He hastened to reassure these foundations that he had absorbed the many criticisms of the IOM and would take steps to remedy the problems. Under his leadership, he promised, the IOM would strive to complete its studies more quickly, with the goal of cutting in half the time necessary to complete studies. Using the IOM's convening power, he planned to bring together the parties interested in drug development and health technology assessment in order to facilitate communication among participants in these particular fields. Finally, Thier vowed to make the IOM more visible to the government, so that government agencies turned reflexively to it for advice.
Like his predecessors, Thier was a respected academic doctor who had produced more than 80 research papers in his chosen field of kidney function. More importantly, however, he had early shown a penchant for medical administration and proved himself to be a superior clinician. The son of a physician, Thier decided to follow his father's profession. Thier graduated from the State University of New York Upstate Medical Center at Syracuse in and then entered the elite echelons of the medical profession by taking his internship and residency at Massachusetts General Hospital in Boston.
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By , he had earned the coveted position of chief resident at Massachusetts General, which prepared him for a career in academic medicine that included positions as chief of the renal service at Massachusetts General and vice chairmanship of the Department of Medicine at the University of Pennsylvania. In , only 15 years removed from medical school, he became chairman of the Department of Medicine at Yale. Fellow doctors admired both his ability to respond to emerging trends in medicine and his clinical skills in diagnosis and treatment.
By the time Thier arrived at the Institute of Medicine at the end of , he had already played an active role in the organization's affairs and in medical affairs more generally. Just before coming to the IOM as president, Thier served as chairman of the American Board of Internal Medicine, the national body that set certification standards for doctors in internal medicine and its subspecialties.
Under his and William Kelley's leadership, the board had established the subspecialty of geriatrics.
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In addition, Thier held many appointments related to his academic position, such as chief of medical service at the Yale-New Haven Hospital and member of the editorial board of the New England Journal of Medicine. Too much energy, he said, had been expended on determining whether the IOM should be involved in health policy or the health sciences. He believed that it was not an either-or proposition, but that instead, the Institute should be responsible for what he described as "the entire spectrum of activities within the National Academy of Sciences NAS complex that deal with human health.
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At the same time, Thier realized that if these units were to be transferred to the IOM, the IOM would have to improve its ability to provide oversight on basic science issues by increasing the number of scientists on the IOM Council. Thier also took immediate steps to address the IOM's financial problems. With this additional money, no staff cutbacks would have to be instituted. More importantly, he convinced Press to grant the IOM a two-year grace period during which it would not be penalized for reasonable deficits.
As soon as Thier took over on a full-time basis at the beginning of , he made the rounds of foundations and appealed for core support. For many of the foundations, such as the Robert Wood Johnson RWJ Foundation, money for an endowment violated their action-oriented view of philanthropy. They wanted to solve specific, pressing problems at a time when people were increasingly turning to private charities, rather than to the government, for such solutions.
They had less interest in endowing institutions and giving them a free rein to run their own affairs.
Thier realized that the key to the effort was the Robert Wood Johnson Foundation because other foundations that specialized in health and medicine tended to follow RWJ's lead. Of all the foundations interested in medicine, RWJ had the most money at its disposal, enjoyed a close relationship with the Institute of Medicine, and played a key role in the formation of the Sproull committee. Of all the foundations, however, RWJ also had the most stringent rules for the accounting of funds and made very few grants to endow specific institutions. It preferred to run its own fellowship programs, often in conjunction with other institutions such as Johns Hopkins University and the Institute of Medicine, and to take a coordinated approach to the solution of a specific problem such as homelessness.
The foundation asked Thier to meet with a small subcommittee of its board in the fall of The meeting proved a considerable success. For the first time, the Institute of Medicine would be able to enjoy the benefits of an endowment that would yield substantial income each year. These significant new sources of income did not exempt the IOM from the usual sort of confrontation with the foundations.
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The Robert Wood Johnson Foundation, in particular, proved to be a demanding patron. Becoming very angry, Thier accused the foundation of not honoring its previous commitments. As a compromise, foundation officials suggested that RWJ pay half of the indirect costs and that the IOM pay the other half from its endowment funds. As Marion Ein Lewin, the IOM staff member who ran the fellowship program, explained, foundation officials regarded the endowment money as an ''unusual, generous grant'' that had served as seed money for other grants.
The foundation was also firmly against paying indirect costs.
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Thier refused to see it this way, insisting that the use of the endowment to defray indirect costs had never been a condition of the RWJ grant. IOM Council members expressed a reluctance to "disrupt relations" with a foundation that had been so generous to the IOM for so long. Thier, for his part, did not want to compromise on an important point "in order to placate a powerful donor. Despite these inevitable disagreements, the fact is that the IOM enjoyed unprecedented success in its outreach to foundations during the presidency of Samuel Thier.
One factor in this success was the surge in the stock market and the economic boom that occurred in the mid-to late s. After a sharp recession in the early s, economic conditions brightened. This meant that the value of the securities that foundations held in their portfolios increased, and because the foundations were required by law to spend a certain percentage of their income, the amount of money they awarded also increased.
For example, the Kellogg Foundation discovered at the end of fiscal year that it had "a significant overrun in income" that had to be spent by the end of the calendar year. Another factor in the IOM's fund-raising success was that the Reagan revolution appeared to have run its course.
Because the foundations were no longer quite so panicked about defining their role in an era of shrinking government, they felt able to make grants to their traditional clients such as the IOM. A third factor was the persistence and confidence with which Thier approached the foundations. Unlike Fred Robbins, who tolerated the fund-raising process because he recognized its importance and knew it was expected of him, Thier made fund-raising a priority and enjoyed the experience.
He excelled at reassuring the foundations that their money would be well spent and proved adept at creating a bandwagon effect, urging one foundation not to get left behind by another. From the day he took over as IOM president, he vowed to make an effort to distribute IOM reports in an organized fashion, beginning with the original proposal and extending through the evaluation of the final report's impact. The prenatal care study, designed to suggest ways of increasing the utilization of prenatal care by mothers early in their pregnancies, began in Headed by Joyce Lashof, dean of Berkeley's School of Public Health, it followed from the recommendations of the widely acclaimed report from the Fred Robbins's era that had cited increased prenatal care as a primary means of preventing low birthweight.
Therefore, the very fact that the IOM undertook the second study indicated a new ability to achieve continuity in its program. To ensure wide dissemination of the final report, which appeared in October , the IOM received additional money from Carnegie and Ford that enabled it to issue a separately bound summary of the report to more than 10, people and organizations. On the evening before formal release of the report, the IOM hosted a special dinner for 70 key leaders in the field of maternal and child health, and the following morning the IOM held a press conference.
The IOM next focused on giving speeches about the report to influential groups and on getting coverage in medical and scholarly journals. These efforts resulted in presentations in such settings as the U. In the next phase of dissemination activity, the IOM sought to interest Congress in the report. This sort of attention to dissemination became a key part of Thier's plan to improve the performance and influence of the IOM. As one document of the period stated, "The recommendations of a study can only be regarded as disseminated when they are acted upon by the health enterprise.
Increased funds and more attention to dissemination brought positive results in the form of increased prominence within the National Academy of Sciences, growth of the IOM staff, and expansion of the IOM's organizational responsibilities.
One sign of its increased clout within the larger organization was an agreement that increased the NAS funds that went to the IOM. These funds took the form of payments for the overhead costs of some of IOM's program activities. The more that the IOM contributed to the total pool of overhead funds, the more it could demand from the Academy. At the beginning of , the IOM had 85 project staff members compared with 20 in December and 20 core staff members.
The staff was growing so rapidly that finding a place to house them in relative proximity proved a serious challenge. These organizational changes marked the realization of plans that went at least as far back as the Ebert report in , which had called for the IOM to assume more administrative responsibility for the components of the Commission on Life Sciences CLS that dealt primarily with medicine. Press assigned Walter Rosenblith, emeritus professor at MIT and former member of the Board on Medicine, to head the group charged with this task. His primary recommendation was that the Medical Follow-Up Agency should be transferred to the IOM, and his secondary recommendation called for the Food and Nutrition Board to have part of its activities overseen by the National Research Council and part by the Institute of Medicine.
The agency's main purpose was to facilitate the use of federal records, primarily those of the armed forces and the Veterans Administration, for medical research. The agency also maintained a special data base on twins who had served in the armed forces. Among topics of interest to the agency, which contained a staff of six professionals, were the psychological and medical results of military captivity, the risk of cancer following exposure to a nuclear weapons test, and the natural history of various forms of hepatitis.
Unlike the other parts of the Institute of Medicine, the Medical Follow-Up Agency engaged in the conduct of original research, often with statisticians and epidemiologists on the staff acting in collaboration with clinical investigators and epidemiologists from academic medical centers. The Food and Nutrition Board was a larger and more complex undertaking. Started during the Second World War, it addressed issues of critical importance that pertained to the adequacy and safety of the nation's food supply as well as matters that related to proper diet and nutrition.
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Among the questions it sought to address were ones of considerable political and economic sensitivity, such as the effects of chemical additives on the quality of the food supply or the nutritional qualities and harmful side effects of particular foods. Most of the members of the person board were academic physicians or scientists concerned with the study of nutrition. Typical of the work of the Board was a large report on Diet and Health that recommended the appropriate daily levels of fats and salt necessary to maintain health and prevent disease. Other aspects of the board's work concerned the international dimensions of nutrition, such as how to correct the deficiency of vitamin A in the diets of Third World children that led to blindness.
Still other parts of the board's mission involved the maintenance of proper nutrition during pregnancy and lactation. Not only did the IOM acquire new agencies as part of its newfound prosperity, it also revived components that had been moribund and invented new entities. The Board on International Health served as a good case in point.
An important priority of David Hamburg's, international health had languished as an IOM activity during the s, becoming the IOM division that encountered the most difficulty in attracting outside funds. To the proprietors of an increasingly troubled American health care system, international problems appeared remote, and the Reagan administration was reluctant to spend money on controversial forms of foreign aid such as advice on population control. As a result of these forces, the Board on International Health, which had struggled to come into existence in the first place, was effectively dissolved by the end of Thier and his staff set out to raise funds for a revived board and succeeded in gaining money from the Rockefeller Foundation, the Public Health Service, and the Agency for International Development.
The IOM also contributed some of its newly gained endowment money. As a result, the new Board on International Health met for the first time in January In reconstituting the board, Thier vowed to avoid the mistakes of the past. The new board, unlike the old one, would have a firm funding base and be less susceptible to changing political fashions in which health shifted as a priority in economic development and foreign aid portfolios.
It would be smaller and better focused than the previous board, and it would include foreign experts on health care policy. With this new outlook, Thier hoped that the new board would shape "a clear image of a distinctive role for itself' and convey this to the international health community. This latter project ultimately resulted in the publication of a volume that showed how the IOM had changed over the years.
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