NAS: speaking the truth to power for 150 years

Abstract

As the US National Academy of Sciences prepares to celebrate 150 years, Zoë Corbyn reflects on its history and achievements in public health and medicine, nationally and globally.The executive director of the US Institute of Medicine (IOM) doesn't have to think for long to find an example of the impact her organisation has had. “Now we take it for granted that when you go into hospital for surgery on your right side somebody marks your right side, but these things did not happen before”, says Judith Salerno. Salerno's “before” is the time preceding two landmark IOM reports: To Err is Human in 1999 and Crossing the Quality Chasm in 2001, which examined medical mistakes and the quality of patient treatment in the US health-care system, estimating that up to 98 000 people a year were dying as a result of preventable clinical errors. The reports, with their international reach, launched a new patient safety and quality movement, and catalysed a series of policies to address a hitherto hidden problem. When the IOM, the health arm of the US National Academy of Sciences (NAS), started the work it wasn't a popular cause, but the result transformed medicine. “That is our only job: to speak truth to power”, says Salerno.The NAS—a prestigious non-profit academy, unique in its structure as both an honorific society with an elected membership and a non-governmental consulting body—turns 150 years old this week. The Academy was signed into being by US President Abraham Lincoln in the midst of civil war on March 3, 1863, to “investigate, examine, experiment, and report upon any subject of science or art [technology]” whenever called upon to do so by any department of the government.Subsequently expanded to include the National Research Council (NRC) in 1916, the National Academy of Engineering (NAE) in 1964, and the IOM in 1970, the NAS today produces around 200 reports annually, drawing on the expertise of its members to provide independent and authoritative policy advice. Collectively the four organisations, which bring together the nation's top scientists, engineers, and health professionals, make up the US National Academies—with the NRC acting as the operating arm of the NAS and NAE when it comes to their advisory projects (the IOM undertakes its own using the same mechanisms).In health and medicine, NAS studies have underpinned some of the nation's most important scientific milestones such as uniform nutritional guidelines. They have also provided advice on some of the most crucial issues of the day, shaping policies on everything from HIV/AIDS to vaccine safety to the USA's new federal health-care law. Recent studies have covered topics from the use of chimpanzees in biomedical research to the future of nursing to the nation's obesity epidemic. Ongoing themes range from global health care to the effects of Agent Orange on war veterans. “There isn't a major public health issue in which the IOM has not been involved”, says Ruth Schwartz Cowan, emeritus professor of the history and sociology of science at the University of Pennsylvania, and one of three historians commissioned by the NAS to write its 150 year history. Schwartz Cowan calls the NAS America's “court of last resort” for controversial issues.“I can only hope that the NAS's honest efforts to be objective and non-partisan would make Lincoln proud and that he would see the NAS as useful”, says Ralph Cicerone, president of the NAS and chair of its NRC.Most NAS reports are undertaken at the request of, and paid for, by US federal government departments and agencies though they may also be requested and funded by others such as private foundations. The organisation also has a small endowment to initiate its own reports (To Err is Human was funded internally). The NAS drew in about US$330 million in 2011, about 85% of which came from federal government requests.NAS advice can give agencies “courage” to move ahead in directions they may be too tentative to otherwise go, as well as help shape their research agendas, says Alan Leshner, chief executive officer of the American Association for the Advancement of Science and an IOM member. As former director of the National Institutes of Health (NIH) National Institute on Drug Abuse, Leshner also has experience of commissioning NAS's services.To safeguard against bias and conflicts of interest, NAS uses a complex process of oversight. Sponsors have no role in the committees deliberations or recommendations.“The IOM doesn't always give you the answer you want”, notes Leshner. “But that independence adds to the credibility…there aren't very many [bodies] with that stamp.”“We go to the IOM when we are looking for a report from a source that is authoritative, above the political fray, and will be able to catch the attention of the nation”, says John Lumpkin senior vice president of the Robert Wood Johnson Foundation, which requests about one report a year.Stephen Hilgartner, an expert in science and technology studies at Cornell University, NY, has analysed how the organisation arrives at its advice. Many of the issues it addresses involve “complicated tangles of scientific facts, technical uncertainties, disagreement among experts, and conflicting values and interests” but it has a “long track record” of producing high-quality science advice, he says.It was not really until the first World War and the creation of the NRC for war preparedness that NAS started to become active in the areas of health and medicine. Much of that initial work centred on battlefield medicine with committees and subcommittees set up to advise on hygiene, shock, and transfusion before a 1919 peacetime reorganisation which saw the NRC Division of Medical Sciences created and the committees diversify.The second World War required a new focus. Influential NAS work from the period included helping oversee the development of penicillin for clinical use. Funding was also channelled to Alfred Kinsey who began working under the auspices of NRC's Committee for Research in Problems of Sex in 1941 and published his two famous book-length reports on human sexual behaviour in 1948 and 1953. “It was the first wide study of sexual behaviour”, says Schwartz Cowan, and hugely controversial.Other projects included studying the medical effects of the atomic bombings of Hiroshima and Nagasaki on the Japanese population. The Atomic Bomb Casualty Commission set up in 1947 and its follow-up Committees on Biological Effects of Atomic Radiation between them established the minimum dosages for radiation exposure that are used today.The NRC also established the Food and Nutrition Board in 1941, which is still part of the IOM today. “There is almost nothing about the Minimum Daily Requirements that has not passed through it”, says Schwartz Cowan.While today some health and medicine studies continue under the NRC, much of the NAS's work in the area is now under the banner of the IOM, which produces around 60–70 studies a year, consisting of consensus reports and reports from workshops and forums. Unique to the IOM compared with the other arms of the NAS is that at least 25% of members must come from outside the health and medicine arena. Experts at the IOM also include scientists, engineers, lawyers, and administrators.One highly influential report in the earlier history of the IOM was the 1986 report Confronting AIDS: Directions for Public Health, Health Care, and Research (which was followed up by further reports in 1988 and 1989). It was the first major examination of the disease, bringing the global issue to the forefront and pointing the US Government to what to do, explains Edward Berkowitz, a historian at George Washington University who has studied the NAS. “President Regan was very reluctant to talk about AIDS, so that put a tightening on the NIH and others that might have been expected to deal with it”, he explains, a chill the NAS with its independent structure and culture did not feel.Yet not everything the NAS recommends comes to pass. Recommendations have “at times languished”, admits Salerno. Sometimes reports aren't welcome. Other times those that request them, such as foundations, don't have the power or the resources for implementation. Sometimes it can just be a case of timing or perseverance, with positive responses not felt until years later.Nancy Adler, a professor of psychiatry at the University of California, San Francisco, and an IOM council member describes an IOM study she chaired on cancer care, dealing with the psychological and social needs of patients following a diagnosis. “We made a series of recommendations that didn't have earth shaking effects on health policy, but I have had people come up afterwards and say ‘that report changed how I practise medicine’”, she says.As to the future, while the NAS can doubtless look forward to another fruitful 150 years there are still challenges. Budgetary issues could loom large with the threat of US federal budget cuts. NAS doesn't receive a direct appropriation but across the board reductions could leave departments with less to spend on requests (though they may also want NAS to help sort through competing priorities). It is difficult to predict notes NAS president Cicerone but “overall we do expect some drop-off”.Cicerone and colleagues also continue to ponder another challenge as old as the NAS itself: how to increase the influence and impact of reports without straying into advocacy on behalf of causes. For Adler it is a case of making the clearest possible recommendations for policy makers. “The most effective reports are those that make very clear recommendations about who should do what and how—many do that but probably more could”, she says.Another challenge, notes IOM's Salerno, is having enough funding to undertake those studies that no one is asking the institute to do. There are many areas that need to be addressed from health literacy to personalised medicine, she says. And, she adds, “we are never done with an issue”.Abraham LincolnView Large Image Copyright © 2013 CorbisBombing of Hiroshima, 1945View Large Image Copyright © 2013 SuperStock/CorbisIOM's 1986 report on AIDSView Large Image Copyright © 2013 Institute of Medicine/National Academy of SciencesAlfred KinseyView Large Image Copyright © 2013 Bettmann/Corbis As the US National Academy of Sciences prepares to celebrate 150 years, Zoë Corbyn reflects on its history and achievements in public health and medicine, nationally and globally. The executive director of the US Institute of Medicine (IOM) doesn't have to think for long to find an example of the impact her organisation has had. “Now we take it for granted that when you go into hospital for surgery on your right side somebody marks your right side, but these things did not happen before”, says Judith Salerno. Salerno's “before” is the time preceding two landmark IOM reports: To Err is Human in 1999 and Crossing the Quality Chasm in 2001, which examined medical mistakes and the quality of patient treatment in the US health-care system, estimating that up to 98 000 people a year were dying as a result of preventable clinical errors. The reports, with their international reach, launched a new patient safety and quality movement, and catalysed a series of policies to address a hitherto hidden problem. When the IOM, the health arm of the US National Academy of Sciences (NAS), started the work it wasn't a popular cause, but the result transformed medicine. “That is our only job: to speak truth to power”, says Salerno. The NAS—a prestigious non-profit academy, unique in its structure as both an honorific society with an elected membership and a non-governmental consulting body—turns 150 years old this week. The Academy was signed into being by US President Abraham Lincoln in the midst of civil war on March 3, 1863, to “investigate, examine, experiment, and report upon any subject of science or art [technology]” whenever called upon to do so by any department of the government. Subsequently expanded to include the National Research Council (NRC) in 1916, the National Academy of Engineering (NAE) in 1964, and the IOM in 1970, the NAS today produces around 200 reports annually, drawing on the expertise of its members to provide independent and authoritative policy advice. Collectively the four organisations, which bring together the nation's top scientists, engineers, and health professionals, make up the US National Academies—with the NRC acting as the operating arm of the NAS and NAE when it comes to their advisory projects (the IOM undertakes its own using the same mechanisms). In health and medicine, NAS studies have underpinned some of the nation's most important scientific milestones such as uniform nutritional guidelines. They have also provided advice on some of the most crucial issues of the day, shaping policies on everything from HIV/AIDS to vaccine safety to the USA's new federal health-care law. Recent studies have covered topics from the use of chimpanzees in biomedical research to the future of nursing to the nation's obesity epidemic. Ongoing themes range from global health care to the effects of Agent Orange on war veterans. “There isn't a major public health issue in which the IOM has not been involved”, says Ruth Schwartz Cowan, emeritus professor of the history and sociology of science at the University of Pennsylvania, and one of three historians commissioned by the NAS to write its 150 year history. Schwartz Cowan calls the NAS America's “court of last resort” for controversial issues. “I can only hope that the NAS's honest efforts to be objective and non-partisan would make Lincoln proud and that he would see the NAS as useful”, says Ralph Cicerone, president of the NAS and chair of its NRC. Most NAS reports are undertaken at the request of, and paid for, by US federal government departments and agencies though they may also be requested and funded by others such as private foundations. The organisation also has a small endowment to initiate its own reports (To Err is Human was funded internally). The NAS drew in about US$330 million in 2011, about 85% of which came from federal government requests. NAS advice can give agencies “courage” to move ahead in directions they may be too tentative to otherwise go, as well as help shape their research agendas, says Alan Leshner, chief executive officer of the American Association for the Advancement of Science and an IOM member. As former director of the National Institutes of Health (NIH) National Institute on Drug Abuse, Leshner also has experience of commissioning NAS's services. To safeguard against bias and conflicts of interest, NAS uses a complex process of oversight. Sponsors have no role in the committees deliberations or recommendations. “The IOM doesn't always give you the answer you want”, notes Leshner. “But that independence adds to the credibility…there aren't very many [bodies] with that stamp.” “We go to the IOM when we are looking for a report from a source that is authoritative, above the political fray, and will be able to catch the attention of the nation”, says John Lumpkin senior vice president of the Robert Wood Johnson Foundation, which requests about one report a year. Stephen Hilgartner, an expert in science and technology studies at Cornell University, NY, has analysed how the organisation arrives at its advice. Many of the issues it addresses involve “complicated tangles of scientific facts, technical uncertainties, disagreement among experts, and conflicting values and interests” but it has a “long track record” of producing high-quality science advice, he says. It was not really until the first World War and the creation of the NRC for war preparedness that NAS started to become active in the areas of health and medicine. Much of that initial work centred on battlefield medicine with committees and subcommittees set up to advise on hygiene, shock, and transfusion before a 1919 peacetime reorganisation which saw the NRC Division of Medical Sciences created and the committees diversify. The second World War required a new focus. Influential NAS work from the period included helping oversee the development of penicillin for clinical use. Funding was also channelled to Alfred Kinsey who began working under the auspices of NRC's Committee for Research in Problems of Sex in 1941 and published his two famous book-length reports on human sexual behaviour in 1948 and 1953. “It was the first wide study of sexual behaviour”, says Schwartz Cowan, and hugely controversial. Other projects included studying the medical effects of the atomic bombings of Hiroshima and Nagasaki on the Japanese population. The Atomic Bomb Casualty Commission set up in 1947 and its follow-up Committees on Biological Effects of Atomic Radiation between them established the minimum dosages for radiation exposure that are used today. The NRC also established the Food and Nutrition Board in 1941, which is still part of the IOM today. “There is almost nothing about the Minimum Daily Requirements that has not passed through it”, says Schwartz Cowan. While today some health and medicine studies continue under the NRC, much of the NAS's work in the area is now under the banner of the IOM, which produces around 60–70 studies a year, consisting of consensus reports and reports from workshops and forums. Unique to the IOM compared with the other arms of the NAS is that at least 25% of members must come from outside the health and medicine arena. Experts at the IOM also include scientists, engineers, lawyers, and administrators. One highly influential report in the earlier history of the IOM was the 1986 report Confronting AIDS: Directions for Public Health, Health Care, and Research (which was followed up by further reports in 1988 and 1989). It was the first major examination of the disease, bringing the global issue to the forefront and pointing the US Government to what to do, explains Edward Berkowitz, a historian at George Washington University who has studied the NAS. “President Regan was very reluctant to talk about AIDS, so that put a tightening on the NIH and others that might have been expected to deal with it”, he explains, a chill the NAS with its independent structure and culture did not feel. Yet not everything the NAS recommends comes to pass. Recommendations have “at times languished”, admits Salerno. Sometimes reports aren't welcome. Other times those that request them, such as foundations, don't have the power or the resources for implementation. Sometimes it can just be a case of timing or perseverance, with positive responses not felt until years later. Nancy Adler, a professor of psychiatry at the University of California, San Francisco, and an IOM council member describes an IOM study she chaired on cancer care, dealing with the psychological and social needs of patients following a diagnosis. “We made a series of recommendations that didn't have earth shaking effects on health policy, but I have had people come up afterwards and say ‘that report changed how I practise medicine’”, she says. As to the future, while the NAS can doubtless look forward to another fruitful 150 years there are still challenges. Budgetary issues could loom large with the threat of US federal budget cuts. NAS doesn't receive a direct appropriation but across the board reductions could leave departments with less to spend on requests (though they may also want NAS to help sort through competing priorities). It is difficult to predict notes NAS president Cicerone but “overall we do expect some drop-off”. Cicerone and colleagues also continue to ponder another challenge as old as the NAS itself: how to increase the influence and impact of reports without straying into advocacy on behalf of causes. For Adler it is a case of making the clearest possible recommendations for policy makers. “The most effective reports are those that make very clear recommendations about who should do what and how—many do that but probably more could”, she says. Another challenge, notes IOM's Salerno, is having enough funding to undertake those studies that no one is asking the institute to do. There are many areas that need to be addressed from health literacy to personalised medicine, she says. And, she adds, “we are never done with an issue”.