TheMillerCircle.org

A recent report published in the Proceedings of the National Academy of Sciences (PNAS) has compared the history of funding levels for the National Institutes of Health (NIH), with improvements in the health of United States citizens over a period that goes back more than fifty years. The historical dilemma facing our society is threefold: 1) when programs like Social Security were passed in the 1930s, the life expectancy in the United States was about 50 years of age, so most Americans at that time did not live long enough to begin collecting from that Federal program–that has changed; 2) when the baby boomers start to retire in 2010, large numbers of seniors will move through our system, aging our work force and stretching the mean age of our population until 2034 and 3) the aging of our workforce implies that we must maintain a healthy population of seniors who seek work for a variety of reasons, one of which will be a growing dependency on their work contributions.  Investments in research show that these objectives can be met by increasing the resources we allocate for research, which has a direct influence on building our economy and insuring increasingly healthy seniors as important members of the work force. Many previous studies have argued that we need to increase research funding by at least a factor of 4. Asia investments in research  now surpass those of the United States and will grow more rapidly as their rate of investment is much higher than that of our own. We are falling seriously behind in our investment strategy which is needed to support an affordable social safety net and a healthy, aging workforce.

During the first half of the 20th Century, improvements in public health, sanitation, nutrition and better medical care advanced life expectancy until today, as it hovers around age 77, with a few years difference between men and women (by life expectancy criteria, the male is the more fragile gender). Once a majority of citizens began reaching advanced life expectancies in the latter half of the 20th Century, the nature of diseases changed from acute to chronic.  In the 1930s medical care issues were more focused on diseases like infections caused by pathogens and less attention was paid to chronic diseases like cancer. A famous case illustrates the point: in the 1930s, a pathologist at Washington University in St Louis called all the pathology residents in to see a special rare case brought to autopsy. The residents were told they would probably never see another like it, so the chief pathologist wanted them all to get a good look–it was a case of lung cancer!

In the last half of the 20th Century, the increased longevity of Americans introduced new diseases, including cardiovascular disease, many types of cancer, type II diabetes, kidney disease, increased incidence of stroke, high blood pressure and chronic pulmonary diseases. Many of these diseases reflected life-style decisions, such as smoking and dietary habits, which were improved through research and education. Americans began living long enough to shift the balance of disease focus from acute to chronic. It was during this early disease transition that the National Institutes of Health got going in a substantive way. NIH traces its history all the way back to 1887 when the U.S. government created the Marine Hospital in Staten Island, New York. The purpose of the first National Institute was to verify that bacteria caused disease, which, at the time, was a new theory.  The National Cancer Institute (NCI) was formed in 1938, while the beginning of the modern form of NIH began in 1948 with the formation of four additional institutes, including The National Health Blood and Lung Institute (NHLBI), formed to deal with the newly emerging problems in circulatory and pulmonary diseases in the postwar era. Epidemiological research was sponsored by NHLBI to better understand the importance of behavioral and nutritional inputs and to also promote better health care through control of risk factors. The other institutes formed in 1948 included The National Institute of Allergy and Infectious Diseases (NIAID), The National Institute of Dental and Craniofacial Research (NIDCR) and the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK). Many additional institutes were added later until 2000, when the most recent National Institute of Biomedical Imaging and Bioengineering (NIBIB) was established as the 27th Institute comprising NIH.

A group led by Kenneth G. Manton carried out an extensive analysis on the impact that NIH-funded research has had on the health of Americans, analyzed by the death rates attributed to major diseases. Figure 1 was taken from their paper: it shows the overall relationship between NIH funding and the age-adjusted death rates for four prominent types of diseases, including cancer, diabetes, heart disease and stroke. Each of these disorders has their own separate history, so interested readers should consult the Manton paper for a more detailed analysis of the data.

NIH funding correlations with heart, stroke, diabetes and cancer deaths

Although NIH as a multidiscipline organization was formed in 1948, it did not receive significant funding until the mid-1950s, when the Sputnik satellite was launched by the Russians and served as a big stimulus for additional funding (Mary Lasker played a major role in shaping the politics of research funding in the 1940s and 1950s–hence the Lasker Prize, probably America’s most prestigious award for medical research). As the figure illustrates, for all diseases except diabetes, there is a correlation between NIH funding and improvements in the death rates of these four disease areas. However, they are not all the same and the most recalcitrant disease, cancer, did not begin to decline until the 1990s when the convergence of newer methods for diagnostic and treatment capabilities began to impact on death rates. Since 1990, there has been a 16% drop in the death rates attributed to cancer. Perhaps the most discouraging result has come from diabetes, which showed an early drop in the 1950s (not very detectable on this scale), when better recognition of the disease and better glucose control methods were introduced. But then in the late 1950s, we discovered type II diabetes and diabetic deaths began to climb, partly from recognition of Type II, but also because of the rise of obesity in America which exacerbates diabetic symptoms and can precipitate the onset of type II diabetes. One can expect significant improvements in diabetes death rates by improving the life-style changes associated with our current epidemic of obesity–the fast food/American diet disease.

Perhaps the most interesting graph in the Manton paper is that of Fig 2, again taken from their paper (Fig 4). That graph plots the age-adjusted mortality rates in the United States (dotted line presented as the least square fit) as a function of the 0verall  NIH funding (in 1938 $) but lumped and  lagged by 10 years to better coincide with the research delay that typically exists between research funding and a useful clinical application. In this case, the graph demonstrates four major shift parameters, including the modest slope during NIH formation (1950-1969), followed by the steeper slope when NIH funding began to have a significant impact on mortality rates. The NIH budget growth between 1970-1989, stimulated by Nixon’s war on cancer, was followed by the modest plateau in 1990-1997, followed by a doubling of the NIH budget from 1998-2003, the impact of which is yet to be fully appreciated in terms of mortality rates.You can look at Fig 2 and derive the number of deaths that have been averted by the influence of NIH funding. While initially modest, between 1998 and 2004,  the number of deaths averted by NIH funding amounted to 1.47 million. The average number of deaths  averted per annum from 1950 to 1969 is only 60,000, due primarily to the incidence of cardiovascular disease. The authors admit that some of the averted deaths attributed to NIH funding could be the result of the carry-over influence of public health and nutrition improvements prior to the establishment of NIH. However, nutrition improvements have carried a double whammy–the first of which improved health, while the second round has led to increased obesity rates and another phase in health problems related to diabetes and cardiovascular diseases, including the effects of high blood pressure.

The proportion of GDP spending associated with NIH funding reached its peak in 1962 at 0.33% and declined to 0.3% in 1974 and 0.16% in 1997, its post-1960 low water mark. In contrast, today, China  incrementally increased its research budgets by 17%.

The researchers in the Manton article concluded that increased funding to NIH would be a stimulus to the economy and have the additional benefit of further reducing chronic disease, particularly among the elderly, where such problems are more prominent. One of the major implications of this paper points towards the impact of NIH funding on its ability to extend, not just the life expectancy of Americans, but also the general health of senior citizens,  so that they can stay in the workforce  if required (an increasingly likely possibility).  Failed pension systems, dwindling 401k retirement plans and the job loss rates of the past few years have all placed greater emphasis on working longer to support our expanded life expectancy. This study points out that increased funding through NIH can be expected to not only contribute to further extending life expectancy, but also provide seniors with greater health in their later years and an increased capacity to engage in work and retirement activities.

Previous studies have estimated that the declines in U.S. mortality rates from 1970 to 2000 were worth $95 trillion or $60 trillion after subtracting the health care expenditures–not a bad trade-off. Half of that financial benefit came from health improvements that reduced cardiovascular disease mortality. Put another way, the reductions in death rates attributed to research in this period, increased the value of a single person by 18% in the year 2000. By the same logic, a 1% reduction in mortality rates for cancer would have a value of $500 billion, meaning that the observed cancer rate declines are worth $5 trillion. Improvements in health generated by investments in research add value to the quality of life and to the productivity of seniors, many of whom will have to work beyond the normal retirement age of 65. I will be 70 this year and I’m still going strong! No doubt many of you feel similarly.

Data that goes back to the civil war suggests that the improvements we have made in public health and nutrition  have increased the average size of Americans and enhanced their cognitive capacity by increasing IQ by 25 points from 1918 to 1995. There is also evidence to suggest that measurements of health quality are increasing faster than the improvements in longevity, indicating that people who live longer are having an increased capacity to enjoy their enhanced longevity. One message from these studies is clear–don’t go into your senior years carrying a lot of extra weight–lean is keen!

RFM