In this occasional series we record the views and personal experience of people who have especially contributed to the evolution of ideas in the Journal's field of interest. Lee Towle played a crucial role in developing National Institute on Alcohol Abuse and Alcoholisms (NIAAA’s) international activities.
FROM BENCH TO DESK RESEARCH
Addiction (A): You enjoyed a long and productive career in the field of alcohol studies, first with the Stanford Research Institute (SRI), then with the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Yet your academic training in Chemistry and Business does not seem to have prepared you for the kinds of work you performed over a 25-year period. What got you started in alcohol research administration, international relations and policy analysis?
Lee H. Towle (LHT): I started at SRI, in 1956. After 3 or 4 years doing bench research, which was interesting, but limiting given that I was not a PhD, my scientific/technical knowledge was loaned out to a project in another department. In effect, over a few years, my work moved from the ‘bench’ to the ‘desk’ and the research reports that were produced were based on information-gathering in the field rather than the laboratory. During the 1960s, I was asked to participate in a couple of European-based projects and the challenges were quite rewarding. This was the beginning of my international research and international relations interests, which ultimately became a major focus of my career. With time and growth in my capabilities in applied contract research at SRI and after some major projects that involved information/data systems development in the health and medical field, I was given the OK to establish a small program in ‘health sciences research’ funded by government contracts.
A: One of your first areas of focus was on the monitoring and evaluation of alcoholism treatment at SRI in the late 1960s and early 1970s. What was the role of the US government on the emergence of a viable alcoholism treatment system during this period?
LHT: It actually began in 1971 after creation of NIAAA by legislation passed by Congress. It recognized alcohol abuse and alcoholism as a major public health problem and charged the Institute with the responsibility for planning and developing programs to deal with the problem. This included establishing a viable US alcoholism treatment system.
The first Director of NIAAA was absolutely insistent that if the Institute was to be held accountable for funding these centers, then they must collect the information necessary to ensure that the centers would not only be monitored, but also evaluated. My small SRI Health Sciences Program was fortunate to receive one of the first contracts to establish a system for monitoring the alcoholism treatment centers. As we succeeded, additional contracts were forthcoming and my career and reputation in ‘alcohol research’ began in earnest.
The broad-based background of contract research studies at SRI was paramount to undertaking the work for NIAAA and ultimately led to my being invited to join the Institute, first as a visiting scientist and then as civil servant.
A: In 1975 you were involved in the development of a seminal report on the role of Alcohol Beverage Control (ABC) Laws on the state level in the USA. What was your perception of the influence of local and state alcohol control policies on the rates of alcohol-related problems in the USA?
LHT: Actually my involvement was rather modest over a 2–3-month period. My main job was to gather and compile information on ABC Laws as they were being implemented by the various States—the two principal categories being monopoly States and license States. The information included number of on-premise and off-premise sales outlets, taxes and prices, days and hours of operation, age for purchase, advertising, etc. My perception from working on this project was that the relationship between alcohol control policies and the rates of alcohol-related problems was not a major factor in the way in which these policies were established and implemented. Of course, social problems such as public drunkenness and DUI, and illicit or ‘after-hour’ sales, were to be dealt with, but health and medical problems did not seem to be of great interest.
WORKING WITH NIAAA
A: You began working at NIAAA as a Visiting Scientist in 1975. As the Institute was only a few years old at that time, you must have had a perfect vantage point to witness the evolution of a federal-level bureaucracy devoted to the prevention and treatment of alcohol-related problems. What was it like in the early years?
LHT: Yes, there were a lot of growing pains. The Institute was part of the National Institute on Mental Health (NIMH) during the first few years. The main thrust was not research at that time—it was on the establishment of the alcoholism treatment system with centers funded by individual grants for training, prevention and treatment. Funds were made available by Congress for this express purpose, and NIAAA had to create the organizational capability to do this. Then there was the external influence of the alcoholism field and some rather influential and vocal people with ‘clout’ in Congress. Some, but not all, were recovered alcoholics with great intentions but with sometimes misplaced ideas on where the Institute should be headed. Total abstinence as a treatment goal à la Alcoholics Anonymous (AA) was a bone of contention for a few years, as were alcohol-related problems other than alcoholism. Addiction to alcohol was avoided terminology in the early years because it implied alcohol was a drug.
‘Addiction to alcohol was avoided terminology in the early years because it implied alcohol was a drug.’
Learning to work within a Federal bureaucracy was sometimes a difficult and time-consuming endeavor. Although party politics was not an issue, the Institute did have to relate to the political party in office and to the pertinent Congressional Committees and Subcommittees. Within the Institute there was also an in-house political environment, as is the case with most organizations. During the early years, the Institute seemed to have a large share of this—not always of a positive nature. But, as the Institute matured, these problems seem to improve.
A: What do you see as the Institute's major accomplishments in research and policy during your 20 years of government service?
LHT: I think that NIAAA was not only successful, but very successful in establishing a nation-wide alcoholism treatment system—so much so that even after the direct funding of training, prevention and treatment centers was stopped, Federal funds continued to be made available via block grants to the States. Of course, this was the politics of the times, but if NIAAA had not already been responsible for establishment of the system, the block grants probably would not have had the same result. The cadre of alcohol abuse and alcoholism workers in the field is another major accomplishment, and I think we must also add to that the researchers in the field. The amount of money that has now gone into research is really quite substantial and has created a capability that was not even dreamed of in the early 1970s. The knowledge base has advanced significantly as a result of NIAAA's intramural and extramural research programs. One only needs to compare the latest Reports to Congress on Alcohol and Health with the early reports to see the growth in addiction science.
A: How did the Institute change during this period?
LHT: The 20-year period from 1975 to 1995 saw the Institute mature from one focused on building a nation-wide alcoholism treatment system to one focused on scientific research—not just in the basic sciences but also in the social and policy arenas. The whole NIAAA organization shifted from the initial Institute within NIMH, to an accepted, mature and integral part of the US National Institutes of Health (NIH). The scientific standards of NIAAA also changed substantially during time with the whole peer-review process growing into the NIH structure.
A: What kind of influence did the NIAAA Director have on the research and policy agenda?
A: Whom do you see as the most influential Director?
LHT: Tough question to answer, really. Each Director made his own unique contribution and had influence in a wide variety of ways. I do not believe that naming names would be appropriate.
DEVELOPING NIAAA's INTERNATIONAL ACTIVITIES
A: When you moved into the Office of Program Development and Analysis (OPDA), you took on responsibilities in relation to policy formulation, legislative initiatives, program planning and evaluation. As an often-nameless bureaucrat in a small and somewhat obscure federal agency, what do you consider your major accomplishments?
LHT: Organizationally, I was responsible for creation of the Policy Studies and Special Reports Branch within OPDA and we designed several studies and commissioned numerous papers and reports, which served the basis for the Third Special Report to Congress on Alcohol and Health. This was such a large effort that in addition to the report that went officially to Congress, a ‘technical support’ report was prepared with substantially more detailed results and data from the development effort. As one example, we commissioned the first major study of the ‘economic costs of alcohol abuse and alcoholism’ on US society. We also made major contributions to strategic plans being put together, e.g. national plans to combat alcohol abuse and alcoholism, input to the Surgeon General's Report on Health Promotion and Disease Prevention. We also developed and managed the principal information systems used to monitor and evaluate the more than 400 treatment programs being funded by NIAAA. Reports were fed back to each program, to the States, and to the NIAAA staff managing the grants, as well as to the NIAAA Director.
One of my most significant accomplishments began as a relatively modest role as International Activities Officer. Initially, this was mostly a liaison role, coordinating the few international activities of the Institute and representing the Institute in meetings with other governmental levels, and with other international organizations and foreign countries. But, as time went on, this role expanded considerably and by 1981 my role blossomed into almost a full-time job as Director of International Affairs. By then, there was a substantial program of International Collaborative Research with WHO, and collaborative efforts under way or being developed with the governments of several countries, including, Japan, Mexico, Spain and Israel. NIAAA was able to have a significant input into the World Health Assembly Technical Discussions in 1982 and after much groundwork, NIAAA was named officially as a WHO Collaborating Center in 1985.
A: Up to your retirement from NIAAA, you worked as the main liaison between NIAAA and the World Health Organization. What kinds of projects did NIAAA conduct with WHO?
LHT: Liaison with WHO actually began in 1975 with preliminary consultations in 1976 that led up to the beginning of the WHO project on Community Response to Alcohol Related Problems. NIAAA provided the principal backing for this project, both in terms of funds and technical support. It was truly a collaborative research effort that involved participation of the governments and research entities in several countries, initially Mexico, Scotland and Zambia, in addition to the WHO and the NIAAA. This project included community action efforts, and led to a number of other comparative alcohol research studies.
NIAAA also had another significant role in relation to WHO. That involved working together with NIMH and NIDA in collaboration with WHO in the development of the 10th Revision of the International Classification of Diseases. This involved a wide range of activities, including meetings, consultations, technical support, and the conduct of a wide array of epidemiological and nosological studies. Through no small effort, NIAAA was also instrumental in establishing the coding of alcohol's role in casualties in the 10th revision of the International Classification of Diseases (ICD). In fact, alcohol and casualties was a major focus of NIAAA's international research efforts in collaboration not only with WHO, but also with the Addiction Research Foundation in Toronto.
A: What was the rationale for initiating these projects?
LHT: There were at least two major goals. One was to build and strengthen WHO's program of work in the alcohol field, especially in relation to cross-national studies of alcohol-related problems, and applying the knowledge gained to community action programs, such as alcohol education, prevention and interventions appropriate to the particular populations and cultures. In a broad sense, there was genuine interest in assisting the WHO in its programs of work in the alcohol field. Another was to build and strengthen NIAAA's program of international collaborations. The knowledge and experience gained via the WHO program of work led to collaboration with scientists and researchers in other countries. It also enhanced NIAAA's role in developing scientist exchange programs, the conduct and participation in international meetings and the building of alcohol research collaboration with organizations and researchers in other countries.
A: How important are public health agencies like WHO on the development of meaningful alcohol policies and the dissemination of scientific information?
LHT: This should be one of the roles of public health agencies. How well they do depends on numerous factors, money being one, of course, but knowledge and experience being another. The WHO became a leader in the field and many of the countries we dealt with looked to WHO for guidance.
A: You played a critical role in the facilitation of government-to-government contacts between the USSR and the USA at the beginning of the Gorbachev era. How did those contacts develop around alcohol research?
LHT: The problem of alcohol abuse and alcoholism in the Soviet Union was one that was very severe and highly entrenched in its society. At the beginning, contacts were initiated by the USSR by individuals who were well aware of NIAAA's position in the field in the United States. However, because responsibility for USSR's alcohol work was (apparently) situated organizationally in the psychiatric department and clinics, there was a great reluctance by the United States to respond to the overtures of these individuals because of the alleged misuse of psychiatry. The Serbski Institute was presumably at the center of this misuse and that was where, organizationally, the Soviet alcohol work was located initially. I say ‘work’, because at that time I don’t think that a program really existed—but that, of course, was what they wanted to develop and NIAAA was seen important toward that end. From the NIAAA perspective, the possibility of developing collaboration with the Russians was seen as a way of accessing the potentially rich but mostly unknown body of work being conducted in the USSR in the alcohol field. Initial correspondence with the Soviets was slow and deliberate, even though the political climate in the Gorbachev era was most favorable. I cannot go into the various aspects of this, but it became clear that time was needed to develop a program with the Soviets and the likelihood of this happening would be considerably strengthened if they moved their apparently nascent alcohol effort out of the Serbski Institute. During these early times, in addition to the carefully written correspondence, I had the opportunity of meeting one of the key Russian individuals at a WHO-related meeting in Edinburgh. Although our conversation was limited due to our mutual language difficulties and the fact that I could say very little officially, it became apparent that this was a very positive beginning. Over time we would eventually work together as colleagues and personally became good friends. He and I were the principals behind the eventual bilateral agreement that became the official basis for the collaboration that was developed. This happened, of course, after the first exchange meeting in Moscow between the NIAAA Director, key staff/individuals, and the Russian Director and key individuals.
The evolvement of the bilateral collaborative program of work with the Russians has been well documented, but I would just like to say that it was for me, personally, one of the greatest challenges of my career and one of the most rewarding.
‘the bilateral collaborative program of work with the Russians . . . was for me, personally, one of the greatest challenges of my career and one of the most rewarding’.
A: During this period, it seems like the bi-lateral agreements and collaboration among US and Russian scientists had a political as well as a scientific agenda. Which was more important?
LHT: In my view, the scientific agenda was always the more important but satisfying the political agenda seemed to be the best way of developing the scientific agenda. Maybe ‘best way’ is too strong—but, at least one of the ways of building the scientific base.
TIME OVER AGAIN?
A: If you could do it over again, what would you do differently in the international and policy arena?
LHT: I am not really sure that I would do anything differently, given the constraints and the rules that had to be followed. Actually, I was able to do more than might otherwise have been possible because I generally had the support of Institute Directors or was able to gain it over time. Personally, I found it most rewarding not only to manage the Institute's international program but to also participate in the collaborative research that was done with WHO and with some of the bilateral projects. In my opinion, when I left NIAAA at the end of March 1995, the International Affairs Program was strong and had contributed significantly to the field of international alcohol research. I am proud that just following my departure, I was the recipient of an NIH Director's Award. Not wanting to be boastful and feeling considerable humility in saying this here, the award read: ‘For leadership shaping the direction and scientific content of the Institute's international program, enhancing the international image and credibility of research on alcohol related problems.’