The recent congressional appropriations hearings on the fiscal year 1996 budget for the National Institutes of Health (NIH) provided a good opportunity to reflect on the status of biomedical research in general and the goals and achievements of the National Heart, Lung, and Blood Institute (NHLBI) in particular. Facing appropriations subcommittees with many new members, new leadership, and an ambitious agenda for the American people, how could we best convey the importance and promise of the work that we do? We have gained so much mastery over cardiovascular, lung, and blood diseases that their significance and urgency sometimes get lost in the face of other threats to the public health. Indeed, the first question asked of me by the House Appropriations Subcommittee was: Is your institute a victim of its own success?
Of course, we take much pleasure in enumerating the successes of our programs; certainly, they have been unprecedented in the history of chronic disease. Consider the fact that between 1970 and 1993, age-adjusted coronary heart disease death rates declined 53% and stroke death rates declined 60%. Moreover, favorable recent population trends in major risk factors for cardiovascular disease (eg, blood pressure, serum cholesterol, and smoking) suggest that continued reductions in death rates will be achievable. We have also enjoyed considerable success in the area of infant mortality as a result of research on neonatal respiratory distress syndrome, and we have improved life expectancy for people with inherited diseases, such as cystic fibrosis and sickle cell anemia, that previously claimed their victims in childhood.
Nonetheless, as the readership of this journal well knows, there is still much work to be done. About half of the deaths that occur in this country each year have their origins in cardiovascular, lung, or blood diseases. Of even greater concern is the protracted disability and considerable expense associated with these chronic diseases. For instance, we now have a growing population of survivors of myocardial infarction who are at high risk of developing congestive heart failure. This condition not only compromises quality of life but also generates enormous healthcare costs. This is a compelling thought, given the current fiscal climate.
As might be expected, the economic benefits to be gained from government support of biomedical research constituted a major theme of this year’s hearings. As NIH Director Harold Varmus testified, “Because the nation’s expenditures for health care have risen dramatically over the past decade, largely for reasons unrelated to NIH-based research, the savings provided by our discoveries are often overlooked.” In this light, the NHLBI was pleased to report findings from several recent studies that exemplify the contributions that research can make to reducing the human and monetary costs of disease. For example, the NHLBI-supported Multicenter Study of Hydroxyurea in Sickle Cell Anemia recently established the benefits to be gained from use of a simple, safe treatment for sickle cell disease. The trial came to a conclusion ahead of schedule when it was determined that daily use of the drug hydroxyurea greatly reduced the occurrence of painful crises and associated hospitalizations, decreased episodes of acute chest syndrome, and reduced the need for blood transfusions. These findings are expected to have a large impact on the cost of caring for patients with sickle cell disease.
The Postmenopausal Estrogen/Progestin Interventions trial (PEPI) established the beneficial effects of hormone replacement therapy (HRT) on cardiovascular disease risk factors, including HDL and LDL cholesterol and fibrinogen levels. Use of unopposed estrogen was associated with endometrial hyperplasia among study participants who had a uterus, but this condition did not occur among women taking any of three estrogen/progestin combinations. Although proof of the cardiovascular benefits associated with HRT awaits the outcome of trials with clinical end points, PEPI provides important information for women who are considering use of HRT to lessen the risk of heart disease. The cost savings associated with forestalling development of heart disease in postmenopausal women are potentially very large.
A final example is the recent development of a highly sensitive, rapid assay of subforms of creatine kinase–MB to diagnose or rule out acute myocardial infarction. Use of this assay in emergency rooms is expected to reduce unnecessary admissions to coronary care units, currently estimated to cost the nation $4 billion per year.
The Congress readily appreciates one message that comes from these examples: that a vital avenue for cost savings is prevention. A less obvious but critically important message is that these very practical achievements were possible only because the groundwork had been laid by prior achievements in basic science. Similarly, our ability to meet new public health challenges hinges on the extent to which we nurture our fundamental knowledge base. This approach has worked in the past, and we are committed to its continuation in our future endeavors.
- Copyright © 1995 by American Heart Association