Despite the fact that more than 50 percent of the leading causes of death are due to behavior, the National Institutes of Health, says APS Executive Director Alan G. Kraut, has to be “dragged kicking and screaming” to the behavioral science table.
“Saying ‘biomedical’ does not mean you’ve said ‘behavioral,’ any more than saying ‘men’ means you’ve said ‘women,'” he said. “We need to change our view of what health research is just as we need to understand that health involves more than biological functioning. It also involves psychological, social, and environmental issues.”
Kraut’s comments were made a recent conference sponsored by The Hastings Center intended to explore a variety of social and ethical issues raised by the development of biological knowledge and clinical progress at NIH. Kraut – who was joined on the dias by an political science and public policy professor and the chair of Columbia University’s Department of Physiology and Cellular Biophysics–took part in a symposium on understanding the biomedical versus the behavioral causes of illness at “Biomedical Research: Problems, Possibilities, Puzzles, and Priorities,” held February 1, and he noted that behavioral research at the country’s largest source of health research funding is not a priority.
At the heart of NIH’s problem with the behavioral aspects of health, said Kraut, is the agency’s reductionist culture. “Its overarching question too often is: What is the smallest unit that relates to the phenomenon? Where is the gene? What is the neurotransmitter? Which part of the cell is responsible for what?” said Kraut, who added that instead, NIH should look to explain the broader phenomenon. “Otherwise we will be in danger of understanding something like the complete genetics of nothingness. What we want to know is how that gene shows itself in obesity, or how that neurotransmitter affects emotion, or how that cell supports the organism’s life. We want to know about the disease, the trait, and the human behaviors that result from all of the small pieces.”
Acknowledging that the behavioral and biomedical side of an individual are inexorably linked, Kraut said his doesn’t think that most molecular/biological types–outside of paying lip service to it from time to time–don’t make that acknowledgment.
“I often hear outright astonishment from my biological colleagues after they’ve just sat through a talk on, say, the impact of learning on brain structure, or the way genes work to allow a child to live within his or her environment, or some new finding about the biological basis of emotion, or information about electrical brain activity associated with changes in thinking. ‘Oh, so that’s behavioral science,’ they say. ‘I didn’t know you people did that–but that’s real science,'” said Kraut. “And I respond in my most polite manner, ‘Well, we think some of you people do real science, too, even if it is only biomedical’ Aaarrrgh! It’s as if ‘real’ science can only be reductionistic.”
In addition to its reductionistic culture, Kraut derided the driving force of the disease model on NIH policies.
“When you look at what determines health, you can’t help but notice behavior. Smoking, drinking, and taking drugs all begin as behaviors. But in the disease model, the initial behavior is ignored. It isn’t usually until a person gets lung cancer, emphysema, heart disease, liver damage, brain damage, that doctors even address the origins of the problem. Just think of the many connections between health and behavior,” he said, citing obesity, substance abuse, drinking, teen pregnancy, suicide, child abuse, and AIDS as examples. “Most would probably agree these are major public health problems. Probably no one is untouched by these problems. But how much NIH research is being done on the fundamental processes of thinking, motivation, on social development, attitude change, and community or family support underlying these behaviors? What cognitive, emotional, and psychological mechanisms are involved when teens ignore the risks associated with substance abuse or unprotected sex? What are the individual and environmental origins of violence? And just as important, what are the protective factors that keep so many kids from engaging in these risky behaviors.”
Kraut said behavior also has a key role in addressing health problems that originate in biological causes, and cited a recent Journal of the American Medical Association report that showed that behavioral treatment was not only significantly more effective than drug treatment for urinary incontinence in older women, but it also didn’t have the side effects pharmacological treatments can have. He cited other studies that have shown the effectiveness of behavioral techniques in helping people suffering arthritis and diabetes manage their pain, their health status, their psychological state, and their use of health services.
“The point is, behavior is as threatening to health as any genetic or biological condition,” he said. “Yet NIH officials talk as if they sponsor only biomedical research on disease, a curious position for the National Institutes of Health. But does it really matter if NIH is ignoring behavior because of reductionism or the disease model in the way I describe if the money keeps rolling in? Won’t those huge budget increases NIH has gotten fix the underfunding of behavioral research there? I don’t think so. NIH has always been relatively prosperous, so that’s not the issue here. The problem is structural. True, the budget increase hopefully means everyone’s boat will rise. But without a change in the hierarchy of priorities, – a hierarchy in which behavioral science is now on a lower tier–increases at NIH won’t correct the imbalance.”
NIH, said Kraut, owes its existence to the belief that science holds the answers for solving health problems.
“But a too-narrow scientific focus has eclipsed the part about ‘solving health problems,'” he said. “It’s time to revisit the original philosophy of NIH and reconsider what drives the nation’s preeminent health research organization. The space between behavior and biology is shrinking in research; in real life and in health, it doesn’t exist at all. It shouldn’t exist at NIH either.”