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CANCER CRUSADE
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RICHARD A. RETTIG
Cancer
Cado
The Story of the National
Cancer Act of 1971
JOSEPH HENRY PRESS
Washington, D.C.
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Joseph Henry Press · 2101 Constitution Avenue, N.W. · Washington, D.C. 20418
The Joseph Henry Press, an imprint of the National Academy Press, was created
with the goal of making books on science, technology, and health more widely
available to professionals and the public. Joseph Henry was one of the founders
of the National Academy of Sciences and a leader of early American science.
International Standard Book Number 0-309-07082-1
Library of Congress Catalog Card Number
Copyright 2000 by Richard A. Rettig. All rights reserved.
Published by Joseph Henry Press, Washington, D.C.
Originally printed in the United States of America by Princeton University Press,
Princeton, New Jersey.
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To Angie,
for her patience
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Contents
Tables
Chronology of Events
Preface
A National Crusade for the Conquest
of Cancer
2. The Benevolent Plotters
3. The National Cancer Institute
4. A "Moon Shot" for Cancer?
5. Cancer Research and
Presidential Politics
6. Two Days in March
7. Mr. Dominick's Number,
Mr. Kennedy's Bill
8. The Cup and the Saucer
9. Mr. Rogers Builds a Case
10. The Politics of Compromise
1 1. The National Cancer Act of 1971
Afterword
Notes
Index
IX
xi
...
X111
18
42
77
115
133
163
197
225
248
281
317
327
375
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Tables
Nominal Cancer institute AppropM~ns Hutton,
Fiscal Yeam 1 g71-1 g77
2. National institutes of Hea#h, Research institutes
and Daises Budget Authors,
Fiscal Yeam 1 g71-1 g76
o00
311
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Chronology of Events
1912 Congress establishes the U.S. Public Health Service (PHS)
1922 Cancer research initiated within the PHS
1930 PHS Hygienic Laboratory renamed National Institute of
Health (singular)
1937 Congress establishes the National Cancer Institute within
PHS
1948 Congress establishes National Institutes of Health (plural),
National Heart Institute, and National Institute of Dental Re
search
Congress enacts Social Security Amendments of 1965,
thus establishing Medicare and Medicaid; Congress enacts
Heart Disease, Cancer, and Stroke Amendments of 1965,
thereby establishing Regional Medical Program
1970 April 27: Senate Resolution 376 authorizes a Panel of Con
sultants on the Conquest of Cancer
December 4: Panel reports to Senate Committee on Labor
and Public Welfare
1971 January 22: President Richard M. Nixon calls for additional
$100 million for cancer research in State of the Union mes-
sage
January 25: Senators Kennedy and Javits introduce S.
34- the Conquest of Cancer Act
March 9 and 10: Senate Subcommittee on Health holds
hearings on S. 34
April 20: Ann Landers column appears in syndicated news-
papers
May 11: President Nixon announces Cancer Cure Program;
S. 1828 introduced by Senator Dominick
June 10: Subcommittee on Health holds hearing on S. 1828
July 7: Senate adopts S. 1828 by vote of 79 yeas, 1 nay
September 15: Representative Rogers introduces H.R.
10681 the National Cancer Attack Amendments of
1971 and four weeks of House hearings begin
October 12-15: House Subcommittee on Public Health and
Environment meets, reports H.R. 11302 to Committee on
Interstate and Foreign Commerce by unanimous vote
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xli · Chronology of Events
November 3 and 4: Commerce Committee considers
H.R. 1 1302, reports bill to House by vote of 26 to 2
November 15: House of Representatives adopts H.R.
11302 by vote of 350 yeas, 5 nays
December 1 and 7: Joint Senate-House conference com-
mittee meets, reports compromise legislation to both
houses of Congress
December 9: House adopts compromise legislation
December 10: Senate adopts compromise legislation
December 23: President Nixon signs the National Cancer
Act of 1971
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Preface
The National Cancer Act of 1971 was a political event of intrinsic
significance, directed as it was to increasing our scientific under-
standing of cancer and to developing improved means of preven-
tion, diagnosis and treatment of this highly feared disease. The
Act was of great significance, as well, for the entire biomedical
research enterprise, carrying substantial implications for the allo-
cation of resources, the strategy of research management, and the
organization of the enterprise that reached well beyond cancer.
In political terms, the Act is of interest because it indicates how
a small but powerful elite composed of private citizens mobilized
sufficient political resources to secure passage of legislation op-
posed by the National Institutes of Health and by most of the
biomedical scientific community. In policy terms, the Act cap-
tures much of the current conflict between the public and its
elected representatives eager to see life-saving and life-prolonging
results flow from biomedical research and, on the other hand, a
scientific community acutely conscious of the long time and great
uncertainty characteristic of the process by which medical re-
search is translated into clinically useful results. These reasons
justify our attention to this statute.
The story of the National Cancer Act of 1971 has essentially
three parts. The first consists of the antecedents to the legislation,
the second is the legislative history of the Act itself, and the
third-which continues to unfold involves the implementation
by the National Cancer Institute of the mandate of the 1971 legis-
lation.
The first part of the story deals with the general antecedents to
the Act and with the specific agenda-setting activities that brought
cancer to a position of prominence on the national legislative
agenda in 1971. It is told in chapters 2 through 5. Chapter 2 sets
forth the activities of Mrs. Mary Lasker and her colleagues over
the years in attempting to influence the rate and direction of
cancer research. This consideration includes a historical view of
the development of the underlying assumptions, strategies, and
objectives behind the cancer crusaders. In chapter 3, the perspec
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xiv Preface
live is administrative rather than political, focused on the evolu-
tion of the National Cancer Institute and its relationships with the
National Institutes of Health. The emergence of contract-sup-
ported directed research is among the topics considered here.
Chapter 4 details the establishment of the Panel of Consultants on
the Conquest of Cancer, the selection of its members and chair-
man, and the process by which it developed its report. Included is
a discussion of the steps taken by the panel and its supporters to
secure a positive reception to its report in the House of Represent-
atives as well as the Senate, and in the executive branch as well as
in the legislature. How were the recommendations of an obscure
panel, working in closed and largely private sessions, reporting in
a poorly covered hearing to a defeated Senate committee chair-
man transformed into a matter receiving attention in a State of the
Union message for 1971? Chapter 5 analyzes the emergence of
cancer as an important matter in the presidential politics of 1971
and 1972.
The second part of the story is the legislative history of the Act
itself. Events that began in the Senate, moved to the House, then
to the joint conference committee, and finally to the White House
are detailed in chapters 6 through 10. Here is recorded the debate
over the issues in the proposed new cancer program as it moved
through the discrete stages of the legislative process. The relative
weights attached to each issue, the degree to which each was
thoroughly or perfunctorily considered, and the degree of analysis
supporting views on each can be observed. The manner in which
the agenda-setting work of the Panel of Consultants affected the
nature and outcome of the legislative debate is indicated, as is the
importance of the provisions that emerge in the final stages of the
legislative process the "end game" provisions.
The story of the National Cancer Act of 1971 has, in effect, no
conclusion. Rather, the third part of the story is still unfolding in
the implementation of the national cancer program. In chapter 11
we provide a general assessment of the legislative debate, touch
briefly on some of the highlights of implementation, and focus on
several issues of continuing importance in the continuing apprais-
al of the cancer program. This is appropriate, since the "conclu-
sion" to this story will be found only in scientific laboratories, in
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Preface · xv
the translation of research findings into improved means of pre-
vention, diagnosis, and treatment, and in the willingness of the
public to confront the nature of cancer and the means available to
deal with it in personal and collective terms.
This book is not simply another legislative history. It represents
an effort to place the case of the National Cancer Act in a
framework of agenda-setting and policy formation. Though it is
an addition to the small literature on the politics of biomedical re-
search in the U.S., as well as an account of the most significant
political event in biomedicine in recent years, it is also an attempt
to place the detail of the story in a larger context of the policy
process.
There is a logic to this larger perspective that places nearly as
much emphasis on the origins of a piece of legislation as on the
legislative history itself. We may liken the legislative history to a
dramatic production play, and agenda-setting to the processes
which precede opening night. These processes include a writer
who conceives of the basic idea for the drama, writes a script, and
sells it to a producer; a producer who secures investment backing
for the production and locates a director; a director who selects the
actors, guides rehearsals, and modifies the script; and the actors
who learn their roles and their lines with reference to the script
and the director's interpretation of it.
In this instance, the individual most responsible for the idea of
a cancer initiative was Mrs. Mary Lasker. She and her associates
saw a need for such an endeavor and developed that perceived
need into a preliminary script. Senator Ralph W. Yarborough (D.,
Texas) played a critical role as chairman of the Senate Health
Subcommittee and of its parent, the Committee on Labor and Pub-
lic Welfare, in securing passage of the resolution that enabled the
Panel of Consultants on the Conquest of Cancer to do its work in
1970. Mrs. Lasker and the senator were basically co-producers
of the cancer initiative, though the entrepreneurial skill and com-
mitment that was the essential ingredient of success was primarily
Mrs. Lasker's. Selection of the players was dominated by Mrs.
Lasker and the choice of Mr. Benno Schmidt was a stroke of polit-
ical artistry. As director, Schmidt had the task of writing the de-
tailed script and extracting from the individual talents of the Panel
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xvi Preface
of Consultants a collectively functioning cast that would both on
and on the stag~perform their roles with effectiveness. It would
be inappropriate to try to map the structure of the theater onto
political events too slavishly, partly because the drama of politics
emerges from the unrehearsed and unanticipated, as several im-
portant "end game" provisions make clear. But the analogy is suf-
ficiently apt to make the point, amply supported below, Cat pre-
production or agenda-setting activity is an important determinant
of what happens on the political stage.
The literature on agenda-setting has distinguished between the
public agenda and the formal agenda of government.) The public
agenda includes issues that have achieved a high level of public
interest and visibility, that require government action in the view
of a sizable proportion of the public, and that are the appropriate
concerns of government. The formal agenda of government in-
cludes those issues or demands that are under active and serious
consideration by the governments In this light, cancer has been
on the public agenda since the early part of this century. It has
been on the formal agenda of the government since 1937, when
the legislation establishing the National Cancer Institute was
enacted. And it has remained on the formal agenda since that time
through the annual appropriations process. Why then was there a
need for the initiative of 1971?
Jones has written, "The agenda of government is not set by
new problems emerging in a state of nature. Most of what gov-
ernment acts on results from the continuing application and evalu-
ation of ongoing policies."3 Consistent with this view, the Na-
tional Cancer Act of 1971 does not represent the emergence of a
new policy so much as it reflects the reformulation of an existing
policy. But we are still left with our question of why the need for
this reformulation.
Agenda-building, or agenda-setting, has been defined as "the-
process by which the demands of various groups in the population
are translated into items vying for the serious attention of public
officials."4 In the case of the National Cancer Act of 1971, we are
concerned with the process of reformulation of existing policy.
Specifically, we are interested in three questions. First, what were
the sources of concern, the motivations, which led to the effort to
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Preface ~ xvii
reformulate the government's policy toward cancer? Second,
what were the processes by which this desire for policy reformula-
tion advanced die issue of government policy toward cancer to the
stage of new legislation? Finally, how did the prelegislation stage
of activity determine the outcome of the legislative history of the
National Cancer Act?
There are three audiences to whom this book is directed. First,
there is the large body of biomedical scientists, physicians,
policy-makers, and others of the attentive public, who make,
carry out, and are directly influenced by the policies of the U.S.
government toward cancer and medical research. It is my hope
that they will find in this story a useful account of some of the
main forces shaping biomedical research policy today. The sec-
ond audience consists of those members of the general public who
are genuinely interested in how their government arrives at policy
formulations regarding cancer and medical research. I hope that
they find the account informative about the policy process related
to this complex area of science and medicine. Finally, this book is
directed to political and social scientists interested both in health
policy and in the nature of the policy process. It is hoped that
some will be encouraged by this account to study the many policy
issues that surround biomedical research in the United States. It is
also hoped that they will find this case study useful as a detailed
account of the way in which the prelegislative processes of
agenda-setting contribute substantially to the outcome of legisla-
tion.
I am indebted to many individuals for assistance in the writing
of this book. Stephen P. Strickland read the entire first draft and
made many helpful comments. And, in a fundamental sense, his
book, Science, Politics, and Dread Disease ,5 with its broad scope
and historical perspective on the politics of biomedical research,
provides an important contextual orientation to an understanding
of the cancer initiative.
The idea for this book originated while I was at Comell Univer-
sity. There a small group of students Peter F. Bachman, Sal
Chieffo, Pierce B. MacKay; Sister M. Juliana O'Hara, and
Spencer C. Johnson-speculated with me in the fall of 1970 about
the work of a little-known group of consultants to the Senate
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xviii Preface
Committee on Labor and Public Welfare, a group whose activities
are now spelled out in detail in chapter 4. Thanks are also due to
two others at Cornell: H. Justin Davidson, dean of the Graduate
School of Business and Public Administration, and Franklin A.
Long, then director of the Program on Science, Technology, and
Society. Each gave encouragement to a young scholar in very
helpful ways.
This book was written mainly while I was at Ohio State Univer-
sity. William Wyman and Alan Boyd provided helpful research
assistance. Special thanks go to Ronald Smith who functioned as
research assistant as well as counselor on style and grammar. Dr.
Clinton V. Oster, director of the School of Public Administration,
provided support for these research assistants. Dr. Richard C.
Snyder, director of the Mershon Center at Ohio State, was en-
couraging and provided critical support for travel associated with
the manuscript. To all these individuals this effort owes a great
deal.
This account is based upon the careful examination of legisla-
tive hearings and reports, official government agency documents,
and numerous journalistic reports on the progress of the cancer
legislation. In addition, over sixty individuals were interviewed,
either personally or by telephone, and to them I am greatly in-
debted for invaluable information and perspective. Some of these
individuals have been identified in the text, but others who pre-
ferred to remain anonymous have not been identified. Alan C.
Davis, of the American Cancer Society, and Robert F. Sweek,
formerly of the special staffof the Senate Committee on Labor and
Public Welfare, were both helpful in providing access to materials
in their files.
Portions of an earlier draft of this manuscript were read by Carl
G. Baker, Kenneth M. Endicott, Carl Fixman, Gene Godley,
Robert Hams, Stephen Lawton, Thomas J. Kennedy, G. Bur-
roughs Midler, Edwin Mirand, Gerald P. Murphy, James A.
Shannon, and Robert F. Sweek. A nearly final version of the book
was read by Theodore R. Marmor and John F. Sherman. These
individuals made a number of helpful comments, though none of
them is responsible for any errors of omission or commission. Re-
sponsibility for interpretative judgments, of course, is wholly
mine.
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Preface · xix
I am greasy indebted to Roy M. Cromer of Ohio State Univer-
sity for his watchful supervision of the preparation of this manu-
script. Altha Shear and Mary Hixon, for their typing and retyping
of several drafts, also have my very deep thanks. The fact that
they found the story interesting and readable confirmed the
worthwhile nature of this effort. The completion of the manuscript
came after I had moved to the Washington, D. C. office of the
Rand Corporation, and special thanks go to Sally Croasman and
Shirley Lithgow for typing the final changes.
The members of my family, who collectively breathed a sigh of
relief to see this work completed, deserve a measure of thanks that
cannot be calibrated. Jerry good-naturedly saw the manuscript
claim time that might have been spent watching baseball games.
Kirsten, with less comprehension, watched several birthdays
come and go while her father continued to write his book. Finally,
my wife, Angie, endured with good humor the subtle deprivations
that authorship imposes on a family and managed to bring her
editorial capacities to bear upon the manuscript in a way which
led to its improvement. My thanks to her are inestimable.
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