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The Atlantic Honth!y December 1967 .° THE HEALTH S, YINID! CATE / Washlngton's Noble Consph'ators by Elizabeth Brett,ter Drew llealth ranks hlyh up zoilh moll, erhood as a condition to be espoased, and lhal helps to explain the seenzing ease w~lh which a small dedicaled band of research- and-cure deeotees have combined lheir ideas/concerns, and intimations of morlalily into one of lhe most effec- tive lobbies Washinglon has ever seen. In another of her deep-down examinations of lhe working of aovern- ment, Mrs. Drew calls the roll of the heallh lobby, de- scribes its achieremenls, and snggesls respectfully some of the problems provoked by ils multibillion-dollar success. race the end of World War 1I, the direct involve- mentof the U.S. government in trying to improve the health of its citizens has grown by enormous proportions. Federal agencies support research into the causes of diseases, into development of cures and application of the most advanced medical find- ings. At the National Institutes of Health in Be- thesda, Maryland, the government has built the greatest biomedical research institution in the world. In the eleven institutes on the Bethesda ~:ampus ~ each devoted to a specific problem such as heart disease, cancer, neurological diseases, men- tal illness ~ and through grants to researchers in clinics and medical schools, the NIH directly sup- ports over 40 percent of the biomedical research in this country. It is, moreover, a government enter- prise of exceptional quality which attracts many of the natio'n's outstanding scientists. Yet even more interesting than the fact of the growth of the government's role is how it happened. For one thing, it probably represents a uniqfic his- torical phenomenon. For another, the decisions behind it have been made, as they must be, in the political context. And while there is no question that it represents a great achievement, within that .overall achievement, even because of it, there have arisen some distortions and questionable departures in federal health policy. The extraordinary growth of the federal role in medical research had as its base a historical conflu- ence of forces in the post-war period. First, the "payoffs" from research in the physical sciences during the war ~ radar, the Bomb ~ gave basic research new respectability in political circles. Sec- ond, tht~ end of the war left the nation with unem- ployed scientists and more money. Third, the med- ical societies concerned with specific diseases such as polio and cancer were taken over from the doc- tors by civilians and turned toward promotion to raise money and educate the public. Finally there" were three remarkable men in positions of great power in Washington whose consuming interest was medical research: Dr. James Shannon, for the last twelve years the director of NIH; the late Repre- sentative John E. Fogarty of Rhode Island, who died of a heart attack early this year; and Senator Lister: Hill of Alabama. But it was Mrs. Mary Lasker, a very wealthy public-spirited citizen of New York with a fierce in- terest in health, who spun the web that linked all of these factors together. She did it with the help of what is referred to as her "stable" of doctor-allies, including men from the great medical centers such as Dr. Sidney Father of Harvard and Dr. Michael De Bakey, the famous heart surgeon, of the Baylor Medical School, and a doctor who guards the health of the President of the United States; of her longtime friend Mrs. Florence Mahoney, t___ 75

The Atlantic Monthly 7 who entertains government figures in her elegant Georgetown home and pushes both her own and Mrs. Laskcr's causes; of her able Washington lob- byist, Mike Gorman, a redhead who wears a Phi Beta Kappa key and talks like a rough, cynical impresario. She also did it with her own brains, charm, appetite for power, and unshakable belief in the efficacy of money. For the past twenty years Mrs. Lasker has been, in the words of one federal health official, "the most important single factor in the rise of support for biomedicial research." In the process, she has helped the NIH budget to explode from $2.5 million in 1945 to $1.4 billion this year, influenced Presidents, immobilized Secretaries of Health, Education, and Welfare, selected health policy makers, and pushed heahh policy in con- troversial directions. Mrs. Lasker's network is probably unparalleled in the influence th-at a small group of private citi- zens has had over such a major area of national policy. One federal official refers to it'as a "noble conspiracy." Gorman calls it a "high class kind of subversion, very high class. 3Are're not second story burglars. We go right ira the h-ont door." Speaking at the Lasker Medical Awards lunch- con last year, Douglass Cater, President Johnson's White House assistant on health matters, told the audience: "President Johnson's last appointment before he left the White House for the hospital was with Mary Lasker. And he didn't get away, either, without two memoranda from her to study while he was recuperating." "Mary and her colleagues,". said Cater, "have set a new fashion in lobbyists. The moving and shaking done by such womenfolk affects everybody, including the most obdurate of politicians. Be glad for them, for our children's children will reap the benefits." A problem with hcahh policy making in gen- eral, and the role of the health syndicate ira particu- lar, is the tendency to attempt to translate personal cxperlencc and concerns into national hcahh pol- icy. This leads to a good deal of flukiness. There is probably no more award-laden field ~in which the $10,000 Lasker Awards are the most prestiglous. Everyone who is for health is doing the Lord's work. This does not, however, preclude some questions about who has "a direct line to heaven, or some fallings-out among the disciples. Tm health movers and shakers found each other through a combination of accidents and word of mouth. When Albert D. Lasker, an advertising genius, married Mary Woodard Reinhardt in 19-~0, his bride, a cure iaude graduate of .Radcliffe and former graduate student of Oxford, was already a successful businesswoman and energetic devotee of public causes. Albert Laskcr, meanwhile, amassed a fortune, which one associate estimates at close to $80 million by the 1940s. In 1942, Lasker liquidated his advertising busi- ness and set up the Albert and Mary Laskcr Foun- dation, to push for federal support for" medical re- search, then a new and controversial idea. It was Albert Lasker's thought that the foundation should provkle the "seed money" forresearch projects, then catalyze the federal government to follow on once the private efforts became established. Their primary interests were in mental health, birth con- trol, and -- after the Laskers' cook was stricken with cancer in the early 1940s--cancer research. (Al- bert Lasker died of cancer in 1952.) Albert Lasker used to vacation in Miami Beach, and there he introduced Mary to his fl'icnds Flor- ence and Daniel Mahoney. Daniel Mahoney's late first wife had been the daughter of Ohio Gov- ernor James Cox, and Mr. Mahoncy had inherited" a substantial position in the Cox family newspaper chain, the largest Democratic chain in the country. Florence had always been interested in medicine, to the point of taking pre-med coursesl Now, through her husband's own interest in medicine, the Cox family's connections, the outlet of the news- papers, and her access to the congressional press galleries, she could push her causes. Florence Mahoney read about the crusade to impro~/e treatment of the mentally ill by an Okla- homa newspaperman named Mike Gorman. "5 asked Mahoney," she recalls, "to get him to work on the paper in Miami. He came for two weeks and stayed for six weeks. Hc wrote a sensational series headlines every day. Then Mike went to the state legislature to lobby them, and he got $6 nail- lion for mental health within six weeks." In 1944, Senator Claude Pepper (Democrat, Florida) was persuaded by the Mahoncys (whose newspaper support he needed) and the Laskers (who contributed campaign funds) to hold hear- ings on federal support of heahh research. Mrs. Lasker supplied the senator with horrifying statis- tics about the mortality and morbidity rates of vari- ous diseases. She suggested that he read these off, have outside witnesses testify to the nccd for more resea!'eh, and then ask federal officials how much they were spending to combat the diseases. The total being spent at the then modest National Insti- tute of Heahh and its affiliated Cancer Institute was $2.5 million. The Lasker forces believe that the Pepper hcarlng.~;, the first of their kind, wcrc very influential. Historically, they were the beginning of what became the health syndicate's highly devel- oped mo&ts operandi in Congress. B0th Mrs. LaskCr and .Mi:S..Maii6ncy Werc frienci2 ly with the Trumans (.Mrs. Tru|nan was helpfitl in passing on messages and memoranda to her busy 76 ¢

husband), and during the Truman Administration there was White /:louse support for building the NIH. The budget began to be increased, and tile number of subsidiary institutes expanded. The great defeat of the Truman health insurance pro- gram taught Mrs. Lasker, who had devoted large amounts of money and energy to the fight, that head-on clashes with the AMA were to be avoided. But tile AMA was so busy combating "socialized medicine" that it failed to notice the implications for medical practice and medical education of the growing federal budget for health research. This, in turn, provided health research as a platform from which congressmen gould voice a concern for health without incurring the powerful wrath of the AMA. Toward the end of the Truman Administration the President established, largely through the ef- forts of his medical adviser, Dr. Howard Rusk, the President's Commission on the Health Needs of the Nation. Dr. Rusk has been a friend of Presidents through his pioneering work in vocational rehabili- tation in his clinic at New York University and his influential medical column in the New York Times. He has also been a friend of Mrs. Lasker's, "l'he executive director of the President's commission and author of its report was Mike Gorman. The report called for higher levels of federal spending for medical research. This was tile first evidence of what was to become another piece of the health syndicate's pattern: what Gorman calls "the White Paper device." "Through this type of study," he explained in a re- cent speech, "you develop the facts, you involve a great number of organizations previously not inter- ested, and you hopefully create a militant consensus in support of the findings of the Commission. The White Paper, or Commission report, is the founda- tion stone for legislation, and it provides an Obvi- ous answer to the familiar myriad of charges raised by hostile legislators--you didn't study the prob- lem long enough, ]tour conclusions were hastily drawn, you didn't consult a broad enough segment of professional groups or of the American people at large, and so on." After his effective work on the commission, Mrs. Lasker asked Mike Gorman to run a Washington operation for the Lasker Foundation. Gorman, with his great interest in psychiatry and mental health, wanted a committee of his own to operate. "You want a committee?" he recalls Mrs. Lasker asking, and they thereupon set up what "is now the National Committee Against Mental Illness-- Mrs. Albert D. Laskcr and Mrs. Florence Mahoney, co-chair- men; Mike Gorman, executive director. From the committee's offices on Connecticut Avenue, Gor- man pushes Mrs. Lasker's interests in Washington. In 1950, ~[rs. Mahoney, having divorced her husband, moved to Washington and established TIlE IIEALTII SYNDICATE " what has become the utterly purposeful social side of the syndicate's operations. It is probable that there is no one who has bccn important to health policy in Washington who has not dined--on, among other things, assorted but tasty health foods at Mrs. Mahoney's. They usually leave with an armload of reading matter. (At one point, Mrs. Mahoney sent material on birth control to the Pope.) When Kennedy White House aides played softball, Mrs. Mahoney showed up at the games and invited them back to her house for beer. She taught Jaequeline Kennedy about export porcelain, and when'Luci Johnson was married she gave her a set of rare china. Mrs. Mahoney will help officials' wives find maids, and she will send a tureen of soup to the ofl~cials at their offices. Both Mrs. Lasker and Mrs. Mahoney are guests at the intimate dinners given by theJohnsons. Hap- pily for Mrs. Lasker, she and Mrs. Johnson now share an interest in planting shrubs and flowers all over the country. Mrs. Lasker is known for her parties at her Beckman Place townhouse in New York, where the worlds of politics and medicine meet, and when she comes to X, Vashington she stays and entertains at Mrs. Mahoney's. Mrs. Lasker is admired; Mrs. Mahoney is liked. Mrs. Lasker has been considered an able woman who has done good things but is too covetous of power, too ,insistent on her pursuits, too confident of her own expertise in the minutiae of medicine. Mrs. Mahoney is seen as gentler and warmer, and since she has never made the same claims, she has been easier to take. WHr-N Mrs. Lasker comes to ~Vashington, she puts in long• and strenuous days in pursuit of health. She carries in her handbag a foldea onionskin chart tracing the rise of NIH appropriations over the years. Mrs. Lasker is known to be one of the nation's more generous campaign contributors. "I'm on a first-name basis with one hundred fifty, one hundred seventy-five members of the House," says Gorman. "You know. A warm relationship." "We work on all the members of the Appropriations committees," he says. One year, the key vote was held by the late Senator Styles Bridges of New Hampshire, tlxe ranking Republican on the Senate Appropriations Committee. Mrs. Lasker had been cultivating Bridges' friendship; she sent him the latest drugs and brought him special diet food for his hypertension. One day Mrs. Lasker waited over three hours to see Bridges. Once in his office she talked about his hypertension and discussed the importance of more research facilities. "Gen- eral *lotors can't work without equipment, Styles,', she "told him. Bridges agreed to support an in~ creased appropriation. 77

i i~ ~: ~' .!- Tile Alltmtic Monthly Early in 1967, Senate Majority Leader Mike Mansfield of Montana agreed to host a luncheon for his colleagues, at which Mrs. Lasker could prcss for more funds for heart research. Some thirty-six senators/~ttcnded. Dr. De Bakey and oth.cr distin-' gulshed cardiologists told the senators about the million people who dic of heart disease each year. "I order the food," say.s Gorman, "and see that the tables are bussed: properly; Mansfield makes the opening remarks, and we go t.o work." When Lyndon Johnson was.running thc Senate, Mrs. Lasker befriended him, too. In 1959, Mr. Johnson agreed to speak in support of a $200 million increase in the NIH budget over that requested by President Eisenhower. (Two years later Vice President Johnson was the" featured speakcr at the Laskcr Medical Awards luncheon.) The 1959 speech was his maiden speech on health .research. It was written by Mike Gorman, It was a classic of sorts: "In the childhood of many of us in this chamber, diphtheria, typhoid fever, smallpox, pneumonia, tuberculosis and a host of other dis- eases "brought heartbreak to hundreds of thousands of American families. Few were thc families in Texas, or in any part of the country for that matter, who did not lose at least one child to one of these major killers .... Over the past decade alone, cancer has claimed the lives of five members of this body .... Cancer has killed many of our military heroes whom enemy bullets failed to stop .... By another ironic twist of fate, the Senate Appropriations Committce hearings on the Budget for the National Cancer Institute for the coming year were held on the very day that our great Secretary of State, John Foster Dulles, was • laid to rest .... Its deadly stranglehold upon the fiber of our democracy was nowhere bettcr assessed than in a brief editorial which appeared several days after the death of John Foster Dullcs in the 'Machinist,' the official publication of the International Association of Machinists: 'For six years the Communists tried every trick in the book to get John Foster Dulles out of their hair. What the Commies couldn't do to our former Secretary of State, cancer did.'" Tm technique of reminding the lawmakers of their mortality has been consistently effective in raising the ante for health research, and this ac- counts in good part for the astounding exponcntial growth of the NIH budget. So do the "fact books" produced by the National Health Education Com- mittee, another Lasker organization in New York, showing how biomedical research has increased longevity, and thc clear-cut definition of what the congressmen were being asked to vote for: to "cure" 78 cancer, heart disease, and so on. "Cancer and heart disease have more money," says h'/rs. Lasker, "because they are major causes of death, and the members of Congress can understand that." The story goes that in the days when One of the NIH branches was called the Institute of Microbiology, one congressman asked, "Whoever died of micro- biology?" The name was changed to the Institute of Allergy and Infectious Diseases. The growth of NIH can also be attributed to the concurrent appearance on the scene, of Senator Hill, Representative Fogarty, and Dr. Shannon. John Fogarty was a brilliant rough-edged Irish- man :who entered Congress in 1941 at the age of twenty-olght with a high school education and ten years' experience as a bricklayer. In i949 he be- came the chairman of the House Appropriations subcommit.tee that handled the funds for health, a post of great power. Until a couple of years ago, Fogarty underscored his own power by denying sufficient staff to the secretary of HEW. Gorman claims that Mrs. Lasker "made" Fogarty, taught him everything he knew, but this is not quite the ease. It understates Fogarty's independent, ira- • pressive mastery of the details of federal heahh pro: grams. Moreover, though Mrs. Lasker and Fogartg were close allies, Fogarty was even closer to Dr. Shannon. Shannon, through an extraordinary combination of professional standards and political instincts, traits which in other men are frequently at cross-purposes, managed to build both a great re- search institution and a political base for it in Con- gress. Mrs. Lasker was closer to Hill than to Fo- garry. Hill, as it happens, had an innate interest in health policy: his father was a prominent surgeon, five cousins and two brothers-in-law were doctors, and Hill himself was named for the great surgeon Joseph Lister. Hill directed health policy from a dual position of power in tl~e Senate, as chairman of the Labor and Public Welfare Committee, which authorizes health programs, and as chairman of the Appropriations subcommittee which provides the money. In the raising of the budget, Fogarty, Hill, Shan- non, and Lasker performed each year as a highly polished quartet. First, the Administration would submit a budget request. As with just about every government agency's request, it would be lower than the NIIt had suggested to HEW and than HEW in turn had suggested to the Budget Burcau. Holding his hearings, Fogarty would casti- gate the White House for the "cutbacks" and elicit from the NIH officials, as if hc didn't already know, the amount they had initially requested and thc comment that they could do wcll with the full amotmt. Fogarty would say that he did not care what the bureaucrats in the Budget Bureau thought; he wantcd to hear from the "experts." Thcn Got'-

man would field his "citizen witnesses," well- known physicians such as De Bakey, Farber, Paul Dudley White, Karl Menninger, who would state the case for more money. Finding good medical witnesses, accbrding to Gorman, is not easy. "Their language is extremely technical, jargonistic. I forbid doctors to use the term 'myocardial infarction.' I say, 'You call it heart attack or you leave the room.' That and 'no smoking.' Those are tlle two rules. It's hard to find the right combination. De Bakgy is unique; he has the aura of the surgeon, he's articulate, enthusias- tic. Most doctors are not enthusiastic, not used to the verbal give and take. The Rusks, Farbers, De Bakeys have the evangelistic pizzazz. Put a tam- bourine in their hands and they go to work." Carefully assessing the mood within his own sub- committee, and the more conservative full Appro- priatlons Committee, Fogarty would then raise the NIH budget and write a justifying report in which Gorman and Shannon usually had a hand. Such is the stature of the Appropriations subcom- mittee chairmen in general, and suela was Fogarty's in particular, that he had his way when the bill came to the House floor. The budget raises which Fogarty produced en- abled Hill to take them still higher. Essentially the same routine would be followed in the Senate "citizen witnesses" and all, During this time, Got- man and Mrs. Lasker would be making their • rounds, doing what they could to assure the success of Fogarty's and Hill's budget-raising performances. In 1959, after years of what Gorman calls "glori- ous adversity" during tile Eisenhower Administra- tion (the NIH budget went from $59 million to $400 million between 1953 and 1960), some Repub7 lieans began to propose a closer look at the runaway NIH budget. Senator Hill graciously offered to di- rect the study himself, and appointed a Committee of Consuhants on Medical Research. Among its members were Michael De Bakey, Sidney Farber, and others who were in the heahh syndicate's inner circles. Gorman helped out with the report, which called for a substantial rise in federal support for medical research. The study, says Hill, was "very helpful." IN a'llz~r, view, one of tile most satisfying successes of the health syndicate is the federally sponsored system of special centers for the treatment of heart disease, cancer, and stroke which is now being established throughout the country. In 1960 Mike Gorman succeeded in getting inserted into the Democratic platform a call for a special White House study of heart disease and cancer. In 1961, a spe- 61ally appointed body produced a report now known as the "Bay of Pigs Report," both because it Tnl~,I[I,;A.LTII~ SYNDICATI'; • 'a i was prcscntcd to Prcsident Kcnncdy on thc day of thc invasion, and bccausc it was so badly donc that it was a bit of a disastcr in its own right. Thc Laskcr forccs pushcd for another commission, and it is said that it was suggcstcd now that it bc a com- mission on strokc as wcll as on canccr and hcart disease, although strokcs arc con~idcred a subspc- cics of hcart discasc, to appcal to Prcsidcnt Kcn- ncdy, whosc fathcr had suffcrcd a strokc. In any cvcnt, thc Prcsidcnt was considcring a ncw commis- sion bcforc hc was killcd. Bchind .thc cfforts for such a commission lay thc Laskcr group's growing impaticncc to gct thc rc- suits "off thc shclf," as thcy say, and out into thc country. ,Thcy visualizcd a network of hcart, can- ccr, and strokc institutcs which would conduct rc- search, training, and paticnt carc. The idca ap- pcalcd to Prcsidcnt Johnson. Beyond thc fact that Mr. Johnson likes Mrs. Laskcr and admircs hcr achicvcmcnts, her impaticncc to gct practical ap- plication of thc fruits of research was consistent with his own naturc. In the spring of 1964, thc Prcsi- dcnt's Commission on Hcart Discasc, Canccr and Strokc was cstablishcd. Its chairman was Michacl Dc Bakcy. Among thc mcmbcrs wcrc Mrs. Flor- cncc Mahoncy, Mrs. Harry Truman, Dr. Sidncy FarbcD Dr. Howard Rusk, Dr. Edward Dempscy, and a numbcr of othcrs closc to thc Laskcr circlc. "Wc had a quorum," says Gorman. Includcd in that quorum was Dr. J. Willis Hurst of Emory University, the man who monitors Presi- dent Johnson's heart. ("He's with us," says Gor- man.) Being the President's doctor seems to be a promising route into a position of health policy making. Dr. James Cain of the Mayo Clinic is a longtime friend of Mr. Johnson's and has general responsibility for his health. Dr. Cain told the President over dinner one night that he was worried about the way that the Pentagon was drafting doc- tors, and this led to establishment of the National Advisory Commission on Health Manpower (its areas of concern were broadened at the insistence of other health officials). Dr. Cain, of course, served on the commission. Dr. Wilbur Gould, who oper- ated on the President's larynx, has been suggested by the White House for a position on a heahh ad- visory council, and hc is expected to be making health policy before the year is out. Even Luci Johnson Nugent's doctor's wife was named to a consumer advisory council not long ago. In December, 1964, the President's Commission on Heart Disease~ Cancer and Stroke reported, call- ing for a national network of heart disease, cancer, and stroke centers Which would conduct research, training, and patient care. So hurriedly was the legislation drafted for the forthcoming session of Congress that one man working with thc White House who saw the bill zip by says that "in all nay 79

The Atlanlic Monthly experience I never saw a piece of legislation leave the White House on which there was less clarity on what the federal government was going to do." Nevcrthe!css, tile President made it one of his priori- ties, and tile bill was passcd by Congress in 1965. While tile goals of the Lasker forces in pushing tile heart tdiscase, cancer, and stroke program may seem unexceptionable, others who are as ill favor of .health as they are are disturbed by the decision to embark on tills type of program. For it raises some of tile most serious and difficult questions, moral as well as medical and financial, involved in defining the federal government's role in health care. Tile centers are to provide the most advanced treatment of these diseases, but in most cases even tile most ad- vanced treatme~at can only ameliorate them, not cure them, and can only postpone death. Is the government therefore assuming responsibility for tile care of these patients for tile rest of their lives? If tile federal government is going to begin to pro- vide centers for certain diseases, would it be better to provide them for diseases which: can be cured or for those which cannot yet be cured? Similarly, if such a departure is to be made, should it focus on diseases which affect primarily tile elderly, as these do, or on diseases which affect prhnarily tile young? These kinds of policy considerations should have preceded a decision to initiate a program of centers for heart disease, cancer, and stroke, but they did not. The very name of the commission~ and its membership, preordained its conclusions. Moreover, the issues involved in producing the "payoffs" from research, in getting the findings "off the shelf," are not so simple as the Lasker forces make out ~ as President Johnson, at great pain, learned this past year. Tm Lasker forces feel that the NIH directors must be pushed into more concern for faster "pay- off" fi'om the research dollar. "They should be paying more attention to helping human beings," says Mrs. Lasker, "who after all are the ones who are paying for research. I know you have to have basic research, but once you've spent $8.5 billion, I think you should do more to see how the dollars apply to human beings. The NIH people are not people with a sense ofmlssion to reduce the death rate directly. I don't mean that they're not well motivated. Too many of them are without a sense of dccp urgency." As Gorman puts it, "We figure they get tile seven-year itch in eight years." One of the ways that the Lasker group has pushed for "payoff" has been through getting themselves appointed to the NIH advisory councils, which ap- prove all research grants and therefore have con- siderable voice in NIH policy. Mrs. Lasker has served on the councils more often than has anyone else, and way up there are Mrs. Mahoney, Dr. Farber, and Dr. De Bakey. Mrs. Lasker's slstcr, Alice W. Ford},ce, is on the National Advisory Allergy and Int'dctious Diseases Council. Their uses of these positions have often put them at odds with Dr. Shannon and the directors of specific institutes. A few years ago, for instance, the Natio,ml Ad- visory Heart Council stated that tile higlaest pri- ority should be given to a $100 million program to develop an artificial heart. Shannon resisted, on the grounds that there was not yet a sufficient scien- title base on which to develop an artificial heart. He knew, moreover, that development would be highly e>zpensive, and once started, the demands for tile product could end in consuming all of the funds for research on artificial hearts- at the cost of a better product in the longer run. The limits on medical and economic resources raise, again, dif- ficult social as well as medical issues. When is it" scientifically feasible to proceed with the develop- ment of such devices? Would the price, in deaths, of postponement be offset by the saving of more lives through a more effective instrument at some future time? Shannon initiated instead a much smaller, highly directed program designed to learn a good deal more about what kinds of devices would be useful at what stages in what sorts of heart prob- lems. l~,eslsting the all-out artificial heart produc- tion program was not easy, particularly since it had the backing of Dr. De Bakey, a physician quite adept at publicizing his causes. Another way that the Lasker group has pushed for earlier cures is through allies in Congress. Sena- tor Hill has been especially helpful. "There is noth- ing more important," he says, "than getting the findings and getting them out to the patient's bed- side.'~ Dr. Farber has been a strong supporter of studying the effects of various drugs on cancer, and Senator Hill, through simply adding the money for it to its budget, pushed the NIH into a massive pro- gram of cancer chemotherapy. The program, which began in 1955 over the objections of a large number of scientists, has now cost about $250 mil- lion. Although there have been a few useful re- suits, many question whether more progress would not have been purchased through a similar invest- ment elsewhere. A special committee which stud- led the NIH in 1965 (this group contained no traces of the syndicate) said that the program had been begun on too large a scale, based on too little scientific data. "Tile availability of money," it said, "exceeded the availability of sound ideas." A second objection to the cancer chemotherapy pro- gram has been that it was a search for a cure when there was little knowledge about the cause, and that this seldom works. Finally, the availability of research money in a given medical field has circular 80

cffccts: the moncy attracts the researchcrs who in turn request more money. There are always vogues in medicine. If the most enthusiastic supporters of a certain vogue have political access, the circular ef- fect can be intensified. If the program doesn't show sufficient results, its backers can say that it is because it needs more money. This can cause some serious displacement. Cancer chemotherapy research, for example, consistently received ever expanding fimds, while those interested in viruses as a cause of cancer received little support. It now appears that the study of viruses might produce the most impor- tant knowledge yet about cancer. In recent years, Mrs. Lasker has become increas- ingly insistent upon large-scale field trials of drugs. People who know her ascribe this to a combination of her general interest in health and her own intimations of mortality. This year, for example, her forces persuaded Senator Hill to add $4 million to the NIH budget, without asking NIH, for a test of an anti-coagulant drug, to see if it will reduce heart attacks. NIH scientists say that the project is poorly conceived, and that it may take ten years and over $100 million to test just this one drug. Still another way to push for "payoff" isto go straight to the President. One day last spring, dur- ing a White House meeting of doctors and hospital omcials on Medicare, President Johnson made the slightly irrelevant announcement that he was "serv- ing notice" on his secretary of Health, Education, and Wclfare to convcne a meeting of the NIH directors, which the President would attend, to "hear the plans, if any, they have of reducing deaths and disability, of expanding research." It pleases the Lasker group that this was the first that HEW officials heard about it. But no one was un- clear about where the President got the idea. At the meeting which took place a few weeks later, the President asked the NIH directors a series of ques- tions, drawn up by Mrs. Lasker and Gorman. The President's initiative, as if he didn't have • enough problems, caused an explosion among the scientists and in the universities. They took it to mean that the Lasker forces were in the saddle; that support for applied research and development was to be substituted for support for basic research by'an anti-intellectual, unsophisticated President who could never understand such things. Many scientists feel that basic research in general gets shortchanged. (Officially, less than half of the federal health research budget is classified as going for basic research; in many other scientific fields, the balance is heavily on the side of application and development.) They know that premature appli- cation can Icad to wasteful, or imbalanccd, pro- grains. They feel that national policy reflects this country's instinct for the practical, its assumption, as one leading scientist put it, "that it can buy re- TiIE lligAL']'l[ SYNDICATI~ x. ,~ search by the yard." This leads then~ to conclude that basic research must have the strongest possible advocacy in the public arena. Their opponents argue that too high a proportion of the biomedical research dollar has gone to basic research, and that unless the strongest possible advocacy is given to clinical testing and production of medical services, the fi'uits of the research will remain in the labora- tories. Too much of what might help us, they say, is left to serendipity and Germanic journals. While there is obviously some validity to what both sides say, the argument is not quite real be- cause it implies far greater separations and distinc- tions between basic and applied biomedical re- search tha~ actually exist. There are many exam- ple~ in the work at NIH. Through basic research in genetics, more was learned about the origins of a number of diseases. Basic research on tissue cul- ture led to a series of virus vaccines. The argument posits a clear-cut choice between one or the other. This is an issue which calls for sophisticated policy- making machinery, not to come up with a single policy, but constantly weigh the priorities between alternatives, each of which is laudable. This is not an issue which should be decided on the basis of who happens to have the President's ear. Sometime last spring Mrs. Lasker thought it was time fo~ the President to prod the NIH directors again. This time, however, the President heard from some of his official advisers that the entire affair had done him no good. In a dramatic at- tempt to recoup, the President helicoptered to the NIH campus in Bethesda, nodded approvingly at its facilities, and made a speech which managed not to make either side mad. He bowed to basic research ('.'The government supports this creative exploration because we believe that all knowledge is precious; because we know that all progress would halt without it") and to cures ("There is no use in opening someone up and saying, 'It is too far gone. I can't do anything about it' "). But most of all he made the men at NIH happy by calling their institution a "billion-dollar success story." In scientific circles, the President's trip is referred to as "the Pcdernales solution." There are a number of thoughtful people with a role in health policy who are apt to become highly exasperated with Mrs. Lasker. But then they re- mind themselves of the contribution that she and her group have made. In its buccaneering fashion, the health syndicate has done great good. "People get so mad at her," says one government man, "that they say that Mary Lasker is ahnost al- ways wrong. In fact, she has been almost always right. Her instincts are very correct- that bio- medical research must be built up, that there must be more delivery of health services. The problems come when these get mixed up with her personal 81

The .-'lllardic Mot~lhly intcrcsts, her politicking, and her taste for powc,', and then she gets into trouble and causes trouble." The exasperation stems largely from the fact that Mrs. Laskcr's group would not recognize the need for choices, but then do-gooders seldom do. It is questionable that the Lasker forces should be blamed for the fact that they were so successful, or for the related fact that there were no equivalent forces pressing for other health priorities. It is not their fault that the U.S. Public Health Service, a quasi-military corps based on aia eighteenth-century concept, has been so lacking in courage and imagi- nation, so deferential, in dealing with cverytl}ing from disease prevcntlon to pollutim~ control, to the status quo. Nonethclcss, the resulting distortions in federal health policy cannot be blinked aside. To be very hard about it, the prevention, or postponement, of death among the aged may not be the most impor- tant priority in medicine, yet that is the decision that the politicians have made. The resources that go into the research and treatment of diseases which affect primarily the aged, in combination with Medicare and Medicaid and other health programs of benefit to the eidcrly, consume at least 50 percent of the federal health budget. While roughly one eighth of the U.S. population is over 60, almost half of it is under 25. And for all of its medical prowess, the United States has an infant mortality rate that is worse than that in fourteen other countries. About 40 percent of those called up for the draft fail to pass its tests for mental, physical, and emotional health. It has been estimated that large percentages of the handicapping conditions which children now suffer- congenital malformations, vision or hear- -ing dcfccts, psychiatric problems, and others-- could be prevented. This year, the federal govern- ment is spending only $167 million on child health services programs, and another $65 million on child heahh and mental retardation research at NIH's Institute of Child Health and Human De- velopment, as against S165 million at the Heart Institute for research alone. There is much less fcdcral support for research on trauma and acci- dents, which hospitalize nmre than 2 million people each yea," and kill another 100,000, than there is on diseases that kill.or disable far fewer people at a far lower social cost. Moreover, distortions beget dis- tortions. Physicians who go into research a.re at- tracted to the fields where there is a large amount of support for research. Nor can some of the assumptions on which health policy has becn sold be accepted on their face. Despite the claims of the Lasker group about how our investment in heahh research has pi'oduced longevity, this is not at all clear. Longevity in the United States has increased, but it has incrcascd morc in other nations, even those which started from a higher longevity base. The mortality rate is a crude indicator, in any event. It says nothing about the social, economic, or emotional conse- quences of diseases. It does not measure the effects of chronic diseases that arc not primarily killers. It is not at all clear, either, that in buying health services we have'bought health. H I¢'~V policymakers say that they have searched, but have not been able to find, documentation of the assumption that pe0- ple who receive regular medical attention are healthier than those who do not. This may require an entirely new definition of the components of "health." A great many nmre deaths might be pre- vented, or diseases "cured," if smoking were re- duced, if automobiles were safer, if the air were cleaner, than through post-facto, disease-oriented research and services. In the days when there were less social and military claims on the budget, and when these alternatives were less understood, such choices did not have to be faced. But now they do. Even the "payoff" argument has somewhat missed the point. It is now widely believed that the great gap in the deliver); of health services is not simply between the laboratory and the prac- titioner, but between the treatment received if one is lucky enough to have access to a great university medical complex and the treatment rcceived in the small towns and rural areas, or between the treat- ment in the medical complexes and the ghetto. These gaps are less romantic, and they are more diflqcult to deal with. There is increasing concern among health policy makers over the disorganization and inequities in medical services. There is a growing feeling that the categorical, disconnected, disease-oriented, spe- cific-fee-for-specific-service approach is outmoded. (Even Medicare does not ensure comprehensive medical treatment; it ensures the payment of doc- tors' bills.) The comprehensive health clinics which the poverty prog,'am has begun to open in ghetto neighborhoods, using new approaches to health care, are seen as the first step in a new direction. This, the general awareness of the needs of the poor that came with the poverty program, the demands of the labor movement, the involvement of tim insurance companies, tim restivcncss of the medical students--all are going to have an in- creasing voice in defining health policies. This means that the voice of the health syndicate will be diminished. This comes at a time when its powers would inevitably fade. John Fogarty is dead. Lister Itill is seventy-two and in political trouble. Mary Lasker and Florence Mahoney are no longer young women. The political climate is changing. The health syndicate has been, there- fore, a historical phenomenon, probably an un- parallelcd one, certainly an important one. There may never be anything like it again. 82