance, and urged expanded collaboration to develop vaccines, new treatments, and better control options (IOM, 1991c). A 1996 IOM report, Vaccines Against Malaria, reiterated the urgent need for a malaria vaccine, stating that the successful development and widespread application of a vaccine that can prevent the illness and death of malaria could be one of the most important advances in medicine, with the potential for improving the lives of hundreds of millions of people (IOM, 1996g).

Nearly a decade later, the IOM released a follow-up report in 2004 called Saving Lives, Buying Time: The Economics of Malaria Drugs in an Age of Resistance, which made recommendations to expand access to new, more effective combination treatments in countries where the disease was endemic. In its report, the committee, which was chaired by NAS member Kenneth J. Arrow,¹²² concluded that without funding to supply these new treatments, “malaria mortality could double over the next 10–20 years and transmission will intensify” (IOM, 2004g). The report’s central recommendation became a reality in 2009, when private and public donors, including the Bill & Melinda Gates Foundation and the World Bank, collaborated to establish the Affordable Medicines Facility-malaria, which is managed through the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Affordable Medicines Facility-malaria was developed as a financing program with an initial budget of $225 million to expand access to affordable and high-quality therapies.¹²³ Through its African Science Academy Development Initiative (see Chapter 4), the IOM was also able to support other countries in improving their responses to malaria; one example of this was the Cameroon Academy of Sciences’ 2004 report Drug Resistance to Anti-Malaria Drugs in Cameroon: Strategies for Control.¹²⁴

In addition to malaria, the IOM also considered the global impact of drug-resistant TB. For example, the IOM’s Forum on Drug Discovery, Development, and Translation examined the threat of drug-resistant variants of TB and possible responses in a series of six workshop summaries. As part of its series, which was released between 2009 and 2014 (see Box 6-7), the forum collaborated with the academies of sciences in South Africa, Russia, India, and China to host workshops in each of those countries. Through its joint workshops, the forum estimated that TB killed about 4,500 people every day, making TB the leading cause of death worldwide (IOM, 2009d). The presenters and participants at these international workshops discussed a range of topics that included the “increasing burden of drug-resistant tuberculosis,” the “new challenges to traditional TB control and treatment programs” that drug-resistant TB presented, and the urgent need for “the global health community to collaborate and share scientific information in new and different ways,” as well as country-specific experiences and needs in managing drug-resistant TB locally (IOM, 2012p, p. 129).

Following the rapid transmission of the Zika virus—a mosquito-borne illness associated with a specific mosquito species (Ae. aegypti and Ae. albopictus)—across 26 countries in the Americas, HHS called on the National Academies in 2015 to help define “future research that could be conducted under real-world conditions … that would provide … additional accurate information about virus transmission, mitigation of health risks, and appropriate measures to prevent the spread

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¹²¹ Charles C.J. Carpenter was a Professor of Medicine at Brown University and the Physician-in-Chief at the Miriam Hospital in Providence, Rhode Island, when this report was released.

¹²² Kenneth J. Arrow was a Professor Emeritus in the Department of Economics at Stanford University in Stanford, California, during this time.

¹²³ Impact of IOM Reports (Database), IOM/NAM Records.

¹²⁴ IOM Council Minutes, October 21, 2014, IOM/NAM Records.

of disease” (NASEM, 2016k; see Figure 6-7). In response, the HMD hosted a fast-track, 1-day workshop in February 2016 that brought together experts and stakeholders to discuss factors that could reduce the risk of transmission in the United States, knowledge gaps related to prevention strategies, specific high-priority research questions, and opportunities to improve evidence-based communication regarding risk factors, transmission mechanisms, prevention measures, and health consequences (NASEM, 2016k). HMD published a workshop in brief that summarized the key points of discussion, reinforcing the National Academies’ ability to respond to emerging public health threats while maintaining its commitment to providing evidence-based advice.

Disaster Preparedness and Response

As with infectious diseases and emerging health threats, terrorism and natural disasters often have a global reach that requires varying degrees of international response and preparedness. Following the terrorist attacks of September 11, 2001, the IOM along with many government agencies and interested stakeholders, began reevaluating disaster preparedness plans. Weighing in on medical response plans, the IOM released Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program in 2002. HHS commissioned this study to help formulate mechanisms to evaluate the efficacy of HHS’s Metropolitan Medical Response System program, which provided large U.S. cities with assistance “in develop[ing] plans for coping with the health and medical consequences of a terrorist attack with chemical, biological, or radiological … agents” (IOM, 2002d). In its report, the committee, which was chaired by NAM member Lewis Goldfrank,¹²⁵ provided a set of program assessment tools that corresponded to a three-part evaluation strategy and preparedness indicators for specific response capabilities. The following year, the IOM released Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. The report considered the degree to which the U.S. public health infrastructure was adequately prepared to respond to the nation’s psychological needs following an attack. The committee, which was also chaired by Goldfrank, offered an array of recommendations that spoke to “the training

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¹²⁵ Lewis Goldfrank was the Director of Emergency Medicine at the New York University Medical Center and Bellevue Hospital Center in New York when this report was released.

and education of service providers, ensuring appropriate guidelines for the protection of service providers, and developing public health surveillance for pre-event, event, and post-event factors related to psychological consequences” (IOM, 2003j, p. 5).

During this timeframe, the IOM also considered preparedness and response plans for potential bioterrorism attacks, focusing on threats from agents such as smallpox and anthrax. In 2005, the IOM released The Smallpox Vaccination Program: Public Health in an Age of Terrorism, which was the culmination of 2 years of work and encompassed seven letter reports to the Director of the CDC. The purpose of the committee’s work, which was chaired by Brian Strom,¹²⁶ was to advise the CDC as it planned and implemented a national smallpox vaccination program that would be designed to “vaccinate people against a disease that does not exist with a vaccine that poses some well-known risks” in a “low-likelihood, high-consequence” bioterrorism attack scenario (IOM, 2005d, p. 1). Following the 2001 anthrax mailing attacks, the IOM also reviewed the safety of the currently available anthrax vaccine for wide-scale use in the military and possible public use in its 2002 report The Anthrax Vaccine: Is It Safe? (see Chapter 4). Because wide-scale implementation and use of the anthrax vaccine was not recommended or practical—in part because “it require[d] multiple initial doses followed by annual boosters”—preparedness and response plans for an anthrax attack also required plans to quickly deliver antibiotics to potentially large populations of exposed people. In 2012, the IOM released Prepositioning Antibiotics for Anthrax, which considered “the use of prepositioning strategies to complement current plans for distributing and dispensing anthrax antibiotics” (IOM, 2012m, p. 1). The committee, which was chaired by external

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¹²⁶ Brian Strom was the George S. Pepper Professor of Public Health and Preventive Medicine and a Professor of Biostatistics and Epidemiology, Medicine, and Pharmacology at the University of Pennsylvania Perelman School of Medicine in Philadelphia when this report was released.

volunteer Robert R. Bass,¹²⁷ provided a framework and seven recommendations to aid state and local policy makers and public health officials to determine what, if any, prepositioning strategies would be advantageous for their specific populations and communities.

Seeing the need for a permanent convening body to host ongoing discussions related to preparedness and response, the IOM established the Forum on Medical and Public Health Preparedness for Disasters and Emergencies in 2007. The forum’s stated mission was to “improve the nation’s preparedness for, response to, and recovery from disasters, public health emergencies, and emerging threats” (NASEM, n.d.z). Its wide focus included such topics as how emergency medical services should respond to a multisite terrorist attack and which strategies should be used to mitigate the Zika virus. Over the years, the forum hosted workshops related to rural mass casualty response, the distribution of antiviral medications, data priority needs in the wake of Hurricane Sandy, and the preparedness impacts of the ACA. As with other forums and roundtables, the goal of the forum was to provide a neutral space in which interested parties could come together to discuss timely issues with a dedicated focus on how best to prepare the country for medical and public health emergencies and disasters.

In 2009, the IOM launched a series of reports and workshop summaries that explored crisis standards of care that could be applied in disaster situations such as pandemics, natural disasters, and terrorist attacks—scenarios “in which thousands, tens of thousands, or even hundreds of thousands of people suddenly require and seek medical care in communities across the United States” (IOM, 2009e). The first report in the series was a letter report titled Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: Letter Report. In this report, the committee, which was chaired by Lawrence O. Gostin,¹²⁸ laid out its vision for crisis standards of care, including application of fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law (IOM, 2009e). The IOM’s next two reports were released in 2012 and 2013 and were called Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (2012) and Crisis Standards of Care: A Toolkit for Indicators and Triggers (2013). The 2012 report, which was produced by a committee also chaired by Gostin, consisted of seven volumes that provided detailed functions and tasks for various groups that would be engaged in crisis standards of care following a disaster (e.g., state and local governments, hospitals, first responders) (IOM, 2012n). The 2013 report—drafted by a committee co-chaired by external volunteers Dan Hanfling¹²⁹ and John L. Hick¹³⁰—explored possible indicators and triggers that could “help guide operational decision making about providing care during public health and medical emergencies and disasters” (IOM, 2013m). The Forum on Medical and Public Health Preparedness for Disasters and Emergencies continued the conversation about crisis standards of care with a parallel effort that included three workshops that featured discussions related to medical surge capacity and barriers to integrating crisis standards into international disaster response plans. Together, these publications were designed to guide policy makers, governments, health care systems, and other stakeholders in planning for disasters in which it “is necessary to provide the best possible health care during a crisis and, if needed, equitably allocate scarce resources” (IOM, 2013m).

The IOM’s series on crisis standards for care examined how communities could provide health care and social services during a crisis, but questions about what happens after a crisis and how communities and health systems recover and restore services required additional study. In 2015, the IOM released a report called Healthy, Resilient, and Sustainable Communities After Disasters. Not-

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¹²⁷ Robert R. Bass was with the Maryland Institute for Emergency Medical Services Systems when this report was published.

¹²⁸ Lawrence O. Gostin was at Georgetown University Law Center, Washington, DC during this timeframe.

¹²⁹ Dan Hanfling was with the Inova Health System in Falls Church, Virginia, when this report was released.

¹³⁰ John L. Hick was at Hennepin County Medical Center in Minneapolis, Minnesota, at the time.

ing that pre-disaster socioeconomic and health conditions in communities are not often optimal, the committee, which was chaired by NAM member Reed V. Tuckson,¹³¹ described disaster recovery as an opportunity to “advance the long-term health, resilience, and sustainability of communities—thereby better preparing them for future challenges” (IOM, 2015h). The committee also argued that ensuring health and well-being should be at the forefront of all disaster planning and recovery efforts. The committee’s report proposed a conceptual framework and 12 recommendations that provided operational guidance for stakeholders involved in disaster planning, such establishing a post-disaster vision for healthy communities and coordinating and leveraging available recovery resources to promote health.

CONCLUSION

From its earliest days, the IOM was committed to improving public health both within the United States and internationally. The organization played a key role in defining the field and mission of public health, as well as outlining the investments and infrastructure necessary for its successful practice. Advice from the IOM—and later the NAM and HMD—guided the national and global response to many of the most significant public health threats of the 20th and 21st centuries—including setting the initial research agenda for HIV/AIDS and later driving the expansion of PEPFAR, a historically impactful program that expanded access to HIV/AIDS prevention and treatment internationally. The IOM was also influential in promoting recognition of the global burden of chronic conditions such as cardiovascular disease and mental health and substance use disorders. Confronting the obesity epidemic in the United States was a particularly important area of focus for the IOM, and its recommendations were impactful, leading in particular to increased access to healthy foods (and decreased marketing of unhealthy foods) to children. Finally, the IOM, the NAM, and the HMD, arguing for the fundamental interconnectedness of health across borders, countries, and nations, were stalwart proponents of U.S. leadership and investment in global health—a position that gained new importance amid the COVID-19 pandemic and drove an related focus on environmental health and climate change, which threatened to increase the spread of novel infectious diseases.

Over five decades, the IOM, the NAM, and the HMD produced a sweeping body of work in the area of public health—with subjects ranging from individual infectious disease outbreaks to the worldwide burden of chronic illness, from recommendations for the implementation of specific U.S. programs to broader guidance about the future of public health and the necessity of international collaboration and coordination. Equity was a common theme across this work, as studies emphasized the importance of attention to health disparities and extending research and services to underserved populations. In sum, the organization made its mark both in the United States and internationally as a dedicated proponent of public health and an advocate for support of populations in need—building on the vision of its founders more than 50 years earlier.

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¹³¹ Reed. V. Tuckson was the Managing Director at Tuckson Health Connections, LLC, in Sandy Springs, Georgia, when this report was released.

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