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The purposes of this paper are twofold: 1. to demonstrate that medical education reform in the US was part of the broader social changes taking place in the late 19th and early 20th centuries, and 2. to show that the fundamental aspects of educational reform in medicine were first proposed by Frederick T. Gates, the trusted advisor to John D. Rockefeller. In order to promote scientific education throughout the US, Rockefeller philanthropy established the General Education Board (GEB) which further developed key strategies for educational reform. Gates invited Abraham Flexner, considered the patron saint of medical education, to join Rockefeller philanthropy to help create a system of scientific education throughout North America. The paper concludes that the impetus for reforming medical education originated with Gates, while the Flexner report was only a link in a chain of events involving a number of individuals.
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Introduction
There is a widely held belief among social historians of medicine that the transformation of medical education in North America from mediocre to one of the best in the world which occurred within a few decades in the twentieth century was mainly due to Abraham Flexner, author of the famous Flexner Report.1 A plethora of books and essays over the years has transformed Flexner into a "patron saint," who rescued North American medical education from the control of private medical schools and raised its scientific standards to produce the best medical practitioners in the world. As one author argued, "the Flexner Report took medical education out of the hands of the practitioners and put it in the hands of the universities, where quality presumably could be assured."2 Another went as far as to suggest that there is a "flexnerian" tradition "signifying strong convictions about the role of basic science in the curricula of medical schools."3 As recently as 1993, reflecting on the progress of a half-century of Canadian medical education, a leading medical educator wrote: "The Flexnerian paradigm of medical education, rooted in biomedical science and conducted under the aegis of a university, reached its apotheosis by the late 1960s and the early 1970s."4 These remarks represent the general perception of Flexner's role in medical education reform.
Although glowing tributes to Flexner continue, there has been very little effort to examine his precise role in medical education reform in a broader historical context of the late nineteenth and early twentieth centuries.5 As Kenneth Ludmerer argues, the revolutionary transformation of American medical education was a result of a mixture of political (growing professionalism), historical (increased private funding) and intellectual (advancement of quality research) forces that shaped the American higher education's coming of age. The Flexner Report and its immediate impact on medical education in North America have been, for the most part, examined without taking into account a vast amount of archival materials pertaining to a6 complex historical background of educational reform during that period. Although these archival records became available to researchers in the early 1970s, the influence of the Flexner Report on medical education was such that it had created the powerful image of Abraham Flexner as being the single contributor to medical education reform in North America. As a result, students of medical history have unwittingly ignored the important contributions of those before him who prepared the groundwork for medical education reform and laid the foundation for the Flexner Report.
The Flexner Report, without doubt, is a comprehensive and meticulous study of the condition of medical education in North America. Since its publication in 1910 by the Carnegie Foundation, the Flexner Report has been extensively studied and analyzed by many historians. Besides its impact on medical education reform, the Report itself is overwhelming, with systematic and detailed accounts on almost every aspect of the 155 medical schools in the United States and Canada visited by Flexner. Thus, some commentators have portrayed Flexner as an "articulate, uncompromising intellectual who was deeply involved in activities of considerable importance."7 Viewed against this background, it is no surprise to see such veneration for both Flexner and his Report in the literature on the history of medicine.
The purpose of this paper is two-fold: First, to demonstrate that medical education reform in the United States was part of the broader social changes taking place in the late nineteenth and early twentieth centuries. With a rapidly expanding industrial economy, it became evident that the nation must have modem scientific education to provide a well-trained industrial labor force, and properly educated medical professionals, scientists and engineers, The modem philanthropic foundation, which was considered to be the solution to the "problem of proper administration of wealth" in the "Gilded Age," assumed responsibility for developing a system of scientific education with the help of prominent educational reformers, such as Charles W, Eliot, William R. Harper, Daniel C. Gilman and William H. Welch, long before the Flexner Report was published. Second, to show that the fundamental aspects of educational reform in medicine were first proposed by Frederick T. Gates, the trusted adviser to John D. Rockefeller. Influenced by the burgeoning biomedical model and the germ theory of disease in the late nineteenth century, Gates convinced Rockefeller to establish an institute of medical research in which the key strategies for medical education reform were first to be implemented. Further, in order to promote scientific education throughout the United States, Rockefeller philanthropy established the General Education Board (hereafter GEB) which further developed the key strategies for educational reform. In 1905, in an attempt to keep Andrew Carnegie out of this reform, Gates persuaded Rockefeller to make an endowment, the biggest gift to higher education at that time, through the newly created GEB. Having lost the momentum to Rockefeller, the Carnegie Foundation appointed Abraham Flexner to study the state of medical education in North America and make recommendations to improve it. Because Carnegie made no financial commitment to implement Flexner's recommendations and they were consistent with the medical education reform sponsored by the GEB, Gates invited Flexner to join Rockefeller philanthropy to help create a "system of scientific education" throughout North America. The paper will conclude that the impetus for reforming medical education originated with Gates, while the Flexner Report was only a link in a chain of events, involving a number of individuals who not only designed a systematic program of medical education, but also worked hard to make it a reality.
Understanding American Philanthropy
In an earlier attempt to articulate a conceptual framework for the analysis of the relationship between American philanthropy and the development of higher education, E. V Hollis suggested that there was no systematic policy of philanthropic foundations, which stipulated the nature of corporate giving other than the personal convictions of those who were closely associated with modern foundations. These personal convictions, Hollis argued, "constituted in turn the philosophy of the philanthropic foundations." Further, he pointed out that the "principles and policies" of modern philanthropic foundations "are little more than the rationalized residue of experiences" of those who became preoccupied with "giving away other people's money so that it will do more good than harm."' The fundamental philosophical tenet that Hollis was articulating here is paramount to understanding not only the moral basis of American philanthropy, but also the long history of the relationship between philanthropy and education. It is this expression of rationalized moral convictions that Max Weber described as the "process of rationalization" in modern society.
In his well-known book The Protestant Ethic and the Spirit of Capitalism ([1920] 1958), Weber observed that he was interested in ascertaining "those psychological sanctions which, originating in religious belief and the practice of religion, gave a direction to practical conduct and held the individual to it."9 Weber's aim was to show how Protestantism had given new impetus and meaning to the rational pursuit of social and economic activity. The anxious search for the certainty of eternal salvation by Protestant Christians, according to Weber, resulted in a fundamental change in the individual's interpretation of the world during the period of the Reformation. For Weber, the change was away from mysticism as well as traditional ways of thinking and doing things. Basically this change involved the origin of the process of rationalization in the West - the capacity of the individual to think logically and rationally. Weber called it "instrumental rational action," which he defined in terms of predictability and calculability. In other words, the goal and the means are methodically and rationally linked: "Action is instrumentally rational," argued Weber, "when the end, the means, and the results are all rationally taken into account and weighed."" Rationalization emphasized calculability and predictability as the basis for human social actions, and rejected metaphysical speculations. Weber suggested that the process of rationalization has penetrated into almost every aspect of life in modern society - medicine, science, arts, music, commerce, jurisdiction and public administration, to mention a few - and has produced unparalleled development in the West. For Weber, this is an "inescapable trend," in which previously "unsystematic" and "informal human activities" are now being done by professional experts in modern bureaucratic organizations. Greater technical rationality, or what Weber called "formal rationality," of specially trained bureaucracies allowed individuals in their formal duties to detach themselves from all personal and emotional feelings toward others. "Objective discharge of business," Weber wrote, "primarily means a discharge of business according to calculable rules and without regard for person."11 Thus, Weber maintained that a "fully developed bureaucratic apparatus compares with organizations exactly as does the machine with the non-mechanical modes of production."12 The modem state is characterized by impersonality in the sense that its apparatus, such as bureaucracy, functions "in a matter of fact manner, without regard to the person, sine ira et studio, without hate and therefore without love." The homo politicus, like the homo oeconomicus, performs "without personal predilection and therefore without grace, but sheerly in accordance with the impersonal duty imposed by his calling, and not as a result of any concrete personal relationship. He discharges his responsibility best if he acts as closely as possible in accordance with the rational regulations of the modem power system."13
Weber's interpretations on the development of modern Western capitalism, bureaucracy, science, medicine and numerous other institutional systems represent a theoretical model, which articulates social change as a product of human social values. Although Weber's own observations in sociology did not deal directly with philanthropy, his open-ended theoretical conclusions on a broad range of subjects make explicit reference to philanthropy, and invite others to interpret emerging social institutions, such as modern philanthropic foundations, which have become an integral part of modem Western capitalism.14 As rational conduct of economic activity by the followers of the Protestant ethic resulted in enormous wealth, it also created a deep sense of duty to society. The responsibility entrusted with the newly acquired wealth was unprecedented, and they realized that they were not free to enjoy their wealth for anything beyond their essential needs. The literature on American philanthropy in the late nineteenth and early twentieth centuries is replete with evidence that illustrates the deep sense of social responsibility felt by self-made millionaires.15 They considered themselves to be God's trustees, and thus resisted the temptation to indulge in their own wealth. Instead, they preserved it, enlarged it, and put it to work for the common good. Peter Cooper, best-known for his business sagacity and public-spiritedness in the nineteenth century, described this sense of stewardship in the following words: "I do not recognize myself as owner in fee of one dollar of the wealth which has come into my hands, I am simply responsible for the management of an estate which belongs to humanity."16 Most Americans of his class readily acknowledged this particular conviction, and directly contributed to the good of their communities or larger society. Andrew Carnegie, the most "devout" of the "doctrine of civic duty" in the "Gilded Age," best articulated this view in "The Gospel of Wealth" (1889), in which he proposed a lasting amiable relationship between "the haves" and "the haves not." Thus, for Carnegie, the concern was how to administer the wealth in a manner that would give the most benefit to society. He advocated a higher tax on inheritance to mark society's displeasure with those who had failed to administer their wealth for public good during their life: "Men who continue hoarding great sums all their lives, the proper use of which for public ends would work good to the community, should be made to feel that the community, in the form of the state, cannot thus be deprived of its proper share. By taxing the estates heavily at death the state marks its condemnation of the selfish millionaire's unworthy life."17
The tradition continued with new emphasis on the profound harmony between Protestant teachings and modern capitalistic values. The need to earn as much money as possible by honorable means was deemed a prerequisite to serve humanity. In 1907, John D. Rockefeller solemnly affirmed Carnegie's decree by declaring: "Every man owes a debt to humanity, and in accordance with the manner in which he discharges that debt will he be judged."18 Russell Conwell, a Baptist minister, self-made millionaire and the founder of Temple University, argued that it was important for every individual to get rich through honest means. It was a "noble duty bestowed upon everyone, that no good Christian could refuse."19 There was a conscious effort to establish a strong theological equation between getting rich and doing good throughout American history. This was particularly evident in the early twentieth century, when the rich had been vilified by the popular media.20 Conwell insisted that a vast majority of rich Americans stood above their fellow men in honesty. "That is why they are rich," argued Conwell. "That is why they are trusted with money. That is why they carry on great enterprises and find plenty of people to work with them."21 To suggest that wealth was a gift from God, or an indication of his favor for those who had been faithful to his commandments, was a comforting assurance for the rich who had been labeled as "robber barons." The poor had no reason to be scornful about the giver or his chosen few. Such assurances in turn became an integral part of the social conscience of the rich. Speaking to the first graduating class of the University of Chicago, Rockefeller, the founder of that institute, confidently suggested that "the good Lord gave me my money and how could I withhold it from the University of Chicago."22 The doctrine of stewardship of wealth also provided the sense of responsibility in the manner in which wealth should be used. Because it was God who made the rich man's lot different from that of the poor, his money was simply held in trust to be used in doing God's work. Thus, Protestant virtues guided Americans in both objectives: making money and giving money. The outcome was that philanthropy as an act of human benevolence became thoroughly integrated with the structure and process of the industrial capitalist economic system. Benevolent conduct was no longer an informal act based on the emotions of individual givers, but a rational and calculable act coordinated within the modem organizational system.
Viewed from the perspective of the social gospel in the late nineteenth century, it comes as no surprise that organized philanthropy became an important part of the development of civil society in the United States. Because individuals are only trustees of God's money and are accountable to every penny they spend, they must exercise the utmost caution, rational judgment and organizational skill in dispensing their wealth. Modern philanthropic foundations, at least in the words of the key organizers, represented all these fundamental Protestant virtues. They emerged at a time when the question of disposing accumulated wealth had become a major concern for those Americans, who saw themselves to be God's trustees. They found philanthropy to be a methodical and rational way to fulfill their duty to God without disgracing themselves and their descendents. Furthermore, the early philanthropists and their close advisors found that the underlying principles of organized philanthropy - the structure and process - were essentially no different from those of modern bureaucratic business organizations which they had been involved in over many decades. As the philanthropic foundations were built on a combination of scientific principles and commercial practices, administered by paid executives with expertise in specific fields - law, medicine, public administration, education, etc., - they became businesses in their own right.
Scientific Philanthropy of John D. Rockefeller
Rockefeller's giving evolved in several stages. During his early business career, i.e., from the early 1850s to the early 1880s, his benevolent activities aimed to support local needs. Kenneth W. Rose, who has examined Rockefeller's early charitable work, has suggested that until the early 1880s, a large part of his philanthropic contributions went to the "organizational and financial needs of the Baptist church, and to social needs as perceived by the leaders of that denomination."23 By the late 1880s, according to Rose, Rockefeller realized that he needed an organizational mechanism to channel his gifts more efficiently. He began to work with Henry L. Morehouse, the corresponding secretary of the American Baptist Home Mission Society." The new-found goodwill relationship with one of the richest Baptists in the country encouraged Morehouse to renew his campaign for a national Baptist organization to support Baptist education. With the support of other Baptist organizations in the country, Morehouse finally succeeded in establishing the American Baptist Education Society in 1888. This was an important historical event in both the development of Rockefeller philanthropy and the history of education in the United States.
The importance of the new American Baptist Education Society, as it relates to the overall development of education, was vividly described by its first secretary, Frederick T. Gates: "It was really a popular victory for the moneyless and educationally destitute West and South, over the moneyed and educationally well-provided Eastern and New England states."25 The most important aspect of the establishment of this new organization was that it marked the beginning of Rockefeller philanthropy's long involvement in education. Further, the close relationship between Rockefeller and the Education Society that was present from its inception had a direct impact on systematizing the methods of Rockefeller philanthropy. There is no doubt that the leaders of the Baptist Education Society played a critical role in persuading Rockefeller to choose education as his main target for philanthropy.26 The most important individual who came in contact with Rockefeller through the American Baptist Education Society and remained the most influential in developing Rockefeller philanthropy in the early part of the twentieth century was Frederick T. Gates. As we will see, it was under Gates' leadership that major philanthropic programs and organizations were developed in public health, medical research and education in the early twentieth century.
Frederick T. Gates was born on July 2, 1853 in Maine, Broome County, New York, where his father, the Rev. Granville Gates, was the minister of the Baptist Church.27 After graduating from the Rochester Theological Seminary, Gates' first appointment was to one of the poorest Baptist congregations in Minneapolis, where he played an active role in the community. Of all the people with whom Gates came in contact in Minneapolis, the most prominent was George A. Pillsbury, the owner of the Pillsbury flour mills, who approached Gates seeking his advice on his plan to leave $200,000 for a Baptist Academy. Pillsbury was concerned whether there was sufficient interest on the part of the community to warrant the project. After investigating the general mood of the community, Gates advised Pillsbury to make an initial $50,000 contribution to be matched by an equal amount from Baptists in Minnesota. The plan was so attractive to Pillsbury that he offered Gates the job of raising the matching funds. While continuing his duties at the pulpit, Gates raised over $60,000 in less than six weeks.28 With the successful completion of the task, Gates instantly felt the taste of ascendancy - he was elected as the first principal of the Academy. However, before he could even consider the offer, he was appointed Executive Secretary of the American Baptist Education Society. Gates decided in favor of the latter which he thought offered the most opportunities to contribute to education.
As the first Executive Secretary of the American Baptist Education Society, Gates' responsibility was to raise money for a Baptist university. When Morehouse wrote Rockefeller on August 18, 1888 informing him of Gates' appointment he appropriately described Gates as someone who "possesses special adaptation for the duties of this position."29 However, Rockefeller showed his usual cautious approach to the proposed work of the new organization and made no pledge of gifts. "I am not surprised," Morehouse wrote, "that you hesitate to make a pledge toward the expenses of the new Education Society, partly because of a lack of sufficient information, and partly because of the adverse judgement of some with whom you have spoken on the subject..I am as confident as I live that the future work of the denomination in educational matters, especially in the west, must become greater and greater through some such organizations as this."30 The idea of establishing a university in the west was not shared by all members of the Society. Particularly, Augustus H. Strong, one of Rockefeller's earliest mentors from Cleveland, preferred to have the university in New York. Those who favored Chicago as the site for the proposed new university included a group of more progressive personalities of the organization: William Rainey Harper of Yale University, Thomas W. Goodspeed of the Morgan Park Theological Seminary and Frederick T. Gates. While both sides tried to convince Rockefeller of the merits of their own plan, Rockefeller himself remained uncommitted. However, Gates was more persuasive and persistent, and continued to present the issue to Rockefeller from different angles. Following a series of correspondences, Rockefeller finally agreed to meet with Gates in January 1889. Four months later, he pledged $600,000 toward the project, under the condition that the Society must raise $400,000 of matching funds.31 Undoubtedly, Gates made a favorable impression on many people during the course of negotiations for the Chicago project, but the man he impressed most was Rockefeller. As Allan Nevins pointed out, after one or two meetings with Gates, Rockefeller felt that "he could at least begin to discuss a great educational gift upon a practical and dependable basis."32 Although Goodspeed and Harper had been trying without success for years to get Rockefeller to make a pledge for the proposed university, it was Gates who convinced "Rockefeller and others both of the crying need for a strong university in the West, and the possibility of enlisting a broad popular support for it."33 This event marked an important step in the evolution of Rockefeller philanthropy that began to develop as a systematic and organized program.
Gates' success in getting other people's money to support a grand project like the University of Chicago was no small achievement for a man just thirty-eight years of age. Not only did it raise his stature within the powerful Baptist community of the country, but also it prepared him for much more difficult assignments in the future, which he may not have envisioned. While negotiating for the Chicago project, Rockefeller had a revealing conversation with Gates about the state of his benevolent activity. "In March of 1891," Gates wrote in his biography, "during an interview with him on other subjects, he told me that the pressure of appeals for philanthropic causes on his time and strength had become too great to be borne; that he was so constituted as to be unable to give away money with satisfaction without inquiry as to the worthiness of the cause; that these inquiries were now consuming more of his time and energy than his business and indeed injuring his health, and that either he must shift the burden to other shoulders, or he must cease giving entirely." At the end of this conversation, Rockefeller invited Gates to "come to New York and assist him in his benevolent work by taking the interviews and inquiries and reporting result for his action."34 The content of this meeting clearly shows that Rockefeller was overwhelmed by the appeals for money and his investigations into the authenticity of these appeals. As his wealth began to accumulate, the amount of money that he was giving away for benevolent purposes also increased. He could no longer give without having doubts that his giving was doing more harm than good. Rockefeller was at a critical juncture - he needed an expert to organize his giving in such way that it could satisfy his conscience. Rockefeller's invitation to Gates to help him organize his philanthropy shows a genuine interest in finding a rational solution to his dilemma. Gates accepted Rockefeller's invitation with considerable pleasure and began work in September of the same year.35
Gates' first mission in the new job was to review the entire list of all donations Rockefeller had been making annually to various Baptist Foreign Mission Societies. He found that almost all these missionary organizations were competing with each other for the largest possible contribution from Rockefeller. Because they were unaware of what the other organizations were doing, they often duplicated their activities. "Of course this was all wrong," Gates later wrote in his biography, "it meant chaos in missionary activity and was subversive of discipline and effectiveness."36 He devised a plan to remedy this problem of what he described as "often selfish, and relatively unjust appeals." He cut off direct funding for all of these individual applicants. Instead, he created national and municipal missionary executive boards, which were given large sums of money once a year. When Rockefeller received appeals from individual organizations they were referred to those executive boards. The efficiency of this mechanism was prodigious, instead of investigating the legitimacy and fruitfulness of the numerous individual appeals, Gates now had to examine the budgetary documents of only the executive societies. Using this system, Rockefeller was able to account for "every dollar which was expended by the experienced Board," Gates wrote, "with due reference to the relative needs of every field and every department of the work." This particular method of distributing funds satisfied what he called "Rockefeller's business sagacity," and contributed to the fact that Rockefeller derived "hardly less pleasure in the organization of his philanthropy than in the efficiency of his business."37 In so doing, Gates introduced Rockefeller to a systematic and rational program of philanthropy which satisfied both his desire to give and the need to ensure his giving would benefit the larger society.
This was Gates' first and most brilliant achievement in Rockefeller philanthropy, one that had far-reaching implications. He described this as the "principle of wholesale giving," which not only allowed Rockefeller to abandon his long and arduous habit of "retail giving," but more importantly enabled him to spend more time on his business.38 The term "wholesale giving" as opposed to retail giving, was, no doubt, a Gates' invention, but the fundamental principle involved was by no means new to Rockefeller. Gates was indeed borrowing Rockefeller's shrewd business strategies. Two of the key tactics - centralization and rationalization - that Gates applied in developing wholesale giving were favorite tactics of Rockefeller, who had built Standard Oil during the preceding decades. Although in this game of centralization/consolidation Rockefeller was a "guru," it was Gates who had the imagination to apply that same strategy to Rockefeller's philanthropy. As implied by his choice of words, "wholesale giving," Gates proved to Rockefeller that he had become "a man of business." Just as Rockefeller had done in the oil business, Gates effectively eschewed retail philanthropies and dealt directly with wholesale philanthropy by funneling the donations through larger umbrella organizations.39 In this way he forced those what he called "worthless" and "redundant" missionary organizations to disappear altogether.
Gates and Scientific Medicine
Being the key organizer of Rockefeller philanthropy and the trusted advisor to John D. Rockefeller, Gates came to occupy a powerful position among the leading advocates of educational reform. Gates' understanding of the nature of medicine and his choice of medical education to be supported by Rockefeller philanthropy would have a lasting impact on the future of medical education in the United States. Between 1897 and 1910, a period of vigorous campaigns for medical education reform in the United States, several crucial memoranda by Gates to Rockefeller show that Gates was heavily influenced by the germ theory of disease. It is for this reason that we must take a quick look at the key assumptions of the burgeoning biomedical model and the germ theory of disease in the late nineteenth century.
The impact of rationalization is perhaps best evident in the field of medicine. The discovery of the circulation of blood (De motu Cordis) in 1628 by William Harvey (1578-1657) revolutionized the understanding of the human body, which he compared to a large mechanical system. Harvey's discovery was reinforced by Rend Descartes (1596-1650). In his Treatise on Man, published in 1664, Descartes clearly separated the human body from the mind. In so doing, he subscribed to what was known during his time as the "analytical method," that is, entities to be investigated are resolved into separable causal units.40 The whole could be understood, both materially and conceptually, by reconstituting the parts. The Cartesian mind-body dualism expanded Harvey's mechanical analogy of the human body by insisting that the body is composed of separate but independent parts, directed by a rational soul located in the pineal gland. This mechanical model of the body was consistent with the broader technological and scientific developments during the postRenaissance.41
The philosophical foundation of the mechanistic biomedical model was reinforced in the nineteenth century by the development of the germ theory of disease, which postulated that every disease was caused by a specific, identifiable agent (such as a bacterium or virus). Cures were sought that were understood to destroy the infecting agent within the biological realm. In a series of empirical studies between 1861 and 1880, Louis Pasteur demonstrated that injection of cholera vibrio into chickens produced this (and no other) disease. In 1882, Robert Koch discovered the tubercle bacillus, which was pronounced as the cause of tuberculosis. These two important discoveries contributed to the doctrine of "specific etiology" and the concept of a "magic bullet" (chemical agents that destroy the organisms). Researchers aimed to find single, specific causes of disease, and then destroy them with "magic bullets," leaving other organisms unharmed.42
As is evident in the foregoing discussion, the biomedical model takes a reductionist approach to disease. The complex phenomenon of disease is reduced to a single primary principle of cause and effect. Here, the primary causal factor is physical, which can be explained in terms of the language of chemistry and physics. The germ theory of disease was a major breakthrough in the development of medicine. It had a profound impact on how we understand health and disease in modern society.43
By the late nineteenth century, the centers of excellence in medical education were in Europe, particularly in Germany and France. Research in bacteriology, pathology, physiology, chemistry and anatomy were making rapid progress in these countries, whereas in the United States medical education lagged far behind. After spending a year or two learning basic materials in core medical courses, ambitious and well-to-do students from North America generally went to Europe for further studies. For example, William Welch, who later spearheaded educational reform at Johns Hopkins University, praised medical education in Germany during his studies in that country: "I feel as if I were only just initiated into the great science of medicine. My previous experiences compared with the present are like the difference between reading of a fair country and seeing it with one's own eyes. To live in the atmosphere of these scientific workshops or laboratories, to come into the science of to-day, to have the opportunity of doing a little original investigation myself are all advantages, which, if they do not prove fruitful in my future life, will always be to me a source of pleasure and profit." In his frequent writings from Germany, Welch made vivid comparisons between German and American medical schools, and thought that medical education in his native country was inadequate. Welch and many others who went to Europe for medical education considered German universities to be the model for their own institutions: "If we only had such laboratories in America," wrote Welch, "I am sure that we should be as productive in scientific discoveries as the Germans."44
Being involved in matters of higher education, Gates was not a total stranger to what was going on in medical education at home and abroad during that time. There were several factors that contributed to his interest in medicine. As a young man, Gates recalled in his biography, he had been "a convinced skeptic of the value of medicine," as practiced during that time, and for years he contemplated some serious reading of medical textbooks. There were also personal reasons, one being the sudden death of his first wife and the other being a lifethreatening illness he suffered as a young man.45 The most immediate reason for his interest, however, might have been events related to the University of Chicago. Both Rockefeller and Gates opposed President Harper's decision to merge the University of Chicago with Rush Medical College, simply on the grounds that they did not believe in sectarian medicine. The faculty of Rush Medical College represented some of the strongest critics of homeopathy.46 "I have no doubt," Gates wrote, "that Mr. Rockefeller would favor an institution that was neither allopath nor homeopath, but simply scientific in its investigations of medical science." Therefore, according to Gates, "such an institution would have to be endowed and would be ran on a far higher principle than the principle of Rush College or any other of the ordinary institutions."47 He did not believe that what the existing medical schools were teaching had any effect on the health of the people: "If there existed a science of medicine, that science was not being taught or practiced in the United States."48
Gates' enthusiasm for medicine was ignited during the summer of 1897 while vacationing in the Catskills, New York. While there, he read with exceptional zeal William Osler's monumental text, Principles and Practice of Medicine. As he recalled, "I read the whole book without skipping any of it...There was a fascination about the style itself that led me on and, having once started I found a hook in my nose that pulled me from page to page, and chapter to chapter, until the whole of about a thousand closely printed pages brought me to the end."49 As he read it through, Gates realized that there were hundreds of diseases indexed by names, their pathologies and symptoms. However, he was struck by the conspicuous absence of information pertaining to the causes and cures of the vast majority of diseases. He enumerated a long list that included a hundred or more diseases which had no cures: "I saw clearly from the work of this able and honest man, perhaps the ablest physician of his time, that medicine had in fact, with the four or five exceptions..., no cures for disease. Pasteur had indeed established his germ theory, but I learned from Osler that few germs had as yet been identified and isolated....When I laid down this book I had begun to realize how woefully neglected had been the scientific medicine in the United States."5" What was even more disturbing to Gates was that the potential for medicine had not been achieved, unlike every other field of science, because it was not adequately endowed: "While other departments of science such as astronomy, chemistry, physics, geology, etc., had been endowed very generously in colleges and universities, medicine, owing to the commercial organization of medical colleges, had rarely been endowed, and research had been left to shift for itself, dependent altogether on such chance time as a rare spirit, without facilities, might steal from his practice." It became clear to Gates that in order to raise the standard of medicine and to achieve its full potential, medical education must be adequately endowed, with qualified people engaged in full-time research and teaching. To this end, for Gates, all that was required was money. "Here was an opportunity," writes Gates, "for Mr. Rockefeller to do an immense service to his country and perhaps the world. This idea took possession of me."51
Medicine appeared to Gates as an open road to the advancement of humanity and to the progress of civilization. Every disease that had no known cause and cure was a formidable threat to millions of lives around the world. As well, Gates could not perceive any public criticism, political objection or complaint to medical research; the discoveries would have no disadvantage to any individual or group. Furthermore, only in medicine could he see such a well-defined objective: "In medicine the field of research is perfectly clear-cut. The ills to be remedied are well known; they are catalogued; they are fundamental; they are urgent. The material and means of research, such as bacteria, delicate instruments, animals sufficiently like human beings and easily available are at command."52 Troubled by what he found in Osler's book, Gates decided to draw Rockefeller's attention to the conditions of medical education. "Filled with these thoughts and enthusiasms, I returned from my vacation... and there I dictated for Mr. Rockefeller's eye a memorandum. It enumerated the infectious diseases and pointed out how few of the germs had yet been discovered, and how great the field of discovery, how few specifics had yet been found, and how appalling was the unremedied suffering. It pointed to the usefulness of the Koch Institute in Berlin and the success of the Pasteur Institute in Paris."53
Gates now became as strong an advocate of the value of medicine as he had previously been a skeptic. He felt that no other field of knowledge offered such promise and that the best philanthropy was therefore philanthropy in medicine. In this sense, for Gates, scientific philanthropy was analogous to medicine, health and medical research supported through endowments. He interpreted all social problems of the day as inextricably interwoven with disease. There was no single problem that could not trace its source to disease: "Disease is a prolific root of every conceivable ill, physical, economic, mental, moral, social," writes Gates. All human miseries, Gates argued, for which great charities have been given so far, were "due to disease." But these charities have not served the purpose because they did not reach the source of the evil. "For, unfortunately, disease has not hitherto been intelligently, widely, and scientifically studied, nor with adequate instruments and resources."54
Gates' long and detailed memorandum succeeded in generating Rockefeller's enthusiastic support for a program of medical research. Starr J. Murphy, a lawyer who had recently joined Rockefeller philanthropy, made inquiries among the leading medical educators and practitioners regarding the feasibility of the proposed institute. Murphy's inquiries produced only lukewarm support from most medical men, who "thought that an institute could do little, and it would be more profitable to subsidize promising experimenters who were already at work."55 In an attempt to enlist broader support for the idea, Gates began to discuss the matter with John D. Rockefeller, Jr., who had just joined his father's philanthropic program. Rockefeller, Jr. was receptive to the idea, and made enquiries of his own regarding the possibility of creating an institute of medical research. In 1900, Rockefeller, Jr. wrote to Seth Low, the President of Columbia University, asking whether he would support the plan to set up an institute of medical research in the United States similar to that of the Pasteur Institute in Paris. Impressed by Rockefeller's proposition, Low wrote to T. Mitchell Prudden at Bellevue Hospital and William H. Welch of Johns Hopkins University inquiring whether such an institute would be "a matter of great advantage to medical science, and through it to humanity."56 They responded with overwhelming enthusiasm: "I do not know," wrote Prudden, "of any other means by which with so much certainty individual suffering and misery could be relieved and prevented and research be fostered along lines involving the highest general welfare."57 However, instead of creating an institute immediately, they recommended giving grants to existing research laboratories in the United States and Europe. After a short period of providing subventions to research laboratories, Gates concluded the program "utterly futile."
Likewise, Gates was not in favor of giving the proposed institute to a university. He rejected numerous appeals from major universities such as Columbia, Harvard and Chicago. Lowellys F. Barker, who has been credited for introducing Gates to the idea of "full-time research and teaching," made a fervent appeal to Gates stressing the suitability of the University of Chicago for such an institute. But Gates was unmoved: "What is known as Full Time in Medicine," argued Gates, "...was first publicly advocated in this country, I think, by Dr. L. F. Barker, in about 1900, in an address afterwards printed and extensively circulated. I read this address with interest and conviction, and through Dr. Harper met Dr. Barker, then a brilliant young professor in the medical department of the University of Chicago. I had already read Dr. Osler's Principles and Practice of Medicine, and had advocated the founding of the Rockefeller Institute, then in immediate prospect .... Dr. Barker proposed that medical chairs be endowed and that the instructors, like other professors, be placed in a position of independence, not permitted to receive fees for private practice, and their entire time secured thus for instruction and clinical investigation. From the time of my interview with Dr. Barker I became a hearty advocate of this idea ..But full time bore its first fruitage in America in the Rockefeller Institute for Medical Research."58 Gates knew that there was very little to gain by establishing the proposed institute as a part of academic medicine in any university. He was concerned that the institute could become a permanent financial burden to Rockefeller philanthropy under the management of a university. Moreover, it was Gates' own dream to create such an institute, which was adequately endowed and fully devoted to research, second to none in the world. He contended that the creation of such an institute of medical research by Rockefeller philanthropy, even if it did not make any major discovery, would have a significant domino effect in the field of medicine in the United States. It was in this spirit that the Rockefeller Institute for Medical Research was established in 1901.59
There are a number of points that must be reiterated. First, the University of Chicago, being the first major gift to higher education by Rockefeller and completely arranged by Gates, was expected to become the model institute for the nation's higher education, or as Gates put it "a great university at Chicago, a model of economy, thrift, and skill."60 In 1898, at the height of the dispute over Harper's decision to affiliate with Rush Medical College, Gates wrote that the merger was "against that far higher and better conception, which has been one of the dreams of my own mind." That dream was shattered when Harper decided to proceed with the merger plan, and Gates was deeply disappointed." From then on, he was determined not to give in to the temptations of others, as it could undermine his own ambitious project to create an institute of medical research. It was for this reason that Gates resisted all efforts by many others to lure the proposed institute to their respective universities. Second, the policy of adequate endowment in medical education and the appointment of full-time instructors in research and teaching, both of which became the key recommendations of the Flexner Report" in 19 10, were first implemented with the creation of the Rockefeller Institute for Medical Research. This was a landmark achievement in the history of medical education in the United States, which Gates intended to repeat across the country. For Gates, the Rockefeller Institute for Medical Research was considered to be the "model" for medical education reform. Once that model was firmly in place, he focused his energy within Rockefeller philanthropy to build what he called "a system of scientific education" for the United States.
The General Education Board
The General Education Board (GEB) was established in 1903 by an Act of Congress of the United States. It was the first Rockefeller philanthropic organization with broad educational objectives to be created along the lines of modern bureaucratic organizations. The original Charter of the Board declares as its objective to "promote education within the United States of America, without distinction of race, sex, or creed."63 The GEB had very modest beginnings, with a one million dollar pledge from Rockefeller for a period of ten years. At the beginning, its main objective was to promote primary education in the South, where education had been neglected for a long time. The Board was composed of seventeen executive members, who came from diverse social and educational backgrounds, which later proved to be a drawback for reaching consensus on regional educational matters. Gates, who was the chairman of the Board, wrote: "We were without experience, and we attributed to others our own entire disinterestedness. Our organization was not so carefully guarded as experience would have dictated... Our first error was in adopting the representative principle in the make up of the Board. At the time it was perhaps necessary. We chose territorial representatives, institutional, ecclesiastical, sectional, racial representatives, with the naive expectation that they would hang their representative character with their hats, outside the boardroom, and enter only as disinterested citizens of our common country, and patriots."4 Yet, to some extent Gates' reflections were belied by the Board's successes. For although a diversity of interests was represented by the Board of Executives, "it proved," according to Raymond Fosdick, "to be one of Mr. Rockefeller's greatest benefactions."65 Indeed, the GEB was able to achieve remarkable educational goals largely because all the members shared the view that education was the critical means of establishing public well-being in the long deprived South. Hence, they agreed on specific educational policies and implemented them to their fullest ability. In all these, Gates, as the key organizer of Rockefeller philanthropy and chairman of the GEB, played a crucial role. In his biography, Gates wrote: "Up to 1917, when I resigned as chairman, the policies of the Board had been formulated by me, its beneficiaries had been chosen, and the amount and the conditions of its gifts had been largely influenced by me."66
Although the Southern educational programs occupied an important place in Rockefeller philanthropy, Gates did not want these extensive educational works in the South to distract from the larger scheme of educational reform he had projected for the GEB. He maintained that if the GEB was to provide funds for every educational need in the country, it would require much more resources and time. Thus, he reiterated that the aim of the GEB was to achieve "the most economical and the most efficient system" of higher education in the United States.67 Perhaps the most important concern was that Gates sensed a looming competition on the horizon from Carnegie, who had been making small but steady contributions to medical laboratories in the United States and Europe.68 He feared that if Rockefeller continued to focus on those regional educational needs, he would soon lose the national spotlight to Carnegie. In a lengthy memorandum to Rockefeller in April 1905, Gates expressed his concerns in these words: "The question of the smaller colleges of the United States, to which Mr. Carnegie is now beginning to give, is a very great one. Mr. Carnegie has said nothing as yet, in his various contributions to the newspapers about what he is proposing to do for country colleges, which discloses any adequate conception of the situation... I think he is making an awful blunder in undertaking to distribute to them in the way of buildings, or endowments, as he is now doing. The thing for him to have done is the thing which yet remains to be done, and I greatly hope you may yet find it wise to do it, viz: Establish a find of as many millions as you may choose to spare from your fortune. Place that fund in the hands of capable men, with due provision for their succession, the income to be used in paying the current expenses of educational institutions."69
Gates felt that for wealthy men to give their money to higher education without a systematic plan was a waste of resources. Further, he believed that giving away money to those colleges and universities that were struggling to survive would not serve the educational needs of the country. Thus, the critical need in the nation's higher education, according to Gates, was to have a systematic plan, which would eliminate excess colleges, and streamline the rest in terms of the distribution of the population and provide substantial endowments to improve their standards. This particular approach was applicable to all postsecondary institutions which had been established on the basis of denominational competition and commercial interests across the country. As Gates put it, "money should be used for such institutions, in such locations, for such specific purposes and to gain such general ends as will tend to produce in time and always trend towards an ideal system of education..with no duplication and with every part duly adjusted, like a machine, to its corresponding part, the whole compact, efficient and economic."70 This was the first indication that a systematic plan for educational reform was Gates' key objective for the GEB. In the next few months, Gates continued to refine this plan and present it to Rockefeller for action. As usual, Rockefeller was in no hurry to open his coffers, and took his time. While waiting for Rockefeller to come around, Gates consulted other leading academics on the plan and passed their comments to Rockefeller in order to strengthen his proposal. In April 1905, Gates wrote: "Dr. Benjamin Andrews [President of Brown University] spent a night at my house recently. I talked over with him the plan of assisting education by means of a large endowment fund in the hands of wise trustees ..His approval was enthusiastic and unqualified."71
Immersed in his plan to set up a large endowment fund to finance educational reform, Gates did not want Carnegie, or anyone else for that matter, to undermine this plan with alternative agendas. In particular, he felt that Carnegie's style of giving buildings and endowments to existing colleges was lacking a precise program, and it would only "perpetuate a system of over-crowding" in higher education by simply keeping those impoverished colleges alive. Thus, Gates insisted that Rockefeller should immediately act on his plan with a public announcement of a major contribution to education in order to keep Carnegie out of educational reform. "If you yoke up with Mr. Carnegie in it," Gates argued, "he will somehow or other manage to absorb the whole thing and use your connection with it simply as a tail to his kite. I would like to let this plan come out as a great contrast to Mr. Camegie's scheme, in its wisdom, its efficiency, its promise of good to the community at large." Gates not only disliked Carnegie's involvement in educational reform, but also suspected his ulterior motives. As he indicated to Rockefeller: "Mr. Carnegie's intimate friends tell me that it is no secret between them that he does these things for the sake of leaving his name written in stone all over the country....Some of us cannot help thinking that these buildings are deemed by him as so many monuments to Andrew Carnegie, while others give the endowment funds to keep them use....We are being inundated with appeals for the other half,- money to care for the Carnegie name."72 Thus, Gates was anxious for Rockefeller to act immediately and make his intentions public so that Carnegie would not be able to steal the limelight. Finally, Rockefeller agreed with Gates, not only to follow through his recommendations toward the creation of a large endowment fund for educational reform, but also to keep Carnegie out of it. On June 24, 1905, Rockefeller telegraphed Gates, making a $10 million pledge to the GEB to be used towards the development of a system of scientific education.
A System of Scientific Education
Rockefeller's letter (which, incidentally, was written by Gates) that accompanied the gift recommended the GEB to adopt a much more comprehensive nationwide plan of higher education. It stated that, beyond administrative expenses, the income was "to be distributed to, or used for the benefit of, such institutions of learning, at such times, in such amounts, for such purposes, and under such conditions, or employed in such other ways, as the Board may deem best adapted to promote a comprehensive system of higher education in the United States."74 Although the letter identified higher education as the beneficiary of the gift in very broad terms, it left specific fields and programs open to be defined by the trustees themselves. This made it easier for more imaginative and active supporters of higher education, like Gates, to develop innovative educational schemes that would not only address specific regional needs, but also lead to a standardized post-secondary educational system in the country. In a formal statement to the trustees, Gates carefully began by illustrating the challenges that Rockefeller's enormous gift presented to the GEB: "The outlook before us would be trackless and confusing like a boundless ocean hiding in fog. We have a territory four thousand miles long and two thousand miles broad with some four hundred and fifty institutions of learning calling themselves colleges or universities."75 Yet, naturally, Gates saw a vast array of opportunities within the field of higher education for organized philanthropy. He recognized that the existing post-secondary educational institutions were like seeds "sown unevenly over the great landscape," desperately in need of long-term financial support. "Shall we try to help [them] all?" asked Gates. "Happily our founder has explored the ground before us... He says we are to select for our benefaction not all colleges and universities, but only such agencies of learning as may justly claim a place in a system of higher education, and we are to choose such ways of aiding these selected agencies as in our judgement will be best adapted to promote such a system. There is a word in the letter about which every other word turns. It is the word system. That word is the pivot of the whole conception. It must be our sun by day and our pole star by night."76
This was a critical juncture in the development of educational policies of the GEB which had far reaching implications for higher education, in general, and medical education, in particular, in the United States. As noted above, the man who had the most decisive impact on these policies was Gates. Although he pointedly argued that Rockefeller himself had stipulated some directions by emphasizing the key word "system" in the letter that accompanied his gift, it was Gates who interpreted the word according to his own vision of scientific education. At the invitation of the Board, Gates prepared a policy statement for the GEB in January 1906 in which he detailed a road map for the future of post-secondary education in the United States. How much this statement was a product of Gates' own knowledge and experiences is evident in these words in his biography: "I did [it] in a long and carefully wrought paper.. embodying about all that seventeen years of study and experience had taught me as to the needs of higher education and the most effective ways of meeting them."77 A close examination of the paper reveals Gates' wealth of knowledge about the existing problems in higher education, and his steady determination to deal with them. He wanted to establish an educational system that was adequately endowed with financial resources to develop the best scientific standards and methods. As he vividly demonstrated all the different aspects of a national educational system, with regional representations, in a twenty-eight-page paper, Gates had no difficulty in winning broad support for his plan. As such, it is important to examine some of its key arguments.78
Gates' definition of the system implies that his immediate objective was to eliminate the excessive duplications and disparities in higher education. He recognized four fundamental attributes of a well-established and properly functioning educational system in a given state: 1) institutions must be distributed comprehensively and efficiently; 2) they must function in a complementary manner to each other; 3) they must be established within the major population centers as integrated units, and should not be scattered far apart; and 4) the system as a whole, and its parts, must be stable and permanent. Gates argued that these were the attributes that Rockefeller implied by "a comprehensive system," and that if the GEB succeeded in allocating its funds in a manner that could lead to their development in the distribution of post-secondary educational institutions, "there shall gradually emerge a series of institutions of higher learning which shall be for the United States territorially comprehensive, harmoniously related, individually complete and so solidly founded that it will, as a whole and in all its parts, survive the vicissitudes of time."79 While each state would have its own educational system consisting of certain uniform standards, collectively they would represent the national system of higher education in the United States. As Gates put it, "Our national system will be simply the sum total of the state systems. This fact, while it may interfere slightly with symmetry, is as desirable as it is inevitable."80
In addition, Gates' objection to using GEB funds to support the hundreds of struggling colleges and universities became entrenched in his policy statement. He contended that those institutions were in that particular state because they were inferior to begin with, and were not worthy of preserving: "Endow or die has been the universal imperative in higher education. Scattered over our western prairies, buried from the sight of the casual observer in the sands of time are scores of institutions which have perished in their infancy from lack of endowment. In the single year 1902, the last reported, nine more colleges died in the United States than were born."81 Following Gates' ground-rules of establishing endowments for colleges and universities, the GEB systematically evaluated all post-secondary institutions that sought its financial assistance. These evaluations were carried out by using a detailed questionnaire prepared by Wallace Buttrick and Starr J. Murphy, Secretaries of the GEB. The questionnaire dealt with all aspects of the institution, ranging from management techniques and accounting methods to examination procedures, curricula, coursework and the academic credentials of its instructors. The Board required minute details regarding the financial status, student enrolments, existing endowments and much more, to be prepared by qualified accountants recommended by the Board. Upon the receipt of this information, an officer of the Board, often either Buttrick or Murphy, visited the institution without prior notification for personal observation.82 In September 1906, following such a visit to the state of Iowa, Murphy wrote: "My study of the colleges of Iowa leads me to the conclusion that there are four institutions in that State which are worthy of our consideration...the other colleges of the State should be ignored by our Board for many years to come."83 Inevitably, the vigorous evaluation process disqualified many colleges and universities from receiving endowments from the GEB.
A systematic application of a comprehensive policy toward medical education began to emerge in early 1907, when Gates effectively entrusted the scientific directors of the Rockefeller Institute for Medical Research with the responsibility to guide the GEB making endowments to universities. In April 1907, William Osler, who had now become a professor of medicine at Oxford, made an appeal to Gates for financial assistance on behalf of his alma mater, McGill University in Montreal, to rebuild the medical college, which had been destroyed by a recent fire. Osler wrote: "I am afraid from what I hear that the medical faculty has been very hard hit by the loss of their fine buildings. Do you think it would be possible to interest Mr. Rockefeller to the extent of a couple of hundred thousand dollars? It would mean everything to them and would really encourage a group of men who have been doing splendid work for the community."84 In response to Osler's request, Gates required that a formal application of funding be made by the Dean of Medicine at McGill explaining the medical school's recent contributions to research and the impact of the fire on its work. At the same time, Gates asked the scientific directors of the Rockefeller Institute for Medical Research to formulate criteria to evaluate medical schools when making endowments by the GEB. Determined to ensure that his own vision of medical education as a research-oriented field was securely embedded in the future program of educational reform supported by Rockefeller philanthropy, and to eliminate any competing visions of educational reform, Gates deliberately put forward the critical question that he wished the scientific directors to bear in mind when preparing their evaluative criteria: "The only question which interests us here is this: Is the Medical School at McGill University [or any medical school, for that matter, which seeks endowments from the GEB] a center of investigation?"85 Clearly, Gates' intention was to use the endowment funds as a "carrot and stick" in dealing with medical schools which appealed for funding from the GEB, a strategy which began to make a major impact on medical education in North America. At the same time, by asking the scientific directors of the Rockefeller Institute to play a major role in developing the criteria for evaluation, Gates also succeeded in achieving a vital consensus for his vision of medical education reform among leading educators.
In 1907, in view of Gates' stipulations, Welch articulated the following criteria by which medical colleges were to be evaluated when making endowments by the GEB: 1) The medical school should be an integral part of a major university, administered and controlled by the university trustees; 2) The faculty of the medical school was to be paid salaries by the university; 3) The medical school should have established research laboratories engaged in academic research; 4) The heads of these laboratories and their staff were to be recruited on the basis of their academic credentials, and were to provide training for their students on a full-time basis; 5) The medical school should have advanced entrance requirements such as a bachelor's degree, with basic training in chemistry, physics and biology.86
With these criteria, for the first time, Gates and the scientific directors of the Rockefeller Institute set out a comprehensive plan for the development of medical education in the United States. Besides the Rockefeller Institute, certain aspects of this model had already been incorporated into the medical schools of a number of major universities, such as Johns Hopkins, Harvard, Western Reserve of Cleveland, Chicago, and to some degree McGill. Gates maintained that if this program of educational reform was implemented with the endowment funds of the GEB, a vast majority of inferior medical colleges in North America would soon disappear. "There is no basal fact in medicine more certain than that medical science in America, as always on the Continent, has been and can be taught only in schools that are on the academic basis. Our Board should make no contributions to medical schools which do not accept in advance the academic standards of our higher education."87 As Tables 1 and 2 reveal, a number of leading medical schools in the United States and Canada received substantial financial assistance from Rockefeller philanthropy. Every institution, which received money, was subjected to a thorough review by a member of the Board, who compiled a detailed report on almost every aspect of the medical school, as outlined by the criteria. Thus, in November 1908, when Flexner was appointed by the Carnegie Foundation to undertake the survey of medical schools in the United States and Canada, a well-developed model of medical education was already being implemented by Rockefeller philanthropy under Gates' leadership.88
Conclusion
Raymond B. Fosdick, who was President of the Rockefeller Foundation from 1936-1948, argued, "It is a mistake to conclude, as many commentators have, that Flexner was the father of the full-time plan."89 As an "insider" of the Rockefeller philanthropic establishment, Fosdick's remarks underscored the concerns about the true architect of the reform program in medical education and the need to set the record straight. Even Flexner himself, according to Fosdick, had refused to accept any credit for the creation of the program. In the early twentieth century, the problems of higher education, in general, and of medical education, in particular, were well known to most people who were involved in educational matters. When Flexner began his survey of medical schools in North America, the campaign for educational reform was already well underway. Therefore, Flexner did not commence his investigation from scratch.
From the inception of the nation, the field of education in the United States became dominated by both religious and commercial interests. The college was a frontier institution to meet the needs of the frontier communities. Religious denominations, which were competing with each other to spread the Gospel, sought to expand educational institutions even beyond their means. "In the absence of an established culture and scholarly tradition, except in a few of the older states, standards were lowered so that almost any enterprise setting up a claim as a collegiate institute, seminary, college, or university was given the right to confer degrees and dispense the benefits of a liberal education."90 In professional fields, such as medicine, the commercial interests of the proprietors superseded all educational standards. Most medical schools were nominally affiliated with universities, and even in those owned by universities, the faculty was partly or altogether comprised of independent practitioners, who were constantly struggling to make ends meet. They had little or no time to conduct research or to supervise the clinical work of their students.91 Charles W. Eliot, who became President of Harvard University in 1869, wrote: "No thoughtful American in active life reaches manhood without painfully realizing the deficiencies and shortcomings of his own early training."92 He believed that the problems in medical education epitomized the overall backwardness in the American educational system. Within two years of his presidency, Eliot took several bold initiatives to reorganize medical education, including bringing the medical school under the university's control and placing professors on salary. The academic year was extended from four months to nine months, and the length of training for graduation increased from two to three years, while making laboratory work in chemistry, physiology and anatomy mandatory.93 In 1901, in support of Eliot's reform, Gates recommended a gift of $1,000,000 from Rockefeller to Harvard Medical School.94
In 1893, when Johns Hopkins University School of Medicine opened, it was the first American university to offer a four-year medical degree program. Under the leadership of Daniel C. Gilman, the University had become the leader of modem university education in the United States.95 Students were required to have a bachelor's degree with an adequate knowledge in chemistry, biology and physics in order to enter the medical program. Medical education being classified as a research discipline, members of the faculty, except in clinical departments, were appointed as full-time professors of the university. These impressive developments did not go unnoticed by Gates. He became interested in Johns Hopkins University as early as 1897 when he first decided to create an institute of medical research. In 1904, after the Baltimore fire, Gates arranged $500,000 to Johns Hopkins Hospital. The medical school of Johns Hopkins was very dear to Gates, as it closely represented a system of scientific education that he had envisioned: "The Johns Hopkins Medical College," argued Gates, "is to be as free from commercialism as the Rockefeller Institute and strictly devoted to teaching medical science as the institute is to creating it."96 In Gates' vision of medical education, these two institutions were inseparably interconnected.
Against this background, when the Carnegie Foundation published the Flexner Report in 1910, Gates found it to be highly complementary to his own program of medical education reform that he had been advocating for many years. Moreover, Carnegie's refusal to provide money to implement the Flexner Report reassured Gates that there would be no interference from Carnegie for the implementation of his own reform program in medical education.97 In 1911, in a lengthy memorandum to Rockefeller, Gates triumphantly stated that his thoughts and observations regarding medical education had now been confirmed by others, and had reached maturity and were ready for further action. He reported that he had "called in Mr. Abraham Flexner, who had already become celebrated as an investigator [emphasis is mine] in this very field" to make inquiries on behalf of the GEB in order to make an endowment to the Johns Hopkins Medical School.98 Ultimately, Flexner became a member of the GEB, and assisted Gates in promoting a system of scientific medicine in North America.
Acknowledgement
I wish to express my sincere appreciation to the Rockefeller Archive Center of the Rockefeller University, New York for providing financial assistance to undertake this research. I especially thank Dr. Darwin H. Stapleton, the Executive Director, for his continuing generosity during my numerous visits to the Archive Center. Also, during this project, I was helped in many ways by Elizabeth Hewa, for whom I owe my greatest debt.
Endnotes
1. Abraham, Flexner, 1910 Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, (New York, 437, Madison Avenue). The Flexner Report, as it is generally called, was the Bulletin Number Four of a series of studies sponsored by the Carnegie Foundation For the Advancement of Teaching. Flexner began his study in 1908, and visited 155 medical colleges in the United States and Canada. The study examined a wide range of issues pertaining to medical education, including entrance requirements, the number of students and professors, standards and conditions of laboratories, the clinical facilities, such as the availability of teaching hospitals, and the size of endowments or any other source of income besides the fees charged from students. Although it was well-known to those involved in educational matters that medical education in North America was substandard, the report documented, for the first time, in detail what Flexner described as 66 appalling conditions" in medical education. In most proprietary medical schools, the laboratories described in their catalogues were not there, or existed only as a collection of few test tubes packed away in a cigar box, libraries had no books, and instructors were nowhere to be found, as they were busy with their own practices. Owing to the commercial interest in medical education, a large number of the existing medical schools were ill-equipped, poorly staffed and produced too many uneducated doctors.
Flexner proposed that the number of medical schools should be reduced from 155 to 31, a number which he thought would be adequate to meet the requirement of doctors for North America. In addition, he recommended that medical schools were to be included within the university system; students were to have a minimum of two years college degree with a sufficient knowledge in chemistry, biology and physics in order to enter medical college; medical schools were to adopt a four-year medical curriculum, of which the first two years were to be devoted to laboratory sciences and the last two for clinical sciences; the medical school was to have access to a modern hospital located in a
major urban center. For a summary of Flexner's recommendations, see the introduction, pp. x-xi.
2. P. Frishauf, "The AAMC Story: The Rise to Power," New Physician, 1974, Vol.23, pp. 36-9.
3. Daniel M. Fox, "Abraham Flexner's Unpublished Report: Foundations and medical education, 1909-1928," Bulletin of the History of Medicine, 1980, Vol. 54, pp. 475-96.
4. Arnold Naimark, "Universities and Medical Schools: reflections on a half-century of Canadian medical education," Canadian Medical Association Journal, 1993, Vol. 148, pp. 1538-42.
5. Howard S. Berliner, for example, has argued that the campaign to reform higher education, and medical education in particular, was a part of a wider conspiracy of the capitalist class to "ameliorate" the growing discontentment of the working class in the United States during the early twentieth century. Such an analysis raises more questions than it answers. For example, if the purpose of educational reform was to "ameliorate" the working class and the larger socio-economic contradictions, the Flexner Report actually intensified such contradictions as it restricted medical education to the well-off and urban middle class Americans, following educational reform.
6. Kenneth M. Ludmerer, 1999 Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York, Oxford University Press).
7. Fox, op. cit., p. 475. However, contrary to these positive images of Flexner that have surfaced after the publication of the Report, one cannot ignore the fact that the impression of Flexner among his colleagues and friends at the time he was working on the Report was that he was "somewhat erratic," and there was "doubt upon his judgement." Concerned with Flexner's ability to complete the project, Henry S. Pritchett, the President of the Carnegie Foundation, made several inquiries about his previous record including the reasons for not completing a Master of Education degree that he had started at Harvard in 1905. Howard S. Berliner, "New Light on the Flexner Report: Notes
on the AMA-Carnegie Foundation Background," Bulletin of the History of Medicine, 1977, Vol. 51, pp. 603-9.
8. E. V Hollis, 1938 Philanthropic Foundations and Higher Education (New York, Columbia University Press), p. 27.
9. Max Weber, [1920] 1958 The Protestant Ethic and the Spirit of Capitalism (New York, Charles Scribner's Sons), p. 97.
10. Max Weber, [1922] 1978 Economy and Society, (eds.) Guenther Roth and Claus Wittich (Berkeley, University of California Press), Vol. I, p. 26.
11. Weber, op. cit., [ 1922] 1978, Vol. 1, p. 975.
12. Ibid., p. 973.
13. Ibid., p. 600.
14. For a detailed analysis of the relationship between Protestant teachings and philanthropy, see: Soma Hewa, "The Protestant Ethic and Rockefeller Benevolence: The Religious Impulse in American Philanthropy," Journal For the Theory of Social Behaviour, 1997, Vol. 27, pp. 419-52.
15. Undoubtedly, it was this sense of burden that was described by Andrew Carnegie when he suggested, "The man who dies rich dies disgraced....The day is not far distant when the man who dies leaving behind him millions of available wealth, which was free for him to administer during life, will pass away unwept, unhonored and unsung." Andrew Carnegie, "Wealth," North American Review, June 1889, p. 664. Gates made similar remarks when he wrote to Rockefeller in 1905 urging him to create a series of philanthropic foundations endowed with large sums of money. See Rockefeller Archive Center (hereafter RAC), Letter from Gates to Rockefeller, Gates Collection, June 30, 1905, Box 2, Folder 48.
17. Quoted by Thomas A. Bland, 1881 How to Grow Rich (Washington), p. 18.
18. Andrew Carnegie, 1889 "Wealth," North American Review, No. CCCXCI, June, p. 659.
19. John D. Rockefeller, 1907 Cosmopolitan, XLIII, p. 369.
20. Russell H. Conwell, 1915 Acres of Diamonds (New York, Harper and Brothers), p. 30.
21. Rockefeller was humiliated by the media in 1905 when his gift of $ 100,000 to the American Congregational Board of Commissioners of Foreign Missions was turned down by a group of Congregational ministers arguing that the money had been earned improperly, and that if the gift was accepted it would constitute an acceptance of Rockefeller's business conduct. The issue led a newspaper sensation known as the "tainted money" controversy. Allan Nevins, 1940, John D. Rockefeller, The Heroic Age of American Enterprise (New York, Charles Scribner's Sons), pp. 534-54.
22. Conwell, op. cit., pp. 18-9.
23. John T. Flynn, 1932 Gods Gold: The Story of Rockefeller and His Times (New York, Harcourt Brace), p. 306.
24. Kenneth W. Rose, "Why Chicago and Not Cleveland? The Religious Imperative Behind John D. Rockefeller's Early Philanthropy, 1855-1900." Unpublished Paper, 1995, p. 2.
25. Ibid., pp. 5-7.
26. Gates, op. cit., p. 91.
27. One must observe caution here not to overemphasize the influence of Baptist education leaders because such an argument implies that Rockefeller was without his own particular world view and that he was dependent upon the opinions of his advisors. In Random Reminiscences, Rockefeller argued that "every right-minded man has a philosophy of life, whether he knows it or not. Hidden away in his mind are certain governing principles.... Surely, his ideal ought to be to contribute all that he can, however little it may be, whether of money or service, to human progress." Rockefeller, op. cit., p. 104.
28. One particular aspect of Gates' religious beliefs that continued to shape his views toward philanthropy was his opposition to sectarianism within the Christian Church. Writing against making endowments
for churches, on May 7, 1924, Gates argued: "I scarcely know of a town in any rural community in the United States containing a thousand people that has not at least five Protestant denominations, rivalling each other, looking at each other with scant kindness instead of Christian love, with no more essential difference between them than between Tweedledee and Tweedledum." RAC, Letter from Gates to Rockefeller Jr., Gates Collection, May 7, 1924, p. 4, Box 3, Folder 59. 29. Gates, op. cit., pp. 86-7.
30. RAC, Educational Interests, University of Chicago, Letter from H. L. Morehouse to John D. Rockefeller, Aug. 1, 1888, Box. 100.
31. RAC, Educational Interests, University of Chicago, Letter from H. L. Morehouse to John D. Rockefeller, Aug. 9, 18 88, Box 100.
32. RAC, Educational Interests, University of Chicago, Letter from John D. Rockefeller to Frederick T Gates, May 15, 1889, Box 100.
33. Nevins, op. cit., p. 210. 34. Ibid., p. 211.
35. Gates, op.cit., p. 159.
36. For a detailed analysis of Gates' role in organizing of Rockefeller philanthropy from the late nineteenth to the early twentieth centuries, see: Soma Hewa, "Toward the Well-Being of Mankind: Rockefeller Philanthropy and the Problem of Economic Research," International Journal of Sociology and Social Policy, 1998, Vol. 18, pp. 85-129.
37. Gates, op. cit., p. 162.
38. Ibid., p. 163. 39. Ibid., p. 277.
40. John Ettling, The Germ of Laziness (Cambridge, Harvard University Press), 1981, p.66.
41. Engel G "The need for a new medical model: A challenge for biomedicine," Science, 1977, Vol. 196, pp. 129-36.
42. Soma Hewa and Robert W. Hetherington, "Specialists without Spirit: Limitations of the Mechanistic Biomedical Model," Theoretical Medicine, 1995, Vol. 16, pp. 129-39.
43. Kelvyn Jones and Graham Moon, 1987 Health Disease and Society (London, Routledge and Kegan Paul).
44. William Osler, one of the leading medical educators in the late nineteenth century, writes: "From the brilliant overthrow by Pasteur, in 1961, and by Koch and Cohn, in 1876, of the theory of spontaneous generation, we may date its modem growth. Wrapped up in this theory of spontaneous generation, upon which speculation raged centuries before the invention of microscope, lies the history of bacteriology....From that time onward innumerable workers have satisfied the critical scientific world as to the cause of pneumonia, diphtheria, tetanus, influenza, and bubonic plague, besides many diseases of cattle, horses, sheep, and other animals and insects." Osler, 1932 Aequanimitas (Philadelphia, P. Blakiston's Son & Co.), pp. 227-9.
45. Simon Flexner and James Thomas Flexner, 1941 William Henry Welch and the Heroic Age ofAmerican Medicine, (New York, The Viking Press), p. 91.
46. RAC, Dr. Simon Flexner s Address to Honor the Memory of Frederick Taylor Gates, May 15th, 1929, p. 14. Gates Collection, Box 3, Folder 62. Flexner stated in his address: "Mr. Gates' desire, therefore, to see the establishment of an institution, the purpose of which was to be the study of the actual nature of disease, precisely as problems in chemistry and physics are studied, grew in part, out of this personal experience."
47. Paul Starr, 1982 The Social Transformation ofAmerican Medicine (New York, Basic Books, Inc.), pp. 93-7.
48. RAC, Educational Interest, University of Chicago, Letter from Frederick T Gates to Thomas W Goodspeed, January 12th, 1898, Box 105.
49. Gates, op. cit., p. 180.
50. Ibid., p. 181. It is important to note that Gates was so convinced of medicine's ability to cure disease at its roots that his whole focus of medicine effectively removed the critical social and economic dimension that contribute to disease causation.
51. Ibid., p. 182.
52. This original memorandum has since been lost. However, Gates quotes the memorandum in its entirety in his autobiography. Ibid., p. 182.
53. RAC, In Opposition to Endowment of Economic Research, Gates Collection, p.1. 1914, Box 2, Folder 24.
54. Gates, op. cit., p. 182. 55. Ibid., p. 186.
56. Nevins, op. cit., Vol. 2, p. 470.
57. Quoted in Howard S. Berliner, 1985 A System of Scientific Medicine, Philanthropic Foundations in the Flexner Era (New York, Tavistock Publications), p. 60.
58. Steven C. Wheatley, 1988 The Politics of Philanthropy, Abraham Flexner and Medical Education (Madison, The University of Wisconsin Press), p. 30.
59. Gates, op.cit., p. 231.
60. There was also a personal dimension to Rockefeller's commitment to medicine. In 1901, the death of John Rockefeller McCormick (also known as Jackie McCormick), the first grandson of John D. Rockefeller, of scarlet fever at the age of four was a shock to the grandfather, who had offered to pay half a million dollars to a physician in New York if he could save the life of the child. Jackie's death strengthened Rockefeller's determination to create an institute of medical research. See, Ron Chernow, 1998 TITAN, The Life of John D. Rockefeller, Sr., (New York, Random House), pp. 417-8.
61. Gates, op. cit., p. 193. 62. Ibid., p. 280.
63. Flexner, op. cit., pp. 25-68, 71-89, 56, 60, 92, 106, 111-124, 129-136.
64. RAC, General Education Board, Purpose and Program, 2 (OMR), GEB, Box 15.
65, RAC, General Education Board, Memorandum by Gates, Gates Collection, Box 2, pp. 2-3.
66, Raymond Fosdick, 1989 The Story of the Rockefeller Foundation (New Brunswick, Transaction Publications), p. 9. Also, see Fosdick, 1962 Adventure in Giving: The Story of the General Education Board (New York, Harper and Brothers).
67. Gates, op. cit., p. 218. I have discussed the role of the GEB in the development of a system of education in detail elsewhere, see Soma Hewa, "The Protestant Personality and Higher Education: American Philanthropy Beyond the Progressive Era," Politics, Culture and Society, 1998, Vol. 12, pp. 135-63.
68. RAC, Letterfi-om F T Gates to John D. Rockefeller, June, 6, 1905, (OMR), GEB, Box 18, p. 1.
69. J. Wall, 1970 Andrew Carnegie (New York, Oxford University Press).
70. RAC, Letter from F T Gates to John D. Rockefeller, April 18, 1905, (OMR), GEB, Box 18, pp. 1-2.
71. Ibid., pp. 1-2.
72. RAC, Letter from F T Gates to John D. Rockefeller, April 24, 1905, (OMR), GEB, Box 18, pp. 1-6.
73. Ibid., pp. 1-6.
74. RAC, Letter From John D. Rockefeller to F T Gates, June 24, 1905, General Education Board 2 (OMR), Box 18.
75. RAC, Letter of Pledge from F T Gates to Wallace Buttrick and Starr J. Murphy, Secretaries and Executive Officers of the General Education Board. June 30, 1905, 2 (OMR), Box 19. Also, see Some
Reflections on Questions of Policy, prepared by Gates. 2 (OMR), GEB, Box 19, Folder 19.
76. Ibid., p. 3. 77. Ibid., p. 4.
78. Gates, op. cit., p. 218.
79. RAC, Some Reflections on Questions of Policy, Presented by F. T. Gates to the annual meeting of the General Education Board, January 23, 1906, 2 (OMR), GEB, Box 19, Folder 198.
80. Ibid., pp. 4-5. 81. Ibid., p. 6. 82. Ibid., p. 16.
83. RAC, Memorandum by Starr J Murphy and Wallace Buttrick to the General Education Board, October 10, 1905, 2 (OMR), GEB, Box 15.
84. RAC, Memorandum by Starr J Murphy to the General Education Board, September 24, 1906, 2 (OMR), GEB, Box 16.
85. RAC, Letter from William Osler to F T Gates, April 26, 1907, Gates Collection, Box 1, Folder 19.
86. Welch, op.cit., p. 286.
87. Ibid., p. 287. Compare these criteria proposed by Welch with Flexner's recommendations in the Note 1 above. Welch's original hand-written memo to Gates in 1907 has been reproduced in his biography by Simon Flexner and James Thomas Flexner in 1941.
88. RAC, Some Elements ofan Effective System of Scientific Medicine in the United States. Gates Collection, Box 2, Item 44. P. 12.
89. RAC, F. T. Gates, Memorandum, November 24, 1909, 2 (OMR), GEB, Box 19. By the end of 1909, Rockefeller had contributed about $53,000,000 to the GEB to be used for educational reform.
90. Raymond B. Fosdick, 1962 Adventure In Giving: The Story of the General Education Board (New York, Harper and Row Publishers), p. 159.
91. Donald G. Tewksbury, 1932 The Founding of American Colleges and Universities Before the Civil War (New York, Bureau of Publications, Teachers College, Columbia University), p. 5.
92. Soma Hewa, "Physicians, The Medical Profession and Medical Practice," in Health, Illness, and Health Care in Canada. Edited by B. Singh Bolaria and Harley D. Dickinson, Third Edition (Toronto, Nelson Thomson Learning), p. 63.
93. Charles W. Eliot, "The New Education. Its Organization," Atlantic Monthly, 1869, Vol. XXIII, p. 203.
94. Starr, op. cit., p. 114.
95. RAC, Letter from F T Gates to C. W Eliot, December 7, 1910. Gates Collection, Box 1,Folder 21.
96. Hugh Hawkins, Pioneer: A History of the Johns Hopkins University, 1874-1889 (Ithaca, Cornell University Press).
97. RAC, F. T. Gates, Memorandum, August 1911, pp. 8-9, Gates Collection, Box 4, Folder 74.
98. According to Fosdick, from the beginning of Flexner's investigation, Carnegie "had no intention of making extensive benefactions" to educational reform. Flexner, as the Foundation's investigator, was compelled to inform every medical college he visited that there would be no money forthcoming from Carnegie. Fosdick, op. cit., p. 153. 99. RAC, F. I Gates, Memorandum, August 1911, pp. 9-9. Gates Collection, Box 4, Folder 74. This particular endowment was intended to provide financial support to place clinical teaching on a full-time basis at the Johns Hopkins Medical School. The GEB authorized $1.5 million to help reorganize both hospital and teaching staff in the three important clinical branches of medicine, surgery and pediatrics. RAC, RF History, Vol. 10, p. 2651.
by Soma Hewa, Principal Investigator, Research in Philanthropy and Social Development, 2039 Harvard Avenue, Montreal, Quebec, H4A 2V8, Canada
Copyright Barmarick Press 2002