A report published today by the US Institute of Medicine (IOM) calls for an overhaul of the way public health departments conduct surveillance and treatment of chronic diseases ranging from arthritis to depression. The report, co-sponsored by the US Centers for Disease Control and Prevention (CDC) and the Arthritis Foundation, both based in Atlanta, warns that chronic disease, which accounts for three quarters of healthcare spending in the United States, is an overlooked crisis. The authors argue that the CDC can use funds more efficiently by expanding surveillance systems, integrating community health systems in schools and workplaces and prioritizing patient education.

The report, Living Well with Chronic Illness, focuses on nine chronic conditions. In addition to cancer and type 2 diabetes, diseases for which substantial public health initiatives already exist, it names mental illnesses such as dementia, post-traumatic stress disorder, schizophrenia and depression. Such diseases decrease the productivity and quality of life of millions of Americans, but public health departments do not adequately address such illnesses, the report argues, in part because surveillance systems fail to assess the needs of patients with chronic disease. For example, little information exists about how people with chronic illnesses such as arthritis access healthcare and what interventions are most effective at increasing their productivity and decreasing the cost of managing the disease.

“Historically, when infectious diseases were the dominant thing, that was what surveillance systems counted,” says Robert Wallace, a physician at the University of Iowa and the chairman of the committee that produced the report. “But now there are enormous numbers of people with chronic illnesses and not enough information about what is and is not working in the public health sphere.”

At the core of the report’s recommendations is a call for the CDC to enact policies that empower people to seek care for chronic diseases. Such policies could include integrating health services in schools and workplaces to encourage healthy lifestyle choices that can prevent or mitigate chronic illness. The report also stresses the importance of getting individuals into the healthcare system early and helping them navigate care options to avoid confusion and alienation.

John Klippel, president of the Arthritis Foundation, says the IOM’s decision to issue a report on chronic illness is timely, and he hopes the public pays attention. “I don’t know that the public quite recognizes the importance and magnitude of chronic illness,” he says. “The effects of these illnesses on lifestyle and quality of life are profound. We need to use resources better, but we also need to empower people to take control of their own care.”

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The current controversy over the publishing of H5N1 research is good news for one unlikely group: bioethicists. Controversy in medicine breeds conversation about ethical questions, and the more people are talking, the more likely researchers are to go looking for ethical guidance as they design studies. Some bioethicists think the best way to address such questions is via ethics consultation services that act independently of institutional review boards (IRBs) so that formal regulatory and informal consulting functions are kept separate.

One of those bioethicists is David Magnus, director of Stanford University Center for Bioethics in California. Writing today in Science Translational Medicine, Magnus and his colleagues argue that IRBs are ill-equipped to provide consultation to researchers on thorny protocol design issues in translational areas such as DNA banking and stem cell therapies because IRBs are already overseeing protocols as regulators..

“There are pitfalls to having a regulatory body in a consulting role,” Magnus told Nature Medicine. “It can lead to slowdowns in the oversight system.”

Such arguments are not exactly new territory, however. Since the creation of the Clinical and Translational Science Awards (CTSA) by the now-defunct US National Center for Research Resources (NCRR) in 2006, bioethicists have been considering such a proposal. In the intervening years, they have published countless reports calling for institutions to fund ethics consultation services for their researchers.

But other than a few select institutions, such as Stanford, most academic centers have not bothered with ethics consultation services, and, in fact, many bioethicists today don’t see the need for additional ethics groups. Tom Murray, president of the Hastings Center, a bioethics think tank in Washington, DC, thinks that the overall goal should be to help institutions come up with clear, consistent and detailed policies for translational research. But, as Murray points out, “That doesn’t necessitate on-the-fly consulting so much as it requires a sounding board for researchers to communicate with their IRB.” So, perhaps it’s time to reinvest in the infrastructure already in place at most academic institutions rather than adding more administrative burdens to cash-strapped research hospitals.

What a difference a few inches can make. On 1 January, the US National Institutes of Health (NIH) adopted the recommendations set forth in the latest version of the Guide for the Care and Use of Laboratory Animals, and already the usually soporific document is raising hackles.

Among other measures, the document—the eighth such volume from the US National Research Council and the first update since 1996—sets out guidelines for the minimum number of square inches required to house female rodents and their offspring. The recommended cage sizes are roomier than the accommodations currently in use at most animal research facilities in the country, and so adopting the new policy could be an expensive undertaking with little proven benefit, critics say.

“There is no data indicating that the current housing requirements are inadequate,” says Frankie Trull, president of the National Association of Biomedical Research, a Washington, DC-based advocacy group. “The research community was very surprised by the new rules.”

The uproar, news of which was broken earlier this week by National Public Radio, has come as a surprise to the NIH’s Office of Laboratory Animal Welfare (OLAW), which commissioned the review of the Guide and oversees its implementation. “The concerns seem to have been based on misinterpretation of the standards in the Guide,” Patricia Brown, director of the OLAW, wrote in an email. “Implementation of the Guide is expected to have a minimal impact on most institutions.”

Under the new rules, institutions that receive NIH funds will have to submit plans for how they plan to implement the guidelines by the end of the year. To help lessen the impact, the OLAW says institutions may request an exemption from the cage recommendations on animal-welfare grounds. But, as Trull points out, exemptions can be reversed with each annual review, and institutions cannot be sure that the guidelines will not be more strictly enforced in the future.

Such uncertainty, especially when compliance carries an enormous price tag, is detrimental to institutions with limited funds. “People are confused,” Trull says, “and the lack of certainty makes planning ahead difficult.”

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