Dr. William Raub Oral History 2008

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NINR History Project Telephone Interview with William F. Raub

Conducted on May 21, 2008, by Philip Cantelon

PC:     The interview today is with William F. Raub, R-A-U-B, on May 21^st, 2008. I have your permission to record the call?

WR:    Yes you do.

PC:     Thank you very much. I’d like to turn the clock back a few years to the mid-1980s when you were first deputy director of NIH. Do you recall the Institute of Medicine report on nursing?

WR:    In general. I recall very few of the details of it now.

PC:     One of the details was recommending a national institute for nursing research, buried in the back to be sure, but there. And of course the nurses focused on that for a campaign over the next couple of years in Congress, primarily, for a national institute. At that point, I think, Dr. Wyngaarden was the director of NIH?

WR:    Yes.

PC:     Was there much discussion among the officials at NIH regarding this legislation and their views on it? This would be between ’83 and ’85.

WR:    I think in general it was against a backdrop of other recommendations for other new NIH entities.  So first of all, the recommendation about an institute of nursing research was one of a series of things that various advocates were pushing for new institutes or new expanded names for existing institutes, along that line. So first off, there was that general background noise. Second, I think there were many at NIH who thought nursing research fell outside the NIH mission, having more to do, in their view, with health services activities than it did with fundamental science. A third confounding issue was that early on, many of the advocates of nursing research were not clear as to what they were advocating. So for many of them, it came out sounding like nursing research is anything in which a nurse is engaged as an investigator. And some of the more unfortunate examples in terms of making the case for the institute were those where it was a nurse who also happened to have a Ph.D. in physiology and who was doing laboratory animal experimentation, and many at NIH I think correctly said that’s not nursing research. Now there were a few of us who were advocates of the idea of an entity for nursing research, and of course it began as the center and then later was transformed to an institute. One of my allies in this was Don Lindberg in the National Library of Medicine, for example.

Don and I and a few others felt strongly that health services research always was and should have been part of the NIH mission, that nursing was only part of that, but a very important entrée for NIH into those questions that had to do with the efficacy of certain clinical procedures, with the effectiveness and efficiency of certain health care activities. And nurses, important as they are to the health care institution, were perfectly logical to lead much of that research effort and to be a thin end to the wedge in terms of regularizing and making more visible that part of NIH’s involvement in that end of the spectrum, the other end of the spectrum being undirected basic science. So at least from my point of view, I was pleased to see the nursing center idea emerge, creating an NIH entity which then could demonstrate, as it did, that it had a proper place there, that there was an important set of clinically oriented research questions that had to do with important facets of health care delivery to which nurses were central.

PC:     In 1985, was it the official policy of NIH to just let Congress do what it wanted and adjust thereafter?

WR:    In a way, that’s always been NIH’s policy about everything.

[Laughter]

WR:    This is one we may need to edit. NIH has always been very responsive to the will of the Congress. I don’t know, I just don’t remember whether NIH or higher levels of the administration ever actually formally opposed the creation of the nursing center. It’s possible that happened, I just don’t remember. If it was, I wasn’t involved in it. From time to time, there would be a letter when other notions were proposed, a national back institute, for example, where the administration made its opposition known to those in the Congress who were promoting it. So it may be, and the historical record may show, that somewhere there was actually a formal opposition by either the executive branch or more specifically the Department of Health and Human Services, or maybe even the NIH. I don’t remember any.

PC:     Well, the president vetoed it. That’s a pretty strong opposition.

WR:    Vetoed it as the institute or the center?

PC:     Both.

WR:    I’m just drawing a complete blank on that.

PC:     The initial opposition was an institute, so they changed the legislation to read center, and without really changing the role or responsibilities. Then it was passed over the president’s veto.

WR:    I just don’t remember NIH being very fussed up about any of that.

PC:     Let me just shift ahead then a little bit, because the person selected to head the center was a woman named Dr. Doris Merritt. Do you remember her?

WR:    Very well. In fact, I was instrumental in recommending her as—it was really acting. I was instrumental in recommending Doris as the acting head of the center as part of wanting to ensure it got off to a good start until there was a proper recruitment.

PC:     Why her?

WR:    She was in the Office of the Director, NIH, was a long experienced academic clinician with a very broad mind and an open view, and actually somebody who saw the importance of nursing research. Jim Wyngaarden had a lot of confidence in Doris as well, knew her independently of her working with me. So both of us viewed it that we could count on Doris to give a hundred-fifty percent effort that the nursing community would see as supportive. Now there may well have been some initial concern with Doris as a physician doing it, but I think Doris quickly set any of that to rest. I’m now recalling at a later time where Doris was actually honored by one of the nursing groups for her contributions to the launching of the nursing center.

PC:     I think it’s no secret that space on the campus is . . . well I guess it’s harder to get space there than it is to get a ticket to the coronation of the queen. How did she pull that off?

WR:    You mean the space issue?

PC:     Yes.

WR:    If I’m remembering correctly, the original locus of the office was over in the Lister Hill complex. Is that right?

PC:     Yes.

WR:    That’s what I’m remembering.

PC:     Is Lister Hill Building 1?

WR:    Well, Building 1 was where Doris was at the time.

PC:     Then to 31?

WR:    I’m not remembering anything about 31. What I am remembering is some office space over in the—it’s the National Library of Medicine complex—

PC:     Oh, okay.

WR:    —that the first appointed director, Ada Sue Hinshaw, had, and I think Doris was instrumental in getting that established. And I think that was just NIH being a good citizen of giving—there had been a decision that there would be a nursing center, that NIH was going to make reasonable provision for it. And I think some of that was no doubt the support of Don Lindberg who saw the importance of this dimension to the NIH mission, and so was helpful to Doris and then later Ada Sue in getting that started.

PC:     In terms of the NIH being what I would call bench science, I guess, as opposed to the nurses would be more behavioral, would I be misusing a term there? There always seemed to be a tension between . . . .

WR:    Well certainly. Then and now, much of the NIH orientation is to basic science, meaning life processes, and a lot of it oriented to laboratory and clinical investigation. Many of the early advocates of nursing research were focused on behavioral studies. But early on in the tenure of the national center, while there’s nothing wrong with the behavioral studies, it became—I think Ada Sue and others demonstrated that that wasn’t the limit of it, that there were in fact proper clinical studies involving assessments of various kinds of clinical interventions, were in every bit as rigorous clinical trial of that could be carried out as let’s say a trial of a new drug. So I think one of her contributions was trying to broaden the spectrum, not to disown or disavow some of the tradition on behavioral measures, but try to get it away from the stigma that that’s what it is. Essentially it could be research on anything that nurses do. And that’s why I keyed on the health services aspect, that to me, the opportunity that was there and I believe the early leadership seized it was to try to address the health services question.

PC:     Was there any discussion within NIH about keeping all of this at HRSA and the Division of Nursing?

WR:    Early on there were certainly some at NIH who—they didn’t see it as part of NIH’s mission and therefore thought that the Division of Nursing at HRSA was the logical place for it.  There were those at HRSA who thought it was too researchy to be at HRSA.  But it was more people looking in the rearview mirror as to where their agencies had been, you know, than looking ahead as to what the opportunities were.

PC:     So once the center became established under Merritt, the idea was to provide grants for research. But to do that, doesn’t each institute have to have an advisory council?

WR:    Correct.

PC:     And those are political appointments? Would that be a correct statement . . . or it takes a while to vet the—

WR:    Specifically, every institute has a national advisory council. The members are appointed by the secretary, but they’re appointed based on recommendations that come to the secretary from a variety of sources, but primarily from the NIH. So I think it’s incorrect to characterize the councils as political. The councils do have a responsibility to look at the agency priorities and the departmental priorities. But I would not characterize any of the councils as political in the sense of partisan political.

PC:     But if you were starting a council, how long would it take you to get one?

WR:    There’s no right answer to that. What’s involved is a set of procedures under the Federal Advisory Committee Act that are coordinated by the General Services Administration.

So for any component of NIH, it could take easily months or more to do it because there has to be a charter approved, there has to be budget provided for it, and then there has to be a slate of nominees that go through a process, and I’ve seen some take a year.

PC:     So there is a vetting process kind of thing?

WR:    Sure.

PC:     Okay.

WR:    That’s true of every component. That’s as true of the National Cancer Institute as it is true of the National Institute for Nursing Research.

PC:     I understand that. But when you have the first one, the issue confronting—

WR:    It’s harder.

PC:     What I’m told that happened is that the advisory council from the Division of Nursing, or people from that advisory council, were borrowed from HRSA to give the National Center for Nursing Research an advisory council so it could make grants once the funds were in place. Would that be accurate?

WR:    I don’t know. That doesn’t ring a bell specifically, but that wouldn’t surprise me.

PC:     But it would be possible—

WR:    It would be possible

PC:     —because it’s already a vetted advisory council under the act.

WR:    Yes. And it would actually be evidence of the intent of the administration to try to get something done, rather than be paralyzed by some administrative procedure.

PC:     One of the things that both Merritt and Ada Sue Hinshaw tried to do were work collaboratively with other institutes. At that time, I guess by then you were or would soon become acting director of NIH?

WR:    I was acting director from 1989 to 1991, so for some of that period, I was either deputy or acting director.

PC:     Is that something that the director or acting director would encourage or was it left to the individual institutes?

WR:    I actively encouraged it. I thought it was especially important for nursing research for two reasons. One is the subject matter was such that it could touch one or more of the institute’s categorical missions, you know, of heart disease or diabetes or so on, where other of the themes were more generic in terms of, again, health services issues. But also I thought it would be a good way for the rest of NIH to accept this new member of the flock. Doris was very attentive to that from the first day, as was Ada Sue as I remember it, and both had the intellect and the personality that every recollection I have is the other institute directors not only received them graciously, but actually were impressed with them. I’m not recalling many details after all these years, but I think there were some genuine collaborations.

PC:     Yes. Indeed there were.

WR:    Now left to their own devices, the institutes don’t do a lot of that because they tend to be stove-piped and categorical is I think the NIH buzzword. But there are very important exceptions where institute directors have reached out to others and formed some very important collaborations. Most recently, Elias Zerhouni has put a lot of effort into defining certain crosscutting themes for NIH like neuroscience, for example, and has a number of institutes operating under a collaborative structure. They’re still independent, they still have their own budgets, they haven’t given up any sovereignties so to speak, but I think Elias has been very effective in getting some of them to recognize that they’re part of a larger common neuroscience mission.

PC:     With the national center, do you recall whether there was a constant push to create that into an institute?

WR:    Yes. I had frankly forgotten all the issues of the vetoes and things before it came on NIH’s screen. I appreciate you reminding me of that. But I recall very vividly that for many of the advocates, the notion of a center was only a way station.

PC:     And by advocates, you mean by the nursing—

WR:    Yes. The advocates, particularly the nursing community and that it would not be seen as having full standing at the NIH unless and until it was a national institute. Now again, that’s a common issue. The National Center for Research Resources, for example, has never made it to institute status. It doesn’t have the same kind of constituency.

PC:     The nursing constituency is pretty broad, as someone said, in every congressional district.

WR:    I think there used to be a bumper sticker something to the effect of one out of every twenty voters is a nurse.

PC:     Pretty effective. [Laughs]

WR:    But they were good at what they did, and they got the attention, both from the Congress and the administration. But again, other groups have been comparably successful.

Diabetes was not in the name at any institute until the seventies, and it was outside advocacy that changed that.

PC:     Well, there was a good deal of outside advocacy for a number of these institutes, I think the one that was formed about the same time, musculoskeletal.

WR:    Exactly. And some of the renamings were a response to requests for separate institutes, but a feeling that NIH would be so fragmented it wouldn’t be able to function, so many of those multi-named institutes are the manifestations of compromise for people who really wanted a separate institute.

PC:     Remind me, when Wyngaarden left, there was a period of time in which there was no director and you were acting director—

WR:    Yes. Two years.

PC:     Two years, and the reason for that was . . . ?

WR:    Abortion. There was then interest in using human fetal tissue for transplantation. The underlying issue is exactly the same as the stem cell debate now, the moral status of the human embryo. So basically, nobody wanted the job.

PC:     And the first person who took it finally, was it Sullivan first?

WR:    Dr. Healy. Sullivan was secretary.

PC:     I’m sorry. Sullivan came in as secretary, and Healy came in. She was an advocate for the nurses?

WR:    I’d say so.

PC:     And it was under her that the changes came to be.

WR:    The changes meaning the transition—

PC:     Transition to the institute—

WR:    Yes.

PC:     —under the next extension of legislation. What other issues can you recall that would be of interest that I haven’t brought up here?

WR:    Some of the issues were in training. I’m not remembering a lot of the details, but the scope and the volume of what the training program should be. I gave you the earlier example of some of the advocates viewed any research that a nurse did as nursing research, and that spilled over into the debate of research training. And while the program came out broad, and again, I’m forgetting a lot of details now after all these years, but I think one of the challenges of the training program was not to take the easy road of well, you can get a Ph.D. and become a laboratory scientist, but rather try to keep nurses in nursing and in nursing education and in nursing science, more into clinical milieu. And so a lot of the early struggle was finding places where that kind of training even could happen, you know, where there was enough of an intellectual and academic base that schools of nursing in fact had enough of a research tradition that they were able to train more of such people. That was one of the early challenges that Doris and especially Ada Sue had.

PC:     Right. And there were a few universities who could do that, but not a lot at the time.

WR:    That’s right. But it followed the same history that the rest of NIH had. The early days of NIH’s growth in the fifties, there weren’t many academic centers that could turn out the research people either, and NIH’s training grants transformed the academic landscape.

PC:     And they did the same for nursing.

WR:    Yes. So the nursing followed in miniature much the same model that NIH at large had carried out, say, forty years before.

PC:     Interesting. They were sort of divided between the nursing education schools, even the graduate education as opposed to junior college nursing program schools, which were largely part of the Division of Nursing’s training ideas or education ideas. Well that’s very helpful. Anything else?

WR:    I think that’s about it. I think most people as I’ve talked to over the years feel good about what came about from that period.

PC:     Did you ever run into a congressman named Carl Pursell?

WR:    Oh yes.

PC:     Is he still alive?

WR:    I don’t know. I haven’t had any recent contact.

PC:     Okay. I’ve been trying to track him down. I just thought I’d take a stab at that, too.

Well, I want to thank you very much, and I will have that in the mail to you this afternoon.

WR:    Okay.

PC:     I appreciate it. If I have any more issues, do you mind if I give Sheila a call back and check in?

WR:    Not at all.

PC:     Okay. Thanks very much.

WR:    Okay. Very good. Bye.

PC:     Bye.

[End of interview]