July 16 1943
Dear Ray:
Here's a letter which is largely an experiment in communication between you and me about the M.S. and R.F.  I have kept a copy but I have written this with the assumption that you will not read any of it or show any of it to anyone without my assent.
It is not a review, nor a preview, nor a set of requests.  It is a critique more than an exposition.  Some of its statements are unnecessary, vague in some ways and perhaps not provable.  I have tried to record some ideas on the way I feel about the MS--and the values I attach to some aspects of it and some of the opportunities I see.
The subject is nowhere near covered nor is it any well condensed.  Skill in writing such a letter effectively would be desirable, but skill in reading it is almost necessary.  I could fill a page with the mere index of what I haven't mentioned but I'll spare you and hope that you will find this worthwhile as an experiment in keeping in touch with you informally.
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Before saying anything about the MS I'd like to say three or four things about the environment--the world at present--which the MS acknowledges as its field.
Change dominates that world; economic change in the form of heavy taxation and possible inflation; a change to "Our World", talked about now to make the war more excusable but to be brought about anyhow by the air planes; and more concrete and important a changed personnel in nearly every country in the world, new men whom we don't know though they may know of us.  Change dominates the world; but all our divisional heads are over fifty.  I've got to work explicitly and fairly to hard to keep a foundation of 80 million dollars now directly by [. . .] averaging 56 years old to keep it young enough, and enough in touch with younger men, and freshly imagination for the future, near or far.
In addition to these truisms about coming changes there are the less obvious changes which have already taken place without being recognized.  Where Pearce started in his [. . .] surveys and visits and was the first person to obtain an idea of world-wide conditions in medicine.  Though he would have been far more competent than am I to give advice, he did not have twenty years of experience, nor the regulation of the R.F. [. . .] building him into the position of an informed adviser than now makes so many people asking for my time.  At the
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present when medical men all over the world want more than ever before to avoid provincialism and narrowness of view.  The MS is more conspicuously expected to give advice and information than any other organization.  Twenty years ago when we were busy informing ourselves about world conditions in medicine, they wanted and took our grants.  Now when this information is beginning to be out of date, they want our advice and information.  I could easily fill a paper with recent instances in which our opinion was sought were more than our friends, and if I know more about what is going on, the demand would be still greater.  We have failed to see that the accumulated experiences of world medicine obtained through active study and intimate confidence have made us more valued as advisers than as givers--unless we had ten times of amount to disburse.  My fear is that we are going to think in terms of money and grants and thus escape the responsibilities of our own maturity.
Practice in deciding year after year how to spend our free funds has seasoned us.  The universities and their medical school deans have almost no free funds and dangerously little of such seasoning.  No wonder that they seem green and inept and unimaginative.  Yet we have taught by example if not by precept, that numerous small, short, earmarked grants constitute the "best way" to give money to research.  Whom we have taught?  Some twenty smaller foundations and thousands of private donors.  Look at the Stanford Annual Report for a specimen[?] picture.  Less
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than 1 percent of the gifts received are unearmarked.  Such gifts do not call for any exercise of the faculty of knowing when and on what effort and money can wisely be spent.  Capital grants and fluid research funds constitute but feeble exceptions to the general example we have set for the past ten years.  To see a foundation let its directing personnel steadily go on with the busyness[sic] of distributing small corn on unparched soil drives me to psychology for an explanation of such behavior--unless it be quite unreflecting.
We need to get out of the office more.  We need to give fewer grants and we should be getting more first hand information.  We can't keep up with a world like the present one by giving Rockefeller drives to worthy little investigative impeccabilities[?].  I'm not afraid of our judgements[sic] when we are familiar with what is in the world; I'm afraid of our decisions when tending to the food of picayune requests makes our knowledge at about the level of our secretaries and the recipients.
At a considerable risk of being thought [. . .] I'll say that unless the R.F. work is so oriented and so performed as to make the officers grow and mature to a recognizable degree, the Foundation is on the wrong track, or the men are not the right men for their opportunities.  The oncoming world will not pause in rapt admiration while we stand on our record: unless we travel more and seek more and learn more and ourselves change we shall give money to the things
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appropriate five years but which are far from the frontiers of today or tomorrow.
I shall be more explicit later in this letter, but much of the foregoing comes to this this: if the officers--yourself included--could spend much of the next three years in travel in the insistent effort to learn who is who and what is what especially outside America we would grow and mature and stave off a pleasure in perfected trifles which will otherwise overtake us.  Such travel and study would attract instant and admiring attention: we should lead in such an attitude.  We could be more useful showing medical schools how to choose what is worth doing than paying the expenses of secretaries and animal keepers involved in neat but trivial local projects.
Strategy is the art of knowing when and on what you will engage your strength; tactics is the case, the grace, the economy of performance once you have chosen what to do.  I feel that if we can improve our strategy and especially help the medical schools and research men to improve their strategy by exercising it, then that will be out best contribution--and not small grants to facilitate the tactics of a hundred secondary endeavors a year, while many other donors are doing the same in the wake of our example set over the last fifteen years.
Much of the above relates to the task of adapting ourselves to the envision-
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ment of the present and the immediate future. Now for a few comments on the M.S. as an organization.
To say the less agreeable things first the relations with the NS and the CMB remind me of an engine which runs more thanks to ample lubrication than good mechanical design.  Lambert and O'Brien deserve credit for making the N.S. relations free from too much friction, as do Weaver, Hanson, and Miller.  Where Mason presented to a special committee appointed to review the work of the N.S. and padded that list of grants to illustrate the work of the N.S., and padded that list with M.S. grants without nothing the fact that they were made by the M.S., I tampered my sense of injustice with the hope that Weaver would disclaim such a fast one.  Another circumstance which keeps me in a rather reserved state is the policy that keeps N.S. theoretically aloof from pure physics, chemistry and mathematics though progress these would provide tomorrow's progress in biology.  That is just stupidity.  You know my convictions on the C.M.B. structure: we differ on timing the redesigning of that engine.
Our relations with the administration all goes well.  Appleget's example of self-assured and lazy but ingratiating officiousness is nothing for any further complain on top of my telling you that it increasingly is deteriorating
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office morale.
Lambert has done and will always do a superb job in charge of the fellows and is ideal for the South American assignment.  He is extremely helpful in many other ways and I shall greatly miss him when he retires.  O'Brien is not good enough for his opportunities and illustrates--as does TBA--that fact that employment as an assistant or associate in the Foundation is hard to discontinue.
There has never been any discussion or definition of policy in RF staff appointments.  I've had the impression more than once that somebody of importance wanted to evade or at least postpone the admission that the Foundation is an institution which will develop wages and traditions whether one likes it or not.  As long as we defer any decision as to whether division heads are to be found or to be trained we shall drift into the easier aspects of both systems--employ second rate assistants as personal helpers to the chiefs and then keep them on after chief leaves to be at first a hopeful help and then misfit handicaps to the next dynasty.  Having lost the chance of getting Raymond Allen and Charles McKhann because Harvard and Illinois were willing to pay more, and having seen what happens when a useful assistant is promoted beyond his capacity I have come to the rather resigned conviction that the Foundation's tradition in point of recruitment is a studied indecision.  I think we are going to pay more for ignoring recruitment procedures than foundations which face the situation clearly.  I would like to try two to three year terms of
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contract with some men in their thirties on leave of absence.  I would prefer this to taking second rate assistants permanently.  Though Lambert covers South America, and O'Brien a much needed constricted Europe, I have no one for the Orient, Russia, India, Australia, and South Africa.  Experience shows that territorial assignment is best for our sort of work--and in the next ten years with their changes territorial representation will be even more important.  In fact any organization covering the medical world in the next ten years in the capacity of informant, consultant, friendly ethic, and intermediary would do more than could be accomplished by our present tactics, programs and policies.  I can't help repeating it--we are moving into a new would in which our experience and our knowledge and our point of view and an occasional large appropriation will mean more than a scattering of many small grants in so large an area.
If some of the above seems critical let me add that I could be more critical of myself and my own performance.  Mason told Gunn my appointment in 1931 was a mistake, which has some truth despite the irony of the origin of this news.  I am better as a phraser than as a thinker and better as a thinker than as an administrator.  I like to be of use to people in trouble and I don't like to dominate or control them or even to interfere with them.  I can't comfortably refuse my time in the face of what seems like real need.
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And my scientific competence is small indeed when compared to all of the other MDs in the office.  I expect people to be decent and self controlled and conscientious though why this naivete[sic] persists God only knows.  In all these points and perhaps some other Mason was right.
Of what I may have of value to the work of Foundation I am no good judge.  I think much of any possible value must be in cumulative experience, and in the wide varieties of problems and solutions to which Lambert and O'Brien and I are privy witnesses if not privy counselors.  The tasks this summer are characteristic of what has been increasing during the last four years: I have an address to give before the American Psychiatric Society at its[?] next spring in which I am asked to be the "relentless critic of American Psychiatry".  Two speeches at Western Reserve in October, one to the Assoc. of Am. Med. Colleges and the other the convocation address at Water Reserve [?].  And a talk in September to the military Surgeons Annual Meeting on "Some Problems of Rehabilitation."  They all derive from the length in time , breadth in scope of the job I've had.  And R.F. personnel as your well know is the major service of persons with worldwide medical experience in the United States if not in the world.  It is not that speeches are important but that our experience is unique.
If I can begin soon to get out of the confines of the office and be of use as an impartial advisor and visitor from the "the outside" then
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I can play my long suits which I think are in studying conditions and factors involved in medical teaching and research and in talking and writing about the,. In the kind of reconstruction I see ahead our experience and judgment can go no further than out funds but only if our experience be refreshed and enlarged constantly by direct study and contact.
I am not going to put into this letter any extended discussion of the last ten years work on any elaboration of current projects or policy.  It would take fifteen or twenty pages and though I want to do it sometimes I would have to have all my records at hand to do it reasonably well.  But a few general statements can be made.
Thanks to the Foundation psychiatry or in some cases neurology is nor for the first time reasonably well presented to medical students at Yale, Duke, Columbia, and McGill, Chicago and Washington Univ St Lous.  Tulane and U. of Tennessee Research as well as teaching is done with out funds at all but the but the last two of these institutions.  This means that every graduating class in those eight schools goes into practice now, as it had not before, with a comprehension of the nature and importance of mental disease and the emotional aspects of many other diseases.  Further than this we have substantially strengthened the teaching and research in this field at Harvard, Pennsylvania, Hopkins, Northwestern, Illinois, Colorado, Michigan, Toronto, and Cincinnati, at Oxford, the Maudolay Hospital in London, and at Edinburgh.  There is no doubt that our example has directed the attention of several other foundations to the same
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subjects--medical psychology, psychiatry, neurology, and neurosurgery.  We cannot claim that insulin shock, nor metrasol shock nor the electric shock treatment have been discovered under our[?] or aid.  They are all European in origin.  But we can claim that in America and Canada these therapeutic methods have received a type of critical study and discriminating rejections or use that would otherwise not have occurred.  In 1933 psychiatry seriously lacked adequate recruitment.  Almost everywhere the need was for good men with good training.  We tackled the death of men by trying to help present the subject much better and to a much larger number of students, supplementing this preliminary presentation by fellowships for the advanced training of future teachers.  Psychiatry has a notably different status now, both as a special field and as an integral part of the medical education of 1800 to 2000 medical students every year if we speak only of the schools we have specially aided.
Aside from the large endowment for the department of Public Health $600,000 and a two year grant at Johns Hopkins the MS has not undertaken much of significance in the improvement of departments of public health in the medical schools.  A good opportunity exists at Washington University St Louis but nothing should be done until the general finance of that school is on a sounder footing.  Occasional fellowships have been given and travel grants for teachers have proven useful.
most of the departments of Hygiene and Public Health have fudged the issues
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of Social Medicine.  By comparison the Foundation is a pioneer.  Our support to the Institute of the History of Medicine at Baltimore was the first grant of importance in the field of Social Medicine.  The paradox--or is it the irony?--of the IHD being directly involved in medical research and neglecting all the major opportunities offered by projects in the field of social medicine, while the Medical Sciences gives up biochemistry and biophysics to the Natural Sciences but supports Social Medicine suggests a realistic view of divisional programs and policies.  "What is reason for if it isn't to make reasonable what you want to do"--c.g. Miller's idea of what ought to be done in building for the Department of Hygiene in the University of Uruguay got by as part of an N.S. program.
The main mistake I see the M.S. making derives from the Trustees attitude toward long term grants.  Caution may be the mainspring by the results are that I am crowded with all the machinery of renewals for which appraisal is premature if it is not actually meaningless, and the recipients are kept in a state of repeated uncertainty, and the job does not receive what it deserves of their attention.  Besides--and I think more important--I am kept facing backward a third of my time on renewals of short term staff for another hopeful but timid period of a year or two instead of looking forward and watching closely a radically changing future.  I don't know whether the Trustees realize in how many ways this attitude defeats their purposes.
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What tangible suggestions from all this?
First:  Reduce MS grants in number, increase their term and thus their size, and clean up many of the commitments now encumbering our deskwork and our time.
Second:  Spend a large amount of my time in the field studying the changing circumstances and meeting the new men.  this would mean England this winter and perhaps China or India, but in any case the US and Canada
Third:  I'd like to see if I could get an assistant or two on leave of absence from medical school for two or three years at salaries not over $6000 to assign surveys and home office work.  I'd like to have three or four candidates to choose from when it comes to getting Lambert's successor six years from now.
Fourth:  Bring into the Board more proposals bearing on international exchanges of information of personnel in different grades of maturity, and stressing the need for strategy in world medicine in contrast to scattered bits of nice tactics.
Fifth:  Accept and explore our side as visitors and helpful critics rather than short-term grant workers.
Sixth:  Act on the assumption that in an impoverished world it will be more valuable to preserve the very best institutions and so preserve the source of research men for the future, rather than to subsidize
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projects while the lights go out uniformly and careers for first rate research disappear everywhere.
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So much for a cross section of what is in my mind after a week's distance from the job.
Alan Gregg