Michael Crow, president of Arizona State University, poses the right question:
What if the overriding goal of the National Institutes of Health was not further advances in medical research, but actually improving people’s health? Were we to start from scratch, what institutional arrangement would do a better job of improving the health and well-being of the citizens of the United States for the $30 billion we spend on it every year?
The NIH is a set of 27 institutes that map roughly onto the guild structure of medicine, which in turn maps onto organisms and major diseases. Thus, we have the National Cancer Institute (for the oncologists), the National Heart, Lung, and Blood Institute (cardiologists and pulmonologists), the National Institute of Mental Health (psychiatrists and psychologists), and so on. There is a lot to be said for this, as reflected in the extraordinary scientific and technical achievements of US biomedical science.
There are also, however, critical problems. First, some of the divisions between Institutes are arbitrary. Why, for example, do we have a National Institute of Drug Abuse and a National Institute of Alcohol Abuse and Alcoholism, instead of a National Institute of Addiction Science? Second, there are issues that are critical to every care process, such as understanding patient behavior and provider behavior. Precisely because the issues are similar across diseases, none of the Institutes have truly seen them as critical to their discipline-driven mission, and the issues do not get the attention they merit. Finally, the sickest patients, and the patients that drive health care costs, often appear with many diseases. We have no Institute devoted to the clinical challenges posed by these complex patients.
As an alternative, Crow proposes a simpler NIH built around three Institutes:
- A fundamental biomedical systems research institute could focus on the core questions deemed most critical to understanding human health in all its complexity.
- Research on health outcomes — that is, measuring what improves people’s health. It would seek to determine what actually works in clinical practice.
- A “health transformation” institute, could focus on a problem that increasingly looms over our entire health care system, as the population ages and health care becomes more expensive: how to deliver health care in a way that stays affordable to the nation.
The transdisciplinary goals of better outcomes and health system transformation are currently being tackled outside of the NIH, by the Agency for Health Research and Quality. But these issues should help define all of our health research efforts -- and indeed, our health care reform efforts --and hence they should be central to the mission of the NIH.
By the way, the Canadian Institutes of Health Research happen to be organized around four themes: biomedical science, clinical care, health systems, and social, cultural, environmental and population health. If someone knows of studies comparing the NIH and CIHR, I would be glad to hear of them.
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