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Group Weight Loss and Multiple Screening This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. Group Weight Loss and Multiple Screening: A Tale of Two Heart Disease Programs in Postwar American Public Health NICOLAS RASMUSSEN SUMMARY: In the late 1940s, amid elevated concern about heart disease and new funding to fight it, multiple screening emerged alongside group psychotherapy for weight loss as two innovative responses of the American public health community. I describe the early trajectory and fate in the 1950s of both programs as shaped by the ongoing political controversy about national health insurance. Group weight loss became the main de facto American response to a perceived obesity-driven heart disease crisis. The episode casts light on the larger picture of how postwar American public health gravitated toward interventions centered on individual behavior and may offer lessons for obesity interventions today. KEYWORDS: obesity, public health, history, Paul Dudley White, David Rutstein, Louis Israel Dublin, Framingham study, epidemiology, group therapy 1 This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. The dramatic expansion of biomedicine in the postwar United States has long attracted the attention of historians. With many in Congress wishing to show concern for the nation’s health, without running afoul of organized medicine’s fierce opposition to President Truman’s 1948 health reform initiative, generous federal research funding to conquer disease in the future emerged as a bipartisan project that substituted for funding to fight illness in the present. Thus the National Institute(s) of Health (NIH) expanded from one to seven institutes between 1947 and 1950, while the budget grew from $8 to $53 million. Historians have not devoted equal attention to the changes brought with this rapid expansion across the various fields of biomedicine.1 This essay takes a step toward a better understanding of the shape assumed by public health research and intervention on heart disease by looking at the range of responses by the U.S. Public Health Service (PHS), and the broader American academic public health community, in the late 1940s and early 1950s. In particular I look at the fate of two major new public health programs tested and introduced in this period, born of a sudden surge of interest in cardiovascular and other chronic diseases: multiple screening for heart disease and its signs, and group psychotherapy for control of obesity (understood as a contributor to heart disease). I argue that screening, initially viewed as most promising, was hobbled by the hostile political and fiscal environment for public health that followed on the clash over national health insurance around 1950. In contrast, group weight loss flourished because it was cheap and precipitated no resistance from clinical medicine. The episode sheds light on the shifting problems, ambitions, and constraints that shaped American public health in the 1950s. It may also offer insight into responses today 2 This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. toward the greater obesity epidemic that silently developed until recognized (again) in the 1990s. Political Interest in Heart Disease The expansion of heart disease research was a core element of the sudden general enthusiasm for science sweeping the American polity at the end of the Second World War, and public health researchers stood alongside surgeons and laboratory workers set to benefit. A well-remembered sign of that enthusiasm was a report (and soon after, a best-selling book) called Science: The Endless Frontier, dramatizing science’s wartime contributions not just to national defense, through weapons such as radar and the atom bomb, but also to medicine. Penned with encouragement from the White House by Vannevar Bush, an MIT dean who had led one of the most visible wartime research agencies, the book argued that generous government funding of academic science should continue. Although opinions differed greatly on how best the federal largesse should be distributed and managed, the main idea was very well received and immediately taken up by congressional advocates of research.2 One of these was Senator Harley Kilgore who in October 1945 called David Rutstein, a New York public health official and rheumatic heart disease expert, to testify before his science committee on the importance of heart disease and on the need for more funds for a rheumatic heart disease research and intervention initiative Rutstein was planning on behalf of the American Heart Association (AHA). The AHA at the time was trying to reinvent itself as a major research patron, and Rutstein had been invited through the Association’s public relations representatives, 3 This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. presumably in response to senatorial interest in showcasing heart disease work that was languishing for lack of money. AHA representatives including Rutstein (an AHA executive employee in 1946–47 before assuming a Harvard professorship) would testify before congressional science and health committees numerous times over the next few years about what could be done to fight heart disease—the nation’s leading cause of death by far.3 Rutstein and fellow AHA leaders were summoned to Washington in the spring of 1947 to confer with Surgeon General Parran, Senator Claude Pepper, and Congressman Jacob Javits to help draft a bill that would establish a heart disease institute within NIH.4 This bill would be signed into law as the National Heart Act in mid-1948, following on the heels of a stunningly successful AHA fund-raising drive that proved the nation willing to spend much more to fight heart disease. It was helped along by the powerful cabal of congressmen and lobbyists promoting the expansion of biomedical research more generally, including Mary Lasker, a friend of the AHA and formerly a key figure in the successful campaign to establish the National Cancer Institute in 1937. The 1948 Heart Act did the same for heart disease, creating the National Heart Institute (NHI).5 ⬧ In early May 1948, with the Heart Act on its way to Truman’s desk, the national Sunday newspaper supplement Parade carried a feature titled “Wanted: Better Public Health,” authored, rather unusually, by a high federal official named Oscar Ewing. In it, the chief of the Federal Security Agency (FSA), parent agency of the Social Security Administration and PHS (including NIH), publicized the ongoing National 4 This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. Health Assembly, a conference of health policy experts he had convened at Truman’s request to develop a comprehensive health plan for the nation. Ewing’s piece opened by attacking the commonplace, complacent belief among Americans that they were “the healthiest nation in the world.” The United States ranked behind other developed nations in combatting tuberculosis and many other major causes of death, he noted, and in the recent war five million draft inductees had been rejected as unfit and another three million discharged for preexisting health reasons. And no wonder that 10 percent of the nation’s young men were too unhealthy to serve, urged Ewing, given the shortage of doctors, dentists, and nurses in many parts of the country, and a third of the population lacking “organized public health services” altogether. Noting that cancer research, then accounting for over half of the $28 million federal budget for medical research, was “making good use of every penny,” Ewing joined his voice to many others then arguing for much more federal research funding to fight other diseases—beginning with heart disease, the top killer, and mental illness, sometimes estimated to cost the economy the most. And the Truman administration, for whom Ewing spoke, planned that the federal government should take an even greater part in improving the public’s health directly, through conjoined initiatives to provide both preventive services and health care—through the FSA and very possibly PHS.6 A major architect of Ewing’s National Health Assembly was epidemiologist Louis Dublin, a vice president of Metropolitan Life Insurance and past president of the American Public Health Association (APHA), who devoted his career to studying and fighting the chronic diseases that had displaced acute infections as the leading causes of ill health. When he accepted Ewing’s invitation, he hoped that “a (broader) public health program for the country as a whole” finally would come from the 5 This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details. Assembly—here evincing the attitude shared by many proponents of the “New Public Health” that emerged in the 1920s, according to which that field should manage the state’s approach to health as whole, so that preventive services, clinical care, and many aspects of the built environment would be coordinated for optimum and cost- effective health outcomes.
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