Redefining the Federal Role in Public Health, Medical Research, and Education, 1949-1960
"So long as I am a member of this House, I shall press the case for medical research until the Nation can rest assured that every competent medical investigator has the funds he needs to do his work, that we are providing the Nation with an adequate pool of highly trained scientists for the years ahead, and that the scientists are working in facilities that enable them to advance their research most effectively."– John E. Fogarty, in a speech to the House of Representatives, June 10, 1954
Between 1949, when Fogarty became chair of the House Appropriations Committee subcommittee on Labor and the Federal Security Agency, and 1960 (Eisenhower's last year as President), the federal medical research establishment grew at an astounding rate. The National Institutes of Health appropriations went from about $53 million in FY 1950 to nearly $400 million in FY 1960. The NIH added four new institutes (the National Institute of Mental Health, and those for Arthritis and Metabolic Diseases, Neurological Diseases and Blindness, and Allergy and Infectious Disease) and the National Library of Medicine. It also opened a big new Clinical Center in 1953. The Health Research Facilities Act of 1956 provided matching grants for construction of research facilities, and the International Health Research Act of 1960 was established to fund collaborative research and training with other countries. Other legislation supported education in the health professions, and the expansion of the Communicable Diseases Center (now the Centers for Disease Control and Prevention.)
The Health Coalition
To bring it all about, Fogarty worked closely with a remarkable coalition made up of fellow legislators, several Surgeons General and NIH directors, well-connected and knowledgeable citizen-advocates, and prominent medical experts. In Congress, he had many allies, including the chairmen of the Senate Appropriations Subcommittee for Labor-Health, Education, and Welfare: Edward Thye (R-MN), Dennis Chavez (D-NM), and Lister Hill (D-AL). Hill, who had served in Congress since 1923, was best known for co-sponsoring the Hospital Survey and Construction Act of 1946 (often called the Hill-Burton Act) and became chairman of the Senate Labor and Welfare Committee and the Appropriations Subcommittee for Labor-Health, Education, and Welfare in 1955. In the House, Fogarty was aided by Melvin R. Laird, (R-WI) who joined the Appropriations Committee in 1953, and the Labor-HEW subcommittee in 1957. Later known for his work in Defense Department appropriations and as Secretary of Defense, Laird was also dedicated to medical research from his early days, through his friendship with the physicians at the Marshfield Clinic in his hometown. As ranking minority member of the subcommittee, he became Fogarty's closest friend and ally. They were so effective at rallying support and building a record through hearings that they even campaigned for each other in election years, to keep their partnership intact.
In the Public Health Service, Surgeons General Leonard Scheele (1948-56) and Leroy Burney (1956-61), lent their support to the expansion of health services and medical research. James A. Shannon, who served as Director of NIH from 1955 to 1968, became a leading member of the coalition. Shannon had done significant malaria research during the war, directed the Squibb Institute of Medical Research for several years, and then joined NIH as assistant director of the National Heart Institute. An experienced public health investigator and savvy administrator, he shared the Congressmen's vision for NIH as the major locus of medical research. The Secretaries of Health, Education, and Welfare, Marion B. Folsom (1955-58) and Arthur Flemming (1958-61) also advocated for increased funding, sometimes going against the Eisenhower administration's budget preferences.
Advocates from the private sector were also crucial supporters (and shapers) of increased appropriations and new health-related legislation. Mary Lasker, Florence Mahoney, and Mike Gorman had become very active in advocating for expansion of research into cancer, heart disease, and mental illness just after the war. [See the Mary Lasker and Mike Gorman sites on Profiles in Science.] They raised money through citizens groups like the American Cancer Society, raised awareness through their National Committee Against Mental Illness, and, armed with facts and figures, demanded that Congress do more for research into causes and cures of dread diseases. They deftly cultivated relationships with members of Congress, presidents and cabinet members, medical experts, the press, and anyone else who could aid their cause. Lasker's group and other disease-focused organizations provided much of the essential data and expert testimony that persuaded legislators to support ever-increasing research budgets. Among the expert witnesses who appeared frequently before Fogarty's committee were Sidney Farber, pioneering cancer researcher; Paul Dudley White, "father of American cardiology"; Michael DeBakey, cardiovascular surgeon extraordinaire; and Howard A. Rusk, "father of rehabilitation medicine" and longtime medical columnist for the New York Times. They were all eminent in their fields, articulate, and passionate about the need for health-related funding.
The hearings held by the House and Senate Labor-HEW committees were central to the appropriations process, because the committees always found the President's proposed annual Labor-HEW budget inadequate and added hefty amounts for many programs. To get these larger budgets passed, Fogarty and his colleagues had to provide persuasive evidence that the extra funds were needed, necessary, and could be used properly. Accordingly, the heads of all the various agencies would give summaries of the many recent achievements of their departments. Fogarty would question them closely about their progress, often asking how much more could be accomplished with increased funds. Expert witnesses--carefully chosen and coached--would testify to the need for more research on cancer, heart disease, mental illness or other conditions, or for expanded facilities, training programs, and so on. The committees might also hear from patients and families who were coping with a particular disease, to underscore the everyday experiences of those who suffered while they waited for medical advances or services that would ease their situation. Written testimony from other experts and interested parties would be added to the hearings record, to provide yet more evidence. Fogarty, though he had no college degree, routinely surprised committee witnesses with his knowledge of illness and diseases (and their economic impact), scientific work, and the progress of research.
Year after year, the coalition worked together to build a solid case for increased appropriations and for adding new areas of research to the scope of the NIH. Sometimes the new areas were proposed by the lobbyists or experts, but suggestions also came from encounters with constituents. For example, Fogarty proposed funding more research into muscular dystrophy and related conditions after talking with a boy crippled by MD. In 1954, J. Arthur Trudeau, president of the Rhode Island Parents Council for Mentally Retarded Children, invited him to attend a meeting of that group, and he quickly became an advocate for mental retardation research and for services and education for the mentally retarded. The committee funded projects such as water fluoridation, x-ray screening for tuberculosis, and use of the Papanicolaou test for cervical cancer after learning about them in hearings.
Challenges and Obstacles
Despite their strong bipartisan alliance and supporting players, Fogarty and his like-minded colleagues faced substantial resistance during this period, and didn't always achieve their budgetary goals. Their primary opponents were budget traditionalists (often but not always Republicans), who believed that the first duty of elected officials was to keep taxes low and spend frugally. In their view, the federal government should not have a major role in health or social programs except in times of war or other emergency. Clarence A. Cannon (D-MO) (1879-1964) who chaired the full House Appropriations Committee for most of the 1941-1964 period, was a legendary budget-cutter, and exerted great control over his sub-committees through various committee rules. Even after Appropriations Committee members rebelled in 1951 and carried motions--several made by Fogarty--that curtailed the chair's influence, Cannon continued to oppose most big spending measures. Likewise, President Eisenhower felt that it wasn't the federal government's place to pay for health care, research, or education. In contrast to his Democratic predecessors, he wanted to reduce the political and social engineering that had characterized the New Deal, to rein in government expansion and restore the authority of state and local governments.
The war in Korea (1950-1953) provided a rationale for curbing domestic programs, and conservatives also resisted big spending for health and education when the Cold War was escalating and funds might be better spent on defense. Fears of Communism also provoked concerns that federal support of education, or science and medicine would quickly lead to federal control of those fields. In the early 1950s, for example, the American Medical Association succeeded in derailing legislation that would provide scholarships to medical students, calling the plan a first step to socialized medicine. Finally, resistance also came from some who supported the health coalition's cause, but simply couldn't envision how big the research enterprise needed to be to deliver substantial results. Other supportive legislators believed that increasing research budgets too fast would simply result in more funding for unworthy projects, which would dilute the quality of scientific work and waste tax dollars.
Nonetheless, Fogarty and his coalition succeeded in expanding federal medical and social programs to levels that few could have imagined in the previous decade. Their biggest achievement, of course, was a seven-fold increase in the NIH budget. But they also appropriated the first-ever federal funding for mental retardation research in 1955 and increased support for education and services to mentally retarded children in subsequent years. In 1957 Fogarty sponsored a bill to expand rehabilitation services. He also sponsored bills to expand the training of teachers of deaf children and improve distribution of books and other instructional materials for blind students. In 1956, Congress passed the Library Services Act, to fund construction of libraries in rural areas that lacked them. The same year, the National Library of Medicine Act transferred the Armed Forces Medical Library to the Public Health Service, and it became part of NIH. Fogarty strongly supported these library bills and staunchly defended the budgets for both acts the following year, chastising politicians who would authorize programs to get publicity, only to gut them at appropriations time.
In 1955, recognizing that the population of Americans over sixty-five was growing and had its own special needs, Fogarty and a number of other representatives introduced bills to authorize a White House Conference on Aging. The conference, finally held in 1961, would bring together many experts to assess the problems of older citizens, and provide a foundation for the Older Americans Act of 1965.
In 1957, Fogarty attended the World Health Assembly in Geneva, Switzerland as a congressional advisor to the U.S. delegation. Impressed by the global scope and effects of common health problems, he immediately recognized the value of medical collaboration in international relations. When he returned, he began working on legislation to establish a National Institute for International Medical Research. Located at NIH, this would provide grants for teaching and research, fellowships, conferences, and other activities promoting international cooperation and collaboration on health issues. Lister Hill introduced a companion bill in the Senate, which soon became known as the "Health for Peace" bill. Despite enthusiastic support from health activists (Dr. Howard Rusk headed a large group called the Committee for Health for Peace) the bill failed to pass for several years. The International Health Research Act of 1960 was a milestone, allowing the Surgeon General to make grants, though it didn't authorize a new institute. (When the institute was finally authorized soon after Fogarty's death, it was named the Fogarty International Center.)
Fogarty and Hill both received Lasker Awards in 1959, for their many contributions to medical research and public health.