The people's agenda
How public-private partnerships can advance cardiovascular research
In separate interviews with Lens editor Bill Snyder in 2007, Elizabeth G. Nabel, M.D., director of the National Heart, Lung, and Blood Institute (NHLBI), and Rose Marie Robertson, M.D., chief science officer of the American Heart Association (AHA), discussed the challenges in the fight against heart disease and stroke, and the value of collaboration.
Nabel is a well-known cardiovascular researcher who was chief of Cardiology at the University of Michigan before joining the NHLBI in 1999 as scientific director of clinical research. She was named institute director in 2005. Robertson is a professor of Medicine at Vanderbilt University School of Medicine. A long-time researcher and AHA volunteer, she served as the association’s president in 2000-2001, and has been its chief science officer since 2003.
Death rates from heart disease and stroke have dropped by about two thirds in the past 30 years. What can we expect in the next 30?
Nabel: The dramatic drop in coronary heart disease… is largely due to identification of risk factors for heart disease and implementation of primary and secondary prevention programs. But… we have not been fully successful in implementing (them) ... We need more research to understanding the social and behavioral reasons why we haven’t.
If everyone in the United States fully knew their risk factors for heart disease and fully implemented risk factor modification or reduction, could we eliminate heart disease in this country? I would predict that we probably could, except perhaps for those cases where there’s a clear genetic cause of heart disease.
Robertson: Surely we will be able to better direct our interventions, of whatever sort they are—lifestyle improvements, drugs, devices, other new therapies—because we’ll better understand the people to whom we’re delivering them. We’ll understand the genetic makeup of individuals and which interventions will most benefit them.
However, there are a number of aspects of heart disease that continue to be related to lifestyle, and so individuals can outdo our best efforts with drugs and devices if they don’t eat well, exercise and avoid smoking.
And of course we have so many people who have no access to health insurance. If that isn’t improved, there will be millions of people who may not benefit at all from whatever benefits we derive from biomedical research.
We need to fix that; people need to have access to the benefits that we can provide. I actually am encouraged that there seems to be more public will to address that issue than there has been before.
Which areas of research do you think will be most fruitful, and why?
Nabel: We’ve just initiated a clinical cardiovascular stem cell network to conduct in a collaborative way clinical trials in stem cell therapies for cardiovascular diseases ... Vanderbilt is one of those centers…
Personalized medicine is another area that we’re very keen on. We’re very interested in understanding genetic susceptibility to heart disease and we’re doing this by sponsoring a number of genome-wide association studies, to understand the genotype of individuals who develop heart disease.
We’re putting a lot of research dollars into molecular imaging to try to image vulnerable plaque or blockages within blood vessels.
And then the whole area of biomarkers: There are some people who do not have any of the established risk factors who still develop heart disease. (They) may have risk factors that we just haven’t identified yet. So much of biomarker research will really be focused on trying to identify these new risk factors.
How has the flattening of the NIH budget affected your research agendas?
Nabel: It causes us to really think hard and focus on our priorities and on our core values.
About 70 percent of our budget goes towards investigator-initiated research… grant applications that investigators submit based on their own ideas ... We will continue to support investigator-initiated research to the best level that we can.
Second, we want to support new investigators… new faculty members who are applying for their first RO1 (research project grant)… As a third priority, this year we are helping first-time RO1 investigators who are coming in for their first competitive renewal…
NHLBI (also) has an important role to play in sponsoring randomized clinical trials, and addressing important questions that really impact public health and wouldn’t be funded by the pharmaceutical industry…
We found that the use of a daily diuretic, which costs pennies, is just as effective as the more expensive, more sophisticated anti-hypertensives. That’s not a study that a drug company is going to do. But it’s a study that we did… We felt that it was important to ask that question.
(We) are continuing to support our clinical trial networks, our large, population-based studies like the Framingham Heart Study, the Jackson Heart Study, our Hispanic Cohort Study, and… our personalized medicine program. We have many more initiatives that we would like to fund, (but)… when times get tough like this, progress in research is… slowed.
Robertson: In our strategic planning there continues to be a strong feeling that the AHA needs to be the resource for early career development, and there needs to be a commitment to and focus on the young investigator… We think that’s critical for the future, and many research stars of today, including Nobel Prize winners in cardiovascular research, got their start with an AHA grant.
Of course, we also advocate strongly for the NIH budget ... The problem is that when you have these huge fluctuations, when you suddenly come to a point where the NIH budget actually decreases for the first time in 35 years, you sometimes lose the best people to other careers. They make a contribution, but they don’t make the scientific contribution they could make in terms of the health of human beings ...
There is (also) concern… that great research opportunities will be lost during these times. If you have to cut back or stop funding an important long-term study, there’s no way to go back and reproduce that…
The AHA can’t compensate for flat congressional funding of the NIH… On the other hand… we can act as a catalyst for change. We can be a place where new models are tested. And we can partner with the NIH as we did recently in resuscitation studies.
Does our health care system make it difficult to apply the latest findings to the care of patients?
Robertson: I think there are several ways in which… the system makes it difficult to translate results… There’s insufficient time in an office visit these days, for example, for physicians to do the really substantial work you need to do to learn about patients’ lifestyles, to educate them and then to motivate them about ways to live healthier lives.
I think we would do better if we spent some dollars on the time to do prevention well, following evidence-based guidelines. Perhaps that would save us funds at the other end—certainly it would save lives.
Nabel: Absolutely, our health care system does not have good incentives for doing the right thing. Prevention is a good example. We desperately need health care reform in this country.
What can the institute do about this?
Nabel: We’re not CMS (the Centers for Medicare and Medicaid Services). We don’t set the policies and do the reimbursing. We’re not the FDA (Food and Drug Administration), so we don’t do the regulating.
We fund the research that generates the knowledge that goes into the evidence-based guidelines. If we do research that shows preventive measures are effective, then it’s really up to the policy organizations to take those on and make sure that those activities are reimbursed.
How can people be better motivated to reduce their risk factors for heart disease?
Robertson: It’s hard for the public to be responsible for things that it isn’t educated about. I don’t think we in this country educate our citizens very well about science and its importance in their lives…
(In addition), people do need to have their basic needs cared for… if you’re worried about keeping your kids off drugs and having them not shot on the street, you may not focus on preventing long-term health risks…
But we also need to build an environment in which the default is healthier. And some of that direct translation is actually done best by private organizations. So the American Heart Association with 20-plus million volunteers and supporters across the country, an extraordinary grassroots network and an ability to engage communities can do a lot to take research directly into action.
There’s been a lot of research on nutrition and physical activity over the years, much of it funded by the NIH, which can be taken into a program like the Healthier Schools Program that the AHA is doing with the Clinton Foundation and the Robert Wood Johnson Foundation across the country. We’ve had some successes there, with a beverage agreement and snack foods agreement that will make food and drink in schools healthier for kids.
And we can advocate for changes in regulation and legislation, something that the NIH isn’t allowed to do.
Nabel: It’s important for us to do research to understand what type of interventions make a difference. For example, what types of intervention will be effective in adolescents to help them make healthy lifestyle choices in terms of food selection and physical activity?
Remember that heart disease begins in your teens and your 20s, and that we have an obesity epidemic going on in this country, and obesity leads diabetes and cardiovascular disease. In fact, we’re very concerned that the favorable trends that we’ve seen in heart disease in this country may be reversed by the next generation of young people who have obesity and diabetes.
(But) unless we can communicate our research advances to the public, we might as well pack up our bags and go home.
We are a research and education institution. We fund research, we support research findings and then we have to be in the business of communicating those findings. We do have a very strong program that disseminates many of our research findings… CARD—the Center for the Application of Research Discoveries.
From my perspective, that communication is best done in partnership with organizations and agencies that also are concerned about public health. And the American Heart Association is a great partner in that regard.
What are you doing to attract and prepare the next generation of scientists and physicians?
Nabel: At the high school and college level, we have a very vigorous summer internship program, where students can come to the NIH campus and intern in a laboratory over the summer and get exposed to scientific and medical research.
And we find that this is often an important imprinting period in which students develop a passion for scientific research and will come back to it at a later point in their career… These are programs that have long existed in the institute, and we are making sure that during these difficult times we continue to support them.
Robertson: We think that training science teachers in the summer and giving them experiences in cutting-edge labs may make a real difference in how they educate and motivate their students. We’re planning to do more of that.
We’ve also recognized the need for young investigators to be trained in new ways… Translation is not just from the bench to the bedside, but in its most effective mode, is from the bedside to the bench as well. You have to have people at the bedside who are scientists as well: patient-oriented investigators…
If you have someone like this who is clinically expert, their colleagues send them their difficult patients, patients who don’t fit the mold. When they see those patients, instead of saying, ‘Well, you just don’t fit, we’ll work around that,’ they say, ‘Gee, isn’t that interesting?’ and then they may discover new diseases, or new manifestations of old ones.
Also, great advances do often happen at the edges between fields… at the junctures between one field and another… It’s tricky to figure out how to facilitate that. Both we and the NIH talk about it a lot. It’s the unusual place that does collaboration very well… it’s historically one of Vanderbilt’s real strengths.
How can the public become more involved in cardiovascular research?
Nabel: I think that people in this country are very generous and really do want to help out and make a difference. Take a look at our Jackson Heart Study, where the response of the African-American community in Jackson, Miss., has just been overwhelming.
I think if these studies are done with transparency, full disclosure of risks and benefits and clear, informed consent, people in communities will participate.
Robertson: Having done clinical research for many years, I have always been remarkably impressed by the altruism of people. I think people are extraordinarily willing to participate in trials, even when the trial doesn’t hold any specific benefit for them but simply holds the potential for helping us learn about something that will help other people in the future. So why don’t we support research better?
When you survey the public, they do feel that increased research funding for medical advances is a highly desirable goal, and they would like Congress to invest in that… That’s not always expressed vocally enough to make it happen.
So we do need to increase both the knowledge and the desire in the public, and some of that is just a matter of basic science education.