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Between Expertise and Biomedicine: Public Health Research in France after the Second World War

Published online by Cambridge University Press:  17 May 2012

Luc Berlivet
Luc Berlivet
Affiliation:
Luc Berlivet, PhD, Research Fellow, Centre de Recherche Médecine, Sciences, Santé et Société (CERMES), Site CNRS, 7 rue Guy Môquet, 94801 Villejuif Cedex, France; berlivet@vjf.cnrs.fr
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Medical History , Volume 52 , Issue 4 , October 2008 , pp. 471 - 492
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Copyright © The Author(s) 2008. Published by Cambridge University Press

References

1 Jean-Paul Gaudillière, Inventer la biomédecine: la France, l'Amérique et la production des savoirs du vivant (1945–1965), Paris, La Découverte, 2002, p. 93. Pioneer studies by Lily E Kay, The molecular vision of life: Caltech, the Rockefeller Foundation, and the rise of the new biology, Oxford and New York, Oxford University Press, 1993, and Who wrote the book of life? A history of the genetic code, Stanford University Press, 2000, have paved the way to a mushrooming literature.

2 For a concise, still enlightening introduction to the “(con)figurational” approach to social processes, see Norbert Elias, What is sociology?, New York, Columbia University Press, 1978, pp. 128–32. For an alternative approach to relational analysis of social action, see Andrew Delano Abbott, Chaos of disciplines, University of Chicago Press, 2001.

3 David E Lilienfeld, ‘“The greening of epidemiology”: sanitary physicians and the London Epidemiological Society (1830–1870)’, Bull. Hist. Med., 1978, 52: 503–28, on p. 527. For a more balanced analysis, see Anne Hardy, ‘On the cusp: epidemiology and bacteriology at the Local Government Board, 1890–1905’, Med. Hist., 1998, 42: 328–46, and idem, ‘Methods of outbreak investigation in the “era of bacteriology” 1880–1920’, Soz. Präventivmed., 2001, 46 (6): 355–60; J Andrew Mendelsohn, ‘“Typhoid Mary” strikes again: the social and the scientific in the making of modern public health’, Isis, 1995, 86: 268–77; and idem, ‘From eradication to equilibrium: how epidemics became complex after World War I’, in Christopher Lawrence and George Weisz (eds), Greater than the parts: holism in biomedicine, 1920–1950, Oxford University Press, 1998, pp. 303–31.

4 See J Andrew Mendelsohn, ‘Medicine and the making of bodily inequality in twentieth-century Europe’, in Jean-Paul Gaudillière and Ilana Löwy (eds), Heredity and infection: the history of disease transmission, London, Routledge, 2001, pp. 21–79; as well as Olga Amsterdamska, ‘Standardizing epidemics: infections, inheritance and environment in prewar experimental epidemiology’, in ibid., pp. 135–79, and idem, ‘Achieving disbelief: microbial variation and the disciplinary and national styles in epidemiology’, Stud. Hist. Biolog. Biomed. Sci., 2004, 3: 483–507.

5 The INH's hegemony in public health research did not go unchallenged. For instance, after the creation of the Institut National d'Etudes Demographiques (INED), in 1946, a group of demographers proved instrumental in framing the anti-alcohol policy, although they tended to approach this particularly French “social plague” merely through its impact on the mortality of middle-aged males, and did not address medical issues (such as the care of alcoholics). INED's influence on the issue vanished after its leading demographer on the topic, Sully Ledermann, died suddenly in 1967. Luc Berlivet, ‘Les démographes et l'alcoolisme: le populationnisme, l'INED et la “lutte contre les fléaux sociaux”’, Vingtième Siècle, 2007, n° 95: 93–113.

6 This, despite the renewed interest in “social hygiene” and “social medicine” witnessed in the decade or so that followed the Liberation of France; see Lion Murard and Patrick Zylberman, ‘Apôtres et experts: une histoire de la médecine sociale’, unpublished report for the Ministère de l’équipement, Paris, 1982.

7 In reality, 1964 marked a redefinition of the aims of and approach to medical research, the renaming of the INH as INSERM put the finishing touch to the incorporation of a few medical research laboratories that had been created in 1952 by physicians under the title “Fondation Claude Bernard”; see Jean-François Picard, ‘Poussée scientifique ou demande de médecins? La recherche médicale en France de l'Institut National d'Hygiène à l'INSERM: contributions à l'histoire de la recherche médicale en France au XXème siècle’, Sciences Sociales et Santé, 1992, 10 (4): 47–106, pp. 85–8.

8 In 1963, a project was discussed that would have seen the transformation of the INH into a “national institute for medical research”, without any reference to “health”; see ‘Projet d'un INR’, 28 Aug. 1963; INSERM Archives: Bugnard Papers (Centre des Archives Contemporaines (hereafter CAC) 20060293), box 1. However, fears that such a renaming could be interpreted as indifference to peoples’ wellbeing ensured that “health” remained in the Institute's title.

9 Jean-François Picard, ‘Aux origines de l'INSERM: André Chevallier et l'Institut national d'hygiène’, Sciences Sociales et Santé, 2003, 21 (1): 5–26; Jean-François Picard and William H Schneider, ‘From the art of medicine to biomedical science in France: modernization or Americanization?’, in William H Schneider (ed.), Rockefeller philanthropy and modern biomedicine: international initiatives from World War I to the Cold War, Bloomington, Indiana University Press, 2002, pp. 106–124; William H Schneider, ‘War, philanthropy, and the National Institute of Hygiene in France’, Minerva, 2003, 41(1): 1–23.

10 Lion Murard and Patrick Zylberman, ‘La mission Rockefeller en France et la création du comité national de défense contre la tuberculose (1917–23)’, Revue d'histoire moderne et contemporaine, 1987, 34: 257–81.

11 William H Schneider, ‘The men who followed Flexner: Richard Pearce, Alan Gregg, and the Rockefeller Foundation medical divisions 1919–1951’, in Schneider (ed.), op. cit., note 9 above, pp. 7–60, on pp. 7–13.

12 Picard and Schneider, op. cit., note 9 above, pp. 113–14. The Rockefeller was also instrumental in the contemporary establishment, along the same lines, of the London School of Hygiene and Tropical Medicine; Lise Wilkinson and Anne Hardy, Prevention and cure. The London School of Hygiene & Tropical Medicine: a 20th century quest for global public health, London, Kegan Paul, 2001. The articulation between teaching and research, and its situation within the most important French medical school, would have provided Léon Bernard’s Institute with key assets that the all too idiosyncratic Institut Pasteur could not dream of.

13 Schneider, ‘War, philanthropy’, op. cit., note 9 above, pp. 13–15.

14 Ibid., p. 19.

15 For an historiographical overview, see François Rouquet, ‘La technocratie sous Vichy: opportunité, continuité et représentations’, in Vincent Dubois and Delphine Dulong (eds), La question technocratique: de l'invention d'une figure aux transformations de l'action publique, Strasbourg, Presses Universitaires de Strasbourg, 1999, pp. 55–75.

16 Picard, op. cit., note 9 above, pp. 14–17.

17 Ibid., p. 13. The Marseille Institute of Hygiene, of Rockefeller origin, remained one of the most important of the INH's research centres, with 1.5 million francs, a tenth of the first budget (5 million francs) allocated to its activities.

18 Ilana Löwy, ‘La science dans son contexte: l'Institut national d'hygiène et la recherche médicale sous Vichy’, Sciences Sociales et Santé, 2003, 21 (1): 27–30.

19 Alexis Carrel adroitly seized the opportunity created by the French capitulation and the subsequent installation of a political regime that attempted to fight the “degeneration” of the country, source of all its problems. He sailed back to France in 1941 (he had by then retired from the Rockefeller Institute) wreathed in glory, his scientific prestige reinforced by the huge international success of his bestseller: Man, the unknown, first published in 1935 (in English by Harper & Brothers, and in French by Plon). Thanks to his connections with Pétain's entourage, he persuaded the government to set up a research institute of a new kind, entirely dedicated to the “study of man's problems”. Alain Drouard, Une inconnue des sciences sociales: la Fondation Alexis Carrel (1941–1945), Paris, INED, Editions de la Maison des sciences de l'homme, 1992; Andrés Horacio Reggiani, ‘Alexis Carrel, the unknown: eugenics and population research under Vichy’, French Historical Studies, 2002, 25 (2): 331–56.

20 The full citation, praising the help provided by Chevallier, as head of the INH, to the US Army Medical Service in Europe, is included amongst a selection of his personal papers reproduced on a CD-Rom: ‘André Chevalier 1896–1964’, published in 2005 by INSERM. Chevalier's papers have recently been deposited at the Centre des Archives Contemporaines (CAC) of the French National Archives, in Fontainebleau: see the files 20050593/1 to 6.

21 From December 1945 to March 1946, Louis Bugnard had travelled along the East Coast of the United States, in order to study the American way of doing research. However, the British organization of research might have seemed much easier to emulate than the mighty American one (Bugnard's travel diaries of a later trip to Britain are deposited at CAC: 20010165/1). As late as 1962–63, during negotiations between the INH and the Comission du Plan (Planning Commission) on the development of the Institute, he pledged the creation of fifty research units by the end of the decade, so as to equal the number already established by the British Medical Research Council. Gaudillière, op. cit., note 1 above, pp. 26 and 309.

22 The minutes of this “Conseil scientifique”, as the advisory body was named, for the period up to 1976 are kept at the INSERM Archives: 9440/01and 02.

23 Trémolières had previously worked with Chevallier on the impact of the war on the diet of the French population, see A Chevallier and J Trémolières, ‘Enquêtes sur l’état de nutrition des populations pendant la guerre dans certains pays d'Europe’, INH, 80 pages. (This unpublished report is reproduced on the CD-Rom mentioned in note 20 above.)

24 Jean-Paul Gaudillière, ‘Normal pathways: Controlling isotopes and building biomedical research in postwar France’, J. Hist. Biol., 2006, 39 (4): 737–64, esp. pp. 757–9.

25 CNRS had been established as early as October 1939, but did not deal with medical research; Jean-François Picard, La république des savants: la recherche française et le CNRS, Paris, Flammarion, 1990.

26 Although the INH's budget more than doubled between 1944 and 1947, when it amounted to 50 million francs, this was little compared to the one billion francs received by the main French research institutes: CNRS, CEA, and the Pasteur Institute that very year; Picard, op. cit., note 7 above, p. 79.

27 It was not until the “Debré reform” of 1958 (named after its instigator, Robert Debré, the arch-mandarin and father of the then prime minister) that full-time hospital appointments became the norm rather than the (rare) exception. Until then, even the doctors and professors appointed to teaching hospitals had to make a living out of private practice. Haroun Jamous, Sociologie de la décision: la réforme des études médicales et des structures hospitalières, Paris, Editions du CNRS, 1969.

28 Minutes of the Conseil d'administration meeting, 14 Dec. 1955; INSERM Archives: 9239/01.

29 Results of these investigations (based on basic cartographical techniques that highlighted the difference in incidence of the various diseases between the French regions) were published in the first issue of the Recueil des travaux de l'Institut National d'Hygiène, in May 1944.

30 Under the leadership of Georges Martin-Bouyer, the Section des Maladies Transmissibles carried out a wide range of activities that eventually included the investigation of non-infectious disease. Martin-Bouyer gained some notoriety in 1972 when he managed to trace the poisoning of over 200 babies to the use of talcum powder contaminated by hexachlorophene (an episode otherwise known as l'affaire du talc Morhange).

31 From 1966 to 1969, they undertook a pioneering survey of the health needs (besoin de santé) of a supposed prototypical population: the inhabitants of Soissons, in Picardie (one amongst the hundreds of French cities with a population of about 20,000 inhabitants); CAC: 19760224/4-120.

32 The issue had already been touched upon by specialists in “community medicine”, such as Jerry Morris, and the importance of the issue for the future of the NHS prompted the rise of “health services research” from the 1980s onwards. See Kelly Loughlin, ‘Epidemiology, social medicine and public health: a celebration of the 90th birthday of Professor J N Morris’, Int. J. Epidemiol., 2001, 30 (5): 1198–99; and Virginia Berridge, Daphne A Christie and E M Tansey (eds), Public health in the 1980s and 1990s: decline and rise?, Wellcome Witnesses to Twentieth Century Medicine, vol. 26, London, Wellcome Trust Centre for the History of Medicine at UCL, 2006, pp. 42–9.

33 Lucie Laporte had been one of Eugène Aujaleu's closest aides during his eighteen-year-long mandate as head of the Direction de l' Hygiène Sociale, when he reorganized and reinforced the role of the central health administration; Murard and Zylberman, op. cit., note 6 above, pp. 241–51. She then followed Aujaleu when he was appointed as INSERM's first Director, in 1964. See also the entry ‘Aujaleu’ in Roland Drago, Jean Humbert, and Jean Tulard (eds), Dictionnaire biographique des membres du Conseil d'Etat (1799–2002), Paris, Fayard, 2004.

34 Among the sources of information on morbidity were the statistics routinely produced by the system of compulsory declaration of diseases (“dispositif de surveillance des maladies à declaration obligatoires”). In a series of memoranda to the Minister of Health, Simone Veil, Burg worried that INSERM “[was] in an ambiguous situation, as while its budget should fund nothing but research activities, within the Medico-Social [Research] Division it also covers activities that partly amount[ed] to control and routine.” (‘Confidentiel—Notes à l'attention de Madame Veil, Ministre de la santé’, 22 April 1976; Note 2: ‘Réorganisation de la Division de la Recherche Médico-Sociale—Division de la Recherche Médico-Sociale: Historique’, p. 2. The original text reads: “se trouve dans une situation ambigüe car son budget, qui ne devrait servir qu’à financer des activités de recherche, couvre au niveau de la Division Médico-Sociale, des activités qui relèvent en partie du contrôle et de la routine”). In another memorandum of the same series, Burg described three of the sections as “pursuing general activities of research and routine [sic], on public health actions …”. (Note 1: “Réorganisation de la Division de la Recherche Médico-Sociale—Situation actuelle de la recherche en santé publique et en épidémiologie à l'INSERM—Place des Sections Spécialisées de la Division de la Recherche Médico-Sociale’, p. 2. The French text reads: “sections ayant des activités générales de recherche et de routine sur les actions en santé publique …”.) Both documents are kept in: INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC: 2001165), box 23.

35 Even Bugnard's praise for medical statistics in his foreword to the first of the long series of monographs published by the INH, rang hollow: “Only the progress of statistics, very intensive in these last years, could bring to the physician, the hygienist, and the researcher, the necessary tool for the accomplishment of their task.” (“Seuls les progrès de la statistique, très accentués au cours de ces dernières années, pouvaient apporter au médecin, à l'hygiéniste, au chercheur, l'outil indispensable à l'accomplissement de leur tâche.”) Ministère de la santé publique, Documents statistiques sur la morbidité par cancer dans le monde, Monographie de l'Institut national d'hygiène No. 1, Paris, INH, 1952, pp. 3–5, on p. 3.

36 “Ces statistiques on été confiées à l'INSERM par l'INSEE [Institut National de la Statistique et des Etudes Economiques]. En aucun cas elles ne peuvent être assimilées à une activité de recherche.” Ibid., p. 36.

37 See, for example, M Guidevaux, B Morando, F Derriennic, ‘Mortalité périnatale’, Bull. Inst. Natl. Santé Rech. Méd., 1970, 25 (4): 623–37; M H Bouvier and M Guidevaux, ‘Mortality from disorders of the respiratory system throughout the world between 1950 and 1972’, World Health Stat. Q., 1979, 32 (3): 174–97.

38 François d'Aubert, Claude Evin, Rapport fait au nom de la commission d'enquête sur les conséquences sanitaires et sociales de la canicule, Paris, Assemblée Nationale (Documents d'information de l'Assemblée nationale, n° 1455), 2004, vol. 2, p. 140. The report is online at http://www.assemblee-nationale.fr/12/dossiers/canicule.asp; last accessed 4 July 2008.

39 In December 1965, that is just before DRMS was established, the number of researchers appointed to permanent positions by the Institute already amounted to 455: 10 directeurs de recherche, 52 maîtres de recherche, 140 chargés de recherche, and 253 attachés. The number of technicians was 528. Propositions de l'INSERM pour le Vème plan, p. 2; CAC: 19800235/7. Ten years later, the number of researchers had more than doubled to 1,020; meanwhile, the overall budget had jumped from 54 million francs in 1964 to 246 million in 1974. That year, DRMS's resources reached 839,000 francs (salaries, and other personnel expenses excluded). See N Campanini's letter to L Laporte, 27 March 1975, CAC: 19800235/13.

40 Alice Lotte, Georges Pequignot, and Françoise Hatton belonged to this majority of boursiers who entered the world of public health by chance, before embarking on a career in research, and being eventually appointed as head of a section. Lotte was among the pioneers who joined the INH during the war; Pequignot started working in the Nutrition Section ten years later; while Françoise Hatton was one of the last defenders of the DRMS, before it was disbanded and her section was converted into a research unit in 1977/8. (Interview with Hatton, 30 June 2005, and Pequignot, 8 July 2005; a transcription of Lotte's interview by S Mouchet and J F Picard is accessible at http://picardp1.ivry.cnrs.fr/Lotte.html; accessed 11 April 2008.) Two successive heads of the Cancer Section, Pierre Denoix and Robert Flament, moved on to become professors of medicine, and later directors of the Institut Gustave Roussy, by far the most prominent French research and treatment centre in the field (Denoix was eventually appointed Director General for Health).

41 For an exploration of the material culture of punching, sorting, computing, etc., see Jon Agar, The government machine: a revolutionary history of the computer, Cambridge, MA, MIT Press, 2003.

42 The difficulties in the management of the DRMS are spelt out in: ‘7e plan: Effectifs chercheurs, techniciens, administratifs’, CAC: 19800235/13.

43 Every year, the DRMS submitted a list of surveys (enquêtes) either in preparation, or in progress to the Minister of Health for approval. However, more investigations were undertaken to answer demands by the Comité d'Etudes Sanitaires de la Sécurité Sociale that had been established in 1948 to help funding research in public health. For an overview of these surveys, see, especially, ‘Liste récapitulative des enquêtes effectuées par les sections spécialisées de l'INSERM’, and ‘Enquêtes statistiques, études épidémiologiques en cours. Projets d'enquêtes pour l'année 1975’, October 1974. INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 19, file ‘Le Vésinet 1972’; and box 18, file ‘Mlle Laporte’.

44 L Laporte, ‘Note pour Monsieur Maglott, Directeur Administratif et Financier, n° 869/S’, 5 December 1974; CAC: 19800235/13. (The French original of the two quotes reads, respectively: “l'insuffisance des effectifs permanents”, and “niveau d'effectif satisfaisant”.)

45 Laporte and at least four of these directors had been trained as public health doctors, an unusual background in the world of French medical research. See Laporte's letter to Mr Jeunot (then INSERM's head of personnel), 26 July 1976, N°268/S; CAC: 19800235/4.

46 See the recent report, Les femmes dans la recherche française, Livre blanc, Paris, Ministère de la Recherche, 2002.

47 Personal communication from Pierre Aïach; interview with Françoise Hatton. I first heard of these terms during informal conversations with the INH/INSERM medical or public health researchers, who quoted them to stress the feeling many had that the DRMS was somehow a world apart.

48 Marie Ménoret, ‘The genesis of the notion of stage in oncology: the French Permanent Cancer Survey (1943–1952)’, Soc. Hist. Med., 2002, 15 (2): 291–302.

49 On Denoix's role in the development of the epidemiology of cancer in France, see Luc Berlivet, ‘Une santé à risques. L'action publique de lutte contre le tabagisme et l'alcoolisme en France (1954–1999)’, PhD thesis, University of Rennes 1, 2000, pp. 75–7.

50 D Minvielle, P Aïach, D Cebe, et al., Problèmes de santé dans une agglomération urbaine en mutation: Boulogne-Billancourt, Paris, INSERM, 1975. Another much smaller investigation launched approximately at the same time also addressed the problem of social inequalities in health: DRMS, ‘Les processus cumulatifs d'inégalités: étude de cas dans un quartier défavorisé de Paris – 11ème’, 22 January 1974; INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 18, file ‘Mlle Laporte’.

51 Pierre Aïach, a young economist who had just joined INSERM in 1969, was instrumental in the planning and implementation of the investigation. For comments on his frustrations regarding the medical approach to health and disease that prevailed at INSERM, see P Aïach, ‘Une confrontation initiatique. Un exemple de recherche en santé publique: la DRMS’, Cahier du Centre de Recherches Sociologiques, 1988, 9: 243–56; and idem, ‘Limites et ambiguïtés de la recherche en santé publique: l'exemple de l'enquête de Boulogne-Billancourt’, Cahiers de Sciences Humaines, 1992, 28: 13–21.

52 This was the view most commonly expressed during my interviews with medical statisticians when I started researching the history of twentieth-century French epidemiology in the mid-1990s. I explored a much more complicated genealogy in my PhD dissertation, Berlivet, op. cit., note 49 above, pp. 73–107.

53 Ibid., pp. 74–7.

54 Luc Berlivet, ‘“Association and causation”: the debate on the scientific status of risk factor epidemiology 1947–c.1965’, in Virginia Berridge (ed.), Making health policy: networks in research and policy after 1945, Amsterdam and New York, Rodopi, 2005, pp. 43–74; idem, ‘Exigence scientifique et isolement institutionnel: l'essor contrarié de l’épidémiologie française dans la seconde moitié du XXe siècle’, in Gérard Jorland, Annick Opinel and George Weisz (eds), Body counts: medical quantification in historical and sociological perspective, Montreal, McGill-Queen's University Press, 2005, pp. 335–58, pp. 341–2.

55 The “Groupe d’Étude sur la Fumée du Tabac” (Tobacco Smoke Research Group) was established by SEITA's Director General in order to finance research on the alleged dangers of tobacco smoke. In 1965, SEITA contributed 600,000 francs to INSERM's budget, while the Social Security contributed a mere 400,000 francs. (Propositions de l'INSERM pour le Ve plan, p. 3; CAC: 19800235/7).

56 One of the first two medical doctors to join the unit later wrote about the kind of sarcasm he was subjected to by fellow interns when he opted for medical statistics: “Colleagues from other disciplines had written on the walls of the staff room, among other notable statements, this sentence: ‘Statistics is to the statistician what the gas street-lamp is to the drunkard; it supports him more than it illuminates him.’ In 1955, to embark on a career in medical statistics was a real adventure!” (“Mes collègues des autres discipline avaient écrit sur les murs de la salle de garde, entre autre déclarations remarquées, la phrase suivante: ‘La statistique est au statisticien ce que le bec de gaz est à l'ivrogne; elle le soutient plus qu'elle ne l’éclaire.’ S'embarquer dans la statistique en médecine était, en 1955, une véritable aventure!” Robert Flamant, Malade ou cobaye: Plaidoyer pour les essais thérapeutiques, Paris, Albin Michel, 1994, pp. 24–5.)

57 Schwartz's interests were so alien to French medical education that in 1963 he resolved to set up an association to organize short courses in medical statistics. The Centre d'Enseignement de la Statistique Appliquée à la Médecine (CESAM) proved a great success: the number of students rose from 60 in the first year to over 1200 some twenty-two years later. This rather militant approach also bound the pioneers very strongly together; the young researchers were soon put in charge of lectures, seminars, and “practicals”. Many of the most motivated students would later swap places and start teaching in their turn; Berlivet, op. cit., note 49 above, pp. 79–81.

58 During her interview with Mouchet and Picard in 2002 (op. cit., note 40 above) Alice Lotte (former head of the Epidemiology Section) asserted that: “One had to be a [trained] clinician to comprehend correctly social medicine and epidemiology… . There were things that Daniel Schwartz, who was a mathematician, and very clever, did not understand.” (“Pour bien comprendre la médecine sociale et l’épidémiologie, il fallait être clinicien… . Daniel Schwartz, qui était mathématicien et très intelligent, ne comprenait pas certaines choses.”)

59 Edward Higgs, ‘Medical statistics, patronage and the state: the development of the MRC Statistical Unit, 1911–1948’, Med. Hist., 2000, 44 (3): 323–40. The Unit had already become world famous for planning and implementing the first properly randomized clinical trial of streptomicyn, as well as the already mentioned investigation into the relation between smoking and lung cancer (see Berlivet, ‘“Association or causation”’, op. cit., note 54 above).

60 See Unit 21's Annual Reports: Archives INSERM 19920342, ‘Dossier U. 21 1960–1974’.

61 L Fleck, Genesis and development of a scientific fact, University of Chicago Press, 1979 (first published 1935); on the rise of “relative risk epidemiology”, see Berlivet, ‘“Association or causation”’, op. cit., note 54 above, and G M Oppenheimer, ‘Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947–70)’, Int. J. Epidemiol., 2006, 35 (3): 720–30.

62 Schwartz's attention to the dissemination of results was notable from his first investigation. One of his earliest articles came out in the most important French medical periodical of the time: D Schwartz and P Denoix, ‘L'enquête française sur l’étiologie du cancer broncho-pulmonaire: le rôle du tabac’, La Semaine des Hôpitaux de Paris, 1957, 33: 424–37; whereas the final results (which underlined the role of inhalation, and pointed at a relationship between smoking and cancer of the bladder) were published in a prominent American journal: D Schwartz, R Flamant, J Lellouch and P Denoix, ‘Results of a French survey on the role of tobacco, particularly inhalation, in different cancer sites’, Journal of the National Cancer Institute, 1961, 26: 1085–108 (despite what the title suggests, the investigation in question was a case-control study, rather than a survey).

63 Archives INSERM 19920342, ‘Dossier U. 21 1960–1974’; Unit 21's Annual report for 1969, p. 34; “pastis” is the name of a popular French anise-flavoured apéritif.

64 “Ça nous a permis de mettre en œuvre … un travail qui était moderne et qui sortait de l'archaïsme de nos vieilles méthodes.” (Berlivet, op. cit., note 49 above, p. 77.)

65 In Britain, M Greenwood, and A B Hill had prompted a debate on this question in the early 1930s; Joan Austoker and Linda Bryder, ‘The National Institute for Medical Research and related activities of the MRC’, in Joan Austoker and Linda Bryder (eds), Historical perspectives on the role of the MRC: essays in the history of the Medical Research Council of the United Kingdom and its predecessor, the Medical Research Committee, 1913–53, Oxford University Press, 1989, pp. 35–57, esp. pp. 46–7.

66 E Eschwege, H Sancho, A Spira, H P Beyer, and D Schwartz, ‘Résultats après cinq ans d'un essai thérapeutique sur l'angiome tubéreux cutané’, Archives Françaises de Pédiatrie, 1972, 29 (1): 49–65. The first reference to this clinical trial is in Unit 21's (unpaginated) Annual report for 1961 (Archives INSERM 19920342, ‘Dossier U. 21 1960–1974’; § C “Recherche dans le domaine thérapeutique”).

67 In 1962, a meeting of seventeen European oncologists from six countries launched the Groupe Européen de Chimiothérapie Anticancéreuse (European Group of Anti-cancer Chemotherapy), which became EORTC in 1968. The Group played a most prominent part in the organization of multi-centre clinical trials in oncology.

68 See, for example, the ‘Evaluation of the needs in terms of functional rehabilitation in hospital departments’ in collaboration with Minvielle's section: Annual report for 1967, p. 18 (Archives INSERM, 19920342, ‘Dossier U. 21 1960–1974’).

69 In 1962, the research unit received a request from two clinicians to research cardiovascular diseases; see Rapport annuel pour l'année 1962, un-paginated, § A ‘Recherche sur les maladies cardio-vasculaires’. (Archives INSERM, 19920342, ‘Dossier U. 21 1960–1974’.)

70 Claude Rumeau-Rouquette, Bien naître: la périnatalité entre espoir et désenchantement, Paris, EDK, 2001.

71 See Denoix's enthusiastic letter (as Director General for Health) to Burg, 17 Nov. 1976: ‘Note pour Mr le Directeur Général de l'INSERM’; INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23, file ‘DGS (2)’.

72 See, for example, Burg's incensed letters to Françoise Hatton dated 28 Nov. 1974 and 26 Dec. 1974, criticizing two separate investigations recently launched by two different sections. INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (Cote CAC: 2001165), box 18, file ‘Mme Hatton’.

73 See the memorandum: ‘Projet d'un INR’, 28 Aug. 1963; INSERM Archives: Bugnard Papers (CAC: 20060293), box 1.

74 Even Burg, in the middle of his offensive against the sections, considered that up to 1970 at least: “le niveau des activités de la DRMS était plutôt meilleur [was rather superior] que le niveau moyen des autres laboratoires de l'INSERM.” ‘Confidentiel —Notes à l'attention de Madame Veil, Ministre de la santé; Note 3 : Projet de Réorganisation de la DRMS’, 22 April 1976, on p. 3. INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23.

75 The INH had launched its collection of monographs in 1952. According to most public health researchers, the format imposed by medical journals did not allow them to reveal with precision either the technicalities of their investigations, or the mass of information gathered in the course of a research project that had taken years to complete. (Interview with Françoise Hatton, 30 June 2005.)

76 Harold Garfinkel, ‘Conditions of successful degradation ceremonies’, American Journal of Sociology, 1956, 5: 420–4.

77 See the minutes of the meeting: ‘Conseil scientifique 13–16 décembre 1976’, INSERM Archives: 9440/02.

78 See the series of memoranda: ‘Confidentiel—Notes à l'attention de Madame Veil’, 22 April 1976, especially ‘Note 4: Modalités d'application’, 3 pages. INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23.

79 ‘Confidentiel—Notes à l'attention de Madame Veil, Ministre de la santé; Note 3 : Projet de Réorganisation de la DRMS’, 22 April 1976, on p. 4. INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23.

80 “Il en découlera obligatoirement [sic]: a- Une critique globale des activités de la DRMS, critique devant faciliter l'application du projet de réforme. b- Une proposition de continuer à implanter progressivement les sections de la DRMS au sein des hôpitaux à orientation spécialisée correspondante.” ‘Note 4: Modalités d'application’, pp. 1–2, on p. 1; INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23.

81 ‘Note 2: Réorganisation de la Division de la Recherche Médico-Sociale—Division de la Recherche Médico-Sociale: Historique’, p. 4; INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC classification mark: 2001165), box 23.

82 Interview with Philippe Lazar, 24 Nov. 2005; see also Berlivet, op. cit., note 49 above, pp. 128–9.

83 ‘Confidentiel—Notes à l'attention de Madame Veil, Ministre de la santé’, 22 April 1976; Note 2: ‘Réorganisation de la Division de la Recherche Médico-Sociale—Division de la Recherche Médico-Sociale Historique’, INSERM Archives: ‘Archives Direction Générale INSERM, 1969–1989’ (CAC: 2001165), box 23, on p. 4.

84 On this “revolution”, see Viviane Quirke, Collaboration in the pharmaceutical industry: changing relationships in Britain and France, 1935–1965, New York and Abingdon, Routledge, 2007, ch. 5.

85 Berlivet, op. cit., note 49 above, pp. 83–8. Social epidemiology draws attention to the “social determinants of population distribution of health”, N Krieger, ‘A glossary for social epidemiology’, J. Epidemiol. Community Health, 2001, 55 (10): 693–700, on p. 693.

86 Tellingly, the investigation (supervised by Natalie Bajos and Alfred Spira, another of Schwarz's former collaborators) was organized in collaboration with the Institut National d'Etudes Demographiques (INED), which had never stopped surveying the French population on demographic issues. See Population's special issue (vol. 48, no. 5), Sexualité et Sciences Sociales: les apports d'une enquête, ed. M Bozon and H Léridon, 1993.

87 The Institut de Veille Sanitaire (Institute for Public Health Surveillance) was established in 1998; it took over from the Réseau National de Santé Publique (National Network for Public Health) created in 1992.

88 See Pierre Ducimetière interviewed by J F Picard: “Il semble a posteriori que les missions de la DRMS n’étaient pas très éloignées de celles de l'InVS lors de sa création. En plus de la réalisation d'enquêtes ad hoc, la DRMS avait la responsabilité de l’établissement de plusieurs statistiques de routine dont la statistique nationale des causes de décès [après 1968] qui est demeurée jusqu’à ce jour une activité propre de l'INSERM. Cependant les liens de la DRMS avec le reste de l'INSERM et particulièrement de sa direction générale se sont distendus parallèlement à la priorité donnée au développement de la recherche biomédicale.” http://picardp1.ivry.cnrs.fr/Ducimetiere.html; accessed 11 April 2008.

89 In an interview with the author (24 Nov. 2005), Lazar made it plain that, as Director of France's main biomedical research institute, he could not afford to be seen to follow a private agenda when a global view of the field was paramount.