The relationship between medicine and the study of life is as old as medicine itself.
Nevertheless, historians have highlighted the great transformation that took place
in the nineteenth century when first physiology and then bacteriology became important
resources for the classification, diagnosis, and treatment of human diseases.
1
In that period, significant links developed between the sites specializing in biological
experimentation (i.e. laboratories) on the one hand, and the places of healing (i.e.
hospitals, dispensaries) and public health offices on the other. Together, they helped
to fashion modern, professional medicine.
2
However, many historical studies have also argued that this mobilization of biological
knowledge exerted a limited impact on medical practice in general, and clinical practice
in particular.
3
The well-documented history of bacteriology is emblematic of these conflicting trends.
While one may point out the importance of widely circulated and celebrated innovations,
such as bacteriological cultures and diagnoses, or a few but impressive therapeutic
agents like diphtheria antitoxin, bacteriology itself did not have a radical impact
on early-twentieth-century public health.
4
The history of tuberculosis in industrial Europe is a powerful—and often mentioned—illustration
of this. The bacteriological trajectory of tuberculosis is not only remembered because
of the success of animal modelling, which led to the identification of Koch’s bacillus,
or because of the effectiveness of X-rays, which enabled the early detection of tubercular
lesions. It is also marked by the failure of Koch’s tuberculin as a miracle drug,
by the controversies surrounding the efficacy of BCG vaccination and the Lübeck affair,
by the uncertainties about the combined roles of heredity and infection in the aetiology
of the disease, as well as by the enduring domination of public hygiene and palliative
care in sanatoria.
5
It is only after the beginning of the antibiotic era, in the late 1940s and early
1950s, that decisive improvements in the control of the white plague could be attributed
to the conjunction of chemical and bacteriological work conducted both in academic
and industrial laboratories.
6
Generalizing from the example of tuberculosis, one can therefore argue that biomedicine
was only truly “invented” after the Second World War.
The transformation of biology and medicine, and their convergence after 1945, is far
from being uncharted territory for historians.
7
Several studies have revealed a step change in the scale of investment in research,
a new role for the state as scientific entrepreneur, an increasingly fundamental level
of investigation in biology and medicine, and a closer relationship between the laboratory
and the clinic. They have also described the culture of the therapeutic miracle that
has pervaded scientific and medical communities, and inspired the search for magic
bullets against tuberculosis, cancer, and cardiovascular diseases.
8
In fact, the links between these changes have been such that the period 1945–1975
could be described as one of a new system of relations between science, technology
and medicine, or as a new “way of knowing”.
9
That the post-war period saw the growth of biomedical complexes characterized by the
intensification of research in the life sciences, the hunt for novel molecules, and
a new alliance between biologists and the state, should not obscure the fact that
it also saw renewed tensions and local variations, which challenge any description
of it as the culmination of a uniform trend. Firstly, there have been tensions between
three different kinds of medicine: experimental medicine, clinical medicine, and social
medicine. Although biomedicine has, above all, been dominated by experimental medicine,
other sets of practices have persisted alongside those employed by the experimenter,
including molecular modelling and analysis, and biomedical scientists have developed
complex relationships with hospital clinicians and public health officials, which
have varied from arms-length distance, to mutual inter-dependence, and—more rarely—to
outright collaboration.
Then, of course, there have been variations due to different local and national contexts.
Whether these have affected the status of medical goods and services, the relationship
between health professionals and the state, the evolution of scientific disciplines
and medical specialties, the hierarchy between them, the regulation of the pharmaceutical
industry and the medical market, or simply what is meant by “social”, these different
contexts have influenced the evolution and nature of biomedical complexes. Even within
the relatively homogeneous scientific landscape of post-war Europe, one might therefore
expect national differences to have played a role that has been all the more important
in that, in the decades after the war, the management of life and health became a
matter for the state, exceeding in scale and scope the demographic concerns of earlier
governments.
However, as Anne Hardy and Tilli Tansey have rightly pointed out, “there is no satisfactory
general overview of the history of western medicine after 1945”,
10
particularly concerning the changing relationship between laboratories, clinical settings,
and public health authorities, and taking into account the different countries that
have contributed to the western medical tradition. The purpose of the following collection
is therefore to examine further this changing relationship, as well as encourage the
study of biomedicine in different national contexts.
The first choice we made in preparing this issue was to concentrate on post-war clinical
and public health research, in order to examine the forces and influences that fashioned
western medicine in the “era of biomedicine”. Biological research and laboratory investigations
have been the subject of much historical work in science and medicine after 1945,
most notably in relation to the so-called “molecularization” that led biologists to
relocate life and its most basic processes at the level of macromolecular structures,
more especially DNA and genes. Historians of molecular biology and its parent disciplines,
biochemistry, genetics, and virology, have stressed the critical role that the development
of new tools and instrumental practices—such as the use of the ultracentrifuge, electron
microscope, and electrophoresis—have played in this transformation.
11
These studies have also shown how the “molecular vision” of life was linked to the
political and cultural aspects of the Cold War, its emphasis on information and control,
and its permanent state of scientific mobilization in preparation for war.
12
Hence, between 1945 and 1965, biological experimentation changed radically, even if
important fields like embryology and developmental studies proved much more difficult
to attach to the molecular bandwagon than geneticists and biochemists had hoped.
These developments in the life sciences were not without their consequences for, and
echoes in, medicine. The most obvious was the incorporation of new entities, ranging
from enzymes to cancer viruses and inbred strains of mice, in the aetiological characterization
of diseases. Despite such advances, the direct impact of molecular biology on medical
practice remained confined to new explanatory models and diagnostic tools. The most
significant displacements were more indirect, resulting from the complex interaction
between the molecularization of the life sciences and the molecularization of medical
intervention, i.e. the transformation of therapeutic targets and the generalization
of a chemotherapeutic model of treatment, a situation influenced as well as exemplified
by the post-war history of cancer.
13
This aspect of “biomedicine”, in particular the relationship between the misnamed
“therapeutic revolution”—too readily attributed to the changing scale, organization,
and targets of pharmaceutical research—and clinical and social medicine, which this
issue touches upon, largely remains to be explored.
14
The second principle guiding our selection was the particular interest of comparing
Britain with France, for the history of these two countries’ biomedical complexes
has many similar features, such as the relative underdevelopment of certain fields
in the inter-war years, followed by a process of catching up after the Second World
War.
15
Yet the differences between Britain and France, not least their different systems
of health care, might be significant enough to lead to distinct but nevertheless related
biomedical practices, partly because none of the developments described above took
place in isolation. However, exchanges were less a matter of direct, bilateral “crossed
history”, than of intricate circulation, with the American biomedical complex as third
party, functioning at once as a model, competitor, and provider of means—cognitive
and financial, as well as instrumental—which reflected the economic, political and
scientific hegemony of the United States.
16
The very word “biomedicine”, its emergence and subsequent uses, is a testimony to
these differences. The prominence acquired by the term between 1945 and 1975 coincided
with the appearance of a new system of medical innovation in relation to biology and
health policy. However, this system was far from homogeneous, and the meaning of biomedicine
has been deeply influenced by the different scientific and national cultures that
have shaped western medicine since the late nineteenth century. In Britain, the word
biomedicine first appeared in Dorland’s 1923 Medical dictionary, and meant “clinical
medicine based on the principles of physiology and biochemistry”.
17
Although in the inter-war years the term was used only sporadically, it is significant
that its invention coincided with the Medical Research Council’s move away from public
health concerns, towards biological research.
18
In this period, the “biomedical” work of the Council consisted in establishing a number
of research units, mostly within the London teaching hospitals, where it promoted
a distinct research style inspired by the Cambridge School of Physiology with the
aim of making British clinical medicine more scientific.
19
By contrast, in the French context, the word biomedicine appeared only in the 1960s,
when it was used mainly by science policy makers and state administrators. Paradoxically,
the term was not employed by the biologists involved in the post-war development of
state-funded research agencies (the Centre National de la Recherche Scientifique (CNRS),
or the Institut National d’Hygiene (INH), later Institut National de Santé et de la
Recherche Médicale (INSERM), the French equivalent of the Medical Research Council
[MRC]). On the contrary, they pleaded for a “de-medicalization” of disciplines such
as bacteriology, immunology and virology, whose expansion had, according to them,
been hampered by the influence of “medical mandarins”, and their disciplinary agenda
led them to reject the very idea of “biomedicine”.
20
As for clinicians, they preferred the term “medical research” (“recherche médicale”)
to describe what they saw as a domain based first and foremost on clinical expertise,
even if it was influenced by advances made in the life sciences.
21
The fate of “biomedicine” as a word is a marker of the specific, and yet parallel,
changes that affected the relationship between science, medicine and public health
in Britain and France. Although direct comparisons between the two countries are relatively
rare,
22
the historiography has tended to reinforce the idea of their distinct patterns of
evolution. Thus, it has become commonplace to oppose the “nationalization” of the
medical profession and the central planning of health services under the National
Health Service (NHS) to the policy of laissez-faire and professional governance that
prevailed with the Sécurité Sociale, even if in both cases the creation of a national
health system allowed access to care to the vast majority of the population, and provided
the basis upon which hospitals became the main site for—often high-tech—medical intervention.
23
Similarly, the expansion of biological and medical research followed different paths
in the two countries: while the French favoured a model of full-time research under
the umbrella of government agencies (the CNRS, INH and later INSERM), the British
built on an older and stronger tradition of university-based research.
24
Furthermore, increasing post-war investments in experimental medicine had the effect
of perpetuating long-established disciplinary hierarchies, in Britain with the growth
of genetics and biochemistry, and in France with the expansion of the “pasteurian”
sciences, namely bacteriology, virology and immunology, which after the Second World
War came under the influence of fundamental molecular biology.
25
Last but not least, the extensive use of medical statistics in Britain, where it was
nurtured by a strong public health administration, contributed to clinical investigations
of therapeutic efficacy and regulation of research practices, which came together
in the controlled drug trial, an example rarely imitated before the late 1970s by
the case-loving French clinicians. These observations drawn from the historiography
help to highlight the legitimacy and significance of a comparison between Britain
and France, particularly in view of the need to examine further the link between science,
medicine and public health in the era of biomedicine.
However, a major paradox resulting from our comparison is that, despite these differences,
French and British biologists and clinicians considered American biomedicine in much
the same way, i.e. as a reference point, a resource, and a challenge. The American
biomedical model is a “ghost” haunting European biomedical research.
26
Its pervading influence is evident in the reorientation of the circulation of people,
tools and results from a trans-European to a trans-Atlantic direction, and by the
realignment of research practices in western medicine in the years following the war.
27
It is therefore not a complete surprise if the most significant conclusions to emerge
from our comparative exercise stress the similarities between Britain and France,
for the rise of biomedicine led to profound changes, which blur the contrasts that
have usually been drawn when thinking about the two sides of the “medical Channel”.
The most striking similarity, considering the strength of the British tradition in
social medicine, was the re-definition of “public health” as essentially hospital-
and drug-based, or in other words as curative rather than preventive medicine. The
papers by John Stewart and Luc Berlivet show how this convergence emerged out of two
different public health systems, the first in Britain, the second in France. The creation
of the British NHS in the period of the “classic” welfare state—that is, from the
end of the Second World War to the economic crises of the mid-1970s—produced many
new research opportunities.
28
Stewart’s paper goes on to argue that, important as these opportunities and the resulting
achievements were, there were also considerable constraints, which affected not only
the NHS, but also the MRC operating within it. The opportunities were in many respects
obvious enough—universal health care for British citizens, which was comprehensive,
free at the point of delivery, and accompanied by steadily rising expenditures. However,
the creation of the NHS has been problematic for those with aspirations to a form
of medicine that takes into account the socio-economic environment, emphasizing prevention
rather than cure, and thus overall seeks to deal with health in an integrated rather
than molecular manner. The reasons for this were firstly, financial, since Britain’s
commitment to social medicine was limited even by European standards; secondly, structural,
since in the process of policy formation key influence was handed over to the medical
profession, thus empowering actors who were largely wedded to the biomedical model,
and paid relatively little attention to environmental factors; and thirdly, political,
since although all the major parties were in favour of the NHS in some form or another,
in matters of health policy strategy politicians were not only prepared to cede power
to the medical profession, they also conferred a relatively low status upon the Ministry
of Health. All this resulted in a system in which the emphasis was on curative medicine/biomedicine
(particularly in a hospital environment) at the expense of the interrelated and overlapping
fields of preventive medicine/social medicine/public health/integrated and proactive
primary care. Thus, the public health sector and the local authorities experienced
a significant loss of power. Social medicine in particular was discouraged as a discipline,
and eventually declined into a version of medical statistics.
29
On this point, Berlivet’s paper converges and intersects with Stewart’s. Berlivet
analyses how the rise of biomedicine impacted on French public health research after
the Second World War. In France, the rise of biomedicine did not depend upon, or lead
to, displacements of concepts, instruments or people; on the contrary. As in the case
of Britain, it was a matter of intellectual and institutional competition between
various forms of health-related enquiries. The INH, established by the Vichy regime
but later maintained and expanded by the political and scientific elites of the Fourth
and Fifth Republics, was initially set up to monitor the health of the French population.
30
This institutional configuration allowed for the development of a wide range of investigations,
characterized by an emphasis on the social dimension of disease. However, in the 1950s
and 1960s, changes in the approach to medical research prompted a transformation of
the INH into an institute of biomedicine, a trend that accelerated after it was renamed
the Institut National de Santé et de la Recherche Médicale (INSERM) in 1964. The social
and population approach to public health previously adopted by the INH, and reflected
in its large surveys of infectious diseases and later chronic illnesses—cancer and
respiratory disorders among them—was gradually marginalized. At the same time, the
rise of biomedicine encouraged a different kind of population-based research. A group
of medical statisticians built on their links with some influential clinicians and
experimenters to promote a version of epidemiology that concentrated mainly on clinical
trial methodology and on the inferential analysis of complex aetiologies like cancer
and cardiovascular diseases, thus advancing a form of “experimental” medicine typical
of the era of biomedicine, but not biological in essence.
The last two papers deal with yet another similarity that emerges from this comparison,
namely the common rise of the clinical trial as a privileged form of, and site for,
therapeutic evaluation. The history of clinical trials has begun to move away from
the once overarching concern with methodological innovation and the problematic emergence
of statistics as a legitimate form of evidence in medicine. Recent work on the British
aspect of the story has focused on the peculiar history of statistical studies and
clinical research conducted under the aegis of the MRC.
31
The Second World War and post-war reconstruction, not least with the launch of the
NHS in 1948, provided the MRC with scope and opportunity to expand its activities
significantly and venture into new areas such as cancer, which had previously been
dominated by other bodies,
32
as well as consolidate its role in more traditional fields of study, such as tuberculosis.
In this connection, the MRC trials of streptomycin for the treatment of tuberculosis
are usually seen as a highpoint in the history of modern biomedicine. These trials
helped to establish the Randomized Controlled Trial (RCT) as a gold standard in clinical
research.
33
By contrast, the historiography on the American route to controlled trials has been
less interested in randomization and trial design than in clinical work, organizational
change, and drug regulation.
34
The 1962 Kefauver–Harris amendments to the Food and Drug Act, which provided the Food
and Drug Agency (FDA) with a mandate to enforce investigations of both toxicity and
efficacy when examining drug marketing applications, deeply altered clinical and pharmaceutical
research, since “controlled trials” were made a legal requirement. These amendments
were supported by an alliance of American public health administrators and clinical
reformers working in prominent teaching hospitals, such as those at Harvard and Johns
Hopkins, who had long been searching for instruments of medical evaluation that would
at once make clinical practice more “rational”, and the average practitioner less
dependent on the claims of the pharmaceutical industry.
35
Parallel studies of the “trial culture” in post-war medicine have concentrated on
the generalization of the RCT in cancer chemotherapy.
36
Although the roots of this evolution remain equivocal, the industrial origins of cancer
chemotherapy as well as the political context of the American war on cancer have played
a crucial role in the success of the RCT. Clinical investigations of chemotherapeutic
treatments were developed by the National Cancer Institute in association with a mass-screening
enterprise, which adopted a high-throughput approach, and the use of standard molecules,
animal models, and therapeutic protocols.
37
In this context, clinical trials were a means of alignment and control over heterogeneous
local practices. They played an important part in scaling-up activities and achieving
statistical significance, but unexpectedly resulted in a blurring of the boundaries
between the biological modelling of cancer causation and the therapeutic combination
of surgery, radiotherapy, and drugs. In addition, clinical trials seemed particularly
well suited to the production of evidence in cases where efficacy was not a matter
of cure but rather a question of survival time, and to the evaluation of palliative
forms of medical intervention, as in the case of cancer.
If the 1947 streptomycin trials are well remembered, it is less well known that the
MRC Tuberculosis Research Unit that oversaw these trials also organized clinical trials
on the treatment of lung cancer, which were far less successful in that they produced
less clear-cut evidence than their predecessors. In their paper, Helen Valier and
Carsten Timmermann look at both sets of trials, comparing the (often similar) problems
the MRC researchers encountered when organizing the different studies, and the various
ways in which they dealt with these. In contrast to the TB trials, lung cancer trials
proved a poor instrument of investigation, as the assessment of the effectiveness
of combined radiotherapy and surgery in relation to various radiotherapy regimes delivered
inconclusive results, which merely confirmed the status lung tumours acquired in the
1960s as “untreatable” cancers because of the constant comparison made with the highly
visible and successful example of childhood leukaemia. The value of the MRC researchers’
attempts was therefore—Valier and Timmermann argue—less in the knowledge produced,
than in their organizational significance. This distinction confirms Löwy’s observations
on the palliative function of the trials, as well as her vision of a biomedical world
divided into two domains, the first a biological realm where research entities are
easy to control and manipulate, the second a clinical realm where cure is difficult
to achieve and research messy. Thus the post-war MRC trials participated in the transformation
of clinical research into a collective enterprise that relied on sophisticated forms
of co-ordination and division of labour, a development mirroring the hospital-based
organization of the NHS.
The “resistance” (a term invented by professional statisticians) of the French grands
cliniciens towards medical statistics is a common trope in the history of French medicine,
often linked to Claude Bernard’s famous plea against the use of percentage and computation
in both experimental and clinical medicine.
38
Examining the clinical research programme on leukaemia carried out under the leadership
of Jean Bernard at the Saint-Louis Hospital in Paris, Christelle Rigal’s paper shows
us how in some circles of the medical elite such disdain for numbers had by the 1960s
become unacceptable. The internationalization of leukaemia research was an important
element in this transformation. Rigal’s study reveals the “biomedical triangle” referred
to earlier, describing as it does the development of international studies launched
by the American National Cancer Institute, which tested molecules of American origin,
but repeatedly mobilized a methodology that was attributed to British inferential
statistics. Local tinkering led to a combination of RCTs and alternative designs that
included historical controls, as well non-randomized trials, a situation far from
specific to France.
39
Specificity was not absent, however. Unlike its American counterpart, French “clinical
biomedicine” was not based on a pharmaceutical culture of industrial standardization,
but in a way similar to Britain, Rigal argues, on an administrative culture of state
planning.
What message can historians of twentieth-century medicine take from this selection
of articles? Our first conclusion is that it is worth embedding biomedicine within
the broader context of different post-war national health systems, and vice-versa,
and looking more precisely at the articulation as well as tensions between the three
forms of medicine, experimental, clinical, and social, which make up the western medical
tradition. The second conclusion is that—contrary to what one might expect—in the
era of biomedicine, individual national patterns have had a relatively limited influence.
The moral and political economy of the post-war period stimulated the rapid internationalization
of biological research. This, in turn, resulted in similar challenges for different
national scientific communities, if not similar practices, with the consequence that
analogous responses were worked out when “experimentalizing” clinical or public health
research. Our third and last conclusion is simply that recognizing this complex history
may be helpful in making the current wave of “biomedicalization” less radical and
unexpected than social analysts are tempted to assume.
40