Biomedicine in the Twentieth Century: Practices, Policies, and Politics (review)

At start, I must own up to my potential conflicts of interest. For many years I was employed by the Department of Veterans Affairs, a Cabinet-level branch of the U.S. Government. I bring this bias to my review of this book, which does deal in large part with the role of the federal government in biomedicine. Since my experience with the VA medical care system was superb, the bias should be a positive one. I am also a personal friend with the editors of this journal, one of whom was involved in the project from which this book emanated. The editors have not discussed the book with me, however.

Nonetheless, I experienced difficulty in completing this assignment. I could not understand why I always found other chores to intervene, delaying my writing. Suddenly it dawned on me that the reason had to do with the lack of a compelling theme for this book. It is a series of essays, individually quite good, without a unifying editorial theme or guidance. The editor, Caroline Hannaway, a Historical Consultant for the Office of NIH History, missed the opportunity to spell out a theme in the preface (only 1¼ pages), and this would have been very helpful. She does state that the book is based on a conference at the NIH in December 2005 “to promote historical research on biomedical science in the twentieth century,” but such is a protean focus. She does refine it a bit in her chapter, “Inventing the Office of NIH History,” but still notes that the other authors “offer insights on a range of subjects.”

After my second read, I did divine a theme, which may or may not be intentional. It derives its focus from the compelling second essay, “The Socialization of Research and the Transformation of the Academy” by Richard Lewontin, and from the last essay, “Scientific Discoveries: An Institutionalist and Path-Dependent Perspective” by J. Rogers Hollingsworth. Lewontin argues that the practice of medical research has become a socialized phenomenon, as the pervasiveness of the NIH as the funding source has increased over the years. This socialization had its early impetus from the focused research during World War II (such as the Atomic Bomb Project, development of DDT, antibiotics, anti-malarial drugs, and plasma fractionation products), which was funded and closely overseen by the federal government (via the Office of Scientific Research and Development, headed by Vannevar Bush). Thereafter, the control of biomedical research has become progressively more vested in the “feds,” including the NIH, the Department of Veterans Affairs, and the National Science Foundation. The federal government has also socialized much of higher education, through its educational and construction grants. Lewontin argues that “the major expenditure of funds for educational purposes shows that the state is involved not only in the socialization of research costs, but also in the formation of a managerial and technological cadre without which the operation of the modern economy is impossible. . . .The socialization of the cost of intellectual work is now a permanent feature of the American economy.” Thus, the author describes an evolution of structure and control that has been essential for the continued flourishing of much of research and education but, conversely, not the costs of medical practice.

Hollingsworth sees this socialization phenomenon from a different, and not entirely beneficent, perspective. He argues that major discoveries—those that come as a surprise and lead to major changes in the research landscape (such as the development of the PCR technique by Kary Mullis)—come most often from individuals who are themselves very imaginative, not necessarily well organized, and willing to follow flights of fancy; and from institutions, in which these individuals frequently work, that are loosely (sometimes poorly) organized or managed. He provides tables and graphs, presumably substantiated by real data in other publications, to illustrate his thesis. He notes that institutional organization (and hyper-organization) in the United States has increased with time—a time that is concordant with...