The promise of change inspired most Americans to rejoice when President Barack Obama was inaugurated last month. But among the many changes our nation desperately needs, reform of the medical system must not get lost in the shuffle.

There is much talk of health-care reform and what appears to be a real commitment to making long-needed fixes. But we must address the root causes of our most serious problems.

One is cost, which limits access. We must do far more to prevent illness and reduce our dependence on costly interventions that often fail to restore good health or ensure a meaningful quality of life.

Pittsburgh history makes the point: Countless lives were spared by the Salk polio vaccine that cost pennies per dose. Previously, polio victims had been kept alive with iron lungs, devices which cost as much in the 1940s as a house and which trapped patients in metal containers, often for their entire lives.

Physicians and clinics now are reimbursed by insurers mainly for treating illness, and the more treatment, the more reimbursement. There is little financial incentive to encourage weight loss, foster adequate nutrition, counsel smoking cessation or probe the causes of anxiety and depression in our patients -- actions which can improve their quality of life and avert expensive medical treatment.

Our exploration of the human genome is revealing the genetic causes of disease and offering myriad new ways to prevent illness, yet funds for this research are utterly inadequate.

Medical research also requires scientist-physicians and Ph.Ds, but the median tuition debt burden of today's medical-school graduates is $145,000 for public universities and $180,000 for private schools. A quarter have a debt of $200,000 or more.

It is no wonder that these graduates opt for high-paying subspecialties in wealthy communities while shunning low-paying research jobs or primary care practices in inner cities or small towns. This contributes to our dysfunctional health-care system and to disparities in health care among regions, races and classes.

It is my view that medical education should be fully underwritten by the government in exchange for a few years of national service.

Under the previous administration, the purchasing power of the National Institutes of Health, the major source of support for medical research, declined by almost 18 percent between 2003 and 2008. The NIH now funds fewer than one in five grant applications seen as meritorious after peer review. Ten thousand approved but unfunded grant applications wait in the wings.

Research support from other sources -- foundation grants, individual gifts, interest on endowments, state funding -- also has declined dramatically, subject to the same market woes as the rest of our economy. Even in the best of circumstances, the federal government supports only 75 percent of the cost of medical research; other sources must fund the rest. And remember, we can't prevent a disease or disorder unless we understand its cause.

This past Wednesday, members of the House and Senate agreed on an economic stimulus bill, and through the efforts of Sen. Arlen Specter of Pennsylvania, $10 billion was included for the NIH. While this is wonderful news, the stimulus bill would provide only two years of support for biomedical research. Unless the normal NIH appropriation is increased thereafter, the deficit in long-term support will be severe. The development of vaccines against cancer, diabetes and HIV will take considerably longer than two years, so we still face a daunting challenge.

All of American science is desperate for more stable and consistent long-term support, and breakthroughs in medicine come not only from medical research but also from physics, chemistry, engineering, even botany.

The United States has long led the world in scientific and medical ambition, commitment and scope, but now we are on the wane. Change we can believe in demands that we reimburse efforts to prevent illness, reduce the massive debt of medical students, re- adjust the incentives for how and where doctors choose to practice, make scientifically proven health care available to everyone and quickly rebuild our research capabilities.

All of these changes, and more, are critical not only to improving our health but also to rebuilding our national economy. After all, sick people can't work productively. And research leads not only to the treatment and prevention of illness, but also to new inventions and discoveries that can be manufactured and exported.

Those of us who work at medical schools watch with dismay as many of our young colleagues leave research, their enthusiasm for science deeply eroded. Still, I am hopeful because we now have a president -- and a Congress -- who value science and recognize its potential for healing not only individuals but also our society.