The transformation of medical research and the rise of biomedicine since the inter-war
period have attracted a great deal of attention from social scientists in general,
and from historians in particular. A wide range of publications has addressed crucial
issues, such as the changing relationship between the clinical and laboratory sciences
(the attempt “to experimentalize the clinic”, in Jean-Paul Gaudillière's words); the
scaling up of research activities related to the shift from one regime of knowledge
production to another, and the resulting debate about whether there was such a thing
as “Big Medicine”; the role of the “molecularization” of medicine and the life sciences
in this evolution.
However, the impact of the rise of biomedicine on different, but connected fields
of research, such as public health, has not so far attracted the same amount of interest.
As constituent parts of a single intellectual, as well as institutional configuration
(or “figuration” in Norbert Elias's words),
different research areas can be interdependent in many ways. The rise and fall of
a style of thought can challenge scientists operating in other areas, either directly,
as when an expanding discipline undermines or trespasses on other domains; or indirectly,
by questioning basic, widely shared assumptions, forcing their proponents either to
reposition themselves within the changing configuration, or to affect (sometimes ostentatiously)
to ignore the challenge. On the other hand, cross-disciplinary alliances reinforce
the interdependence that exists between different scientific communities. Competition
and co-operation between disciplines also play a crucial role in the allocation of
public and private money to higher education and research. Finally, the success of
a particular discipline can transform the organization of research as a whole, as
when a specific division of labour developed within a new, promising area (e.g. in
molecular biology) is imposed by enthusiastic policy makers as a model to be emulated
by other scientific fields.
Hygiene, social hygiene, epidemiology, social medicine, community medicine, health
promotion: all the public health disciplines and sub-disciplines that have multiplied
since the nineteenth century have been strongly affected by the evolution of medical
teaching, even after independent schools of public health had been established, as
well as by the progress of laboratory research. A famous example of this co-evolution
of public health and related medical disciplines can be found in the threat posed
to epidemiology by the rise of bacteriology. Although David Lilienfeld's view that
“the Bacteriological Era overshadowed epidemiology” and put it into “hibernat[ion]”
for some forty years was somewhat simplistic,
the challenge from bacteriology nevertheless forced epidemiologists to adapt to the
new discipline, if only by criticizing its focus on the “agent” as opposed to the
The aim of this article is to reflect upon the impact of biomedicine on the related
field of public health. By examining the transformation of public health research
in France between the early 1940s and the late 1970s, I intend to shed light on a
specific organizational setting that came to be seen as a handicap for public health
researchers, and eventually led to their marginalization. The specificities of the
French case make it ideally suited to such a study. First of all, the hegemonic position
enjoyed by the Institut National d'Hygiène (INH), which became the Institut National
de la Santé et de la Recherche Médicale (INSERM: National Institute for Health and
Medical Research) in 1964, allows a detailed examination of the relationship between
clinical, population, and laboratory-based disciplines. This is not to say that the
Institute, which was established by the Vichy regime in 1941, ever wholly embodied
the vast and diverse field of administrative and medical practices captured under
the umbrella term of “public health”. At any rate, a history of public health interventions
in France during this half-century (a topic that has hitherto received little scholarly
attention) would far exceed the limits of this article. However, it is important to
highlight how the peculiarities of the French situation coalesced to enhance the role
of the Institute. On the one hand the lack of interest in public health in medical
schools and teaching hospitals, combined with the weakness of these institutions in
research, led to the INH's dominant position in investigations concerning the health
of the population.
On the other, the chronic difficulties experienced by the Ministry of Health in terms
of staffing, funding, and finally legitimacy made French government officials dependent
on the INH's (and later INSERM's) expertise.
All the same, despite the initial centrality of public health in its activities, the
research institute gradually evolved into the country's biomedical powerhouse. Its
story therefore provides valuable insights into the growing influence exerted by biomedical
approaches to health and disease on apparently distinct areas of research, such as
Interestingly, this slow transformation of a “hygiene-oriented” institute into a biomedical
one was quietly overlooked during the commemoration of INSERM's fortieth anniversary,
and so was the fact that the Institute did not appear “fully formed” in 1964, but
rather took over from the INH.
The INH's association with Vichy was understandably repellent. However, this bizarre
lapse of memory also hints at the difficulty contemporary French scientists have in
associating themselves with the kind of public health research undertaken at the INH,
in accordance with a “style of thought” rendered obsolete by the rise of the biomedical
approach to disease and health. Indeed, these developments need to be placed in a
wider time frame and analysed as a moment in a process that began in the 1940s and
continued until the late 1970s, that is some fifteen years after the transformation
of the INH into INSERM had taken place.
Investigating the Health of the Population: Hygiene as Expertise
Although the foundation of the Institut National d'Hygiène in November 1941 unquestionably
bears the mark of the Vichy regime, it was by no means a direct outcome of the infamous
“collaboration policy” promoted by Marshal Pétain in the aftermath of French capitulation
to Germany in June 1940. On the contrary, and paradoxically, this creation can also
be seen as the end-point of a long series of discussions and negotiations between
the Paris-based representatives of the Rockefeller Foundation and a handful of the
most dynamic of the French medical “mandarins”.
The Rockefeller had been active in the Hexagone since 1917, when it started supporting
the French government's fight against tuberculosis.
Contacts intensified in the early 1920s, and lasted until June 1941, when the Rockefeller's
Paris-based staff had to leave the country.
Two separate, but partly interconnected issues were debated over these years. First,
the possibility of promoting a more “scientific”, that is laboratory-based, approach
to medical teaching by awarding grants to innovative individuals, or to medical schools
that agreed to include pre-clinical sciences in their curriculum. Second, the founding
of an institute of public health that would combine teaching and research in a single,
appropriately equipped location, under the leadership of Léon Bernard, who held the
chair of hygiene at the Paris Medical School.
Neither the difficulties encountered by the awards programme, nor the ultimate failure
of the second project after more than a decade of alternating hope and frustration,
prevented the Foundation from sponsoring innovative research in defeated France. On
the contrary, the Rockefeller took great interest in a series of nutrition studies
(an understandably crucial topic in wartime) undertaken in Paris and Marseilles. In
this case, the provincial city proved even more responsive than the capital, to the
point that in the winter of 1940–41 the collaboration between Rockefeller's envoy,
George K Strode, and a group of medical researchers headed by Professor André Chevallier
at Marseilles University, led to the foundation of an Institut des Recherches d'Hygiène,
whose activities quickly expanded beyond nutrition.
The Vichy regime was so impressed by these initiatives that the Marseilles Institute
was granted 375,000 francs in its first year of existence, a sum increased to one
million francs in 1942; in March 1941, the Secretary of State for Health, Serge Huard,
even paid a visit to the Institute.
It is therefore no surprise, and perhaps even ironic, that once he had been promoted
to Secretary of State for Family and Health in Admiral Darlan's new government, in
August 1941, Huard built on this experience when making plans for an institut national
d'hygiène with headquarters in Paris. A regime that vilified the “Anglo-Saxons” on
every possible occasion quietly followed in the footsteps of the Foundation which
epitomized American philanthropy. Conversely, the French technocratic elites that
were taking advantage of the social and political crisis to promote a “government
of technicians” played little part in this creation,
although André Chevallier, appointed by Huard as Director General of the new national
institute, was no stranger to the regime, having previously served as a health expert
for the government.
Despite the constraints of the Occupation, about thirty medical researchers, helped
by a limited number of technical staff, managed to follow up and even expand on earlier
investigations into nutritional deficiencies (Chevallier's topic of choice). In addition,
they started a series of studies on issues as diverse as the epidemiology of cancers,
syphilis, alcoholism, and other “social diseases”; the quality of water, as well as
problems of general and occupational hygiene; and some laboratory research in radiobiology
and physiobiology (on the biology of metastases for example).
The budget of the Institute grew from 15 million francs in 1942 to 20 million in 1944,
two thirds of which was dedicated to public health research.
The qualities displayed by Chevallier on this occasion did not prevent him from being
criticized when Liberation came. For the INH's activities were not immune from political
even if they were less easily discredited than many of the investigations undertaken
at the same time by the Fondation pour l'Etude des Problèmes Humains, better known
as “Fondation Carrel”, after its promoter and Régent, the surgeon-turned-physiologist,
Nobel Prize winner, and infamous eugenicist, Alexis Carrel.
Although Chevallier managed to deflect the charges brought against him by the “Commission
d'Epuration” of the Ministry of Health in August 1944, his growing disagreement with
the communist Minister of Health appointed by the provisional government of the French
Republic a month later eventually forced him to resign his post at the end of 1945.
Nevertheless, he remained on the board of the Institute, and was awarded the American
Medal of Merit in August 1946.
Chevallier's successor was Louis Bugnard, a professor of biophysics at the Toulouse
Medical School, a physician and graduate of the Ecole Polytechnique who had taken
advantage of a Rockefeller fellowship to travel to London and work with A V Hill in
1932–34. While the new Director General of the Institute was clearly eager to shift
the balance of its activities from expertise, its initial raison d’être, towards research,
he nevertheless had to muddle through with an organizational setting inherited from
In matters of medical research, Bugnard was influenced by both the experience of the
USA and that of Britain.
As early as May 1946, he expressed his support for the creation of an advisory research
Then, from the early 1950s onwards, he backed the creation of research centres, small
groups of scientists located (ideally “embedded”) within teaching hospitals, mostly
in Paris, whose research topics were not directly linked to any particular public
health issue. This was true even of the first of these centres, established by Professor
Jean Trémolières (a former head of the Nutrition Section)
at the Bichat Hospital to investigate the biochemistry of “human nutrition and dietetics”.
A similar attempt to combine experimental science with the quest for medical applications
characterizes what was to become the most fashionable research field of the late 1940s
and 1950s: “medical physics”, thanks to the support of Bugnard. Thus, in close association
with the Commissariat à l'Energie Atomique (Atomic Energy Commissariat), the INH made
rapid progress in the use of radioactive isotopes, whilst developing a new generation
of machines for cancer therapy, and contributing effectively to dosimetrics (the measurement
of exposure to sources of radiation).
However, for a period of about twenty years, efforts in these areas were hampered
by the financial and practical limits to the creation of permanent research positions,
which were perhaps the most crucial element in the Institute's strategy. A decree
in May 1947 had provided medical researchers with the same status as their colleagues
at the Centre National pour la Recherche Scientifique (CNRS).
However, the paucity of funds,
combined with the difficulty of luring promising physicians into joining a research
institute in a country where private clinical practice remained central to their professional
hindered the creation of full-time, permanent positions. In 1949, 58 out of the 103
researchers employed by the INH were trainees (stagiaires); ten years later the ratio
was largely unchanged, while the overall number of research positions had only slightly
increased to 130.
Indeed, the rise of biomedicine in France was neither effortless nor quick, and for
at least twenty years after the end of the Second World War, the public health sections
remained key components of the Institute.
The Social World of Public Health Research
In the 1940s as before, “public health” was a highly fluid term, and the investigations
into the health of the population undertaken at the INH took a great variety of forms,
while the methods used in the different sections ranged from descriptive statistics
to laboratory analysis. Nevertheless, they shared many features, including a common
approach to the publication of results, which favoured monographs over journal articles.
Altogether, these investigations created a particular research environment, characterized
by a specific organization and set of customs, until the slow, hesitant rise of biomedicine
à la française finally subverted the former social order, transforming what had until
then been mainstream practices into anomalies and shameful reminders of an all-too
recent past that needed to be forgotten.
The INH was initially organized in four different sections: the Nutrition Section,
of great historical importance; the Hygiene Section, whose expertise included occupational
issues; a Social Diseases Section covering an enormous domain embracing topics as
varied as alcoholism, cancer, and tuberculosis; and finally the Epidemiology Section.
Directed by a young physician named Alice Lotte, this last section originally focused
on the descriptive statistics of epidemics brought on or worsened by war (such as
diphtheria, typhus, measles, and scarlet fever),
before widening its field of investigation after the Liberation of France. Epidemiologists
also provided other sections with technical assistance in the gathering and treatment
of quantitative data. From the end of the Second World War to the mid-1970s, the number
of sections as well as their scope increased spectacularly, through a process that
mirrored the transformation of public health over the period in most of the western
world. Soon after the end of the war, the Social Diseases Section split into a series
of separate entities specializing in specific pathologies: there were sections on
cancer, alcoholism, tuberculosis, and cardiology. Increased medical specialization,
the lynchpin of this new organization of the Institute, also led, conversely, to the
amalgamation within a single section of the different groups working on acute infectious
In the 1950s and 1960s, new fields of research were explored, such as paediatrics
and perinatal health, and “mental hygiene” (later renamed “psychiatry”), from a public
health perspective that focused on populations rather than clinical cases. Simultaneously,
the much broader access to health services ensured by the wide social security scheme
established in the aftermath of the Second World War, combined with a rise in the
number and size of hospitals, created new research topics (such as the evaluation
of the population's “health needs”) that had significant economic and political implications.
One section was dedicated specifically to clarifying such issues,
though this kind of research never received the level of academic and political attention
it enjoyed in Britain.
In the late 1960s, although INSERM had taken over from the INH and the interest of
its Directorate in public health had already declined, the sections merged into the
Division de la Recherche Médico-Sociale (DRMS: Division of Medico-Social Research).
Dr Lucie Laporte, who had been instrumental in the reorganization and expansion of
the Direction de l'Hygiène Sociale at the Ministry of Health, was appointed its director.
By the mid-1970s, all the by then eleven components of the DRMS had been gradually
regrouped on a large campus situated on the western outskirts of Paris, in the leafy
suburb of Le Vésinet.
It is worth reflecting on the very name given to the DRMS. In the second half of twentieth
century, the term “medico-social” was widely used in France to describe the blurred
area where public health issues mingled with considerations regarding the welfare
of the population (admittedly a much wider concern), and the growing number of social
services dedicated to that purpose. The meaning and importance of the activities undertaken
by the different sections are difficult to grasp as not all of them amounted to research.
Constant Burg, INSERM's Director General from 1968 to 1978, tellingly distinguished
between what he described as “routine” investigations, which aimed at providing the
Ministry of Health with information on the mortality and morbidity of the population,
and proper research.
Yet, for all of Burg's pronouncements, drawing a clear distinction between the two
kinds of activity remained a difficult task. This was particularly the case in a country
where the marginalization of public health in medical education meant that most scientists
were unable to distinguish genuine research work from apparently dull, routine, investigations.
For example, Burg's description of “Mademoiselle Guidevaux's” section, which specialized
in medical statistics, and included a WHO reference centre for the standardization
and classification of causes of death, was reserved: “These statistics have been handed
over to INSERM by INSEE [France's National Statistics Office]. They cannot, at any
rate, be likened to research activity.”
In fact, the apparently purely bureaucratic work on mortality kept prompting methodological
questions that called for proper statistical research, and simultaneously allowed
some staff members to embark on epidemiological investigations.
Ironically, Madeleine Guidevaux's research on the rise in mortality rates attributable
to the heat wave that struck France in 1976 recently resurfaced, when members of parliament
in charge of the official enquiry on the alleged political and administrative mishandling
of the 2003 heat wave argued that her “interesting study” should have alerted the
Department of Health and public health agencies to the imminent disaster.
An examination of the DRMS's workforce reveals, however, the low number of senior
researchers appointed to the various sections compared with the number of “technicians”
and junior researchers supported by individual grants. In April 1976, the year it
was officially disbanded, the Division counted no more than 19 researchers with permanent
positions, out of a total of 237 staff members.
Indeed, some sections employed no more than a couple of researchers, mostly medical
doctors. The implementation of surveys and the analysis of their results, which were
the core activities of the DRMS, required a large number of boursiers (INH and later
INSERM research fellows), as well as technicians. The former, who numbered 108 at
that time, were either medical students, or else young doctors. While most were merely
looking for a temporary source of income, others built on this first experience of
research to secure more interesting and permanent posts, either within the Division
or, more often than not, in clinical research centres or laboratories based in Parisian
As boursiers, their role was primarily to draft or tailor questionnaires and guidelines
to fit the topic of the investigation; to monitor its completion; and finally gather
any kind of complementary information where appropriate. For their part, the 110 technicians
who worked in the eleven sections in 1976 were responsible for the material aspects
of the investigations, including the mechanical and computational sorting of results.
In all, this was a rich and ramified social world of highly interdependent occupations,
as, for example, perforateur (the technicians, mostly women, who “punched the cards”)
and opérateur mécano (for mécanographe, in charge of the sorting machines).
For more than fifty years before the introduction of personal computers in the 1970s,
a good deal of research in public health and social sciences rested on the correct
functioning of such complex networks of machines and highly specialized human actors.
Not surprisingly, the management of this extensive and diversified workforce, characterized
by a high turnover, proved daunting. The boursiers held their positions for only short
periods of time, and often had to change sections in order to stay in employment,
whereas the large number of poorly qualified technicians in charge of secretarial
or mechanical tasks frequently left the Institute to seek more interesting or secure
jobs. As a result, a temporary shortage of personnel at the atelier central de perforation
(central punching workshop) could delay all the ongoing surveys.
In 1974, when the number of investigations undertaken reached an all-time high,
Lucie Laporte complained that due to the “shortage of permanent employees” only four
out of the eleven sections were “adequately staffed”.
Another peculiarity of this social world of public health was that it was highly feminized,
a feature in no way confined to technical and clerical staff. In October 1974, seven
of the eleven heads of section were women, while the Division itself (see Table 1
above) was still under the guidance of Lucie Laporte.
This situation contrasted sharply with the gender distribution that prevailed elsewhere
in the Institute: the INH's and INSERM's successive director generals were all men,
as were the members of both the Board of Governors and the Scientific Council. Even
today, heads of research units and directors of research are predominantly male.
Such a strong contrast could hardly pass unnoticed; according to former DRMS researchers,
“les dames du Vésinet”, or “les demoiselles du Vésinet” (the latter term emphasized
the unmarried status of some of these women, starting with Laporte) were dismissive
descriptions of the Division often used by its critics to underline a double distinctiveness:
this female leadership had prospered on the fringe of the French medical world, at
a safe distance from Paris teaching hospitals (where the research units were located)
totally dominated by male mandarins.
The Public Health Sections in 1974
Head of Section
Statistical Information on General Mortality and Morbidity
Dr Madeleine Guidevaux
Research on Public Health Actions: 1. Public and Mental Health Problems Linked to
the social Environment
Dr Françoise Davidson
Research on Public Health Actions: 2. Prevention
Dr François Chicou
Research on Public Health Actions: 3. Health Problems in the Community (“Collectivité”)
in relation with the Health Services (“Système de soin”)
Dr Denise Minvielle
Dr Maurice Brunet
Dr Jacques-Lucien Richard
Tuberculosis and Respiratory Diseases
Dr Alice Lotte and Dr Simone Perdrizet
Transmissible Diseases (other than Tuberculosis)
Dr Gilbert Martin-Boyer
Dr Claude Rumeau-Rouquette
Dr Georges Pequignot
Statistics-Epidemiology and Computer Science (“Informatique”)
Dr Françoise Hatton
In 1972, the Section of Psychiatry had been transformed into a research unit: Unit
110, Epidemiology in Mental Health, headed by Dr Raymond Sadoun and based at Saint-Anne
psychiatric hospital, in central Paris. (‘DRMS—Bilan des activités et orientations
actuelles’, October 1974, 42 pages; INSERM Archives; ‘Archives Direction Générale
INSERM, 1969–1989’ (CAC: 2001165), box 23.)
All these idiosyncrasies, combined with the difficulties experienced by the Directorate
of the Institute in identifying and precisely evaluating the research produced by
the different sections, help to explain the gradual marginalization that led to the
final disbandment of the Division in the late 1970s. By then, the pace of work in
the sections was much slower than in the rest of the Institute, which had become completely
focused on supporting research units dedicated to biomedical research. As mentioned
above, a trademark of the sections since the creation of the INH had been the organization
of large-scale investigations, surveys often, that took years to complete and even
longer to publish. Indeed, the most famous of these investigations, appositely titled
‘Enquête Permanente Cancer’ (Permanent Cancer Survey), has continued unremittingly
since its official launch in 1943, resulting in a series of publications over the
Conceived and initially supervised by Pierre Denoix, a young surgeon who was to become
a key figure in French oncology, this study of the incidence and the distribution
of the different types of tumour in the country relied on information channelled by
the network of cancer clinics (centres anticancéreux) that had been set up in the
inter-war period, chiefly by the Ligue Nationale Contre le Cancer, the most prominent
charity in the field.
Another important, though less prominent, research project was the so-called ‘Enquête
Boulogne’. Following on from a pioneering investigation into the health status and
needs of the inhabitants of Soissons, the Community Health Section (overseen by Denise
Minvielle) had selected the population of Boulogne-Billancourt, a suburb of Paris
close to Le Vésinet, in order to study the differences in the reporting of disease
and use of health services between social classes.
The investigation, which lasted from 1969 to 1975, constituted a significant attempt
to bring the social sciences (chiefly economics and sociology) into French public
Such efforts did not enjoy much support within the Institute, however. On the contrary,
by the end of the 1960s, the DRMS approach was increasingly being superseded by another
kind of population-based research. This alternative approach was developed by a group
of statisticians working under the direction of Daniel Schwartz, who had managed to
gain a foothold in the promising world of biomedicine by establishing their own research
unit within a major cancer hospital. In contrast with their colleagues based in the
sections, they always took great pains to ensure that their research would lead to
useful applications for clinicians as well as biologists.
Medical Statistics at Villejuif: The Importance of Being Useful
As the memory of the DRMS has faded away, evocations of the introduction and expansion
of epidemiology at the INH, and later INSERM, never fail to underline the role played
by Daniel Schwartz. In some accounts, Schwartz and his school of thought—l’école Schwartz,
or l’école de Villejuif (named after the southern suburb of Paris where their first
research unit was located)—appear as pioneers in this field, and as its lone supporters.
The great irony is that, when he first embarked on a career in medical research, Schwartz's
interests had little to do with public health. Later, the approach to medical statistics
promoted by his “school” happened to sit well with the demands and constraints of
the burgeoning field which practitioners and commentators alike would later call “biomedicine”.
Indeed, it was the closing down of the DRMS that led to a shift in the statistician's
position among the various disciplines represented at INSERM, and identified them
as the main, if not the sole, practitioners of population-based research, even though
the range of their research topics and methods was much narrower than those developed
by the different sections. In fact, neither Schwartz nor his lieutenants ever aimed
at supplanting the DRMS; on the contrary, they openly opposed its disbandment.
Daniel Schwartz was born in 1917 to a prominent medical family. His father was a surgeon
in a Paris teaching hospital, while his maternal uncle was none other than Robert
Debré, the most formidable French mandarin of the twentieth century, and mentor of
many in the generation that introduced biomedicine into the country.
Initially, however, Schwartz had no intention of following in their profession, and
it took a series of fortuitous events to bring him back to the medical world. After
graduating from the prestigious Ecole Polytechnique in 1939, he joined the national
tobacco monopoly—the Service d'Exploitation Industrielle des Tabacs et Alumettes (SEITA)—as
an engineer. There, an appointment in the agronomy department allowed him to use his
knowledge of probabilities and statistics, and to familiarize himself with the fundamentals
of plant genetics. As his interest in genetics grew, Schwartz considered switching
careers. In 1950, Debré introduced him to a group of young and innovative professors
of medicine. He began lecturing on the use of statistics in medical research, but
the position he expected in the emerging field of medical genetics never materialized.
Four years later, Pierre Denoix, who had heard of him through the inevitable Debré,
asked Schwartz to join an investigation into the aetiology of lung cancer. This research
project sought to investigate whether the association between smoking and this particular
cancer, uncovered almost simultaneously by Bradford Hill and Richard Doll, in Britain,
and a handful of American investigators, could also be found in the French population.
Suddenly, the ingénieur des tabacs (Schwartz's official title), then researching the
impact of mosaic disease on tobacco plants, started studying the effect of tobacco
smoke on human lungs, bladders, and an increasingly long list of organs, with the
complete approval of SEITA's Director General and the financial support of the firm.
Though unexpected, the collaboration went very well indeed, and Denoix, appointed
as Director of the Institut Gustave Roussy (IGR) in 1956, hired Schwartz to establish
a statistical research unit. The first challenge for the engineer-turned-medical-statistician
was to build up a proper team, in an era when probability was taught in very few university
departments, and certainly not in the medical schools. In fact, only two of the seven
researchers on the staff of the research unit in the 1950s and early 1960s were medical
doctors; the others were young graduates of the Ecole Polytechnique attracted by Schwartz's
reputation and the prospect of a career in scientific research. Even after the INH
decided to support their activities and made them the twenty-first Research Unit in
1959, they continued to experience difficulty in attracting medical doctors.
Despite the support of Debré and Denoix, this group remained to some extent on the
margins of the medical world. In the early 1960s they launched a course intended to
spread the gospel of inferential statistics amongst physicians. Initially taught at
the Paris University Statistics Institute (ISUP), it remained on the fringes of medical
education for some twenty years.
Even after Schwartz was appointed professor of medical statistics at the Paris Medical
School (a rare honour for a “non-medic”) in 1968, he remained an outsider in the eyes
of many of his colleagues. Within the DRMS too, some researchers seem to have shared
the opinion that a lack of any clinical background amounted to an insurmountable handicap,
and the engineers fresh from the Ecole Polytechnique unfortunately lacked any medical
Conscious of the interest their quantitative methods generated among a new generation
of medical researchers, and of the enduring hostility of many clinicians—even in teaching
hospitals—toward the probabilistic approach to health and disease, the newborn Unit
21 adopted a strategy that had already been successfully used by another statistical
research unit, that established by the Medical Research Council (MRC) in Britain in
Like Major Greenwood and Austin Bradford Hill (the successive heads of this unit to
1961) before him, Schwartz encouraged his team to develop statistical applications
in three complementary fields: epidemiology, clinical trials, and laboratory experiments.
Although the group's first task had originally been to contribute mathematical expertise
to an investigation into the origins of lung cancer, its members were not primarily
motivated by an interest in public health. In fact, within Unit 21 the substance of
“epidemiology” shrank to little more than the probabilistic analysis of the aetiology
of chronic, non-transmissible diseases. Both the Unit's location within the most important
cancer hospital in the country, which provided an easy access to a great concentration
of patients, and its aspiration to establish close relationships with clinicians,
led these researchers to adopt the case-control study as their method of choice, at
a time when the DRMS sections favoured surveys.
This approach, which compared the characteristics of patients admitted for one specific
disease (in this instance lung cancer) with those of patients unaffected by the disease,
in order to identify a statistically significant difference between the two groups,
was applied in a growing number of areas. While Schwartz himself continued to study
cancer, junior members of his team were encouraged to explore other fields. They started
working on cardiovascular diseases, reproductive health, paediatrics, and obstetrics.
Although the scope of these investigations widened gradually, the “relative risk”
approach to aetiology that was revolutionizing epidemiology at the time provided a
unifying style of thought.
The whole team felt at ease with the methodological tools and scientific concepts
underpinning mainstream Anglo-American epidemiology, and soon established links with
some of their more prominent counterparts in Britain (Richard Doll) and the United
States (E Cuyler Hammond, Daniel Horn, and Jacob Yerushalmy). Schwartz and his collaborators
proved eager to publish in the major French medical journals, and quickly learned
also to write for Anglo-American publications.
Equally crucial to the success of Unit 21 was its ability to contribute to the distinct,
yet related field of clinical research. IGR had originally hired Schwartz, and helped
him to constitute a research team in order to provide statistical assistance to its
clinicians. One of their first tasks was to help standardizing and mechanizing medical
records produced by the different departments so as to make information more easily
available to house physicians. A programme developed for that very purpose had the
somewhat bizarre acronym of “PASTIS”.
Jean Lacour, a former head of department at IGR, later recalled how the Statistical
Research Unit helped them to develop a “modern” approach to clinical research that
“broke with the archaisms of [their] old methods”.
Not everyone shared his enthusiasm, however, and resistance to the statisticians’
intrusion into clinical matters centred on the randomization of therapeutic trials.
Letting chance decide whether or not a patient should receive a promising treatment
had already proved the thorniest issue in the debate among British and American physicians.
It is a measure of the difficulties encountered by Schwartz and his group that the
first properly randomized trial organized at IGR was not completed and published before
This did not prevent them from gaining early international recognition through their
participation in the activities of the European Organisation for Research and Treatment
of Cancer (EORTC) from its inception.
Within France, the statisticians found support among those (still in the minority,
but growing in numbers) who relied on inferential methods to design and interpret
their laboratory experiments. As the hybridization between medicine, biology and,
to a lesser extent perhaps, chemistry and physics, gathered momentum, statistics applied
to experimental research quickly appeared as the third significant domain of activity
in Unit 21's annual reports. The group was soon able to establish working relationships
with a growing number of biophysicists, biochemists, and geneticists. Although some
remained reluctant to believe that there was such thing as “statistical research”,
and tended to belittle the statisticians’ contribution as somehow ancillary to their
own work, at least Schwartz and his team appeared on the map of French biomedicine,
if only on the margins.
The strategic decision to insert Unit 21 firmly within the new world of medical research
did not prevent the group from interacting with the DRMS. Up to the early 1970s at
least, Unit 21 contributed to various investigations launched by the different sections.
Tellingly, however, their interventions focused almost exclusively on the most medicalized
aspects of public health, which allowed them to carry out their research in a hospital
setting, avoiding studies in the community or any other kind of investigation among
the general population.
The few preventive programmes to which they contributed merely aimed at adjusting
the treatment for cardiovascular disease according to patients’ risk profiles.
Different public health sections also facilitated Schwartz's plan to develop a team
of medical statisticians by taking on some of his young assistants who could not immediately
obtain permanent positions in his much smaller research unit. Pierre Ducimetière,
a graduate of the Ecole Polytechnique, was for years officially attached to the Cardiology
Section, while working very closely with Schwartz. For her part, Claude Rumeau-Rouquette,
the first medical graduate to join Unit 21, went on to become the head of the Perinatal
Health Section. At the beginning of the 1970s, she began to benefit from a renewal
of interest in such issues, and when the department of health launched its Plan Périnatalité
in 1971, she became their chief expert.
In both these functions, however, Rumeau-Rouquette broke with the DRMS tradition.
Her approach bore all the marks of Unit 21. So keen was she to reinforce her links
with obstetricians and paediatricians that she successfully argued for the relocation
of her section to Baudelocque, France's leading maternity hospital, rather than to
the public health campus at Le Vésinet. In that matter, as in many others, she received
the full support of Constant Burg, for her approach sat very well with his own views
on medical research, as opposed to “routine” work. After all, Rumeau-Rouquette's analysis
of risk factors for diseases or accidents incurred by the pregnant mother, the newborn,
or both, were of immediate interest to clinicians.
When Burg's criticisms of the Division became fiercer in the mid-1970s,
he never failed to balance his denigration with praise for her work, thus underlying
the difference between the two approaches.
The End of an Era: the Demise of the DRMS
The disbanding of the Division put a halt to the long-lasting discussion that had
taken place over the future of the public health sections. In 1963, Bugnard submitted
to government a plan to transform the INH into a national institute of medical research,
with the emphasis shifting from “hygiene” to “medical research”.
However, the scheme proved more difficult to implement than expected, as the sections
enjoyed statutory protection under various acts and decrees passed since the 1940s.
Furthermore, it appeared difficult to reduce the activities of bodies responsible
for informing the Ministry of Health on an increasingly wide range of issues, particularly
since the quality of their publications and reports was much praised.
The situation changed dramatically as a new generation of medical researchers came
of age in the 1960s and early 1970s. Public health was far removed from their research
interests, and in the view of laboratory scientists like Burg, who ran small, flexible
research teams, the sections consumed too many resources, especially in terms of manpower.
More irritatingly still, at a time when INSERM was increasingly encouraging researchers
to submit their manuscripts exclusively to the most prestigious Anglo-American journals,
their colleagues in the sections still favoured the book-length monograph (in French)
as their medium of choice.
In 1964, when a series of “specialized scientific commissions” was established to
advise INSERM's scientific council, public health underwent a symbolic degradation,
as the commission in charge of that field came last on the list. None the less, many
clinicians and laboratory scientists still believed that the production of information
on the health of the population should remain within the province of the new research
institute. As late as December 1976, the Scientific Council approved a resolution
that reaffirmed this view.
However, members of the council did not know that Burg had already submitted to the
Minister of Health a highly confidential plan to disband the DRMS in such a way, as
he himself wrote, that it would silence the declared opponents of his scheme.
Well aware of any changes made to the organization of the Institute, the Director
General realized that a unique window of opportunity had just opened. Not only had
a 1974 decree, quite providentially, deprived the sections of the statutory protection
they had enjoyed since 1941, but the anticipated retirement of Lucie Laporte (the
DRMS's director since its foundation) in June 1976, allowed for a complete reorganization
of the field.
The plan was to transform each of the sections into either a technical support team
(a service commun in INSERM parlance) or, where possible, into a proper research unit,
whose activities could then be monitored by the relevant scientific commission.
At that time, the Director General had extensive powers to choose the members of these
commissions. Burg's main concern lay in the high level of unionization among DRMS
staff and the consequent risk of political turmoil. The mischievous strategy he developed
to overcome this opposition consisted in tarnishing the scientific reputation of the
Division to a point where even the most passionate call for its preservation would
sound purely corporatist, politically biased, and ultimately illegitimate. To achieve
this aim, Burg openly proposed to assign a series of inquiries into the quality of
the work produced by the sections to a few professors of medicine, presented as “undisputed
authorities”. In fact, while the public health credentials of the academics listed
in the memorandum were rather limited, all were closely associated with Burg. For
this reason, perhaps, Burg felt able to anticipate, with utter confidence, the results
of these future investigations:
There will inevitably ensue [sic]: (a) An all-encompassing critique of the DRMS's
activities that would make the implementation of the reform project easier; (b) A
suggestion to carry on establishing [relocating] the DRMS's sections within relevant
Battering the Division in this way, however, would not be enough to convince a Minister
of Health who relied on INSERM for information on the health of the population. Burg
therefore claimed that civil servants and public health physicians would be better
off once the traditional, old-fashioned sections had been transformed into innovative
and responsive research units. Again, he cited Rumeau-Rouquette's group as a model,
for in 1974, at her own instigation, her section had been transmuted into INSERM's
Burg also pointed out that Schwartz had trained several other brilliant medical statisticians,
who could be granted more autonomy, and be encouraged to establish their own independent
Ironically, Schwartz and his collaborators, with the notable exception of Rumeau-Rouquette,
openly opposed a plan that should in principle have reinforced their position. Certainly,
their loyalty towards their trade union, which resisted the demise of the public health
sections, helps to explain their apparently paradoxical position. However, scientific
issues were also at stake, as the attitude of Philippe Lazar, one of Schwartz’s closest
protégés, clearly demonstrates. The second graduate of the Ecole Polytechnique to
join Unit 21 (in 1960), Lazar had been based at Villejuif until 1975, when he spent
a sabbatical year at the Harvard School of Public Health. There he discovered another
approach to epidemiology, promoted by the likes of Brian MacMahon. He saw for himself
how medical statisticians collaborated with public health scientists from various
disciplines, and noted the stimulating effect it had on the whole field.
Once back in France, Lazar was so eager to see this model emulated in his home country,
that he met Burg and pleaded for the transformation of Le Vésinet into a vibrant campus
where researchers and graduate students, organized in neither sections nor research
units, would work together, teach, and learn. Such an institution had never existed
in France, the so-called National School of Public Health (Ecole Nationale de la Santé
Publique, based at Rennes) being essentially in charge of training health service
managers and civil servants in administrative matters.
Burg thought otherwise. When the DRMS was disbanded in 1977, five sections were transformed
into research units, and gradually relocated in various Parisian teaching hospitals.
None survived for long, as the peculiarities of their topics, and the small number
of scientists on their staff made it extremely difficult for them to meet the criteria
established by INSERM's Directorate and Scientific Council for the evaluation of units’
activities. The need to appoint many more epidemiologists, as well as other public
health scientists, had been clearly stressed in one of Burg's 1976 memoranda.
However, the number of such positions effectively opened at INSERM in the following
years remained very limited.
The demise of the public health sections, and their fall into oblivion over the thirty-five
years that followed, had important long-term consequences. From that moment, the number
of legitimate topics of public health interest investigated at INSERM shrank noticeably.
The population-based study of human health did not fit well with the reductionist
approach favoured in biomedical laboratories. Moreover, the unstable mix of contributions
to policy making and pursuit of an independent research agenda, which had characterized
the work of the sections and helped to secure financial support for the INH in the
previous period, was now viewed with aversion. It was seen as a pollution of science,
paradoxically, at a time when research units were increasingly urged to collaborate
with the pharmaceutical industry and other private firms.
This long-term development explains, for example, why social epidemiology, with all
its political implications, remained marginal in France, despite the efforts of a
research group (Unit 88), which in the late 1970s and early 1980s would pose the sole
scientific challenge to the Villejuif School.
More generally, some of the key methods favoured within the Division, such as surveys
of the general population, did not suit the means allocated to and the constraints
imposed on research units. On the one hand restrictions on finance and the size of
the workforce, and on the other pressure to produce results within a limited timescale,
also account for the extremely small number of cohort studies commissioned by INSERM
until very recently. The resulting dependence on “case-control studies” had important
consequences for the framing of scientific research within the Institute. Many topics,
including issues of burning interest to policy makers, were difficult to investigate
by such means. The limits imposed on knowledge of the health of the population proved
extremely costly, both in medical and political terms, when in the 1980s and 1990s
a series of epidemics (AIDS, hepatitis) and health scares (like the so-called “mad
cow disease”) challenged the state's capacity to protect its citizens. It took social
and political mobilization against AIDS to convince INSERM and the French government
to launch a comprehensive survey on the sexual habits of the population.
However, on many other crucial issues, including well-identified problems such as
smoking and alcohol consumption, the information available to policy makers and the
public remained patchy. In turn, a succession of health scandals prompted the creation
of public health agencies independent of the Department of Health, whose tasks included
both the gathering of available data and the commissioning and practical organization
of specific investigations—just as the DRMS had done. The similarities are becoming
even more striking as the agencies, such as the Institut de Veille Sanitaire (InVS),
increasingly feel the need to expand this area of their research activities.
In a recently released interview with a historian of science and medicine, an epidemiologist
and close collaborator of Schwartz, who had been associated with a public health section,
could not help noticing the similarities between InVS's activities and those of the
Meanwhile, the position of INSERM research units specializing in epidemiology and
biostatistics, such as the twenty or so groups that came out of the successive partitions
undergone by Schwartz's Unit 21, was not as auspicious as might have seemed. The closing
of Le Vésinet had almost automatically changed their position within the configuration
of disciplines represented at INSERM. Being among the few remaining proponents of
the huge research field of public health could certainly count as an asset; at the
same time, the fact that these units were the last remaining exponents of a field
situated on the lower rungs of the (part implicit, part explicit) scientific hierarchy
that prevailed in the research Institute made them an easy target for criticism by
more powerful disciplines. In spite of Philippe Lazar's promotion as INSERM's Director
General, in 1982, public health remained largely alien to the biomedical world.