Health and Safety
A Healthier Nation
 For many Americans, reforming our health care system should be at the top of the national agenda. Study after study reveals the high costs of ineffective care for individuals and society, and new challenges such as the increase in older patients in coming years threaten to further strain an already overburdened system. The U.S. Department of Health and Human Services, an agency whose programs touch the lives of almost every American, will be largely responsible for implementing the nation’s health care reform efforts. In 2008, two reports from the Institute of Medicine examined how HHS and health care services in general can be improved to better serve all Americans.
The first report, HHS in the 21st Century: Charting a New Course for a Healthier America, says that rather than attempt a wholesale reorganization of the agency, the next secretary of health should define a vision that would actively promote the nation’s health, ensure that the department’s mission supports that vision, and establish a small number of measurable goals focused on current challenges. In addition, the new health secretary should work closely with the White House and Congress and play a major role in promoting and achieving health reform nationwide.
Over the years, change at HHS has been driven by piecemeal programs legislated by various congressional committees, frequently without appropriate resources or consideration of the agency’s capacity to manage them, the report says. A new agreement between Congress and HHS is essential for achieving the agency’s vision for a healthy nation. Under this “compact,” the secretary of health would provide Congress and the nation with regular, rigorous reports about the department’s activities and assume greater accountability for improving performance and obtaining results. In return, Congress should allow the department greater flexibility in its internal operations and decision making, the report says.
Leaders with scientific integrity and qualifications are equally important for HHS. In particular, the surgeon general should take on a more powerful role as a strong advocate for health and work actively to educate Americans on important health issues. Highly qualified people should also be appointed as heads of key scientific agencies within HHS in order to preserve and advance the scientific missions of the department — notably, the National Institutes of Health, Food and Drug Administration, and the Centers for Disease Control and Prevention. To accomplish this goal, the secretary should work with Congress and the president to establish a selection process for these important positions that emphasizes experience and qualifications without regard to politics, the report says.
The secretary of health should also place a high priority on recruiting and retaining talented public health workers to serve within HHS and in health care professions nationwide, the report says. Analysts predict serious shortages of people with the right backgrounds, training, and skills in the department’s senior levels, in the nation’s health care work force, in state and local public health agencies, and in the science establishment. The report makes a number of recommendations aimed at providing incentives for qualified workers, strengthening education and training programs, and allowing talented professionals to transfer back and forth between government and private-sector service.
The report calls for a comprehensive system of evaluating health care services, also the subject of a second IOM report. Knowing What Works in Health Care: A Roadmap for the Nation says that Congress should direct HHS to establish a national program with the authority, expertise, and resources needed to produce credible, unbiased, and understandable syntheses of evidence on clinical effectiveness. The report provides a blueprint for a program that would better identify effective health care services based on evidence and promote voluntary but rigorous standards for clinical practice guidelines.
Such a program could help end the confusion that comes with dozens — and in some cases, hundreds — of competing guidelines, the report says. Uncertainties about which study results and guidelines are the most reliable complicates efforts to empower individuals to manage their own care. Even the most sophisticated health care consumers struggle to gather reliable information about which treatments are appropriate for their conditions and circumstances.
Most people, including many health professionals, lack the scientific training necessary to evaluate and interpret findings from thousands of new clinical studies published every year. If established in a way that ensures transparency, scientific rigor, and high standards for accountability and objectivity, the proposed program could be a trusted resource for reliable information on the effectiveness of health services, the report says.
Since the report was released, Congress asked IOM to conduct follow-on studies to recommend standards for conducting systematic reviews of comparative effectiveness and for developing trustworthy clinical practice guidelines. In addition, a third congressionally mandated IOM study will recommend national priorities for allocating $400 million in funding designated by the 2009 American Recovery and Reinvestment Act for comparative effectiveness research.
HHS in the 21st Century was funded by the National Academies and Knowing What Works in Health Care was funded by the Robert Wood Johnson Foundation.
Caring for America’s Aging Population
 The first of the nation’s 78 million baby boomers will celebrate their 65th birthday in 2011. For the next few decades, a swell of older patients will place increased demands on a strained and unprepared health care system. Few health professionals specialize in geriatric care, and most clinicians receive little if any training in even the common conditions associated with aging. Ironically, more training is required to become a dog groomer or manicurist than a direct-care worker in many parts of the country.
To ward off an impending crisis and help older Americans get quality care, a report from the Institute of Medicine calls for a bold new strategy in health care delivery and financing to be implemented by 2030 — the year by which all baby boomers will have reached the age of 65. Retooling for an Aging America: Building the Health Care Workforce identifies major reforms to train and recruit health care providers, ensure that all caregivers can meet the physical and emotional needs of the elderly, and enhance the way care is delivered.
Already, almost all health care providers treat older patients to some extent, and they will be even more likely to do so as the baby boom generation ages. Health care workers should be required to demonstrate competence in basic geriatric care to maintain their licenses and certifications, the report says. All health professional schools and health care training programs should expand coursework and training in the treatment of older individuals, it adds.
For more effective care and to alleviate shortages of adequately trained workers, health care professionals and regulators should consider expanding the roles of care providers. For example, if a certified nursing assistant was permitted to administer certain medications, a professional nurse could concentrate on more complex patient needs. In addition, to prepare direct-care workers for the demands of their jobs, the federally required minimum number of hours of training should be raised to at least 120.
To attract more geriatric specialists and care workers and keep them on the job, Medicare, Medicaid, and other health plans should pay more for their services, the report urges. Medicare’s low reimbursement rate for primary care is the main reason that geriatric specialists earn lower salaries than specialists in other fields. States should also allocate funds to be added to Medicaid payments that cover services provided by direct-care workers, whose median wage of approximately $10 an hour falls below the poverty line. In addition, Medicare and other public and private insurance plans need to remove disincentives that prevent health care providers from adopting new models of care delivery — such as interdisciplinary team care — that could improve patients’ health and lower costs.
The report notes that as many as 52 million family members, friends, and others tend to aging parents or other elderly, but little is done to ensure these informal caregivers have the necessary knowledge or skills. Health facilities, community organizations, and other public and private groups should offer training programs to help nonprofessional caregivers cope.
The study was funded by the John A. Hartford Foundation, Atlantic Philanthropies, Josiah Macy Jr. Foundation, Robert Wood Johnson Foundation, Retirement Research Foundation, California Endowment, Archstone Foundation, AARP, Fan Fox and Leslie R. Samuels Foundation, and the Commonwealth Fund.
Enhancing Children’s Health and Development
 The federal government is preparing to undertake the largest long-term study of environmental and genetic effects on children’s health ever conducted. Known as the National Children’s Study (NCS), it will track approximately 100,000 children from before birth until age 21 and examine how biological, chemical, physical, genetic, social, geographical, and a host of other factors in a child’s environment affect health and development. The study, administered by a consortium of government agencies, is intended to be a valuable resource for data and analyses conducted many years into the future.
The National Children’s Study Research Plan: A Review, a report by the National Research Council and the Institute of Medicine, says that NCS offers an excellent opportunity to examine the environmental influences on children’s health, as well as to explore complex interactions between genes and environments. However, several weaknesses in the research plan could diminish the survey’s value. The report highlights more than 20 important areas in which NCS could be improved.
NCS’s current design has many strengths. Tracking a large number of births will provide enough statistical power to examine a multitude of hypotheses about environmental influences that could not be investigated with smaller samples, and gathering longitudinal data on children into adulthood will enable research on many potential relationships between exposures and health outcomes, the report says. The great array of social, psychological, biological, chemical, and physical measures to be included in the study will undoubtedly generate new areas of research.
Nevertheless, such a large survey will be very complex to administer. Not having a pilot testing period is a serious shortcoming of the study, the report says. Current plans call for data gathering to begin at seven designated centers and be expanded to more after a year. NCS should delay the expansion beyond the seven sites and use the time to improve study procedures and refine key concepts, hypotheses, and measures. NCS should also use these designated centers to test and experiment with data collection methods throughout the study process.
In addition, NCS should give high priority to identifying ways to bolster its ability to contribute to understanding of health disparities among different population groups, the report says. Studying these issues is one of the reasons NCS was established, yet the study plan contains few, if any, hypotheses about racial and ethnic health disparities.
The report offers other recommendations for improving various technical and conceptual aspects of NCS, including for specific areas of research such as pregnancy outcomes, asthma, obesity and growth, chemical exposures, and demographic and socio-economic measures.
Since its release, NCS has implemented several of the report’s recommendations, including delaying the expansion of data gathering.
The study was funded by the National Institute for Child Health and Human Development.
Leadership for a Possible Flu Pandemic
 The strain of influenza that swept the world in 1918 killed an estimated 50 million people. Given the characteristics of influenza viruses, many experts have warned that another flu pandemic may soon be upon us. To contain and cope with a widespread influenza outbreak, U.S. and international public health officials have been developing strategies over the past two decades that include building reserves of antiviral drugs to both treat the illness and prevent its spread.
A report from the Institute of Medicine says federal and state officials should begin a national discussion about the difficult choices they may be forced to make in the event of an influenza epidemic and develop in advance a set of priorities for distributing the drugs. Antivirals for Pandemic Influenza: Guidance on Developing a Distribution and Dispensing Program cautions that uncertainty about the severity of the next pandemic strain and whether existing drugs would be effective against it, as well as the high cost of stockpiling large amounts of drugs that will eventually expire, make it difficult to predict the right mix of drugs for treatment and prevention.
Medications such as oseltamivir (Tamiflu) and zanamivir (Relenza) are expected to play a key role in managing the early stages of a pandemic, and federal and state agencies have been building stockpiles. Public health officials plan to use these drugs to treat and prevent influenza during the several months required to develop a targeted vaccine. However, it is difficult to know whether the specific pandemic strain could rapidly become resistant to the antiviral drugs, the report says. The stockpiles may not contain sufficient doses to serve as both a broad prophylaxis and a treatment if the virus is particularly lethal or fast-spreading.
Before an outbreak occurs, officials should develop an ethical framework for prioritizing the order in which different groups of people receive the drugs. Such a framework would guide decision makers from the outset and should be flexible enough to adjust for the particular circumstances of an actual outbreak. A scientific advisory body also should be established now, and be ready to advise the government in the midst of a pandemic.
Like all medications, antiviral drugs carry expiration dates. The federal Shelf Life Extension Program that covers antiviral drugs in stockpiles managed by federal agencies should be expanded to include the antivirals in other stockpiles, such as those maintained by the states, the report says. Under this program, drugs are tested periodically to see if they are potent beyond the manufacturer’s expiration date. Extending the program to other stockpiles could prevent the discarding of viable medications.
The study was funded by the U.S. Department of Health and Human Services.
A Better Way to Assess Risks
 In everything from protecting air and water quality to ensuring the safety of food and drugs, the process of risk assessment has become an important tool for many government agencies. Officials and regulators use risk assessments to decide how to protect the public from exposure to chemicals and toxic substances. However, the process is becoming increasingly slow and complex as knowledge of environmental contaminants and potential health impacts grows. The U.S. Environmental Protection Agency asked the National Research Council for guidance on how to address these issues.
Its report, Science and Decisions: Advancing Risk Assessment, calls on EPA to streamline its risk assessment process to ensure the appropriate use of available science, technical accuracy, and tailoring to the specific needs of the problem. The current process is often hindered by a disconnect between available scientific data and the information needs of officials.
The agency is struggling to keep up with demands for hazard and dose-response information and is challenged by a lack of resources. For example, an assessment of the risks of exposure to tricholorethylene, which has been linked to cancer, has been under development since the 1980s and is not expected to be completed until 2010. But state and federal officials must still make risk management decisions even when these assessments are not completed. If this continues, the value and credibility of risk assessments will decline, the report says.
EPA should focus more attention on the early stages of risk assessment, such as planning, scoping, and problem formulation. This includes defining a clear set of options before assessment begins and involving decision makers, stakeholders, and risk assessors to evaluate whether the design of the assessment is suitable.
As described in a landmark 1983 National Research Council report known as the Red Book, risk assessment involves four steps — hazard identification, exposure assessment, dose-response assessment, and risk characterization. The new report urges EPA to adopt an expanded risk assessment framework that has the same core process as the Red Book model but enhances the preliminary and final stages. Under this framework, the questions posed come from early and careful planning and stress the appropriate level of scientific depth required to evaluate the relative options under consideration. In this way, risk assessments will be focused on the right questions and the best available science and will address the needs of decision makers.
EPA also should adopt a more cohesive approach to the dose-response step of risk assessment, which estimates the amount of a chemical that would lead to an adverse health effect, the report notes. Currently, these assessments are conducted differently for chemicals that produce cancerous effects and those that produce other health effects. A unified approach would incorporate advances in scientific knowledge and provide clearer estimates of population risk — information that is critical for decision making.
The study was funded by EPA.
Shortcomings of Great Lakes Study
 The United States and Canada have formally committed to restoring and maintaining the chemical, physical, and biological integrity of the Great Lakes basin ecosystem, the subject of concern in part because of the potential presence of toxic substances in the region. In 2001 the International Joint Commission, which monitors and assesses the progress under this agreement, asked the U.S. Centers for Disease Control and Prevention’s Agency for Toxic Substances and Disease Registry (ATSDR) for assistance in evaluating the public health implications of hazardous materials in the Great Lakes. In response, ATSDR prepared two drafts of a report for the international commission. Questions about the scientific quality of the two drafts, and issues raised following the unauthorized publication of one on a public Web site, led CDC to request a review of the drafts by the Institute of Medicine.
Scientific shortcomings in the ways the draft reports were prepared limit their usefulness in determining health risks of living near the Great Lakes, says IOM’s Review of ATSDR’s Great Lakes Report Drafts — Letter Report. The IOM review — which focuses solely on the drafts’ scientific quality and does not assess whether pollution around the Great Lakes poses health concerns — examined a draft prepared in 2007 and a version that followed after directors within ATSDR expressed apprehension about the methodology and conclusions of the 2007 draft and postponed its public release.
Most of the concerns about the earlier draft, such as how data were selected and used, are valid, the IOM noted. Pollution and health data were lumped together despite differences in where and when the information was collected and despite lack of supporting evidence or explanation of how particular contaminants could lead to any of the identified health problems. This juxtaposition of data without explanation or support could lead readers to assume links between contamination and health problems regardless of whether they actually exist. In addition, some data that might have been useful were not considered, and the drafts contained little explanation for how data were chosen.
The second draft provides only a summary of selected data on chemical releases and contamination and does not add substantially to the understanding of pollution around the Great Lakes. The IOM said the decision to leave out health data is understandable given its incompatibilities with the available contamination data, but it significantly changed the nature of the report and the scope of response to the original request to CDC.
Most of the drafts’ problems seem to stem from lack of a clear statement about what each was intended to achieve and a clear outline of its approach. The original request from the International Joint Commission for a study could have been interpreted in more than one way, IOM said, and neither of the drafts offered an explanation of how the request was interpreted.
Since the IOM letter report was released, ATSDR released its final report, ATSDR Studies on Chemical Releases in the Great Lakes Region. The report responded to many of the concerns raised by IOM.
The study was funded by the U.S. Department of Health and Human Services.
A Fuller Picture of Brain Injuries
 Traumatic brain injury (TBI) has become the signature wound for military personnel serving in Iraq and Afghanistan. More than 5,500 U.S. service members have suffered from TBIs — far more than in earlier wars, largely because explosive devices and other weaponry being used are more powerful and devastating. As part of an ongoing series of studies assessing issues surrounding the health of veterans, the U.S. Department of Veterans Affairs asked the Institute of Medicine to examine the possible long-term health consequences resulting from TBIs.
The IOM’s report, Gulf War and Health, Vol. 7: Long-Term Consequences of Traumatic Brain Injury, says that military personnel who sustain these brain injuries face an increased risk for developing several long-term health problems, such as Alzheimer’s-like dementia, aggression, memory loss, depression, and symptoms similar to Parkinson’s disease.
TBI can be mild, moderate, or severe. The report says that even mild TBI, with loss of consciousness, can lead to some of these adverse consequences. Brain injuries resulting from severe, skull-piercing wounds can cause unprovoked seizures and premature death. Severe, nonpenetrating TBI and more moderate brain injury can also cause seizures.
The report notes that blast-induced neurotrauma (BINT) — brain injuries sustained after exposure to the force of an explosion without a direct strike to the head — are often underdiagnosed. These types of injuries are one of the most common faced by soldiers in Iraq and Afghanistan. The departments of Defense and Veterans Affairs should step up clinical and animal studies of BINT. Neurological and behavioral changes in blast victims may be underestimated and undiagnosed because of inadequate research on the injuries.
To develop a fuller picture of the effects of TBI and blast injuries, the report says, DOD should conduct predeployment neurocognitive tests of all military personnel to establish a baseline for identifying post-injury consequences. In addition, VA should include uninjured service members and other comparison groups in the creation of the Traumatic Brain Injury Veterans Health Registry.
The study was funded by the U.S. Department of Veterans Affairs.
A Renewed Commitment to Global Health
 In the last decade, the United States spent record amounts on improving the health of people in developing countries, with federal annual overseas development assistance reaching an all-time high of $7.5 billion in 2008. However, the government agencies and other organizations responsible for global health initiatives are not well-coordinated, and although these funds have improved millions of lives, the money often is not distributed evenly. For example, between 2004 and 2008, more than 70 percent of U.S. government global health funds were allocated to AIDS programs, while funds for chronic disease programs — which now account for more than half of all deaths in low- and middle-income countries — were virtually nonexistent.
To correct these disparities and renew the nation’s commitment to worldwide health, the United States should increase funding and make global health a key component of its foreign policy, according to a report from the Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration says that especially in these hard economic times, improving health around the world is the responsibility of the United States as a global leader.
To make sure that global health efforts are incorporated into U.S. foreign policy, the administration should create a White House Interagency Committee on Global Health, the report says. This high-level committee should be composed of heads of major federal departments and agencies involved in global health and be responsible for ensuring balanced and strategic health efforts. A senior White House official at the level of deputy assistant to the president should chair the Interagency Committee and serve as the primary White House adviser on setting global health policy.
Despite the growth of public support and funding for global health initiatives in recent years, the U.S. commitment for health abroad still remains below that needed to meet the United Nations Millennium Development Goals. The internationally acknowledged goals are aimed at reducing poverty, hunger, and disease worldwide by 2015. The U.S. should increase global health assistance to $15 billion by 2012 to meet these goals as well as respond to other emerging health challenges, the report says. Funding should be spread across a breadth of global health issues including treating and preventing AIDS, malaria, and tuberculosis; improving health systems, nutrition, family planning, and reproductive health; and combating chronic, noncommunicable disease and injury.
The quality of global health programs also should be increased along with funding, the report says, and evaluations should be improved to help determine which efforts are working and which are not. The United States needs to work with other national governments and coordinate health efforts with priorities of the countries receiving aid. The independence and leadership of the World Health Organization should also be supported because it is in a unique position to set global, evidence-based norms on technical and policy matters.
The study was funded by the Bill & Melinda Gates Foundation; Burroughs Wellcome Fund; Centers for Disease Control and Prevention and the National Institutes of Health; Google.org; Merck Company Foundation; Rockefeller Foundation; U.S. Department of Homeland Security’s Office of International Affairs and Global Health Security, Office of the Assistant Secretary for Health Affairs; and the U.S. State Department’s Bureau of International Security and Nonproliferation.
Effective Health Care for Adolescents
 Most of the nearly 42 million adolescents ages 10-19 who reside in the United States are healthy. But too frequently, young people engage in risky behavior, develop unhealthy habits, or have chronic conditions that can jeopardize their immediate health and safety. The three leading causes of death in adolescents — motor vehicle crashes, homicide, and suicide — are all tied to risky or unhealthful behaviors.
Health care providers need better training in how to meet the specific needs of adolescents, says Adolescent Health Services: Missing Opportunities, a report from the National Research Council and the Institute of Medicine. Current health services for this age group are fragmented and poorly designed to meet their needs. The report calls on federal and state agencies, private foundations, and insurers to develop a coordinated health care system that improves services for all adolescents.
Some young people, particularly those who are uninsured or underinsured, rely largely on “safety-net” settings, such as hospital emergency rooms, community health centers, and school-based health centers, which results in gaps in their care, the report says. Specialty services in mental health, sexual health, oral health, and substance abuse treatment often are not accessible to most adolescents. The health care system should link primary and specialty care for adolescents, the report says. It should also help adolescents access primary care services through hospitals, community-based organizations, and other safety-net settings. Young people who are poor, recent immigrants, or in foster care are especially vulnerable to risky behavior or poor health, and special efforts should be made to meet their needs.
Too often, health care providers are ill-equipped to interact effectively with this age group. At all levels of professional education, health care professionals who serve adolescents should receive detailed education about this population’s health problems and effective ways to treat diseases and promote healthy behaviors, the report says. Regulatory bodies need to incorporate competencies in adolescent care in their licensing, certification, and accreditation requirements.
The report says that allowing adolescents to give their own consent before health information is shared with their parents or any others should be an overarching care principle. Balance is needed between maintaining confidentiality about care for which minors are allowed to consent, and encouraging involvement from parents and families whenever possible. Federal and state policymakers should maintain current laws and policies that enable adolescents to give their own consent for health services, and to receive services on a confidential basis when necessary to protect their health.
The study was funded by the Atlantic Philanthropies.
| 
