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Gio Batta Gori, c1975.Source: ‘Dr. Gio Gori Becomes Dep. Director of Cancer Cause, Prevention Div.’, The NIH Record, 27, 1 (14 January 1975), 7, courtesy of Rich McManus, editor of The NIH Record.https://www.cambridge.org/core/journals/medical-history/article/between-prevention-and-therapy-gio-batta-gori-and-the-national-cancer-institutes-diet-nutrition-and-cancer-programme-19741978/4D7A885ACD980F04A5F29CF6B372DEC12022-07-01-cambridge-org-core-journals-20160624070311974-0934.gif
Saved Wikipedia (July 1, 2022) for "Gio Batta Gori"
Saved Wikipedia (July 1, 2022) for "Gio Batta Gori"
https://en.wikipedia.org/wiki/Gio_Batta_Gori
2022-07-01-wikipedia-org-gio-batta-gori.pdf
Gio Batta Gori is an epidemiologist and fellow with the Health Policy Center in Bethesda, Maryland which he established in 1997 and where he specializes in risk assessment and scientific research.[1] He was deputy director of the United States' National Cancer Institute's Division of Cancer Cause and Prevention, where he directed the Smoking and Health Program and the Diet and Cancer Program.
He organized and directed the Franklin Institute Policy Analysis Center, funded by Brown & Williamson. He is the editor-in-chief of the journal Regulatory Toxicology and Pharmacology.[2]
He has consulted for the tobacco industry, challenging specific scientific claims concerning the risks associated with tobacco use.[3][4] He is also known for advocating the regulation and taxation of cigarettes and other tobacco products based on their specific delivery of carcinogens and other hazardous substances, so as to promote risk reduction.[5][6][7]
Gio Batta Gori has a doctorate in biological sciences and a master's degree in public health. Between 1968 and 1980, he was a scientist and senior official at the United States' National Cancer Institute (NCI), where he specialized in toxicology, epidemiology and nutrition. He held several positions, including Deputy Director of the Division of Cancer Causes and Prevention; Acting Associate Director, Carcinogenesis Program; Director of the Diet, Nutrition and Cancer Program and Director of the Smoking and Health Program.[8]
In 1980 Gori became Vice President of the Franklin Institute Policy Analysis Center (FIPAC), a consulting firm funded initially by a $400,000 grant from the Brown & Williamson Tobacco Corporation (B&W).[9] Following its initial formation, FIPAC continued to receive hundreds of thousands of dollars in funding annually from B&W.[10][11][12] Gori worked on Research & Development projects for B&W Tobacco, such as analysis of the sensory perception of smoke and how to reduce the amount of tobacco in cigarettes. By 1989, Gori was a full-time consultant on environmental tobacco smoke issues for the Tobacco Institute in the Institute's ETS/IAQ (Indoor Air Quality) Consultants Project.[13] In May 1993, Gori entered an exclusive consulting arrangement with B&W Tobacco, receiving $200/hour a day to $1,000/day for attending conferences.[14] In the 118-page book Passive Smoke: The EPA's Betrayal of Science and Policy, Gio Gori and his co-author and fellow industry consultant, John Luik, falsely claimed the U.S. Environmental Protection Agency (EPA) used "junk science" to distort the health effects of secondhand smoke. The book was funded by B&W, which funneled the money through a third party, the Fraser Institute.[15]
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David Cantor writes that Gori has been criticised for his career as a consultant for the tobacco industry and that critics of Gori have questioned his scientific and management credentials.[16] Other academics who have criticised Gori include Richard Kluger and Devra Davis.[16]
Gio Batta Gori, Virtually Safe Cigarettes: Reviving an Opportunity Once Tragically Rejected, IOS Press Inc, January 2000. ISBN 1-58603-057-4 ISBN 978-1586030575
Gio B. Gori, John Luik, Passive Smoke: The EPA's Betrayal of Science and Policy, The Fraser Institute, 1999. ISBN 0-88975-196-X
^ "Health Policy Center". Manta.
^ "Regulatory Toxicology and Pharmacology Editorial Board" – via www.journals.elsevier.com.
^ United States of America v. Philip Morris et al. Archived 2007-07-21 at the Wayback Machine, Final Opinion of Judge Gladys Kessler, United States District Court for the District of Columbia, p. 162. Accessed October 4, 2007.
^ United States of America v. Philip Morris et al., United States Factual Memorandum Pursuant to Order #470, Section V, United States District Court for the District of Columbia, p. 44. Accessed October 4, 2007.
^ Gori, Gio B. Virtually Safe Cigarettes: Reviving an Opportunity Once Tragically Rejected. IOS Press, 2000.
^ Gori, Gio B. "Less Hazardous Smokes?" Regulation 25:4 (Winter 2002): 66-72.
^ Gori, Gio B., "Pursuing Less Risky Smokes -- At Last." Regulation 32:2 (Summer 2009): 3-4.
^ "Legacy Tobacco Documents Library: DR. GIO BATTA GORI (frh21e00)". Retrieved 2007-07-19.
^ "Legacy Tobacco Documents Library: The Franklin Institute Policy Analysis C... (wpw70f00)". Retrieved 2007-07-19.
^ "Legacy Tobacco Documents Library: -- No Title -- (krn33f00)". Retrieved 2007-07-19.
^ "Legacy Tobacco Documents Library: For contribution to Policy Analysis Center program at Franklin Institute (tow70f00)". Retrieved 2007-07-22.
^ "Legacy Tobacco Documents Library: -- No Title -- (rnw70f00)". Retrieved 2007-07-19.
^ "Legacy Tobacco Documents Library: ETS / IAQ SCIENTIFIC CONSULTANTS (hxh70e00)". Retrieved 2007-07-19.
^ "Legacy Tobacco Documents Library: AGREEMENT (aja53f00)". Retrieved 2007-07-19.
^ Kessler, Gladys (August 17, 2006). "United States of America v. Philip Morris et al" (PDF). United States District Court for the District of Columbia. p. 624. Archived from the original (PDF) on July 21, 2007. Retrieved 2007-07-29.
^
a b Cantor, David (October 14, 2012). "Between Prevention and Therapy: Gio Batta Gori and the National Cancer Institute's Diet, Nutrition and Cancer Programme, 1974–1978". Medical History. 56 (4): 531–561. doi:10.1017/mdh.2012.73. PMC 3483769. PMID 23112384.
Text adapted from Gio Batta Gori - SourceWatch under the GFDL
Gio Batta Gori
Gio Batta Gori
Add or update information
Detail Source
Name:
Gio Batta Gori
[Giobatta Gori]
[Gori Gio Batta]
Birth Date:
Feb 1931
Residence Date:
1987-2020
Address:
6704 Barr Rd
Residence:
Bethesda, Maryland, USA
Postal Code:
20816
Second Address:
6503 Pyle Rd
Second Residence:
Bethesda, Maryland, USA
Second Postal Code:
20817
2022-07-01-ancestry-com-directory-transcript-gio-batta-gori.pdf
Born Feb 23, 1931 ..
Gio B Gori
Gio B Gori
Add or update information
Detail Source
Name:
Gio B Gori
[Gio Gori]
Birth Date:
23 Feb 1931
Residence Date:
1994
Phone Number:
229-4277
Address:
6704 Barr Rd
Residence:
Bethesda, MD
Postal Code:
20816-1016
Second Residence Date:
1984
Second Phone Number:
229-4277
Second Address:
6503 Pyle Rd
Second Residence:
Bethesda, MD
Second Postal Code:
20817-5451
2022-07-01-ancestry-com-directory-transcripts-gio-b-gori-2.pdf
Decade's Warnings Fail to Cut Smoking
Decade's Warnings Fail to Cut Smoking
1974-01-11-nytimes-decades-warnings-fail-to-cut-smoking.pdf
Jan. 11, 1974
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Ten years ago today, the Surgeon General of the Public Health Service issued a momentous report citing cigarette smoking as a major hazard to life and health. Yet, on the anniversary of that historic, 387‐page document, cigarette sales are at a record, per capita consumption is increasing and 3,000 teenagers are becoming new smokers each day.
Despite repeated scientific confirmation of the Surgeon General's warnings, an everexpanding list of smokingrelated risks, an intense educational effort, restrictions on cigarette advertising and a growing force of nonsmokers seeking to limit smoking in public places, about 40 per cent of men and 30 per cent of women are current cigarette smokers.
An estimated 10 million Americans, mostly men., have quit cigarettes since the report was issued, but the population growth and a steady influx of new smokers have increased the ranks of current smokers from 50 million in 1964 to 52 million today.
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However, public health officials estimate that the report and the studies, warnings and educational efforts it generated helped to reverse a trend that otherwise would have meant 75 million smokers today.
At the same time, concern over health has led to an increasing use of cigarette filters and tobacco substitutes that, in turn, has resulted in an 18 per cent drop in per capita consumption of cigarette tobacco and a 32 per cent decline in tar and nicotine content.
Thus, smokers of today are puffing on less potent and presumably, somewhat less harmful cigarettes than a decade ago, although there is not yet proof that their risk is reduced.
The tobacco industry,
while continuing to maintain that cigarettes are not the health hazard they are made out to be, has nonetheless catered to the public demand for less tar and nicotine.
Dr. Luther L. Terry, the former Surgeon General, who issued the 1964 report, said, “In general, I'm encouraged, by the progress of the last decade and optimistic about the future. But I also have some important reservations.”
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“I'm most discouraged by our lack of success with youth,” he explained. “There hasn't been a significant drop in smoking among young people. In fact, they're starting at earlier ages and there's been a dramatic increase in the percentage of girls who smoke.”
New ‘Bill of Rights’
As a consultant on tobacco and health for the American Cancer Society and a member‐at‐large of the National Interagency Council on Smoking and Health, Dr. Terry has dedicated much of the last decade to combating smoking and supporting nonsmokers in their efforts to breathe air free of tobacco smoke.
Today, in Philadelphia's Congress Hall, the former Surgeon General is participating in the adoption of the “Nonsmoker's Bill of Rights,” sponsored by the interagency council. The bill proclaims the right of nonsmokers to breathe clean air (which “supersedes the right to smoke when the two conflict”), the right to speak out about their discomfort in the presence of tobacco smoke, and the right to act in legiti, mate ways to restrict smoking in public places.
“The nonsmoking movement has just begun to show itself and already it has made substantial gains,” Dr. Terry remarked.
Increased Awareness
Airlines are now subject to $1,000 fines for failing to provide a smoke‐free seat for any passenger who wants one; the Interstate Commerce Commission has just made “no smoking” the rule, rather than the exception, on all passenger trains; the military has begun to segregate smokers and has stopped distributing cigarettes in C‐rations; a growing number of restaurants now offer segregated areas for nonsmokers; Arizona has banned smoking in a wide variety of public places, and similar legislation has been passed or is being considered in many cities and states as well as in Congress.
All these efforts have enhanced public awareness of cigarettes and made the smoker increasingly self‐conscious and, at times, uncomfortable about his habit. Indeed, some experts believe that in the future a decline in the social acceptability of smoking will do more to swell the ranks of former smokers and nonsmokers than the continuing barrage of eversterner health warnings.
Few doubt, however, that health risks have been the primary motivation for most of the 29 million Americans who have already become former smokers.
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The 1964 report cited cigarette smoking as the major cause of lung cancer and chronic bronchitis, as an important cause of cancer of the larynx and as associ
The data available in 1964 were based on studies of men, with only a suggestion that women might face similar risks. In the intervening years, it has been shown that women smokers also face a greatly increased risk of lung cancer, heart disease, cirrhosis of the liver, emphysema and cancer of the mouth, pharynx, esophagus, pancreas and bladder.
Effects Upon Mothers
And mothers who smoke during pregnancy have been shown to be more likely to experience miscarriage, stillbirth and death of the newborn child. Smokers’ babies tend to weigh less at birth and, according to British findings, tend to perform less well academically and socially at the age of 7 years.
All told, the Public Health Service conservatively estimates that 300,000 Americans die prematurely each year because they smoked cigarettes. In addition, a National Health Survey ‘found that there were 12 million more chronic illnesses among adult Americans than there would be if everyone had the illness rate of nonsmokers.
Accordingly, smokers miss 40 per cent more days of work (a total of more than 77 million working days), make more visits to the doctor, spend more days in the hospital and undergo more surgery than do nonsmokers.
In addition, the children of smoking parents have twice the incidence of respiratory illness found in nonsmoking families.
Role of Carbon Monoxide
Scientists have also begun to delineate the specific effects of tobacco smoke and to identify the factors that may cause harm. Among other things, tobacco smoke has been found to interfere with the natural cleansing mechanisms of the respiratory tract.
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A number of cancer‐causing components of cigarette “tar” have been isolated. Nicotine, in addition to stimulating the heart rate and raising blood pressure, has been shown to affect the cells involved in blood clotting and to interfere with immunity mechanisms that help prevent infection.
Recently, carbon monoxide, a combustion product in cigarette smoke, has been singled out as a previously unappreciated cause of damage, particularly to the heart and blood vessels. Carbon monoxide combines with the blood's oxygen‐carrying pigment, hemoglobin, and reduces the amount of oxygen available to the heart and other body tissues. It has also been shown to increase the rate of artery‐clogging atherosclerosis and cause swelling and degeneration of certain heart tissues.
A pack‐a‐day smoker has two to three times the level of carbon monoxide in his blood as the nonsmoker, and a recent nationwide study found that smoking was a far more.important source of carbon monoxide in the blood than was air pollution.
The Industry Viewpoint
While most of the scientific and medical community believes, on the basis of current evidence, that cigarettes are an important cause of death and disability, some scientists and the tobacco industry, which has spent more than $30‐million on smoking and health research in the last decade, maintain other‐wise.
Horace R. Kornegay, president of the Tobacco Institute, the industry's trade association, said in a statement yesterday that the Surgeon General's report raised more questions than it answered and that final answers were still not in.
He said that future research into such influences on health as “environment and pollution, sex and race differences, geography and genetics will be much more significant than what has already been done.”
But while the industry keeps the smoking‐health controversy smoldering, 75 per cent of current smokers acknowledge and accept the health risks of cigarettes.
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And more than half the cur
U.S, Lung Cancer Death Rates ated with an increased risk of cancer of the bladder and esophagus, heart. disease, peptic ulcer, cirrhosis of the liver and the smallness of babies at birth.
In the decade since, these risks have been repeatedly demonstrated—in studies in Japan and Great Britain as well as in the United States. And the list of smoking‐associated hazards has grown to include cancer of the mouth, pharynx, pancreas and kidney; atherosclerosis and several vascular diseases, and periodontal (gum) disease, Cigarettes are now established as a major cause of emphysema and as an important contributing cause of death from heart disease.
In Britain, as in the United States, cigarette smoking is now the largest single avoidable cause of death and,disability. Sir George Godber, Britain's chief medical officer, has reported that cigarettes are responsible for nine in 10 lung cancer deaths, three in four chronic bronchitis deaths and one in four deaths from heart disease. rent smokers have attempted to quit.
It appears, however, that most of the smokers who would find it relatively easy to quit have already done so. The ranks of former smokers consist largely of those who were light smokers to begin with or who had already developed a smokingrelated illness that forced their hand.
For many, cigarette smoking is a deeply ingrained habit that is extremely difficult to break; for others, it is source of pleasure they are reluctant to give up.
“In spite of everything the Surgeon General's report, the educational programs of the National Clearinghouse on Smoking and Health and other health organizations—we still have more than 50 million smokers,” said Dr. Gio B. Gori, who heads the Tobacco Working Group of the National Cancer Institute. “And it is likely that this habit will continue for the next few decades, at least.”
Less‐Hazardous Cigarette
Therefore, the institute, in addition to supporting antismoking educational efforts, has decided to focus its research attention on ways of reducing the risk to those who continue to smoke.
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As Dr. Gori outlined them. the institute's main lines of research include trying to identify those individuals who are at high risk of developing smoking related illnesses and finding ways to help them give up cigarettes; developing drugs that will counteract the unwanted ef: fects of substances in tobacco smoke or mimic their pleasure‐giving properties without doing damage, and trying to reduce the risk of smoking by making a less hazardous cigarette.
“This last one is the approach we think will be most successful in the long run,” Dr. Gori said. “The trick is to remove the harmful substances and leave in those that give the smoker pleasure.”
In one experiment, Agriculture Department scientists are trying to identify the precursors of harmfdl tar substances in the tobacco plant and breed them out.
Other scientists are studying new ways of curing tobacco and improving the combustion of cigarettes to reduce the amount of cancer ‐ inducing hydrocarbons and carbon monoxide in the smoke. Filters that can selectively remove harmful substances, yet leave in pleasure‐giving ones, are also under investigation,
All these studies, however, are difficult and time‐consuming. Whatever the scientists come up with must be ‘ tested in laboratory animals for a minimum of two years. Some animal studies are already under way, but it will be some time before the results reach the ‘consumer.
And some scientists oppose this whole approach,’ saying thA cigarettes can never be made harmless and that this effort will ultimately put government health officials in the position of advocating a harmful, although somewhat less harmful, product.
1975 (Dec 09)
1975-12-09-nytimes-cancer-control-a-fight-on-100-disease.pdf
Cancer Control, a Fight on 100 Disease
Cancer Control, a Fight on 100 Disease
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Dec. 9, 1975
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Hardly a week goes by with out a new report that some previously unsuspected substance has been found to cause cancer. Thus far the scientists have pinpointed more than 1,000 agents as definite, or suspected causes of cancer in man. In recent years, such agents — called carcinogens —have been discovered in the air we breathe, the water we drink, the food we eat, the clothes we wear, the drugs we take, the jobs we hold, the habits we pursue.
Discoveries of such agents are emphasizing the pervasiveness of the cancer problem, the complexities of controlling it and, ultimately, the need to make difficult personal and public choices about how to lead satisfying, yet healthful, lives.
Last week, three new reports were released on cancer causes —one stating that a number of common cancers may be caused, directly or indirectly, by ordi, nary components of the daily diet; a second linking the use of estrogens during and after the menopause to an increased risk of developing uterine cancer and a third describing a high rate of skin cancer among workers who produce synthetic fuels.
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Such reports are apt to con fuse many people, including doctors, who wonder what they will next have to give up if they want to protect themselves from the scourge of malignancy. Indeed, in the face of such a long list of cancercausing agents, many people are inclined to think that almost everything causes cancer and that they might as well resign themselves to the fact that there is no way to prevent exposure to such a broad spectrum of carcinogens.
If nothing else, the reports illustrate that cancer is an extremely complex disease. In fact, although a single word is used to describe it, cancer is really at least 100 different diseases. Furthermore, any one form of cancer may be caused by a number of factors working alone or in concert, directly or indirectly. For example, in last week's report on nutritional factors in cancer, diets high in animal fats (such as the typical American diet) were associated with an increased risk of developing cancers of the colon and breast.
Fats in the diet do not appear to directly change cells from normal to cancerous. Rather, the fats are believed to change the metabolism in ways that render organs like the colon and breast more susceptible to cancer. Yet, even if a fatty diet is only an indirect cause of cancer, a change in that diet would lower a person's cancer risk.
The newly discovered link between estrogens and cancer of the endometrium, or lining of the uterus, is like the fattydiet link, a statistical one, although here the evidence suggests a direct carcinogenic effect of the hormones on a sensitive organ.
Some suspected cancer‐causing agents—such as the artificial sweetener, cyclamates—have indicated possible carcinogenic potential only in animal tests. A few substances, such as the ingredients of hair dyes, are thought to have cancercausing ability on the basis of tests on bacteria.
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But other recently described agents, including vinyl chloride, the plastics chemical that has thus far been associated with 45 cases of a fatal liver cancer among exposed workers, have been clearly established through human and animal studies as a definite cause of cancer in man.
It has also been shown that susceptibility to different carcinogens can vary greatly from one person to another. Such factors as a person's genetic predisposition, age, sex, immunologic responsiveness and perhaps even psychological state may modify the effect of a carcinogen, resulting in cancer in one person while another individual similarly exposed to the agent remains healthy.
For example, at a conference last week on the genetic aspects of cancer, a survey of 5,000 persons was described. It showed that, on a routine checkup, nearly 10 percent of those who had a parent or sibling with cancer were also found to have cancer. If two of such relatives had cancer, the cancer risk was 16 percent, and it jumped to 22 percent—more than one in five—for persons with three or more cancer victims among their close relatives.
Carcinogenic substances may also interact with one another or with certain viruses to cause a cancer that one substance alone could not produce. Although there is currently an intense search for human can cer viruses, none have been identified, and most cancer specialists, including some virologists, are looking more and more to environmental factors as the most important causes of cancer in man.
Yesterday, the three American winners of the 1975 Nobel Prize in medicine, who were honored for their discoveries involving cancer viruses, blamed outside environmental factors for causing up to 80 percent of cancers in man.
The Nobel laureates, Drs. David Baltimore, Howard M. Temin and Renato Dulbecco, said that about half of the cancers from these factors could be eliminated—especially those related to cigarette smoking, the most prominent environmental cause of cancer—but the public appears to turn its back on expert advice.
In today's complex society, there are hundreds of thou sands of man‐made substances, many of which may be inimical to the human body. As Dr. Gio B Gori of the National Cancer Institute stated in a report on nutrition and cancer, today's diet probably is biologically disadvantageous.
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“From an evolutionary point of view,” he said, “modern man is still outfitted with a body that over millions of years has adapted to Stone Age conditions, when the foods available were very different from our modern diet and the caloric consumption probably far exceeded the demands of our sedentary habits.”
Similarly, adaptability of the numan body is probably being overwhelmed with other ear marks of progress, and environmentally caused cancers may be the price for certain “luxuries.” For example, women who once had to put up with the discomforts of menopause now can take estrogens, which are effective in relieving these symptoms — but which may cause cancer.
The mere fact that other causes of death have been conquered, greatly reducing mortality before middle age, means that most people are now living to the older ages when cancer becomes far more common.
Identification of environmental carcinogens helps society to decide what trade‐offs to make in the name of progress. Knowing the risks helps in finding ways to avoid some and to minimize others. Another form of hormone treatment may be just as effective as estrogens in controlling menopausal symptoms but without creating a risk of cancer. Or persons genetically predisposed to cancer may be advised to restrict their exposure to certain agents. Or exposed persons may be monitored periodically to detect reversible precancerous changes.
It seems, however, that we may have to live with some cancer risks if the benefits derived from the condition that leads to those risks—or the costs of elminating the risks—are sufficiently great.
1976-10-30-nytimes-lowtar-cigarettes-creating-a-revolution.pdf
1976-10-30-nytimes-lowtar-cigarettes-creating-a-revolution-img-1
Low‐Tar Cigarettes Creating a ‘Revolution’
Low‐Tar Cigarettes Creating a ‘Revolution’
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By Wayne King Special to The New York Times
Oct. 30, 1976
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WINSTON‐SALEM, N.C.—Each weekday morning, before he begins his job in the flavor application section of the R. J. Reynolds Tobacco Company, 41year‐old John Shore puts in a stint as a member of the company's expert smokers panel.
He usually compares from two to six cigarettes, in pairs, holding them in one hand, He puffs each alternately, and deems them “rosy,” “fruity,” “winey,” “buttery,” “sulfury,” “scratchy,” “smooth,” or any of a number of other designations of taste and character.
But increasingly, what Mr. Shore is tasting comes not from real tobacco, but from what the industry calls “flavorants”—a multitude of synthetic flavor components added to make up for the taste lost in filtering out the “tar” that has been linked to cancer and other diseases.
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Low‐Tar Brands Stressed
The work of Mr. Shore and nine fellow panelists, unpaid volunteers from company ranks trained to recognize and consistently describe cigarette characteristics, is becoming increasingly important. New brands and variations are coming on to the market at the fastest pace in the history of the industry, signaling the most dramatic change in cigarettes since the switch to filters in the 1950's and ‘60's.
The new hull market is in “low tar.” Although the low‐tar cigarette category now commands only 15 percent of the market, it has picked up 5 percent of that (worth $375 million) in the last year, and the cigarette companies are estimated to be spending nearly half of their total advertising budget of from $350 million to $400 million on low‐tar brands this year.
“We are experiencing a dramatic change in the market,” said Thomas Sandefur, vice president for advertising and brand management for Reynolds, the sales leader in the tobacco industry in the United States. “If you call the filter market of the ‘50's a revolution, then you call this a revolution.”
Less Harm Found in Study
The cigarette industry is trying to avoid conceding that it believes that lower tar levels are less harmful because to do so would be to concede that higher levels are harmful. The tobacco companies all say that the tremendous emphasis on low‐tar products is a result of “consumer demand.” That demand has almost certainly been spurred by health concerns.
A recent study of mortality tables sponsored by the American Cancer Society found that smokers of low‐tar cagarettes suffered less from those diseases that have been linked to cigarette smoking than those who smoked cigarettes with a higher tar content. Such studies have signaled a less harsh attitude toward smoking.
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In the mid‐1950's, there were only 16 brands produced by the nation's six cigarette companies. Now there are some 150, not counting the variations within brands—the kings, superkings, menthols, soft‐packs, boxes, lights, longs, long lights and other mutations.
Of the brands available, 43 are in the. “low tar” field—that is, one cigarette yields 15 milligrams of tar or less, the standard accepted by the Federal Trade Commission.
Moreover, tar and nicotine have been reduced substantially across the board in the last two decades. The National Cancer Institute noted this year that in 1955 the average tar yield was 43 milligrams. Now it is 18 milligrams, and dropping with each new low‐tar introduction. Nicotine has been more than cut in half, from 2.8 milligrams to 1.2 milligrams in the same period.
Dr. Gio B. Gori of the institute's division of cancer cause and research, said that a rapid shift to less hazardous cigarettes could “reduce the current epidemic proportions of smoking‐related diseases to minimal levels in a few decades.”
All this could bode well for the tobacco industry, which has suffered badly from adverse publicity since 1964, when the first report by the Surgeon General of the United States Public Health Service linked cigarette smoking to cancer and other diseases.
But all is far from well in the industry's view.
Definitive Evidence Lacking
“There's one aspect that is not good news,” said William Kloepfer Jr., of the Tobacco Institute, a trade association with headquarters in Washington, “and that is that the medical literature has not yet demonstrated an advantage to low tar. So you have two thrusts. The tobacco industry cannot find definitive evidence that tar above a certain level is harmful, and below it is not. At the same time, they are responding to what we might call the ‘scare market.’ “
One industry source said privately that cigarette makers are “not unaware of the efforts to limit tar by statute or by tax methods” and that the present emphasis on low tars is one hedge against the day when some form of tar limit might be imposed.
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Whatever the motives, the battle has been drawn, with companies bringing out lower and lower tar brands, several in the last year. in that time, Reynolds's Vantage, the industry leader in low‐tars, has been challenged by such newcomers as Merit, Kent Golden Liles, low‐tar Pall Mall, Fact, and several others, including even further reductions in existing low‐tar brands like True and Carlton.
With the addition of Merit, the entry from Philip Morris, the second largest company and maker of the top‐selling Marlboro line, the battle took on a new front.
For the first time, a cigarette company built its advertising campaign around the fact that the taste of its cigarette was “added on,” not blended in through the use of real tobaccos. Philip Morris calls it “enriched flavor” and advertises it as a “scientific breakthrough.”
What Philip Morris has done with Merit is to use an old, established technique to overcome what has been one glaring fault with low‐tar cigarettes—they have very little taste.
Cigarette tar is reduced not by treating the tobacco, but by tightening the filter and using porous paper and tiny airholes in the filter to mix in air. Some reductions are also made by greater use of “reconstituted leaf,” which is, according to Reynolds, “stems, scraps and dust,” swept up and reprocessed into a sheet.
Injection of Freon Gas
Reynolds has also created a process called “tobacco expansion,” or “puffing,” which involves injecting tobacco with freon gas and letting it expand, or puff up. So, less is needed (about 35 percent less in the case of Vantage), meaning there is also less tar.
To make up for the missing tar, flavoring is added to almost every cigarette manufactured, a practice going back at least to 1913 when licorice, chocolate and sugar were added to Reynolds's extraordinarily successful Camel.
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But the low‐tars use more flavorings, and they have become considerably more complex. Dr. Alan Rodgman, director of research for Reynolds, said that a given cigarette might have “from a dozen to about 75” tlavorants, the blends of which are closely held secrets.
In the last two decades, the tobacco companies have been using sophisticated instruments to isolate and identify the components of cigarette smoke. So far, they have found about 2,300. The blenders simply buy or create synthetic chemical compounds that resemble these compounds, and these are sprayed onto the tobacco.
A monograph titled “Tobacco Flavoring for Smoking Products,” published for the tobacco industry by Reynolds in 1972, lists 1,290 substances that can be used for flavoring tobaccos.
They range from 209 readily recognizable natural substances such as almond oil, camphor, corn silk, dill oil, garlic oil, myrrh oil, pine needle oil, turpentine and violet leaves to assorted organic and amino acids, alcohols, ethers, pyrones, ketones, lactones, phenols, pyrazines, dihydropyrazines, pyroles and sulfur compounds. Some have formulas like the following: 2,3,4a,5,6,6a,7,8,9,10,10a,10y2,3,4a,5,6,6a, 7,8,9,10,10a,10b — Dodecahydro‐3,4a,7,7, 10a — pentamethy1‐1(H)naphthol [2.1 blpyran. This is said to impart a “cedarcooling” taste and aroma.
Unlike food additives, which must be approved by the Food and Drug Administration, tobacco flavorants and additives arc not specifically tested and regulated by the Government.
Cancer Expert Urges New Effort I To Reduce Hazard in Cigarettes
Cancer Expert Urges New Effort I To Reduce Hazard in Cigarettes
1976-10-29-nytimes-cancer-expert-urges-new-effort-to-reduce-hazard-in-cigarettes.pdf
By Harold M. Schmeck Jr. Special to The New York Times
Oct. 29, 1976
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WASHLNGTON, Oct. 28—The hope of turning the United States quickly into a nonsmoking society is unrealistic, an officer of the National Cancer Institute said today, and therefore more attention should be paid to the development and use of less hazardous cigarettes.
Such a shift to less hazardous cigarettes is already taking place and can be carried further within the possibilities of modern technology, said Dr. Gio B Gori. He is deputy director of the institute's division of cancer cause and prevention.
“A rapid shift in general cigarette consumption patterns,” said Dr. Gori, “could reduce the current epidemic proportions of smoking‐related diseases to minimal levels in a few decades.”
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Illness Related Ills
At present, the scientist of the cancer institute said, about 90 percent of lung cancer is related to tobacco use—primarily cigarette smoking. He said about 30 percent of atherosclerosis, underlying cause of most heart disease, can be linked to tobacco; 75 percent of chronic bronchitis, and 80 percent of emphysema.
Dr. Gori said, however, that “critical” amounts of such hazardous components of cigarette smoke as “tar,” nicotine and carbon monoxide could be calculated and cigarettes could be designed to stay below those critical levels.
The average cigarette available to the consumer could have these desirable characteristics in a decade if manufacturers made a concerted effort by 1980 and continued to make improvements thereafter, he said.
There would be a time lag in the benefits from such an effort, he said, but the excess risk of illness and death caused by cigarette smoking would begin to decline by about 1985 and could continue downward until the year 2008, at which point the health risks of the smoking population would be almost indistinguishable from those of nonsmokers.
Dr. Gori said this trend would translate into substantial declines in mortality among cigarette smokers.
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“By 2008 then, we have the potential to save 300,000 to 600.000 premature deaths every year,” he said.
“Thus,” said Dr. Gori, “the single most important and potentially successful disease prevention opportunity in contemporary society can be set in motion by responsible marketing decisions in the cigarette industry and, to a less controllable extent, through a major public education drive and legislative measures leading smokers to new patterns of acceptance.”
Speaks at Symposium
Dr. Gori spoke at a symposium on smoking and disease at the annual meeting of the institute of Medicine of the National Academy of Sciences, Some of the comments made by other scientists in the discussion period after Dr. Gori's talk indicated that his call for emphasis on less‐hazardous cigarettes would be somewhat controversial.
One speaker suggested that such a policy might simply play into the hands of the tobacco industry and dilute efforts to persuade Americans that they should stop smoking altogether.
While Federal health agencies and the American Cancer Society favor trends toward less‐hazardous cigarettes, they have put much greater emphasis on efforts to discourage the smoking habit. The cancer institute is the Federal Government's main agency for research on cancer and cancer education and control. The cancer society, a nongovernment organization, has for years led the fight to convince Americans that cigarette smoking is dangerous to health.
Dr. Gori said that between 50 million and 60 million Americans are cigarette smokers even though there was some reduction in the smoking habit following the Surgeon General's report on the health consequences of smoking in 1969. The cancer institute official said the current gross consumption of cigarettes was over 600 billion a year.
While efforts against smoking have failed to eliminate the habit, he said. these efforts have clearly resulted in the manufacture and consumption of somewhat less hazardous cigarettes.
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Tar yield of today's cigarettes is about one third that delivered in 1955 products, the scientist said, and nicotine levels have decreased by one‐half. The average pre1960 cigarette delivered 43 milligrams of tar, 3 milligrams of nicotine and 23 milligrams of carbon monoxide, according to the scientist's figures.
Abolishing tobacco use altogether is impractical at present, Dr. Gori said.
“Therefore,” he added, “it is important that we protect those people who continue to smoke despite all warnings. Leaving them to their fate is neither humane nor economical.”
Between Prevention and Therapy: Gio Batta Gori and the National Cancer Institute’s Diet, Nutrition and Cancer Programme, 1974–1978Published online by Cambridge University Press: 24 October 2012
David Cantor
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Rights & Permissions[Opens in a new window]AbstractThis paper explores the origins of the Diet, Nutrition and Cancer Programme (DNCP) of the National Cancer Institute (NCI) and its fate under its first director, Gio Batta Gori. The DNCP is used to explore the emergence of federal support for research on diet, nutrition and cancer following the 1971 Cancer Act, the complex relations between cancer prevention and therapeutics in the NCI during the 1970s, the broader politics around diet, nutrition and cancer during that decade, and their relations to Senator George McGovern’s select committee on Nutrition and Human Needs. It also provides a window onto the debates and struggles over whether NCI research should be funded by contracts or grants, the nature of the patronage system within the federal cancer research agency, how a director, Gio Gori, lost patronage within that system and how a tightening of the budget for cancer research in the mid-to-late 1970s affected the DNCP.
KeywordsUS National Cancer InstituteDietNutrition and CancerCancer Prevention and TherapySelect Committee on Nutrition and Human Needs (McGovern Committee)the CandlelightersGio GoriTypeArticlesInformationMedical History , Volume 56 , Issue 4 , October 2012 , pp. 531 - 561DOI: https://doi.org/10.1017/mdh.2012.73[Opens in a new window]Copyright© The Author 2012 Published by Cambridge University Press. This is a work of the US Government and is not subject to copyright protection in the United States.This is a work of the US Government and is not subject to copyright protection in the United States.The few turbulent years that Gio Batta Gori headed the National Cancer Institute’s Diet, Nutrition and Cancer Programme (NCI DNCP) started with high expectations of a new beginning for cancer prevention. After years of neglect, it seemed that the federal agency would take advantage of new opportunities to build on a growing body of epidemiological and experimental work that implicated diet and nutrition as causes of this group of diseases. The programme began in 1974 amid a flurry of new initiatives in cancer prevention and control. However, by 1977 it was in crisis, and in 1978 Gori left under a cloud. The DNCP might have begun with great expectations of a new beginning for cancer prevention, but these expectations were frustrated by the time that Gori left.
The story of the DNCP is often told within the NCI as part of a broader narrative of the difficult birth of federal support for cancer prevention. In this account, the NCI’s interest in cancer control initially focused on early detection and treatment.Footnote1 Less attention focused on prevention – or, more specifically, what came to be known as ‘primary prevention’Footnote2 – with the exception from the 1950s of smoking and tobacco. Then, in the late 1960s and 1970s this began to change. Researchers associated a growing number of occupational, environmental and lifestyle factors with cancer, and Congress and advocacy groups pressured a sometimes-reluctant NCI to devote more resources to aetiology and primary prevention (hereafter just ‘prevention’).Footnote3 Federal support for diet and nutrition emerged with this new interest in prevention.
Prevention is only part of the story of the DNCP, however, and at times not even the main one. Its origins began with the problems of parents trying to feed their leukaemic children, and much of its funding went not on prevention, but on studies of the role of diet and nutrition in cancer therapy. Indeed, the early history of the DNCP is a microcosm of a broader struggle over research priorities in which physicians and scientists aggressively defended therapeutically related research against demands that more resources go to prevention. Such struggles, I suggest, were exacerbated by anxieties from the food and farming industries that the NCI’s interest in diet and nutrition in cancer causation might add to pressure to reduce consumption of their products on health grounds. None of this succeeded in ending prevention-related research, but it did ensure that advocates of prevention were thwarted in their more ambitious expectations of the DNCP, especially as the NCI’s budget began to tighten in the mid-1970s, and the DNCP found itself struggling against bigger, more established programmes, at the heart of NCI policy, and ever hungry for more money. The story of the DNCP is thus a tale of what happened to a marginal programme when funding got scarce, and when entrenched interests came to be threatened.
This paper has three aims. The first is to use the DNCP as a window onto the growth of federal support for research on diet, nutrition and cancer following the 1971 Cancer Act, the legislative beginning of what was sometimes known as the War on Cancer. This programme and the broader field of diet, nutrition and cancer research are largely neglected in the voluminous literature on the 1971 Act and its aftermath.Footnote4 Nor do the general historiographies of either diet and nutrition or cancer therapeutics and prevention in the 1970s give them much attention.Footnote5 In the case of cancer therapy, the best we have are a few internal accounts of technical developments in the nutrition of cancer patients and some comments on continued anxieties over diet as a form of ‘quack’ treatment.Footnote6 In the case of prevention, diet and nutrition are – with two exceptions – largely subordinated to accounts of smoking and occupational and environmental cancers. One exception is a literature on additives and hormones such as diethylstilbestrol (DES) which were not the focus of the DNCP for reasons discussed below.Footnote7 The other exception is a literature on the growing interest in diet, nutrition and cancer in the 1980s, but this last literature largely skips over the 1970s.Footnote8 Part of the historiographic intent of this paper is to recover the missing decade of the 1970s: to explain why interest in diet, nutrition and cancer emerged during that decade, to document the range of interest in this field (beyond additives and hormones), to explore how the NCI responded to this interest and to describe why its early efforts foundered. The paper ends in 1978 when the DNCP’s first director left, and prevention and therapy separated within the programme.
The second aim of this paper is to explore the problematic relations between therapeutics and prevention within the DNCP in the 1970s. It is well known that the NCI was widely criticised during that decade for favouring therapeutics over prevention.Footnote9 Much of the substantial historiography on this topic, however, is written from a prevention perspective in which arguments in favour of therapy tend to be portrayed as little more than barriers to prevention’s advancement. One of the goals of this paper is to recover the perspectives not only of those who advocated prevention, but also of those who advocated therapeutic research, and to show how each related to the other. The DNCP provides a valuable opportunity to explore this intertwined story. Both sides saw the programme as an opportunity to advance their research objectives, but there was never enough money to support all their proposals, and they became competitors for a limited funding pool. Yet, paradoxically, if they were competitors they were also uneasy allies. The DNCP’s marginal status within the NCI meant that the two sides were bound together in a fraught relationship as partners in preserving the programme as a whole against external threats. It was a difficult position for each. Both were forced to weigh their common interests in protecting the programme against their competing interests in securing funding from a small DNCP budget.
A third aim of the paper is to use the DNCP as a window on to the broader politics around diet, nutrition and cancer in the 1970s. The DNCP is a story of how a range of external stakeholders – with different, sometimes conflicting, interests and agendas – sought to shape NCI policy in this area. Thus, where some advocacy groups pressured Congress and the NCI for more funding for prevention, other stakeholders, such as the meat industry, worried that DNCP research might highlight public health issues that would undermine the commercial value of their products. Congress itself was divided, sometimes more willing to privilege the voices of advocates of therapeutics, sometimes those of prevention. And, within the NCI, advocates of prevention and therapeutics played up these divisions to argue political cases for their various positions, often backed up with data that they hoped would support more research in their fields and highlight the limitations of research favoured by their opponents.
This then is a story about how the fate of the programme in the 1970s was determined by the political struggles between various stakeholders, both within and without the NCI. It is also a story of how these struggles were complicated, on the one hand, by broader efforts by the NCI leadership to reform and restructure the organisation in the mid-to-late 1970s and, on the other hand, by Gio Gori, the director of the programme. Gori’s controversial efforts from 1977 to counter the DNCP’s budgetary problems, combined with his simultaneous involvement in disputes around smoking, succeeded in alienating powerful figures within the NCI. The DNCP director found himself in a hostile institutional environment, politically exposed and without allies having lost the support of former patrons during the reorganisation of the mid-to-late 1970s. Gori was eventually compelled to give up directorship of the DNCP, and his political problems helped set the stage for the growing institutional separation of therapeutics and prevention within the programme.
1974–77The beginnings of the DNCP can be traced to one of the therapeutic ‘success’ stories of the post-war years – childhood cancer.Footnote10 Where once a diagnosis of leukaemia had meant the death of the child, by the late 1960s and 1970s the situation was very different. Mortality from childhood leukaemia fell, children survived the disease longer and a new set of problems emerged around their long-term care. Among these problems diet and nutrition figured large. Parents found their leukaemic offspring often unable or unwilling to eat, fluctuating from skeletal to obese during the course of treatment, and their physicians often seemed at a loss to help. By the 1970s, a number of parents’ support groups had formed. One of these – the Candlelighters, based in Washington, DCFootnote11 – was to set in motion the events that led to the creation of the DNCP.
The Candlelighters was the inspiration of Grace Ann Monaco (also known as Grace Powers Monaco), a young attorney in Washington, DC.Footnote12 In 1968 her daughter, Kathleen Rea, was diagnosed with acute lymphoblastic leukaemia and began treatment at Children’s National Medical Center. There Monaco met parents of other children undergoing treatment, and – encouraged by the paediatrician Sanford Leiken and other physicians and nurses at Children’sFootnote13 – together they formed a support group for parents of children with cancer. Monaco later recalled: ‘About 25 of us started meeting wherever we could find space – boiler rooms, corridors outside the emergency room – and Candlelighters was born.’Footnote14 The parents lobbied Congress on issues such as better access to paediatric clinical trials, the establishment of a national comprehensive cancer registry for childhood and adolescent cancers, and outreach programmes for the demonstration of successful methods of treating those cancers.Footnote15 The organisation also gained a reputation for its support of greater federal involvement in research, and for its ability to present practical suggestions on how this might be achieved in Congress.Footnote16 One of the founding members, Richard (Dick) Sullivan, was a congressional staffer, which facilitated access to legislators. Sullivan’s daughter had a neuroblastoma and died in 1970, the same year as Kathleen Rea. The Candlelighters’ ‘birth’ – also in 1970 – came out of these personal tragedies.
The Candlelighters expanded beyond the Washington area. ‘Our traveling members really got the ball rolling’, Monaco later noted of members who visited children’s hospitals across the country.Footnote17 ‘We talked about the importance of parent-peer support and networked with parents across the US and Canada.’ To build and maintain their network, Monaco and Julie Sullivan, Dick’s wife, founded a newsletter in 1970, written with the help of other parents, and printed on the House of Representatives’ mimeograph machine. The number of local Candlelighters groups jumped from perhaps three in the early 1970s to over 100 by the end of the decade, in 42 states, and in Europe and Canada.Footnote18 By then the organisation had also developed what it called the Childhood Cancer Ombudsman Programme that used panels of volunteer doctors and lawyers to give free opinions on issues such as treatment choices, informed consent, employment discrimination against parents, educational discrimination, access to military service and barriers to insurance. In 1976, the Candlelighters created a Foundation to promote self-help groups, to improve communications between parents and parents’ groups, and to enhance the quality of information available to parents of children with cancer.Footnote19
The poor quality of information available to parents had been a concern of the Candlelighters long before the establishment of the Foundation.Footnote20 During debates over extending the 1971 National Cancer Programme, the organisation persuaded the House Sub-Committee on Health and the Environment headed by Paul Rogers (D-Fla) to write into the section of the bill authorising NCI information programmes a statement that such programmes should include ‘information respecting nutrition programs for cancer patients and the relationship between nutrition and cancer’. It was this proposed authorisation that marks the beginning of the Diet, Nutrition and Cancer Programme. At some point in the Congressional deliberations the terms of the authorisation expanded, and under the National Cancer Amendment enacted 23 July 1974 (P.L. 93-352) Congress ordered the NCI to increase its support for research into the role of nutrition in both the cause and treatment of cancer.Footnote21 By November 1974, the first plans for what would become the DNCP were set out, and the programme was launched the following year.Footnote22
The Diet, Nutrition and Cancer ProgrammeThe DNCP might have started as an appeal for more nutritional information from parents trying to feed their sick children, but it had turned into much more. In 1974, the director of the NCI, Frank J. Rauscher, appointed an internal committee of NCI scientists – the Diet Nutrition and Cancer Coordinating Group (DNCCG) – to define the goals of this programme and to recommend an organisational structure. The DNCCG interpreted the 1974 Cancer Act as calling for a two-pronged programme in diet and nutrition focused on information provision and research, the latter including studies on cancer aetiology and on the treatment, long-term management and rehabilitation of cancer patients. (Hereafter treatment, management and rehabilitation will be abbreviated to therapy.)Footnote23 Towards these ends, the DNCP began a literature survey on diet, nutrition and cancer, and organised two workshops in 1975 – one on diet in cancer therapy,Footnote24 the other on nutrition and cancer causation.Footnote25 These shifts towards therapy and aetiology seem to have had the approval of the Candlelighters, which remained a strong supporter of the programme throughout the 1970s, pressing the NCI to increase nutrition research.Footnote26 In 1979, the NCI fulfilled a debt to the Candlelighters by producing a dietary resource book for parents of children with cancer.Footnote27
Table 1: Gio Batta Gori’s appointments prior to joining NCI. Source: Gio Batta Gori, Resume (June 1968), NCI archives: item number DC-6800-006346.
To get the DNCP going the NCI began by appointing a programme director and an advisory committee. The directorship went to Gio Batta Gori, then deputy director of the NCI’s Division of Cancer Causes and Prevention (DCCP), see Figure 1.Footnote28 Today, Gori is a controversial figure in part because of his subsequent career as a consultant to the tobacco industry, and critics have questioned his scientific and management credentials. Richard Kluger, for example, describes Gori as a ‘journeyman microbiologist’ whose ‘medical training had been at a backwater school, he had no scholarly publications to speak of, and he brought no depth of knowledge on the nuances of cancer’.Footnote29 And Devra Davis adds to Kluger’s criticism. ‘What Gori lacked in scientific pedigrees at the time, he more than made up for in schmoozing ability’, she claims, ‘many of his colleagues found him to be an overdressed bureaucrat with an exaggerated sense of his own importance’.Footnote30 But such evaluations seem to have come in part from critics within the NCI. For others within that organisation, Gori seems to have gained a reputation as an effective administrator.
Figure 1: Gio Batta Gori, c1975. Source: ‘Dr. Gio Gori Becomes Dep. Director of Cancer Cause, Prevention Div.’, The NIH Record, 27, 1 (14 January 1975), 7, courtesy of Rich McManus, editor of The NIH Record.
Born in Tarcento, Italy, Gori had trained in microbiology and botany at the University of Camerino, see Table 1. In 1959/60 he moved to Pittsburgh to work with Jonas Salk on the poliovirus. He returned briefly to Italy to establish a laboratory to produce polio vaccine in Siena, before re-crossing the Atlantic to join Hilary Koprowski, the microbiologist director of the Wistar Institute in Philadelphia. After the Wistar, Gori worked in private industry before joining the NCI in 1968, where he gained a reputation as an efficient manager, someone able to get along with most people. As we shall see, this reputation would be in tatters by the time he left NCI. At least in the beginning, however, it is likely that it was his good managerial reputation, more than his modest scientific accomplishments, that explains why he quickly moved up the administrative ladder. From 1973 to 1980, he was (Acting) Deputy Director of the DCCP, with simultaneous responsibilities as Director of the Smoking and Health Programme (1973–c.78), and Acting (Associate) Director of the Carcinogenesis Programme (1976–77). He was to be Director of the Diet, Nutrition and Cancer Programme from 1975 to c.1978 (Figure 2).Footnote31
The advisory committee met for the first time on 19–20 August 1975. Chaired by the Massachusetts Institute of Technology (MIT) toxicologist, Gerald Wogan, the committee was eventually named the Diet, Nutrition and Cancer Advisory Committee – hereafter the DNCAC or the Advisory Committee (Table 2). According to Gori, the DNCAC was intended to reflect a cross section of scientific expertise in epidemiology, experimental carcinogenesis, animal nutrition, human clinical nutrition, the biochemistry of nutrition and clinical oncology, as well as the federal government, the academic community, industry, the American Cancer Society (ACS) and other interests.Footnote32 Yet from the start there were tensions within it. In part, the issue was the division of power between Gori (as Director of the programme) and the Committee that advised him. The substantive problem, however, was how to divide the US$5000 000 (later US$6000 000) allotted to the programme between research on therapeutics and aetiology. To the dismay of advocates of therapeutics, Gori submitted a plan in which research on aetiology and therapy would each have 45% of the budget of the new programme – the remaining 10% going on general support.Footnote33 (Table 3) It was this plan that marks the beginning of the struggle over research priorities within DNCP, pitting advocates of therapeutically related research against those who promoted prevention and aetiology.
Table 2: Members of the Diet, Nutrition and Cancer Programme Advisory Committee.
Table 3: Gori’s proposed breakdown of the budget for DNCP, August 1975 (% percentage of the total DNCP budget). Source: ‘Nutrition Program Starts to Zero in on Mass of Data, Plan Contract and Grant Project Areas’, The Cancer Letter, 1, 35 (29 August 1975), 1–6: 2–3.
Diet and TherapyAdvocates of therapy argued there were pressing clinical reasons why they needed more resources than Gori proposed. They pointed out that the disease itself could cause malnutrition (through anorexia, hormonal disturbances or by other unknown mechanisms); that the resulting nutritional deficiencies could enhance or retard tumour growth directly, or through their effects on the immune system, or on drug absorption and metabolism; that the frequent presence of acute infection created further nutritional complications by increasing the basic metabolic expenditure by 30–40%; and that nutritional problems could also be caused or aggravated by cancer treatment, sometimes the result of the anorexia, nausea, vomiting and diarrhoea which could follow chemotherapy or radiotherapy, and sometimes the result of depletion by antimetabolite therapy (see Table 4).Footnote34 However, despite numerous reports indicating that dietary factors might play a critical role in cancer treatment, commentators noted that there were few definitive studies on the contribution of diet to the clinical management of cancer. The complexity of the relationships among tumour, host and diet/nutrition made reproducible results difficult to obtain.Footnote35
Table 4: Consequences of cancer treatment predisposing to nutrition problems. Source: Maurice E. Shils, ‘Nutritional Problems Arising from the Treatment of Cancer’, CA. A Cancer Journal for Clinicians, 20 (1970), 188–96: 193.
For many physicians, research into the role of diet and nutrition in cancer had particular urgency because of the anorexia and cachexia associated with the disease. Anorexia was a frequent problem in the treatment of cancer. It could persist for such a long time that the patient lost a huge amount of body weight, became malnourished and was less able to counteract the complicating factors of cancer, or to endure aggressive anti-cancer therapies such as radiation, surgery or chemotherapy. According to one estimate, about two-thirds of those who died of cancer were cachectic at death.Footnote36 In some cases, the anorexia and cachexia seemed to be the result of reduced food intake, either because patients with cancer found it painful to eat or because they found their food to be much less palatable – the disease or its treatments sometimes seemed to affect taste and smell. In other cases, the anorexia or cachexia seemed to have little to do with food intake. Some patients continued to lose weight even when they ate and appeared to assimilate a normal diet, perhaps because the tumour pre-empted available nutrients, or because the host underwent an increased metabolic rate – scientists disagreed on the reason. In addition, some studies showed that food restriction generally inhibited tumour growth, lending support to suggestions that the cachexia might be an adaptive device of the host to starve the tumour. It was, therefore, possible that improving patient food intake would actually accelerate the growth of the tumour, and improve its viability and resistance to therapy.
For the DNCAC, such concerns opened a series of possible research projects, including studies of the nature of host–tumour competition, the causes of impaired food intake, the role of individual nutrients as they related to cancer treatment (including nutrient depletion by therapy) and the activities of enzymes involved in the metabolism of cancer chemotherapeutic agents. The Advisory Committee considered studies on why modified taste perception occurred, and discussed proposals for research to develop means for restoring normal taste patterns, to modify traditional tastes of foods so that they became palatable again and to change patient’s behaviours so that they increased food intake.Footnote37 It also considered research into artificial methods of feeding (for those cases where conventional feeding was impossible) to improve the formulation of nutrient solutions, to reduce costs, to improve hardware, to reduce the chance of sepsis and to devise low-cost, mass-produced portable infusion units for ambulatory patients. The latter research was of particular interest to two members of the DNCAC, Jonathan Rhoads and Stanley Dudrick. In 1968, they had developed a technique of total parenteral nutrition (TNP) that became a standard American technique for providing patients with long-term nutritional support.Footnote38
A final problem focused on the question of whether nutrition could be used as a direct form of cancer therapy. The recognition that the nutritional requirements of many tumours were quite different to those of the host – the patient – opened the prospect of adjusting available nutrients so as to starve the tumour while feeding the patient.Footnote39 In addition, it was also possible that therapy might be based on the interruption of the cachexia, rather than the inhibition of the tumour, especially in the early stages of tumour growth before frank emaciation set in.Footnote40
So far I have suggested that calls for research into the relations between diet, nutrition and cancer therapy were motivated, in part, by a series of clinical and scientific questions related to the practical problems of cancer therapy. These technical questions were given political urgency by growing public concern in the 1960s and 1970s of poor survival rates for patients undergoing therapy.Footnote41 Despite years of research and millions of dollars, critics argued that survival rates had not significantly improved since the Second World War. For physicians these figures were confirmation of the need for more research into methods of improving cancer therapy, but they also raised a new quandary. Increasingly such figures were also used to argue that cancer research was too focused on therapeutics and basic laboratory studies, and that a fundamental reorientation towards prevention was needed. For therapists, all this gave new importance to research that promised practical methods of improving survival rates. Studies of artificial nutrition, direct nutritional therapy, and the role of diet and nutrition in the host/tumour relationship were particularly promising here, they claimed.
Yet, until the creation of the DNCP, the NCI seemed more focused on other research areas, and there seemed little prospect of change. As Gori noted, nutrition science was often poorly provided for in the medical schools, and tainted with the mark of quackery, not the sort of field that the NCI would generally support.Footnote42 Practitioners interested in nutritional issues – nurses, nutritionists and others – were often low status and without a strong voice on the NCI. The Candlelighters’ initiative had improved the prospects for change and money for a host of new projects seemed a possibility. Yet with all these new possibilities came the unwelcome probability of having to share a small budget with researchers more interested in preventing cancer in the future than in dealing with the urgent needs of desperately ill patients in the 1970s. Whatever their sympathy for prevention, physicians remained focused on their sick patients, and anxious that money might disappear into a seemingly bottomless hole of aetiological research that offered little prospect of reducing cancer incidence or mortality for many years, if ever.
Diet as a Cause of CancerIf advocates of therapeutically related research argued that their needs were pressing, so too did those interested in prevention. During the 1950s and especially the 1960s a growing body of epidemiological and experimental evidence had implicated diet and nutrition as causes of cancer. But – as with therapeutics – advocates of prevention argued that much more research was needed. In their view, the nature of the relationship between diet and nutrition was poorly understood, in part because of the historical neglect of prevention-related research, the technical difficulties of research in this area and the poor status of nutrition as a scientific field. The DNCP offered an opportunity to reverse such neglect at a time when public and Congressional concern about the NCI’s failure to promote prevention was growing. ‘Prevention is the only way we can make a major impact on survival’, commented the epidemiologist, Ernst Wynder, at the first meeting of the DNCAC,Footnote43 ‘As interesting as therapy is, it will not make a major inroad on cancer…[it] has never wiped out a disease’.
Wynder’s was the strongest voice on the DNCAC arguing for more research into the cancer aetiology.Footnote44 Best known for identifying cigarette smoking as a cause of lung cancer, Wynder became convinced that diet was a significant cause of this group of diseases, and that prevention was undervalued by the cancer establishment and often opposed by powerful industrial interests.Footnote45 In 1969 he founded the American Health Foundation, eventually based in Valhalla north of New York City, to research cancer aetiology and prevention, including epidemiological and animal research in nutrition.Footnote46 He told the committee that he thought about half of all cancers were nutrition related. According to Wynder, occupational cancers accounted for about 1% of the total, tobacco for 40% of cancers in males and, as he put it, ‘Most of the rest are related to nutrition’.Footnote47
Wynder’s evidence for this statement derived from epidemiological studies of migrant populations that had blossomed in the 1960s, pioneered in part by NCI statisticians such as William Haenszel. Differences in colon, stomach, breast, kidney and bladder cancer rates between Japan and the US, he argued, had been attributed, to dietary differences.Footnote48 Cancer rates in Puerto Rico were similar to those in Japan, and second-generation Puerto Rican migrants, like Japanese migrants, adopted a US diet and soon experienced cancer rates similar to the rest of the US. Had he wished to, Wynder could also have pointed to other studies – for example, among Polish migrants to the US, and rural migrants to Cali, ColombiaFootnote49 – that showed that cancer incidence patterns of migrants changed from that of their native country/region to that common to the population of their new country/region; a transition often attributed to changes in dietary habits. Other studies of populations with special dietary practices, Wynder noted, showed positive evidence of a dietary relationship to cancer aetiology – Jewish populations in New York, Seventh-Day Adventists in California and the Mormon populations of Utah.Footnote50 In migration studies, diet was difficult to disentangle from other environmental factors. These other studies offered an opportunity to control environmental factors: they focused on populations that lived in the same environment, but differed principally in terms of diet.
Such studies were not the first to link diet and cancer.Footnote51 Yet earlier studies had remarkably little impact on the national cancer campaigns that emerged in the first two decades of the twentieth century. Dominated by physicians and scientists who tended to see cancer as a local cellular disease that subsequently spread to affect other parts of the body, such campaigns tended to focus efforts to control the disease on early detection and treatment.Footnote52 Very little attention was paid to dietary causes of cancer or dietary means of preventing cancer, which were regarded as of unproven value and, like direct nutritional therapy, associated with quackery.Footnote53 The creation of the NCI in 1937 did little to change the picture.Footnote54 The new Institute broadly endorsed the model of early detection and treatment, and tended to share with other cancer control agencies a suspicion of claims that diet caused cancer. The Institute did support a small amount of research on diet and nutrition, notably Albert Tannenbaum’s important studies in the late 1930s and 1940s on the effects of caloric restriction on the development of spontaneous and chemically induced tumours in mice.Footnote55 However, diet and nutrition were never central to its mission. According to Michael Shimkin, its intramural efforts in this area faded after 1950, paradoxically just as Wynder and others elsewhere began to take an interest in the subject.Footnote56 Then, in the 1960s and especially the 1970s, the NCI’s disinterest in diet and nutrition came to be challenged by growing public and political interest in environmental and lifestyle causes of cancer and a growing acceptance within medicine of statistical associations as evidence of causal relations, notably following epidemiological research undertaken in the 1940s that identified cigarette smoking as a cause of lung cancer.Footnote57 Such studies laid a foundation for the reception of studies of migrant and other populations that identified associations between diet and cancer.
This is not to say that the growing interest in environmental and lifestyle factors was unproblematic for the DNCP. As Robert Proctor has noted, much of the interest in environmental cancers in the 1970s focused not on diet and nutrition but on occupational cancers,Footnote58 and where interest did focus on diet it often focused on subjects such as pesticides and additives that were beyond the remit of the DNCP.Footnote59 It has already been noted that Wynder dismissed occupational cancers as a tiny proportion of cancers (1%), and he was similarly dismissive of additives and pesticides. Wynder argued that there were three major dietary factors in relation to cancer: food contaminants (which he regarded as the least important), specific nutritional deficiencies or imbalances, and specific nutritional excesses or imbalances notably in regard to fat and alcohol consumption (which he regarded as the most important). In his view, there was already enough evidence for the committee to advise the public to ‘reduce the total calories, reduce the calories from fat, and reduce the cholesterol intake’.Footnote60
But, if Wynder had hoped for support from the DNCAC, he was to be disappointed. Even supporters of prevention on the committee were not persuaded of his arguments about dietary imbalances. Gori, for example, noted that there was very little scientific evidence as to what constituted a normal human diet, ‘rendering irrelevant talk of dietary excesses and deficiencies’.Footnote61 In his view, it would only be possible to talk about excesses and deficiencies once the normalcy ranges for the human diet were known. This information, Gori claimed, combined with epidemiological studies, dietary surveys and exploratory studies in animals could help define the epidemiological significance and eventually the carcinogenic potential of altered dietary intake in humans. But the range of questions was immense – what was the impact of diet on the hormonal balance, internal secretions, the composition and substrates available to the enteric flora, and the carcinogenic and toxic stimuli that might intervene on cellular and genetic stability, the immune status, the detoxification and reproductive competence of the individual. There were so many unknowns about the relationship between cancer, nutrition and diet, and it was likely to take years to sort out.
It was here that the political weakness of prevention-related research was evident. While Congress was a strong advocate of such research, it was notoriously impatient for results, and spoke with more than one voice, pressing for a cure for the disease as much as (if not more than) it pressed for prevention. Critics of prevention were quick to highlight the point. ‘We could quickly use up $6 million in etiology, and it would be years before we could show progress’, noted the surgeon Stanley Dudrick,Footnote62 ‘The legislators might become discouraged’. Dudrick and other critics argued that therapeutic-related research would provide quicker results than prevention;Footnote63 that it was too early to reach conclusions on the relationship of diet to cancer;Footnote64 that a focus on prevention might undermine efforts to do something for people whose cancers had already started;Footnote65 and that the workshops sponsored by DNCP in 1975 came up with many more promising research ideas in therapy than in aetiology. The surgeon, Jonathan Rhoads (the Chair of the National Cancer Advisory Board), was moved to regret the poor showing of aetiology: nine of the top ten projects were in therapy or management and support, he noted.Footnote66
Faced with such arguments, Gori retreated from his earlier position on prevention. He conceded that therapeutic research was likely to have a faster pay-off than that of aetiology, and that they had to show quick results if legislators were not to become discouraged. Congress had, he argued, been motivated to include diet and nutrition in the 1974 Act more by a concern about therapy than by statistics on aetiology. The epidemiological evidence, he noted, pointed to a variety of causative factors, but it pointed to too many things, and there was a consensus that the epidemiological approach to aetiology would be slow and difficult. By the end of the debate, the therapeutic lobby had prevailed. Instead, of Gori’s proposal of a budget split of 45%–45%–10%, the Advisory Committee recommended that the budget be divided 55% for therapy; 35% for aetiology and 10% for programme management and support.Footnote67 In practice, therapeutics got an even larger slice of the cake: the actual funding in the fiscal year 1976 was 67.4% for therapy, 25.4% for aetiology and 7.2% for management and support, with the largest percentage increase going to work on artificial alimentation.Footnote68 (Table 5) In the following years Congressional pressure would increase the percentage going to prevention.Footnote69 The base-line from which future negotiations would start, however, had been set.
Table 5: ‘DNCP Recommended and Actual Funds Allocation, Fiscal Year 1976’. Source: Diet, Nutrition and Cancer Program, Status Report and Working Papers for the Advisory Committee Meeting December 14–15, 1976, National Institutes of Health, Building 31, Wing C, Conference Room 10, Bethesda Maryland 20014 (Bethesda: National Cancer Program, 1976), 12.
1977–78So far the story of the DNCP is a tale of internal committee struggles over NCI research priorities in which epidemiologists and statisticians defended prevention-related research against pressure for more resources to go on therapeutics – and found themselves giving ground. But from 1977 these struggles moved out of the committee rooms and into a broader public arena. Frustrated with their poor showing against the therapists, and upset by NCI cutbacks in spending on diet and nutrition, advocates of prevention began a political and media campaign critical of NCI neglect of prevention research. This revitalised campaign brought the DNCP into the sights of the food industry, which was increasingly concerned about the direction of federal food policy. It also alienated senior figures within the NCI with its public criticism of their policies towards prevention. These problems, combined with Gori’s involvement in the separate debates over smoking, meant the DNCP faced a very unclear future.
Budget ProblemsThe DNCP had been established when the NCI was flush with money for small new projects in the early 1970s. Its budget had jumped after the 1971 Act, from US$190 million in 1970 to just under US$1 billion in 1977, allowing the NCI to initiate a range of new programmes, including the DNCP.Footnote70 By 1977, the golden days were over. The budget continued to rise, but the money was draining out elsewhere, notably to the Comprehensive Cancer Centres (established across the country from 1973 to bring results of research rapidly to patients), and to the Special Virus Cancer Programme.Footnote71 Other programmes began to feel the financial pinch. The NCI – under funding pressure from the Ford and Carter administrations – cut Gori’s proposed budget in half.Footnote72
Gori reported in 1977 that funding limitations meant that the DNCP had not been able to implement many research recommendations of its Advisory Committee.Footnote73 Congress had allocated US$6 million to the DNCP in 1975 rising to US$7.7 million in 1977. The problem was that these sums did not come close to meeting the needs of the programme. Gori estimated that proposed projects would cost about US$25 570 000, with about 103 projects needing support, and no-one knew where the money was to come from. Despite early concerns that few scientists would be interested in such a low status area of research as nutrition and diet, Gori had found himself deluged by enquiries and proposals for research at a time when the NCI faced a financial shortfall.Footnote74 Nutrition research seemed to be caught between its own success and the general budget crunch. It was not the only NCI programme to suffer this way, but Gori took the difficulties to heart.
Frustrated with his inability to change NCI policy, in February 1977 Gori and his Advisory Committee went over the heads of NCI bosses, and wrote to the newly inaugurated President Carter and key congressional figures to complain about poor funding.Footnote75 The previous month, Newsday had published a 16-day series of articles critical of the NCI’s war on cancer.Footnote76 The nub of the Newsday criticism was that the NCI was losing the war on cancer, that too much emphasis was given to the virus programme and comprehensive cancer centres at the expense of more promising areas of research including prevention and that a reason for this was that the NCI’s peer review system and its advisory committee – the National Advisory Committee on Cancer – were loaded with people who were the recipients of funding and few had an interest in prevention, including diet and nutrition.Footnote77 In short, NCI decision-making was rife with conflicts of interest that worked against promoting work in the most productive areas. Gori was one of Newsday’s sources.
According to Newsday, Gori charged that the heavy emphasis on virus research and treatment centres was a misuse of federal funds: the scientific consensus was that virus research was no longer the best route to a cure (the virus programme was ‘a flop’, an unnamed scientist was quoted by Newsday); nor was the focus on therapy the best route to reducing cancer incidence or mortality. In spite of the enormous increase in treatment money, the survival rates of cancer victims – except for some cancers in children – had not increased substantially in 30 years. How different the prospects seemed for prevention. Gori noted that the evidence was that the majority of cancers were environmentally produced and could be prevented. ‘In spite of this clear evidence’, Gori was quoted as saying, ‘the money is not where the priorities are’.Footnote78
Public criticism set the seal on a growing rift between Gori and his NCI superiors. As one report put it later, ‘Going public with an intramural fight over the budget is a no-no in the federal government’.Footnote79 Gori’s comments in Newsday, and the DNCAC’s approach to Carter, attracted the ire of Benno Schmidt (Chairman of the President’s Cancer Panel) and Guy Newell (the NCI’s acting director: Frank Rauscher having left to join the ACS, 1 November 1976). Newell began by publicly warning (unnamed) Advisory Committees not to engage in lobbying.Footnote80 Then, in April 1977, he cut all of Gori’s advisory committees – the carcinogenesis, tobacco, and diet and nutrition committees.Footnote81
The Carter administration – which had run on a promise of reducing the size of the federal government – had urged the NCI to reduce the number of its advisory groups. (Advisory group members were considered FTEs – full-time equivalents – and were an immediate target for downsizing.) Newell denied that his focus on Gori was retribution for the Diet and Nutrition Cancer Advisory Committee’s action, but commentators saw a connection.Footnote82 Without the DNCAC, Gori was unable to use it to critique ongoing research or to generate new research priorities. One former member of the Advisory committee came to worry that it left the NCI inadequately advised on nutrition issues, a sign of its lack of commitment to the field.Footnote83 At the same time, a shift in the NCI’s funding mechanisms – from contracts to grants – further reduced Gori’s ability to control diet and nutrition research.
Academic researchers had pushed hard for this shift, since grants were investigator initiated and gave more influence to the researchers than government administrators. From the point of view of researchers, contract mechanisms were vulnerable to favouritism, a means of extending the National Institutes for Health (NIH) intramural research without a proper review, potentially harmful to cancer research (research, they claimed, often targeted areas where basic knowledge about cancer was underdeveloped), and based on a flawed ‘philosophy that the role of management of fundamental science is the same as the role of management for engineering or development when the fundamental knowledge is available’.Footnote84 By contrast, from the point of view of administrators, contracts were a convenient and quick means of promoting work in targeted areas, of differentiating programme objectives from scientific objectives and of maintaining management control over scientists who, in administrators’ views, often confused scientific and programmatic endpoints. As one DCCP document put it, advocating management through a mix of contracts and grants: ‘[M]any scientists do not understand that even successful completion of their proposed project may not necessarily contribute to the attainment of program goals’.Footnote85 Contracts had the added benefit, for administrators, that they could be initiated without undergoing the sorts of review that was expected of grants. This is not to say that contracts were not subject to peer review: they were, but in different ways to grants. The 1974 amendments to the National Cancer Act required research and development contract proposals to be subject to peer review by groups composed of not less than 75% of non-federal employees.Footnote86
In 1976 the vast bulk of therapeutic research was carried out by contract (65.9% of the total DNCP budget distribution), which included all the research on artificial alimentation and anorexia. By contrast 1.5% of the budget went on therapeutic research funded through cancer research emphasis grants (CREGs), a targeted grant established in the mid-1970s that aimed to replace some of the work done under contract. The equivalent figures for aetiology were 8.6% of total budget distribution on contracts and 16.8% on CREGs. With the appointment of Arthur Upton as NCI director, on 29 July 1977, all this was about to change. The NCI underwent a major reorganisation in 1978 in which Upton sought to separate programme management from grant and contract administration, and from the peer review of grants and contracts. Resources were diverted to fund more investigator-initiated grants, and heads of internal NCI research programmes were banned from wielding direct control over how funds were to be awarded to extramural investigators. Such developments limited the autonomy of the DNCP, which would have less independence than formally.Footnote87
To complicate matters further, with the NCI in limbo searching for a new director before Upton’s appointment, the Director of the NIH, Donald Frederickson, attempted to reassert NIH authority over the NCI, lost after the 1971 Act, when the director of NCI had been made a direct Presidential appointee. (Before 1971, the director of NCI, like other directors at the NIH, had operated under authority delegated to him by the Surgeon General.) Part of the problem for Gori was that in 1975 the NIH established its own Nutrition Coordinating Committee (NCC).Footnote88 Gori was a member of this committee, but he came to suspect that NIH was not particularly sympathetic to the difficulties faced by the NCI’s programme, since the NCC allowed the NIH to assert authority over the DNCP by integrating it into an overall set of NIH priorities in nutrition.Footnote89 Things did not get much better for Gori with the appointment of Upton. While Upton was able to reassert NCI’s independence of NIH, he fired Gori’s boss at the DCCP, James Peters, and replaced him with an acting director, Gregory O’Conor, who eventually became director in April 1978.Footnote90 Gori remained deputy director of DCCP, but rumours circulated that O’Conor wanted to choose his own deputy.Footnote91
McGovernGori’s position in the NCI might have weakened, but he retained support in Congress, notably from Senator George McGovern (D-SD) who chaired a select committee on Nutrition and Human Needs.Footnote92 Originally created in July 1968 to lead the ‘war’ against hunger among the nation’s young, old and poor, the committee later broadened its focus to include more controversial areas of food policy such as the role of diet in promoting chronic and degenerative diseases, including cancer. In 1976 the committee began a series of hearings, labelled ‘Diet Related to Killer Diseases’, which Gori allegedly shocked when he told it in August 1976 that diet might be related to more than half of all cancers in women and one-third of all cancers in men.Footnote93 (He and Wynder published revised figures the following year, suggesting that about 60% of cancers in women and 40% in men might be diet related.Footnote94) In 1977 the Committee released six dietary goals for the Nation: to increase carbohydrate consumption, and reduce the consumption of fat, saturated fat, cholesterol, sugar and salt. Briefly put, the committee sought to encourage people to eat more fruit, vegetables, whole grains, poultry and fish; to reduce their consumption of meat, eggs and foods high in fat, butterfat, sugar and salt; and to abandon whole milk in favour of non-fat milk. The report received a mixed reception from dieticians and nutrition scientists. Protests by the meat, egg, sugar and dairy industries forced McGovern to issue revised (and to these industries, less draconian) goals later in the year.Footnote95
With the food industry alerted to its activities, in June 1978, the subcommittee on Nutrition undertook hearings into the diet and nutrition programme, under the chairmanship of McGovern, and with the support of the republican senator for Kansas, Bob Dole.Footnote96 Gori did not provide evidence to the committee, but it was clear that it largely backed his position. As McGovern put it, about half of all cancers were linked to nutrition, and yet the NCI only spent about 1% of its funds on diet and cancer research and there appeared to be no prospect of an increase. In his view, the virus programme was not producing the results it promised, and stagnant survival figures for treatment did not support the NCI’s continued emphasis on therapeutic research.Footnote97 Picking up on issues raised by Newsday, members of McGovern’s committee attacked the NCI for conflicts of interest in its review process that worked against nutrition research, and highlighted the neglect of nutrition in the medical schools, including Arthur Upton’s former institution, the State University of New York at Stony Brook. Called before the Committee, Upton was repeatedly put on the defensive, forced to regret the neglect of nutrition in the medical schools and to confess that the NCI had difficulty in knowing exactly how much it spent on nutrition. He also conceded that controls on spending were inadequate, that the NCI did not do enough in the field and that it would seek more for nutrition research.Footnote98
Upton’s difficulties with the McGovern Committee can have done little to endear Gori to the NCI director. Gori’s close connections to McGovern were well-known: he was a regular advisor to McGovern, as well as to Dole and another congressional supporter, the former presidential candidate, Hubert Humphrey. The difficulty for Gori was that these connections were becoming as much a liability as a help. Dole was rising in the Republican Party, but McGovern’s political star was on the wane after the problems of the Nutrition committee’s 1977 report, and Humphrey was dying of cancer.Footnote99
Then, in August 1978, Gori sealed his political fate on a completely separate issue, when he and Cornelius Lynch published an article that sought to quantify ‘less hazardous’ levels of smoking by calculating the number of cigarettes of different brands that could theoretically be smoked without exceeding what they called critical levels for six major toxic smoke components. A report in the Washington Post that Gori and Lynch had identified safe or tolerable cigarettes generated a public storm. The article not only angered his bosses at NCI, but also drew the ire of the Surgeon General, the ACS and the Department of Health, Education, and Welfare (HEW) Secretary Joseph Califano, then in the midst of an anti-smoking campaign.Footnote100 The article was the end of what influence Gori retained at NCI, and by September 1978 he had effectively lost control of all his programmes. Gori remained as DCCP deputy director, but he went to Johns Hopkins University to do a Master of Public Health (MPH) degree, a move widely seen as removing him from significant power within NCI.Footnote101
Thus, after a volatile four years, Gori was gone. With his MPH in hand, he returned to his position as Deputy Director of the DCCP, but without many of his former responsibilities. He left the NCI in 1980, joined the Franklin Institute with a US$400 000 endowment from the Brown and Williamson Tobacco Company, and later worked as a consultant to the company in its legal cases.Footnote102 The DNCP, which had been administered by the Division of Cancer Cause and Prevention, was reorganised and decentralised (Figures 3a and 3b). The DNCP itself was transferred to the Office of the Director of NCI, and programme development was devolved to the divisions under the umbrella of the DNCP.Footnote103 Put another way, the new DNCP would co-ordinate but not direct the nutrition work of the Division of Cancer Treatment (DCT), the DCCP and the Division of Cancer Control and Rehabilitation. This structure was in line with Upton’s broader reorganisational goal of separating programme management from grant and contract administration, and from the peer review of grants and contracts.
Figure 2: NCI offices, divisions and programmes associated with the DNCP, 1974–78
Figure 3: Structure and framework of the Diet, Nutrition and Cancer Programme, 1978. Figures (a) and (b) provide two snapshots of the DNCP structure and framework as it evolved in 1978. Both illustrate the decentralisation of the programme after Newell took over, components of the programme being developed within the three divisions rather than by the DNCP Director. Figure (a) illustrates the structure of the DNCP as it was envisaged by Newell shortly after he took over in 1978, and includes the individuals responsible for the diet and nutrition research within each division, as well as the DCRRC (Division of Cancer Research Resources and Centres), the division responsible for managing NCI grant supported activities, including the review and coordination of programmes such as DNCP. Figure (b), which was published about the same time, provides a slightly different structure, and may be a later iteration, and sets out the research areas of each division and the relation of the DNCP to the NCI director. The absence of the DCRRC should not be taken as indicating that it had no review function in relation to the DNCP. Sources: Figure (a) Guy Newell, ‘Presentation to the National Cancer Advisory Board’, 18 September 1978, NCI archives: item number PB003861. The full names of the directors/officials are Guy R. Newell, Mildred Ellison, Thaddeus J. Domanski, Daniel L. Kisner and Lawrence D. Burke. There is no original paper copy of this document, and the quality of the PDF/photocopy image is very poor. This image has been enhanced for clarity by Hank Grasso. Figure (b) Diet, Nutrition and Cancer Program. Status Report. September 1978 (Bethesda, MD: Diet, Nutrition and Cancer Program, September 1978), 26.
Upton gave the job of programme coordinator to Gori’s nemesis, Guy Newell, who shortly after turned it over to Diane Fink, the head since 1974 of the NCI’s Division of Cancer Control and Rehabilitation. ‘I view my role as one of management rather than direction. The direction will come from within the major NCI Divisions’,Footnote104 Newell noted in September 1978, discussing the role of the ‘director’ within the new decentralised DNCP structure (Figure 3). Newell also announced that whereas in the past much of the research supported by the DNCP had been funded under contracts, in FY 1979 grants would be emphasised as the means of funding research. Contracts would be used for a much more limited range of activities, not generally including research.Footnote105
Prevention and TherapyIn a series of articles written in the 1970s, the Washington Post journalist, Daniel S. Greenberg, attacked the NCI for favouring basic research and cures rather than studies of environmental causes of cancer.Footnote106 Behind such an emphasis, Greenberg detected the hidden hand of the ACS, the major non-profit organisation concerned with cancer. In his view, the ACS (dominated by physicians interested in cancer therapy) exploited its extensive social and business connections to overwhelm a politically timid NCI. The result, according to him, was that most of the NCI’s money went either on therapeutic research or on work on cancer causation that was unlikely to upset any significant political or business constituency, with the possible exception of the tobacco industry. By contrast, studies of environmental carcinogens were politically much more difficult, since many were produced by powerful industrial corporations. The point was particularly significant in the case of diet and nutrition. As evidence mounted about the carcinogenic effects of pesticides, food additives and diets high in meat or certain fats and sugars, the farming and food-processing industries began to become alarmed. Greenberg saw such interests – combined with the low status of nutrition science and elitism within NIH – behind federal neglect of nutrition research.Footnote107 Whatever the truth of Greenberg’s assertions, he was repeatedly able to force the NCI to issue rebuttals to his attacks. In 1977, a world-weary NIH director forwarded one Greenberg article to the NCI director congratulating him ‘on being considered worthy of a despairing sigh by Daniel S. Cassandra’.Footnote108
Greenberg’s analysis would have found many supporters within the DNCP, and it captures and elaborates one of the themes of this essay – the uneasy birth of federal support for cancer prevention in the 1970s. But if this essay is a story of the problems of prevention research, it is also story of the problems of therapeutics. It tells the tale of how growing public criticism of the NCI in the 1960s and 1970s gave diet and nutrition research increasing significance as a means of improving therapy, and so brought advocates of therapy into competition with prevention over scarce resources. As we have seen, therapists were able to persuade the DNCAC that therapeutically related research proposals had stronger scientific merit, were more likely to produce results and quickly, and were more likely to appease the programme’s supporters in Congress. Even Gori – an advocate of prevention – came to acknowledge the political calculation that prevention research was unlikely to provide the sorts of results that would satisfy Congress, especially as it also risked aggravating allies of the food industry on Capitol Hill. The mere threat that the industry’s powerful supporters could cause problems for a field already struggling to satisfy Congress was enough to make prevention research seem a risky political venture.
The DNCP can, therefore, be seen, in part, as a microcosm of broader tensions within the NCI between therapeutics and prevention over funding priorities. But, if its early history is a story of the tensions between the two, its later history is a story of an emergent (albeit temporary and uneasy) alliance between prevention and therapeutics, as from the mid-1970s the DNCP came into competition for funds with larger NCI programmes, notably the Special Virus Cancer Programme and the Comprehensive Cancer Centres. In some ways, this competition exacerbated tensions between therapy and prevention on the DNCAC, for it was advocates of prevention who figured most prominently in the political and media campaigns to save the DNCP, and much of their criticism was directed at the therapeutic orientation of the NCI. Yet, I suggest, it also brought the two sides of the DNCAC together to fight the common threat to their programme. Advocates of prevention saw political benefits in allying themselves with therapists (given the latter’s political clout within the NCI and on Capitol Hill), while therapists also saw political benefits in allying themselves with advocates of prevention (given the strong sympathy for prevention within Congress and in certain sections of the media).
As the debate on diet and nutrition intensified in 1977, strains between prevention and therapeutics grew. The temptation to jump ship, however, was briefly held in check as all sides of the DNCAC waited to see how events would play themselves out. The move to go over the heads of the NCI and appeal to President Carter resulted in no (public) criticism from any member of the DNCAC, advocate of therapy or prevention. Privately, some may have disagreed with this move, but Newell’s response – the cutting of Gori’s committees – seems to have temporarily sealed an uneasy union, since it ended any opportunity for anyone to use the DNCAC to promote their agendas, and opened the possibility of all having to compete against other investigator-initiated proposals rather than determine policy behind committee doors.Footnote109 The union ended with Gori’s removal, and probably more importantly Upton’s reorganisation of NCI and the DNCP in 1978, which meant that the actual direction of research shifted to the division responsible for administering that part of the programme (Figure 3). The reorganisation was presented as a means of broadening the scope of the programme, and of integrating all diet and nutrition elements of the national cancer programme. It also gave sectional interests a greater level of autonomy, however, and reduced administrators’ ability to shape the programme, especially with the shift from contracts to investigator-initiated grants. The sorts of political alliance that had held under Gori’s tenure began to break up and new ones to form.
The story of the DNCP is thus a tale of shifting alliances and co-evolving relations between cancer therapy and prevention. Its emergence began with parental concerns about their sick children expressed though the Candlelighters, one of a new breed of single-issue health advocacy groups that emerged in the 1960s and 1970s pressuring Congress to redirect NCI spending to areas of their interest.Footnote110 It was also facilitated by a growing political interest in environmentalist critiques of medicine in the 1960s and 1970s, and Congressional concern about the neglect of nutrition in the medical schools, the role of diet and nutrition in the onset of chronic disease, and the NCI’s focus on therapeutics and basic (virus) research. But Congress was often a divided house, subject to conflicting lobbies from commercial, biomedical, patients’ and other advocacy groups, and these divisions were exploited within the NCI to direct funding one way or another – as when supporters of therapeutics persuaded the DNCP that it would be politically worthwhile directing more resources to therapeutics at the expense of aetiology, or when the political calculations changed in 1977 and therapists came to support advocates of prevention to save the DNCP from outside predations. The history of the DNCP was thus the product of struggles and negotiations between numerous often conflicting groups and individuals, distributed across many institutions (governmental and voluntary), all seeking to promote their own interests and agendas.
Such struggles were exacerbated by Gori who emerged as a polarising figure in the fights over the DNCP. The NCI was an organisation sensitive to public criticism, in which budgetary decisions were often fought out behind closed doors, with public displays of consensus masking internal conflict. This is not to say that it was not possible to make discontent public, but it was often done discreetly, perhaps through third parties and anonymous leaks, and always in ways that did not embarrass those higher up the organisational hierarchy upon whom subordinates depended for support. By the mid-1970s, Gori had abandoned such discretion, and so opened himself to attacks from powerful groups and individuals within the NCI, public expressions of discontent being especially dangerous to smaller, weaker groups within the organisation, and those who worked within them. It could be argued that the DNCP would have suffered cuts in the mid-1970s no matter who was chief. Gori’s strategy, personality and simultaneous involvement in controversies over tobacco, however, ensured a more spectacular conclusion to his directorship than others might have achieved. As one report put it euphemistically he was ‘one of NCI’s less inhibited infighters at budget distribution time’.Footnote111
Gori’s problems thus provide an insight into the patronage system within the NCI.Footnote112 The agency in the 1970s often presented itself as a meritocracy in which the route to success on the Bethesda campus of the NIH was research or administrative excellence. But, if the NCI was a meritocracy, it was also a hierarchical organisation that revolved around networks of patronage. The Institute was a warren of fiefdoms headed by the NCI director (from 1971, a Presidential appointee), who presided over subordinate directors, who in turn presided over more minor officials. Each director and subordinate supported individuals and groups within his or her section of the organisation, which might also be subdivided into further sub-sections, headed by subordinate subordinates, all of whom offered patronage to those under them and (at least public) support and loyalty to those above. Thus a key to advancing a career within the NCI could involve finding powerful patrons and keeping them on board as supporters. These patrons might act as mentors and advisors, and could shield less powerful individuals from political harm. Equally, a patron could leave a subordinate vulnerable if the latter did not live up to expectations, the politics got too hot, the patron was negligent of support or moved on elsewhere. In all such circumstances a previously sheltered subordinate could suddenly feel chill winds.
Gori fell afoul of such shifts. Starting under the wing of his director/patron James Peters, he found himself isolated and vulnerable after Peters’ left, with rumours that his new boss wanted someone else in his place. As economic circumstances changed in the mid-1970s, Gori found himself constantly struggling against the NCI hierarchy for more funds, and loosing support, especially after he tried to circumvent his seniors within the NCI by appealing to their political masters. This, and the political miscalculation of his involvement in the smoking debate, left him vulnerable and without support from powerful individuals within the organisation, and he lost control of the DNCP, and eventually had to leave the NCI. This did not end the programme, but it allowed it to be split along pre-existing lines of tension, which ensured that therapeutic and preventive research on diet, nutrition and cancer were carried out relatively autonomously under separate parts of the NCI, albeit still under the umbrella of the DNCP.
Subsequent NCI leaders would distance themselves from Gori, and some erased him from historical accounts of the programme.Footnote113 But, it is also arguable that his willingness to go public maintained pressure on the NCI to improve what in 1978 one staff member on McGovern’s Senate Committee on Nutrition and Human needs called ‘the abysmal nutrition research effort by the NCI’.Footnote114 Gori might have gone, but he had set the stage for NCI interest in diet and nutrition research in the 1970s and especially the 1980s, as it sought to address an emergent scientific consensus that diet and nutrition were the major preventable causes of cancer after smoking.Footnote115
References
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84Quotation in Ad Hoc Committee for the Review of the Special Virus Cancer Program (Zinder Committee), 5 March 1973, p. 29, NCI archives: item number AR-7300-001108. The Special Virus Cancer Programme was one the largest contract programmes in the NCI, and the subject of special criticism from biomedical scientists, see Nicholas Wade, ‘Special Virus Cancer Program: Travails of a Biological Moon shot’, Science, 174 (1971), 1306–11. More generally see Doogab Yi’s book manuscript, op. cit. (note 71). For criticism focused on another of Gori’s programmes, see R. Jeffrey Smith, ‘NCI Bioassays Yield a Trail of Blunders’, Science, 204 (22 June 1979), 1287–92. For more general critiques of contract mechanisms see ‘Review of National Cancer Institute Contracting Operations Performed by the Office of the Inspector General’, 1 May 1978, NCI archives: item number AR010082 and A. Lynn Bryant, Fred J. Svec, Delmar W. Brim, Paul W. Wagner, Robert M. Namovicz, Paul H. Schaffer and Kim Horgan, A Management Review of the National Cancer Institute’s Research Contracts Branch Operations (US Army Management Engineering Training Agency and the Management Policy Branch, National Cancer Institute, February 1978), NCI archives: item number AR-7802-010713. See also United States Congress Senate Committee on Labor and Human Resources, National Cancer Institute Contracting and Procurement Procedures, 1981: Hearing before the Committee on Labor and Human Resources, United States Senate, Ninety-seventh Congress, First Session, on Examination of the National Cancer Institute Contracting and Grant procedures, June 2, 1981 (Washington, DC: US Government Printing Office, 1981). For an internal history of contracting within the NCI see Vincent T. DeVita Jr., David M. Keefer, Louis M. Carrese, Bayard H. Morrison III and J. Paul Van Nevel, The National Cancer Institute Contracting Process, NIH Publication No. 82-2425 (US Department of Health and Human Services, Public Health Service, National Institutes of Health, Reprinted September 1982).Google Scholar
85National Cancer Institute, Division of Cancer Cause and Prevention, Annual Program Review Document Fiscal Year 1974, Prepared for the National Cancer Advisory Board Meeting of 7–9 October 1974, p. 4, NCI archives: item number AR-7410-010825.Google Scholar
86‘Gori Goes to Hopkins Part-time, Will Retain Job as DCCP Deputy’, The Cancer Letter, 4, 35 (1 September 1978), 4. For problems over the mechanism of funding – contract, grants or cancer research emphasis grants (CREGS) (the latter being grants intended to shift money from contract support to investigator initiated research) – see ‘Diet, Nutrition Committee to Select Projects for $6 million in Contracts’, The Cancer Letter, 2, 2 (9 January 1976), 6; ‘Nutrition RFPs to be so Flexible They’ll Really be Grants, Gori Says’, The Cancer Letter, 2, 4 (23 January 1976), 5–6; ‘Diet, Nutrition Program to Fund Projects with Program Grants’, The Cancer Letter, 2, 8 (20 February 1976), 8; ‘Diet Grant Guidelines Available; NIH Says They’re CREGs, Gori Says Not’, The Cancer Letter, 2, 15 (9 April 1976), 4–6; ‘De-emphasis of Traditional Grants Still Haunts some; Recent NCI Actions Held Up as Evidence’, The Cancer Letter, 2, 21 (21 May 1976), 1–2: 2; ‘Lawsuit Could Delay Diet-Nutrition CREGS’, The Cancer Letter, 2, 25 (18 June 1976), 1. For further problems, see also ‘Three Diet/Nutrition RFPs Withdrawn Due to “Vagueness”; To Be Rewritten’, The Cancer Letter, 3, 27 (8 July 1977), 4; see also Carl G. Baker, ‘Cancer Research Program Strategy and Planning-The Use of Contracts for Program Implementation’, Journal of the National Cancer Institute, 59, 2 (supplement), (August 1977), 651–669. For a defence of contracts, see Frank J. Rauscher, ‘Budget and the National Cancer Program’, Science, 184 (1974), 871–5; DeVita et al., op. cit. (note 84), VI-11. More generally on peer review at the NIH, see Richard Mandel, A Half Century of Peer Review, 1946–1996, (Bethesda, MA: Division of Research Grants, National Institutes of Health, 1996). For the various review committees of the DNCP see Diet, Nutrition and Cancer Program, Status Report, op. cit. (note 68), A1-18.Google Scholar
87Diet, Nutrition and Cancer Program, Status Report, op. cit. (note 68), 14–16. On CREG’s see ‘Cancer Research Emphasis Grants (CREG) Offered as a New Way to Fund Contract Research Efforts’, The Cancer Letter, 1, 42 (22 November 1974), 1–4; ‘Upton says NCI Division Directors Won’t Control Their Grants Budgets,’ The Cancer Letter, 4, 8 (24 February 1978), 6; National Cancer Institute, Office of the Director, Annual Report, 1 October 1977–30 September1978, Part I, 30 September 1978, NCI archives, item number PB034866; Arthur C. Upton, ‘Reorganization: Division of Cancer Cause and Prevention – Revised’, 19 July 1978, NCI archives: item number AR010422; Arthur C. Upton, ‘Reorganization of the Division of Cancer Treatment’, 21 June 1978, NCI archives: item number AR010435; Arthur C. Upton, ‘Reorganization – Division of Cancer Biology and Diagnosis’, 15 May 1978, NCI archives: item number AR010419; Arthur C. Upton, ‘Reorganization – Division of Cancer Control and Rehabilitation’, 28 August 1978, NCI archives: item number AR010404.Google Scholar
88Minutes of the NCC are available in NIH Director’s Files, Executive Secretariat, Office of the Director, NIH, file location, COMM 2-13.Google Scholar
89Gori interview, 6 November 2003, op. cit. (note 31). For a brief account of the NCC see ‘Statement of the Candlelighters’, op. cit. (note 26).Google Scholar
90‘O’Conor Named DCCP Director, Says He’ll Push Development of NCI’s Efforts in Epidemiology’, The Cancer Letter, 4, 17 (28 April 1978), 1–3.Google Scholar
91‘Gori Goes to Hopkins’, op. cit. (note 86).Google Scholar
92On the McGovern Committee see Marion Nestle, Food Politics. How the Food Industry Influences Nutrition and Health (Berkeley: University of California Press, 2002), ch. 1; and Gerald Oppenheimer and I. Daniel Benrubi, ‘Food Fight: The McGovern Senate Select Committee on Nutrition and Human Needs and the Meat Industry’s Battle over the Diet-Heart Question, 1976–1977’, paper presented to the 84th Annual Meeting of the American Association for the History of Medicine, 28 April–1 May, 2011, Philadelphia.Google Scholar
93‘One-Third to One-Half of All Cancer Related to Diet, Gori Tells Senate’, The Cancer Letter, 2, 32 (6 August 1976), 3. A typescript of Gori’s 28 July 1976 statement to the select committee is available in ‘Statement by Gio B. Gori’, op. cit. (note 37) and in the George S. McGovern Papers, Mudd Library, Princeton University, Box 628. See also Gio B. Gori to George McGovern, date stamped 20 August 1976, and George McGovern memorandum to the President, 1976, both in George S. McGovern Papers, Mudd Library, Princeton University, Box 628. For other NCI documentation on the McGovern Committee see ‘1978 McGovern Committee Questions and Answers on Nutrition Research’, NCI archives: item number DC010295.Google Scholar
94Wynder, Ernst L. and Gori, Gio B. , ‘Contribution of the Environment to Cancer Incidence: An Epidemiologic Exercise’, Journal of the National Cancer Institute, 58 (1977), 825–832.CrossRefGoogle Scholar
95Oppenheimer and Benrubi, op. cit. (note 92).Google Scholar
96Nutrition and Cancer Research, op. cit. (note 41).Google Scholar
97Nutrition and Cancer Research, op. cit. (note 41), 1–2.Google Scholar
98‘Upton Responds to McGovern Blast, Says NCI to Seek more Nutrition Research’, The Cancer Letter, 4, 25 (23 June 1978), 5–7.Google Scholar
99Solberg, Carl , Hubert Humphrey: A Biography (New York: Norton, 1984; Bruce Miroff, The Liberals’ Moment: The McGovern Insurgency and the Identity Crisis of the Democratic Party (Lawrence: University Press of Kansas, 2009); Jake H. Thompson, Bob Dole: The Republicans’ Man for all Seasons (New York: D.I. Fine Books, 1996).Google Scholar
100‘Gori Gets into Another Controversy’, op. cit. (note 82). For accounts of Gori’s and NCI’s work with the ‘safe cigarette’ see Mark Parascandola, ‘Lessons from the History of Tobacco Harm Reduction: The National Cancer Institute’s Smoking and Health Program and the “Less Hazardous Cigarette” ’, Nicotine and Tobacco Research, 7 (2005), 779–89; Mark Parascandola, ‘Science, Industry, and Tobacco Harm Reduction: A Case Study of Tobacco Industry Scientists’ Involvement in the National Cancer Institute’s Smoking and Health Program, 1964–1980’, Public Health Reports, 120 (2005), 338–49; Amy Fairchild and James Colgrove, ‘Out of the Ashes: The Life, Death, and Rebirth of the “Safer” Cigarette in the United States’, American Journal of Public Health, 94 (2004), 192–204. On Califano see Joseph A. Califano, Jr., Inside: A Public and Private Life (New York: Public Affairs, 2004).Google Scholar
101‘Gori Goes to Hopkins’, op. cit. (note 86). See also Parascandola, ‘Lessons from the History’, ibid. For O’Conor’s report on Gori’s move to Johns Hopkins see his response to a congressional enquiry from the office of Representative Lawrence H. Fountain (D-North Carolina), G.T. O’Conor memo, ‘Congressional Inquiry Received and Answered By Phone’, 19 September 1978, NCI archives: item number DC 003096.Google Scholar
102‘Gio Gori Accepts Franklin’, op. cit. (note 31). ‘Controversial Scientist Considers Leaving NCI’, Science, 208, 4440 (11 April 1980), 156.Google Scholar
103The Division of Cancer Treatment, for example, took over treatment-related projects under the umbrella of the DNCP ‘DCT Board Approves New Contract Projects, Rejects Nutrition Proposal’, The Cancer Letter, 4, 43 (27 October 1978), 3–7; Diane J. Fink, ‘Presentation on the Diet, Nutrition and Cancer Program’, (n.d) (c. 1980), NCI archives: item number AR-8000-008051.Google Scholar
104Newell, ‘Presentation to the National Cancer Advisory Board’, op. cit. (note 31), 2. Emphasis in the original..Google Scholar
105Diet, Nutrition and Cancer Program. Status Report, op. cit. (note 23), 37. Contracts were generally intended to fund support services, data acquisition, management of workshops and conferences, and, in some instances, special programmes such as the group of nutritional status reports then being initiated; Guy R. Newell, ‘Future Directions for NCI’s Diet, Nutrition and Cancer Program’, NCI archives: item number AR008211. For later DNCP developments see ‘Nutrition May Get an Extra $4 Million in FY 1979; Program Announcement Describes Opportunities’, The Cancer Letter, 4, 38 (22 September 1978), 1–6. See also United States Congress Senate Committee on Agriculture, Nutrition, and Forestry, Subcommittee on Nutrition, Diet and Cancer Relationship: Hearing before the Subcommittee on Nutrition of the Committee on Agriculture, Nutrition, and Forestry, United States Senate, Ninety-sixth Congress, First Session on Diet and Cancer Research at the National Cancer Institute, Clinical Nutrition Research at the National Institutes of Health, and Problems with the Peer Review System at NIH, October 2, 1979 (Washington, DC: US Government Printing Office, 1980).Google Scholar
106Daniel S. Greenberg and Judith E. Randal, ‘Waging the Wrong War on Cancer’, Washington Post Outlook (1 May 1977) C1 & C4; Daniel S. Greenberg, ‘ “New Broom” at the Cancer Institute’, New England Journal of Medicine, 297, 12 (22 September 1977), 679–80; Daniel S. Greenberg, ‘Cancer: Now, the Bad News’, Washington Post Outlook (19 January 1975), CI and C4; see also Daniel S. Greenberg, The Politics of Pure Science (New York: New American Library, 1968). For a critical response to Greenberg see William S. Gray, ‘The Data…Tell Only Part of the Story’, Washington Post Outlook (19 January 1975) C4. For another report critical of the war on cancer see Robert Houston and Gary Null, ‘We are Losing the War against Cancer. A Long Day’s Dying’, Our Town(New York), 9, 26 (29 October–4 November, 1978), 6, 11, 25. Our Town was a local paper, not normally of wide circulation, but one correspondent, writing to alert the NCI and NIH of Houston and Null’s piece, noted: ‘This article received wide attention here because during the newspaper strike, literally everyone read this paper and similar ones that are normally neglected.’ Alton Meister (Department of Biochemistry, Cornell University Medical College) to Alan S. Rabson (Associate Director, Intramural Research, NCI), 7 November 1978, NCI archives: item number PB-004512.Google Scholar
107Daniel S. Greenberg, ‘Nutrition, Stepchild of the Medical Sciences’, Washington Post (23 May 1978), reprinted in Nutrition and Cancer Research, op. cit. (note 41), 80–1.Google Scholar
108Donald S. Frederickson, to Director NCI, 30 September 1977, NCI archives: item number AR-7709-009041. Ironically, Frederickson misused the myth of Cassandra. Her prophesies were true and accurate fore-tellings of the future: her curse was that no one believed her. For a rebuttal to Greenberg see ‘Rauscher Responds to Cancer Program Criticism Based on Survival Figures’, The Cancer Letter, 1, 12 (21 March 1975), 4–5, and Frank J. Rauscher, ‘The National Cancer Program: Now the Good News’, 9 May 1975, NCI archives: item number AR008015.Google Scholar
109Any desires by the therapeutic lobby to jump ship may have been briefly held in check pending the outcome of criticism in 1977 of the clinical trials undertaken by the DNCP. In February 1977 the NIH’s clinical trials committee reviewed evidence that clinical trial designs would fail to provide meaningful statistical results. See Marvin A. Schneiderman memorandum to Robert Gordon, Subject, ‘Clinical Trials’, (18 February 1977), File Location: COMM 2-54, Work Folder: NIH 19423; Melvin S. Fish (Collaborative Programs Procedures Officer) memorandum to Associate Director for Collaborative Research, Subject: Procedural Deficiencies in the Diet, Nutrition and Cancer Program, DCCP, NCI, 9 June 1977, File Location: COMM 2-54, Work Folder: NIH 19433; ‘Memo for the Record. Presentation by Dr. Gio Gori, NCI, of the NCI Clinical Trails on Nutrition and Cancer in Children and Adults’, 30 June 1977, File Location: COMM 2-54, Work Folder: NIH 19436. All in NIH Director’s Files, Executive Secretariat, Office of the Director, NIH.Google Scholar
110On advocacy politics in relation to cancer see Maren Klawiter, ‘Risk, Prevention and the Breast Cancer Continuum: The NCI, the FDA, Health Activism and the Pharmaceutical Industry’, History and Technology, 18 (2002), 309–353; Lerner, Breast Cancer Wars, op. cit. (note 1). More generally see Judith Aliza Hyman Rosenbaum, ‘Whose Bodies? Whose Selves? A History of American Women’s Health Activism, 1968-Present’ (unpublished PhD Thesis: Brown University, 2004). On the longer history of women’s activism in regard to cancer see Kirsten E. Gardner, Early Detection. Women, Cancer, and Awareness Campaigns in the Twentieth-Century United States (Chapel Hill: University of North Carolina Press, 2006).Google Scholar
111‘Newell tells Advisory Committee it isn’t a Lobbying Group’, op. cit. (note 80).Google Scholar
112For a comment on the NIH as an admirable and effective ‘remnant of Renaissance patronage in the practice of modern science’, see J. Michael Bishop, How to Win the Nobel Prize: An Unexpected Life in Science (Cambridge, MA and London: Harvard University Press, 2003), 49.Google Scholar
113Note how Arthur Upton never refers to Gori in his oral history account of NCI diet and nutrition research in the 1970s. ‘NCI Oral History Project. Interview with Arthur C. Upton M.D., June 4, 1997, conducted by Gretchen A Case’, NCI archives: item number AR012235.Google Scholar
114Quotation in Chris [Hitt] memorandum to Senator McGovern, 17 April 1978, George S. McGovern Papers, Mudd Library, Princeton University, Box 622. For other examples of continuing pressure on NCI to improve prevention efforts from Congress see ‘New Jersey Congressman Seeks to Push NCI into Greater Prevention Efforts’, The Cancer Letter, 4, 10 (10 March 1978), 3–5; ‘Cancer Act Renewal Cleared for Early Vote by House; Senate Bill Differs’, The Cancer Letter, 4, 32 (11 August 1978), 3–5; see also ‘NCI Must Play More Vigorous Role in Prevention, Upton Tells ACCC’, The Cancer Letter, 4, 5 (3 February 1978), 4; Gregory O’Conor noted he would include DNCP in a possible Prevention Branch see ‘O’Conor Named’, op. cit. (note 90), 2. Note that while research dollars were expected to drop in 1980, that nutrition research was to be an exception. ‘Research Contract Dollars Will Drop in 1980, But Will Increase Sharply For Some Programs’, The Cancer Letter, 2, 27 (7 July 1978), 1–5.Google Scholar
115Richard Doll and Richard Peto, ‘The Causes of Cancer: Quantitative Estimates of Avoidable Risks of Cancer in the United States Today’, Journal of the National Cancer Institute, 66 (1981), 1192–1308. National Academy of Sciences, Diet, Nutrition and Cancer, Report of Committee of Diet, Nutrition and Cancer, Assembly of Life Sciences, National Research Council, (Washington, DC: National Academy Press, 1982). National Academy of Sciences, Diet, Nutrition and Cancer: Directions for Research, Report of Committee of Diet, Nutrition and Cancer, Assembly of Life Sciences, National Research Council (Washington, DC: National Academy Press, 1983); see Hilgartner, op. cit. (note 8).Google Scholar
David Cantor
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Rights & Permissions[Opens in a new window]AbstractThis paper explores the origins of the Diet, Nutrition and Cancer Programme (DNCP) of the National Cancer Institute (NCI) and its fate under its first director, Gio Batta Gori. The DNCP is used to explore the emergence of federal support for research on diet, nutrition and cancer following the 1971 Cancer Act, the complex relations between cancer prevention and therapeutics in the NCI during the 1970s, the broader politics around diet, nutrition and cancer during that decade, and their relations to Senator George McGovern’s select committee on Nutrition and Human Needs. It also provides a window onto the debates and struggles over whether NCI research should be funded by contracts or grants, the nature of the patronage system within the federal cancer research agency, how a director, Gio Gori, lost patronage within that system and how a tightening of the budget for cancer research in the mid-to-late 1970s affected the DNCP.
KeywordsUS National Cancer InstituteDietNutrition and CancerCancer Prevention and TherapySelect Committee on Nutrition and Human Needs (McGovern Committee)the CandlelightersGio GoriTypeArticlesInformationMedical History , Volume 56 , Issue 4 , October 2012 , pp. 531 - 561DOI: https://doi.org/10.1017/mdh.2012.73[Opens in a new window]Copyright© The Author 2012 Published by Cambridge University Press. This is a work of the US Government and is not subject to copyright protection in the United States.This is a work of the US Government and is not subject to copyright protection in the United States.The few turbulent years that Gio Batta Gori headed the National Cancer Institute’s Diet, Nutrition and Cancer Programme (NCI DNCP) started with high expectations of a new beginning for cancer prevention. After years of neglect, it seemed that the federal agency would take advantage of new opportunities to build on a growing body of epidemiological and experimental work that implicated diet and nutrition as causes of this group of diseases. The programme began in 1974 amid a flurry of new initiatives in cancer prevention and control. However, by 1977 it was in crisis, and in 1978 Gori left under a cloud. The DNCP might have begun with great expectations of a new beginning for cancer prevention, but these expectations were frustrated by the time that Gori left.
The story of the DNCP is often told within the NCI as part of a broader narrative of the difficult birth of federal support for cancer prevention. In this account, the NCI’s interest in cancer control initially focused on early detection and treatment.Footnote1 Less attention focused on prevention – or, more specifically, what came to be known as ‘primary prevention’Footnote2 – with the exception from the 1950s of smoking and tobacco. Then, in the late 1960s and 1970s this began to change. Researchers associated a growing number of occupational, environmental and lifestyle factors with cancer, and Congress and advocacy groups pressured a sometimes-reluctant NCI to devote more resources to aetiology and primary prevention (hereafter just ‘prevention’).Footnote3 Federal support for diet and nutrition emerged with this new interest in prevention.
Prevention is only part of the story of the DNCP, however, and at times not even the main one. Its origins began with the problems of parents trying to feed their leukaemic children, and much of its funding went not on prevention, but on studies of the role of diet and nutrition in cancer therapy. Indeed, the early history of the DNCP is a microcosm of a broader struggle over research priorities in which physicians and scientists aggressively defended therapeutically related research against demands that more resources go to prevention. Such struggles, I suggest, were exacerbated by anxieties from the food and farming industries that the NCI’s interest in diet and nutrition in cancer causation might add to pressure to reduce consumption of their products on health grounds. None of this succeeded in ending prevention-related research, but it did ensure that advocates of prevention were thwarted in their more ambitious expectations of the DNCP, especially as the NCI’s budget began to tighten in the mid-1970s, and the DNCP found itself struggling against bigger, more established programmes, at the heart of NCI policy, and ever hungry for more money. The story of the DNCP is thus a tale of what happened to a marginal programme when funding got scarce, and when entrenched interests came to be threatened.
This paper has three aims. The first is to use the DNCP as a window onto the growth of federal support for research on diet, nutrition and cancer following the 1971 Cancer Act, the legislative beginning of what was sometimes known as the War on Cancer. This programme and the broader field of diet, nutrition and cancer research are largely neglected in the voluminous literature on the 1971 Act and its aftermath.Footnote4 Nor do the general historiographies of either diet and nutrition or cancer therapeutics and prevention in the 1970s give them much attention.Footnote5 In the case of cancer therapy, the best we have are a few internal accounts of technical developments in the nutrition of cancer patients and some comments on continued anxieties over diet as a form of ‘quack’ treatment.Footnote6 In the case of prevention, diet and nutrition are – with two exceptions – largely subordinated to accounts of smoking and occupational and environmental cancers. One exception is a literature on additives and hormones such as diethylstilbestrol (DES) which were not the focus of the DNCP for reasons discussed below.Footnote7 The other exception is a literature on the growing interest in diet, nutrition and cancer in the 1980s, but this last literature largely skips over the 1970s.Footnote8 Part of the historiographic intent of this paper is to recover the missing decade of the 1970s: to explain why interest in diet, nutrition and cancer emerged during that decade, to document the range of interest in this field (beyond additives and hormones), to explore how the NCI responded to this interest and to describe why its early efforts foundered. The paper ends in 1978 when the DNCP’s first director left, and prevention and therapy separated within the programme.
The second aim of this paper is to explore the problematic relations between therapeutics and prevention within the DNCP in the 1970s. It is well known that the NCI was widely criticised during that decade for favouring therapeutics over prevention.Footnote9 Much of the substantial historiography on this topic, however, is written from a prevention perspective in which arguments in favour of therapy tend to be portrayed as little more than barriers to prevention’s advancement. One of the goals of this paper is to recover the perspectives not only of those who advocated prevention, but also of those who advocated therapeutic research, and to show how each related to the other. The DNCP provides a valuable opportunity to explore this intertwined story. Both sides saw the programme as an opportunity to advance their research objectives, but there was never enough money to support all their proposals, and they became competitors for a limited funding pool. Yet, paradoxically, if they were competitors they were also uneasy allies. The DNCP’s marginal status within the NCI meant that the two sides were bound together in a fraught relationship as partners in preserving the programme as a whole against external threats. It was a difficult position for each. Both were forced to weigh their common interests in protecting the programme against their competing interests in securing funding from a small DNCP budget.
A third aim of the paper is to use the DNCP as a window on to the broader politics around diet, nutrition and cancer in the 1970s. The DNCP is a story of how a range of external stakeholders – with different, sometimes conflicting, interests and agendas – sought to shape NCI policy in this area. Thus, where some advocacy groups pressured Congress and the NCI for more funding for prevention, other stakeholders, such as the meat industry, worried that DNCP research might highlight public health issues that would undermine the commercial value of their products. Congress itself was divided, sometimes more willing to privilege the voices of advocates of therapeutics, sometimes those of prevention. And, within the NCI, advocates of prevention and therapeutics played up these divisions to argue political cases for their various positions, often backed up with data that they hoped would support more research in their fields and highlight the limitations of research favoured by their opponents.
This then is a story about how the fate of the programme in the 1970s was determined by the political struggles between various stakeholders, both within and without the NCI. It is also a story of how these struggles were complicated, on the one hand, by broader efforts by the NCI leadership to reform and restructure the organisation in the mid-to-late 1970s and, on the other hand, by Gio Gori, the director of the programme. Gori’s controversial efforts from 1977 to counter the DNCP’s budgetary problems, combined with his simultaneous involvement in disputes around smoking, succeeded in alienating powerful figures within the NCI. The DNCP director found himself in a hostile institutional environment, politically exposed and without allies having lost the support of former patrons during the reorganisation of the mid-to-late 1970s. Gori was eventually compelled to give up directorship of the DNCP, and his political problems helped set the stage for the growing institutional separation of therapeutics and prevention within the programme.
1974–77The beginnings of the DNCP can be traced to one of the therapeutic ‘success’ stories of the post-war years – childhood cancer.Footnote10 Where once a diagnosis of leukaemia had meant the death of the child, by the late 1960s and 1970s the situation was very different. Mortality from childhood leukaemia fell, children survived the disease longer and a new set of problems emerged around their long-term care. Among these problems diet and nutrition figured large. Parents found their leukaemic offspring often unable or unwilling to eat, fluctuating from skeletal to obese during the course of treatment, and their physicians often seemed at a loss to help. By the 1970s, a number of parents’ support groups had formed. One of these – the Candlelighters, based in Washington, DCFootnote11 – was to set in motion the events that led to the creation of the DNCP.
The Candlelighters was the inspiration of Grace Ann Monaco (also known as Grace Powers Monaco), a young attorney in Washington, DC.Footnote12 In 1968 her daughter, Kathleen Rea, was diagnosed with acute lymphoblastic leukaemia and began treatment at Children’s National Medical Center. There Monaco met parents of other children undergoing treatment, and – encouraged by the paediatrician Sanford Leiken and other physicians and nurses at Children’sFootnote13 – together they formed a support group for parents of children with cancer. Monaco later recalled: ‘About 25 of us started meeting wherever we could find space – boiler rooms, corridors outside the emergency room – and Candlelighters was born.’Footnote14 The parents lobbied Congress on issues such as better access to paediatric clinical trials, the establishment of a national comprehensive cancer registry for childhood and adolescent cancers, and outreach programmes for the demonstration of successful methods of treating those cancers.Footnote15 The organisation also gained a reputation for its support of greater federal involvement in research, and for its ability to present practical suggestions on how this might be achieved in Congress.Footnote16 One of the founding members, Richard (Dick) Sullivan, was a congressional staffer, which facilitated access to legislators. Sullivan’s daughter had a neuroblastoma and died in 1970, the same year as Kathleen Rea. The Candlelighters’ ‘birth’ – also in 1970 – came out of these personal tragedies.
The Candlelighters expanded beyond the Washington area. ‘Our traveling members really got the ball rolling’, Monaco later noted of members who visited children’s hospitals across the country.Footnote17 ‘We talked about the importance of parent-peer support and networked with parents across the US and Canada.’ To build and maintain their network, Monaco and Julie Sullivan, Dick’s wife, founded a newsletter in 1970, written with the help of other parents, and printed on the House of Representatives’ mimeograph machine. The number of local Candlelighters groups jumped from perhaps three in the early 1970s to over 100 by the end of the decade, in 42 states, and in Europe and Canada.Footnote18 By then the organisation had also developed what it called the Childhood Cancer Ombudsman Programme that used panels of volunteer doctors and lawyers to give free opinions on issues such as treatment choices, informed consent, employment discrimination against parents, educational discrimination, access to military service and barriers to insurance. In 1976, the Candlelighters created a Foundation to promote self-help groups, to improve communications between parents and parents’ groups, and to enhance the quality of information available to parents of children with cancer.Footnote19
The poor quality of information available to parents had been a concern of the Candlelighters long before the establishment of the Foundation.Footnote20 During debates over extending the 1971 National Cancer Programme, the organisation persuaded the House Sub-Committee on Health and the Environment headed by Paul Rogers (D-Fla) to write into the section of the bill authorising NCI information programmes a statement that such programmes should include ‘information respecting nutrition programs for cancer patients and the relationship between nutrition and cancer’. It was this proposed authorisation that marks the beginning of the Diet, Nutrition and Cancer Programme. At some point in the Congressional deliberations the terms of the authorisation expanded, and under the National Cancer Amendment enacted 23 July 1974 (P.L. 93-352) Congress ordered the NCI to increase its support for research into the role of nutrition in both the cause and treatment of cancer.Footnote21 By November 1974, the first plans for what would become the DNCP were set out, and the programme was launched the following year.Footnote22
The Diet, Nutrition and Cancer ProgrammeThe DNCP might have started as an appeal for more nutritional information from parents trying to feed their sick children, but it had turned into much more. In 1974, the director of the NCI, Frank J. Rauscher, appointed an internal committee of NCI scientists – the Diet Nutrition and Cancer Coordinating Group (DNCCG) – to define the goals of this programme and to recommend an organisational structure. The DNCCG interpreted the 1974 Cancer Act as calling for a two-pronged programme in diet and nutrition focused on information provision and research, the latter including studies on cancer aetiology and on the treatment, long-term management and rehabilitation of cancer patients. (Hereafter treatment, management and rehabilitation will be abbreviated to therapy.)Footnote23 Towards these ends, the DNCP began a literature survey on diet, nutrition and cancer, and organised two workshops in 1975 – one on diet in cancer therapy,Footnote24 the other on nutrition and cancer causation.Footnote25 These shifts towards therapy and aetiology seem to have had the approval of the Candlelighters, which remained a strong supporter of the programme throughout the 1970s, pressing the NCI to increase nutrition research.Footnote26 In 1979, the NCI fulfilled a debt to the Candlelighters by producing a dietary resource book for parents of children with cancer.Footnote27
Table 1: Gio Batta Gori’s appointments prior to joining NCI. Source: Gio Batta Gori, Resume (June 1968), NCI archives: item number DC-6800-006346.
To get the DNCP going the NCI began by appointing a programme director and an advisory committee. The directorship went to Gio Batta Gori, then deputy director of the NCI’s Division of Cancer Causes and Prevention (DCCP), see Figure 1.Footnote28 Today, Gori is a controversial figure in part because of his subsequent career as a consultant to the tobacco industry, and critics have questioned his scientific and management credentials. Richard Kluger, for example, describes Gori as a ‘journeyman microbiologist’ whose ‘medical training had been at a backwater school, he had no scholarly publications to speak of, and he brought no depth of knowledge on the nuances of cancer’.Footnote29 And Devra Davis adds to Kluger’s criticism. ‘What Gori lacked in scientific pedigrees at the time, he more than made up for in schmoozing ability’, she claims, ‘many of his colleagues found him to be an overdressed bureaucrat with an exaggerated sense of his own importance’.Footnote30 But such evaluations seem to have come in part from critics within the NCI. For others within that organisation, Gori seems to have gained a reputation as an effective administrator.
Figure 1: Gio Batta Gori, c1975. Source: ‘Dr. Gio Gori Becomes Dep. Director of Cancer Cause, Prevention Div.’, The NIH Record, 27, 1 (14 January 1975), 7, courtesy of Rich McManus, editor of The NIH Record.
Born in Tarcento, Italy, Gori had trained in microbiology and botany at the University of Camerino, see Table 1. In 1959/60 he moved to Pittsburgh to work with Jonas Salk on the poliovirus. He returned briefly to Italy to establish a laboratory to produce polio vaccine in Siena, before re-crossing the Atlantic to join Hilary Koprowski, the microbiologist director of the Wistar Institute in Philadelphia. After the Wistar, Gori worked in private industry before joining the NCI in 1968, where he gained a reputation as an efficient manager, someone able to get along with most people. As we shall see, this reputation would be in tatters by the time he left NCI. At least in the beginning, however, it is likely that it was his good managerial reputation, more than his modest scientific accomplishments, that explains why he quickly moved up the administrative ladder. From 1973 to 1980, he was (Acting) Deputy Director of the DCCP, with simultaneous responsibilities as Director of the Smoking and Health Programme (1973–c.78), and Acting (Associate) Director of the Carcinogenesis Programme (1976–77). He was to be Director of the Diet, Nutrition and Cancer Programme from 1975 to c.1978 (Figure 2).Footnote31
The advisory committee met for the first time on 19–20 August 1975. Chaired by the Massachusetts Institute of Technology (MIT) toxicologist, Gerald Wogan, the committee was eventually named the Diet, Nutrition and Cancer Advisory Committee – hereafter the DNCAC or the Advisory Committee (Table 2). According to Gori, the DNCAC was intended to reflect a cross section of scientific expertise in epidemiology, experimental carcinogenesis, animal nutrition, human clinical nutrition, the biochemistry of nutrition and clinical oncology, as well as the federal government, the academic community, industry, the American Cancer Society (ACS) and other interests.Footnote32 Yet from the start there were tensions within it. In part, the issue was the division of power between Gori (as Director of the programme) and the Committee that advised him. The substantive problem, however, was how to divide the US$5000 000 (later US$6000 000) allotted to the programme between research on therapeutics and aetiology. To the dismay of advocates of therapeutics, Gori submitted a plan in which research on aetiology and therapy would each have 45% of the budget of the new programme – the remaining 10% going on general support.Footnote33 (Table 3) It was this plan that marks the beginning of the struggle over research priorities within DNCP, pitting advocates of therapeutically related research against those who promoted prevention and aetiology.
Table 2: Members of the Diet, Nutrition and Cancer Programme Advisory Committee.
Table 3: Gori’s proposed breakdown of the budget for DNCP, August 1975 (% percentage of the total DNCP budget). Source: ‘Nutrition Program Starts to Zero in on Mass of Data, Plan Contract and Grant Project Areas’, The Cancer Letter, 1, 35 (29 August 1975), 1–6: 2–3.
Diet and TherapyAdvocates of therapy argued there were pressing clinical reasons why they needed more resources than Gori proposed. They pointed out that the disease itself could cause malnutrition (through anorexia, hormonal disturbances or by other unknown mechanisms); that the resulting nutritional deficiencies could enhance or retard tumour growth directly, or through their effects on the immune system, or on drug absorption and metabolism; that the frequent presence of acute infection created further nutritional complications by increasing the basic metabolic expenditure by 30–40%; and that nutritional problems could also be caused or aggravated by cancer treatment, sometimes the result of the anorexia, nausea, vomiting and diarrhoea which could follow chemotherapy or radiotherapy, and sometimes the result of depletion by antimetabolite therapy (see Table 4).Footnote34 However, despite numerous reports indicating that dietary factors might play a critical role in cancer treatment, commentators noted that there were few definitive studies on the contribution of diet to the clinical management of cancer. The complexity of the relationships among tumour, host and diet/nutrition made reproducible results difficult to obtain.Footnote35
Table 4: Consequences of cancer treatment predisposing to nutrition problems. Source: Maurice E. Shils, ‘Nutritional Problems Arising from the Treatment of Cancer’, CA. A Cancer Journal for Clinicians, 20 (1970), 188–96: 193.
For many physicians, research into the role of diet and nutrition in cancer had particular urgency because of the anorexia and cachexia associated with the disease. Anorexia was a frequent problem in the treatment of cancer. It could persist for such a long time that the patient lost a huge amount of body weight, became malnourished and was less able to counteract the complicating factors of cancer, or to endure aggressive anti-cancer therapies such as radiation, surgery or chemotherapy. According to one estimate, about two-thirds of those who died of cancer were cachectic at death.Footnote36 In some cases, the anorexia and cachexia seemed to be the result of reduced food intake, either because patients with cancer found it painful to eat or because they found their food to be much less palatable – the disease or its treatments sometimes seemed to affect taste and smell. In other cases, the anorexia or cachexia seemed to have little to do with food intake. Some patients continued to lose weight even when they ate and appeared to assimilate a normal diet, perhaps because the tumour pre-empted available nutrients, or because the host underwent an increased metabolic rate – scientists disagreed on the reason. In addition, some studies showed that food restriction generally inhibited tumour growth, lending support to suggestions that the cachexia might be an adaptive device of the host to starve the tumour. It was, therefore, possible that improving patient food intake would actually accelerate the growth of the tumour, and improve its viability and resistance to therapy.
For the DNCAC, such concerns opened a series of possible research projects, including studies of the nature of host–tumour competition, the causes of impaired food intake, the role of individual nutrients as they related to cancer treatment (including nutrient depletion by therapy) and the activities of enzymes involved in the metabolism of cancer chemotherapeutic agents. The Advisory Committee considered studies on why modified taste perception occurred, and discussed proposals for research to develop means for restoring normal taste patterns, to modify traditional tastes of foods so that they became palatable again and to change patient’s behaviours so that they increased food intake.Footnote37 It also considered research into artificial methods of feeding (for those cases where conventional feeding was impossible) to improve the formulation of nutrient solutions, to reduce costs, to improve hardware, to reduce the chance of sepsis and to devise low-cost, mass-produced portable infusion units for ambulatory patients. The latter research was of particular interest to two members of the DNCAC, Jonathan Rhoads and Stanley Dudrick. In 1968, they had developed a technique of total parenteral nutrition (TNP) that became a standard American technique for providing patients with long-term nutritional support.Footnote38
A final problem focused on the question of whether nutrition could be used as a direct form of cancer therapy. The recognition that the nutritional requirements of many tumours were quite different to those of the host – the patient – opened the prospect of adjusting available nutrients so as to starve the tumour while feeding the patient.Footnote39 In addition, it was also possible that therapy might be based on the interruption of the cachexia, rather than the inhibition of the tumour, especially in the early stages of tumour growth before frank emaciation set in.Footnote40
So far I have suggested that calls for research into the relations between diet, nutrition and cancer therapy were motivated, in part, by a series of clinical and scientific questions related to the practical problems of cancer therapy. These technical questions were given political urgency by growing public concern in the 1960s and 1970s of poor survival rates for patients undergoing therapy.Footnote41 Despite years of research and millions of dollars, critics argued that survival rates had not significantly improved since the Second World War. For physicians these figures were confirmation of the need for more research into methods of improving cancer therapy, but they also raised a new quandary. Increasingly such figures were also used to argue that cancer research was too focused on therapeutics and basic laboratory studies, and that a fundamental reorientation towards prevention was needed. For therapists, all this gave new importance to research that promised practical methods of improving survival rates. Studies of artificial nutrition, direct nutritional therapy, and the role of diet and nutrition in the host/tumour relationship were particularly promising here, they claimed.
Yet, until the creation of the DNCP, the NCI seemed more focused on other research areas, and there seemed little prospect of change. As Gori noted, nutrition science was often poorly provided for in the medical schools, and tainted with the mark of quackery, not the sort of field that the NCI would generally support.Footnote42 Practitioners interested in nutritional issues – nurses, nutritionists and others – were often low status and without a strong voice on the NCI. The Candlelighters’ initiative had improved the prospects for change and money for a host of new projects seemed a possibility. Yet with all these new possibilities came the unwelcome probability of having to share a small budget with researchers more interested in preventing cancer in the future than in dealing with the urgent needs of desperately ill patients in the 1970s. Whatever their sympathy for prevention, physicians remained focused on their sick patients, and anxious that money might disappear into a seemingly bottomless hole of aetiological research that offered little prospect of reducing cancer incidence or mortality for many years, if ever.
Diet as a Cause of CancerIf advocates of therapeutically related research argued that their needs were pressing, so too did those interested in prevention. During the 1950s and especially the 1960s a growing body of epidemiological and experimental evidence had implicated diet and nutrition as causes of cancer. But – as with therapeutics – advocates of prevention argued that much more research was needed. In their view, the nature of the relationship between diet and nutrition was poorly understood, in part because of the historical neglect of prevention-related research, the technical difficulties of research in this area and the poor status of nutrition as a scientific field. The DNCP offered an opportunity to reverse such neglect at a time when public and Congressional concern about the NCI’s failure to promote prevention was growing. ‘Prevention is the only way we can make a major impact on survival’, commented the epidemiologist, Ernst Wynder, at the first meeting of the DNCAC,Footnote43 ‘As interesting as therapy is, it will not make a major inroad on cancer…[it] has never wiped out a disease’.
Wynder’s was the strongest voice on the DNCAC arguing for more research into the cancer aetiology.Footnote44 Best known for identifying cigarette smoking as a cause of lung cancer, Wynder became convinced that diet was a significant cause of this group of diseases, and that prevention was undervalued by the cancer establishment and often opposed by powerful industrial interests.Footnote45 In 1969 he founded the American Health Foundation, eventually based in Valhalla north of New York City, to research cancer aetiology and prevention, including epidemiological and animal research in nutrition.Footnote46 He told the committee that he thought about half of all cancers were nutrition related. According to Wynder, occupational cancers accounted for about 1% of the total, tobacco for 40% of cancers in males and, as he put it, ‘Most of the rest are related to nutrition’.Footnote47
Wynder’s evidence for this statement derived from epidemiological studies of migrant populations that had blossomed in the 1960s, pioneered in part by NCI statisticians such as William Haenszel. Differences in colon, stomach, breast, kidney and bladder cancer rates between Japan and the US, he argued, had been attributed, to dietary differences.Footnote48 Cancer rates in Puerto Rico were similar to those in Japan, and second-generation Puerto Rican migrants, like Japanese migrants, adopted a US diet and soon experienced cancer rates similar to the rest of the US. Had he wished to, Wynder could also have pointed to other studies – for example, among Polish migrants to the US, and rural migrants to Cali, ColombiaFootnote49 – that showed that cancer incidence patterns of migrants changed from that of their native country/region to that common to the population of their new country/region; a transition often attributed to changes in dietary habits. Other studies of populations with special dietary practices, Wynder noted, showed positive evidence of a dietary relationship to cancer aetiology – Jewish populations in New York, Seventh-Day Adventists in California and the Mormon populations of Utah.Footnote50 In migration studies, diet was difficult to disentangle from other environmental factors. These other studies offered an opportunity to control environmental factors: they focused on populations that lived in the same environment, but differed principally in terms of diet.
Such studies were not the first to link diet and cancer.Footnote51 Yet earlier studies had remarkably little impact on the national cancer campaigns that emerged in the first two decades of the twentieth century. Dominated by physicians and scientists who tended to see cancer as a local cellular disease that subsequently spread to affect other parts of the body, such campaigns tended to focus efforts to control the disease on early detection and treatment.Footnote52 Very little attention was paid to dietary causes of cancer or dietary means of preventing cancer, which were regarded as of unproven value and, like direct nutritional therapy, associated with quackery.Footnote53 The creation of the NCI in 1937 did little to change the picture.Footnote54 The new Institute broadly endorsed the model of early detection and treatment, and tended to share with other cancer control agencies a suspicion of claims that diet caused cancer. The Institute did support a small amount of research on diet and nutrition, notably Albert Tannenbaum’s important studies in the late 1930s and 1940s on the effects of caloric restriction on the development of spontaneous and chemically induced tumours in mice.Footnote55 However, diet and nutrition were never central to its mission. According to Michael Shimkin, its intramural efforts in this area faded after 1950, paradoxically just as Wynder and others elsewhere began to take an interest in the subject.Footnote56 Then, in the 1960s and especially the 1970s, the NCI’s disinterest in diet and nutrition came to be challenged by growing public and political interest in environmental and lifestyle causes of cancer and a growing acceptance within medicine of statistical associations as evidence of causal relations, notably following epidemiological research undertaken in the 1940s that identified cigarette smoking as a cause of lung cancer.Footnote57 Such studies laid a foundation for the reception of studies of migrant and other populations that identified associations between diet and cancer.
This is not to say that the growing interest in environmental and lifestyle factors was unproblematic for the DNCP. As Robert Proctor has noted, much of the interest in environmental cancers in the 1970s focused not on diet and nutrition but on occupational cancers,Footnote58 and where interest did focus on diet it often focused on subjects such as pesticides and additives that were beyond the remit of the DNCP.Footnote59 It has already been noted that Wynder dismissed occupational cancers as a tiny proportion of cancers (1%), and he was similarly dismissive of additives and pesticides. Wynder argued that there were three major dietary factors in relation to cancer: food contaminants (which he regarded as the least important), specific nutritional deficiencies or imbalances, and specific nutritional excesses or imbalances notably in regard to fat and alcohol consumption (which he regarded as the most important). In his view, there was already enough evidence for the committee to advise the public to ‘reduce the total calories, reduce the calories from fat, and reduce the cholesterol intake’.Footnote60
But, if Wynder had hoped for support from the DNCAC, he was to be disappointed. Even supporters of prevention on the committee were not persuaded of his arguments about dietary imbalances. Gori, for example, noted that there was very little scientific evidence as to what constituted a normal human diet, ‘rendering irrelevant talk of dietary excesses and deficiencies’.Footnote61 In his view, it would only be possible to talk about excesses and deficiencies once the normalcy ranges for the human diet were known. This information, Gori claimed, combined with epidemiological studies, dietary surveys and exploratory studies in animals could help define the epidemiological significance and eventually the carcinogenic potential of altered dietary intake in humans. But the range of questions was immense – what was the impact of diet on the hormonal balance, internal secretions, the composition and substrates available to the enteric flora, and the carcinogenic and toxic stimuli that might intervene on cellular and genetic stability, the immune status, the detoxification and reproductive competence of the individual. There were so many unknowns about the relationship between cancer, nutrition and diet, and it was likely to take years to sort out.
It was here that the political weakness of prevention-related research was evident. While Congress was a strong advocate of such research, it was notoriously impatient for results, and spoke with more than one voice, pressing for a cure for the disease as much as (if not more than) it pressed for prevention. Critics of prevention were quick to highlight the point. ‘We could quickly use up $6 million in etiology, and it would be years before we could show progress’, noted the surgeon Stanley Dudrick,Footnote62 ‘The legislators might become discouraged’. Dudrick and other critics argued that therapeutic-related research would provide quicker results than prevention;Footnote63 that it was too early to reach conclusions on the relationship of diet to cancer;Footnote64 that a focus on prevention might undermine efforts to do something for people whose cancers had already started;Footnote65 and that the workshops sponsored by DNCP in 1975 came up with many more promising research ideas in therapy than in aetiology. The surgeon, Jonathan Rhoads (the Chair of the National Cancer Advisory Board), was moved to regret the poor showing of aetiology: nine of the top ten projects were in therapy or management and support, he noted.Footnote66
Faced with such arguments, Gori retreated from his earlier position on prevention. He conceded that therapeutic research was likely to have a faster pay-off than that of aetiology, and that they had to show quick results if legislators were not to become discouraged. Congress had, he argued, been motivated to include diet and nutrition in the 1974 Act more by a concern about therapy than by statistics on aetiology. The epidemiological evidence, he noted, pointed to a variety of causative factors, but it pointed to too many things, and there was a consensus that the epidemiological approach to aetiology would be slow and difficult. By the end of the debate, the therapeutic lobby had prevailed. Instead, of Gori’s proposal of a budget split of 45%–45%–10%, the Advisory Committee recommended that the budget be divided 55% for therapy; 35% for aetiology and 10% for programme management and support.Footnote67 In practice, therapeutics got an even larger slice of the cake: the actual funding in the fiscal year 1976 was 67.4% for therapy, 25.4% for aetiology and 7.2% for management and support, with the largest percentage increase going to work on artificial alimentation.Footnote68 (Table 5) In the following years Congressional pressure would increase the percentage going to prevention.Footnote69 The base-line from which future negotiations would start, however, had been set.
Table 5: ‘DNCP Recommended and Actual Funds Allocation, Fiscal Year 1976’. Source: Diet, Nutrition and Cancer Program, Status Report and Working Papers for the Advisory Committee Meeting December 14–15, 1976, National Institutes of Health, Building 31, Wing C, Conference Room 10, Bethesda Maryland 20014 (Bethesda: National Cancer Program, 1976), 12.
1977–78So far the story of the DNCP is a tale of internal committee struggles over NCI research priorities in which epidemiologists and statisticians defended prevention-related research against pressure for more resources to go on therapeutics – and found themselves giving ground. But from 1977 these struggles moved out of the committee rooms and into a broader public arena. Frustrated with their poor showing against the therapists, and upset by NCI cutbacks in spending on diet and nutrition, advocates of prevention began a political and media campaign critical of NCI neglect of prevention research. This revitalised campaign brought the DNCP into the sights of the food industry, which was increasingly concerned about the direction of federal food policy. It also alienated senior figures within the NCI with its public criticism of their policies towards prevention. These problems, combined with Gori’s involvement in the separate debates over smoking, meant the DNCP faced a very unclear future.
Budget ProblemsThe DNCP had been established when the NCI was flush with money for small new projects in the early 1970s. Its budget had jumped after the 1971 Act, from US$190 million in 1970 to just under US$1 billion in 1977, allowing the NCI to initiate a range of new programmes, including the DNCP.Footnote70 By 1977, the golden days were over. The budget continued to rise, but the money was draining out elsewhere, notably to the Comprehensive Cancer Centres (established across the country from 1973 to bring results of research rapidly to patients), and to the Special Virus Cancer Programme.Footnote71 Other programmes began to feel the financial pinch. The NCI – under funding pressure from the Ford and Carter administrations – cut Gori’s proposed budget in half.Footnote72
Gori reported in 1977 that funding limitations meant that the DNCP had not been able to implement many research recommendations of its Advisory Committee.Footnote73 Congress had allocated US$6 million to the DNCP in 1975 rising to US$7.7 million in 1977. The problem was that these sums did not come close to meeting the needs of the programme. Gori estimated that proposed projects would cost about US$25 570 000, with about 103 projects needing support, and no-one knew where the money was to come from. Despite early concerns that few scientists would be interested in such a low status area of research as nutrition and diet, Gori had found himself deluged by enquiries and proposals for research at a time when the NCI faced a financial shortfall.Footnote74 Nutrition research seemed to be caught between its own success and the general budget crunch. It was not the only NCI programme to suffer this way, but Gori took the difficulties to heart.
Frustrated with his inability to change NCI policy, in February 1977 Gori and his Advisory Committee went over the heads of NCI bosses, and wrote to the newly inaugurated President Carter and key congressional figures to complain about poor funding.Footnote75 The previous month, Newsday had published a 16-day series of articles critical of the NCI’s war on cancer.Footnote76 The nub of the Newsday criticism was that the NCI was losing the war on cancer, that too much emphasis was given to the virus programme and comprehensive cancer centres at the expense of more promising areas of research including prevention and that a reason for this was that the NCI’s peer review system and its advisory committee – the National Advisory Committee on Cancer – were loaded with people who were the recipients of funding and few had an interest in prevention, including diet and nutrition.Footnote77 In short, NCI decision-making was rife with conflicts of interest that worked against promoting work in the most productive areas. Gori was one of Newsday’s sources.
According to Newsday, Gori charged that the heavy emphasis on virus research and treatment centres was a misuse of federal funds: the scientific consensus was that virus research was no longer the best route to a cure (the virus programme was ‘a flop’, an unnamed scientist was quoted by Newsday); nor was the focus on therapy the best route to reducing cancer incidence or mortality. In spite of the enormous increase in treatment money, the survival rates of cancer victims – except for some cancers in children – had not increased substantially in 30 years. How different the prospects seemed for prevention. Gori noted that the evidence was that the majority of cancers were environmentally produced and could be prevented. ‘In spite of this clear evidence’, Gori was quoted as saying, ‘the money is not where the priorities are’.Footnote78
Public criticism set the seal on a growing rift between Gori and his NCI superiors. As one report put it later, ‘Going public with an intramural fight over the budget is a no-no in the federal government’.Footnote79 Gori’s comments in Newsday, and the DNCAC’s approach to Carter, attracted the ire of Benno Schmidt (Chairman of the President’s Cancer Panel) and Guy Newell (the NCI’s acting director: Frank Rauscher having left to join the ACS, 1 November 1976). Newell began by publicly warning (unnamed) Advisory Committees not to engage in lobbying.Footnote80 Then, in April 1977, he cut all of Gori’s advisory committees – the carcinogenesis, tobacco, and diet and nutrition committees.Footnote81
The Carter administration – which had run on a promise of reducing the size of the federal government – had urged the NCI to reduce the number of its advisory groups. (Advisory group members were considered FTEs – full-time equivalents – and were an immediate target for downsizing.) Newell denied that his focus on Gori was retribution for the Diet and Nutrition Cancer Advisory Committee’s action, but commentators saw a connection.Footnote82 Without the DNCAC, Gori was unable to use it to critique ongoing research or to generate new research priorities. One former member of the Advisory committee came to worry that it left the NCI inadequately advised on nutrition issues, a sign of its lack of commitment to the field.Footnote83 At the same time, a shift in the NCI’s funding mechanisms – from contracts to grants – further reduced Gori’s ability to control diet and nutrition research.
Academic researchers had pushed hard for this shift, since grants were investigator initiated and gave more influence to the researchers than government administrators. From the point of view of researchers, contract mechanisms were vulnerable to favouritism, a means of extending the National Institutes for Health (NIH) intramural research without a proper review, potentially harmful to cancer research (research, they claimed, often targeted areas where basic knowledge about cancer was underdeveloped), and based on a flawed ‘philosophy that the role of management of fundamental science is the same as the role of management for engineering or development when the fundamental knowledge is available’.Footnote84 By contrast, from the point of view of administrators, contracts were a convenient and quick means of promoting work in targeted areas, of differentiating programme objectives from scientific objectives and of maintaining management control over scientists who, in administrators’ views, often confused scientific and programmatic endpoints. As one DCCP document put it, advocating management through a mix of contracts and grants: ‘[M]any scientists do not understand that even successful completion of their proposed project may not necessarily contribute to the attainment of program goals’.Footnote85 Contracts had the added benefit, for administrators, that they could be initiated without undergoing the sorts of review that was expected of grants. This is not to say that contracts were not subject to peer review: they were, but in different ways to grants. The 1974 amendments to the National Cancer Act required research and development contract proposals to be subject to peer review by groups composed of not less than 75% of non-federal employees.Footnote86
In 1976 the vast bulk of therapeutic research was carried out by contract (65.9% of the total DNCP budget distribution), which included all the research on artificial alimentation and anorexia. By contrast 1.5% of the budget went on therapeutic research funded through cancer research emphasis grants (CREGs), a targeted grant established in the mid-1970s that aimed to replace some of the work done under contract. The equivalent figures for aetiology were 8.6% of total budget distribution on contracts and 16.8% on CREGs. With the appointment of Arthur Upton as NCI director, on 29 July 1977, all this was about to change. The NCI underwent a major reorganisation in 1978 in which Upton sought to separate programme management from grant and contract administration, and from the peer review of grants and contracts. Resources were diverted to fund more investigator-initiated grants, and heads of internal NCI research programmes were banned from wielding direct control over how funds were to be awarded to extramural investigators. Such developments limited the autonomy of the DNCP, which would have less independence than formally.Footnote87
To complicate matters further, with the NCI in limbo searching for a new director before Upton’s appointment, the Director of the NIH, Donald Frederickson, attempted to reassert NIH authority over the NCI, lost after the 1971 Act, when the director of NCI had been made a direct Presidential appointee. (Before 1971, the director of NCI, like other directors at the NIH, had operated under authority delegated to him by the Surgeon General.) Part of the problem for Gori was that in 1975 the NIH established its own Nutrition Coordinating Committee (NCC).Footnote88 Gori was a member of this committee, but he came to suspect that NIH was not particularly sympathetic to the difficulties faced by the NCI’s programme, since the NCC allowed the NIH to assert authority over the DNCP by integrating it into an overall set of NIH priorities in nutrition.Footnote89 Things did not get much better for Gori with the appointment of Upton. While Upton was able to reassert NCI’s independence of NIH, he fired Gori’s boss at the DCCP, James Peters, and replaced him with an acting director, Gregory O’Conor, who eventually became director in April 1978.Footnote90 Gori remained deputy director of DCCP, but rumours circulated that O’Conor wanted to choose his own deputy.Footnote91
McGovernGori’s position in the NCI might have weakened, but he retained support in Congress, notably from Senator George McGovern (D-SD) who chaired a select committee on Nutrition and Human Needs.Footnote92 Originally created in July 1968 to lead the ‘war’ against hunger among the nation’s young, old and poor, the committee later broadened its focus to include more controversial areas of food policy such as the role of diet in promoting chronic and degenerative diseases, including cancer. In 1976 the committee began a series of hearings, labelled ‘Diet Related to Killer Diseases’, which Gori allegedly shocked when he told it in August 1976 that diet might be related to more than half of all cancers in women and one-third of all cancers in men.Footnote93 (He and Wynder published revised figures the following year, suggesting that about 60% of cancers in women and 40% in men might be diet related.Footnote94) In 1977 the Committee released six dietary goals for the Nation: to increase carbohydrate consumption, and reduce the consumption of fat, saturated fat, cholesterol, sugar and salt. Briefly put, the committee sought to encourage people to eat more fruit, vegetables, whole grains, poultry and fish; to reduce their consumption of meat, eggs and foods high in fat, butterfat, sugar and salt; and to abandon whole milk in favour of non-fat milk. The report received a mixed reception from dieticians and nutrition scientists. Protests by the meat, egg, sugar and dairy industries forced McGovern to issue revised (and to these industries, less draconian) goals later in the year.Footnote95
With the food industry alerted to its activities, in June 1978, the subcommittee on Nutrition undertook hearings into the diet and nutrition programme, under the chairmanship of McGovern, and with the support of the republican senator for Kansas, Bob Dole.Footnote96 Gori did not provide evidence to the committee, but it was clear that it largely backed his position. As McGovern put it, about half of all cancers were linked to nutrition, and yet the NCI only spent about 1% of its funds on diet and cancer research and there appeared to be no prospect of an increase. In his view, the virus programme was not producing the results it promised, and stagnant survival figures for treatment did not support the NCI’s continued emphasis on therapeutic research.Footnote97 Picking up on issues raised by Newsday, members of McGovern’s committee attacked the NCI for conflicts of interest in its review process that worked against nutrition research, and highlighted the neglect of nutrition in the medical schools, including Arthur Upton’s former institution, the State University of New York at Stony Brook. Called before the Committee, Upton was repeatedly put on the defensive, forced to regret the neglect of nutrition in the medical schools and to confess that the NCI had difficulty in knowing exactly how much it spent on nutrition. He also conceded that controls on spending were inadequate, that the NCI did not do enough in the field and that it would seek more for nutrition research.Footnote98
Upton’s difficulties with the McGovern Committee can have done little to endear Gori to the NCI director. Gori’s close connections to McGovern were well-known: he was a regular advisor to McGovern, as well as to Dole and another congressional supporter, the former presidential candidate, Hubert Humphrey. The difficulty for Gori was that these connections were becoming as much a liability as a help. Dole was rising in the Republican Party, but McGovern’s political star was on the wane after the problems of the Nutrition committee’s 1977 report, and Humphrey was dying of cancer.Footnote99
Then, in August 1978, Gori sealed his political fate on a completely separate issue, when he and Cornelius Lynch published an article that sought to quantify ‘less hazardous’ levels of smoking by calculating the number of cigarettes of different brands that could theoretically be smoked without exceeding what they called critical levels for six major toxic smoke components. A report in the Washington Post that Gori and Lynch had identified safe or tolerable cigarettes generated a public storm. The article not only angered his bosses at NCI, but also drew the ire of the Surgeon General, the ACS and the Department of Health, Education, and Welfare (HEW) Secretary Joseph Califano, then in the midst of an anti-smoking campaign.Footnote100 The article was the end of what influence Gori retained at NCI, and by September 1978 he had effectively lost control of all his programmes. Gori remained as DCCP deputy director, but he went to Johns Hopkins University to do a Master of Public Health (MPH) degree, a move widely seen as removing him from significant power within NCI.Footnote101
Thus, after a volatile four years, Gori was gone. With his MPH in hand, he returned to his position as Deputy Director of the DCCP, but without many of his former responsibilities. He left the NCI in 1980, joined the Franklin Institute with a US$400 000 endowment from the Brown and Williamson Tobacco Company, and later worked as a consultant to the company in its legal cases.Footnote102 The DNCP, which had been administered by the Division of Cancer Cause and Prevention, was reorganised and decentralised (Figures 3a and 3b). The DNCP itself was transferred to the Office of the Director of NCI, and programme development was devolved to the divisions under the umbrella of the DNCP.Footnote103 Put another way, the new DNCP would co-ordinate but not direct the nutrition work of the Division of Cancer Treatment (DCT), the DCCP and the Division of Cancer Control and Rehabilitation. This structure was in line with Upton’s broader reorganisational goal of separating programme management from grant and contract administration, and from the peer review of grants and contracts.
Figure 2: NCI offices, divisions and programmes associated with the DNCP, 1974–78
Figure 3: Structure and framework of the Diet, Nutrition and Cancer Programme, 1978. Figures (a) and (b) provide two snapshots of the DNCP structure and framework as it evolved in 1978. Both illustrate the decentralisation of the programme after Newell took over, components of the programme being developed within the three divisions rather than by the DNCP Director. Figure (a) illustrates the structure of the DNCP as it was envisaged by Newell shortly after he took over in 1978, and includes the individuals responsible for the diet and nutrition research within each division, as well as the DCRRC (Division of Cancer Research Resources and Centres), the division responsible for managing NCI grant supported activities, including the review and coordination of programmes such as DNCP. Figure (b), which was published about the same time, provides a slightly different structure, and may be a later iteration, and sets out the research areas of each division and the relation of the DNCP to the NCI director. The absence of the DCRRC should not be taken as indicating that it had no review function in relation to the DNCP. Sources: Figure (a) Guy Newell, ‘Presentation to the National Cancer Advisory Board’, 18 September 1978, NCI archives: item number PB003861. The full names of the directors/officials are Guy R. Newell, Mildred Ellison, Thaddeus J. Domanski, Daniel L. Kisner and Lawrence D. Burke. There is no original paper copy of this document, and the quality of the PDF/photocopy image is very poor. This image has been enhanced for clarity by Hank Grasso. Figure (b) Diet, Nutrition and Cancer Program. Status Report. September 1978 (Bethesda, MD: Diet, Nutrition and Cancer Program, September 1978), 26.
Upton gave the job of programme coordinator to Gori’s nemesis, Guy Newell, who shortly after turned it over to Diane Fink, the head since 1974 of the NCI’s Division of Cancer Control and Rehabilitation. ‘I view my role as one of management rather than direction. The direction will come from within the major NCI Divisions’,Footnote104 Newell noted in September 1978, discussing the role of the ‘director’ within the new decentralised DNCP structure (Figure 3). Newell also announced that whereas in the past much of the research supported by the DNCP had been funded under contracts, in FY 1979 grants would be emphasised as the means of funding research. Contracts would be used for a much more limited range of activities, not generally including research.Footnote105
Prevention and TherapyIn a series of articles written in the 1970s, the Washington Post journalist, Daniel S. Greenberg, attacked the NCI for favouring basic research and cures rather than studies of environmental causes of cancer.Footnote106 Behind such an emphasis, Greenberg detected the hidden hand of the ACS, the major non-profit organisation concerned with cancer. In his view, the ACS (dominated by physicians interested in cancer therapy) exploited its extensive social and business connections to overwhelm a politically timid NCI. The result, according to him, was that most of the NCI’s money went either on therapeutic research or on work on cancer causation that was unlikely to upset any significant political or business constituency, with the possible exception of the tobacco industry. By contrast, studies of environmental carcinogens were politically much more difficult, since many were produced by powerful industrial corporations. The point was particularly significant in the case of diet and nutrition. As evidence mounted about the carcinogenic effects of pesticides, food additives and diets high in meat or certain fats and sugars, the farming and food-processing industries began to become alarmed. Greenberg saw such interests – combined with the low status of nutrition science and elitism within NIH – behind federal neglect of nutrition research.Footnote107 Whatever the truth of Greenberg’s assertions, he was repeatedly able to force the NCI to issue rebuttals to his attacks. In 1977, a world-weary NIH director forwarded one Greenberg article to the NCI director congratulating him ‘on being considered worthy of a despairing sigh by Daniel S. Cassandra’.Footnote108
Greenberg’s analysis would have found many supporters within the DNCP, and it captures and elaborates one of the themes of this essay – the uneasy birth of federal support for cancer prevention in the 1970s. But if this essay is a story of the problems of prevention research, it is also story of the problems of therapeutics. It tells the tale of how growing public criticism of the NCI in the 1960s and 1970s gave diet and nutrition research increasing significance as a means of improving therapy, and so brought advocates of therapy into competition with prevention over scarce resources. As we have seen, therapists were able to persuade the DNCAC that therapeutically related research proposals had stronger scientific merit, were more likely to produce results and quickly, and were more likely to appease the programme’s supporters in Congress. Even Gori – an advocate of prevention – came to acknowledge the political calculation that prevention research was unlikely to provide the sorts of results that would satisfy Congress, especially as it also risked aggravating allies of the food industry on Capitol Hill. The mere threat that the industry’s powerful supporters could cause problems for a field already struggling to satisfy Congress was enough to make prevention research seem a risky political venture.
The DNCP can, therefore, be seen, in part, as a microcosm of broader tensions within the NCI between therapeutics and prevention over funding priorities. But, if its early history is a story of the tensions between the two, its later history is a story of an emergent (albeit temporary and uneasy) alliance between prevention and therapeutics, as from the mid-1970s the DNCP came into competition for funds with larger NCI programmes, notably the Special Virus Cancer Programme and the Comprehensive Cancer Centres. In some ways, this competition exacerbated tensions between therapy and prevention on the DNCAC, for it was advocates of prevention who figured most prominently in the political and media campaigns to save the DNCP, and much of their criticism was directed at the therapeutic orientation of the NCI. Yet, I suggest, it also brought the two sides of the DNCAC together to fight the common threat to their programme. Advocates of prevention saw political benefits in allying themselves with therapists (given the latter’s political clout within the NCI and on Capitol Hill), while therapists also saw political benefits in allying themselves with advocates of prevention (given the strong sympathy for prevention within Congress and in certain sections of the media).
As the debate on diet and nutrition intensified in 1977, strains between prevention and therapeutics grew. The temptation to jump ship, however, was briefly held in check as all sides of the DNCAC waited to see how events would play themselves out. The move to go over the heads of the NCI and appeal to President Carter resulted in no (public) criticism from any member of the DNCAC, advocate of therapy or prevention. Privately, some may have disagreed with this move, but Newell’s response – the cutting of Gori’s committees – seems to have temporarily sealed an uneasy union, since it ended any opportunity for anyone to use the DNCAC to promote their agendas, and opened the possibility of all having to compete against other investigator-initiated proposals rather than determine policy behind committee doors.Footnote109 The union ended with Gori’s removal, and probably more importantly Upton’s reorganisation of NCI and the DNCP in 1978, which meant that the actual direction of research shifted to the division responsible for administering that part of the programme (Figure 3). The reorganisation was presented as a means of broadening the scope of the programme, and of integrating all diet and nutrition elements of the national cancer programme. It also gave sectional interests a greater level of autonomy, however, and reduced administrators’ ability to shape the programme, especially with the shift from contracts to investigator-initiated grants. The sorts of political alliance that had held under Gori’s tenure began to break up and new ones to form.
The story of the DNCP is thus a tale of shifting alliances and co-evolving relations between cancer therapy and prevention. Its emergence began with parental concerns about their sick children expressed though the Candlelighters, one of a new breed of single-issue health advocacy groups that emerged in the 1960s and 1970s pressuring Congress to redirect NCI spending to areas of their interest.Footnote110 It was also facilitated by a growing political interest in environmentalist critiques of medicine in the 1960s and 1970s, and Congressional concern about the neglect of nutrition in the medical schools, the role of diet and nutrition in the onset of chronic disease, and the NCI’s focus on therapeutics and basic (virus) research. But Congress was often a divided house, subject to conflicting lobbies from commercial, biomedical, patients’ and other advocacy groups, and these divisions were exploited within the NCI to direct funding one way or another – as when supporters of therapeutics persuaded the DNCP that it would be politically worthwhile directing more resources to therapeutics at the expense of aetiology, or when the political calculations changed in 1977 and therapists came to support advocates of prevention to save the DNCP from outside predations. The history of the DNCP was thus the product of struggles and negotiations between numerous often conflicting groups and individuals, distributed across many institutions (governmental and voluntary), all seeking to promote their own interests and agendas.
Such struggles were exacerbated by Gori who emerged as a polarising figure in the fights over the DNCP. The NCI was an organisation sensitive to public criticism, in which budgetary decisions were often fought out behind closed doors, with public displays of consensus masking internal conflict. This is not to say that it was not possible to make discontent public, but it was often done discreetly, perhaps through third parties and anonymous leaks, and always in ways that did not embarrass those higher up the organisational hierarchy upon whom subordinates depended for support. By the mid-1970s, Gori had abandoned such discretion, and so opened himself to attacks from powerful groups and individuals within the NCI, public expressions of discontent being especially dangerous to smaller, weaker groups within the organisation, and those who worked within them. It could be argued that the DNCP would have suffered cuts in the mid-1970s no matter who was chief. Gori’s strategy, personality and simultaneous involvement in controversies over tobacco, however, ensured a more spectacular conclusion to his directorship than others might have achieved. As one report put it euphemistically he was ‘one of NCI’s less inhibited infighters at budget distribution time’.Footnote111
Gori’s problems thus provide an insight into the patronage system within the NCI.Footnote112 The agency in the 1970s often presented itself as a meritocracy in which the route to success on the Bethesda campus of the NIH was research or administrative excellence. But, if the NCI was a meritocracy, it was also a hierarchical organisation that revolved around networks of patronage. The Institute was a warren of fiefdoms headed by the NCI director (from 1971, a Presidential appointee), who presided over subordinate directors, who in turn presided over more minor officials. Each director and subordinate supported individuals and groups within his or her section of the organisation, which might also be subdivided into further sub-sections, headed by subordinate subordinates, all of whom offered patronage to those under them and (at least public) support and loyalty to those above. Thus a key to advancing a career within the NCI could involve finding powerful patrons and keeping them on board as supporters. These patrons might act as mentors and advisors, and could shield less powerful individuals from political harm. Equally, a patron could leave a subordinate vulnerable if the latter did not live up to expectations, the politics got too hot, the patron was negligent of support or moved on elsewhere. In all such circumstances a previously sheltered subordinate could suddenly feel chill winds.
Gori fell afoul of such shifts. Starting under the wing of his director/patron James Peters, he found himself isolated and vulnerable after Peters’ left, with rumours that his new boss wanted someone else in his place. As economic circumstances changed in the mid-1970s, Gori found himself constantly struggling against the NCI hierarchy for more funds, and loosing support, especially after he tried to circumvent his seniors within the NCI by appealing to their political masters. This, and the political miscalculation of his involvement in the smoking debate, left him vulnerable and without support from powerful individuals within the organisation, and he lost control of the DNCP, and eventually had to leave the NCI. This did not end the programme, but it allowed it to be split along pre-existing lines of tension, which ensured that therapeutic and preventive research on diet, nutrition and cancer were carried out relatively autonomously under separate parts of the NCI, albeit still under the umbrella of the DNCP.
Subsequent NCI leaders would distance themselves from Gori, and some erased him from historical accounts of the programme.Footnote113 But, it is also arguable that his willingness to go public maintained pressure on the NCI to improve what in 1978 one staff member on McGovern’s Senate Committee on Nutrition and Human needs called ‘the abysmal nutrition research effort by the NCI’.Footnote114 Gori might have gone, but he had set the stage for NCI interest in diet and nutrition research in the 1970s and especially the 1980s, as it sought to address an emergent scientific consensus that diet and nutrition were the major preventable causes of cancer after smoking.Footnote115
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88Minutes of the NCC are available in NIH Director’s Files, Executive Secretariat, Office of the Director, NIH, file location, COMM 2-13.Google Scholar
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92On the McGovern Committee see Marion Nestle, Food Politics. How the Food Industry Influences Nutrition and Health (Berkeley: University of California Press, 2002), ch. 1; and Gerald Oppenheimer and I. Daniel Benrubi, ‘Food Fight: The McGovern Senate Select Committee on Nutrition and Human Needs and the Meat Industry’s Battle over the Diet-Heart Question, 1976–1977’, paper presented to the 84th Annual Meeting of the American Association for the History of Medicine, 28 April–1 May, 2011, Philadelphia.Google Scholar
93‘One-Third to One-Half of All Cancer Related to Diet, Gori Tells Senate’, The Cancer Letter, 2, 32 (6 August 1976), 3. A typescript of Gori’s 28 July 1976 statement to the select committee is available in ‘Statement by Gio B. Gori’, op. cit. (note 37) and in the George S. McGovern Papers, Mudd Library, Princeton University, Box 628. See also Gio B. Gori to George McGovern, date stamped 20 August 1976, and George McGovern memorandum to the President, 1976, both in George S. McGovern Papers, Mudd Library, Princeton University, Box 628. For other NCI documentation on the McGovern Committee see ‘1978 McGovern Committee Questions and Answers on Nutrition Research’, NCI archives: item number DC010295.Google Scholar
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100‘Gori Gets into Another Controversy’, op. cit. (note 82). For accounts of Gori’s and NCI’s work with the ‘safe cigarette’ see Mark Parascandola, ‘Lessons from the History of Tobacco Harm Reduction: The National Cancer Institute’s Smoking and Health Program and the “Less Hazardous Cigarette” ’, Nicotine and Tobacco Research, 7 (2005), 779–89; Mark Parascandola, ‘Science, Industry, and Tobacco Harm Reduction: A Case Study of Tobacco Industry Scientists’ Involvement in the National Cancer Institute’s Smoking and Health Program, 1964–1980’, Public Health Reports, 120 (2005), 338–49; Amy Fairchild and James Colgrove, ‘Out of the Ashes: The Life, Death, and Rebirth of the “Safer” Cigarette in the United States’, American Journal of Public Health, 94 (2004), 192–204. On Califano see Joseph A. Califano, Jr., Inside: A Public and Private Life (New York: Public Affairs, 2004).Google Scholar
101‘Gori Goes to Hopkins’, op. cit. (note 86). See also Parascandola, ‘Lessons from the History’, ibid. For O’Conor’s report on Gori’s move to Johns Hopkins see his response to a congressional enquiry from the office of Representative Lawrence H. Fountain (D-North Carolina), G.T. O’Conor memo, ‘Congressional Inquiry Received and Answered By Phone’, 19 September 1978, NCI archives: item number DC 003096.Google Scholar
102‘Gio Gori Accepts Franklin’, op. cit. (note 31). ‘Controversial Scientist Considers Leaving NCI’, Science, 208, 4440 (11 April 1980), 156.Google Scholar
103The Division of Cancer Treatment, for example, took over treatment-related projects under the umbrella of the DNCP ‘DCT Board Approves New Contract Projects, Rejects Nutrition Proposal’, The Cancer Letter, 4, 43 (27 October 1978), 3–7; Diane J. Fink, ‘Presentation on the Diet, Nutrition and Cancer Program’, (n.d) (c. 1980), NCI archives: item number AR-8000-008051.Google Scholar
104Newell, ‘Presentation to the National Cancer Advisory Board’, op. cit. (note 31), 2. Emphasis in the original..Google Scholar
105Diet, Nutrition and Cancer Program. Status Report, op. cit. (note 23), 37. Contracts were generally intended to fund support services, data acquisition, management of workshops and conferences, and, in some instances, special programmes such as the group of nutritional status reports then being initiated; Guy R. Newell, ‘Future Directions for NCI’s Diet, Nutrition and Cancer Program’, NCI archives: item number AR008211. For later DNCP developments see ‘Nutrition May Get an Extra $4 Million in FY 1979; Program Announcement Describes Opportunities’, The Cancer Letter, 4, 38 (22 September 1978), 1–6. See also United States Congress Senate Committee on Agriculture, Nutrition, and Forestry, Subcommittee on Nutrition, Diet and Cancer Relationship: Hearing before the Subcommittee on Nutrition of the Committee on Agriculture, Nutrition, and Forestry, United States Senate, Ninety-sixth Congress, First Session on Diet and Cancer Research at the National Cancer Institute, Clinical Nutrition Research at the National Institutes of Health, and Problems with the Peer Review System at NIH, October 2, 1979 (Washington, DC: US Government Printing Office, 1980).Google Scholar
106Daniel S. Greenberg and Judith E. Randal, ‘Waging the Wrong War on Cancer’, Washington Post Outlook (1 May 1977) C1 & C4; Daniel S. Greenberg, ‘ “New Broom” at the Cancer Institute’, New England Journal of Medicine, 297, 12 (22 September 1977), 679–80; Daniel S. Greenberg, ‘Cancer: Now, the Bad News’, Washington Post Outlook (19 January 1975), CI and C4; see also Daniel S. Greenberg, The Politics of Pure Science (New York: New American Library, 1968). For a critical response to Greenberg see William S. Gray, ‘The Data…Tell Only Part of the Story’, Washington Post Outlook (19 January 1975) C4. For another report critical of the war on cancer see Robert Houston and Gary Null, ‘We are Losing the War against Cancer. A Long Day’s Dying’, Our Town(New York), 9, 26 (29 October–4 November, 1978), 6, 11, 25. Our Town was a local paper, not normally of wide circulation, but one correspondent, writing to alert the NCI and NIH of Houston and Null’s piece, noted: ‘This article received wide attention here because during the newspaper strike, literally everyone read this paper and similar ones that are normally neglected.’ Alton Meister (Department of Biochemistry, Cornell University Medical College) to Alan S. Rabson (Associate Director, Intramural Research, NCI), 7 November 1978, NCI archives: item number PB-004512.Google Scholar
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Some Cigarettes Now 'Tolerable,' Doctor Says,Some Cigarettes, Lower in Toxins, Now Are 'Tolerable,' Doctors Says
1978-08-10-washington-post-some-cigarettes-now-tolerable-doctor-sayssome-cigarettes-lower-in-toxins.pdf
https://www.washingtonpost.com/archive/politics/1978/08/10/some-cigarettes-now-tolerable-doctor-sayssome-cigarettes-lower-in-toxins-now-are-tolerable-doctors-says/0cd53963-e49d-45b0-9525-daf1c1586576/
By Victor Cohn
August 10, 1978
Some cigarettes now have so little tar, nicotine and other harmful elements that they can be called "less hazardous" and can even be smoked in "tolerable" numbers without "appreciable" ill effects on the average smoker, a leading federal cancer scientist said yesterday.
Cigarettes in recent years have been found guilty beyond reasonable doubt of causing lung cancer, heart disease and several other illnesses.
But Dr. Gio Batta Gori, deputy director of cancer prevention at the National Cancer Institute, and Dr. Cornelius J. Lynch said yesterday there has been huge progress "in the last year and year and a half" in removing toxins - or poisons - from some brands. They expect to report this soon in the Journal of the American Medical Association.
"I am not calling any cigarette 'safe'," Gori emphasized. "The only cigarette that is safe is the cigarette that is not lit.
"I am not talking about what might happen to any individual. I am talking about averages. There may be a risk that still may be there even though we might not see it in overall, large population studies."
Still he said, there has been so much progress in removing toxins that "we can now begin to talk about 'tolerable' levels of smoking from an overall, public health standpoint. I think we will begin to see some beneficial effect in this country" - that is, some abatement in this nation's lung cancer epidemic - "in five or six years."
Gori said one brand - Carlton Menthols - is so low in the toxins that most persons could smoke 23 a day, mor than a pack, with no measurable risk beyond a nonsmoker's.
He said the average smoker might similarly consumer 18 Now Menthols, 17 Nows or Strides or 16 Caltons without any problems beyond a nonsmoker's so far as large-scale statistical studies could detect.
A cancer institute spokesman yesterday said Gori "probably represents the best expertise we have on smoking and health. "Until two weeks ago he headed the institute's program in that field, including the effort to learn to make less hazardous cigarettes. Dr, Arthur Upton, cancer institute director, nonetheless issued a more cautious statement yesterday saying your present knowledge does not permit us to establish" any levels "below which smoking might be safe."
"It is the firm position of the National Cancer Institute, the National Heart, Lung and Blood Institute and the Public Health Service that no cigarette now on the market can be considered wholly without risk to health," he said.
He said Gori's figures cannot indicate whether the risk to any single individual is large or small, only that it is "not demonstrable" in epidemoilogic or population studies. Upton said "you might double your own risk of cancer," for example, "with no appreciable effect" on large-scale population studies."
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Gori also said there are many "high risk" individuals who should "never" smoke. These include present or former workers exposed to asbestos or the families of such workers, women using oral contraceptives, pregnant women, and persons with any of the heart, lung or breathing disorders linked to cigarettes.
Some scientists would also caution anyone exposed to any potentially cancer-causing chemical, since many harmful chemicals add to each others' effects in ways that are still little understood.
"What I am saying," Gori explained, is that the average effect of smoking "tolerable" levels of certain "less hazardous" cigarettes today would be as small as the ill effect on persons who smoked only two cigarettes a day before 1960. Virtually all cigarettes then were loaded with poisons like tar and nicotine far beyond present levels.
Gori disclosed his estimates first in an interview with Associated Press reporter Michael Putzel. The Washington Post then obtained a copy of the Gori-Lynch report.
Lynch is manager of the smoking and health program at Enviro Control Inc. of Rockville, the cancer institute's main contractor in the effort.
The five leading brands of less hazardous cigarettes on the Gori-Lynch list - Carlton Menthols, Now Menthols, Nows, Strides and Carltons - represented just under 2 percent of all cigarettes sold last year. Lynch estimated. But 22 more brands - with 17 to 18 percent of the market - are low enough in toxins so the average smoker might use between three and eight a day without appreciable added risk, Lynch said.
The cancer institute program to remove or minimize the effect of the main toxins found in cigarettes or cigarette smoke - tar or "total particulate matter," nicotine, carbon monoxide, nitrogen oxides an acrolein - began in 1970. At the most it has cost $4 million a year, a drop in the bucket compared to the cost of smoking's huge toll in death and disease.
Still, it is a program that has often been flayed by some critics of smoking who have argued that efforts should be concentrated on halting smoking altogether.
"I think ours has been a worthwhile program," Gori replied. "We are not trying to endorse cigarettes or smoking in any way. We are only trying to put the facts before the public.
"If we could go from 100,000 cases of lung cancer a year to, say, 2,000 or 3,000 by the development of less hazardous cigarettes, I would still regret the 2,000 or 3,000 deaths but I would think we would have made a tremendous public health gain."
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Cornelius James Lynch
Cornelius James Lynch
October 19, 1931 ~ August 8, 2018 (age 86)
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Obituary
Obituary
On Wednesday, August 8, 2018, CORNELIUS JAMES LYNCH of Potomac, MD. "Connie" or "Neil", as he was known to acquaintances, was born in Lowell, MA, on October 19, 1931. Son of the late Thomas Patrick and Catherine Frances Mahoney Lynch. He is survived by his wife Marjorie of 55 years, children Patrick (George Rocawich) and Cathlyn Lynch and grandson Gregory. He is also survived by seven nephews and seven nieces. He was predeceased by his brothers William and Thomas Lynch Jr. and sister Barbara Walsh.
Dr. Lynch completed his undergraduate studies at Catholic University, earned an M.A. in Mathematics from Georgetown University and a Ph.D. in Statistics from American University. His first professional position was with the David Taylor Model Basin in Carderock, MD. There, he developed mathematical software on early IBM and Univac computers for the Navy. At the Research Analysis Corporation in McLean, VA, he engaged in manual and computerized war gaming for the Army and participated in developing cost-analysis programs for the deployment of military forces overseas. As Senior Scientist at the Enviro Control Corporation in Rockville, MD, Dr. Lynch headed the Smoking and Health Program under prime contract to the National Cancer Institute, focusing on hazardous components of smoking products and the evaluation of smoking cessation programs. In this position, he also coordinated international smoking research projects. Dr. Lynch later served as a statistician with the federal government until his retirement in 2000. At various stages of his career, he taught Mathematics at Georgetown University, Statistics at the Postal Management Academy, and was on the adjunct faculty of American University, Johns Hopkins University and the Foundation for Advanced Education in the Sciences, all in the Metropolitan Washington DC Area. Dr. Lynch was elected to the New York Academy of Sciences, served as an active member of numerous professional societies, and authored or co-authored several articles in scientific journals.
Services were private. Memorial contributions may be made to Boston Children's Hospital, 401 Park Drive, Suite 602, Boston, MA 02215. 617-355-6890
Arrangements by Cole Funeral Services, P.A., www.ColeFuneral.com.
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