The Fire in Saint Louis

Progress on MFUA projects was severely impeded when, on July 12, 1973, a fire broke out at the Military Personnel Records Center in St. Louis. There were no injuries, but the fire, which burned sporadically for the next three days, hampered all MFUA studies requiring World War II-era medical details from Army hospital charts or epidemiologic data from Army personnel records. The MFUA staff in St. Louis was forced to relocate during the laborious process of cleaning and restoring the building. In May 1974, Seymour Jablon surveyed the situation for the committee: 80 percent of the Army personnel and medical records from World War II and the Korean War were lost. Mortality follow-up studies were still possible with the continued existence of the Beneficiary Identification and Records Locator Subsystem (BIRLS) on magnetic tape. Studies that aimed at epidemiologic factors or required review of clinical records were largely no longer feasible.

The fire forced the MFUA to rely more heavily on Navy records and less on the Army records with which it was so comfortable. "[O]ne of the great values of the program was precisely that it had been possible to study reasonably large groups of men with relatively rare conditions, and this would no longer be possible," the committee noted. Indeed, except for studies where the indexing was already complete, it became very difficult to develop studies for some diseases.¹⁴⁶

As part of his effort to hold more meetings, Remington convened the committee for a second time in 1973. The committee faced a changed external environment with the completion of the NRC reorganization. The Medical Follow-up Agency and CEVFUS now formed parts of the new Assembly of Life Sciences. The old Division of Medical Sciences continued to exist but as a much reduced entity. With the retirement of Charles Dunham, the MFUA staff and CEVFUS had to get to know an all-new hierarchy, including Leonard Laster, executive director of the new Assembly of Life Sciences.

In addition to discussing the new organizational structure, the committee devoted the bulk of its time at the second 1973 meeting to its subcommittee on MORPE and the revision of the Army's induction examination. The subcommittee focused on the data for cardiovascular research that could be retrieved from the revised examination. The larger committee chose to accept the subcommittee's report without forwarding it to the Army staff on the grounds that the proposal was not "original" enough.¹⁴⁷

In 1975, the issue of the MORPE program arose again. Since the Army had delegated MORPE interests to the Air Force, the current effort to modernize the examination system was directed to Armed Forces Entrance Examination Station (AFEES) operation, with a pilot run to commence at the Baltimore AFEES in 1975. Although the committee expressed its regret that no greater effort was being made to standardize examination procedures, yielding universally applicable data, it was encouraged by the fact that the new record system might make it possible to maintain a data base on those who had been rejected. Such a data base would be useful in controlling for the so-called healthy veteran syndrome, which postulated that men on the MFUA's veteran rosters were less susceptible to disease than the general population since they had passed the physical examination on induction. MFUA staff officer Robert J. Keehn suggested that new data arising from MORPE and the AFEES modernization impelled the committee to take the lead in the establishment of data bases for future studies, rather than relying on data bases laid down and preserved by others. ¹⁴⁸

As it worked with the subcommittees, the MFUA could also report progress in a number of ongoing projects. The group at the VA responsible for research on alcoholism approached the MFUA, anxious to set up long-term studies of alcoholism in association with the armed forces but confused as to how to proceed. Changing attitudes within the military regarding alcoholism—that is, considering it a disease worthy of treatment rather than a reason for summary dismissal—opened up new possibilities for research.¹⁴⁹ Plans were being made to update prisoner of war (POW) mortality for the POW study through 1972, to verify if the excess mortality reported in the first follow-up of World War II Pacific prisoners and Korean War prisoners continued to level off as it had in the 1965 results. Twin studies centering on schizophrenia, cancer morbidity, headache, and economic success were under way. A final report on the epidemiology of herniated lumbar disks was in preparation, following presentation of a preliminary report on this work at the annual meeting of the Society for Epidemiologic Research in May 1972. Also, the ongoing study of multiple sclerosis cases diagnosed in World War II entered a new phase as investigators made efforts to trace the course and prognosis of the disease for 30 years after its diagnosis. Three new studies were approved in late 1973, including a longitudinal study of cardiovascular disease, an examination of childhood cancer in relation to prenatal irradiation, and a series of related epidemiologic studies of various conditions for evidence of later death from cancer among World War II veterans. ¹⁵⁰

In 1974, despite the damage done to the MFUA program by the St. Louis fire, the agency made important strides in other areas. The committee met the new executive director of the Assembly of Life Sciences, Dr. Leonard Laster, who expressed approval of the Medical Follow-up Agency's history and current procedures, and promised not to get in the agency's way. He did, however, affirm a commitment to increase committee turnover, meaning that new CEVFUS members had to learn the ropes very quickly. In later years, this problem was handled by rotating a fixed group of members.

The etiquette of statistical reporting also commanded the committee's attention in 1974. The committee heard discussions of problems with the VA's new BIRLS system. CEVFUS unofficially affirmed its support for the creation of the National Death Index being proposed by the National Center for Health Statistics, a more efficient way to determine mortality for large numbers of people than the then-current system of making inquiries of each state. The National Death Index came on-line in 1979 and eventually proved to be very helpful in the work of the Medical Follow-up Agency.¹⁵¹

Updating the core statistical resources of the agency remained a common theme in the mid-1970s. Jablon continued his efforts to adapt Navy records to MFUA uses, reporting to CEVFUS on his progress at their 1975 meeting. The Navy records were problematic in that no machine-readable diagnostic index to the Navy files for World War II existed, making these files extremely difficult to use. Although "F card files," containing information on admissions to Navy hospitals during World War II existed, they were filed sequentially by hospital and year of admission, and the cards were not punched. When Jablon took a sample of 1,500 cards and examined them for diagnosis, he found that the top two diagnoses were for infectious and parasitic diseases and for acute infections of the respiratory system. Hence, reliance on these records meant a shift in program emphasis to tropical diseases and other common naval ailments. After studying the matter for some time, Jablon estimated in 1976 that $100,000 would be needed for punching items and producing a magnetic tape file in diagnostic sequence for MFUA use, if the agency wished to organize and preserve all of the Navy cards. With support from the National Cancer Institute, 6 million Navy hospital admissions from 1944 to 1945 had been preserved on magnetic tape by the early 1980s.¹⁵²

Although Dr. Zdenek Hrubec's absence during 1974, on a year's detachment at the Karolinska Institute in Stockholm, meant that no new twin studies were launched, the committee approved a new statement of ''Principles Which Govern Use of the NAS-NRC Twin Registry." Among the innovative studies in the area was one by Dr. Paul Taubman. Taubman, an economist rather than an epidemiologist, used the roster of twins to generate data on genetics and earnings. Of 6,000 twin pairs, 2,500 pairs responded to a questionnaire. Taubman ultimately reported his results in a monograph as well as several journal articles.¹⁵³

At Mid-Decade

In 1975, CEVFUS discussed the future of the MFUA program. Dr. Robert W. Miller of the National Cancer Institute noted a retreat from the emphasis on studies of trauma. In fact, no studies of trauma were being undertaken, in part because methods of treating trauma in the 1970s were so different from those used in World War II.

As chairman of the MFUA's advisory committee, Richard Remington urged the agency to approach the Department of Defense for possible consultation efforts, to tailor its program to better fit the needs of the VA, and to try to publish an account of its program in a journal such as the New England Journal of Medicine. Few of these proposals were carried out, however.¹⁵⁴

As a result, in the bicentennial year 1976, the MFUA faced a number of internal and external challenges. As Gilbert Beebe prepared to turn over the reins of the agency upon reaching the age of 65 in 1977, he surveyed the changes in the kind of epidemiologic studies that the MFUA undertook in the 1970s as opposed to the 1940s. He noted a number of complicating factors, including the 1973 fire, the difficulty in contacting the veterans due to the passage of time, the national concern with privacy and confidentiality, the fragmentation of VA files in numerous locations, the destruction of the previous automatic link between VA hospitalization and the claims folder, the growing resistance of veterans to questionnaires or other studies, and the numerous non-VA alternatives open to veterans seeking hospitalization. On the positive side, such developments as the creation of magnetic tape files, the development of epidemiologic knowledge, the creation of BIRLS, the adoption of the Social Security number as the military service serial number, the growing number of veterans, and increasing concern with the effects of environmental factors on human health aided the MFUA program.

One matter that occupied Beebe's attention was the passage of the 1974 Privacy Act by Congress.¹⁵⁵ Beebe prevailed on National Academy of Sciences (NAS) President Philip Handler to bring the committee's concerns to the attention of the Privacy Protection Study Commission in connection with the commission's consideration of regulations to enforce the Privacy Act. Committee members feared that these regulations would make epidemiological studies of the sort that the Medical Follow-up Agency had conducted in the past impossible; confidentiality concerns would preclude the release of patient data by the relevant agencies. Handler wrote the commission's executive director that he hoped its "deliberations on the uses of records will give adequate representation to scientific uses of records in furthering public health." With Handler's support, the MFUA successfully persuaded the commission to issue regulations that made allowance for the use of medical records for the agency's kinds of epidemiological studies.¹⁵⁶

The Assembly of Life Sciences

Closer to home, however, things did not go so well. The Executive Committee of the recently created Assembly of Life Sciences (ALS) experienced as much trouble getting used to the MFUA as had some of its predecessors in the Division of Medical Sciences. In examining the MFUA program in 1976, the Executive Committee called particular attention to the ongoing surgical adjuvant cancer therapy trials, probably the most atypical part of the agency's program. Some Executive Committee members thought the work "too pedestrian and unproductive to justify continuation." Recognizing that it was an ongoing effort, the Executive Committee approved it for fiscal year 1977 with the stipulation that CEVFUS should review the question of continuing MFUA involvement in the series of trials. At its May 25, 1976, meeting, CEVFUS agreed to appoint an ad hoc subcommittee, headed by Dr. Thomas C. Chalmers of the Mount Sinai School of Medicine, to review the matter. Chalmers's subcommittee recommended that the MFUA continue its collaborative role in the studies. He based his recommendations on the finding that although the trials had produced largely negative results thus far point, hope for more successful therapies still existed. Moreover, the protocols were well constructed and the studies well executed, statistical aspects of the design and analysis were of high quality, the work was efficiently managed with little use of precious staff time, and working relations with the coinvestigators were excellent. Calling the trials "an appropriate form of diversification for the MFUA," and arguing that "the future of MFUA collaboration should not be contingent upon showing positive results,'' the committee voted to send the Chalmers subcommittee report to the ALS Executive Committee as its reply to the concern about cancer trials.¹⁵⁷

The matter did not end there. Paul Marks, Columbia's vice president for health sciences and former chairman of the Division of Medical Sciences, became a critic of the Medical Follow-up Agency within the ALS Executive Committee. In response, Beebe, Jablon, and Remington proposed that Marks and other representatives of the Executive Committee organize a "visiting committee'' that would make an informal site visit to examine the MFUA program and its relation to the larger ALS unit. Alvin Lazen, associate executive director of the ALS went so far as to propose formally the creation and mandate of such a committee to Dr. Marks, who would head it. However, Marks did not convene the committee. When the ALS Executive Committee considered the MFUA's contract proposals in 1977, "things went badly," particularly the discussion of blood pressure and multiple sclerosis projects. Beebe worried that he was leaving the agency at a time when the program was vulnerable to attack from within the NRC. Finally, a review committee was appointed by ALS Chairman James Ebert, a biologist with the Carnegie Institution, to "recapitulate the history of MFUA, identify the nature of questions now being raised concerning the Agency and determine how the panel can best address the questions." The presence of both MacMahon and Remington on the six-man panel ensured that the agency would receive a favorable hearing, and Beebe could retire from the Medical Follow-up Agency knowing that, at least for the time being, it was not in danger from within.¹⁵⁸

In 1976, Beebe's imminent retirement, as well as a sense that the agency's program was not growing rapidly enough, led Remington to assign to various committee members the task of assessing the future needs of specific disciplines for Medical Follow-up Agency studies. Dr. Robert H. Felix of the Bi-State Regional Medical Program in St. Louis and the distinguished former head of the National Institute of Mental Health was assigned to consider the field of psychiatry; Dr. DeBakey, surgery; and Dr. Reuel A. Stallones of the University of Texas School of Public Health, cardiovascular disease. At the December 1976 meeting, Dr. Stallones presented his report on cardiovascular disease and the MFUA program, recommending that a summary of the agency's usefulness as a resource be reprinted periodically in the American Journal of Epidemiology and that the agency seek special funding from the NHLBI for planning cardiovascular disease studies. DeBakey presented a number of potential surgical studies that could be undertaken by the agency, including follow-up of studies done in its earliest days, as well as some new ideas such as a study of men with spinal cord injuries. Since Felix was unable to complete his overview of the psychiatric field due to illness, Dr. Ransom J. Arthur of the Neuropsychiatric Institute at the University of California at Los Angeles (UCLA) took his place.¹⁵⁹

Seymour Jablon in Charge

After Beebe retired in 1977, Seymour Jablon took over the day-to-day operations of the Medical Follow-up Agency, as well as those of the Atomic Bomb Casualty Commission's (ABCC's) successor agency, the Radiation Effects Research Foundation (RERF). Jablon had been with the agency almost since the beginning and was a well-respected statistician. As such he possessed the necessary experience to run the agency. Unfortunately, he presided over a difficult period for the agency. The committee began to meet increasingly rarely and considered fewer new program initiatives. Funding became increasingly problematic as the 1980s began. The country's continued economic problems affected the Medical Follow-up Agency during this period, as it did most entities that relied on government funding. However, the agency could point to numerous completed manuscripts, and publication levels remained healthy; only in 1982 did agency projects yield as few as four published manuscripts. Other years in this troubled period saw almost three times as many articles printed in respected journals by agency staff or investigators.¹⁶⁰

Figure

Group photo at the annual meeting of the Radiation Effects Research Foundation Board of Directors, held in Washington, D.C., Photo courtesy of Dr. Gilbert Beebe.

As Remington reached the end of his chairmanship in 1977, he looked over the Medical Follow-up Agency and noted some of the ongoing limitations of the agency's efforts. By now the litany of complaints was familiar. Extensive pilot work was often required to assess project feasibility and cost. The very breadth of the MFUA mission also left it no specific focus. The fragmentation, and even obsolescence, of source documents and the extensive use of non-VA hospitals by veterans lessened the usefulness of the veteran cohort over time. Moreover, its funding pattern left the agency unable to plan effectively, and the weakness of the agency's links to the larger scientific community meant that this funding pattern was unlikely to change soon.¹⁶¹

Yet, the agency continued to take on new projects. Studies exploring the relationships between immunological abnormalities of various kinds and subsequent cancer were undertaken in collaboration with the National Cancer Institute. Twin projects, including topics as diverse as genetic variations in fluoride effects on dental caries, cardiovascular disease, Parkinson's disease, and alcoholism, were approved in the last two meetings of the 1970s. A study of Navy radar workers, which found no measurable health effects from exposure to microwaves, and a study of World War II veterans with limb amputations following trauma (see Box 12) which found excessive mortality from cardiovascular disease, were completed. CEVFUS also approved pilot studies on alcoholism among veterans and the potential relationship between household pets and multiple sclerosis.¹⁶²

BOX 12

Study of Cardiovascular Disease Following Traumatic Limb Amputations. Although the Medical Follow-up Agency is not involved directly in decisions affecting disability compensation following military service, occasionally the results of its studies will (more...)

In 1982, Dr. Lazen of the Academy of Life Sciences proposed reorganizing the MFUA as a more broad-based epidemiological organization, emphasizing "activities of a more traditional, advisory kind," such as the agency's review of the protocol for a study of health effects of phenoxy herbicides in Vietnam and its still-nascent entry into the area of atomic veterans. In part because of Zed Hrubec's departure in 1981, Jablon found himself understaffed as well as underfunded. Jablon realized that much of the work Lazen prescribed for this proposed committee on epidemiology was already being done by other groups in universities and government. "There may be occasional cases in which our own talents and expertise surpass those available to any other group," he wrote, "but I cannot think of any offhand." Lazen backed down. Jablon, after all, had history on his side.¹⁶³

For want of core support with which to pay meeting costs, CEVFUS went four years between meetings, from March 1979 until May 1983. In the meantime, the agency's staff completed studies on multiple sclerosis, Hodgkin's disease, and tetrachloroethane and cancer, and the pilot study on the relationship between household pets and multiple sclerosis. The National Cancer Institute decided, after 25 years, to terminate the cancer chemotherapy trials that had caused such enmity between the MFUA and the ALS. Studies in progress in 1983 included a morbidity update for World War II and Korean War POWs, a prospective study of testicular cancer, study of the possible long-term effects of short-term exposure to chemical agents in a series of tests at Edgewood Arsenal (see Box 13), an epidemiologic study of mesothelioma and employment, and a protocol prepared for the VA on the health effects of Agent Orange.¹⁶⁴

BOX 13

Follow-up of Veterans Experimentally Exposed to Chemical Agents. Interest in the effects of exposure to anticholinesterase agents—for example, the nerve gas sarin—grew in response to reports of the possible exposure of Persian Gulf War (more...)

When CEVFUS next met in 1983, the committee approved all but one of the projects before it. Accepted twin studies involved criminality, senile macular degeneration, and presenile dementia among the roster of twins. Also, the VA approached the MFUA with a proposal to develop a Vietnam-Era service twin register, which the VA ultimately took over but not before much work had been done by MFUA staff. Non-twins proposals that CEVFUS approved included a study of mortality patterns in veterans with psychiatric diagnoses in World War II, three studies of multiple sclerosis, and a follow-up of an earlier hepatitis study. ¹⁶⁵

From the late 1970s through most of the 1980s, the only part of the federal budget that showed steady growth was the Department of Defense (DOD). With MFUA funding constricted in all directions, Jablon looked to this department for new studies. The MFUA and the DOD were an ideal fit. The Defense Department sought experts to study the exposure of various veteran cohorts to atomic radiation. Jablon's experience with the ABCC and some related, smaller-scale studies in the 1970s, gave him and his staff experience needed to carry out such work. Beginning in 1978, the Medical Follow-up Agency and the Defense Department's Defense Nuclear Agency entered into a series of contracts that would last into the 1990s. These radiation contracts were almost the agency's predominant means of support for much of the early 1980s. They were not without political conflicts. Jablon's first study, on the incidence of cancer among veterans who entered Hiroshima and Nagasaki in 1945 immediately after atomic bombs leveled these two Japanese cities, found no unusual incidence of multiple myeloma among these "atomic veterans." However, the protocols and the conclusions of the study came under such intense scrutiny from Capitol Hill and the press, that Jablon agreed to do the study again.¹⁶⁶

Other related studies undertaken by the agency concentrated on servicemen who were present at a number of atmospheric atomic bomb tests between 1946 and 1962, with code names such as SMOKY and CROSSROADS. A series of MFUA subcommittees organized the protocols for these epidemiologic studies, all of which reported results similar to the original Hiroshima and Nagasaki studies. Disappointed veterans groups criticized Jablon, who publicly defended the method behind the studies but privately admitted that they were not the best kind of science. Since the agency needed the money, Jablon continued to take the lead on these studies well after he left the agency staff. His position in the atomic test exposure studies continued until Kenneth Shine, president of the Institute of Medicine, removed him from the CROSSROADS study in 1993 under pressure from atomic veteran groups who were hoping for study results closer to their own, less scientific, predispositions.¹⁶⁷ The studies continued however to demonstrate the essential soundness of Jablon's methodologies and conclusions.

Even without substantial funds, the agency remained "actively involved" in building a new Vietnam-Era Twin Registry, as well as in the study of yellow fever vaccine and hepatitis in World War II veterans (see Box 14), and the ongoing POW work. In building the registry the agency ran into troubles with the Social Security Administration that were reminiscent of its problems with the Federal Bureau of Investigations two decades earlier. Social Security numbers had become standardized military case markers, replacing old serial numbers in the post-Korean War period. When the agency knew a veteran's name and date of birth, it needed the veteran's Social Security number. If it knew the veteran's name and Social Security number, it still required the date of birth. Both processes were easy enough to automate, but the Social Security Administration refused to cooperate on grounds of legal difficulties over the matter of disclosure. Failure to obtain these data made using the National Death Index and obtaining a mailing address from the Internal Revenue Service more difficult. In 1986, however, the Social Security Administration published a routine-use statement for the VA that allowed the Medical Follow-up Agency to gain more ready access to the data it needed.¹⁶⁸

BOX 14

A 41-Year Follow-up of Hepatitis B Epidemic in the U.S. Army. Between late 1941 and early 1942 an epidemic of jaundice occurred in Army training camps across the United States. The epidemic was later determined to have resulted from the inoculation of (more...)

Between 1983 and 1985, the MFUA completed a study of mesothelioma and employment, intended to improve understanding of the health risks presented by exposure to asbestos and other fibers, the data for which were then being analyzed by the National Cancer Institute. Even as the agency expanded the Twin Registry to Vietnam veterans, it mailed new health questionnaires to the living members of the older registry (approximately 24,000 of the original 32,000 members remained in 1985) and planned future studies of diabetes and of possible links between handedness and neurological disease.

At this point in the agency's history, proposals tended to focus on diseases and conditions of the elderly, a natural result of the advancing age of the World War II cohort at the heart of the MFUA program. Proposals during this time included studies of Alzheimer's disease and head injury, brain cancer in elderly men, radio-frequency radiation and cancer, and Vietnam veterans with spinal cord injury.¹⁶⁹

In 1986, the MFUA emerged from the doldrums that had predominated during the early 1980s. During this time, two important staffing changes took place. Robert Keehn retired from the agency and Dr. William Page, a biostatistician on temporary assignment from the VA, joined the staff. Dr. Page eventually made the temporary assignment a permanent one and subsequently came to play an important role in the modern history of the agency. The National Cancer Institute proposed that the MFUA collaborate on studies of cancer epidemiology based on hospital clinical records. Dr. Richard Miller, the future director of the agency but then the director of Walter Reed Army Institute of Research's residency program in general preventive medicine, began work with the agency on AIDS studies, developing a follow-up study of HIV-positive military personnel.¹⁷⁰

In 1987, the ALS commissioned yet another task force to review the work and mission of the MFUA. Chaired by Brian MacMahon, it produced a laudatory report, calling the MFUA a "national resource which should be maintained and strengthened." It recommended keeping the agency within the NRC, securing core funding from the NIH, the VA, and other key governmental agencies, and suggested an immediate search for a new director with the retirement of Seymour Jablon in October 1987. The task force also mentioned the need for greater ties to investigators in academia and government agencies, as well as the possibility of changing the agency's name to reflect the breadth of its mission. ¹⁷¹

William Page's Interim

With Jablon leaving, Alvin Lazen, executive director of the Commission on Life Sciences (the new functional equivalent of the former ALS), appointed William Page as acting director of the MFUA, effective June 15, 1987. In addition to running the day-to-day affairs of the agency, Page continued to manage important components of the program. At first, it appeared that Page would indeed be a transition figure; CEVFUS membership was extended for a year in the fall of 1987 with the idea that "by that time more should be known about the future direction of the Medical Follow-up Agency." Circumstances contrived to make Page's "transition" acting directorship about half as long as Jablon's actual tenure, however.¹⁷²

Despite the confusion associated with the leadership transition, the MFUA was clearly on its way back. Lack of core funding was a key dilemma, and Gilbert Beebe acted from his "advisory" role to provide it. In August 1987, he initiated discussions with staff of the Senate Veterans Affairs Committee concerning the status of the agency. Beebe acted because, even with more grant money coming to the agency in 1987, the staff in St. Louis was reduced to very small numbers and put on temporary leave. Beebe's Senate meeting produced a "workshop" review of the Medical Follow-up Agency by the Office of Technology Assessment (OTA), held at the request of the Senate Veterans Affairs Committee in 1988. In the meantime, Page reapplied for core funding from the agency's major grant sources. The MFUA made it past the worst of a particularly difficult time when the POW and cancer studies were renewed and new studies of atomic veterans and oil adjuvant vaccines were launched.¹⁷³

In 1987, the Medical Follow-up Agency once again reported on numerous accomplishments. Three papers had been generated by the POW study. Work continued on projects related to the long-term effects of the 1942 hepatitis epidemic in the Army. The agency sought to determine the prevalence in victims of various hepatitis markers and to estimate their mortality rates, especially from liver cancer and other liver diseases. Various multiple sclerosis and twin projects were under way or planned, and planning was also being undertaken on a 33-year follow-up of Army recruits immunized with adjuvant influenza vaccine to determine if long-term problems could be associated with this vaccine. In the same year, the committee approved two new studies, one on nephrectomies performed subsequent to trauma and another on posttraumatic stress in riflemen.¹⁷⁴

In the midst of this activity, the appearance of OTA's report in November 1988 became a crucial milestone in the Medical Follow-up Agency's recent history. OTA staff argued that the MFUA was too important to wither away and that only the presence of core funding from NIH, the VA, and the Department of Defense could keep this from happening. As a short-term solution, OTA recommended shared core support for the agency among these three governmental bodies, beginning with fiscal year 1990. OTA staff advocated immediate core funding of $100,000 to allow the agency to carry on its work and search for a strong director. Thereafter, it recommended a total of $500,000 per year over five years. OTA also suggested that the NAS amend its rules on competitive bidding to allow the MFUA to bid for contracts within its natural purview.¹⁷⁵

In the same year, the MFUA again gained a new parent entity within the National Academy of Sciences. This time, however, it left the NRC entirely. The so-called Rosenblith committee, led by Walter Rosenblith of the Massachusetts Institute of Technology, decided to transfer the MFUA, along with the better-known Food and Nutrition Board, to the Institute of Medicine (IOM). The IOM, an entity analogous in the Academy structure to the National Academy of Engineering (NAE), had developed out of discussions in the 1960s regarding the need for a "National Academy of Medicine," led by Dr. Irvine Page of the Cleveland Clinic (no relation to William Page of the MFUA). The entity that became the IOM started as the Board on Medicine. After the 1972 NRC reorganization, the IOM became a full-fledged "sister" organization to the NAS, NRC, and NAE.

This medical branch of the National Academy of Sciences was by no means an illogical place for the MFUA's epidemiological methods, and Page found himself as comfortable there as he had been in the NRC.¹⁷⁶

However, the IOM was as uncomfortable with the MFUA as the agency's other parental entities had been in its more than 40 years of existence. A site visit by two outside investigators to familiarize the IOM with the workings of the MFUA took place in 1989. Pronouncing themselves ''shocked" to learn that the Medical Follow-up Agency's very existence was in peril (although they admitted to being previously unaware of its existence themselves), the investigators called for "important changes" so that the agency might "continue, or even perhaps become again, the national resource it was intended to be." To quell the "interim'' feelings that they detected on the part of the staff (only about ten persons at that time), the investigators recommended that the MFUA fill the position of a permanent director as soon as possible, preferably with a physician or epidemiologist. They urged securing long-term core funding, subsequent staff growth, and computer upgrades and spoke of the need for the agency to reach out better to the scientific community and the VA.¹⁷⁷

By 1990, the Medical Follow-up Agency was again pursuing an active mandate. The agency sponsored a conference on epidemiology in military and veteran populations, as a sort of sequel to the workshop held in 1988, even publishing the proceedings with Dr. Page as editor. Seventy people attended the conference, which was intended both to report on the work of the agency and to draw new investigators into its orbit. After two years of wrangling and arm twisting by Senator Alan Cranston (D-California) and other members of the Senate Committee on Veterans Affairs, some of it public, first the NIH and then the VA agreed to fund the core program of the MFUA. Page and his staff believed that the funding derived from these agencies was more than sufficient for planning activities as the MFUA continued to grow in size for the second time in its history.¹⁷⁸

In 1990, CEVFUS met again to discuss the agency's program and discovered an abundant amount of research done under MFUA auspices. Staff reported on the completed POW questionnaire, which found depressive symptomatology in POWs at a level three to five times higher than expected in a comparable general population. A study of hepatitis B and liver cancer in World War II veterans discovered little incidence of liver cancer in the study group. Ongoing efforts featured an examination study of former POWs, two other hepatitis studies, the mineral oil adjuvant study, and a pilot study of World War II veteran death reporting. Studies that awaited funding included the HIV study, an examination of Korean hemorrhagic fever (see Box 15), a study of multiple sclerosis, three twin studies, and a follow-up of nuclear veterans. In addition, the committee heard discussions of the body build registry, posttraumatic stress disorder in World War II riflemen, Alzheimer's disease, and head injury.¹⁷⁹

BOX 15

Study of Hemorrhagic Fever with Renal Syndrome. Interest in hantavirus infection was abruptly stimulated by a 1993 outbreak of hantavirus pulmonary syndrome in the Four Corners area of the United States—with case fatality rates as high as 50 percent. (more...)

The 1990s

The 1990s proved to be a decade of positive developments for the MFUA. In 1991, Page could report that core funding had been secured from the National Institutes of Health, the Department of Defense, and the Veterans Administration. Two years later, this was again jeopardized by indifference within the funding agencies, but a follow-up OTA study in 1994 persuaded all three agencies to provide the money. In 1991, the agency completed its study of Army recruits immunized with oil adjuvant influenza vaccine, finding no statistically significant adverse effects of the oil adjuvant. With core funding in hand, Page urged the committee to broaden the agency's horizons. He discussed pilot studies of Health Care Finance Administration hospitalization and Social Security Administration mortality records, as well as MFUA's various computer needs in both hardware and software. Among the new projects proposed in that year were a follow-up study of 1950 Air Force recruits infected with hepatitis C, a follow-up of the West Point Class of 1956, and studies using the Navy hospitalization files that Seymour Jablon had preserved on computer tape with funding from the National Cancer Institute more than a decade before.¹⁸⁰

William Page's tenure as acting director reached an end in 1992 with the appointment of Chris Howson as interim director. After the ensuing search, IOM leadership recruited Dr. Richard Miller from the Walter Reed Medical Center as the new director of the program in 1993. Coming from both a medical and a military background, Miller fit many of the stipulations for a successful director set forth by the site visit group shortly after Jablon left the agency. Miller continued efforts begun under both Page and Howson. One especially notable study begun under Howson was designed to monitor the health status of Persian Gulf veterans (see Box 16). The mere fact of this study indicated that the agency fit better into the 1990s than at any time in decades. Page, Howson, and Miller would not let the opportunity presented by the Gulf War slip the way the Vietnam War had through the fingers of the MFUA staff in the early 1970s.

BOX 16

Health Consequences of Persian Gulf War Service. In the years following Operations Desert Shield and Desert Storm in 1990–1991, reports of illnesses among Gulf War veterans raised public concerns about a "mystery illness" in this population. In (more...)

Miller took steps to make the agency more visible within the IOM structure, successfully arguing that the MFUA's oversight group should be a board instead of a committee. Looking toward the future, Miller and his staff envisioned a Medical Follow-up Agency that would balance ongoing follow-up as in the multiple sclerosis or POW studies, cutting-edge research as in the various twin studies, and politically delicate studies such as those of Persian Gulf veterans or of atomic veterans (see Box 17).¹⁸¹

BOX 17

Studies of Participants in Atmospheric Tests of Nuclear Weapons. In 1976 the case report of a paratrooper diagnosed with acute myelocytic leukemia reached the Centers for Disease Control and Prevention (CDC). The paratrooper attributed the leukemia's (more...)

Conclusion

Since its founding in 1946, the Medical Follow-up Agency has successfully met many challenges. The agency continues to contribute to the research community because of the ingenuity and resolve of researchers such as Dr. Michael DeBakey. DeBakey and Gilbert Beebe sensed the opportunity to create a medical organization that would be a force for good in post-World War II America by channeling the experience of the war into useful medical knowledge. Beebe and his successors—Jablon, Page, Miller, and numerous others have fostered an entity flexible enough to mold itself to the times but resolute enough to overcome the numerous obstacles in its path. Although DeBakey and Beebe thought the agency would help guide clinical practice, the entity they created instead developed great expertise in epidemiology. The agency remains a central repository of data and analytical talent. It continues to nurture some of the best epidemiological and medical research of the postwar period. This body of work is its central legacy and its best claim to excellence.

Figure

Past and present MFUA leadership gathered at the 50th Anniversary Meeting on October 16, 1996. From left to right, back row: Dr. William Page, Dr. Richard Miller, and Mr. Seymour Jablon; front row: Dr. Michael DeBakey and Dr. Gilbert Beebe. Photo courtesy (more...)

Footnotes

138

"Recommendations to the Research Service, VA Department of Medicine and Surgery Concerning Support of the Activities of the Follow-up Agency at National Research Council-National Academy of Sciences," Lawrence W. Shaw and Armand Littman, February 16, 1972, CEVFUS Files, NAS Archives.

139

Gilbert Beebe to Frederick H. Epstein, University of Michigan, May 2, 1972, CEVFUS Files, NAS Archives; Beebe discussion with the DMS Executive Committee, April 1972, DMS Files, NAS Archives. The study is Beebe memo to file, "Source of Investigation Interest in R-Projects," March 31, 1977, CEVFUS Files, NAS Archives.

140

Gilbert Beebe to William J. Zukel, National Heart and Lung Institute (NHLI), June 2, 1972, and Beebe to Brian MacMahon, March 6, 1972, both in CEVFUS Files, NAS Archives.

141

Ibid.

142

Division of Medical Sciences, "Annual Report," June 30, 1972, and Division of Medical Sciences, "Annual Report," June 30, 1973, both in DMS Files, NAS Archives; Minutes, CEVFUS Meeting, April 11, 1972; Charles Dunham to Robert McClelland, University of Texas, July 24, 1972; and Gilbert Beebe to Dunham, May 28, 1971, all in CEVFUS Files, NAS Archives.

143

Gilbert Beebe, discussion before the DMS Executive Committee, April 1972, and Division of Medical Sciences Annual Report, June 1972, both in DMS Files, NAS Archives; "Report of Progress ... Medical Follow-up and Epidemiologic Studies on Veterans," February 29, 1972, CEVFUS Files, NAS Archives.

144

Charles Dunham to Brian MacMahon, July 24, 1972, and Gilbert Beebe memo to file "Conference with Dr. Lee, VACO, Relative to the FUA Program and VA Support, 26 March 1970," both in CEVFUS Files, NAS Archives.

145

Minutes, CEVFUS Meeting, January 11, 1973, and "Service by the Follow-up Agency to Other Investigators," December 26, 1972," both in CEVFUS Files, NAS Archives.

146

Gilbert Beebe to CEVFUS, July 23, 1973, "Fire Losses at St. Louis Records Center" (apparently authored by Seymour Jablon), May 9, 1974, and Minutes, CEVFUS Meeting, May 21, 1974, all in CEVFUS Files, NAS Archives.

147

Minutes, CEVFUS Meeting, June 15, 1973; Seymour Jablon to Richard Remington, September 11, 1973; and Gilbert Beebe to Frederick H. Epstein, July 26, 1973, all in CEVFUS Files, NAS Archives.

148

Minutes, CEVFUS Meeting, February 7, 1975, CEVFUS Files, NAS Archives.

149

Gilbert Beebe to Stuart Roberts, Peoria School of Medicine, June 4, 1973; Beebe to Seymour Jablon, August 20, 1973; and Beebe to Capt. Ransom J. Arthur, Navy Medical Neuropsychiatric Research Unit, January 22, 1973, all in CEVFUS Files, NAS Archives.

150

"Report of Progress ... Medical Follow-up and Epidemiologic Studies on Veterans," February 26, 1973, CEVFUS Files, NAS Archives.

151

Minutes, CEVFUS Meeting, May 21, 1974; Seymour Jablon to Richard Remington, June 11, 1974; and Remington to Thomas Newcomb, Veterans Administration, August 22, 1974, all in CEVFUS Files, NAS Archives.

152

"Proposal to Create Magnetic Tape Index to Navy Hospital Diagnoses in World War II (1944–1945)" (Seymour Jablon), May 11, 1976, and Minutes, CEVFUS Meeting, May 11, 1983, both in CEVFUS Files, NAS Archives.

153

Ibid. Taubman's research resulted in three journal publications: Taubman, P. The determinants of earnings: Genetics, family and other environments: A study of white male twins. American Economic Review 66:858–870, 1976; Earnings, education, genetics, and environment. Journal of Human Resources 11 (fall):447–461, 1976; and What we learn from estimating the genetic contribution to inequality of earning: Reply. American Economic Review 68:970–976, 1978. This research also resulted in a book chapter: Behrman, J., Taubman, P., Wales, T. Controlling for and measuring the effects of genetics and family environment in equations for schooling and labor market success. In (P. Taubman ed.): Kinometrics: Determinant of Socioeconomic Success Within and Between Families. New York: North-Holland Publishing Company, 1977.

154

Ibid.

155

Gilbert Beebe memo to CEVFUS, "Future Program," May 10, 1976, CEVFUS Files, NAS Archives.

156

Philip Handler, NAS president, to Carole W. Parsons, executive director, Privacy Protection Study Commission, May 27, 1976, with attachment "Some Implications of the 1974 Privacy Act, and of the Extension of Its Principles to Health-Care Institutions, for Biomedical Research," MFUA Office Files.

157

Gilbert Beebe to James Neel, March 23, 1976, and Minutes, CEVFUS Meetings, May 25, 1976, and December 15, 1976, all in CEVFUS Files, NAS Archives.

158

Seymour Jablon to Richard Remington, October 8, 1976, CEVFUS Files; Alvin G. Lazen, Assembly of Life Sciences, to Paul Marks, Columbia University, November 8, 1976, Accession 91-028-02/11; Gilbert Beebe to Remington, March 29, 1977, CEVFUS Files; Beebe to CEVFUS, March 31, 1977, Accession 91-028-02/11; Remington to CEVFUS, March 31, 1977, Accession 91-028-02/11; and Councilman Morgan to Paul Ebert, Mark Hegsted, Brian MacMahon, Richard Remington, and Donald Seldin, April 18, 1977, Accession 91-028-02/11, all in NAS Archives.

159

"Report of the Subcommittee on Epidemiological Studies of Cardiovascular Disease" (Reuel Stallones), December 1976, and Minutes, CEVFUS Meeting, December 15, 1976, both in CEVFUS Files, NAS Archives.

160

"Bibliography of the Medical Follow-up Agency," September 1998, MFUA unpublished document.

161

"Critical Issues for the Future," Item VI, CEVFUS Meeting (April 11–12, 1977) Agenda, March 30, 1977, CEVFUS Files, NAS Archives.

162

Zdenek Hrubec to Richard Remington, April 1, 1977, and Minutes, CEVFUS Meetings, April 11–12, 1977, and March 15, 1979, all in CEVFUS Files, NAS Archives.

163

Barbara S. Hulka, University of North Carolina at Chapel Hill, to Seymour Jablon, July 16, 1981, and Jablon to Alvin Lazen, "Your Draft Letter to Brian MacMahon Dated 10/25/82" (letter to MacMahon enclosed), MFUA Office Files. MacMahon at the time had returned to the CEVFUS chair.

164

Minutes, CEVFUS Meeting, May 11, 1983, MFUA Office Files.

165

Ibid.

166

Seymour Jablon to CEVFUS; April 3, 1978; Smith, R.J. Study of atomic veterans fuels controversy. Science 221(4612):733–4, 1983; and Anderson, C. NAS to redo atomic studies found to be flawed. Nature 359:354, 1992.

167

Robinette, C.D. Cancer among atomic veterans: No consistent increase found, but excess leukemia confirmed in one group. CLS Lifelines 11(2–3):5, 1985; Seymour Jablon to Kenneth I. Shine, president, Institute of Medicine, January 27, 1993, MFUA Office Files.

168

C. Dennis Robinette, MFUA staff, to Richard Remington, July 29, 1985; Seymour Jablon to Remington, November 4, 1985; Minutes, CEVFUS Meeting, November 13, 1985; and Robinette to Remington, March 10, 1986, all in MFUA Office Files.

169

Minutes, CEVFUS Meeting, November 13, 1985, MFUA Office Files.

170

Richard Remington to Seymour Jablon, March 3, 1986, and C. Dennis Robinette to Remington, March 10, 1986, both in MFUA Office Files. (This HIV study was one of the first that the MFUA presented in 1988 to its new parent body, the Institute of Medicine, for review.)

171

"Report of an Ad Hoc Executive Committee charged to review the Medical Follow-up Agency" (MacMahon committee), July 27, 1987, Accession 91-028-02/11, NAS Archives.

172

Alvin Lazen, Commission on Life Sciences (CLS) executive director, to MFUA staff, June 13, 1987, and John Dowling, CLS chairman to Brian MacMahon, August 14, 1987; and William Page to Richard Remington, October 6, 1987, both from Accession 91-028-02/11, NAS Archives; the latter is from MFUA Office Files.

173

Gilbert Beebe to Frank Press, NAS president, June 19, 1987, and Beebe memo to Records "Discussion with Staff of Senate Committee on Veterans Affairs Concerning the Status of the Medical Follow-up Agency of the National Research Council," August 7, 1987, both from the MFUA office files; William Page to Alvin Lazen, November 5, 1987, and Commission of Life Sciences "Status Report" on Follow-up to MFUA Review, December 10–11, 1987, both from Accession 91-028-02/11, NAS Archives.

174

Medical Follow-up Agency, "Annual Report," December 31, 1986, Accession 91-028-02/11, NAS Archives; National Research Council, Commission on Life Sciences, Medical Follow-up Agency, June 4, 1987, and Minutes, CEVFUS Meeting, June 4, 1987, both from MFUA Office Files.

175

Office of Technology Assessment, "Report of an OTA Workshop on the Medical Follow-up Agency," November 1988, MFUA Office Files.

176

Richard B. Setlow, Brookhaven National Laboratory, to John Dowling, Harvard University, May 6, 1988; William Page to Michael DeBakey, May 24, 1988; and Page to DeBakey, June 29, 1988, all in MFUA Office Files.

177

O. Dale Williams and C. Morton Hawkins, "Report of the Site Visit to the Medical Follow-up Agency of the Institute of Medicine," 1989, MFUA Office Files.

178

William Page to Samuel Thier, IOM president, December 29, 1989; Page to Richard Remington, January 5, 1990; and Edward J. Derwinski, Secretary of Veterans Affairs, to Senator Alan Cranston, Senate Veterans Affairs Committee, May 4, 1990, all in MFUA Office Files.

179

Minutes, CEVFUS Meeting, May 21, 1990, MFUA Office Files.

180

Minutes, CEVFUS Meeting, September 24, 1991, MFUA Office Files.

181

Chris Howson, MFUA interim director, to CEVFUS, May 11, 1993; and Dick Miller, MFUA director, to Ken Shine, IOM president, July 23, 1993, both in MFUA Office Files. Also interview with Dick Miller, May 28, 1998.