Clinical Trials and the Reorganization of Medical Research in post-Second World War Britain

Abstract

The rise of biomedicine is usually associated with the transformation of biological and medical research in the United States following the vast expansion of funding, both private and public, in the years after the Second World War.1 Along with the other authors in this issue, we are interested in describing this phenomenon in national contexts other than the United States. Our discussion of biomedicine in Britain draws upon many of the same themes as our fellow authors and the existing literature on the US—the new role of the state as scientific entrepreneur; the relationship between experimental medicine and clinical services; and the growing institutionalization of associations between laboratory and clinic—to emphasize the clinical trial as a privileged form of therapeutic evaluation in the post-war years. In particular we are keen to stress that the randomized clinical, or controlled, trial (RCT) in Britain developed within a period of increasing centralization of state policy and planning for health services and medical research. The epistemological success of the RCT in demonstrating the value of the anti-tuberculosis drug streptomycin elevated the technique to international prominence in the late 1940s. The 1948 trials of streptomycin conducted by the British Medical Research Council (MRC), along with similar trials in the United States, are usually recognized as the world's first randomized controlled trials. Indeed, the streptomycin trials, and the trials of PAS and isoniazid that followed in the early 1950s, did combine the statistical technique of randomization, with new organizational techniques, such as the division of specialist labour, and central review and data collection, across multiple sites of study. As Peter Keating and Alberto Cambrosio, Ilana Lowy, and Harry Marks have shown for the US, the success of the co-operative (that is, multi-centre) clinical trial was intimately related to the new role of the federal government, through the National Institutes of Health, in funding such organized biomedical research.2 Similarly, using treatment trials for tuberculosis and lung cancer as our case studies, we show for Britain that the promotion and organization of co-operative trials was fundamentally part of the MRC's new role within the state. We argue that the Council pursued the trials as a means of unifying a research landscape that was characterized by localism and suspicions about MRC plans to remodel clinical research to resemble the basic sciences. We argue further that a controlled trial must be understood both as a tool to produce knowledge persuasive enough to direct best clinical practice, and as a powerful means to discipline research workers in disparate settings.3 Neither process was particularly straightforward. It took years of clinical trials of anti-tuberculosis chemotherapies before sanatorium treatment and bed-rest were entirely given up by British physicians. The MRC's 1955 trials carried out in the Indian city of Madras (Chennai) are generally regarded as conclusively showing domiciliary care to be redundant in the presence of chemotherapeutic intervention; however, we argue that trials influenced but did not change practice overnight. Similarly, the lung cancer trials initiated by the MRC following a conference in 1957 as part of a broader programme of therapy trials for various types of cancer, proved difficult to run. Furthermore, they did not resolve the controversy as intended, not least because procedures and treatment pathways were well established before the trials. Serious historical attention to the organizational details, reception of such RCTs, and resulting changes in practice, is needed if we are not to be blinded by hindsight. Before we turn to the trials, however, we need to discuss the role of the MRC in the history of biomedicine in Britain and the place of the Council within the post-war socialized National Health Service (NHS).