Biomedical Research, Politics and Health Policy

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Biomedical Research, Politics and Health Policy

by Jonathan King & David Ozonoff

‘Science for the People’ Vol. 8, No. 2, March 1976, p. 21-23

In the thirty years from 1945 to the present, federal support for biomedical research has increased over 1000-fold to its current 1.7 billion dollar level. This increase in federal support for biomedical research has not been accompanied by a corresponding increase in federal support for health care. In fact, as shown by Stephen Strickland in “Integration of Medical Research and Health Policy”1, the growth of the research sector was a side-effect of organized opposition by the American Medical Association to federal spending for health care. However, having expanded so rapidly, the research sector has come to play a major economic and ideological role in shaping medical training. In addition the powerful biological and genetic technologies which have been developed are generating their own social problems. Readers of this magazine are familiar with a number of these: XYY research (SftP, Sept., 1974); Genetic Engineering (this issue); misplaced priorities in cancer research (SftP, Sept., 1975); and exploitative human experimentation, to name a few. The origins of our present circumstances are outlined below. For an overview of the malfunctioning of the health-care system with respect to fulfilling people’s health needs, see Kotelchuck’s article (this issue). 

Origins of Govt. Support for Biomedical Research

Prior to World War II there was little or no federal support for biomedical research. What research support there was from the government was usually directed at aiding special agricultural interests. An early example of effective federally supported research was the discovery of the insect carrier of Texas Cattle Fever, by Theobald Smith of the Bureau of Animal Industry, in the 1880’s and 1890’s. State and city governments also supported some kinds of research, most notably in bacteriology and public health. This was primarily in response to the explosive epidemics that periodically created panic among all social classes and interrupted commerce. However, for the most part research was only a minor component of medicine and was supported primarily by private foundations such as the Rockefeller Foundation, with secondary support from state legislatures to their land-grant schools.

With the outbreak of World War II it was obvious that the country was not equipped to carry on a highly technical war. Thus the Office of Scientific Research and Development (OSRD) was created by Roosevelt in 1941, with Vannevar Bush at its head.2 OSRD rapidly identified war-generated problems requiring further research and development; in the medical area these included tropical medicine (as a result of the war in the Pacific), shock and transfusion, aviation medicine, the control of wound infections, and the development of antibacterial agents. The Committee on Medical Research (CMR) of OSRD mobilized medical investigators to focus on these problems. Scientists with relevant skills were located, draft deferments were obtained, priorities were set so that scarce material was available for research, and efforts were made to ensure free and open communication among participataing groups.3 This program of coordinated, cooperative research was enormously successful, resulting in the development of sulfa drugs, gamma globulin, cortisone, and the mass production of penicillin, to name a few examples. 

The CMR/OSRD efforts were a novel step in American medicine: planned, coordinated research on a large scale. At the end of the war OSRD was loathe to dissolve the research apparatus that had been developed. Vannevar Bush actively pushed for the setting up of a National Science Fondation to carry on research for national needs, for example, the Public Health Services Act of 1944, which was the precursor for our current legislation.4 It authorized the fledgling Public Health Service to pay for research done in institutions, colleges, etc., by a system of research grants with specific authority lodged in individual investigators.5 At the end of the war, however, enthusiasm for a national research program lessened, and CMR/OSRD was dissolved. 

 With the end of the rationed wartime economy of consumer scarcity came rising public demands for goods and services. One area of public pressure was increased access to health care. Hundreds of thousands of troops returned from the service, only to discover that they couldn’t afford to take their kids to the doctor. In addition the standard medical examinations given to draftees had revealed that fully one-third of the draftees were unfit for service because of poor health. This was the first time the sorry state of American health had been revealed; the AMA had previously been able to block the collecting of national health data. The selective-service statistics gave the lie to the AMA myth that all was peaches and cream, that Americans were the healthiest people in the world. Senator Claude Pepper’s Subcommittee on Wartime Health and Education publicized these facts widely.6 

Public pressure for improved health care led to congressional action – numerous bills were introduced after the war to provide national health insurance (!), federal aid to medical schools, and aid to medical students. These were fought down by a multimillion dollar public relations and political lobbying campaign mounted by the AMA, attacking “socialized medicine”.7 Then in 1949, as a last effort, Truman introduced a comprehensive health-care bill, with a five-point· program, including federal support for biomedical research. The AMA chose not to oppose the research provision. In the end, with crucial support from Senator Taft, the AMA and the southern conservative bloc was able to squash federal aid for health care and medical schools, but federal support for research was allowed to slip through.8 

Thus began the blossoming of the American biomedical-research community. Research became the single area where a congressman could cast a vote for health. From a budget of $52 million in 1950, the National Institutes of Health budget grew to $430 million by 1960, to its peak in 1968 at one-billion, six-hundred-million dollars. Biomedical-research spending was pushed by a strong congressional group led by Rep. John Fogarty and Senator Lister Hill, and aided by powerful allies, notably the philanthropists Mary Lasker and Florence Mahoney. Though the money was ostensibly being spent for research, “The sophisticated congressional proponents of medical research knew that funds for medical research were building medical school budgets and increasingly supporting medical school facilities”.9 In addition, Sputnik and the Cold War, the need to keep up with the Russians, provided additional priming for the pump of federal research support. As Strickland so clearly establishes, medical research was forced to serve as national health insurance, in the absence of the real thing.

Unfortunately little of public or congressional intention penetrated into the research community per se. In a sense this was not surprising, since it was politically necessary to pretend that research was only distantly related to national health, to avoid the stigma of “socialized medicine”. The obvious substitute was that the research was being pursued for its own sake. Though from 1950 onward almost all the biomedical Ph.D.’s in the country were fully supported by government health fellowships, there was no component of their training which reflected the public-service aspect of their training. Rather they were trained to disdain “applied” research which related directly to health, and were taught to value “pure” research, performed for its own sake. Research relating to social needs was accorded very low status. Given the fact that the research system was set up on a competitive, free-enterprise model, rather than a cooperative model, the perceived status of research areas was extremely influential. When we were in graduate school, though supported by National Institutes of Health Fellowships like our peers, we had to sign a form stipulating that our training was directed toward aiding the national health. This was widely believed to be a joke, and was a subject of abuse. That is, the socialization of scientists trained under the federal research program led to a scientific establishment uninterested in the application of research to health care. The form of the training, emphasizing intense specialization, and disregarding historical, social, and political aspects, is a component leading to a number of the current problems in health care. The research system was of course extremely successful in generating new knowledge, and great advances were made in understanding many biological phenomena. Unfortunately very little of this knowledge has turned out to be socially useful, and the uncoupling of the generation of biological knowledge from health care needs has resulted in the knowledge accumulating in the wrong areas.

The Distortion of Medical Training by The Research Sector

As Kotelchuck makes clear, though the U.S. has had a well organized professional medical sector for over fifty years, we have never had a health-care system. Rather we have had a medical market place, with medical care a profitable commodity whose benefits are distributed to the rich, and unavailable to the disadvantaged. This is even true at the research level, where the risks of human experimentation have been borne most heavily by those sectors of the society least likely to receive the benefits of the knowledge. Given the coupling of medical care to economic factors, it is not surprising that medical schools came to be heavily influenced by research spending. 

Though private practitioners were extremely well off after the war, medical schools and hospitals, responsible for providing broader health-care services, were experiencing economic difficulties. The AMA block to direct or indirect federal aid to medical schools and hospitals began to be felt sharply in the 1950’s. Medical Schools simply could not afford to continue operating on private income. They were rescued, as intended by Congress, by the growth of the research budget. All federal grants carried with them funds to recompense institutions for overhead costs maintenance of buildings, libraries, insurance, etc. Research grants also paid a substantial fraction of the investigators salary, and the salaries of supporting personel. As a result all medical schools began to build research departments and research funds became a major source of operating revenues. Table 1 shows the growth of the federal component of medical school budgets over a ten-year period. As pressure has mounted to hire researchers who bring in grant money, the traditional medical faculty has been replaced by research-oriented faculty. In fact there has been tremendous total growth of medical faculties, almost entirely due to the addition of research people. From 1951-1966 full time medical faculty increased from 3,500 to 17,000. However, as shown in Table 1, this was not accompanied by an increase in the production of M.D.’s. Research money was being effectively pumped into medical schools, but it was not moving from there to increased health-care service. 

The influx of the medical researchers was one of the components that contributed to the weakening of the AMA’s grip on the medical system. In a certain sense the switch was progressive, with a conservative old guard being displaced. Unfortunately their replacements, with their narrow competitive focus on “basic research” and “pure science” had very little interest or experience in the delivery of health-care. Their presence in fact contributes to a new kind of distortion of the health-care system, whose control moves into the hands of a managerial elite.

By beginning a trend toward capital intensiveness in medicine (complex equipment, division of labor into specialities and subspecialities, expensive technologies, increased centralization of facilities) the balance of power moved away from the AMA — representing the solo-practitioner — and towards new forces. With its powerful guild structure the AMA had faithfully represented the historically dominant solo-practitioner, but the increasing dependence of standard medical practice on high technology and hospital facilities resulted in the subordination of the individual practitioner to the emerging elite of the doctor-managers of the large institutions, represented by the American Hospital Association. In a sense there was a kind of proletarianization of the doctor. The antagonisms of these two groups was most evident when the Nixon administration’s AHA-affiliated candidate for undersecretary of HEW, John Knowles, was vigorously and successfully opposed by AMA stalwarts. But the power of the AMA has continued to ebb, leaving us now in the hands of corporate hospital managers, and an institutionalized research elite.

The Distortion of Research Priorities

The most obvious result of the uncoupling of biomedical-research goals from national health goals, is in the distortion of research priorities. Given that scientific priorities are set more or less in an ad hoc fashion by scientists, and that these scientists have been trained to believe that the research is being done for its own sake, the entire system is subject to social misuse. Thus genetic disorders, a very minor component of ill health in this country, is tremendously overemphasized due to the development of advanced genetic technologies in search of an application. On the other hand, ill health due to occupational or environmental poisoning is sorely neglected. In this case corporate influence over the decision-making apparatus at high levels holds sway, with the scientific community completely unaware of the hidden pressures (see for example reference 10).

One net result is to focus attention on defects of individuals, rather than on the state of the workplace or the general environment. Thus despite the fact that the bulk of human cancer is due to exposure to industrial carcinogens, most cancer research focuses on viruses. This creates the illusion in working people that what they have to fear is exposure to cancerous individuals, rather than poisonous workplaces. The research sector, unwilling to tackle economic and social problems, retreats to the laboratory to pursue brilliantly conceived red herrings. The precise mechanisms by which scientific priorities get distorted will be documented in a later article in this magazine. For a chilling example, read “Asbestos, Science for Sale “10 

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  1. S.P. Strickland, “Integration of Medical Research and Health Policies”, Science, Vol. 173, 17 Sept. (1971), p. 1093.
  2. I. Stewart, Organizing Scientific Research for War, Atlantic, Little Brown (1948).
  3. I. Stewart, Organizing Scientific Research for War, Atlantic, Little Brown (1948).
  4. J.M. England, “Dr. Bush Writes a Report: ‘Science- The Endless Frontier’ “, Science, vol. 191, 9 Jan. (1976).
  5. S.P. Strickland, Science, Politics, and Dread and Disease, Harvard Univ. Press (1972).
  6. S.P. Strickland, Science, Politics, and Dread and Disease, Harvard Univ. Press (1972).
  7. S.P. Strickland, “Integration of Medical Research and Health Policies”, Science, Vol. 173, 17 Sept. (1971), p. 1093.
  8. S.P. Strickland, Science, Politics, and Dread and Disease, Harvard Univ. Press (1972).
  9. S.P. Strickland, Science, Politics, and Dread and Disease, Harvard Univ. Press (1972).
  10. D. Kotelchuck, “Asbestos: $cience for $ale,” Science for the People, Sept. 1975 .