Mobilizing a Constituency for Chronic Disabling Disease

For some prominent people in health affairs in the 1920s and 1930s, however, the burden of chronic illness was the major unresolved issue of health policy. The advocates of higher priority for chronic illness in health policy were employees of prestigious institutions. Their advocacy was politely phrased and encountered noncomprehension more often than principled resistance. Unlike the clashes between organized medicine and advocates of national health insurance, this story received no attention in the mass media and has been ignored by most historians of health and social policy.

Six men organized a coalition to advocate higher priority for chronic illness in health policy. These men were Alfred E. Cohn, George Bigelow, Ernst Boas, Louis Dublin, Alan Gregg, and Sig-mund S. Goldwater. They worked separately and together, conducting research, writing in professional journals, teaching, and serving on committees and boards. Two of them, Bigelow and Goldwater, both physicians, held prominent public positions. Bigelow served as commissioner of health for the Commonwealth of Massachusetts. Goldwater was superintendent of Mount Sinai Hospital and commissioner of health and, later, commissioner of hospitals for New York City. In the last years of his life, he became the chief executive of the largest Blue Cross plan in the country. Cohn was a clinical scientist at the Rockefeller Institute for medical research. Boas was chief physician at the Montefiore Hospital and held an academic position at the College of Physicians and Surgeons of Columbia University. Dublin, trained in biology, was chief statistician for the Metropolitan Life Insurance Company. Gregg, a physician educated at Harvard, was a senior official of the Rockefeller Foundation.14

From the 1920s to the 1940s, Cohn was the leading advocate of higher priority for research on chronic disease. He recalled in 1953 that he first became aware of the importance of chronic disease in 1922, when Royal S. Copeland, then New York City commissioner of health and soon to be a United States senator, published newspaper articles claiming that death rates from infectious diseases of childhood had been falling for many years. By 1926, Cohn was ready to challenge the priorities of medical research, most of which was funded by foundations, principally the various Rockefeller philanthropies. Using published statistics, he demonstrated that organic heart disease had two underlying causes—not one, as most physicians and scientists believed. Rheumatic fever, an infection, accounted for most heart disease among people under the age of forty. For older people, the principal cause was arteriosclerosis, a chronic degenerative condition; because of this condition, the "rate of so-called heart disease is high and is constantly mounting."

By the early 1930s, Cohn was exerting some influence on the priorities of medical science. A 1933 survey conducted under Boas's auspices for a consortium of New York foundations and service organizations reported that about haft the diseases under study at the Rockefeller Institute's research hospital were chronic conditions. Two years later, Simon Flexner, who had helped shape the policy priorities of the turn of the century, retired as founding director of the institute. His successor, Herbert Gasser, shared Cohen's priorities. Announcing Gasser's appointment to the press, John D. Rockefeller, Jr., said that the "time has now come" to study chronic disease by more intensive "investigation of fundamental life processes at the level of the cell and its constituents."

Cohn's influence extended beyond the Rockefeller Institute. In publications and correspondence, he insisted that each chronic disease is the result of a biological process that should be studied in detail from onset to death. In 1935—speaking to fellow board members of a new foundation that sponsored research on aging—he said that "new armies of destruction . . . the heart diseases, cancer, diseases of the kidney" for instance, required changes in

the concept of the hospital. These changes would include extending the "arm of the outpatient department . . . to the home or the patient's place of occupation." In the emerging world of research and medical practice, moreover, there was no "sharp or clear distinction . . . between normal and pathological."15 The same year, Cohn collaborated with Goldwater, Gregg, and Dublin to establish the first clinical research center anywhere to give priority to the study of chronic disease. The center was part of a new municipal hospital that treated patients with chronic disease on Welfare (now Roosevelt) Island in New York's East River.

Boas was a more visible public figure than Cohn, because he addressed medical and general audiences about the broad implications of chronic illness for medical practice and social policy. His base, Montefiore Hospital, was one of very few voluntary institutions established to care for persons with chronic diseases. Boas challenged two principles of the contemporary health policy consensus. The first was that hospitals should be arrayed in hierarchies, at the top of which were teaching institutions providing acute medical and surgical care. He insisted that persons with chronic disease should be treated, often for long periods of time, either in dedicated units in general hospitals or in separate hospitals. Hospitals that specialized in treating patients with chronic illness should, moreover, be affiliated with medical schools. Second, Boas challenged the principle that health policy should be separated from other social policies, especially for the elderly. For example, he described the most important priorities for health policy as old-age pensions, sickness insurance, and replacement of the remaining almshouses with state hospitals for chronic disease. Boas, like his colleagues in the new network advocating higher priority for chronic illness, repeatedly insisted that these afflictions were neither incurable nor results of the "natural decrepitude of old age."

In 1941, in what seems to have been the first textbook on treating a variety of chronic diseases, Boas linked his principles to general medical practice. He told his readers that because their "young patients are far healthier than they were in former generations . . . many more of them grow to middle age and become

afflicted in their mature years with circulatory disorders, diabetes, chronic 'rheumatism,' cancer or some of the other so-called degenerative chronic diseases." These diseases are "insidious in their onset, chronic in their course, and lead to irreversible changes in the human organism." Treatment for these conditions is" much more complex than [for] the acute infectious diseases." Moreover, the "practicing physician will become the chief agent of preventive medicine in the field of chronic diseases."16

Louis Dublin, chief statistician of the nation's largest life insurance company, sorrowfully concluded in the mid-1920s that the growing burden of chronic illness contradicted the fundamental assumption of health policy since the 1890s: the assumption that medical progress against disease would be continuous. In 1929, for example, he worried in a private memorandum that mortality after age forty-five "apparently has gotten worse" in the past decade. Contemporary conditions" are apparently wiping out the gains from fewer cases of infection." In 1931, Dublin decided that the incidence of cancer had reached epidemic proportions.

Dublin was frustrated by the consensus on the priorities of health policy. In 1934, when he worked with Goldwater to design the first benefits contract for the Associated Hospital Service, the organization that would become New York's Blue Cross, he tried but failed to get agreement to include coverage for venereal disease. He reluctantly yielded to Goldwater's reasoning that chronic disease had to be excluded from coverage because the cost would be excessive if it was spread only over a risk pool made up of volunteers in one city. But even this compromise held too many business risks for his superiors at Metropolitan Life. Wary of any involvement with insurance for illness, they did not permit him to serve on the board of the Associated Hospital Service.

Most public health officers in the 1920s and 1930s regarded chronic disease as a private matter, just as Boas had said. George Bigelow of Massachusetts was almost the sole exception to the prevailing opinion that chronic disease lay outside the authority of government agencies. When he sent a questionnaire about policy for chronic disease to other state and provincial health officers in the United States and Canada, all but three of them replied that

"they were doing nothing about adult hygiene or chronic disease. . . . Many hoped they never would."

Bigelow himself had until recently been ambivalent about the place of chronic disease in public health policy. In 1925, he disagreed with a resolution adopted by the American Public Health Association, at the insistence of academics rather than public officials. The resolution asserted that chronic disease was a legitimate area of public health practice. In Bigelow's view, chronic diseases were a "purely personal matter," not a responsibility of the community. By 1929, he had changed his mind. When a charitable organization invited Dublin to Boston to speak about communicable diseases, Bigelow persuaded him to talk instead about "chronic disease . . . the most important medical social problem facing us." After Dublin's speech, he and Bigelow lobbied a prominent member of the audience, Ray Lyman Wilbur, the former dean of medicine and president of Stanford University, who was serving as President Hoover's secretary of the interior (the Public Health Service was then assigned to the Interior Department). Wilbur had recently been selected to chair a Committee on the Costs of Medical Care financed by major national foundations, including Rockefeller, Rosenwald, and Milbank. But Bigelow and Dublin failed to persuade Wilbur of the overwhelming importance of chronic disease for policy.

Bigelow soon organized the first comprehensive public program to diagnose, treat, and conduct epidemiological research on cancer. His ambivalence about the appropriateness of public health intervention to detect and treat chronic disease was an unexpectedly effective political tactic. The Massachusetts Health Department appeared to be dragged into its cancer program by the legislature, with the cautious support of most leaders of the medical profession and enthusiastic advocacy by a few prominent medical researchers at teaching hospitals affiliated with Harvard.

In 1933, Bigelow and Herbert L. Lombard published an account of the Massachusetts cancer program that became a handbook for subsequent chronic disease surveys and control programs. Abandoning his remaining ambivalence about the importance of chronic disease in public health practice, Bigelow insisted that the "outstanding sickness and health problem of the

present day is the control of chronic diseases of the middle-aged."

Alan Gregg, director of the Division of Medical Sciences of the Rockefeller Foundation, was another prominent member of the coalition advocating greater priority for chronic illness. In 1935, he persuaded the foundation's trustees to establish a new program of research in the sciences underlying psychiatry. Unlike infectious disease, he wrote, chronic diseases, including mental illness, were "disorders of the organism as a whole." Understanding the causes of these diseases required fundamental knowledge that went beyond the study of "bodily disorders caused by parasites and bacteria, viruses, poisons, inadequate nutrition and hereditary defect." Three years later, Gregg recommended that the board give a research grant to the new clinical research center for chronic disease on Welfare Island. That was the first of almost a decade of research grants to the center.

Sigmund S. Goldwater was a reluctant innovator in policy for chronic disease. As the most prominent hospital administrator of his generation, he had defended the prevailing assumption among his peers that care for chronically ill patients was the "function of public hospitals." In the mid-1930s, however, when he served Mayor Fiorello La Guardia as commissioner of hospitals and chaired the committee established by the United Hospital Fund to organize New York's first voluntary health insurance program, Goldwater began to change his opinion. Voluntary hospitals were admitting vast numbers of persons with chronic illness and seeing even more of them in their outpatient clinics. Public hospitals were increasingly being staffed and equipped to treat acutely ill patients. As commissioner of hospitals, and then from 1939 to 1942 as chief executive of Blue Cross, Goldwater spent the last years of his life stimulating partnerships between public and voluntary institutions to address chronic disease.