[Handwritten: Extract from DR 4-69 Agenda for Special Meeting of Trustees April 11, 1933]
The Medical Sciences
Out of the experience of the International Health Board of The Rockefeller Foundation in the control and prevention of disease in the United States and abroad, which began with the work of the Rockefeller Sanitary Commission in 1909, it became evident that the quality of medical education is an essential factor in effecting the prevention as well as the relief or cure of disease. It was consequently considered advisable to institute studies of medical education -- the first in Brazil in 1916 -- and Dr. Pearce, at that time a professor in the Medical Faculty of the University of Pennsylvania, was asked to take part in this work.
Starting from the recognition that the health of mankind depends to a very large degree upon the knowledge and capacity of practitioners of all forms of medicine, the Board undertook to improve the quality of medical education successively in a large number of countries.
The opportunity thus offered was unique in its scope, exceptional in the probability of large financial support, and valuable in its probable results. But to meet the opportunity required extensive and authoritative information as a preliminary to the advocacy of any plan of action. The interests of the General Education Board in medical education in the United States were taken as the basis of a procedure which left Dr. Pearce free to concentrate his attention upon medical education outside the United States.
Needless to say, the history, the status, the objectives, the circumstances of medical education differ in every country, and never before had an attempt been made to collect and compare information so extensive and so widely variant. Also the variety of economic and social conditions in the different countries, as well as the multiplicity of needs in the field of education and medical practice, and the character of local medical problems, required wide travel and the study at first hand of a very large number of institutions for medical education in many countries. At the outset of this undertaking it was an immeasurable advantage to have time without serious interruptions for the survey of the status quo and for the elaboration of a program of action.
As may be readily imagined, the adoption of policies and programs in aid of medical education, even after a considerable amount of published and confidential information had been secured, was not easy. The decade was one of exceptional uncertainty and rapid change, both social and economic. Political or economic changes had in many cases impoverished the universities or profoundly altered their personnel and policies. Occasionally there were unprecedented opportunities for reorganization, but in the main it was a period of innumerable and even insuperable difficulties in the way of stable and continued development. In some countries the very hope of economic stability was in doubt, and the greatest need was the preservation of existing institutions, personnel, and morale, rather than the creation or adaptation of new forms in the face of an unpredictable future. Furthermore, and in a sense quite independent of political, social, and economic circumstances, medicine itself -- in methods of research, teaching, and practice, in its content as well as its objectives -- was by no means stationary. New knowledge brought unexpected results within the realms of possibility and forced the reconsideration of methods and forms of school and hospital organization which previously had seemed adequate and had been accepted even to the point of veneration. Witness the contributions of general biology, of physics, of chemistry, to our knowledge of disease in human beings, and what effects these advances in knowledge were exerting on the study and practice of medicine. Judgment was necessary and care lest new forms destroy valuable elements inherent in the already accepted order of medical education, research, and practice.
The facts secured in surveys of medical education in various countries, when examined from the point of view of an administrator, showed clearly that aid placed in certain centers of medical education would be multiplied and extended by virtue of the very wide and at times international influence of the school or group of schools in question. Capital aid for buildings or endowment was therefore concentrated in certain centers, and the co-operation of governments or local authorities was enlisted as a necessary condition for the granting of the aid proposed.
In London assistance was given to University College toward building and equipment and for the endowment of teaching in the laboratories, and to University College Hospital Medical School for building, equipment, and endowment. The London Hospital Medical College was given aid for a laboratory of patho1ogy. St. Thomas's Hospital Medical School received a grant towards the cost of a clinical laboratory for teaching medical students. In each instance it was the importance of the London school in the British Empire which was acknowledged, and it was hoped that other important schools would be aided indirectly through this support of the teaching "units" and the facilities for instruction which they provided. The wide importance of Edinburgh as a medical center was recognized in contributions to a clinical laboratory, to the endowment of the chair of surgery, to the expenses of teaching in medicine and surgery, and in a program of reconstruction of the medical school building to provide more space for laboratories, library, and research. The role of Cambridge and Oxford, especially in the preclinical years, was strengthened by gifts of buildings for pathology at Cambridge and for biochemistry at Oxford.
The importance of Paris as the center of French medicine led to the series of negotiations which are still in progress regarding the site and erection of new buildings for the Faculty of Medicine.
No program looking to the further development of German or Austrian centers of medical education was recommended by Dr. Pearce in view of the critical economic position in these countries during the postwar decade. A special emergency program was adopted which will be described later.
In the Far East the opportunities offered by the Peiping Union Medical College as a center of wide influence met with a large degree of support from The Rockefeller Foundation both before and during br. Pearce's directorship of the Division of Medical Education. The All-India School of Hygiene and Public Health in Calcutta was aided to purchase land and erect and equip laboratories for advanced training of personnel for the more responsible positions connected with the teaching of hygiene and the administration of public health.
The American University of Beirut, because of its regional importance as a training center for the Near East, was given aid over a five-year period to permit additions to the teaching staff in the preclinical subjects, to increase library and laboratory facilities, and to train men for teaching positions. The Health Center of the University was supported for two years. Later a grant was made to the medical school for building, equipment, and endowment of teaching.
To differentiate between schools or centers of medical education on the basis of the extent of their influence would be invidious, if not impossible, unless it be freely admitted that such influence is often dependent as much upon factors of linguistic, geographical, or political character as upon the excellence of the teaching or research. In a large number of instances aid was given to schools of medicine possessing peculiar significance within boundaries of a political, geographical, or linguistic nature -- schools of special promise or importance to a nation, a region, or a special language group. In this category the list is long.
In Canada, Dalhousie University at Halifax was enabled to remodel and add to existing buildings, to build and equip a dispensary and public health center, to add to general equipment and endowment, to improve clinical facilities, especially in obstetrics, and to strengthen the department of hygiene. McGill received aid for endowment contingent upon securing new funds for buildings, and later aid for the development of the department of medicine. The University of Toronto was given endowment funds also upon a contingent basis. The University of Manitoba was assisted in endowment for improving laboratory and clinical instruction, with the provision that a new building and increased maintenance be secured from other sources. Clinical work in the University of Alberta was developed by yearly grants from 1920 to 1923 and later endowment was given, again on the well fulfilled condition of increased local support. The needs of the French-speaking population of Canada were borne in mind in the grant of an annual sum for the development and maintenance of the laboratories of the University of Montreal; the university, on its part, having increased the general budget of the school, has gone on to erect new buildings.
In the United States^1 aid was given in co-operation with and at the instance of the General Education Board toward the endowment of the Medical School of the University of Chicago, for the erection and equipment of laboratories of Columbia University Medical School, for buildings at the University of Iowa, and toward a building and equipment fund for anatomy and physiological chemistry at the University of Pennsylvania. The Harvard School of Public Health was given endowment to permit further development and for reconstruction and maintenance of the library. At Yale University a contribution was made to the development of psychiatry over a ten-year period beginning in 1929, in the Institute of Human Relations. A contribution over a five-year period beginning in 1929 was made to the Albany Medical College for teaching in medicine in co-operation with the New York State Department of Health, with a view to the better preparation of doctors for rural practice.
In South America the Faculty of Medicine of Sao Paulo, Brazil, received aid in the teaching of pathology and in equipment for the department, and later in the erection of a building to accommodate five laboratory departments.
In Europe, the University of Brussels was aided in the erection, equipment, and endowment of new medical school laboratories, and assistance was offered for the endowment of clinical facilities. The Medical Faculty at Strasbourg was enabled to erect a new laboratory building for histology and to complete accommodations for otolaryngology, and a gift was made in support of research in the medical sciences. At Nancy, the enlargement of the Institute of Hygiene was made possible. The Faculty of Medicine in Lyon received an appropriation, conditional upon grants from local and governmental sources, for the purchase of land and the cost of erecting a new building. In Yugoslavia, grants were made towards equipment and maintenance of the department of hygiene of the University of Zagreb and for the establishment of a new method of teaching hygiene to medical students by enabling them to get direct
[Footnote] 1 In this connection it may be recorded that the following medical schools in the United States received aid toward buildings or endowment from the General Education Board: Chicago, Cincinnati, Colorado, Columbia, Cornell, Harvard, Howard, Iowa, Johns Hopkins, Meharry, Oregon, Pennsylvania, Rochester (N.Y.), Tulane, Vanderbilt, University of Virginia, Washington University (St. Louis), Western Reserve, and Yale.
field experience in public health work in the villages under expert direction. In Great Britain, apart from projects already referred to, the Medical Faculty of the University of Cardiff was helped to build a laboratory for clinical medicine.
In the Far East, several widely scattered institutions were aided. At Tokyo, Keio Gijiku University Medical College was given funds for the construction of a building and equipment of an institute of hygiene and parasitology. At the University of Hong Kong The Rockefeller Foundation endowed chairs of medicine, surgery, and obstetrics on the assurance that the university would develop other phases of the work of the Medical School. An associate dean was lent to the University of the Philippines (1922-1924) for its medical school, and two visiting professors were provided for two years for the departments of bacteriology and parasitology of the Graduate School of Sanitation and Public Health, together with funds for equipment, supplies, and medical literature; plans were matured for building a new wing for use of the graduate school, but actual appropriation of funds for this purpose was not made until 1930. To the Chulalongkorn University Medical School in Bangkok The Rockefeller Foundation gave funds for erecting laboratories of anatomy and physiology and a building for surgery, contingent upon the Siamese Government's maintaining the school on an improved basis and providing other buildings from its own funds; contribution was made to the salaries of six foreign professors for temporary appointment and fellowships were given to train Siamese successors to these teachers; aid was given in the development of premedical education also, and on similar lines. To the King Edward VII College of Medicine in Singapore a grant was made for the endowment of chairs in bacteriology and biochemistry.
In the Caribbean area, the National School of Medicine and Pharmacy at Port au Prince, Haiti, was given additional teaching equipment for the laboratories and some fellowships for members of the teaching staff.
In all of the undertakings mentioned above the assistance given by the Foundation was conditional upon assurances received from the institutions concerned that contributions in the form of new buildings or increased maintenance would be provided. Thus the Foundation co-operated with, rather than merely contributed to, institutions for the improvement of medical education.
Gifted young men are not produced by administrative procedures, but may be recognized and trained through a system of fellowships, later to take places in institutions of more or less significance, but nearly always the better for their increased experience and the extension of their training. Furthermore, the effectiveness and continuity of schools of medicine as of other human institutions, depend on the recruitment and training of the oncoming generation. Two types of fellowships were devised to meet varying conditions and needs -- foreign fellowships and resident fellowships.
Through foreign medical fellowships 472 individuals from forty-seven countries, chiefly promising young teachers and investigators in medical schools and research institutes, were given the opportunity to extend their studies in some country or countries other than their own. Special consideration was given to candidates in the fundamental medical sciences, rather than the clinical subjects, chiefly because the preclinical branches often serve at the same time preventive and curative medicine, and yet are likely to be neglected, especially in the lean years of economic distress. In some instances the foreign fellowships gave an opportunity for thorough training to men whose preparation had been generally inadequate, in other instances the fellowships were given to men of already advanced training quite capable of independent work abroad. In addition to the 472 foreign fellowships in medicine and 24^2 in human biology, directly administered by the medical division of the Foundation, funds for 341 medical fellowships were given to other agencies which took over the details of selection, payment of stipends, counsel, etc. The National Research Council for candidates from the United States and Canada, the Medical Research Council for British candidates, the Notgemeinschaft der Deutschen Wissenschaft for German candidates, Hungarian Scholarship Counci1, accepted responsibilities of administration of fellowships along the lines already indicated. Also
[Footnote] 2 These figures cover only the period of M.S. administration of fellowships afterwards taken over by N.S. and S.S.
fellowships were accorded in connection with development of nursing education (261^3); and through the China Medical Board (78^2); through the National Committee for Mental Hygiene (33^3); the National Research Council (U.S.) in biology (75^2); the Australian National Research Council in the field of human biology (15^2); and through the National Research Council (U.S.) for physics, chemistry, and mathematics (79^2).
The officers of the Foundation who have been in most intimate touch with the foreign program have been increasingly impressed with the soundness and value of this form of work. It is based essentially upon the merit and probable future accomplishment of the individual. The results secured are multiplied by time as long as the beneficiary lives, and are not subject to early or rapid depreciation; and the advantages of wider experience and better training are passed on to others by reason of the institutional position of the returned fellow. It may be of more general interest to add that the fellows have profited in other than professional experience -- in tolerance, understanding, breadth of sympathy, and though the finding of new friends in other lands.
Another program, largely an expression of the teacher's interest in the oncoming generation, was the resident fellowship program in force from 1923 to 1928. This was begun in Germany and later extended to Austria, Czechoslovakia, Hungary, Poland, Rumania, and Yugoslavia. In Central Europe during a period of unprecedented monetary and economic difficulties, the continuity of scientific tradition and of competent personnel in the faculties of medicine
[Footnote] 2 These figures cover only the period of M.S. administration of fellowships afterwards taken over by N.S. and S.S.
[Footnote] 3 This figure includes fellowships given by Division of Studies and Medical Sciences.
was in jeopardy. In addition to aid in the purchase and distribution of medical literature, which could not be bought with local currency then so badly depreciated, the Division of Medical Education gave the funds necessary to hold a substantial number of young workers in scientific medicine through a system of resident fellowships. Committees of eminent professors sided in the administration of these funds and unselfishly agreed upon the paramount importance of maintaining the scientific succession, even when other phases of academic life were in danger of starvation. Altogether 514 young men were enabled to continue their preparation to a point where they were capable of assuming salaried teaching positions.
Furthermore, 223 resident fellowships in China were given in 1927-29, the years when the Division of Medical Education had direct responsibility for the work of the China Medical Board and the Peiping Union Medical College.
A third type of work in which the essential objective was the preparation of promising candidates for future positions in teaching and research, was instituted in Italy, France, and Ireland under the name of developmental aid. A limited number of professors, principally in the medical sciences, who had shown the capacity to attract and train students of unusual promise, were offered the financial support necessary to select and hold, during a period of training, a very few students whom they believed capable of undertaking academic careers in schools of medicine. This program was instituted at the following universities and the total number of young men thus aided was about 100:
In France, Lyon (Institute of Biology and Institute of Histology) Paris (Institute of Pharmacology, Institute of Pathological Anatomy, Institute of Parasitology and Institute of Hygiene) Strasbourg (Institute of Histology and Institute of Biochemistry).
In Ireland, Belfast (department of pathology), and Dublin (department of anatomy in the National University, and department of bacteriology and pathology in Trinity College).
In Italy, Bologna (Institute of Hygiene), Florence (Institute of Anatomy and Institute of General Pathology), Genoa (Institute of Pharmacology), Milan (Institute of Pathological Anatomy), Naples (Institute of Physiology), Padua (Institute of Pharmacology), Pavia, (Institute of General Pathology), Rome (Institute of Hygiene and Institute of Pathological Anatomy), and Turin (Institute of Physiology, Institute of Normal Anatomy and Institute of General Pathology).
The third category under which the work directed by Dr. Pearce may be presented is that which expressed his interest and enthusiasm for research. In the latter part of the decade of 1920-29, an increasing interest in programs of research became evident, but earlier appropriations, such as the laboratory for teaching and research of the medical unit at the Welsh National School of Medicine at Cardiff, of aid to the Pasteur Institute in Paris, the Institute of Physiology at Copenhagen, the Institute of Pharmacology and the Institute of Physiology at Utrecht, and, later, the aid to the Institute of Hygiene at Nancy, were considerably influenced by the expectation that research activities would thereby be strengthened. Research in the field of psychiatry was aided by gifts to the Research Institute for Psychiatry in Munich and to the Institute for Brain Research at Buch near Berlin.
This interest in the development and fostering of investigative work continued to grow. As of January 1, 1929, the Division of Medical Education became known as the Medical Sciences of The Rockefeller Foundation, a change of title that expressed an important change of policy. Thus in the last year of a decade that had been devoted largely to aiding medical schools, principally as institutions for teaching, came an increased emphasis upon aid in the advancement of knowledge through research. The new undertakings differed from earlier programs in being directly aimed at the advancement of knowledge through improvement of clinical facilities or routine teaching laboratories or more fully trained teaching personnel, instead of at the development of institutions as teaching organizations. The distinction between teaching and research needs no belabored explanations: the developments of the last year of the decade were in the direction of aid to special projects in medical research.
A considerable number of undertakings sponsored or supported by The Rockefeller Foundation were allocated for administration to the Division of Medical Education (subsequently known as the Medical Sciences) largely because of the experience and administrative ability of Dr. Pearce. These projects and activities were varied in character and in some cases required much time and care. A brief account of them follows.
Beginning April 1, 1927, the work of the former China Medical Board^4 was taken over by the Division of Medical Education. This work included continuance of aid to the Hsiang-Ya Medical School and to the Medical School of Shantung Christian University; to thirteen colleges and universities in China for their premedical department^5; and to twenty-two hospitals which the China Medical Board had been aiding in order to provide places of training for future graduates of the Peiping Union Medical College as well as to increase the personnel of the hospitals sufficiently to make possible leaves of absence for postgraduate training. Fellowships for Chinese and for members of the staff of the Peiping Union Medical College are referred to in connection with other fellowships. Aid was also continued for anthropological research under the Department of Anatomy of the Peiping Union Medical College, to the China Medical Association, and through a small fund for emergency needs of Chinese hospitals and medical schools. Because of implications of preceding work, contributions were made to Shanghai Union Medical College, to the National Central University College of Medicine, and to the National Medical Association of China.
[Footnote] 4 This is to be distinguished from the present China Medical Board, Inc., which is a corporation for holding funds by which the Peiping Union Medical College is now supported.
[Footnote] 5 This was taken over October 1, 1928, by the Director for the Natural Sciences on his appointment in the Foundation.
The development of schools of nursing and the training of nurses for service in preventive as well as curative medicine was assisted in Austria, Belgium, Bulgaria, Canada, China, Czechoslovakia, England, France, Hungary, Japan, the Philippine Islands, Poland, Rumania, Siam, the United States, and Yugoslavia. This aid took various forms according to circumstances -- visits of directing personnel to other countries, traveling fellowships for study and training, temporary maintenance, and, occasionally, buildings.
At the Johns Hopkins University studies in human biology and genetics were supported; through the Australian National Research Council contributions were made for anthropological studies in Australia; at the University of Hawaii and the Bishop Museum at Honolulu, studies were aided in biology, ethnology, and anthropology; at Yale University, research was aided on the behavior of primates, and at the State University of Iowa, research in brain physiology; through the National Research Council in Washington, aid was given to the Union of American Biological Societies for editorial expenses in the publication of Biological Abstracts; in connection with the development of the study of biology in Japan, three Japanese professors visited America and the services of a visiting professor of biology were supplied to Tohoku Imperial University at Sandai.
In the field of mental hygiene aid was given to the National Committee for Mental Hygiene (New York) for surveys of the care and treatment of mental deficiency and disease, for fellowships, and for general expenses of the committee; and the Canadian National Committee for Mental Hygiene for studies of the application of mental hygiene for school children.
Studies of the function and services of dispensaries were at first supported by the Foundation and gradually transferred to other agencies through the United Hospital Fund. Studies of the training of hospital executives were carried through under grant from the Foundation.
The New York Academy of Medicine was given an endowment fund in support of its work, especially in increasing educational opportunities and services for the medical profession.
Part of the costs of publishing a Spanish edition of the Journal of the American Medical Association was defrayed by grants from 1918 to 1928.
The Hospital Library and Service Bureau in Chicago -- an agency for the exchange of information on the construction and management of hospitals -- was given funds for maintenance and development beginning in 1920 and continuing nearly throughout the decade covered in this report.
Among the less directly scientific programs a lasting record of accomplishment will be found in the aid given to the schools for the training of nurses.
The Foundation's activity in medical education and the ably written books of Mr. Flexner have been responsible for an immensely greater exchange of personnel and thought between different nations and races than had ever before characterized medical history. To this end the Foundation has, since 1924, issued from time to time as accumulated material has seemed to warrant, a series of volumes entitled "Methods and Problems of Medical Education", containing articles written by administrators and teachers describing new buildings, projects and methods of teaching. These volumes are copiously illustrated with floor plans and photographs and other appropriate diagrams and pictures. Each volume as it appears is distributed free to deans of all medical schools and to many others. The number of volumes issued to date is 21, containing in all 448 articles and over 3,100 illustrations and constituting a storehouse of information on problems of building, equipment, organization, courses of study, methods of instruction, and other features of modern training in the science and art of medicine.
In retrospect it would be the director's opinion that the best programs during the past ten years in the field of medical education and medical science have been buildings and endowments at strategic points, fellowships, local and foreign, and long-term research grants-in-aid of capable investigators.
Failures or disappointments in the various programs were most commonly associated with incompetent recipients, premature hopes on our part of progress in fields where no advance has taken place, and over-confidence in the social, economic, and cultural matrix in certain countries.
Financial Summary
Any detailed financial statement would be impossibly long for the present purposes. A highly condensed statement year by year is given herewith.
[Chart = "Medical Sciences -- Financial Statement 1914-1932]
I. Surveys, Visiting Commissions, Travel of Leaders, etc.
II. Gifts to National Agencies, such as National Committee for Mental Hygiene
III. Medical Research Institutes (Rockefeller Institute for Medical Research, Institute for Psychiatry, Munich, etc.)
*IV. Medical Schools and Departments of Institutes therein, including Professors on Loan: also Schools of Hygiene, Nursing Schools and Specific Research Projects.
V. China Medical Board and Peiping Union Medical College, and China Medical Board, Inc.
VI. War Work (Medical)
VII. Fellowships (Medical and Nursing)
VIII. Miscellaneous (Infantile Paralysis Work, New York Academy of Medicine, Methods and Problems of Medical Education, Studies in Hospital Administration, Administration Medical Sciences, etc.)
*For detail see following page.
[Chart = "Medical Sciences -- Financial Statement (Detail)"]
IV. -- Medical Schools and Departments or Institutes therein, including Professors on Loan, Medical Literature, Europe, etc.
IVa. -- Schools of Hygiene.
IVb. -- Nursing.
IVc. -- Specific Research.