Rockefeller Medicine Men: Medicine & Capitalism in America (1979)

No showing seeds, but will keep in client.. thanx nibs! Your files are always great!

For a couple of weeks.

Reseeded; grab it and read it if you care about medicine.

When Rockefeller Medicine Men was first published in 1979, it proved to be a controversial work. In reviewing histories of medicine from 1962 to 1982, Ronald L. Numbers called it "the most controversial medical history of the past decade."' This reprinting of the book provides an opportunity to respond to some of the book's critics as part of a continuing dialogue about the issues it raises.

Part of the controversy generated by the book comes from its social-historical approach to medicine. The growing body of social histories of health care challenges the "great physician" perspective that for so long has dominated the history of medicine.2 Some are dismayed by this new approach to health care, particularly when it involves a critical examination of the broader social, economic, and political contexts of medicine and health-related developments.3 Indeed, 'heroic physicians and medical milestones,"4 whether innovative teachers of clinical practice or breakthrough discoveries by brilliant researchers, do have a profound effect on the development of medicine's technical knowledge and practice. But the history of medicine, like the history of any other social phenomenon, is more than an intellectual history. The actions of men and women, including leaders and the masses of people who follow and participate in professions and social movements, are shaped by economic, political, and social forces as well as by ideas. Ideas themselves develop in a broader context, which they shape but which also shape them.

Perhaps the most substantive and influential criticism has come from Paul Starr, who devoted two pages of his own history of American medicine to critiquing my interpretation of the role of the Rockefeller foundation and the corporate class in the development of American medicine.5 Starr argues that the character and power of American medicine is a product of its "cultural authority" as well as of the political power it mobilized. He attributes prime importance to American medicine's overcoming its lack of technical credibility with the public, both the well-educated strata and the poorer classes, in the late nineteenth century. He believes that somehow medicine won cultural authority, by which its "definitions of reality and judgments of meaning and value [prevailed] as valid and true," and that this authority permitted the profession to wield sufficient political power to protect and extend its social and economic interests.'

It should be noted that Starr's thesis concerning the role of cultural authority is similar to my argument in Chapter 2 concerning the role of scientific medicine in elevating the status and power of the medical profession. I argue that by embracing science the medical profession gained not only more effective techniques, but also technical credibility beyond the actual medical value of contemporary scientific progress in medicine—a credibility that enhanced the profession's legitimacy in a world increasingly dominated by industrialization and technology. Technical credibility and social legitimacy were important weapons in the efforts of the profession's leaders to lift medicine from the ignominious position it occupied throughout most of the nineteenth century. I characterize scientific medicine as providing an ideological tool to leaders of the medical profession in their campaign to elevate medicine. Starr sees the medical profession as gaining cultural authority because of a belief in its broad technical competence that spread among the populace in ill-defined ways. Both accounts give considerable weight to this belief in creating a base of popular support for the profession's increased economic and social power. However, my analysis focuses on the conscious actions of the profession's leaders to take advantage of this spreading legitimacy, while Starr's analysis remains more ambiguous about how this cultural authority was actually translated into the power to elevate the profession.

Starr and I also differ on the role of powerful groups outside the profession in transforming American medicine. In Chapter 3 1 argue that, although medicine's newfound credibility was growing in many public sectors, one of the most important sources of support was among leading institutions of the corporate class. Individual philanthropists gave modest sums to build community hospitals, but the foundations created by corporate giants as philanthropists provided hefty grants to build medical schools, research laboratories, and teaching hospitals. Although Starr acknowledges their role, he implicitly reduces the importance of their contribution without presenting clear evidence in support of his interpretation. Starr parts company with my analysis on the question of why the leaders of these foundations, and of the Rockefeller philanthropies in particular, so generously supported the development of medical science, reform in medical education, and public health.

Let me first describe Starr's account of my views, for therein lies part of the problem with his critique. Despite his eloquent prose, Starr creates a caricature of my argument. He claims I contend that 'capi­talists personally exercised control over the development of medicine through the foundations they established."7 Noting that I argue that Rockefeller philanthropy officers saw great value in medicine's cultural role as a subtle purveyor of the dominant ideology, Stan adds sarcastically, that "one must, I suppose, have a deep appreciation of the fragility of capitalism to imagine that it might have been threatened by the persistence of homeopathy."8 But as the reader of this book will soon observe, Starr misrepresents my position. I show that foundation programs were developed and directed not by John D. Rockefeller, Sr., and Andrew Carnegie, the men of wealth who created the founda­tions, but rather by foundation officers, acting as managers of philanthropy, rather like the managers of Rockefeller's and Carnegie's industrial empires but with somewhat more authority. It was the Reverend Frederick T. Gates (not Rockefeller, his employer) who, both as a manager of Rockefeller's wealth and as chief architect of the Rockefeller medical philanthropies, articulated the role that medicine might play in shaping society. And it was Gates and other officers who developed the strategies by which the foundations might shape medicine.

Although the Rockefeller philanthropy governing board later did fear for the continued existence of wealth and even capitalism,9 Gates was motivated by a desire for social improvement-—not by fear—at the turn of the century, when he was leading the development of the Rockefeller Institute for Medical Research. As the archival record demonstrates, he was concerned with improving the health of human resources (the workforce) and with extending industrial culture and the ideological perspective of capitalism to those in the United States and abroad who did not share them. For Gates, medicine could improve the health and productivity of workforces and populations if it was scientifically based and emphasized prevention as well as cure. And it was an especially good vehicle for cultural transfer because medicine is "a work which penetrates everywhere."10

My interpretation of Gates's views does not rest on "the fragility of capitalism," as Starr suggests. Rather, Gates was an exponent and ardent advocate of the social value of medicine for improving and strengthening corporate capitalism. These views and goals that Gates articulated, often with great passion, shaped the Rockefeller medical philanthropies' early strategies for improving health and well-being in ways described in Chapter 3. And the Rockefeller programmatic strategies were trendsetters for other foundations as well. Although he provides no evidence, Starr attributes the Rockefeller largess to medical research and education in the interest of philanthropists "in legitimating their wealth and power by publicly demonstrating their moral responsibility in ways congruent with the cultural standards of an age that increasingly revered science."11 This is a popular rationale propounded by authorized Rockefeller biographies and foundation histories, but it has little support in the archival record I found.

In his account of the reform of medical education Starr emphasizes historical developments and the growing cultural authority of the medical profession and downplays the explicit leadership role of the Rockefeller and Carnegie philanthropies. He implicitly takes issue with the weight given by myself and others12 to the role of the Rockefeller philanthropies in educational reform, although he neither critically examines our evidence nor provides support for his alternative perspective. In my view. Starr even diminishes the importance of specific leaders within the American Medical Association, instead describing institutional changes devoid of the political dynamics that actually bring about these changes. Although acknowledging the role of political power. Starr describes a diffuse political process based on the profession's growing credibility. For example, in his account the AMA's Council on Medical Education appears a natural outgrowth of efforts to improve medical education. This progression begins with the reforms at Harvard by university president Charles W. Eliot in 1870, continues with the founding of the forerunner of the Association of American Medical Colleges in 1890 and the opening of the Johns Hopkins medical school in 1893, and extends to the reforms of the new century. In Starr's narrative, only certain people stand out as doing battle in this process, particularly Eliot, who forced reforms on some of Harvard's reluctant medical faculty, and individual practi­tioners whose oxen were gored by the reforms.

Starr ignores the role of Arthur Dean Bevan (the combative and wily chair of the AMA's Council on Medical Education), the relationship between Bevan and Henry S. Pritchett (president of the Carnegie Foundation) and Abraham Flexner (author of the famous Carnegie study of medical schools), and the important role of Frederick Gates in directing the Rockefeller involvement in the reform and development of medical education. Bevan was the chief strategist in the AMA's efforts to reform medical education in order to improve the training of physicians and to reduce their numbers and raise their social status and income. He consciously sought the legitimacy that the Carnegie Foundation could provide to the profession's efforts (a transfer of cultural authority, if you like), hoping that such legitimacy would then guide the philanthropy of wealthy men and women who might provide the funds needed for medical education reform. Pritchett complied with Bevan's request that the foundation conduct a "no holds barred" critique of American and Canadian medical schools, even keeping secret the foundation's close relationship with the AMA.

Gates hired Flexner to run the Rockefeller philanthropies' medical education program that provided princely sums for the reform of medical education. Gates supported the profession's reform efforts—but with a twist. He insisted that all recipient institutions adopt the strict full-time policy for clinical faculty, making this policy the cornerstone of the Rockefeller philanthropies' prodigious funding of reform. Gates was adamant about this policy because he saw it as a way to bring the medical profession to heel, forcing it to serve the needs of all society rather than the profession's own narrower self-interest. Gates believed that "commercialism" in the medical profession "confines the benefits of the science too largely to the rich, when it is the rightful inheritance of all the people alike, and the public health requires they have it." But, as 1 show in Chapter 3. Gates's primary concerns were to improve the productivity of workers in the United States and those in other lands and to inculcate acceptance of industrial capitalism and, in particular, the prevailing social order in the first quarter of this century. Gates was a leading member of the corporate class, and he unequivocally believed that he was furthering the interests he shared with other members of that class.

Other foundations have continued up to the present to pursue Gates's goal of rationalizing American medicine so that it might better meet the needs of the larger society rather than being dominated by narrow interest groups within the profession. But unlike many foundation directors in recent years. Gates was willing to go to war with the profession, using the enormous endowment of the Rockefeller philanthropies as his artillery to pound the medical school turf in clinical departments that had been staked out by medical practitioners. As 1 argue in Chapter 4, Gates ultimately lost this battle, and the foundation has been tamer ever since in its efforts to rationalize medicine. 13

Because of these omissions and the corresponding emphasis on the profession's cultural authority, Starr's book conveys an impression of a natural progression rather than a series of gains and losses by groups and individual leaders, often involving hard-fought battles over eco­nomic and status interests as well as differing ideas. Certainly the spreading and deepening political and social receptivity of the public to developments based on science, or at least associated with science, was an important basis for the reform and elevation of medicine. But these beliefs provided only a necessary base of support. The driving force, in my view, was ihe political and economic power secured by the medical profession's leaders on behalf of [heir very conscious cam­paign. And one of the most important sources of this power was an alliance—at times strong, at other times weak—with some of the wealthiest and most influential agencies of corporate capitalism, the foundations established by the foremost captains of industry and run by occasionally visionary managers.

Foundations today play a less significant role in shaping the health care system in the United States than they did from the turn of the century to the 1930s. In part, this lesser role is due to the growth of the health sector in the economy, the financial role in that sector of private insurance and government programs, and the relatively small re­sources available to foundations. In 1983. foundation spending ac­counted for just 0.2 percent of total national health expenditures. Foundations provided $712 million for domestic health-related grants in that year, a substantial decline in real (inflation-adjusted) dollars from the 1975 level.14

The approach of major foundations, like the Robert Wood Johnson Foundation, is explicitly cautious. Eli Ginzberg has identified a number of important challenges in health policy and organization that foundations have avoided taking up, preferring instead to shape the system at the margins and to refrain from challenging either government or established interest groups within the health system. For example, although foundations have supported demonstration projects to improve ambulatory care services to middle-class and poor patients, no foundation has critically assessed the dominance and centrality of the hospital in the health care delivery system (despite the fact that hospitals consume 40 percent of total health expenditures); and although some foundations are exploring small-scale approaches to providing coverage for the nearly 40 million Americans who lack any health insurance protection, none has supported assessments of the possible gains that may be realized by revamping our pluralistic health care financing system into a national health insurance program.15

Alternative foundation grants and studies along these lines might challenge the medical profession, the hospital industry, the insurance industry, and some government policymakers, resulting in controversy, political conflicts, and public scrutiny—all contrary to the operating principles of philanthropic foundations. Despite the fact that foundations seem to share with Frederick Gates a strong interest in rationalizing health care and supporting the development of bio-medical research, they now appear timid compared to Gates's often contentious approach. Nevertheless, these contemporary patterns cannot be fully comprehended without studying their roots in the history of the leading foundations and their leaders who helped shape our present health care system and institutions.

1. Ronald L. Numbers. "The History of American Medicine: A Field in Ferment." Review in American History- 10 (1982). 245-63
2. For a lucid discussion of this conflict, appropriately set in the history of the field, see Susan Reverby and David Rosner, "Beyond 'the Great Doctors.'" in Reverby and Rosner, cds.. Health Care in America: Essays in Social History (Philadelphia: Temple University Press. 1979), pp. 3-16. Numbers, "History of American Medicine." includes a brief discussion of the subject from a different point of view
3. See. for example. Lloyd G. Stevenson. "A Second Opinion, " Bulletin of the History of Medicine. 54 (1980). 134-40. written by the editor because he disagreed with a favorable review
4. Numbers. "History of American Medicine"
5. Paul Starr. The Social Transformation of American Medicine (New York: Basic Books. 1982). pp. 227-29
6. Starr. Social Transformation, pp. 13-24. '
7. Starr. Social Transformation, p. 227
8. I. Ibid. '
9. See pp. 130-32 and 167-71 of this book
10. See p. 122 of this book
11. Starr. Social Transformation, p. 122. Also see his comments about an article by Howard S. Berliner. "A Larger Perspective on the Ftautcr Report" International Journal of Health Services, 5 (1975). 573-92
12. Howard S. Berliner. A System of Scientific Medicine: Philanthropic Foundations in the Flexner Era (New York: Tavistock. I985)
13. On Bevan and the Carnegie Foundation, see pp. 138-52 of this book: on Gates, the Rockefeller philanthropies, and the full-time plan, sec pp. 155-76. For Starr's view, see pp. 112-23 of his book
14. Betty L Dooley. "Patterns in Foundation Health Giving." Health Affairs. 6 (1987). 144-56
15. Eli Ginzberg. "Foundations and thc Nation's Health Agenda." Health Affairs. 6(1987). 128-40. For additional evidence of Ginsberg's argument, sec also Jeffrey C. Merrill and Stephen A. Somers. "The Changing Health Care System: A Challenge for Foundations." Inquiry, 23 (1986), 316-21. and Jane Stein. "Health Care Foundations Take Long-Range View, says Aiken." Business and Health, 2 (October 1985). 46-49