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If It Ain't Broke...
IOM's Fineberg Gives Context To NIH Reorganization Advice

By Rich McManus

Photos: Bill Branson

On the Front Page...

Lest people think that the recent congressionally mandated Institute of Medicine report on the revitalization and reorganization of NIH was a new thing under the sun, IOM president Dr. Harvey Fineberg — who was here giving the seventh James A. Shannon Lecture on Oct. 1 — educated his Masur Auditorium audience that there have been at least 10 major reports on the organization of NIH since the mid-1950's. "All of them differ in detail, focus and time," he allowed, but all uncovered "a familiarity, a thematic repetition: NIH is doing an outstanding job; the scientific enterprise is critical to the nation and deserves support; and the current organization is largely sufficient" to meet NIH's mission.

Continued...

The most recent study, ordered by Congress in FY 2001, reaches many of the same conclusions as its predecessors and shares a common prejudice — that the proliferation of new institutes is something to be avoided. But because the forces shaping NIH are quadrilateral, Fineberg argued, including what NIH wants, what Congress wants, what outside advocacy groups want and what the scientific community wants, NIH sometimes ends up getting what it would rather not have. And the institution plunges forward.

Fineberg elaborated some of the past report findings and their results. Back in 1950, when NIH had 8 institutes and centers, it was recommended that there be no increase in the number of institutes. And in 1965, the Woodbridge report concluded that creating institutes to address disease categories was scientifically inappropriate, he recounted. "By 1976, NIH had 18 institutes and centers, most of them categorical," noted Fineberg.


Dr. Harvey Fineberg
A 1984 IOM report declared that there should be "a presumption against the creation of new institutes," he continued. "By 1990, the number of institutes and centers was up to 21. In the period from 1990 to 2000, the number grew to 27. What does that tell us? Maybe we shouldn't have bothered doing the study?"

Fineberg found it useful to return to former NIH director (1955-1968) James Shannon's founding principles, which resulted during his term of office in average annual budget increases of 26 percent, which, Fineberg noted, would have doubled the NIH budget every 3 years or less. "Shannon had a profound faith in the power of science, a powerful conviction that he was able to convey to all," Fineberg began. Shannon's avowed goals were to increase scientific efforts on all fronts in order to provide a broader base of understanding of health and disease. He held a loose rein, Fineberg explained, urging "bottom-up science" to flower by giving gifted investigators the freedom to follow their noses...when their creativity was unleashed, "wonderful things would and did happen.

"Shannon also had a remarkably close and productive relationship with key leaders in Congress, particularly Sen. Lister Hill and Rep. John Fogarty," continued Fineberg. With Capitol Hill on his side, Shannon took advantage of two other communities — the independent public advocates, which included such influential people as Mary Woodard Lasker and Florence Mahoney, and prominent extramural scientists such as Sidney Farber and Michael DeBakey. With these constituents largely in agreement, NIH had its power base of the future firmly established.

But this separation of powers assured that NIH would not operate like a corporation run by a board of directors, Fineberg explained. "Organizational decisions are not derived in the business-model way; where corporations report to their boards, NIH has committees of Congress."

Thus in 1968, the National Eye Institute became the first new institute that NIH had publicly opposed, "then it became part of the family." While NIH internally proposed the creation of what have become NIEHS and NHGRI, it had imposed upon it from without the NCCAM, Office of AIDS Research, Office of Research on Women's Health, and the breast cancer emphases within NCI, Fineberg stated. "The process of relations between the four key players is as much political as scientific."

Before embarking on its most recent study, IOM asked itself an important question: "What are the core principles in trying to make NIH not neater, but more effective?" said Fineberg. He proceeded to elaborate the report's nine major recommendations, the last of which touched upon structure; whether we close old institutes or open new ones, the decision should be preceded by long consideration with plenty of public comment. He then mentioned eight trends in science and the research enterprise that ought to be accommodated (revitalized clinical research, attention to health disparities, large scale multi-institute projects, expanded public/private relationships), virtually all of which have found themselves incorporated into NIH director Dr. Elias Zerhouni's new Roadmap initiative. "I am impressed to see the resonance between the roadmap and your recommendations — our 300 advisors must have been your advisors too," quipped the director, who came late to Fineberg's presentation because he was down on Capitol Hill preparing for the following day's major hearing on — restructuring NIH.

Dr. William I. Gay (l) and Fineberg enjoy a chat prior to the Shannon Lecture. Gay is past president of the NIH Alumni Association, which sponsors the annual lecture.

Fineberg concluded with the IOM report's 14 specific recommendations, falling into four major clusters, starting with "First, do no harm (in imposing structural change)...Don't make things worse." Again, the new roadmap initiative addresses most of the topics, but special emphasis is placed on NIH's intramural research program — it should be strengthened to assure its "excellence and distinctiveness," Fineberg reported.

He concluded, "NIH today has that special challenge, that special responsibility as the nation's biomedical research leader to forge within it that consensus that will strengthen its own ability to carry out the mission, and in the future enable it to be ever more effective as the steward of the public funds for biomedical progress. In the coming years, if the Congress does its job of overall funding, if it follows the committee's recommendations to establish greater stability for cross-cutting and high-gain initiatives through the set-asides, if it helps to provide stability and independence to the positions of the director and the institute directors, and if the NIH itself works not only within but also without to build the political partnerships, the scientific partnerships, and the coordination required throughout the government, then the promise can be fulfilled."

The full IOM report, Enhancing the Vitality of the National Institutes of Health: Organizational Change to Meet New Challenges, can be viewed at http://search.nap.edu/books/0309089670/html/.


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