In 1910 the Carnegie Foundation issued a landmark report on medical education. Abraham Flexner authored the report, titled Medical Education in the United States and Canada, or Bulletin No. 4, analyzing the educational programs of 155 medical schools throughout Canada and the United States. His research concluded that medical education in North America was woefully inadequate in every aspect, including its lack of laboratory facilities, disorganized administrative practices and lack of teaching and curriculum standards. Flexner’s recommendations profoundly influenced the leading philanthropists of the age, including John D. Rockefeller, Sr. (JDR Sr.), and led to the transformation of medical education in the United States and the world.
Leading the Charge
Spurred by Flexner’s report, the General Education Board (GEB) and later, the Rockefeller Foundation (RF) called for a transformation of, and investment in, medical education in the U.S. Medical education, as Flexner described it, was mostly a for-profit enterprise undertaken by small schools staffed by a few, part-time doctors. In many cases medical education involved no laboratory work or practical training. Students were often admitted without a high school education, and curricula varied widely from school to school.
GEB and RF officials well understood that the success of their program might shutter some of the worst medical schools, while the best, with their help, would compete with the finest schools in Europe. The RF mandated a relationship between hospitals and any medical school that the Foundation funded. The RF also required teaching staff to be under university control and devoted solely to teaching rather than balancing their duties with private, for-profit practice.
The GEB took the lead in the improvement of medical education in the United States. Directing the medical education program was Flexner, who became Secretary of the GEB in 1913. Under his advisement the first grants towards the improvement of medical education went to Johns Hopkins University in 1913. Hopkins received an annual grant to develop its clinical programs, including medicine, surgery and pediatrics. The success realized at Hopkins inspired further grants, including significant sums for the medical programs at Yale and Vanderbilt Universities. It also motivated JDR Sr. to earmark a further $45,000,000 for the GEB’s program in medical education.
Bridging the Gap
The GEB also supported medical schools at historically black colleges. The biggest recipient of this support was Meharry Medical College in Nashville, Tennessee. Support for Meharry began in 1916, and over thirty years the GEB contributed approximately $8 million, helping to create a first-class center for African-American education in medicine, nursing and dentistry. Beginning in 1947 the RF made contributions to the school in order to off-set the increasing costs of operation. Upon announcing this additional support the GEB noted, “In the training of Negro doctors Meharry Medical College easily occupies first place. More than half the country’s Negro practitioners are its graduates, and the College’s present enrollment is greater than the total of Negro medical students in all other American medical schools.”
In 1919, the Division of Medial Education was established within the RF and administered by the International Health Division (IHD). The division became responsible for the improvement of medical education outside of the U.S. The earliest years of the program focused on surveying the state of medical education worldwide and funding targeted institutions for improvements.
A New Focus
RF officials recognized early that to complement their programs in hookworm, malaria and yellow fever eradication they needed a cadre of well-trained public health officials. As noted in the 1923 RF Annual Report:
… medical education plays an essential part in the leadership and success of public health work. The Rockefeller Foundation is concerned, therefore, in aiding influential medical schools in many parts of the world to improve their facilities, to strengthen their teaching staffs, to perfect their methods, to maintain high standards, and gradually, in the words of a distinguished British medical authority, to ‘permeate the curriculum with the preventative idea.’
The first university to benefit significantly from the investment in schools of public health was Johns Hopkins University. Through extensive funding beginning in 1916, the RF created the School of Hygiene and Public Health at Johns Hopkins, and the school quickly became a model of public health education.
Internationally, the two biggest recipients of RF funding were the University of Toronto and the London School of Hygiene and Tropical Medicine. Writing to Sir Alfred Mond, the British Minister of Health, of the RF’s $2 million appropriation, Wickliffe Rose noted, “The object of the Trustees is the advancement of world health in the widest sense, and they are the more glad that they can make the offer at a moment when the outlook seems a little brighter for the close drawing together of the nations in the bonds of mutual understanding and of common effort for human welfare.”
By 1929 the GEB and the RF shifted their focus from institutional development in medical education to research initiatives. In less than two decades the GEB had transformed American medical education into one of the best systems in the world, while the RF had invested over $25 million to build institutes of public health across the globe.
While the Division of Medical Education no longer exists, the RF continues to support efforts in medical education through its Transforming Health Systems program. Grants for curriculum development at universities in Vietnam, Ghana, Thailand, Bangladesh and Rwanda focus on programs in e-health, health informatics and health economics, with the shared goal of increasing access to equal and universal health coverage.