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      Between Expertise and Biomedicine: Public Health Research in France after the Second World War

      Medical History
      Medical History

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          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. 1 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), 2 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, 3 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 “host”. 4 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. 5 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. 6 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 epidemiology. 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. 7 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. 8 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”. 9 The Rockefeller had been active in the Hexagone since 1917, when it started supporting the French government's fight against tuberculosis. 10 Contacts intensified in the early 1920s, and lasted until June 1941, when the Rockefeller's Paris-based staff had to leave the country. 11 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. 12 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. 13 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. 14 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, 15 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). 16 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. 17 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 criticism, 18 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. 19 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. 20 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 wartime. In matters of medical research, Bugnard was influenced by both the experience of the USA and that of Britain. 21 As early as May 1946, he expressed his support for the creation of an advisory research council. 22 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) 23 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). 24 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). 25 However, the paucity of funds, 26 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 identity, 27 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. 28 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), 29 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 diseases. 30 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, 31 though this kind of research never received the level of academic and political attention it enjoyed in Britain. 32 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. 33 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. 34 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. 35 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.” 36 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. 37 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. 38 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. 39 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 teaching hospitals. 40 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. 41 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. 42 In 1974, when the number of investigations undertaken reached an all-time high, 43 Lucie Laporte complained that due to the “shortage of permanent employees” only four out of the eleven sections were “adequately staffed”. 44 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. 45 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. 46 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. 47 Table 1 The Public Health Sections in 1974 Section 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 Cancer Dr Maurice Brunet Cardiology Dr Jacques-Lucien Richard Tuberculosis and Respiratory Diseases Dr Alice Lotte and Dr Simone Perdrizet Transmissible Diseases (other than Tuberculosis) Dr Gilbert Martin-Boyer Maternity-Paediatrics Dr Claude Rumeau-Rouquette Nutrition 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 years. 48 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. 49 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. 50 The investigation, which lasted from 1969 to 1975, constituted a significant attempt to bring the social sciences (chiefly economics and sociology) into French public health research. 51 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. 52 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. 53 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. 54 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. 55 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. 56 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. 57 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 finesse. 58 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 the 1920s. 59 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. 60 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. 61 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. 62 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”. 63 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”. 64 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. 65 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 1972. 66 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. 67 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. 68 The few preventive programmes to which they contributed merely aimed at adjusting the treatment for cardiovascular disease according to patients’ risk profiles. 69 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. 70 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. 71 When Burg's criticisms of the Division became fiercer in the mid-1970s, 72 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”. 73 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. 74 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. 75 In 1964, when a series of “specialized scientific commissions” was established to advise INSERM's scientific council, public health underwent a symbolic degradation, 76 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. 77 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. 78 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. 79 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 specialized hospitals. 80 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 149th Unit. 81 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 research groups. 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. 82 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. 83 However, the number of such positions effectively opened at INSERM in the following years remained very limited. Conclusion 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. 84 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. 85 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. 86 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. 87 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 late DRMS. 88 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. 89

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          Med Hist
          Medical History
          Medical History
          October 2008
          : 52
          : 4
          : 471-492
          *Luc Berlivet, PhD, Research Fellow, Centre de Recherche Médecine, Sciences, Santé et Société (CERMES) Site CNRS, 7 rue Guy Môquet, 94801 Villejuif Cedex, France; berlivet@ 123456vjf.cnrs.fr
          © Luc Berlivet 2008



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