Advocacy Archive
Testimony of ALAN G. KRAUT APS Executive Director
Statement on National Health Research Training Needs
Committee on National Needs for Biomedical and Behavioral Scientists of the
National Research Council
February 24, 1998
Mr. Chairman, Members of the Committee: Thank you for the opportunity to present this statement on national health research training needs. I will touch on a number of issues that should provide a context for discussing national training needs and for behavioral science in particular. These have to do with the role of behavior in health; the recommendations from the 1994 report, Meeting the Nation's Needs for Biomedical and Behavioral Scientists, issued by this Committee; the National Institutes of Health's (NIH) approach to implementing the recommendations from the 1994 report, generally and for behavioral science specifically; and Congressional interest in research training.
Thinking about the Nation's needs for health research training should start with a realistic picture of health problems. Here's one basic fact: Behavior is central in many, maybe most of the nation's leading health concerns: heart disease; high blood pressure; lung disease and cancer; obesity; AIDS - whether from risky sex or IV drug use; suicide; teen pregnancy - with its implications for mothers and babies; drug abuse and addiction; alcoholism; violence; injuries and accidents -- these and other major health problems I could list, and all are largely behavioral.
I have provided to the Committee several reports from the Human Capital Initiative series which detail the role of behavior in different areas of health. They describe many research questions and opportunities. For background, I've also given you some editorial pieces written on behavioral science at NIH and on training more broadly. But you don't need to rely on these writings by me or APS. The same findings come out time and again in official report after official report, from several Surgeons General, from this very National Academy, from Congress, all saying the same thing: 7 of the 10 leading causes of premature death in this country are due in large part to behavior; behavior accounts for over 50% of mortality.
This is the logic that should generate this Committee's momentum around training issues. After all, the National Cancer Institute is a $2 billion-plus institution not only because of the research opportunities in cancer research. It is the largest NIH institute because cancer is rightly seen as an enormous public health problem by Congress and by the American public. I would argue that unhealthy behavior should be seen that same way.
Let me make one more point about the relation of behavior to health. When I talk about behavioral research, I am not only talking about applied or clinical issues. For all the problems I just cited, there is a basic science of behavior that must be in place before any application can be thought of. I hope you are saying "of course that's true," but my sense is that when NIH thinks of behavioral research, with few exceptions, they think of applied research, as in: A vaccine is ready and now the behavioral question is how to convince parents to bring their children in for inoculation. But just as the development of a vaccine builds on basic research in virology and molecular and cellular biology, a persuasive message to parents builds on basic research in cognitive, developmental, and social psychology. The same is true for questions such as: How do you get TB patients to stay on their course of treatment? What is the behavioral approach to controlling blood pressure? What about a behavioral treatment or depression or drug addiction? How do you convince kids not to stop risky sex? How do we help people cope with cognitive loss or disability?
My point is that each of these topics generate their own basic science questions that need to be addressed, questions that involve the basic study of cognition, language, development, social processes, attitudes, emotion, brain and behavior, and the list goes on. To give another example: When schizophrenia is thought of as having a genetic basis, there is an automatic recognition that basic studies of molecular genetics will inform us about the course of the disorder and we hope lead to effective treatments. But schizophrenia is also a disease that involves distorted thoughts, language, and emotions. There ought to be a similar recognition that basic research in cognitive science, the development of language, and the regulation of emotion will also inform us about the course of the disease and lead to effective treatments.
So we know that behavior is as threatening to health as any genetic or other biological condition, and that basic and applied behavioral science produce the knowledge to reduce that threat. The concern for this Committee is that we need people to address these behavioral questions. Training is the first, and in that sense the most critical, step toward increasing our understanding of the role of behavior in health and our ability to treat and prevent behavior-based conditions. Hence, the importance of the National Research Service Awards (NRSAs).
NRSAs may be small in number but they are powerful influences on setting priorities in research training. They set trends that are followed by the entire health research training enterprise. I hear often that when a department of psychology has an NRSA training grant, it is not only a sign of that department's quality, but of where the future of that particular subdiscipline is heading. It's admittedly been a while, but that is just the sense I got as a student supported under NRSA.
Let me turn to the place where NRSAs are largely funded -- the National Institutes of Health. I am assuming that you have seen NIH's recent response to Congress on implementing the recommendations from your 1994 report, sent under NIH Director Harold Varmus' name, but transmitted by NIH Deputy Director Ruth Kirschstein in response to the House and Senate, both of which repeatedly encouraged NIH to use your report to guide research training policy.
In its response, NIH justifies a selective implementation of the 1994 recommendations by what I would characterize as a major misinterpretation of that report. My reading of the report and my discussions with several NRC staff and members of that 1994 Committee was that the Committee wanted stipends increased in the basic biomedical area while holding the number of biomedical NRSAs level; and that in behavioral science and several other areas, the Committee wanted stipend increases and the increased number of awards to happen at the same time. Further -- and this is the critical point, all of the recommendations from the 1994 report were balanced and costed out so that the recommendations of increasing stipend amounts were tied to both maintaining the number of basic biomedical trainees and increasing the number of trainees in various disciplinary areas.
In contradiction to this, NIH points to the recommendation on biomedical awards as justification for saying that the Committee must have wanted stipends to come first, before increasing the number of awards in any area. Or, NIH adds, if you really did mean that stipends and awards should be increased at the same time, then Ait is unlikely that the committee fully anticipated the costs of these changes.@ Never mind the charts at the end of the report, or the fact that the money would be spread out over several years and over many Institutes. Of course, if NIH didn't want to fully implement the 1994 recommendations they certainly could have partially implemented them. But if they wanted to be true to the intent of the report, as Ruth Kirschstein indicated at your December meeting, they should have carefully balanced any increase in stipend support with an increase in trainees.
Let me stop analyzing the NIH intent behind what they did or didn't do on the 1994 recommendations. As much as I think NIH was wrong, debating their intent misses a major point. It assumes that NIH policy on your previous recommendations was the product of thoughtful discussion at Institute Directors meetings, or after consulting at separate Institutes or the community or even with NAS. But no: I have discussed research training at many of the Institutes -- with past and current Institute Directors, with past and current research training program staff, and with budget officers. Never have I heard, at least at the Institute level, that your 1994 report was systematically studied with an eye toward how that Institute planned its research training activities. And this is true whether or not the number of trainees went up or down. We are delighted that some Institutes, NIMH for example, increased their number of behavioral trainees over the last few years. But the 1994 report seemed not to provide much of a role in that process, certainly not any a priori role. And there is little if any NIH-wide planning around research training needs, at least as far as disciplines and areas of emphasis go.
This is what better explains the NIH decision to only increase stipends. Your recommendation to increase stipends was something that could be done at the larger NIH level. It is no wonder that it was that part of the 1994 report that was seized on by NIH. Frankly, it was the only part that they could handle easily under the decentralized training structure that has 24 separate NIH Institutes, centers, and divisions. Your recommendation to increase the number of trainees would have taken a coordinated effort that both doesn't exist and is not an NIH tradition. There is a mismatch between the level of recommendations of the 1994 Committee B which focused at the overall NIH level B and the level at which most substantive NIH research training decisions take place B the Institute level.
Let me talk a little more about my conversations with specific Institutes. For me, those discussions revealed a wide array of Institute-specific practices around research training that seem to be based as much on myth and assumed NIH policy as on actual fact. For example: Some NIH research training staff tell me they cannot encourage more Fellowship applications because there is an NIH-wide limit which dictates that no more than 15% of NRSA money can go to individual awards. This means that post-doctoral fellowship applications with a priority score of better than 140 are going unfunded at some institutes as a result. In fact, the 15% policy is just opposite: the Public Health Service Act states that a minimum of 15% of NRSA money must go toward individual fellowship awards.
Other Institute staff tell me that they are simply unable to move money from a research line to a research training line. They tell me Congress does't want that done' or 'NIH Building 1 won't allow it.' But others move that money around all the time, and creatively use this flexibility to build new expertise in emerging fields. (NIMH's Ellen Stover, who has also appeared before this Committee, used this technique as head of the NIMH Office on AIDS to build a new cadre of AIDS researchers. It is a wonderful example of exactly what needed to be done.)
These problems stem from the fact that compared with just about any other topic, research training is not a priority at NIH. While there will be some discussion about its importance in some Institutes, it is not what you hear Institute Directors talking about to Congress or to the public. When I ask Institute Directors about that, they tell me training is not what Congress wants to discuss. Based on talking to people in Congress, I disagree. The seed corn argument plays well in Congress these days. The notion that Congress isn't supportive of pipeline issues may be have been true at one time, but that's no longer the case, and hasn't been at least for the last half dozen years. There is now a much greater recognition that behind all those exciting breakthroughs and flashy technologies there are basic infrastructure needs. This is evident even in the latest NIH budget, which has new money for buildings, for the clinical center, and even slightly more money for research management.
Plus, there's clear evidence of Capitol Hill's interest in NRSAs for behavioral science. I've given the Committee copies of House and Senate appropriations reports from the past several years. They specifically support the 1994 recommendations. So it's just not true that Congress doesn't want to hear about research training; they do. It was some of this report language that NIH was responding to in the Varmus/Kirschstein document.
If research training were really a priority at NIH, there would be some kind of process in place for looking at the recommendations from this Committee more specifically. And you would find more resources and staff in the various NIH research training offices. Instead, training is something of an NIH afterthought; maybe it gets done under R01s or maybe it doesn't. Part of NIH's justification to Congress was just that -- that behavioral science training is happening on its own in research grants, and that just by supporting behavioral grants the training mission is being fulfilled. I can't imagine that this catch-as-catch-can approach is satisfactory to anyone.
More evidence that training is uncoordinated: at precisely the time that NIH was telling Congress that it was not going to implement your recommendations to increase behavioral trainees, the NIH Office of Behavioral and Social Sciences Research was making your 1994 recommendations a cornerstone of its strategic plan. Unfortunately, as it turns out, the Office will not have any extra funds to do that anyway, but this underscores that the decisions on implementation were not made in consultation with relevant people at NIH.
So they've got a non-system, where research training is not a priority to begin with. How do you go about making sure that NIH takes your recommendations seriously? Let me make some suggestions, at least about behavioral science.
The truth is, many more Institutes should be supporting behavioral science as part of their training mission. Historically, about half of the behavioral science NRSAs have been awarded through the National Institute of Mental Health. NIMH's role should not be diminished in any way. But virtually all NIH Institutes support behavioral science to some degree or another. To get quality researchers, they in essence are asking seasoned researchers from other fields (and Institutes) to switch focus. Relying on established researchers to switch fields means at best an unpredictable supply of investigators, plus it is a little like robbing Peter to pay Paul.
It shouldn't be just NIMH, or drug abuse, or alcoholism producing these researchers -- it should be heart, cancer, neurology and many others. Had the 1994 recommendations been implemented, this already would be happening. So how do we make it happen now? It should begin with a renewal in some form of the 1994 recommendations. They are as valid today as they were then. One of the sadder parts of reviewing the history of this Committee in preparation for my remarks is that so many of the important and pressing issues you raised in 1994 continue to be unaddressed.
However, the recommendations need to be more "NIH-friendly." One way is to specify the kinds of areas where behavioral science ought to be stimulated. Examples could be basic research on craving; on peer pressure and social identification; on stress; on managing chronic illness or chronic pain or managing any long-term health activity; on behavioral changes associated with aging; on the formation of attitudes; on compliance; on relapse; on the developmental effects of prenatal drug or alcohol exposure; on cognitive functioning in psychopathology; on risk-taking; on barriers to treatment; on behavioral genetics, and so on.
For postdoctoral NRSAs, there also could be an emphasis on interdisciplinary training, such as training cognitive scientists in neuroimaging techniques; behavioral geneticists in techniques of molecular genetics; or funding basic behavioral scientists to work in medical settings. (A little vice-versa training for biomedical scientists in behavior also would be appropriate, but that is something probably better said by one of my biomedical colleagues.) Of course, some postdoctoral training should remain at the core of a subdiscipline. For example, social psychology is changing as a field, from one where the postdoc was rare to one where it is nearly impossible to get a good academic job without one. Such a field needs to be supported in this kind of growth spurt.
In addition, the Committee should insist that the National Institute of General Medical Sciences (NIGMS) support behavioral research training. Much of basic behavioral research training now supported by NIH is at NIMH. As I said earlier, that tradition should not be casually tossed aside. But the legislative charge to NIGMS is to support basic research. As far as I can tell, the Institute is not following that mandate in basic behavioral research training.
I also ask this Committee to consider the need for NIH to develop a more coordinated way to address the NRSA recommendations, one that includes the individual Institutes in new ways. This could be done in the report itself: Perhaps the recommendations could be linked to specific Institutes, so that the case is made that Cancer; Heart, Lung and Blood; Diabetes; Allergy and Infectious Disease; Deafness, and others, ought to be participating in ways they are not now participating. Or coordination could be addressed in some implementation plan. For example, the Committee could arrange briefings for each relevant Institute. This is not to say that NIH should be compelled to take the your recommendations, but only that there be a reasonable process in place to consider the recommendations in a way that hasn't been done recently.
This concludes my statement. Again, thank you for the opportunity to present these views. I would be pleased to answer any questions or provide additional information on the issues I've raised here today.