In January 1938, President Franklin Delano Roosevelt created the National Foundation for Infantile Paralysis (NFIP) – the forerunner of the March of Dimes. Its mission was “to lead, direct, and unify the fight” against paralytic poliomyelitis, commonly known as polio. To head the organization, Roosevelt had only one man in mind, his friend and former law partner Basil O’Connor. “I was never a public do-gooder and had no aspirations of that kind,” O’Connor later said. “But I started enjoying it.”1

O’Connor would not accept anything less than conquering polio. An autocratic leader, he built a formidable organization with a national headquarters and 3,100 county chapters. NFIP’s programs included grants for broad scientific research in viruses, cellular biology, and central nervous system disorders; professional education and training fellowships for physical therapists, physicians, and other health workers; public education about polio; and direct financial assistance for the care of polio patients.

Instead of targeting big donors to support its multipronged approach, NFIP raised tens of millions of dollars from the small donations of tens of millions of Americans. The annual Poster Child, Mothers’ March, and March of Dimes fundraising campaigns rallied the nation against polio, a feared disease that crippled thousands, mostly children, during its summer outbreaks.

In 1944, Roosevelt also appointed O’Connor to head the American Red Cross, which he led concurrently with NFIP until 1949. There O’Connor met Raymond Barrows and Melvin Glasser. Barrows, educated in engineering and social work, directed domestic disaster relief. Glasser, a child-welfare activist and skilled administrator, directed the organization’s international activities. O’Connor became fast friends with both.

When NFIP grantee Jonas Salk began developing a polio vaccine at the University of Pittsburgh in 1951, O’Connor knew that it was only a matter of time before NFIP would achieve its founding mission. “I’m the head of General Motors and my automobile is going to be declared obsolete,” he told Glasser over lunch that year. He invited Glasser to be “in charge of worrying” for NFIP’s future. Glasser joined NFIP as assistant to the president for program development in 1953. Two years earlier, Barrows had joined as executive director.

The three men wondered: Must NFIP go out of business? Or could the organization use its volunteer, fundraising, and research machinery to solve another health problem?

With no precedents to draw from, the team undertook a focused effort to identify the strengths and weaknesses of NFIP and the health problems facing the nation. The three men then reformulated NFIP’s mission on the basis of their findings. Despite its leaders’ care, NFIP struggled for several years to establish its broader, more abstract mission, and in the process lost funding, volunteers, and public support. But by focusing its mission, intensifying its public education campaign, training its volunteers, and honing its fundraising techniques, the organization rapidly recovered.

Mission by Number

With support from O’Connor and Barrows, Glasser consulted leading public opinion specialists to chart the organization’s future course. “Of the hundreds of organizations in this country that have modified or changed function,” he noted to O’Connor, “no organization has ever attempted to do it through a study of what the public is interested in and how it supports programs, followed by a careful analysis of unmet needs in the field.”

Glasser enlisted two leading research groups, the American Institute of Public Opinion (Gallup) in Princeton, N.J., and the Bureau of Applied Social Research at Columbia University. In early 1954, Gallup surveyed a representative national sample of 2,000 people to find out what they knew about NFIP, how much support they might give to programs other than polio eradication, and what other health problems they considered important to tackle. Gallup also surveyed NFIP chapter leaders and volunteers nationwide to find out why they worked with NFIP, what they thought the organization’s strengths and weaknesses were, and what they thought would make NFIP even more successful. For its part, Columbia interviewed 234 NFIP chapter leaders and 1,000 members of the general public to find out why they supported NFIP and how loyal they were to the organization.

The findings from the Gallup and Columbia studies showed that NFIP was the strongest voluntary2 health organization in the country and could expect continued support for its polio programs. They also suggested that if the organization preserved some of its unique features – such as its middle-class core of volunteers, as well as its structure of local chapters led by a national headquarters – it could probably expand into other health programs. These conclusions emboldened NFIP leaders to move forward with their mission change. “It would be a criminal disservice to the American people to discontinue an organization with the experience, the talent, the popularity, the community ties, and the scientific know-how that [NFIP] has demonstrated,” O’Connor said.

Never in history had a major voluntary health organization consciously and with advance planning considered this type of change. Using the results of the studies, Glasser developed 28 criteria for judging proposals. Essential criteria included a program that would be broader than the polio program and that would address a health problem that was “a potential threat to all people in all regions of the country and in all strata of society – thus lending itself to the strategy of the small gift and the broad base.”

Glasser then compiled statistics on diseases and disabling conditions in the United States. He paid special attention to health problems that national agencies were not adequately addressing. He discovered 16 areas that needed urgent attention, such as congenital malformations (birth defects), juvenile delinquency, and alcoholism. NFIP also received numerous suggestions for new programs from the general public, leaders in science and medicine, and public health authorities. Various health agencies even invited NFIP to operate their organizations.

Program planning slowed for 18 months when, in 1954, Glasser helped direct the nationwide polio vaccine field trial. Its findings led to the announcement on April 12, 1955, that the Salk polio vaccine was safe and effective. It was the first time that a voluntary health organization had conquered the disease it was created to attack.

With this success, NFIP demonstrated the importance of research for disease management and prevention. Research was no longer the exclusive concern of scientists. Instead, it became a necessary program component and a draw for both volunteers and donors.

The Big Expansion

In late 1955, Glasser resumed his exploration of possible new missions. His short list included geriatrics, mental health, arthritis, and birth defects. He developed detailed program proposals, which NFIP leaders and independent experts in each field reviewed. NFIP’s leaders preferred problems that had solutions and that would benefit from the foundation’s expertise in virus research, heredity studies, and childhood diseases.

O’Connor, Barrows, and Glasser met in the Bahamas to decide the theme and scope of the future program in November 1956. They were joined by Thomas Rivers, who was medical director of NFIP and architect of its virus research program. O’Connor emphasized the need to honor “certain obligations to the American people: finish polio; expand professional education; [expand] virus research.” They debated the advantages and disadvantages of pursuing each proposed area.

For example, Glasser had identified geriatrics as a huge public health concern. Yet aging did not meet many of his inclusion criteria, such as a problem whose solution logically extended from the polio program, or a broadly defined disorder that appealed to the “citizen army against disease” concept that most volunteers held. Rivers was fearful that if the organization took on geriatrics, the public might identify it only with the problems of old age. O’Connor thought that the public perceived geriatrics as welfare, that geriatrics would not interest chapters, and that geriatrics did not compel a clear research path.

Similarly, mental illness was a widespread yet poorly defined problem toward which NFIP could apply very little of its sponsored research. Moreover, the foundation anticipated that enlisting public support for mental illness research would be difficult because of the taboo, fear, and shame surrounding psychiatric problems. Because its volunteer network was one of its greatest strengths, NFIP especially worried about how to give volunteers meaningful work when so little was known about promoting mental health. And the foundation wondered whether staff would be satisfied working with patients for whom recovery took years, if ever.

The debates about arthritis and congenital malformations were more promising. Like polio, arthritis and birth defects affected children and were great cripplers. They also required rehabilitation similar to that for polio. Moreover, Rivers informed his colleagues that a virus possibly caused arthritis, and so the foundation could apply its virus research program. Rivers, O’Connor, Barrows, and Glasser ultimately agreed that arthritis and birth defects were logical choices for the expanded NFIP program.

Meanwhile, the Arthritis and Rheumatism Foundation (ARF) contacted O’Connor twice to suggest a merger. Although the two organizations initially agreed to join forces, ARF chapters refused to support their national officials and voted to continue as a separate organization. They cited basic differences in organizational structure and methods of operation. They requested that NFIP postpone entry into the arthritis field for one year so that the two organizations could have further discussions. O’Connor replied: “There is plenty to do in the field of arthritis that has not yet been done. Individual diseases are not the personal property of individual organizations.” NFIP and ARF went their separate ways.

In July 1958, after five years of unprecedented planning, O’Connor held a historic press conference at the Waldorf- Astoria Hotel in New York City to announce the expanded program. Radio, television, and newsreels broadcast the event nationwide. O’Connor announced: “This is our concept for the future: the development of an organized nonprofit force in the fields of medical research, patient care, and professional education, flexible enough to meet new health problems as they arise. The heart of the new program is research.” He also announced that NFIP would henceforth be called the National Foundation (NF). NF would continue its fight against polio, as well as add research on other viral diseases, arthritis, congenital malformations, and disorders of the central nervous system. The medical care program would expand to aid children with rheumatoid arthritis and certain congenital malformations. NF was a “flexible force” not confined to any particular disease or group of diseases.

Crisis of Change

Conquering polio had been a clear and compelling mission because polio was highly visible and widely feared. In contrast, NF’s expanded program was abstract and multifaceted. Its mission of serving as a flexible force in the field of health set no boundaries on what the organization could pursue. Moreover, its initial set of target diseases – arthritis, birth defects, and polio, presented as the “three faces of crippling” – failed to move the public. People viewed arthritis as an inevitable disease of old age. And they were ignorant about birth defects because families typically kept children with birth defects sequestered at home or in institutions. “We were aiming at a hidden target,” O’Connor said of birth defects.

The public also thought that polio was over. Immediately following the successful development of the Salk vaccine, public contributions started to fall sharply. (See “Money Follows Mission,” right.) The downward trajectory continued for 10 years. O’Connor attributed the contraction of funds to an “image problem”: “The public had so long identified the March of Dimes [fundraising campaign] with polio that our decline in income paralleled the decline in polio incidence.” Contributions would not return to their 1954 high of more than $64 million until the 1980s.

Shrinking donations led to a financial crisis among chapters. By 1959, chapters in half of the states were insolvent, owing about $7 million to hospitals for the patient-care bills of polio victims. Although O’Connor had pledged to continue financing the medical care of polio patients under the expanded program, he soon saw that this long-standing policy had to end. In 1960, he terminated it. This was a wrenching experience for many volunteers, as well as for the many chapters that still regarded themselves as part of “the Polio Foundation.” Headquarters gradually consolidated chapters to cut costs. Chapters resisted this streamlining, and an unexpected number of volunteers left.

Recovery Through Research

Amid the financial crises, O’Connor saw two primary obligations: to advance NF’s unique focus on medical research, and to liquidate the hospital debt from the polio patient aid program. In 1960, he mandated that chapters send 25 percent of their net annual campaign funds to the new Medical Scientific Research Fund at headquarters. He also committed NF to providing financial support for the construction and operation of the Salk Institute for Biological Studies in La Jolla, Calif. Aware of the importance of research, the chapters were supportive, and even took the lead to raise contributions to build the Salk Institute. Over the course of several years, O’Connor liquidated the $7 million hospital debt by transferring funds from chapters with surpluses to those experiencing deficits.

To address NF’s lack of expertise in arthritis and birth defects, O’Connor hired rheumatologist William Clark as director of medical care and anesthesiologist Virginia Apgar as head of the research division of congenital malformations. Clark came up with the idea of a nationwide network of special centers for the treatment and study of patients with birth defects or arthritis. Established in major medical institutions and teaching hospitals, the centers used Clark’s novel approach to comprehensive care, whereby a team of physicians from several specialties guide a patient’s treatment. By late 1964, NF supported 27 arthritis centers and 51 birth defects centers.

The new centers also inspired the support of chapters. Having previously given direct aid to polio patients, the chapters were eager to give tangible community services in the new target areas, and these centers satisfied that desire. Hundreds of chapters pooled their scarce funds to help hospitals establish and operate the centers. The centers also raised awareness and knowledge among volunteers and health professionals about birth defects and arthritis, and made NF’s mission more visible to the public.

Meanwhile, Apgar, who was renowned for developing the Apgar score for evaluating the health of newborns, traveled throughout the country educating the public and NF staff and volunteers about birth defects. Her public education crusade helped dispel the superstitions and parental guilt that previously enveloped birth defects. Apgar also encouraged all areas of research impacting birth defects, including perinatal health and prematurity, which shaped the organization’s research objectives for years to come.

NF’s entry into the field of arthritis caused resentment at ARF. Some ARF representatives even misspoke about NF and its arthritis program to the press, saying, for example, that NF was uncooperative with other health agencies and had the attitude that it “can do the job alone, without any help.”

In 1963, the parent organization of ARF, the American Rheumatism Association (ARA), initiated discussions with NF and ARF about developing a single national nonprofit agency to combat arthritis. ARA was concerned that “public confusion, duplication of efforts and expenses, and a division of loyalty” would result from having more than one organization in the arthritis field.

Deeply committed to curing arthritis, O’Connor was willing to relinquish NF’s arthritis program if the proper agency could be created. In 1964, the three organizations announced that ARF would be reconstituted and strengthened under a new name, the Arthritis Foundation, and a new president, William Clark. Acknowledging his organization’s efforts, O’Connor stated, “The National Foundation gave the arthritis fight the leadership it needed to get it on solid ground.”

Polio was also no longer a primary concern. Further vaccine advances sponsored by NF, as well as increased numbers of vaccinated people, gave confidence that the disease was now firmly under control.

The March of Dimes

Without its arthritis program and with polio no longer a major public health issue, NF focused its energies on the prevention of birth defects. Refocusing its mission on a single issue marked a turning point for NF. While keeping a broad, basic research program as its cornerstone, NF immediately intensified its birth defects public education campaign. It also launched its first Volunteer Leadership Conference to train volunteers and develop their commitment to the birth defects mission. The 1965 March of Dimes fundraising campaign saw the first increase in public contributions to NF in a decade.

Still seeking solutions through research, NF also recognized the importance of prenatal care in preventing or mitigating birth defects. Improving the outcome of pregnancy became the theme of public education programs. In 1976, NF called for the creation of a regional network of neonatal intensive care units (NICUs) in major hospitals to provide lifesaving medical care for premature babies. These NICUs replaced the birth defects centers of the 1960s.

To signal its new, single-minded dedication to addressing birth defects, NF changed its name to the March of Dimes Birth Defects Foundation in 1976. This new name also carried with it the cachet of NFIP and NF’s highly successful fundraising campaigns. In 2007, the organization further shortened its name to the March of Dimes Foundation (MOD). Its mission is “to improve the health of babies by preventing birth defects, premature birth, and infant mortality.”

Since 2001, MOD has promoted family- centered care within NICUs by providing educational materials and emotional support. Its intensive Prematurity Campaign seeks to counter the escalating rate of premature births by awarding research grants and raising awareness through public and professional education. MOD continues to support broad, basic research through grants that support both established and promising young scientists, and through its continued financial support of the Salk Institute. It also advocates legislation that benefits the health and welfare of women, infants, and children.

When NFIP changed its mission in 1958, the organization had 3,100 chapters, more than 80,000 volunteers, and $35 million in revenues. Today, MOD has 52 chapters, more than 3 million volunteers, and revenues of more than $244 million. But as the history of NFIP, NF, and MOD suggests, even careful research and planning cannot guarantee a smooth mission change.

One factor that made the transition so bumpy was that NFIP did not anticipate how difficult it would be for volunteers and the public to make the mental shift from polio to the new mission. The consequence was steeply declining income. For an organization that depends on the public for support, public perception can have as important an impact as the organization’s own actions. If the public sees the mission as completed, it will move on. If the new agenda is overambitious or too broad, the public may not catch on. The new mission must be as compelling, easily understood, and focused as the old one.

NFIP’s transformation into the March of Dimes Foundation shows the value of constant reassessment and flexibility, as well as of clear communication to supporters. It also shows the importance of having strong leadership at the top, in this case O’Connor, who led the organization for more than 30 years. The organization’s experience suggests that a change of mission can be a bumpy ride – one that nonetheless holds exciting potential for growth and satisfaction.

The authors thank the following for their assistance: David W. Rose, archivist, March of Dimes National Office; David Hastings, adjunct professor, Tufts University; Joseph Ward; Evdokia Oikonomou; and Sharon Schulberger, director of program services, March of Dimes Maine Chapter.

1 This article is based on the authors’ research in original source documents at the March of Dimes Archives, National Office, White Plains, N.Y.

2 In 1954, Congress introduced section 501(c) to the Internal Revenue Code. Before that time, what we now call nonprofit organizations were more often called voluntary associations.

3 Dollar amounts are not adjusted for inflation.

GEORGETTE BAGHDADY holds an M.S. in human nutrition and international nutrition from Tufts University. She has worked with UNICEF in the Republic of Maldives and has conducted research on obesity at Tufts.

JOANNE M. MADDOCK has been active in the health care field for 30 years as a registered dietitian with special interest in cystic fibrosis and chronic disease prevention. She received her MPH from Tufts University School of Medicine.

Read more stories by Joanne M. Maddock & Georgette Baghdady.