The Youngest Science

by Lewis Thomas

  Today, Bellevue is a spectacular new building, a huge white square dominating the East River south of Thirtieth Street. Columbia and Cornell have left, and NYU is now responsible for the whole place, with excellent arrangements for sharing certain clinical and technical responsibilities with University Hospital up the block. I regard it still, as I did when I first walked through the unhinged doors of the old building, as the most distinguished hospital in the country, with the most devoted professional staff. If I were to be taken sick in a taxicab with something serious, or struck down on a New York street, I would want to be taken there.

  When I drive past, or think of it at a distance, I have two sharp memories. One is of an early-morning session with the interns in 1959, when I had just begun as professor of medicine. A young intern was presenting his report on a patient who had been on one of the wards for two weeks with advanced pneumonia and meningitis. He had been up all through the previous night, doing everything he could think of and enlisting help from the senior physicians and consultants in infectious disease, but the patient had died. Halfway through his formal presentation tears appeared in his eyes and rolled down his cheeks, and he wept while he finished. I knew that these were tears not of frustration but of grief, and I realized, for the first time, what kind of hospital I was in.

  My second memory is of Mrs. Marjorie Barlow, a New York great lady in her eighties who had charge of the patients’ library. Each day, Mrs. Barlow, my wife, and several other women, all volunteers, set forth on the Bellevue wards with book carts for the patients. Mrs. Barlow, a tall, willowy, fragile-looking lady, a Horace scholar, also an authority on Hroswitha, and knowledgeable about everything ever written on boxing, reserved one set of wards for her own book cart, never allowing anyone else to take it on. It was the psychiatric prison ward, where she always succeeded in making new friends. She had a high regard for the patients on those wards and never seemed frightened, although there were plenty of frightening patients. For some of them, she had words of affectionate respect: “He is a good reader, you know,” she would say.

  13

  THE BOARD OF HEALTH

  Before I went to medical school my knowledge of the public health profession was limited to the childhood singsong: “Marguerite, go wash your feet, the Board of Health is down the street.” I learned very little about public heath in medical school, beyond what was called “The Sanitary Survey,” a required field study in the summer between the third and fourth years, in which all students were assigned in pairs to a municipal or county health department as observers. I had a classmate friend who lived in Cincinnati, and we arranged to survey that city. It took two weeks to do and another week to write a report. We learned more than we had known about sewage disposal, water bacteriology, venereal disease clinics, premarital Wassermann tests, and public baths, but it seemed a long way from medicine, a longer way from science. That was the extent of my training until I was appointed in 1956 as a member of the Board of Health of the City of New York, on which I served for fifteen years.

  The New York Board of Health is the oldest such body in the country, having been organized in 1866 to deal with the epidemics of cholera and yellow fever then plaguing the city. It was statutorily set up as a separate legislative institution, empowered to write its own laws relating directly to matters of public health in the city; these laws comprise what used to be called the Sanitary Code, now known as the Health Code. The board is made up of five members—the commissioner of health, three physicians, and one layman.

  I was appointed to the board to succeed Dr. Thomas Rivers of the Rockefeller Institute, who had just retired. The other members were Dr. Haven Emerson, representing public health, Dr. Samuel Z. Levine, then professor of pediatrics at the Cornell medical school, and Chester Barnard, head of the American Telephone and Telegraph Company. Later on, Louis Loeb, a lawyer in Manhattan, Dr. Walsh McDermott, professor of public health at Cornell, and Paul Hays, professor of law at Columbia, became board members. For most of the fifteen years of my service on the board, Dr. Leona Baumgartner was the health commissioner.

  At about the time I became a member, the Board of Health, and the city’s health department itself, began to run out of things to do. Long before, in the last quarter of the nineteenth century and the early years of the twentieth, the New York City Department of Health had set the style and pace for other American city and state health departments, and its record of accomplishment and innovation was long and distinguished, but now, in 1956, the major problems of public health which had engaged the energies of the department for so many years seemed to have been solved. Tuberculosis had become a relatively uncommon disease, and the formerly elaborate measures for case finding and tracking people in contact with active cases were no longer needed. Syphilis and gonorrhea were still important matters, but now they had become more like therapeutic than preventive problems, or so it seemed. The great epidemics of poliomyelitis, typhoid, scarlet fever, and diphtheria, formerly requiring the quarantining of schools and homes all around the city, had come under control. Smallpox had turned up briefly a few years earlier among returning travelers, requiring the most massive vaccination program ever launched in any city, but there had been no epidemics of this disease, or plague, or cholera, or anything else. The whole Department of Health, whose traditional mission had always been primarily to maintain constant vigilance against contagions in the populace, had to examine its usefulness for the future.

  There were a few traditional functions which the Board of Health would just as soon have set aside, but these had become embedded in the economic life of the city. Milk, for example. In earlier decades the department had been obliged to keep a close eye on the milk industry because of the risks of tuberculosis and streptococcal infection in cattle. This had meant an intricate system of inspection at all levels—at the farms, in the depots and bottling companies, on the trucks, and in all the dairy shops of the city. The dating of milk containers had been introduced as a device for limiting the amount of bacterial growth in milk, not just as a way of protecting the consumer against sour milk. All of these things cost a lot of money, not only for the inspection and sampling work by the department, but also for the added personnel needed by the producers and distributors of milk. In view of the fact that milk no longer seemed a significant vector for disease in New York, the commissioner and Board of Health proposed backing out of the milk business and issued a public statement to that effect. This was followed by an uproar from all sides—the milk producers, the unions of milk handlers and truck drivers, the shop owners, and any number of civic organizations, all demanding that public hearings be held. Lawyers sent in long briefs and petitions protesting the idea of changing anything concerning milk.

  The Board of Health met on the first Wednesday morning of each month, and for nearly all meetings during the first year of my appointment the agenda was crowded with milk items. I remember one morning when the dating of milk bottles was under discussion and a lawyer representing the delivery-truck drivers was addressing the board. His real concern was that if milk dating was modified or given up, the drivers would have fewer jobs to do because of fewer trips to pick up outdated containers, but he didn’t put his case that way. Instead, he strode up to the platform, shook his fist at us, and shouted, “Gentlemen, can you actually prove that stale milk is not a cause of cancer?” We never did get much done. Each change in the law, even minor ones, resulted in new public hearings and appeals to the courts, and the milk laws stayed pretty much as always.

  Fluoridation of the city’s water supply was an even harder and more emotional problem for the department. The evidence was indisputable by the mid-1950s: adding trace amounts of fluoride to drinking water had been proven to furnish solid protection against dental caries, and was also known to be entirely harmless. It seemed the most reasonable of all public health measures. New York had already stalled for too long a time, and the city’s need was greater than most cities’. The ma
jority of children in the poorer sections of town had never been seen by a dentist. Tooth decay and the premature loss of teeth were serious health problems for hundreds of thousands, with nothing being done about them. The department viewed the prospect of fluoridation with zeal, for here was an opportunity to be professionally useful. The Board of Health passed the pro forma resolution mandating the installation of fluoridation, the mayor concurred, and then the roof began falling in. Public hearings were demanded by one after another civic group and their lawyers, protesting what was called an attempt to poison the public, and it looked, for a while, as if the matter would be tied up in the courts for years. In its early stages and throughout the debates, the issue took on an ideological aspect which became increasingly bitter. At one long hearing, starting in midafternoon and running through midnight, held in the auditorium before the Board of Estimate, the members of the Board of Health were accused by impassioned speaker after speaker of being Communists or tools of Communism. In many parts of America, fluoridation was seen as a foreign plot to weaken the country, possibly by setting loose an epidemic of cancer. Fluoride was un-American. This may have been the issue that ultimately turned the tide: in came the medical and dental societies, the nursing organizations, representatives of the New York Bar, and finally the business lobbies, who were persuaded that the city as a whole could save a lot of money by achieving sound teeth for its citizens. Late one night, after the last of the hearings, the mayor and the Board of Estimate approved the appropriation of a considerable sum of money for the necessary equipment, and the Board of Health held a quiet celebration for itself.

  Other problems were identified by the health department staff as new areas for public health reform, and lists were drawn up for consideration by the board. All the conventional concerns were on the lists—restaurant and market sanitation, meat inspection, heroin addiction, cigarette smoking, alcoholism, rats and cockroaches, periodic physical examinations for the citizenry, free clinics for childhood immunization, and so forth, but at the top of the agenda—the one thing the department staff would really have wanted to do something about if it could get at it—was housing. Jerome Trichter, a longtime professional in the department and a genuinely devoted public servant, arranged several tours for the Board of Health to take a direct look at the kinds of quarters people lived in, in Harlem, the South Bronx, Bedford-Stuyvesant, and Brownsville. Even then, back in the late 1950s, it was obvious that massive portions of the city’s housing stock—especially the “old-law” tenements, in which most of the city’s poor resided—were standing ruins. It was also obvious that they were a menace to the health of all tenants. We traveled on several winter days from block to ravaged block in a long gleaming black city limousine, feeling like guilty intruders, climbing in and out of tenements and old multistory apartments, guided by Trichter, who had carefully arranged the tour so that we could sec the worst problems at first hand, along with department photographers taking pictures so that we would not forget what we were looking at: lightless staircases with broken treads to cause long falls in the dark, toilets flooded and leaking continually into apartments below, broken windows in corridors, broken boilers in the basements, rats as big as cats, roaches as big as rats, and every kitchen jam-packed with small children trying to keep warm around a lighted stove, no heat in any other room. The stoves, burners going day and night, carrying obvious hazards of fire and carbon monoxide poisoning, were the only technology for making do. The stoves, and also a variety of ingenious contraptions, principally iron poles, for locking and blocking the front doors of every apartment against thieves looking for money for heroin. This was nearly twenty-five years ago. So far as I know, the only improvement since then has been the final destruction and leveling of many of these buildings in the South Bronx and Brownsville, and probably the crowding of their tenants into other parts of the city, probably now just as bad. It was made clear then to the health department by other parts of the 1950s bureaucracy that this was not a real health problem, not the business of the department, and was being looked after by other city agencies. Anyway, even back then the money was beginning to run out.

  The Board of Health had its attention drawn to other matters, more readily approachable and conveniently trivial. An outbreak of hepatitis in Brooklyn was traced by epidemiologists to a tattoo parlor on the waterfront catering to incoming sailors, and this was turned, for a few weeks, into a major undertaking requiring the writing of new laws. There were more debates, public hearings, and legal documents. Could regulations be written to assure the sterilization of the tattoo needles, or should the establishments be closed down once and for all? This was an easy one. At the end, no convincing arguments could be put together for any sort of public benefit from tattooing, and even though the risk of hepatitis was not entirely convincing, the tattoo parlors were outlawed. It was a small, extremely small, satisfaction, almost no satisfaction at all.

  There exists in the law one great power assigned to the Board of Health as its very own, not shared with any other agency of the city or state. This is the power to declare a State of Imminent Peril. Originally, in the nineteenth century, this was intended to legalize the taking of extraordinary steps by city officials to limit the spread of epidemic disease, quarantining whole areas, stopping the movement of citizens, even locking people up if necessary. Before the government could do things like this, the Board of Health had to declare that, in its professional opinion, imminent peril existed for everyone.

  Twice during my term, the board was under strenuous pressure to make the proclamation, both times to prevent highly inconvenient but hardly perilous strikes by labor unions. The first was a strike by gravediggers for better pay. During the long winter of this strike, coffins were stacked in great columns in every city cemetery. The Board of Health was asked by the other authorities to declare that this would endanger the public safety, especially when the spring thaws came. We were unable to see why, although it was plainly a cause of great dismay and personal anguish for many families. Luckily, the strike was settled soon enough to keep the matter away from public debate or open hearings. The second time the issue arose was in the course of a very long strike by sanitation workers. Garbage piled up in plastic bags and rubbish cans all over the city, covering the sidewalks and spilling out into the streets. Everyone in town was inconvenienced at first, then repelled, finally infuriated by the mess and smell. If there was ever an Imminent Peril, we were loudly told by the press, this is it; please declare it! We thought it would be better (and fairer) to have the strike settled in some other way, rather than set so risky a precedent, and said that we knew of no epidemic disease likely to be started by garbage. We were, at least until the strike was finally settled, the most unpopular five people in city government.

  The research arm of the New York Department of Health was the Bureau of Laboratories, organized in the late nineteenth century by Dr. William H. Park, then commissioner, in order to do work on such problems as diagnostic tests for diphtheria, tuberculosis, and typhoid, and also to study the pathogenesis of contagious disease in general. During Fiorello La Guardia’s administration in the 1930s, the Public Health Research Institute was set up as an independent institution, with funds from the city treasury, to undertake long-term basic research on the human diseases regarded as major public health problems, particularly tuberculosis and nutritional diseases. In 1959, Leona Baumgartner decided that the research activities of the health department needed reappraisal and expansion, and also some clearer view of what would be needed for the long-term future. She organized a two-day meeting of about a hundred biomedical-science and public health authorities from around the country, with the help of Drs. Frank Horsfall, Walsh McDermott, James Shannon, then director of the National Institutes of Health, and me. The outcome was something of a surprise, an agreeable one for the deans and professors of the medical schools in New York City. Instead of advising, as had been expected, an expansion of the Public Health Research Institut
e or the Bureau of Laboratories, which the conferees regarded as near-perfect for their legislated functions at their present size, the conference recommended that the health department organize a new mechanism for sponsoring scientific research in the medical institutions of the city. Mayor Wagner accepted the idea, and announced that $8 million a year, a dollar for each citizen, would henceforth be invested in medical research. The Health Research Council was the outcome.

  This council became an extremely useful social invention, the envy of universities and their medical schools in other parts of the country. Its principal function was to select and financially support young investigators who wanted to join the faculties of the New York medical schools, with five-year fellowships which could be renewed for a second term. The effect on the schools themselves was almost instantaneous: applications came in from as far off as California from young men and women who, as it turned out, had always hoped to live and work in New York. It was a surprise. The city’s institutions had never had funds enough to engage in much recruiting beyond their walls, and the city, for all its great size and seven respected medical schools, ranked a shade behind Boston, Baltimore, and Los Angeles as a center for biomedical science. Within a few years, Mayor Wagner’s dollar-per-citizen began to make all the difference. We used to calculate, for the purpose of encouraging continuation of the Health Research Council at each year’s budget hearing, that each dollar had at least a tenfold multiplying effect. The new HRC fellows were highly successful in the competition for grant support from the NIH, and each grant provided jobs for technicians, laboratory assistants, and other workers. The Health Research Council actually created a new and booming industry for New York. I believe that this single institution moved New York City into unarguable first place among the nation’s scientific medical centers.