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.k ,,'..-'4P V Journal of Public Health Policy _ 4/4 Dec. 1983 The Paradox of the Missing Institute EDITORIAL r THE nation's Institutes of Health comprise a total of fifteen institutes, located as follows: National Institutes of Health National Cancer Institute National Heart, Lung and Blood Institute National' Institute of Allergy and' Infectious Diseases National! Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases National Institute of Child Health and Htiman Development National Institute on Aging National Institute of Dental Research National Institute of Environmental Health Sciences National Institute of GeneraI Medical Sciences National Institute of Neurological and Communicative Disorders and Stroke National Eye Institute Alcohol, Drug Abuse, and Mental Health Administration National Institute of Mental Health National Institute on Alcohol Abuse an& Alcoholism National Institute on Drug Abuse Centers for Disease Control NationaP Institute for Occupational Safety and Health It is instructive to compare this list, which is based largely though not entirely on diagnostic categories, with the most recent estimates available on the economic cost of illhess in the United States, prepared by Barbara Cooper and Dorothy Rice for the year 1972 (1). The table below, which presents their findings„ provides a welcome antidote to the common prac- tice of using mortality alone as the measure of importance. It is worth 394 .

S EDI'TORIAL • THE PARADOX OP' THE MISSING INSTITUTE 395 Kr . noting that mental' illness, which never appears in the list of leading causes of death, ranks sixth in total costs of illness, disability, and mortality. Fur- thermore, the triad' of "heart disease, cancer, and' stroke," widely publi- cized by a Presidential commission as the most important of all health hazards because they are the three leading causes of death, turns out some- what differently when the effects of illness and disability are added to the equation. Cancer falls into fourth plhce, stroke bccomes seventh in impor- tance, and only heart disease maintains its dominant position. Total econotnic costs, with present value of lifetime earnings discounted at 4%, by diagnosis, United States, 1972 Total costs Direct Indirect costs costs Morbidity Mortality Total (in millions) $188,789 $75,231 S42,323 571,235 Diagnosis Percent distribution Total ioo.o 100.0 100.0 ioo.o Disease of the circulatory system 21.2 14.5 15.2 31.9 Accidents, poisonings, an& violence 14.1 6.8 9.2 24.8 Diseases of the digestive system 9.3 14.8 6.2 5.3 Neoplasms 9.2 5.1 2.0 17.7 Diseases of the respiratory system 8.7 7.9 i6.7 4.8 Mental disorders 7.4 9.3 14.6 1.1 Diseases of the nervous system and sense organs 5•8 7.9 9.3 1.5 Diseases of the musculoskeletal system and connective tissue 4.7 4.8 12.1 .3 Discases of the gcnitourinary system 3.4 5.9 3,0 1.0 Endocrine, nutritional; and metabolic diseases 3.1 4.6 2.7 1.9 Infective and parasitic diseases i.8 1.9 2.8 1.2 Complications of pregnancy, childbirth, and thr puerpcrium 1.6 3.5 .6 .1 Diseases of the skin and subcutaneous tissue 1.1 2.0 1.1 .1 Congenital anomalies 1.0 .5 .6 i.8 Diseases of the blood and blood-forming organs .5 .7 •5 •3 Other 7.0 9.8 3.5 6.2 wr-

r 396 JOURNAL OF PUBLIC HEALTH POLICY • DECEMBER 1983 '~ Perhaps the most striking fact that emerges fromi the table is that acci- dents, poisonings, and violence are second only to diseases of the circula- tory system in total economic cost to the nation, accounting for 14% of total'costs, or almost S27 billion~in 1972. They were responsible for 7~/o of direct costs for medical care, 9% of indirect costs due to disability resulting from illness, and a staggering 25% of indirect costs due to premature death. Despite their crucial' importance to the health of the nations injuries remain to this day a neglected and forgotten area of public health concern. It is a curious paradox that, although they constitute the second most important cause of illness, disability, and premature death in the United States, injuries are hardly recognized in the nation's health services. There is no National Institute of Injury Prevention. Most of the National Institutes of Health were established as the result of the interaction of special professional interests and the concerns and demands of public constituencies. In each instance the clinical and research specialists in the politically powerful medical schools and teaching hospitals played a major role in achieving establishment of the institute for their special area; this institute was essential to fund their research an& teaching programs on a scale far beyond their previous hopes and aspirations. In each instance, however, the creation of the institute could not have been successful were it not for the strong demand by the general public for action against cancer, heart disease, and other hazards to health. Parentheti- cally, it was the ability of the research establishment in the medical schools to capture public support that grossly distorted federal health policy, with billions of dollars going into medical research that was often wasteful and unproductive, while effective public health measures for the prevention and control of the very same diseases were downgraded, poorly funded, and almost totally neglected. There are two apparent exceptions to the general pattern. In the estab- lishment of the Narional'. Institute of Environmental Health Sciences and the National Institute for Occupational Safe ty and Health, professional in- terests were much less important; the prime mover in each instance was the public constituency, led in the first case by the organizations concerned about the environment, and in the second by the labor unions. It is perhaps significant in this regard that these are the only institutes that have been located far from~ the centers of power and authority in the Washington health establishment-NIEHS in North~ Carol inaand NIOSH in Georgia. The paradox of the missing institute-the failure to establish a National

C EDIiTORIAL • THE PARADOX OF THE M•ISSINC INSTITUTE 397 Institute of Injury Prevention-can now be understood, at least in part. There is no medicalischool department with a specific interest in research and teaching in the prevention of injuries. The only professional group that could! provide significant support for a National Institute of Injury Prevention is the public healtli movement. Though politically weaker than the medical schools an& their research establishment, it has the potential of playing a key role in this issue. The public health movement can help assure that national health policy will no longer neglect the second most important cause of disability and death. It can work for the establishment of a National Institute of Injury Prevention to develbp and support intramural and extramural research in the epid'emiology of injuries, and'field trials and demonstrations to test the effectiveness of different methods and approaches to prevention. Even more important, it will see to, it that this insdtute will be part of a total program of injury prevention, oriented primarily to the community appli- cation of research findings in the interest of the public. This will require federal aid to the states for injury prevention programs, as well as aid to the schools of public health not only for research in the epidemiology and prevention of injuries, but for the training of specialists in injury preven- tion to help develop effective programs in the states and localities. The amounts needed will be modest by the standards of the existing institutes. The most: important factor in achieving these objectives will be the concern and support of the general public. That such support will be forthcoming is abundantly clear. There is now an upsurge of popular demand for political action on major issues of injury prcvention, such as airbags and child restraints in automobiles, prevention of driving while intoxicated, effective handgun control, and the passage of cigarette safety acts. What is needed' is leadership which will weld together an effective coalition of the organizations representing the general public with those involved in the public health movement. That coalition~ can end the para- dox of the missing institute and ensure that the prevention of injuries will become a major priority in the health policies and programs of the nation. REFERENCES i. Cooper, B. S., and! D. P. Rice. "Thc Economic Cost of Illness Revisited," Soc. Sec. &ill:, February 1976, pp. 21-36. ±... Q ~~ W •. ~f t r'7h • - --.- ..-.._ - --- ~' --- - - -- --- -- ~ . .. .3-~- c..