Shaky start for Canada's health forum

NEWS WASHINGTON PERSPECTIVE

Social and behavioural sciences feel left out

that some of the behavioural stuff that I’ve been shown is quite imaginative and shows a certain flair for trying to think of an original way

through

a

problem that’s

not

quite

tors. Ten years later, Capitol Hill was A public hissing match has erupted ready for the kind of analysis that still expressing frustration with the between Harold Varmus, the physimolecular biology affords". cian and molecular biologist who : response by NIH. Finally, Varmus disputed the conIn May, 1993, the Congressional heads the National Institutes of tention that social and behavioural committees that write NIH legislaHealth, and the country’s major sociresearch is neglected by NIH. The tion took a new approach, eties of social and behavioural scienAIDS programme, he said, spends the creation of an NIH Office of tists. They contend that he does not heavily on behavioural research. Behavioural and Social Sciences appreciate the benefits that these disOverall, he estimated, NIH spends at Research and an inventory of NIH ciplines can provide for the nation’s least US$1 billion a year on social activities in this area. health-given proper recognition and and behavioural sciences, out of a resources. research Furthermore, familiarity with the NIH tactic of total budget of$11 billion. they insist, Varmus has dawdled over labelling research to suit the political Whatever the case, 19 social and clear Congressional directives to give occasion, the directive prohibited behavioural research societies recentthe social and behavioural sciences "the inclusion of neurobiological ly co-signed a letter to Congress more money and prominence on the research or research that uses behavexpressing dismay about NIH’s treatNIH research agenda. Varmus attribiour merely as a measure to determent of their disciplines. "Our interutes the complaints to misundermine activity at cellular or molecular actions", the letter states, "have but has inflamed the issue level". "In the past", the legislators standings, forced us to question whether NIH is with remarks concerning the intellecasserted, "efforts to include such dealing in good faith with the behavtual quality of what many-though research within the framework of ioral and social science research comnot Varmus-refer to as the "soft sciand social science .,’ behavioural munity and with Congress". And a ences". He also says that they are not research have artificially inflated the memo from the Washington-based commitment to resource this American doing badly at all when it comes to Psychological Society to research discipline within NIH". money from NIH. "NIH Behavioral Scientists" quotes Last November, in an interview Eighteen months on, the NIH Office the Varmus interviews and observes with the New York Times shortly after of Behavioural and Social Sciences that "his replies do little to contradict he took office, Varmus remarked, Research still does not exist. NIH the impression that he’s not much for "And while I’m trying to learn more says it is working on it, and has just behavioral science". about behavioural science, I must say completed collecting names for conI don’t feel I get tremendous intellecsideration for the directorship. Daniel S Greenberg tual stimulation from most of the Meanwhile, Varmus, explaining his earlier remarks about the behavioural : things I read". start for Canada’s In other circumstances, the remark sciences, has further incensed practitioners of those disciplines. In an health forum might have won points for frankness. But the social and behavioural sciinterview with him in the newsletter Canada’s ballyhooed National Forum on Science & Government Report (Oct ences have long felt neglected by Health got off to an extremely jittery start I noted that the social and behaviourNIH, as well as by other government last week when the provinces all but al sciences "feel you don’t appreciate agencies that support research. Comboycotted its first meeting in an apparent them". Attributing that view to a dispute over chairmanship of the exercise. ing from the newly installed director of NIH, the statement was perceived Faced with the jurisdictional impossibilmisunderstanding of the Times inter-

directingi

1

Reflecting

1

1

Shaky

1

1),

1

1

of

continuing neglect. The sense of grievance was height- 1 ened by NIH’s long history of grudging responses to Congressional directives to expand research on behavioural factors in disease. Experienced in soothing and putting off legislators who want to reshape research priorities, the NIH management has responded in minimal fashion. In 1983, a Senate committee as an

omen

noted that the Institute of Medicine (part of the National Academy of Sciences) had recommended more attention to behavioural factors in disease causation and prevention, citing them as having a prominent role in leading causes of death. The Senate committee urged NIH to put more emphasis on behavioural fac-

1

view, Varmus

went on to

explain that ity

reading

"I said that from whatever I’ve done, and I admit that it’s probably more limited in behavioural science than it is in genetics, that I see

definitive, exciting discoveries being made in molecular genetics these days than I do in behavioural more

sciences". He added that in his reading of behavioural research, "I’ve seen some things I think are pretty interesting". Asked whether

they

"Intellectually on a par with molecular biology", he replied, "I’m were

not sure that’s a fair way to put it. I .,’ find some of it extremely intriguing. I wouldn’t say the intellectual rigor is the same. But then, what is intellectual rigor?" : Varmus added that "you could say

of reforming the health-care system without provincial participation, Prime Minister Jean Chretien attempted to salvage the exercise by arguing that its real purpose was to examine broader issues such as the determinants of health, rather than the operations and funding of the Can$72-billion health-care system. The function of the$12-million 4-year forum, Chretien said in an opening address to its 22 recently appointed members, is "one of leadership in promoting dialogue and debate about longer-term health issues that are neither federal nor provincial". "The key is we have to look at the determinants of health, which have to do with poverty; with unemployment; with poor, inadequate housing; with violence", said forum member Karen Gainer, criminal lawyer and past chair of the Calgary Board of Health. Chretien told reporters that the

1215

made excessive demands for the forum’s agenda and membership. When their request to

provinces control

.

over

appoint five members

was

granted, they

asked to have a co-chair with Chretien. Chretien said his response was, "No, it’s not federal. It’s a national forum presided by the Prime Minister. So we invited all the premiers to come if they wanted. None have come. So, that’s fine; that we were right, right at the beginning, to have this independent forum". But masking the jurisdictional disputes and niceties about who sat at the head of the table are real concerns about how Medicare is to be properly financed in the face of repeated federal and provincial budget cuts. Currently, Ottawa provides $15-2-billion/year for health care or about 22% of the system’s costs. The provinces provide 46% and Canadians, through government and private health plans, cover the remainder. Although Chretien denied the provinces’ allegation that the forum could be nothing more than a smokescreen for further federal cuts, when asked whether Medicare can survive

cuts, he responded, "We’re asking them to tell us. I hope so". Noting that Canada spends 10% of its GDP on Medicare, while Europe spends 7% and the US 15%, he said, "We want to make sure that we’re not losing and they (the forum) will look at the different techniques and so on and they will report". : The forum is scheduled to meet again next month to determine their "action plan" and subjects to be pursued. Among possibilities are the impact of technology and ageing on the health system and research priorities to support health-system renewal. Dr Mamoru Watanabe, former University of Calgary dean of medicine and director of health research at the Medical Research Council, says he hopes fellow forum members will seek to develop a more evidence-based healthcare system through such mechanisms as a coordinated national strategy for health research, particularly with respect to such issues as the cost efficacy of alternative forms of treatment. : more

Urgent revision of GUSTO IIa protocol

The GUSTO IIa (Global Use of Strategies To open Occluded coronary arteries) trial investigators announced last week : that the study was halted in April because of an unexpected increase in numbers of fatal or severe strokes among patients receiving higher-than-normal doses of : heparin or hirudin (Circulation 1994; 90: 1631-37). The dose of heparin was 20% . higher than that in GUSTO I (N Engl J Med 1993; 329: 673-82). GUSTO IIa was a double-blind, randomised trial that began in September, 1993, and it was conducted at 275 hospitals in 12 countries. The premise was that recombinant hirudin, a direct thrombin inhibitor and the most potent naturally occurring anticoagulant, is more effective than heparin when combined with a thrombolytic agent. The primary end-point was death or myocardial infarction within one month. Wayne Kondro Investigators, led by Eric Topol (Cleveland Clinic, USA), planned to recruit childhood immunisation 12 000 patients with defined electroprehensive More research on US increased from$27 to$270 [Pediatrics ; cardiographic abnormalities within 12 h immunisation rates : 1984; 94: 545-47]). Additionally, in a of onset of ischaemic-type chest pain. But an interim analysis among 2564 particiseparate survey of paediatricians and famPresident Clinton’s controversial Vaccines revealed a high incidence of haempants in Rochester (New York), ily practitioners for Children (VFC) programme, which half the doctors said stroke (see table). The overall orrhagic do not the they give this month extended eligibility for free full four-vaccine stroke rate for anticoagulated patients 18 to complement vaccines to over half of the nation’s chilreceiving thrombolytic therapy was 1-8% month-olds in a single visit because it is dren, has renewed interest in the nation’s "too costly" (Pediatrics 1994; 94: 517-23). (n=1264), compared with 0-3% (n=1168) low rates of preschool immunisation (see The among those who did not (p<0001). But those favouring social impediments Lancet July 30, p 324). A primary goal of to immunisation also gained support. In ’, authors noted that these rates are higher OOVFC is to increase immunisation rates than stroke rates reported in GUSTO I regard to missed opportunities to immuto for the 90% most among 2-year-olds (0-7%). In addition, hirudin seemed to nise, researchers in Seattle found that, "critical doses" (1 measles-mumps-rubelconfer added risk. although 82% of white and 75% of black The protocol has now been modifiedla, 3 diphtheria-tetanus-pertussis, 3 oral infants had an adequate number of wellpoliomyelitis, and 3 Haemophilus influen- : baby visits during the first 7 months of ’, first, by lowering doses of heparin to zae b) and to 70% for 3 hepatitis B vacciGUSTO I levels and, second, by reducing life, only 46% of the white infants and nations by 1996. According to the 34% of the black infants were hirudin doses by about 50%. Since the triup-to-date Centers for Disease Control and Prevenin May, a further 3000 al was restarted on immunisation (5’AAM 1994; 272: tion (MMWR 1994; 43: 705-24), 1993 : have been recruited and, accordpatients 1111-15). Furthermore, according to immunisation rates for 19-35 month olds: CDCP, the to ing Topol, investigators "have not yet percentage of infants having at (median: 27 months) ranged from 16% least one missed opportunity in high-risk experienced any safety issues". for the hepatitis B series to 88% for 3 GUSTO IIa was conceived after clinics of Baltimore, Los Angeles, doses of DTP. A premise underlying the encouraging results from small pilot studPhiladelphia, and Rochester was between Clinton programme is that vaccines are 64% and 82%. Indeed, of 25 000 clinic ies with angiographic end-points and was the first large-scale study of the efficacy of prohibitively expensive for many families. visits evaluated, 21% were associated with hirudin and higher doses of heparin. Sceptics reply that under-immunisation is a missed opportunity. Lapses are often more accurately a reflection of problems Some observers have commented that due to physicians’ overestimation of the such as missed opportunities by doctors risk of immunisation more dose-ranging studies should have minor childduring and inadequate patient recall and trackbeen conducted first. The GUSTO IIa hood illnesses. Unavailability of vaccine :: (most often Hib) and physicians’ preferteam themselves conclude that their "finding. New research supports both sides. A ence to limit the number of shots adminings emphasise the importance of safety studies following and complementing report from the American Academy of istered during a single office visit are also Pediatrics (Pediatrics 1994; 94: 508-13) angiographic studies". Topol, who common causes. As to patient recall and finds that half of members surveyed said tracking, nearly half of paediatricians and described these experiences as a "nightthat they referred at least some patients to mare", and his colleagues now believe that two-thirds of family practitioners in one is a very narrow therapeutic window there public clinics. 90% of referring paediatrimid-sized city reported having no system cians said "hardship for some patients to for anticoagulant therapy in conjunction at all, and fewer than 10% maintain either with pay for the vaccine in a private setting" the thrombolysis. or "tickler file" to task a computer up was a "very important" reason for refer: Controversy surrounds the late release (Pediatrics 1994; 91: 517-23). ral. Moreover, 43% said their number of of this information, 6 months after the such referrals rose in the past 10 years. risk of bleeding was first discovered. An article in the New York Times (Altman LK, (During this period, the cost of com- David H Frankel

.

.

:

1216