The Emergence of Institutions and a Community for Cardiovascular Disease (CVD) Prevention
In mid-twentieth century, leaders in the new fields of CVD epidemiology and preventive cardiology mobilized as an independent branch of medical science. New institutions came into being to provide guidance and support. New research development was closely bound to the influence of these investigators and institutions on each other: the creativity of researchers drove the programs of new agencies, and the agencies, in turn, enthusiastically supported the investigators’ new undertakings and careers.
Prevention research in CVD flourished, particularly in the U.S., in the late 1940s and early 1950s, with the post-war expansion of the National Institutes of Health (NIH) and of government funding for research. This was abetted by the new public role of the American Heart Association with its expanded view of community service, prevention, and the public health. Interest in CVD prevention also grew in Europe, but at a not-so-galloping pace and one in which the workings between scientist and administrator were more distant and nuanced.
1. Origins of governmental medical research policy and institutions
In the U.S., at the first meeting of the Advisory Heart Council to the new National Heart Institute in 1948, Surgeon General Leonard Scheele recounted how the U.S. government became involved with health through President John Adams’s 1798 decree and by legislative acts specifying that the Marine Health Service (MHS) would provide “for the relief of sick and disabled seamen” (National Advisory Heart Council 1948, 4). Both the Public Health Service and the National Institutes of Health had roots in the MHS, which expanded mainly to deal with control of epidemic infections. Non-contagious diseases were brought under the tent of U.S. government sponsorship only after the MHS was reorganized into the Public Health Service in 1912, largely through the classic epidemiological study that identified pellagra, “a scourge of poor Southerners, as a dietary deficiency, and brewers’ yeast as a cheap and widely available cure” (Office of NIH History, 3). Before World Wars I and II, governments were little involved in supporting medical research.
In the United Kingdom, the British Parliament passed the National Insurance Act in 1911, one provision of which created a fund for medical research from the collection of “a penny per working person per year” to be allotted for “sanatorium treatment for cases of tuberculosis and for ‘purposes of research’” (Medical Research Council 2009). But these “purposes of research” received concerted attention only from 1919, following the official establishment of the British Medical Research Council (MRC) and its Department of Clinical Research led by cardiologist and pioneer clinical investigator, Thomas Lewis.
Sir Thomas was a man of “earnest impatience” who insisted that clinical science was an independent discipline in which the duties of medical practice would be separated from the conduct of research. He believed researchers should be “free from their distractions presented by the petty and mainly diagnostic problems of diverse and obscure cases” in order that they might “settle down to a more profound and uninterrupted study of the natural history of selected diseases” (Thomson 1975, 22).
Though his attitude was viewed by some as elitist, it was largely thanks to Lewis that a generation of clinical researchers developed skills to apply scientific methods to clinical problems. Clinical investigation became an influential component of academic medicine and a major source for, as well as a sometimes-competitive antagonist to, research in CVD epidemiology and prevention.
Another major development in the UK came in the early 1930s, from Richard Doll, a young clinician at the London Hospital, and Austin Bradford Hill, then chairman of epidemiology and statistics in the London School of Hygiene and Tropical Medicine (LSHTM). These two set the tone for the epidemiological pursuit of causes, thus preventives, of non-communicable diseases. This took place in an MRC-funded study of gastric ulcer among London busmen, the population of transport workers that would later be exploited by Jeremy Morris for the first studies of coronary disease and occupational physical activity.
Prior to these developments, during and after the World Wars, health services in both the UK and Scandinavia made major advances in national screening for pulmonary tuberculosis, a problem complicated by war. These programs provided the organizational framework for several cardiovascular disease surveys and trials of the 1950s.
At midcentury, U.S. institutions began a vigorous effort to develop resources and provide impetus to deal with the newly recognized epidemic of coronary heart disease. That awareness and movement were slower in coming to the British Isles and to European countries where the focus of medical systems was perforce on reestablishing basic health care and nutrition and on recovery from the privations of war. It was, nevertheless, the historical force of war that brought about the rapid advancement of medical research through government action, with academic participation, on both sides of the Atlantic.
In the U.S., this new vigor in national medical-research policy grew directly out of President Franklin Roosevelt’s wartime National Defense Research Committee and a cascade of post-war events crucial to our story. Among Roosevelt’s “alphabet soup” of new agencies was the Office of Scientific Research and Development established in 1941, with its guiding Committee on Medical Research (CMR), whose composition, like that of the advisory councils of the later National Institutes of Health, included researchers, public health service, and military representatives, along with key lay persons.
During World War II, the CMR had the job of mobilizing medical and scientific personnel to make recommendations on medical problems affecting the national defense. Its staff worked with that of the National Research Council of the National Academy of Sciences to review program needs in medicine, surgery, aviation, physiology, chemistry, and malaria. With its presidential mandate and virtual blank check, the CMR soon became responsible, for example, for the lifesaving use and availability of penicillin, sulfonamides, gamma globulin, and cortisone (Strickland 1972, 17).
From this positive wartime experience, and in the policy vacuum of the immediate post-war years, the U.S. Public Health Service moved to establish the National Institutes of Health (NIH) as the world’s leading medical-research institution. When none of the armed services sought responsibility for the CMR’s residual wartime contracts, NIH seized the opportunity, secured congressional support and, in effect, won out over the National Research Council and the National Science Foundation. Consequently, NIH became the leader and the engine of medical research both nationally and worldwide.
2. Personalities that led post-war medical research in the U.S.
During the 1940s and ‘50s, supported by the new administrative structure of the PHS and NIH, U.S. medical research–particularly in the areas of cancer and heart disease–became a popular cause among American legislators and with a new phenomenon: health lobbyists. Their success grew from the “prescience and persistence” of particular people, such as lobbyist Mary Lasker, along with the power and savvy of Congressmen such as Lister Hill and John Fogarty, and “an extraordinary and felicitous combination of scientific integrity and organizational leadership” in the person of NIH Director James Shannon (ibid. 224). Without the contributions of these four leaders, the stories of NIH and of chronic disease prevention research would surely have been very different. Having lived it ourselves, we find that historian Steven Strickland captured well the people and picture at the center:
- Mary Lasker, probably the most influential citizen lobbyist of her era for medical research [See “Mary Lasker and the National Heart Act.”], often knew the facts about the national burden of illness better than the experts did. Renowned heart surgeon and medical statesman Michael DeBakey praised her for her “quick mind” and for her “ability to focus on the central issues and to sense what combination of talents must be brought together to solve a problem.” And although Lasker, herself, concluded that in the basic struggle over the pace and direction of legislation, she almost always lost, DeBakey maintained that she was “almost always right” (ibid., 226).
- SenatorLister Hill, Democrat from Alabama, was, according to an effusive Senator Paul Douglas of Illinois, “so persuasive, so charming, so quietly indispensable, and so personally self-effacing, that we want to give him everything that is possible to give him. . . . He touches the rock of public credit and abundant streams gush forth so that the National Institutes of Health have money running out of their ears, money they do not always know what to do with” (ibid., 225-26).
- Congressman John Fogarty of Rhode Island was, in 1949, the successor as chair of the Labor-Federal Security Sub-Committee to another Lasker ally, Congressman Frank Keefe of Wisconsin. Together, Fogarty and Keefe recognized the popularity of medical research nationally and arranged for its dramatization by testimony from Lasker and her friends about the need to expand the national effort.
- James Shannon headed NIH from 1955 to 1968. His “broad view” and “capacity for verbally reconciling the differing emphases” was credited for success “in carrying out what had come to be national policy,” that is, supporting medical research (ibid., 175).
Thanks to the efforts of these four and a few other key people, by midcentury the National Institutes of Health were a major vehicle for national policy. The crowning achievement of this period was passage of the National Heart Act of 1948, which established the National Heart Institute and opened the door to all future CVD research and policy in the U.S. (Henry Blackburn).
- One of those “abundant streams,” in fact, was in the amount of four million dollars requested for NIH to conduct a trial of the cholesterol-lowering drug Atromid S. The legislation was sponsored by Congressman Hill, endorsed by noted surgeon Michael DeBakey, and supported by the strong testimony of Mary Lasker’s friend, endocrinologist Jesse Marmoston of Los Angeles. But what many in Congress did not realize until it was reported in a front-page story in the September 3, 1967 Washington Post, was that NIH had neither sought the funds nor recommended the drug. Eventually, the bill was blocked in the House and the clinical trial was not funded. A period thus began in which some legislators felt that Congress and the medical lobby of Lasker et al. were running faster than science and its administration could follow.
- In hindsight, epidemiologists and prevention researchers might take issue with the claim about Shannon holding the “broad view” of medical science to include epidemiology. For example, Framingham statistician Felix Moore complained, “Shannon always felt . . . that every nickel that was being spent on Framingham was being taken away from his labs”(Moore, 1989). But considering the need for research leadership at the time, his accomplishments were substantial. Shannon, on the other hand, gave the main credit for expanded research support to Department of Health, Education, and Welfare (HEW) Secretaries Marion Folsom and John Gardner (ibid.).
Medical Research Council. 2009. History. www.mrc.ac.uk/About/History/index.htm
Moore, F. 1989. Interview by Henry Blackburn and Rick Shekelle. Audio recording. August 8, Lake Tahoe, CA. CVD History Archive, School of Public Health, Univ. of Minnesota.
National Advisory Heart Council. 1948. Minutes of first meeting, September 8. Bethesda, MD: National Heart, Lung, and Blood Institute Archive.
Office of NIH History. A short history of the National Institutes of Health. http://history.nih.gov/exhibits/history/index.html
Strickland, S. 1972. Politics, science and dread disease: A short history of the United States medical research policy. Cambridge: Harvard University Press.
Thomson, A. L., ed. 1975. Half a century of medical research, Vol. II: Program of the Medical Research Council, UK. London: Her Majestey’s Stationery Office.