Transcript: Robert E. Shank, 1980

[. . . Washington University] School of Medicine Oral History Series.  It is June 27, 1980.  I am Paul Anderson and I am privileged to speak today with Dr. Robert E. Shank, who is Danforth Professor of Preventive Medicine and Head of the Department of Preventive Medicine and Public Health at the Washington University School of Medicine.  Dr. Shank, your association with Washington University School of Medicine began as a medical student.  What influenced your choice to come here to study?

A number of things determined that choice, I am sure.  I had gone to college at a small Missouri college, Westminster College.  I had applied and was accepted at several medical schools and came to Washington University for several reasons, I guess.  One, it was one of the better schools to which I was admitted.  Although I might say I did have the chance to go to Harvard.  My father being a minister and living and working in St. Louis; the choice was made easy by that, and I have never regretted that.

I understand that you were a student assistant in research with the Department of Medicine from 1938 to 1939.  Under whom did you work when you were a student assistant?

I was working then with the then-chairman of the Department of Medicine, Dr. David Barr.  Interestingly enough, the problem that he had me involved in had to do with the separation of the fat or lipid components of blood.  Some of Dr. Barr’s later observations still are significant – relative to the relationship between blood fats and coronary artery disease.

Was he a good teacher?

He was perhaps one of the best teachers that I have ever had, and I think he had that reputation among many classes at this school.  He left Washington University just prior to my leaving it to become a professor and chairman of the Department of Medicine at Cornell University in New York and had a long life.  He lived to be, I think, about ninety and died just a year or two ago.

Who else on the faculty here strongly influenced you while you were a student?

Among other professors with whom I worked closely, were Dr. William Olmsted, who at that time was involved with the study of diabetes, which was life interest of his, and Dr. Cyril MacBryde, who was perhaps the first head of a unit of metabolism in the Department of Medicine in this school.

Dr. MacBryde and Dr. Barr, at the time I that was working with them as a senior medical student, were involved in observations of a giant, a man called the Alton Giant.  One of my privileges was to assist in examination of that man during the period when he was being studied while I was here.  He was a man whose total height at that time exceeded nine feet; I think [he] still remains the largest giant that has ever been studied.

The largest giant of all time?

I think that is correct.

I think I’ve heard about the Alton Giant.  Interesting case history.  For a part of the year you were a resident at the St. Louis Isolation Hospital – I believe in 1946.

That’s correct.

Then you moved to a residency at the Rockefeller Institute.  How did this come about?

Well, at that time, the appointments in the Department of Medicine as intern and assistant resident were strangely for a year and a half.  And, in addition, affiliated with the Department of Medicine at that time was a unit in infectious disease at the City Isolation Hospital, which was on Arsenal Street.  That building is now used for studies of gerontology, or older people.  But at that time it was a very exciting place with smallpox and a variety of other then very common infectious diseases that we now don’t see at all.  So that was a very interesting experience for me.

During that period I, of course, was planning for additional hospital training.  [I] had been accepted for an assistant residency at the Peter Bent Brigham Hospital, in Boston, when things changed a bit with the visit here of one Dr. Charles Hoagland, who was a graduate of this medical school.  [He] had moved to the Rockefeller Institute for Medical Research and was then setting up a new division in that research institute.  He was concerned with the metabolic diseases and was focusing most importantly on the diseases of muscles, in particular muscular dystrophy and on liver disease, and specifically cirrhosis.  He asked Dr. Barr if he might speak to me and he did do that and offered me a position there.  And then I had the very difficult choice of deciding whether I’d go to Boston – Peter Bent Brigham Hospital – or to the Rockefeller Institute.  Dr. Barr’s advice was to accept the opportunity at the Rockefeller Institute, saying that that opportunity might never come again, whereas it would be much more likely that I could have another chance to go to the Brigham.  Well I never did get to the Brigham, but the time at the Rockefeller was a most exciting time.

All evidence [indicates] that Rockefeller Institute, then and now, is a truly exciting place to be in medical research.  Can you tell me more about your experiences there?

I went to the Rockefeller Institute for Medical Research in July of 1941.  It might be of some interest to you to know that at that time when new young people went to be interviewed for positions there they were interviewed by several people, most importantly by Dr. [Herbert] Gasser, who was the director of the Institute at that time and had been professor of physiology in this medical school and later the Nobel Prize winner.  The other prime interviewer was Dr. Thomas Rivers, who was director of the Rockefeller Institute Hospital and one of the early virologists [and] an outstanding man in his field.

Dr. Rivers, in interviewing me at that time, made two conditions on my coming there.  One was that I join the Naval Reserve.  Perhaps you will recall that 1940 or ’41, the time the decision was being made, war was brewing and plans had been made for the medical staff of the Rockefeller Institute to formulate itself as a medical research or medical treatment unit.  So, one of the first things I did after being accepted was to make application for the Naval Reserve and went there as a Reserve officer.  The other condition on going there was that one – you were not married and did not intend to be married within the near future.  [Upon] arriving there I was with a group of other unmarried physicians who were committed to a research career and not getting involved with marriage until one was well launched in such a career.

In March of 1942, or just seven or eight months after I went there, the Naval research unit was activated.  The Rockefeller Institute Hospital became a Naval hospital and its prime function was working with and treating patients with viral hepatitis.  This came about this way: the Rockefeller Institute had earlier developed a vaccine for yellow fever and this was used on all of our troops that were being sent.

Was this Dr. River’s contribution?

He was involved in the development of that vaccine, but the prime developer was another virologist by the name of Dr. Max Tyler.  Anyhow, the vaccine was actually prepared in the laboratories of the Rockefeller Institute in New York in hundreds of thousands of doses to be given to troops that were going into the tropics.  Within a few months after the vaccine was being used, it was noted that many of the people who got the vaccine became jaundiced.  Now the disease itself, yellow fever, causes jaundice, but this was another form of the disease, which at that time was called catarrhal jaundice.

From a good old word, catarrh.

To make a long story short, it was soon determined or predicted that catarrhal jaundice or viral hepatitis, would be demonstrated to be a viral disease and this was later demonstrated.  The reason that this disease was induced by the vaccine was a little bit of human serum was added to the preparation of the vaccine to do what they called stabilize it – you could store it and it would still provide immunity to yellow fever more readily when the human serum was added in small amounts.  Unfortunately one of the donors, one or more of the donors who provided serum for a number of batches for the yellow fever vaccine, had the virus of what we now call serum hepatitis, so there were than more than a hundred thousand cases of viral hepatitis following the use of several million doses of yellow fever vaccine at that time.

This was a little oversight causing major catastrophe.

Well, it was not an oversight at that time because we did not know the existence of the virus in presumably normal humans.  Prior to that event, this and other later experiences with the use of blood transfusions demonstrated fully that this virus now known as hepatitis virus B is rather widely distributed.  But that was not known in 1941 or ’42.

Did you have any further contact with Dr. Gasser after the interview?

Many.  One of the nice things about being at the Rockefeller at that time was that there were almost daily contacts with each of these people who were all outstanding in medicine and the medical research at the time.  Each day we had lunch in a common, very nice dining room on the East River, where there was leisurely contact, and weekly seminars and lectures that brought the group together so that Dr. Gasser was readily available to all of us; we talked to him almost as a contemporary.

I had many more contacts with Dr. Rivers, however, because he later became a tennis partner.  Dr. Rivers had early in his life been demonstrated to have a muscle disease.  It was one form of muscular dystrophy, actually.  It was not progressive, fortunately, but to maintain his activity and avoid further progress he played tennis daily and really played very well.  He soon found that I, being one of the younger members of the staff there, could play the back court.  So it was a rather common event for Dr. Rivers to come around the laboratory at 11:00 in the morning, saying. “We are going out to play tennis.  See you in fifteen minutes.”  And those were almost orders – in fact, they were orders, since he was a commander of the Naval unit.

Concurrent to your work at Rockefeller Institute you were an associate with the Division of Nutrition and Physiology in the Public Health Research Institute of the City of New York.  This was after the war – I'm jumping [ahead].

It really wasn’t concurrent.  During the period of the war experience, and working at the Rockefeller, I did a number of things that brought me into contact with another research institute in the city of New York.  The things that I was involved in were these:  we were working with viral hepatitis as I told you and among the things we did was to take punch biopsies of liver.  We’d put a needle into the liver and sucked out a little bit of liver tissue and on that we did a variety of biochemical assays.

In addition, in another kind of study (which went on during the war period in closer association with Dr. Hoagland than with the hepatitis study), we were working with muscle disease and with muscular dystrophy.  One of the first things I did there was to develop a method of taking muscle biopsies.  We could get tiny bits of muscle and apply biochemical methodology to the little bits of muscle that we derived.

Since these were small bits of tissue, I quickly found contact with another group of investigators that were working at the Public Health Research Institute of the City of New York.  It was a group headed by a man by the name of Dr. Otto Bessey, a biochemist.  In the group was Dr. Oliver Lowry who later became professor of Pharmacology here, and Dr. Herman Kalckar, another very famous biochemist.  And Dr. Sidney Colowick, another biochemist who trained under Dr. [Carl] Cori here – was then at the Public Health Research Institute in New York and later moved to Vanderbilt.  So anyhow it was a very stimulating group.

They were working with developing micro-chemical procedures for a variety of enzyme and other biochemical determinations using very tiny bits of blood and tissue.  So, it was just the thing for my little bits of muscle and liver that I was getting by biopsy.  While I was working during the war period with these other things, I became fascinated and wanted to evolve more of my own experience using micro-chemical procedures.  When the Naval group at the Rockefeller was disbanded actually – I think that was in August of 1946), I asked for the opportunity to work at the Public Health Research Institute.  That was when I moved there and was there for two years.

That particular time was a difficult time for the Rockefeller Institute in terms of finance.  You think the Rockefeller dollars were unlimited, but they weren’t, particularly at that time.  The Rockefeller Institute really had two branches, one in medical research that was on York Avenue on the east side of New York City and the other [that] was at Princeton, New Jersey and had to do with agricultural chemistry and veterinary medicine.  Because of the shortage of dollars there was discussion, [and] a lot of planning in 1946 actually, as to whether or not the medical research institute might be moved to Princeton or the Princeton group moved to New York – because of the shortage of dollars, moreover they were contracting staff.  What finally happened was they moved the Princeton group to New York and they later chose to take other funding ([for example] from the NIH) and that resolved their [money] problems.  But it wasn’t particularly a place with much of a future for a young person when I was looking for other opportunities in 1946, and that was one of the determinants of why I moved to the Public Health Research Institute.  I’ve never regretted that move, and the experience I had there served me in many of the things I was to do later.

The Public Health Research Institute – how was that supported and what kind of organization was it?

That too is an interesting story.  There had been for a good many years in New York State and New York City a requirement that every person prior to marriage would have a Wassermann test [for a fee].  When the legislation was set up for this, there was no plan in the legislation to use the dollars for anything.  So the then-mayor of New York, a little short fellow – I forget his name—

Fiorello LaGuardia?

Yeah, LaGuardia decided that he would appeal to the legislature to tap the several millions of dollars that had accumulated on this basis for setting up this Public Health Research Institute – which was done, I guess, in the early 1940s or maybe even in the late ’30s.  The group had several divisions.  There was a group in immunology which was under a man by the name of Dr. Freun (?).  At that time Dr. [Jonas] Salk was there, a contemporary of mine working with Freun, and he picked up the experience whereby he later developed the Salk vaccine.

Which Salk is this?

This is Jonas.  Other divisions – there was one in virology, under a man by the name of Hirsch, and one in biochemistry and nutrition under Dr. Bessey, and still another in physiology and I’ve forgotten who headed that group.  But it was a small group dedicated to laboratory research with very good laboratories and again it was a very stimulating place to be.  It was located in Parker Hospital or adjoining Parker Hospital, which was an infectious disease hospital at the foot of East 14th Street on the east side of New York.  So it had much of the same kind of environment that I had earlier enjoyed at the Rockefeller – the groups were smaller and we really worked very closely together even more closely there than at the Rockefeller.

Being a research institution [meant that] it didn’t concern itself with public health problems of a metropolitan area?

Well, actually they did attempt to do some of that.  And one of my responsibilities there was to apply some of the micro-chemical determinations, that had been developed by Lowry and Bessey for determining vitamin and other nutrient content on tiny drops of blood, to studies of populations in New York.  And one that I had responsibility, most importantly for study, cause there were other nutrition surveys going on at that time by that group, was a study of anemia in teenage girls attending a girl’s high school in the Bronx.  What came out of that study was a determination of the proportion of anemia in that group of adolescent girls which was due to iron deficiency and then another portion, which at that time we were trying to find out other causes and there were multiple other causes.

In 1948, you became Danforth Professor of Preventive Medicine, head of the department here [Washington University School of Medicine].  How did this come about?

Well, it came about this way.  I was visited one day by the then-dean, Dr. Robert Moore, who said they were looking for a new professor of preventive medicine.  He was looking for some different or perhaps new approach to preventive medicine – since most other medical schools at that time – and the first appointment here happened to be in the general area of controlled infectious disease.  He said [that] he thought that the approach for the future might well center on nutrition.  It so happened that Dr. Lowry had six months before been offered the chair in Pharmacology here, and the fact that he was here also made appealing this offer.  At that time there were offers from several other institutions.  For instance, I was offered a position of directing the metabolism laboratory for the Department of Surgery at the Peter Bent Brigham Hospital in Boston and also was offered a position as research professor of medicine in the Department of Medicine at the Western Reserve Medical School.  I really had three possible choices to make at the time and I guess the forth choice was to remain at the Public Health Research Institute and that really was very appealing.  I almost thought I would prefer to do that.  But finally the intrigue of coming back to a medical school that I respected highly and joining others with whom I thought I would like to continue collaborating with, most importantly Dr. Lowry and some of his associates.  This brought me back.

Whom did you succeed as head of the department?

The Department of Preventive Medicine was established just a few years earlier – I think 1944 – and funds had been raised for its initial support by an earlier dean, Dr. Philip Shaffer.  [The funds came] from the Rockefeller Foundation and from the Commonwealth Fund.  Each foundation, as I recall, had agreed to put in fifty thousand dollars a year for a term of five years, with a commitment from the medical school to pick up this and to provide other support after that time.  The first Chairman of the Department was Dr. Gurney Clark, who was recruited from Johns Hopkins Medical School or School of Public Health.  He was an infectious diseases man, most importantly oriented to the disease syphilis and its control.  He brought with him several other people when he came here, all of who were oriented to infectious disease research.  One of the persons who he had brought and who remained here and became a very highly respected member of our staff was Dr. Virgil Scott.  Dr. Clark left very shortly after taking the position here – I think he was here only two years – but he left to become chairman of the Department of Epidemiology in the School of Public Health at Columbia University in New York.  So that was the beginnings for the department.

So there was no question that it was already a research-oriented department?

There was a good base of research when I came here, although the laboratory space was really very small.  One of the determinants of my coming here – perhaps I might tell you [here because] I didn’t think of it a while ago – in trying to decide what might be best in terms of a choice at that time – I went to see someone whom I respected highly and I’d had some earlier contact with.  I guess those earlier contacts came when there had been other jobs offered [to me].  This person was Dr. Alan Gregg, who then was medical director of the Rockefeller Foundation.  I had several very interesting discussions with him about the possibility of coming to St. Louis or taking one of the other choices.  He was very cagey in his advice to me, telling me that there was an important job to be done here, but it was not going to be easy.  It might be a little easier for me since I came from this institution and knew other people who had come more recently.  But that if I took the position, that I would soon find it would be a lonely one.  I must say that advice, at one point, almost turned me off.

And, in some regards, Dr. Gregg’s advice was correct, but I think that what he was really telling me was that taking over as chairman of a clinical department in a large medical school, particularly at a young age, does sort of separate the young investigator or the young academician from his confreres.  Simply because he has the leadership role and has a responsibility of getting funding and assuring support.  I really never found this burdensome or bothersome, and actually felt that I was warmly welcomed when I came here.

The most important early support in the development of the department came from someone whom I hadn’t known before and whom I got to respect very highly, Dr. Barry Wood.  In a sense my first years here were ones in which we tried to use opportunities for developmental preventive medicine to strengthen faculty and staffing in the Department of Medicine.  For instance, one of our first appointments was someone in gastroenterology, Dr. Albert Mendeloff.  At that time there was not a full-time gastroenterologist in the Department of Medicine.  So, our bringing Dr. Mendeloff here from Harvard really strengthened the Department of Medicine as well as provided another important new staff member for the Department of Preventive Medicine.

I take it then that you didn’t feel that an administrative curtain had slammed down on you and kept you away from the lab?

No, no, it wasn’t that at all.  But I think what Dr. Gregg was advising me – and he advised many young people looking to other responsibilities – was that if they were really going to make a success developing and leading departments one really had to leave behind some of the more pleasant associations one had with one’s confreres.  They weren’t eliminated but they weren’t as readily fostered.  And I think that is a common experience.

In a sense you were the boss.

I think that was what he was really telling me, but it was sort of awesome to hear this at that time.

Did it disturb you to leave the center of urban action [New York] to return to the hinterlands?  Or maybe had you wanted to?

Well, we had enjoyed our years in New York and there was some tear in leaving it.  One of the other side-determinants had to do with the fact that I had married in the interval, despite Dr. Rivers’ early ruling and we had young children.  And when I moved to take the position at the Public Health Research Institute, we had moved to one of the New York suburbs, North White Plains, and each day I had to commute using a train or subways – more than an hour and a half each way.  In our first winter there, New York happened to have a snowfall that I think is still a record: between January 1, 1947, I think it was, and March 1, there was something like 125 inches of snow, most of which fell on White Plains.  So there were many days when I couldn’t get from my home to the laboratory in January.  And there were other days when it was very difficult getting back home at the end of the day.  My wife, I think, had had her fill and was looking forward to somewhat easier living, and that we certainly found here.

You have established pretty clearly the beginnings of your research interests in muscle disease and liver disease.  How did you continue your muscular dystrophy research when you came here to Washington University?

Well, I really didn’t continue the work with muscular dystrophy after leaving the Rockefeller.  My work then really became more tightly focused on nutrition and on liver disease.  Before I left the Public Health Research Institute in New York, I had been invited to participate in a nutrition survey in Newfoundland that had been planned by the National Research Council in Washington [and] was headed by a former director of the NIH – his name was Dr. [William] Henry Sebrell.  Dr. Lowry was a member of that group and he chose me to assist him in the biochemical analysis of specimens we picked up in Newfoundland.  The importance of that particular survey was this: during the war years, the island of Newfoundland was subject to— There were blockades – food [supplies] could not move in and out.  Very little food was produced on this island.  So I guess it was the Canadian government had gone in – it probably was the Canadian and British government had gone in 1943 or ’44 – and found rather severe malnutrition there, and had chosen to try to supplement the diets of these people by adding iron and some vitamins to flour and to providing some foods that weren’t readily available before.  So that the 1948 survey was a follow-up following the supplementation.

Was Newfoundland at this time a part of Canada?

It had not yet become, but it did later become a state [province], as you may know.  But they were getting support from Canadian research groups and part of the research team was from Canada.  What we did there was to take along equipment and set up a laboratory and do some of the determinations in a laboratory in St. John’s.  Other specimens were stored – kept on ice and brought back here and analyzed.  And one event had to do with my trying to bring in hundreds of samples of urine and I was stopped in Customs in Boston because this was an agriculture product.  I was delayed there a half a day until some order or acceptance of our bringing in urine specimens from Newfoundland for analysis would get us through Customs.  I was afraid the stuff would melt and we would lose all our specimens.  Fortunately that did not happen.

How many trips to Newfoundland did you make?  Was it just one, or did you shuttle back and forth?

No, we were there for six weeks as I recall, and we did not return.  The report was carried back to them by the National Research Council, I guess by Dr. Sebrell.  But the data were published and this really was the first nutrition survey of a type which formed a model for those done in many other countries later, which we can talk about if you want to.

This is an interesting historical point, that at that time it was not usual for American doctors to go abroad and intervene in a research way into the medical affairs of countries.

One of the unusual parts of this survey mechanism was the use of the micro-chemical procedures.

The medical technology was opening up new ways of—

And the methods that had been developed by Lowry and Bessey at the Public Health Research Institute of New York were being applied on a broad basis and this first international study that had first been used in New York – as I told you before, in a high school and in a state survey that Dr. Lowry and Bessey had done before I joined them.

From 1949 to 1953 you were a special consultant in nutrition for the United States Public Health Service.  Did this allow you to carry forth this kind of work, or was it something different?

It involved the establishment of certain nutrition research laboratories in the then-developing National Institutes of Health.  What had previously been a Bureau of Nutrition in the Public Health Service later took on a totally different function.  This was a time, postwar, when the United States was trying to develop relationships with a group of other nations, particularly in terms of possible other military involvement and, among other things, offered to assist other friendly nations to plan for best feeding of their troops.  Because one of the things that came out of World War II was that troops frequently were at a great disadvantage when they weren’t appropriately fed.  Fortunately our troops were during most of the war.  But there were isolated other instances where this really became a problem.

Was this a calculated, in the case of the American troops, then C-rations, was nutrition something that people thought about or did they just package what people—

During World War II?  Oh, yes this was studied carefully and the C-ration was developed by an agency of the Army and this really was a very effective way of feeding troops in the field during World War II.  Hopefully there are better procedures now.  But that one was well adapted.

This was already on the books as a pioneering concept of nutrition as an element in warfare?

That is right.  What eventually was created was a new agency called the Interdepartmental Committee for National Defense.  It really involved the Department of State, Department of Defense, and the NIH.  And the early surveys were meant to first assess the nutritional status of current troops of friendly nations and then to make suggestions to how the feeding might be improved.  For a survey to be undertaken there had to be a request from the nation and then our country would get a group of physicians, laboratory people, [and] nutritionists together and they then would associate themselves with a comparable size group of people with hopefully the same kind of interest in the other country.  In the other country then there was a bi-national group of surveyors who went in to examine and get data relative to the physical and nutritional status, first of troops.  After four or five years of experience, and because some nations thought that this was an intrusion on their military rights, the defense in the ICNND nomenclature became developed.  So it became the Interdepartmental Committee for National Development rather than national defense.  At that time the sampling in other nations was not limited to military, but took population samples in various parts of the nations that were surveyed.  Some thirty-three or thirty-four nations were participants in these programs.  So it became an important survey mechanism that lasted from about 1953 or ’54 to about 1967 or ’68.  The last undertaking of that program was the ten state nutrition survey in the United States in 1969 and ’70.  So it was a program that lasted better than fifteen years, surveyed some thirty-three or thirty-four countries and did some surveys within the United States.

I see that you had direct involvement as a co-director of a survey of Peru, but before then did you have any involvement with this group?

I was a member of the group of consultants that planned these surveys.

When did planning begin?

About 1952 or ’53.

I see, so this grew out of your work for the U.S. Public Health Service?

Well it grew out of the Newfoundland survey and it really pertained to the first appointment as Nutrition Consultant for the Public Health Service.

I see that there were a great many study sections, committees, advisory councils for the National Institutes of Health that you participated in.  Were these all connected in some respect, or did they just happen to be under that official umbrella?

The other appointments did not relate directly to the survey activities.  The study section mechanism was in the National Institutes of Health – really a post war development.  My first appointment to a study section was to one that no longer exists, it was the Public Health Research study section.  I think I was appointed to that study section again in the early ’50s – ’52 or ’53.

And these were focused strictly on domestic health?

All of these had to do with the review of applications for support of research pertaining to a specific subject area.  The first one would be Public Health Research, dealing with the community.  Later I dealt with epidemiologic research, with nutrition research, more recently with gastro-neurology and nutrition training, and the latest one had to do with clinical trials.

I see so that these were activities that concerned funding of—

It’s the peer review.

Now this is clearer to me that this was not the same as your overseas involvement.  I notice that you were also a consultant for the Indian Health Service, this was our native American population?  Can you tell me something about this?

Yes.  For a number of years I served as a consultant in nutrition for the Indian Health Service and this had to do with: one – planning for getting new health information about Indian populations on reservations in the United States, as well as trying to plan for medical services for these people.  Among the things with which I was involved were studies – first of all I guess, a survey that looked to the rate of occurrence of diabetes in Indian populations; and it is a very high rate of occurrence of this particular disease among American Indians.  We don’t know why.  But this led later to the establishment of a field laboratory in Phoenix, which has produced some very important information concerning the genetics or the transmission of diabetes within familial groups.  Other studies dealt with gout among Indian populations.  Studies of infectious disease, particularly tuberculosis.  Maternal and infant mortality experience was reviewed and efforts made to bring food supplements to a number of Indian populations in the effort to improve birth experience or to lessen infant mortality.  I think that has come about slowly, but it’s much improved now over what it was fifteen years ago.

Did you work with any particular tribes?

I did not get into the field in the role as a consultant to the Indian division of the Public Health Service.  Mine was more a consultant’s role, advising them in their studies and in their plans.

And the years of your activities at the Indian Health Service were 1957 to 1960?

Yes.

Then in 1959, as I eluded earlier, you went to Peru on behalf of the Interdepartmental Committee on Nutrition for National Defense.  And it was National Defense at this time?

Yes, I think in ’59 it was still that.

Tell me about your experiences in Peru.

Well having been a consultant to that program from the start, they pled with me to get into the field to do some of these.  I hesitated to take the time that was required earlier – it meant being away from the university and from my family for a minimal period of three months.  That’s not always easy with a teaching load, a research program going on, and a young family.  So I guess it wasn’t really until 1959 that I thought I could easily arrange to be away for that long, so I agreed to co-direct a nutrition survey in Peru.  The co-director was Dr. Philip White, who since became head of the Division of Nutrition of the offices of the American Medical Association in Chicago.  [He’s] still there.  He had been in Peru working in a nutrition research laboratory there previously for a year or two – knew the language, knew the people.  And I thought this would be a great advantage because I was not an expert linguist in Spanish.  We went there, set up a laboratory in the San Marcos Medical School in Lima.  Then sampled military populations and a few civilian populations along coastal areas to the south and north of Lima as well in the Andes and the shores of Lake Titicaca, and in the Cuzco area.  This was a very interesting experience for me and I guess my first working association with foreign nationals, which I found totally delightful.

Outside of the Newfoundlanders.

Yes that is right, I guess I had forgotten that, but there I could converse more readily, although I did pick up enough Spanish to get along fairly well during the course of those three months.

How does a foreign scientist approach, an American, approach a Latin American and gather samples and data?  How is it done, this contact?  If you could generalize.

Well, in that first experience we used the dean of the Medical School at San Marcos, a well known physiologist, whose name skips me at the moment.  Anyhow, he assisted us in assembling a group of Peruvian physicians, many of whom had been trained in the United States, many of whom spoke English, although not all did.  And we organized ourselves as one group, rather than a divided group and we shared responsibilities in the field, in the laboratory, and it became really a very delightful experience and I got to know many of these people very well and some of them have visited here.

There were also some unusual experiences, by the nature of the topography of Peru.  One unusual experience was – I can remember, we had our survey team of some twenty or twenty-five people down in the south coastal area of Peru at a place called Tacna, which is right on the Chilean border.  We had been taken down there by the Peruvian Air Force and we were told that planes would come to pick us up to return us to our next site of survey.  But they didn’t appear and we tried to contact Peruvian Air Force in Lima – didn’t get a very satisfactory answer.  But in order to get to the next site at Arequipa, we decided one day we’d simply take taxi cabs the distance of five hundred miles over these high Andes on very narrow roads.  Fortunately we made it, but I have since remembered many times looking down a steep side of a mountain with nothing between you and the gorge with the cab driving really very fast on a one-lane road, where if you met anything you would just have backup for miles.

In another instance on that particular trip, we left Arequipa to go to a city by the name of Puno, on the shores of Lake Titicaca.  But in that trip by train we went through a station which is at the highest altitude of any station, railroad station, in the world – it’s 15,600 feet.  And I can remember going up to another car on the train to pick up a rather heavy box of records that I wanted to work on the next leg of the trip, and I went down the steps of one car with my load, then tried to get up into the steps of another car and that load felt like it was a ton.  I made it but—

Like being on another planet, almost.

Yes.

Peru has some amazing, as you have already eluded, topographical climatic differences.  The Amazon is totally different.

That’s the tropics.  And one of the sites for sampling was at Iquitos which is on the Amazon.  We did also, while working in Cuzco, get to Machu Picchu and of all the places I visited in the world that’s the one I would most want to go back to someday.

Wasn’t Peru the country where Richard Nixon was mobbed while visiting as a Vice President at about that time?

That came later.

You were spared the embarrassment of having a Vice President mobbed while you were in the country.  Well, did you encounter at that time any strong pro- or anti- American feelings?

No, this was a very friendly group of people and there really were not anti-American actions going on at that time.  This did come later, as you are surely aware, but we were not bothered by that.

Of course it helped to be working with medical colleagues too – that you were in an area that politics had a minimal significance.  In 1963 you were co-director of another nutritional survey team, this time to Northeast Brazil.  Could you tell me about this?

Yes, at that time the problems of malnutrition in Northeast Brazil were perhaps as bad as those any place in the world.  This was planned totally as a civilian survey; we were not working with military there.  And as you may or may not be aware, the nine states of northeast Brazil represented the first settlements in that country – the first base of government was in Salvador, in the state of Bahia, which is in northeast Brazil.  And the economy was pretty largely based on sugar cane raising, sugar production, with very large estates or plantations with as many as twenty-five or fifty thousand workers on a single plantation.  With the owner being very much the lord-of-all-he-surveyed and with the workers having very little in the way of income or convenience of living.  Malnutrition developed when the economy of that area became very depressed, because these sugar cane plantations weren’t yielding as they had previously and sugar on the world market was bringing relatively little.  Not only was there malnutrition but there was political activity.  The government itself had set up an agency, modeled after our Tennessee Valley Administration in this country, trying to bring Federal support in, and through work activities trying to enhance the economy.  But this wasn’t being very successful at the time.  The Communists, therefore, were very active, very vocal.  When we got to the site where we put our laboratory in the City of Recife, which is the capital of the state of Pernambuco, we found there a small institute of nutrition which was headed by a very dedicated physician and a very well-informed man in the field.  He was pleased to have the laboratory equipment that we brought and which we left (when we finally left).  He proved to be a highly respected man by all portions of people in that area.  He was known to the plantation owners; he worked well with the politicians.  Working with him was easy.

What was this doctor’s name?

I am trying to think of his name, it will come around.  Anyhow what we did was to sample populations in each of the nine states working usually out of the capital city, and trying to get some urban as well as some rural population.  There, we certainly saw malnutrition that far exceeded anything we saw in Peru, and one of the most difficult problems that we ran across was a rather common occurrence of Vitamin A deficiency in infant, child and adult populations.  But most importantly the deficiency was causing blindness in infants and young children.  This became a political interest at the time we were there, and a claim was actually made that our government, in its effort to provide some assistance to Brazil by sending food in to aid these people, was in essence making more likely the occurrence of Vitamin A deficiency in infants because the dried skim milk we sent in was not fortified in Vitamin A or Vitamin D.

In this country at that time all fluid milk was required to be fortified with Vitamin A and D – sold on the American market – but it was not under the law permitted to add Vitamin A and D to dried skim milk, presumably because of the influence of the Wisconsin Dairy interests that did not want dried skim milk competing with fluid milk on the American market.  Some months after we completed our survey and after all of this had been reported to the State Department, President Johnson, one day I guess in October of 1964, decreed that all dried skim milk going out for Food for Peace would have to be fortified with Vitamin A and D.

We welcomed that decision but did not know how to accomplish the addition of this fat soluble vitamin to dry powder.  In a relatively short time, however, we were able to learn that the Hoffman-La Roche laboratories in Switzerland had a material that they had prepared for the addition of these vitamins to a dry cattle and other animal food.  So we simply took over this process and were able to make this addition to the dried skim milk and now you have it on the American market as well as it being distributed [overseas].

So this had long term domestic import for the American Dairy industry.  Well to my understanding, one of the major criticisms of American scientific or commercial involvement, particularly concerning child nutrition is that we have oversold the idea of commercial milk products.  In fact, populations in Latin America and other places, women hesitate to breast feed.  Can you comment on that?

Yes, this is a problem that was a common event in these surveys that we’ve talked about.  On a later mission of another kind I went to Africa for the State Department – the mission was really trying to find a base in Africa to set up a training place for in-nutrition for African nations.  Actually we were looking at sites in Uganda, Nigeria, Zambia and the Sudan.  But while there we did learn of an effort of a British company to enter local markets with an infant formula, again dry.  And it was a perfectly good product in terms of its nutrient content, but they could not get African mothers to accept this product with the image of a black mother and infant on the container.  When someone got the idea that they would take off the black mother and child and put on a white mother and infant we were told, at least, the sales went up immediately.  So, obviously these people were looking to the ways of living and eating that they saw and developed in white nations and were accepting that freely, whereas they were not accepting something we were trying to give them which they thought we were providing for them for their own good, but maybe not what we did.  This has all changed now and the World Health Organization is making a major effort to try to get mothers throughout the world to breast feed and to avoid early feeding by formula.

Well these experiences in the Third World have given you some insight as to immense problems of modernizing developing nations.  Do you have any general conclusions?  Are you pessimistic or optimistic considering the ability of Third World nations to develop the kind of technology that will give them nutrition?

Well, I have some thoughts.  I guess the thing that troubles me most is how there ever can be solutions to these and other problems in the developing nations when populations continue to grow at a rather rapid rate.  Fortunately the rate of growth has dropped off somewhat, but it is still going on a very rampant rate.  As of this point in time, the populations of the developing nations of the world make up three-quarters of the world’s population.  And with current rates of population growth the ratio instead of being three to one as it is now, is expected to be eight to one by about 2020 or forty years from now.  You almost have to anticipate that you can hardly keep up with enhancing economic level of these people when populations are increasing at such a rate.

Also, in this country where we have continued to increase our productiveness from single form units, applying that technology in developing nations has been very difficult and almost impossible.  And with the shortage looming, in the future, of power, this is almost going to be outmoded.  So the outlook, at least to me, isn’t favorable although I think things have improved somewhat over what they were ten, fifteen years ago.  I am afraid that the time again is going to come when we’re slipping off once more.

You know there is a man who lives in Mexico, and I believe he is still in Mexico, named Ivan Illich who has written very savagely about American medicine, and one of the points of his criticism is that we have no right to thrust a highly technological kind of medicine down the throats of poor people and that rather the traditional methods of healing and caring for people are, in the long run, better.  Is there any merit to his argument?

There is probably merit to the claim that they are more readily accepted by these populations.  These things are offered by their peers so they are a more readily accepted.  But what has happened, because of the transfer of some of our medical technology to the developing parts of the world, is that infant mortality rates have dropped, and this allows for the more rapid increase in population.  It also enhances the requirement for the things that sustain life – food for instance, because there are more people growing up to be larger individuals and the quantity of food itself is enhanced.  So it is a very complex problem and I just hope that new wisdom will come of some kind to permit—

Furthermore you as a scientist can’t withhold discoveries or technology simply because somebody might misuse—

I think that is correct.  Just think that in the period since World War II we wiped out smallpox.  A very prevalent disease and the disease caused millions of deaths less than twenty years ago.  We’ve had other experience with applying modern technology to the control of other infectious diseases such as malaria.  In this instance we’ve used insecticides like DDT to control the mosquitoes that transmit the disease and this is a very effective device.  But as in other instances, the mosquito becomes resistant to DDT, and the disease reappears and again it is rampant, and it is rampant in some of its more severe forms now in parts of the world such as Vietnam and Southeast Asia.  So no matter what we do there are likely to be some counter-developments that have to be confronted.

If we may return to your domestic work, or turn the focus away from overseas – over the years I understand that you contributed to the concept of recommended dietary allowances.  Can you trace this concept?

Sure.  Let me tell you a little bit about the group that’s responsible.  This is the National Research Council which is a so-called quasi-governmental agency and the research arm of the National Academy of Science.  So it is advisory to the government, the public, but it is not a government agency.  One of the boards of the National Research Council is the Food Nutrition Board.  It was established in 1940 or ’41, and at that time its first action was to develop a guide for nutrient intake in a war period.  These recommendations became known as Recommended Dietary Allowances, and what they were intended then to do, and intended now to do, is to provide a sufficient intake of each of the required nutrients to allow for health and for appropriate growth and development in childhood.  The recommended dietary allowances have some measure of sufficiency, of most nutrients in them, so that they not only avoid nutrient deficiency disease but to give an excess so that people who might require a little more would get enough in a daily intake if they take the allowance.

The committee that is responsible for Recommended Dietary Allowances is an ongoing committee and has revised these at five year intervals since the first were published in 1941.  I was first associated with this committee, I guess, for the revision that was produced in 1953.  I chaired the committee for the 1958 revision, and served again a member of the committee for the 1963 [edition].  So for three of the revisions that have been produced to date, I have participated.

When you look at labels on foods that you buy in the stores there will be an indication of the proportion of the allowance in a serving of the particular food that you are buying.  These are the guidelines that industry uses for this purpose and the guidelines that we used in feeding in hospitals and institutions.  They are also adapted so that the individual can plan his own meal to try to afford the sufficient amount of each vitamin, mineral or source of calories which the allowances provide for him.

Could we characterize this as a salutary intervention of government?

It is not really government.  That is the point I want to make early.  This was the first attempt of any nation to provide a national food standard.  Since that time many other nations have done this and they have been government activities in other nations.  Recently in the United States, and particularly through the aegis of the governing committee, government has tried to adapt some of the recommendations in Recommended Dietary Allowances for what they call food guidelines.  That has become a government action in contrast to the Recommended Dietary Allowances of the Food Nutrition Board.

So is it voluntary on the part of the food industry that we see these messages concerning nutritional information?

Here again there has been another intervention by government.  The Federal Trade Commission about five or six years ago, for the first time, set up a series of requirements for food labeling and initially they meant that for any claim to be made for a specific food they would have to put on the label the quantity of the nutrient contained and relate it to the amount in the Recommended Dietary Allowance.  That rule still is present, and in addition, other actions of the Federal Trade Commission have encouraged all of the food industry to try broadly to put the nutrient content on single foods to aid people in planning diets.  So it’s not totally a government requirement through the Federal Trade Commission, but it is a mechanism which industry has to follow if they are to put nutrient composition on and if they make any claim for a health benefit they are required to have this information.  It is a little complicated, but those are the conditions.

Well in your career you have seen the vitamin industry grow tremendously.  Can you give us some historical perspective on this?

Yes.  I guess when I first became interested in problems in nutrition, I remember only half a dozen vitamins that seemed to be important, [but] now the numbers have greatly increased and it’s on the order of twelve or fifteen.  But again the ones that were important earlier are the most important ones now – Vitamin A, D, K perhaps, as fat-soluble vitamins; Vitamin C, and niacin, thiamine, riboflavin and perhaps pyridoxine.  These are the ones that are most important, although you might add folic acid and B-12 as well.  Again, if you add the minerals that are required – you come up with quite a list, it gets to be a list of forty to fifty single nutrients that we have to have daily to have our diets complete.  Fortunately, if one gets variety in his diet, that is he eats [from] a number of different food sources, most of these vitamins or other required nutrients are present.

The changes that have occurred with time have been the acceptance by the public that the vitamins are necessary.  But a problem has arisen and I think the public expects them to do more than anyone can claim that they can do.  Or, for the public to believe that by taking more [vitamins], for instance, than the daily allowance, one might get benefits that would not otherwise be present.  That just isn’t usually true.  And there are hazards to the intake of certain of the vitamins, specifically, if you take them in large amounts, particularly Vitamins A and D.  And if one takes very large doses of Vitamin C there are, in a number of people, problems relating to excretion of the vitamin in other products which can cause stones.  So, in contrast to the focus of thirty years ago – trying to do everything we could to avoid deficiency disease – we are now focusing more on the problems that derive from an excess of some of the vitamins through their common availability.

I take it you take exception to Dr. Linus Pauling’s advocacy to Vitamin C.

Yes I do.  I think that Dr. Pauling, although a very accomplished biochemist, is not a very experienced person in terms of clinical research or evaluation of clinical research and is really making claims that are unwarranted.  And for a few people, it may present some hazards.

I think we have touched upon a question really of enormous proportion, whether there is a responsibility on the part of the prepared food industry to the public at large.  Do you have any views you care to express on this or any aspect of it?

I guess I have some views.  My role has usually been in association with research agencies rather than working closely with any part of the food industry, although there are exceptions to that statement too.  I did serve on the National Dairy Council for some time – they have a research arm.  I have been on their scientific advisory board for awhile.  I did see the efforts of that industry to try to adapt to changing public demands and I think they confronted their problem really very well.  What has happened really is that over the last three or four decades the fat in dairy, in milk, is an excess – we don’t consume butter in the amounts we used to consume it.  A fair proportion of the sales of fluid milk are either in low-fat or in skim milk, so the dairy industry has had to provide such products and has done it without [it] being a real economic disadvantage, although I am sure they still like to find other uses for butter fat.

Well we no longer hear of milk being billed as nature’s most nearly perfect food anymore.  Is there any story behind that?

I guess I don’t know the story behind that one.  Well, maybe I do.  The reason that probably is responsible for this is the fact that in the past ten to fifteen years there has been more and more attention given to what might be called milk intolerance and the occurrence in children particularly of symptoms of a variety of kinds when they do consume milk or food that has some milk in it.  This is much more likely to occur in black populations and Asian populations than it is in white populations, in America at least.  And also these may be fleeting – in other words in individuals who do claim to have reactions to milk intake, if they take small quantities for a period then build up these with time, do not reoccur in many.  But it is for this reason, I think, that the claim that you just referred to probably [was] withdrawn.

Would you say there is a danger on the part of scientists in your field to be tempted by conflicts of interest if you work on projects sponsored by the food industry, to overlook problems that food cause or may involve?

Well, I have some concern about that.  I guess it is fair to tell you that in my own experience there have been opportunities to serve [the] food industry in the role of consultant that I have chosen not to undertake because I felt this would in one way or another compromise my other role, such as an advisor to the NIH and its study section and also for appointments I have had under the National Research Council and its Food Nutrition Board.  So I have always chosen not to do that.  Incidentally, I have also felt at times that I had to back off a little bit from too close an association with Ralston Purina Company here, because this chair is endowed by the founder of that firm, who was a very good friend of mine.  And one of the things I would like to record here is that in the many years I have had this chair, Ralston Purina has come for advice occasionally on technical matters, but they have never forced me to any kind of role that I did not feel comfortable in assuming, and I will forever be grateful to them for that.

Along the same line, and you are probably questioning me in this regard now because of the current controversy in the newspaper relative to the food guides of the same food and nutrition board, relative to fat in the diet.  One of my roles in the past, not current, has been serving on the nutrition committee of the American Heart Association and I have had a role in its development of its diet plan which has been attacked by this recent report.

One thing with public information a few years ago but probably isn’t known by the public widely now, is that the egg industry, seven or eight years ago, was advertising that there is no support for the claims of the Heart Association relative to the need for a diet change.  The Federal Trade Commission took the egg industry to court, telling them they had to cease and desist with that form of advertising unless they could bring proof for their statement.  Their lawyers, finding no other way out at that time, came to see the officials and staff of the Heart Association and I was called in as its Nutrition Committee Chairman to advise the egg industry as to what they might do to help resolve the conflict or get the information they would like to see.

When was this?

This was about 1963.  No – [19]73 or ’74.  What we proposed at that time was this: we were fully aware that the tobacco industry, in response to the claims made against cigarette smoking and its relationship to the occurrence of lung cancer, had set up its own research funding in support of cancer research.  We then proposed to the egg industry that they might do something comparable and find a mechanism for supporting research that would try to look more closely at the role of the egg and its relationship to blood cholesterol levels.  They did finally agree to do this and they set up what is called the American Egg Board.  Now that is supported by a write-off on each sale of a dozen eggs, so they accumulate a couple million dollars a year, and under federal charter they used some of that for purposes of their advertising but some also to support research.  In doing this then they turned to the Heart Association and said, “Will you provide us with the names of people who will serve as a scientific advisory committee for us.”  Those names, or group of names, were given to the egg industry.  They selected every one we had proposed, and took [as] the chairman the then-President of the Heart Association, the Chairman of this committee, his name is Dr. Elliott Rappaport, a cardiologist from San Francisco.  That committee meets once a year to review research applications that come in – we last time had some thirty-five or forty – and they finance these to the level of about half a million to 750 thousand dollars a year.  I think this has turned the controversy around in a very meaningful way.

Now, the people who serve on that scientific advisory committee are not paid any more of a stipend for that role than the one-day consultant fee that the NIH pays for its study section.  So my hope is that those of us who are involved in that review aren’t going to be burdened at some time by saying we were supporting them – actually it was the role with the Heart Association that tried to help them in resolving their problem.

Well could we generalize that a food industry group can be persuaded by sponsoring its own scientific research that certain standards are necessary or can be encouraged through this kind of organization to develop a posture that is more responsible?

Well I think the model of the tobacco industry can be applied to the food industry and it has been applied in the food industry by the National Dairy Council and I think now by the American Egg Board.  So I think it is possible.  In addition, the food industry generally supports a group called the Nutrition Foundation, which again has funds for support of a variety of kinds of nutrition research and they put out a very much used journal called Nutrition Reviews.

Well I want to check at this time whether we should be taking an intermission.  I think perhaps the tape machine is coming to the point that I believe we will have to change the reel.

[Tape reel is changed.]

We were talking about problems of nutrition in prepared foods.  I have noticed you have addressed the problem of infant foods.  You wrote an article, “Is there a need to fortify infant foods.”  There has been a lot of criticism of the baby food industry.  Could you comment on that?

Well, this has been an area where there have been a variety of kinds of problems.  Infant formulas, as usually prepared, are planned to provide intake levels that are sufficient for the day for any given infant.  When the mother then adds to the formula, for the relatively young child, other foods that are themselves then fortified with other nutrients, one can build up more than needed amounts.  And this has been the problem that has been focused on and it became a problem most importantly in the late 1950s in England, when a disease was induced because one vitamin, pyridoxine, was provided in excessive quantities.  And there are other events like this that have occurred.

Hasn’t there been an abuse of sugar additives in infant foods and prepared foods in general?

Well, in terms of taste, infant foods have, in the past, been prepared so that they appeal to the parent or to the mother.  This may involve the addition of sugar, or of salt, in amounts which can be and are possibly excessive.  If the sugar is excessive it means putting on more weight than is necessary.  If the salt is excessive it may lead to later taste preferences of the child and young adult, which make more likely the occurrence of hypertension.

I know you have been interested in the question of weight reduction over the years.  Do you have a historical perspective?

I guess this is an area where I think nutritionists have perhaps made as little headway as in any.  The problem of excessive body weight or obesity is one that has been growing.  In other words, the proportion of the adult population that is obese has been increasing and there are health hazards of obesity that relate to such things as the earlier occurrence of hypertension and more frequent occurrence of hypertension, diabetes, [the] risks of surgery are enhanced in the obese, and any number of life-shortening chronic diseases are more common in the obese than in those people who are within more restrained limits of body weight.  Why some people eat to excess and become obese is still a question.  Among the things that may be important are genetic factors – there are family groups who are more likely to have obesity.  It is very difficult to separate that particular influence from the environment, in other words, the feeding practices within the home or the family.

And an area that is of current, significant interest is the so-called dietary thermogenesis.  What this really involves is the hypothesis that individuals who eat calories in excess and don’t gain weight are burning the calories and putting it off as heat.  People who become obese are more efficient in this process – don’t give off as much heat and store the material as fat.  The claim is made that one kind of body fat, brown fat, may be more thermogenic than is the other kind of fat, or white fat.  That form of fat responds to stimulus from the adrenal gland or the sympathetic nervous system, so this could relate to such things as anxiety or stress to either the avoidance or the occurrence of obesity.

But these, to this point, are just theories and we really have no better concept of how to assist people in losing weight now than we did have when I first entered this field forty years ago.

Among the things that are being studied or looked at in this particular department currently that pertain to this, are studies which relate to exercise and the expenditure of calories in this way, and by this means avoid the deposition of fat and the occurrence of obesity.  Dr. [John O.] Holloszy, who heads the Division of Applied Physiology, has been looking at a number of men who are now from their mid 50s up to mid 70s, all of whom were college athletics [and] some of whom have maintained training during all this time.  And he has been determining maximum oxygen uptake in response to exercise in people who maintain training and others who have not.  One of the interesting things that he has found is that older men who have continued to run or continue swimming or training maintain the capability to have relatively high levels of maximum oxygen uptake as they would have had in childhood or in younger life, whereas those who do not maintain training are not capable of doing this.  It is my hope that at some point in time he will be able to demonstrate that associated with this is a reduction in the decrease— We’ll put it another way – commonly studies of body composition show that with aging lean body mass decreases and it decreases on the average of 20 to 25 percent on the male from about age twenty-five to sixty-five.  Now what this means is that muscle mass, organ mass, like liver, decrease in size and these are actively metabolizing tissues, so their requirements for calories are decreasing because the body masses are decreasing.  I would like to think that he might be able to show us later in these older, exercising adults, that the loss of lean body mass hasn’t gone on at quite the same rate as it does in people who are sedentary.

Still another thing that is currently active in this department, Dr. Ruth Brennan, working with the Professor of Psychology, Dr. Ed [Edwin] Fisher, has just recently gotten a National Heart Institute Training Award, in which they are going to try to use the techniques of behavior modification in assisting obese people to lose weight.  That program is just beginning, but involved in that training program are Ph.D. nutritionists and psychologists, who working together hopefully will give us a better approach and a better understanding of how to get the obese person to assist himself in weight reduction.

If I may be facetious and paraphrase a New Yorker cartoon, showing two doctors looking askance at a third and making reference that he has been in practice for twenty years and not even written a diet book, I guess we could conclude that diet books, or the simplicity that they imply, just don’t reflect the true picture.

No, they are not the answer.  They sell books and make money for the person who goes through the trouble to write them.

You haven’t been tempted to write— “The St. Louis Diet?”

No, this is a market that I do not choose to compete in.

Your department over the years has become increasingly complex and I suppose disparate in its interests, is that not the case?

Yes, it has.

We have, for example, next door the Irene Walter Johnson Institute of Rehabilitation.  Can you tell me about the founding of this unit?

Yes, there had existed in Barnes Hospital, from the time of World War I, an active program of training physical therapists which was guided by a physician who was interested in these processes.  When he retired sometime in the 1940s, the Department of Medicine set up a division of physical medicine or rehabilitation medicine, which was not a very successful undertaking.  It did develop a service.  It did raise some money to build the building and when the head of that unit left in the middle 1950s, there was a decision needed as to what would happen with this.  The Executive Faculty and the Head of the Department of Medicine and, I guess, of Surgery did not feel that the Division of Physical Medicine should be continued as it was at that time.

So the then-Dean, Oliver Lowry, appointed a committee headed by Dr. [Carl] Moyer who was Professor of Surgery, and after about a year of deliberation they came to this department [Preventive Medicine and Public Health] for not totally or fully understandable reasons to ask whether we would take on this responsibility.  When I took this up with our faculty the first time around they said they were busy enough doing the things they were doing, [and] not to take on an activity for which they felt they were not trained or competent [to undertake].  A year later the problem still had not been resolved and I guess I gave in, a bit reluctantly, in taking on the responsibility.  Nevertheless, we had funds with which to build a building.

We got a small building built, we recruited a staff and we have had a succession of research-oriented people to direct the Institute who have been interested in problems relating, in one way or another, to rehabilitation needs.  For instance, the first director of the Institute was an internist by the name of Dr. Eric Reiss, who was interested in bone metabolism.  After some five or six years he left to become head of the Department of Medicine at the Michael Reiss Hospital in Chicago and now is a professor of Medicine at the University of Miami in Florida.  We have had a professor of Preventive Medicine, we have had a pediatric neurologist, and now we have a neurologist with a specialty in muscular dystrophy as director of the unit.  So we have had a great variety of people.  The program has grown.  It has been self-sustaining, and fortunately I have not had to put a lot of my own effort and time into it following the initial year or two.  For one year, in an interval, I did serve as Director but that was while we were seeking another.  But I am proud of this; it is a function of the department.  It has trained a lot of occupational and physical therapists and we now have new directors of those programs who are going to move them into graduate education.  So, somebody else is going to have to take over soon, but I think in a good position for whoever succeeds.

Do you think it will remain a part of the department or be autonomous?

It could go any way, and will depend totally on the kind of person they recruit as chairman of the department.

Another program that I believe now is autonomous is the Medical Care group.  Can you tell us how it developed?

Yes, this is a story that might be worth recording.  Shortly after Bill Danforth, our present Chancellor, took over as Vice Chancellor for Medical Affairs, I think he visited each department chairman asking for suggestions to new program areas that might be encompassed or brought about in [the] medical school.  When he came to see me, I made several suggestions, one of which was setting up a Division of Health Care Research – the thought being that universities should be looking at the method and the procedures whereby we provide services, [and] look at their efficiency and their economy and if there were any later effort on the part of the government to set up National Health Insurance we would at least have the experience of doing some trial things on our own.  Hopefully that might help.  It might even help avoid some of the things that might go into a National Health system.

Bill, I think, thought that idea was attractive and so we got going, and the first thing needed was some money.  So he asked me where we might go for first support and I suggested that we go to the Kellogg Foundation.  We made an application to them and they responded rather quickly through giving us a hundred thousand dollars a year for a five year interval.  We began searching for a director of the unit and had looked at a number of people from the outside who were experienced in the field, but became fully aware that if we brought one of these people in, he or she was going to be threatening to our part-time medical staff who would see this diversion as something probably not in their best interest – they let us know that.  So we then turned around a little bit to see if we had someone within our own staff with this interest who might find this as a future career opportunity.  It so happened that Dr. Jerry [Gerald] Perkoff, [who] was heading the medical group at the City Hospital, was looking at how that program of care down there might be amended or changed to provide better care.  He was enticed; he thought this was interesting.

About the time we were offering this position to Dr. Perkoff, the then-president of the Metropolitan Life Insurance Company, a Mr. Siegfried (?) called Dr. Danforth one day and said he was going to be in town and he’d like to talk to him about health care research.  So Dr. Danforth called me and asked whether I would have lunch with him and Mr. Siegfried; we did do this one day.  I told him about our plans for the Division of Health Care Research and the support we had from the Kellogg Foundation.  Well, it ended up, again within a relatively short time – a few weeks – when Mr. Siegfried came back and said, “We’ll match the Kellogg Fund.”  Moreover, he said, “We will give you a population group with which you can work to test some of the things you want to test,” because they had health coverage for a number of large St. Louis industries.

So what began as a plan to set up a Division of Health Care Research in the Department of Preventive Medicine eventually became a Division of Health Care Research set up under the dean’s office and headed by Jerry Perkoff.  And he very quickly, rather than centering on some of our own hospital problems, specifically our clinic administration and health services, thought he would like to try to set up a trial system whereby he would look at the provision of health care under a totally prepaid system and contrast it with the health care given by physicians under our usual system and under the Metropolitan Life coverage.  So what he did was really go to one or two of these industries and say, “We will provide you with totally prepaid care, full care under our experimental system” and he got five hundred families and he had a control group of five hundred families that were getting the other care.  In essence, what he found after four or five years was that although in the initial years the prepaid program costs were not very different, with time they fell about 20 percent under.  So the Medical School then had to make a decision what they were going to do with this experimental group.  And that became the beginning of the Medical Care Group.  It had some rocky times financially – built up a total debt of about three million dollars – which fortunately was resolved last year by a plan that you may well know.

What happened was the Metropolitan Life Insurance Company came in with a proposal saying that if we would remove the Medical Care Group from total university supervision and support, and set it up under a separate board with half of the members of the board coming through or [from] appointments made by the Metropolitan Life Insurance Company, they would provide a million and half dollars of the deficit and pay that back to the Medical School.  The hospitals that are chief users of the service – Barnes, Children’s, and Jewish – were to come up with part of the deficit and the Medical School was to be left with about half a million dollars total out of the three million.  That plan was accepted; the Medical School now was relatively free of this rather large debt.  The Medical Care Group is distinct; it is going to expand and is currently enrolling others and may go to as many as a hundred thousand.  (Current enrollees, wherever they are, are thirty [thirty thousand].)  So all this came out of the original plan.  A long story.

So you would consider Medical Care Group, as it is operating now, as a success?

Yes.  And a pre-paid system that you are likely to see more of in the near future.

Is t a typical HMO?  Health Maintenance Organization?  Are there such variety—

No, this isn’t typical, this is the only one that has had University financing and base support.  I think the only one in the country.  There are several others that have been University affiliated as ours now is, but never any started this way.  Further, I don’t know of any others that require that their medical staff be University-appointed people, in other words they have faculty appointments in their appropriate departments and consultant services are, in this instance, provided by our full-time staff in the various specialties, so these are the things that make it distinct.

Well now that Medical Care Group is autonomous, do you still have a Division of Health Care Research?  And what do they do?

The other things that have happened within the last year are these: Dr. Perkoff has chosen to leave and has gone to the University of Missouri, something he did a year ago about this time, and we have now brought the division of Health Care Research back into the Department of Preventive Medicine where it was initiated.   We have an acting director, an economist by the name of Lee Benham, that is looking again with a number of research projects, at the way we make decisions for the provision of service, the effectiveness of service under various alternative systems and provision of care, and they are also involved in some teaching and training.  So it exists and it is going to be taking some new directions under Dr. Benham, or whomever may succeed him.  In fairness I think I should tell you we asked him to take it as an acting directorship so that a new chairman might determine if he wanted someone else.  And also I guess so that Dr. Benham himself could see this as a role whether he really wants to follow as his major interest for the future.

It is interesting that you’ve hired a non-physician to take this position and it strikes me as something that, granted that physicians assure a quality of care, that this is really outside of medicine per se with clinical practice.

Yes, well, Dr. Benham was brought here by Dr. Perkoff for this purpose.  So he has a base and he is a recognized authority in the field.  He worked closely with physicians but also with other kinds of people, like sociologists; he has a man from the School of Engineering, Dr. [John] Gohagan, who is interested in decision theory.

Engineering?

Yes, in fact he had some very interesting observations that had to do with the things that are done in screening for breast cancer – which of these are effective and cost productive.  A kind of analysis that would be very difficult to get by any other means.

Well then, it is an interesting coming together of many disciplines.

This is the kind of thing that a Department of Preventive Medicine can do – it can be innovative since it isn’t tied to a single discipline.

You also have a Division of Biostatistics, do you not?  How was that founded?

Well, the Department has had responsibility for teaching of biostatistics since the day I came here.  Actually there was a faculty member from the Department of Mathematics who carried a large share of this responsibility prior to my coming and he was assisted by a woman, Mrs. [Barbara] Hixon, who remained on our staff after I came.  Also, Dr. Helen [Tredway] Graham, wife of the then-Chairman of the Department of Surgery, was very interested in this field, and also assisted us greatly in the earlier teaching of biostatistics.

One of my appointments in the NIH was a member of a training committee for epidemiology and biometry.  This provided funds for basic support for these two disciplines and with grant support we did set up earlier a Division of Epidemiology and then later one in biostatistics.  The one in biostatistics was established about 1967 and we brought from Baylor University Dr. Reimut Wette, a German trained biostatistician, who developed the unit, took over teaching responsibilities, assumed some role in graduate training in biostatistics, has provided consultant services for researchers throughout the medical school and even on the outside.  For instance, St. Louis University frequently comes to our Division of Biostatistics for its services.  Then it later took on the responsibility for the external terminal for the big university computer, so that biomedical research data coming from down here could be entered on that computer and the data brought back here.  That service still is within the Division and Dr. Wette recently relinquished his directorship, and as of the first of June actually, a new man took over, an Indian by the name of Dr. D. C. Rao.  He not only is an accomplished statistician that has come to us from the University of Hawaii, but he is a population geneticist who will be in great demand for some of the research programs in the Department of Psychiatry and in Genetics.  That’s the story.

You alluded earlier to a program in Applied Physiology – is this a division like the others?

Yes, it is a division like the Division of Biostatistics, headed by Dr. John Holloszy.  Dr. Holloszy happens to be a graduate of this medical school, who entered the Public Health Service after training and was involved in a heart disease control program with which he developed an interest in muscle physiology and muscle biochemistry.  He had some post-doctoral research experience in the Cori laboratories and then set up laboratories here.  He perhaps has the largest training program in this area of any center in the country.  He is a recognized authority internationally on the biochemical or enzyme adaptations that occur in muscle with training and has a variety of clinical research adaptations that are of interest.  One of these is in a rehabilitation program for men and women who have had heart attacks for whom programs of planned exercise are worked out for them, and we use an inside track in our Rehabilitation building for that purpose.

More recently, Dr. Holloszy and another younger physician working with him, Dr. Andrew Goldberg, is running people who have end-stage renal disease, that is, they are on dialysis.  These people are benefiting greatly from the exercise they get.  So they were finding new uses, energy expenditure, or of exercise, in handling of patients with chronic and very serious diseases.  From a very basic work in rats, Dr. Holloszy’s group worked all the way up to people who were being rehabilitated from coronary artery disease.

Are there other Divisions that we have not mentioned so far?

Well, I told you before, we’ve had previously a Division of Epidemiology which was a very active and good research division up until about 1970 or ’71.  The original head of that division was Dr. Richard Krause, whom we brought here from the Rockefeller University, who returned to the Rockefeller University but now heads one of the National Institutes of Health, the National Institute of Allergy and Infectious Disease.  When he left we began a new program, the Lipid Research Clinic Program, which took the space that the Division of Epidemiology had previously occupied, so we have been hampered in re-establishing that division.

You would like to, it is not a question of epidemics being passé.

There are two questions.  We did try for awhile to find a successor but one of the limitations was space for the person to develop his own unit.  Another limitation was that we were looking for a physician/epidemiologist – there are other kinds, sociologists, economists, I guess – and we were not able to attract people that we wanted.  I am sure that the search committee, in looking for a new chairman of the department, are probably looking at epidemiologists as well as other kinds of people, but a need will be additional space for whatever new development occurs and that can only come with the Clinical Science Building that they’re planning.

Now the Lipid Research Clinic or Center really is a totally distinct division, focused on the problems of blood lipids, dietary fats, and the occurrence of myocardial infarction, and they’re one of some twelve centers that are in one national protocol that has a group – each center has 350 or 400 men who had high blood cholesterol levels and who for seven years agreed to modify their diet and take a drug.  The drug is one that reduces serum cholesterol levels and the control group are people who are on the same diet and taking a placebo, an inactive drug.  It is a double blind study and we won’t know until the end of this study in 1982 what the outcome is.  What we do know is that serum cholesterol levels are significantly lower in both groups than they were initially and lower in— I guess we don’t know which one.  I guess all we can say at this time is that the serum cholesterol levels in the group as a whole are lower than they were initially.

So you have hopes of a therapeutic measure to reduce serum cholesterol?

And the effectiveness of this device and avoiding myocardial infarction or deaths due to heart disease.

I know you have surveyed departments of Preventive Medicine and Public Health in medical schools throughout the country to gain a perspective on how the department should operate in the future.  I notice that you’ve found that great growth in the idea of community medicine, leading equivalents of your department in other medical schools is community medicine.  What are your views as a research area or as an area of medical education?

Well briefly, there perhaps are as many or more departments of Community Medicine in medical schools in the United States today as there are departments that have remained with the name Preventive Medicine.  We chose here not to take that tack when this was a popular change to make, but this wasn’t the first change that had been proposed, even earlier some departments were called the Departments of Social Medicine.  We did not change the name of the department nor the focus of the department at that time, although much of what we were doing in training of medical students was that.  Our chief training during much of the time while I was chairman of the Department was in outpatient care, where we had students full-time in the clinics for three months and they really got their own little panel of patients.  The student had to deal not only with the problem of illness, but the economic and the family problems, so they were really concerned with social and community problems.  Another reason why we haven’t chosen to take that route is that we have been involved with the community in many other ways, and didn’t think we had to change the name of the department just to accomplish that.

It applies a narrower focus, doesn’t it?

Well, and sort of a separation from the mainstream of medical practice, so we don’t want to do that.  We have always tried to bring the department and its interests as close to the practice of medicine as it can.  So it has more, we feel, significance to training and to preparation of doctors for future care.

So you envision the Department to continue as multi-faceted and with each Division having research interests?

That’s a question that I am not going to answer, I guess the way you would like to have me answer, because I think that the role or the right or maybe the need of the School to look at what the Department has done, what it is doing currently, and more importantly what are the needs of the future.  I am sure if I were coming in as Department chairman I might not want to have quite the same organization in the future that we have had in the past.  I think any new chairman should have that option and I would hope that a search committee would select a person who was thoughtful, who was a leader, who could relate whatever new program might evolve here to the mainstream of medical training within other parts of the institution.  Those are my own thoughts.

What are your plans for emeritus professorship?

Well, I guess I don’t have any firmly-made plans.  I am rather looking forward to freedom from the administrative duties because they are many.  One of the great benefits I’ve had in the past, is I’ve had a strong supporting faculty and staff.  The government and university requirements for administrative actions moved us to the point where we had to get a Business Manager or we thought we did.  Fortunately we have a most capable person of that kind, so that the job now is not as difficult as it was a few years ago.  Yet I will be glad to be free of those responsibilities.  I’ll want to write, maybe even get back into the laboratory although that is more a dream than a reality.  And I hope there is some freedom to spend more time in my Michigan cottage and travel more than I have had a chance to do, at least travel for fun – I have had plenty of chances to travel.

But your interests in research and writing will continue?

Oh yes.  I still have some ongoing NIH appointments that are likely to keep me busy for several years.

Well are there any major areas that we failed to cover?

Well, I guess finally I’d like simply to record the fact that although it was said in the beginning, Dr. Alan Gregg had said that this could be a lonely role, and early I found it so.  This has been a most rewarding experience and I think the area in which I worked has been one which there has been a lot of personal satisfaction in watching things evolve and some part of these, being a part of them.  It has been great to see the Medical School grow in numbers and staffing and support so there is a lot more going on here, and certainly a much larger research base than when I first came here.  There have been many rewards in this job and I wouldn’t have it changed.

Well, Dr. Shank I want to thank you for speaking with me today.  I think we have covered many different topics and we have a good addition to the oral history series.  So thank you.

Well I hope it will interest someone.  Thank you.