The Unknown History of Public Health and Medicine: The Case of the Rockefeller Foundation REVISITING THE SCHISM Socrates Litsios

The schism between medicine and public health has deep historical roots. The Rockefeller Foundation’s Clinical Epidemiology program, initiated in the late 1970s, was seen by Kerr White, its director, as the means to heal the schism. This article revisits the role that the Foundation played in creating that schism before reviewing post-World War II efforts on the part of both the Foundation and the World Health Organization to incorporate the teaching of preventive medicine in medical education curricula. White labeled these efforts as failures, but a closer look at the history raises questions concerning what evidence he used to make this judgment and whether clinical epidemiology has not instead widened the gap between cure and prevention.

Many writers have noted how the Rockefeller Foundation helped create the schism between medicine and public health by establishing the Johns Hopkins School of Hygiene and Public Health. Fee, for example, describes in detail the process that led to the founding of this school (1, pp. 26–56). This decision, according to Kerr White, “formally institutionalized” the schism and led to an “estrangement between the two worlds of ‘medicine’ and ‘public health’” (2, p. 3). Even though the two key figures involved, Wickliffe Rose and William Welch, favored its establishment, they had radically different views on what function this school would serve. Welch, dean of the Johns Hopkins School of Medicine, wanted a school that would “focus on research rather than teaching . . . and “science rather than on practice” (1, p. 173), while Rose, originally a philosophy professor in Tennessee but then director of the Rockefeller Sanitary Commission, wanted the opposite. He envisaged this school to be central to an “elaborate International Journal of Health Services, Volume 44, Number 4, Pages 817–834, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.4.h http://baywood.com

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and carefully articulated plan” (1, p. 170) that “would create thoroughly trained and inspired leaders to mold public opinion and train the army of workers in the state’s public health service” (1, p. 172). Welch believed that “public health would be as attractive to medical men as the inducement of private practice” (1, p. 168), but Rose’s experience with the medical profession, while directing anti-hookworm campaigns in America’s southern states, had convinced him that “a new profession was needed, composed of men who would devote their whole careers to the control of disease . . .” (1, p. 163). The Foundation oversaw two other important developments during its early years: the creation of the China Medical Board, whose aim was to improve medical education in China, and the conversion of the Sanitary Commission, which Rose headed, into an International Sanitary Commission, with Rose still in charge. The most important program initiated by the China Medical Board was the building of the Peking Union Medical College (PUMC), which opened its doors to students in 1919. The Sanitary Commission was named the International Health Board in 1916 and the International Health Division (IHD) in 1927 (to simplify matters, only the latter name will be used). In 1919, the Foundation opened a Division of Medical Education (DME) to consolidate its medical education programs around the world; the United States was excluded from DME’s program as American medical education was the responsibility of the General Education Board, another Rockefeller family creation. Historians have described the work of the IHD as having the responsibility for developing public health programs around the world, including the establishment of schools of public health (4). The DME has also been the subject of numerous works (5). What has not been well-documented is the relationship between the two divisions. The lumping of the two divisional directors under the heading of “medical barons” has possibly contributed to the impression that their work was complementary and mutually supportive (6). This article aims to demonstrate that this was not the case. To begin with, the DME expressed little interest in incorporating the teaching of preventive medicine in medical schools; on the other hand, most IHD staff seemed to have tolerated the schism, perhaps because it facilitated their getting on with their public health work. In doing so, however, they distanced themselves from the work of medical practitioners, which indirectly may have further institutionalized the schism. There is another side of the IHD history that may also have played a part in keeping the schism alive, namely, the increasing move toward a vertical approach to disease control in which curative services had little role to play, as most clearly seen in the IHD efforts to control malaria. The article mostly covers the pre-World War II period. It begins with a look at how the schism was institutionalized within the Foundation, first from the medical education side, then that of public health. The article concludes with a brief discussion of Foundation-related post-World War II developments that help explain why this issue remains important today.

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NO PLACE FOR PREVENTIVE MEDICINE IN FOUNDATION’S MEDICAL EDUCATION PROGRAM Richard Pearce, a professor of pathology and research medicine at the University of Pennsylvania, was chosen to direct the DME, whose objective, as indicated by George Vincent, the Foundation’s president, was to help “strategically placed medical schools in various parts of the world to increase their resources and to improve their teaching and research” (quoted in 3, p. 106). Given the great importance of Pearce in this history, it is useful to learn from the beginning how he was perceived by his coworkers. Vincent recalled that Pearce’s “observations were incisive, sometimes surgical, but always aseptic” (quoted in 3, p. 106). Raymond Fosdick, who was a close advisor to the Rockefeller family during the early years and later president of the Foundation (1936–1948), described him as “a man of uncompromising thoroughness, deeply concerned with education.” Until his death in 1930, “he threw his great capacities as administrator, teacher, and scientist behind the idea of improving the quality of medical teaching, and he developed it in a series of bold strokes around the world” (3, p. 106). Alan Gregg, who served as Pearce’s assistant and took over the directorship on Pearce’s death, said he brought to the Foundation “the blunt if regretful candor of the pathologist” (quoted in 3, p. 106). Gregg might have used the word “regretful” to reflect his frustration that “Pearce did not want undergraduates in public health,” a history that is further discussed below (7, p. 1087). Fred Russell took over the directorship of the IHD in 1923 after Rose moved to become president of the General Education Board. Russell had been in charge of the Division of Laboratories and Infectious Disease of the Surgeon General’s Office of the U.S. Army. Fosdick described him as “a thoroughly trained laboratory scientist [and] a scholar whose life had been spent in preventive medicine” (3, p. 44). Selskar “Mike” Gunn was one of the first IHD staff members to raise serious questions about the separation of medical education from public health. He was one of the rare non-medical figures in IHD history, having graduated from MIT where he studied under William Sedgwick. He joined the Foundation in 1917 as part of a team that went to France to organize an anti-tuberculosis campaign. Before joining the Foundation, Gunn was a health officer in New Jersey, held a senior position in the Massachusetts’s health department, was a professor at the MIT-Harvard school, and served as an editor of the American Journal of Public Health. In 1920, Gunn was assigned to Prague, Czechoslovakia, with the specific task of advising that country on how best to strengthen its public health work. This included the establishment of an efficient public laboratory service, which was seen as “the beginning of a school of public health” and the training of young men and women for “higher positions in the Ministry of Health” (8).

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During the 18 or so months he was there, Gunn exchanged letters with Rose on a regular basis. Gunn found poorly educated health personnel and a medical profession “out for the money. They have absolutely no social sense and the teaching they get at the present time is such that questions of this kind never enter their heads. . . . [Nevertheless] the future of health work in this country is in the hands of the medical profession” (9). Rose noted that the “attitude of indifference and quiet hostility on the part of the physicians is not novel . . . this attitude must in the end yield to the public good” (10). Russell, who was also present in Prague at the time to advise more specifically on the development of the health institute, was also optimistic concerning the future attitude of the medical profession toward public health. Writing to Gunn in 1921, he expressed his personal view that he was “not at all sure that curative medicine should be separated from preventive medicine and as the socialization of the medical profession increases, I think we are more apt to bring the two things together than we are to separate them” (11). Despite the fact that full-time health officers constituted one of the basic tenets of the Foundation’s program, Gunn judged this to be “entirely impossible until conditions are radically changed.” What was needed was educational work in health matters “(primarily) among the medical profession, the governing officials, and (secondarily) among the people. A strong demand for adequate health service will have to be created; it is only through this that we can hope for full time trained health officials” (12). The words “primarily” and “secondarily” were crossed out before this letter was posted. Rose agreed that the full-time public health officer was “for the future” (13). Gunn’s calling attention to the importance of educational work among the medical profession was probably due to his experience with the Tuberculosis Commission that he joined in 1917, in which he was responsible for the public educational campaign. This campaign was “much admired by the French” (14, p. 39), but the dispensaries and home visits, modeled on American campaigns, proved unpopular; private physicians “were fiercely opposed to the RF model . . . and the way it pretended to ‘teach’ them how to handle TB” (15). Gunn clearly saw himself as an agent for change, acting in whatever way he could to improve the Czech health services through reform of the national health system. The means available to him as an IHD staff member were limited to the provision of fellowships to promising government medical officers and to the building and running of the health institute. Whether or not he already had in mind the supportive role that the DME could play is not clear. Gunn’s direct engagement with officials of the Ministry of Health was somewhat unique; other IHD officers at the time were either involved in specific disease control projects (see below) or the establishment of public health schools and institutes. On leaving Prague in 1921, Gunn returned to Paris, where he became responsible for the Paris Office as well as the IHD program in Europe. In the meantime,

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Russell had taken over from Rose as IHD director. Gunn’s extensive visits to all of the European countries in which the IHD had any interest meant a continuous exchange between him and Russell. While there is not the same warmth to be found in these exchanges as those between Gunn and Rose, each respected the other’s abilities. Where they mainly differed was in Gunn’s belief that the IHD should be more intimately involved in the work of health ministries, while Russell wished to confine their support to narrowly defined public health work. Each of Gunn’s first visits to countries led him to write extensive reports that described in detail not only the status of public health and medicine, but also all aspects of the social and economic life that he witnessed during his long visits. Of great importance was Gunn meeting Andrija Štampar during his visit to Yugoslavia in late 1923. After his second visit the following year, Gunn wrote Russell that “without any assistance from outside and with a limited and inadequately trained personnel they have been able to accomplish much within a short period of time” (16). Yugoslavia, “barring the unexpected, should have a brilliant future in public health work” (17). Later, Russell credited Gunn with having “discovered” Štampar! With the financial support of the IHD, Yugoslavia developed one of the most comprehensive health systems in the world at the time. Revealingly, when Welch spoke at the opening of the Zagreb school of public health, he said that it represented a “radical break with the past,” one that England and the United States might study (18). The Zagreb school mixed administration, research, and teaching, a combination that did not exist elsewhere. Welch, who objected to public health schools having governmental administrative responsibilities, had intended to protest against such a school, but now was prepared to accept it as a worthy experiment. He even went so far as to express the “need for permeation of public health ideas in schools of medicine” (18). In early 1925 Alan Gregg, who was then associate director of DME in charge of European operations, moved to Paris after having completed a long study of medical education in Italy. At this point Pearce, who also toured Europe for several months, visited Paris to explore the DME’s European program with Gregg. This provided Gunn an opportunity to discuss with him the possibility of the two divisions (IHD and DME) jointly studying undergraduate teaching of public health in medical schools and developing a “joint program” for those countries visited (19). Possibly under the influence of Gunn, Gregg expressed his interest in introducing preventive medicine in the undergraduate curricula of medical schools. Pearce rejected this in a four-page memorandum in which he outlined the importance of starting a “definite program on my [i.e., Pearce’s] ideas.” Pearce’s frustration at not having been able to “work out a consistent program according to his ideas is clear. For him what was important was to help advancement through stimulating work in certain research institutes which can train a higher type of men as graduates” (20, p. 3). Vincent, however, urged upon Daniel

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O’Brien, Gregg’s assistant, the “importance of stressing the preventive idea in all our medical education work—we entered this field for the sake of promoting public health interests—more important to educate the average doctor than even the special public health Officer . . . we should aim at as intimate team-play as possible between the 2 aspects of medicine” (21) (emphasis added). Vincent may have been the president of the Foundation, but his powers were clearly very limited. All he could do, by and large, was to encourage those who were moving in directions that he approved of; in this instance, he organized a conference of officers in May 1925 in New York to discuss the teaching of hygiene and closer cooperation between the IHD and DME and the administration of the Paris Office. The present arrangement, which was that of Gunn conducting complete surveys of public health, was no longer satisfactory to Pearce because he did not believe that Gunn was likely to send in reports on undergraduate education “unless he [Gunn] is held directly responsible for such reports.” One solution, noted by Pearce, was that all hygiene, graduate and undergraduate, be turned over to the IHD. But he then went on to point out that this would “interfere enormously . . . with the development of the medical curriculum,” for which he was responsible! In the end, it was agreed that the unity of the undergraduate medical education should be preserved and that the IHD had the responsibility “on the educational side only for the special training of health officers” (21). This still left the question of educational programs for practicing physicians hanging. One factor that must have interfered in the development of any unified action was that, in contrast to the excellent relationships between Gunn and Gregg (they quickly became very close friends) in Paris, Russell and Pearce couldn’t get along with each other at all. Simon Flexner,1 who visited Russell to discuss various aspects of the work of the IHD, learned that “friction” between Russell and Pearce on occasion led Russell to lose his temper. Furthermore, Russell’s relationship with Vincent was “poor” (23). Vincent visited Paris in July to discuss the outcome of the May meeting, which included Gunn being designated as the administrative head of the Paris Office. Vincent took the occasion of his visit to also point out that any unified program “will have an especially strong appeal to the officers in New York and the Trustees” (24). Vincent was obviously impressed by the spirit of teamwork that was clearly in evidence in the Paris Office.2 With this in mind, he created the

1 Flexner was director of the Rockefeller Institute for Medical Research and a trustee of the Rockefeller Foundation. 2 Gregg, in a letter to Gunn written shortly after his move to the New York Office (early 1931), wrote: “I’m particularly grateful to you for all the help you’ve given me and indeed a good many others in Paris as well for you . . . are the principal cause of the developments that became the Paris Office” (National Library of Medicine archives).

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position of vice-president in Europe, for which he first approached Gunn, with Gregg next in line, should Gunn refuse. Gunn accepted in early 1927. For years there had been rumblings of the Foundation being reorganized as part of a wider reorganization involving all of the philanthropic agencies in which the Rockefeller family was involved. Active discussion of reorganization possibilities began in 1925, with Fosdick in charge. One unspoken objective was to break “the near-monopoly of medicine and public health in the Foundation’s program and turn it into the more comprehensive organization that had been originally envisioned” (25, p. 192). An early development was the DME becoming the Medical Sciences Division. This change alarmed Gunn, who used a visit to New York in October, 1928, to press on Vincent his hopes that aid to medical education would not be “suddenly or wholly abandoned in Europe,” arguing that “country physicians need much better training [since] their co-operation in public health work [is] essential” (26). Following a meeting with Pearce, Gunn expressed the concern that “the new policy of the [Rockefeller Foundation] in connection with medical education would mean that the program to develop strong departments of hygiene and preventive medicine in strategic medical faculties would be abandoned.” Pearce said that it would not necessarily be abandoned but would be approached from “a different point of view, namely in the form of possible aid in research, etc., in bacteriology and immunology, etc.” Gunn doubted “if such aid would really materially affect and modernize teaching of hygiene in the medical schools” (27). Gunn’s predictions proved to be correct, although it should be noted that several years later Gregg, who took over as director of the DMS in 1930 following Pearce’s demise, engaged John G. Fitzgerald from the University of Toronto and Charles Smith from Stanford University to carry out a survey in North American and Western European medical schools. Unfortunately, Fitzgerald’s report “produced few constructive ideas” (1, p. 228). As O’Brien observed, there was “much too much on medical education and inconsequential material on the problem in hand, that is, the teaching of public health to medical students” (28). THE INTERNATIONAL HEALTH DIVISION’S MIXED APPROACH TO PUBLIC HEALTH Gunn’s work in Europe on behalf of the IHD represented a small part of the IHD program. His presence solidified relationships between the Foundation and the League of Nations Health Organization, and it facilitated the organization being kept informed of important public health developments in Europe. Otherwise, the IHD was a disease-oriented organization whose initial focus was on hookworm and malaria in several southern states. When Russell described the work of the IHD in 1930 to a special meeting of the Foundation’s Board of Directors, he indicated that those involved in these early efforts “soon learned that it would require considerable time to bring about

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real changes” because people’s habits were involved (29, p. 4). Programs had to be “individualized to fit the cultural level of each country.” When the cultural level reached “a certain height,” more good could be achieved “by helping to gain new knowledge than by building up the government bureaus.” At this point, several board members “concurred in the opinion that field research is the peculiar function” of the IHD (29, p. 6). One might ask how well-acquainted were the board members concerning those IHD staff members working in situations of “lower” cultural levels, such as Sylvester Lambert and John Hydrick, both American physicians whose histories were so totally outside the tradition of the IHD that Farley had nothing to say about their work in his history of the IHD (14). Nor did the Annual Foundation Report for 1930 describe their activities. Their importance lies in the manner in which they engaged auxiliary staff in preventive and curative work. Lambert joined the Foundation in 1918 and spent his entire career living and working in the South Pacific until 1939, the year of his retirement. Wellindoctrinated in Rose’s educational approach to the hookworm problem, he spent more than one year learning Pidgin English so that he could “talk straight to the people in the trade language which was common over the larger part of Melanesia” (30, p. 61). His hookworm lecture in Pidgin had become so well-known that Vincent asked him to repeat it during a visit to the New York Office in 1922. His description of Mr. Rockefeller as “Master belonga me him make im altogether kerosene. . . . Now he old feller. . . . Money belong him allesame dirt,” had the “solemn scientists who hadn’t smiled for years” nearly falling into the aisles (31, p. 94). Lambert soon discovered the existence of native medical practitioners who had been given a three-year course in simple medicine and surgery but who had “no classroom, no charts, only one small book of simple medicine and hygiene, and that was written in Fijian.” These practitioners had been trained for more than 30 years. He wondered if this was not “an answer to his prayers” (31, p. 118). Seeing what these practitioners were capable of accomplishing, Lambert went on to develop a Central Medical School for the Pacific territories. At first he had to overcome the opposition of the DME (Pearce), which “was dead against us; it was out for ambitious projects, and thought mine very thirdrate indeed.” To “finance a little idea like ours” gave them an almost physical nausea” (31, pp. 273–274). However, with the support of Wilbur Sawyer, who was his immediate supervisor during the 1920s, he received funding from the IHD—the “first time they had given financial support to the building of medical schools” (31, p. 274). This particular history found its way into Fosdick’s history of the Foundation, where, although Lambert was an IHD staff member, his work was described in the chapter on medical education! Fosdick judged Lambert’s efforts as “one of the most interesting and perhaps significant of the Foundation’s undertakings in medical education” (3, p. 117). Lambert’s school “made available a medical and

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health service to native people at low cost and in a form that was most easily assimilable by their society. More than that, it provided a pattern which is perhaps applicable under similar circumstances to other areas” (3, p. 118). Indicative of a deeper regret, Fosdick added, “the question might conceivably be asked whether in a world like this a wider and more pragmatic advance in the teaching of medicine could have been made with a policy which did not adhere so uncompromisingly to the rigorous standards of the best” (3, p. 122) (emphasis added). This is a very rare instance of such personal commentary by a Foundation staff member in a public document. Hydrick began his career in a hookworm campaign in 1924, when he was stationed in Netherlands India (later Dutch East Indies). Hookworm disease was chosen “to show that it would be possible to obtain good results with activities based on educational methods” (32, p. 1). The sanitary habits that were promoted in the anti-hookworm campaign were to serve as “the foundation upon which general hygienic work” could be built (32, p. 4). From hookworm, Hydrick moved to other aspects of environmental sanitation. Like Rose, Hydrick believed that the cooperation of the people was necessary in all of this work and that active cooperation could only be secured through education “until the public has understood the ‘why’ of the measures proposed” (32, p. 25). Hydrick helped establish a number of field stations where preventive work was carried out by hygiene mantris, midwives, and other members of the subordinate personnel. Mantris were health workers who initially were concerned with educating the public about hookworm before moving on to other problems. They were all males (at first), were literate, spoke well, and inspired confidence. Midwives entered the program at a later date. He arranged for their training to be conducted by experienced midwives. Hydrick’s exhibition at the 1937 League of Nations Health Organization’s Conference on Rural Hygiene of the work he was undertaking was judged by Gunn to be “one of the best public health exhibits” he had ever seen (33). It should be noted that while Hydrick believed that medical care should be available for the relief of suffering, “medical care and hygiene-work concern such different fields of activity that for efficient work there should be a different subordinate personnel for each field wherever this is possible” (32, p. 9). That Hydrick was obliged to self-publish his book (32) is mostly likely due to the fact that his boss, Sawyer, who had taken over the responsibility of the IHD from Fred Russell in 1936, thought poorly of Hydrick’s purely educational approach, which was “a deviation from IHD practice” and deprecated his “inability or lack of desire to do research and investigation” (34, pp. 15–16). These criticisms may have contributed to Fosdick having nothing to say about Hydrick’s work in his history of the Foundation (3). Another IHD staff member whose work in the 1930s was not included in either Farley’s book on the IHD (14) or the Foundation’s Annual Report for 1930 is that of John Black Grant, a medical doctor (University of Michigan), who,

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following a Rockefeller Foundation fellowship at the Hopkins School of Public Health (1920–1921), was appointed professor of public health at the PUMC in 1921, a position he held until 1934, at which time he joined Gunn’s rural reconstruction project in China, as discussed below. Grant believed that “any artificial separation of curative and preventive medicine is detrimental to the efficiency of both” (35, p. 42). He was convinced that “curative and preventive medicine could be combined at PUMC and a community approach taught” (36, p. 143). In 1923, he outlined an undergraduate course in hygiene. Introducing any of these ideas in a conventional medical school, according to Grant, would have been “a very uphill job,” but “fortunately, the PUMC heads of departments averaged less than 40 years of age, and were open to suggestions” (37, p. 160). Russell “was sold” on Grant’s “idea of a community practice field” following his visit to China in 1927 (37, p. 229). The early success of the Grant’s Health Station encouraged him to think more widely of government involvement in public health, for both the urban and rural populations of China. In an address to the National Medical Association of China in January 1928, he advocated a system of state-supervised medicine for China, including the development of social machinery to ensure standards of living adequate for the maintenance of health. To his supervisors he wrote euphorically about the general situation of China. The period 1925–1930, he wrote, in all probability would prove “the most significant of any five years when the future medical history comes to be written . . . ; the real birth of Public Health in China is now occurring” (38, p. 1). This was a moment in history that “comes only once in each cycle of civilization.” The IHD had probably “never before been confronted with any better opportunity to assist during the formative period in ensuring adequate architectural plans from which a future health edifice” was to be erected (39). Grant shortly fulfilled another major building block by developing a rural health station in Tinghsien in conjunction with Jimmy Yen’s Mass Education Movement. The Tinghsien project was an innovative, new approach to the provision of health care, one that later gained fame for its use of village-based “barefoot doctors.”3 It demonstrated how state medicine could develop in China. The eventual success of this project was largely due to C. C. Chen, who was one of the exceptionally bright and alert students that Grant had lured into public health. By 1934, Chen had developed a functioning health district that consisted of a district health center, encompassing administrative offices, a 50-bed hospital, a laboratory and classrooms for training, and seven sub-district health stations that served more than 75 villages (see 40, pp. 165–173, and 47).

3 Recent studies, however, suggest that Chen’s village workers were confined to preventive work while the “true” barefoot doctors provided treatment (see Xiaoping Fang, Barefoot Doctors and Western Medicine in China, University of Rochester Press, 2012).

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Grant began discussing the possibility of developing a school of public health in association with the PUMC. While such a development would have been totally in keeping with the Foundation’s approach in America, the Depression cut into the Foundation’s budget to such a degree that no serious consideration was given to it. That the PUMC represented an enormous part of the Foundation’s budget further argued against any new major program. Around this time, Gunn came to China and with the help of Grant developed a rural reconstruction program. Grant joined in 1934; no longer a PUMC staff member, he could not work directly on extending the program of the PUMC in a direction that he felt was best suited for China’s needs. Having judged that the PUMC’s best role would be to prepare teachers suitable for experimental medical schools that China was developing at the time, Grant worked with his ex-students, who now occupied high levels in the Chinese health department, to prepare policy papers that called upon the Foundation to allow the PUMC to play such a role. These he attempted to incorporate in Gunn’s program. Although Gregg, who was now director of the Foundation’s Medical Sciences Division, had no direct responsibility concerning Grant’s new assignment, he went out of his way to express his opinion that it was “not incumbent on Doctor Grant to take the initiative of tying up the PUMC with the National medical program for China” (41). He emphatically rejected the idea that the PUMC would come under the control of the Chinese government, doubting that it was the PUMC’s “most promising function to be a para-governmental institution, nor even that the fullest national utilization of the PUMC should be the objective of the College nor the peculiar role that it could best play.” He did not believe that “Grant’s study of or experience with the educational institutions” was wide enough to make him realize “the danger of forsaking standards of excellence for the standard of fullest national utilization.” And just in case Gunn and Grant had not gotten the message, he added that he would prefer “insistence on quality at the PUMC to a ‘left-handed’ attachment of the PUMC to Grant’s conception of ‘The Chinese Program’” (42). When Gunn finally got around to expressing his views on this issue (late 1936), he pointed out that if the PUMC did not “enter into the national medical picture more definitively,” it would rapidly lose whatever influence it had on developments in China. He sided with the active men who wished “to broaden the PUMC’s outlook and vitalize it as a leading institution. . . .” Clearly contradicting Gregg’s reasoning, Gunn stressed that this was not time for the PUMC “to be an institution where scholars devote themselves only to their science and have little or scant interest in the huge developments that are going on in social medicine throughout this country” (43) While Fosdick reacted favorably to Gunn’s memorandum, there is no evidence that Gregg ever responded to Gunn in writing. It is not likely that Grant, Gregg, or Gunn knew that Vincent believed that the PUMC was the “most notable” departure from the Foundation’s belief that

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lasting results could be secured “only as responsibility is assumed by the agencies which are to be looked to for permanent carrying on of the work,” that is, responsible institutions of governments (44, p. 3). Given this history, it would seem very likely that Fosdick had the PUMC in mind when he questioned the policy that adhered “uncompromisingly to the rigorous standards of the best” referred to above (3, p. 122). Both Grant and Gunn felt strongly the necessity to work closely with government officials; Gregg did not. Which position was dominant in the Foundation is not clear. What seems to be clear is that Russell grew wary of too close an involvement, preferring instead to focus more closely on field research, as best demonstrated by the work of the Foundation’s malariologists. Two IHD staff members, Paul Russell and Lewis Hackett, took the early lead in developing anti-malaria projects around the world. Another staff member, Fred Soper, who was mostly involved in anti-Yellow Fever studies, joined them later. Hackett, Paul Russell’s senior by 10 years, primarily worked in Italy while Russell worked in the Far East, first in the Philippines, then India. Hackett believed that any resort to “general measures of social uplift and hygienic betterment” was tantamount “to a confession of ignorance or defeat” (45, p. 268). His approach to the malaria problem “left no room for any importance to be given to improving people’s knowledge concerning malaria. Nor did he even assign any responsibility to the health officer to assess what the population knew or thought it knew concerning malaria” (46, p. 89). Russell was much less dogmatic. During his first years in the Philippines, he had come to believe that “control work must be locally desired and locally carried out,” which led him to engage community leaders in the development of local control schemes (47, p. 221). Although this project lasted for no more than one or two years, it did lead Russell to prepare A Malaria Primer to be used by students and teachers. This primer was in “the nature of a profusely illustrated elementary handbook” (48, p. 79). Nevertheless, within a year he identified “an automatic or biological weapon” to combat malaria with as “an outstanding need in the Tropics” (47, p. 224). Both Hackett and Russell argued against relying on treatment (at that time limited to quinine) for controlling malaria. Hackett referred to the Italian experience, which featured the distribution of quinine, as a time-honored resource with a “history of three hundred years of constant defeat” (45, p. 20). Russell explained his opposition more clearly: “malaria control by use of anti-malaria drugs reduced the intensity of the disease but not so markedly its incidence” (49, p. 100). This observation helps explain why treatment was not considered as a method of controlling malaria and the lack of interest by the Foundation’s malariologists in the role of treatment services. This also explains how it is that neither Hackett nor Russell described the early-century Italian efforts to control malaria as part of the Italian government’s broad approach to social welfare, which included the teaching of leaders of the

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malaria campaign that “malaria could be successfully defeated only if workers were educated, properly nourished, hygienically housed, guaranteed productive work, and well organized in defense of their rights” (50, p. 63) and the inclusion of malaria in the curriculum peasant schools with a focus on “instruction of a kind that will enlighten our young people with regard to the etiology and pathogenesis of malaria, on the economic consequences that it produces, and on the means that exist to protect oneself from it” (50, p. 79). Russell and Hackett’s focused approach on reducing the incidence of malaria, rather than treating this disease, allows us to understand better how it is that when Soper took time off from his fight against Yellow Fever to engage a malaria epidemic in Brazil due to it having been invaded by the malaria vector Anopheles Gambiae, his attempts to eradicate this dangerous vector led him to establish an anti-Gambiae campaign, “independent of medical efforts” and organized in such a way so as not to have any “responsibility for medical care of the sick in dispensaries or otherwise” (36, pp. 201–202). Obviously, Soper was not against treatment; what he wished to avoid was the resources under his control being used for purposes other than battling the invading malaria vector. Both Paul Russell and Soper were very active following World War II in using the new “weapon” DDT to control malaria, an effort that by the mid1950s had become a global eradication campaign. No other IHD field program managed to survive the war. The China program was interrupted when open hostilities broke out between China and Japan in 1937; Grant moved to India, where he played an important part in helping the Indian government develop forward-looking health policies. Gunn died in 1944 while working on the establishment of the United Nations Relief and Rehabilitation Administration; Lambert retired, while Hydrick continued to pursue similar work in Peru in an unheralded manner. The IHD was closed down in 1950 or, more exactly, merged with medical sciences to become a new division of medicine and public health, at which point Gregg was promoted to vice-president. Grant, who had moved to New York earlier, was one of the new division’s associate directors. Paul Russell was a staff member of this division. Soper had left earlier and become director of the Pan-American Sanitary Bureau. CONCLUDING COMMENTS The eradication campaign began to flounder in the early 1960s. At this point, Soper had retired while Russell was still active, especially as a malaria expert for the World Health Organization (WHO). When signs began to appear in the early 1960s that the goal of eradication was losing the political appeal it had had earlier, Soper (who never doubted that eradication could be achieved) mounted the barricades to defend the role of mass campaigns, whose objective he defined as one of “completely . . . eliminat[ing] the possibility of the occurrence

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of a given disease” (52, p. 1). In his defense, Soper gave his own interpretation of the “schism” that the Foundation had helped create, thus deserving closer attention. Soper blamed the lack of enthusiasm for mass campaigns among professional public health administrators on “the predominance of schools of public health in the United States as international centers for the training of public health administrators” (52, p. 3)! Training in these schools, according to Soper, “reflected the development of public health work in the United States in accord with the political organization on the city and county level, with jurisdiction too limited for the development of eradication campaigns” (52, p. 3). It should be noted that all of Soper’s successes took place in countries under strong central (sometimes dictatorship) rule, thus greatly facilitating a vertical campaign approach to disease control. Soper believed the current generation of professional public health administrators that insists on “the early development of the general health service throughout the undeveloped countries of the world” was “unmindful of the experience of the first generation of international health workers,” that is, the IHD staff of the 1920s (52, p. 9). According to Soper, that generation “moved too fast in its attempts to transform the campaigns for the prevention of a specific disease into a general health service” (52, p. 9) (emphasis added)! This quite extraordinary reading of the IHD history seems to be based on his experience in Brazil, where the Foundation had decided “that hookworm campaigns were to be transformed into or integrated with general health services” (52, p. 11). Soper did not seem to realize that his experience was quite exceptional, largely due to his exceptional character and the exceptional politics of the countries in which he worked. Still, Soper’s observations must be taken seriously. For example, he was highly critical of a WHO maternal and child health Expert Committee report that recommended the inclusion of maternal and child health work in all other WHO programs, including that of malaria, because the work proposed was to be carried out by public health nurses. But, as observed by Soper in a parenthetical comment: “It will be noted that the mass campaign for the prevention of a specific disease in underdeveloped countries is organized without dependence on the nonexistent or scarce public health nurse” (52, p. 6) (emphasis added). The important role assigned to public health nurses grew out of their importance in America in the early decades of the 20th century. Soper might well have added the incongruence of imposing this health worker on other countries to his criticism of other countries sending their health administrators to American schools of public health. Soper’s frequent reference to underdeveloped countries was a reminder to the reader that great care had to be taken in shaping programs around resources that were available or likely to be available in the near future. As experiences of different approaches were gained, Soper suggested that studies should be undertaken of “the strength and weakness” of both the eradication campaign and

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the general health services . . . and the ways in which each can profit from and contribute to the other” (52, p. 23). Such studies have rarely been carried out. The divide between vertical and horizontal approaches to health seems to be as great as ever; both sides seem to be driven by ideology rather than by empirical evidence gleaned from deep studies of many experiences. Returning to the basic schism between medical care and public health, Kerr White, whose quote began this article, developed programs in clinical epidemiology with the aim of orienting medical students to community as opposed to individual care. With the financial support of the Rockefeller Foundation, an international network was established in the late 1980s with units in many countries participating. That this approach to “healing the schism” was not appreciated by all can be seen by the nature of the criticism it attracted. For example, Milton Terris, editor of the Journal of Public Health Policy, accused the Foundation of using the network to strengthen medical schools at the expense of schools of public health: “here we have all this money . . . being spent to teach clinicians how to do clinical trials” while developing countries are suffering “terrible problems of famine, malnutrition, infant diarrhea, malaria, and all the other infectious and noninfectious diseases. . . . They want the medical schools to continue to be dominant; they want the clinicians to keep their political power; they want to make sure that health services don’t infringe on the narrow professional interests of the clinician” (53, p. 984) (emphasis added). Even within the Foundation, Lincoln Chen, executive vice-president, noted that the Rockefeller Foundation’s focus on clinical epidemiology, which was undertaken to “sensitize clinicians to community health . . . relegated public health to ‘second class’ scientific status, and despite the articulated goal of ‘populationbased health care,’ the clinical epidemiology program focused entirely on hospitals and medical schools, fueling the perceptions that the Rockefeller Foundation had ‘abandoned’ public health altogether” (54, p. 4). Today, the Foundation’s history continues to attract those who are striving to bridge the gap between medicine and public health in America, as witnessed by this proposal: In retrospect, the best outcome of the 1914 Rockefeller Foundation conference might have been the adoption of several, perhaps even all, of the proposals. We need strong and vibrant schools of public health, where research and discovery advance our understanding of the underlying basic population health sciences. We also need a national network of public health training programs that maintain a strong pipeline of public health workers for county and state departments. At the same time, the next generation of physicians should be trained to integrate basic, clinical, and the population health sciences and to naturally incorporate the principles of prevention and population-based approaches in their professional activities. Mending the schism offers a vital and essential step in elevating health in an efficient and effective way (55, p. 1156).

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If Soper were still around, it is almost certain that he would be evaluating what impact clinical epidemiology and all subsequent efforts to heal the schism were having on the prevailing communicable diseases in developing countries and not on whether public health schools felt threatened or even whether medical doctors were better oriented to community health than before. He would also be exploring the question of whether developments in America or any of the other more industrialized countries were contributing to or hampering developments in the so-called developing world. Following Soper’s “historical” lead, this history suggests that research is needed that evaluates, in acceptable epidemiological terms, the multitude of experiences that have taken place over the last half-century to uncover empirical “truths” concerning what mix of disciplines and health system structures developed and functioning under differing social, economic, and political conditions have been most successful in improving the health of populations. And if schism healing features in such efforts, so much the better. REFERENCES 1. Fee, E. Disease & Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916–1939. The Johns Hopkins University Press, Baltimore, 1987. 2. White, K. Healing the Schism: Epidemiology, Medicine, and the Public’s Health. Springer-Verlag, New York, 1992. 3. Fosdick, R. B. The Story of the Rockefeller Foundation. Harper & Brother, New York, 1952. 4. Williams, G. Virus Hunters. Alfred A. Knopf, New York, 1960. 5. Schneider, W. The men who followed Flexner: Richard Pearce, Alan Gregg and the Rockefeller Foundation Medical Divisions, 1919–1951. In Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War, ed. W. H. Schneider. Indiana University Press, Bloomington, 2002. Penfield, W. The Difficult Art of Giving: The Epic of Alan Gregg. Little Brown, Boston, 1967. Litsios, S. On the “hitherto untried process of giving doctors adequate training” in preventive medicine and public health. Soc. Med. 5(4), 2010. 6. Kohler, R. E. Partners in Science: Foundations and Natural Scientists 1900–1945. The University of Chicago Press, Chicago, 1991. 7. Lewis Hackett papers. Rockefeller Archives Center (RAC), Rockefeller Foundation (RF), Record Group (RG) 3, Series (S) 908, Box (B) 7H, Folder (F) 86.112. 8. Rose, W., and Gunn, S. M. The Public Health Situation in Czechoslovakia. A report of their visit of February 17–26, 1920 (RAC, RF, RG1.1, Series 712, Box 3, Folder 6). 9. Gunn to Rose, 9 December 1920 (RAC, RF, RG1.1, S712, B2, F10). 10. Rose to Gunn, 10 February 1921 (RAC, RF, RG1.1, S712, B2, F10). 11. Russell to Gunn, 31 March 1921 (RAC, RF, RG1.1, S712, B1, F3). 12. Gunn to Rose, 31 December 1920 (RAC, RF, RG1.1, S712, B2, F10). 13. Rose to Gunn, 17 January 1921 (RAC, RF, RG1.1, S712, B1, F3). 14. Farley, J. To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation (1913–51). Oxford University Press, Oxford, 2004.

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15. Lion Murand, personal communication, 4 March 2014. Murand is a French historian who has written extensively about the Rockefeller Foundation’s efforts in France, including its Anti-TB Commission. 16. Gunn to Russell, 5 September 1924 (RAC, RF, RG5, S3, B46, F524). 17. Gunn, statement with regard to the present situation in the different countries of Europe in which the IHD is cooperating (RAC, RF, RG5, S2, B58, F368). 18. Strode diary entry, 3 October 1927 (RAC, RF, 12.1 diaries). 19. Gunn to Russell, 6 April 1925 (RAC, RF, RG5, S1.1, B91, F1290). 20. Pearce to Gregg, 28 December 1925, concentrated investigation of single subjects (RAC, RF, RG3, S906, B1, F3). 21. Vincent diary entry, Exhibit, 9 May 1925 (RAC, RF, 12.1 diaries). 22. Vincent diary entry, 11 November 1926 (RAC, RF, 12.1 diaries). 23. Flexner to Fosdick, 19 June 1926 (RAC, RF, RG3, S900, B17, F122). 24. Vincent diary entry, Exhibit, 20 July 1925 (RAC, RF, 12.1 diaries). 25. Harr, J. E., and Johnson, P. J. The Rockefeller Century. Charles Scribner’s Sons, New York, 1988. 26. Vincent diary entry, 28 October 1928 (RAC, RF, 12.1 diaries). 27. Gunn diary entry, 31 October 1928 (RAC, RF, 12.1 diaries). 28. O’Brian to Gregg, 5 January 1938 (RAC, RF, RG1, S100, B26, F211). 29. A Brief Summary of the Conference of Trustees and Officers at Princeton, October, 1930 (RAC, RF, RG1, S900, B22, F166). 30. Stuart, A. Parasites Lost? The Rockefeller Foundation and the Expansion of Health Services in the Colonial South Pacific, 1916–1939. University of Canterbury, 2002. 31. Lambert, S. M. A Yankee Doctor in Paradise. Grosset & Dunlap, New York, 1941. 32. Hydrick, J. L. Intensive Rural Hygiene Work and Public Health Education of the Public Health Service of Netherlands India. Self-published, Batavia/Centrum, Java, 1937. 33. Gunn to Fosdick, 6 September 1937 (RAC, RF, RG1.1, S100, B21, F180). 34. Hackett papers (RAC, RF, RG3, S908, B3). 35. Grant, J. B. A Proposal for a Department of Hygiene for Peking Union Medical College, 1923 (RAC, CMB Inc., RG4, B75, F531). 36. Bullock, M. An American Transplant: The Rockefeller Foundation & Peking Union Medical College. University of California Press, Berkeley, 1980. 37. Reminiscences of Dr. John B. Grant (RAC, RF, S900 Hist. Grant, Vols. 1–7). 38. Grant, China – April 1928, General Situation (RAC, RF, RG1, S601, B13, F136). 39. Grant to Greene, 23 January 1929 (RAC, RF, RG1, S601, B13, F136). 40. Chen, C. C. Organization of Health and Medical Services. League of Nations, Intergovernmental Conference of Far-Eastern Countries on Rural Hygiene, August, 1937. CH 1253, No. 2. Chen, C. C. Medicine in Rural China: A Personal Account. University of California Press, Berkeley, 1980. 41. Gregg to Greene, 2 January 1935 (RAC, RF, RG2, S601, B124, F 942). 42. Gregg to Gunn, 22 July 1935 (RAC, RF, RG2, S601, B124, F942). 43. Gunn to Gregg, 7 December 1936 (RAC, CMB, RG35, S240). 44. Agenda for the Special Conference Meeting, February 23–25, 1925, at Princeton, New Jersey (RAC, RF, RG3, S900, B17, F120). 45. Hackett, L. Malaria in Europe. Oxford University Press, Oxford, 1937.

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46. Litsios, S. Popular education and participation in malaria control: A historical overview. In The Global Challenge of Malaria: Past Lessons and Future Prospect, ed. F. M. Snowden and R. Bucala. Imperial College Press, Singapore, 2014. 47. Anderson, W. Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines. Duke University Press, Durham, 2006. 48. The Rockefeller Foundation. Annual Report. 1932. 49. Russell, P. Italy in the history of Malaria. Rivista di Parassitologia 13(1), 1952. 50. Snowden, F. M. The Conquest of Malaria, Italy, 1900–1962. Yale University Press, New Haven, 2006. 51. Packard, R., and Gadelha, P. A land filled with mosquitoes: Fred L. Soper, the Rockefeller Foundation, and the Anopheles gambiae invasion of Brazil. Parassitologia 36(1–2), 1994. 52. Soper, F. L. The Relation of the Mass Campaign for the Prevention of a Specific Disease to the General Health Services. A working document prepared for the WHO Study Group on Integration of Mass Campaigns against Specific Diseases into the General Health Services that met in Geneva in April 1964. 53. Buck, C., et al. The Challenge of Epidemiology: Issues and Selected Readings. PAHO, Washington, DC, 1988. 54. Chen, L. World Health and the Rockefeller Foundation: Can History Inform the Future? Unpublished paper. March 9, 1997. 55. Ruis, A. R., and Golden, R. N. The schism between medical and public health education: A historical perspective. Acad. Med. 83(12), 2008.

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