The Founding

Frederick T. Gates, a Baptist minister who managed John D. Rockefeller's philanthropy, read William Osler's Principles and Practice of Medicine in July 1897. He later recalled concluding that medicine "could hardly hope to become a science until medicine should be endowed and qualified men could give themselves to uninterrupted study and investigation, on ample salary, entirely independent of practice." His memo to Rockefeller that summer argued that Pasteur's discoveries "had saved for the French nation a sum in excess of the entire cost of the Franco-German War."

The Sanitary Commission worked through the boards of health of the Southern states. Gates described the arrangement in his unpublished 1928 autobiography: "the hookworm work is done in every state under the guise of the State Health Boards, while it is in fact minutely directed by Mr. Rockefeller's staff and paid for with Mr. Rockefeller's money." In 1913 the new Rockefeller Foundation extended the hookworm program worldwide through its International Health Commission. Wickliffe Rose, who had run the Sanitary Commission, directed the Foundation's international health program from 1915.

The AMA's Council on Medical Education, chaired by Arthur Dean Bevan, began serious work in 1905. In 1907 it rated 160 schools: 82 as class A, 46 as class B and 32 as class C. Bevan urged state and local medical societies to see that "the right sort of men" were appointed to state licensing boards. Within two years the state medical societies, guided by the Council, dominated the boards.

Bevan then turned to the Carnegie Foundation for the Advancement of Teaching. According to the historian E. Richard Brown, Bevan sought "the foundation's developing prestige and image of 'objectivity,'" because an agency outside the profession "could openly attack medical schools." Bevan invited the Foundation's president, Henry S. Pritchett, to examine the Council's survey materials in 1907. The Foundation's trustees authorized a study in November 1908.

Brown found the Pritchett–Bevan letters in the Carnegie Foundation's files. He calls the arrangement "the conspiracy between the foundation and the AMA" and writes that "This sort of deception increased the credibility of the Flexner report, but it was not essential to the transformation underway." The minutes are known through a 1975 paper by James Monahan, and the letters through Brown's book.

Abraham Flexner was a professional educator. He had taken a bachelor's degree at Johns Hopkins and had founded and run a college preparatory school in Louisville. His brother Simon directed the Rockefeller Institute. Brown reports that Pritchett discussed the study with Charles Eliot, a trustee of the Carnegie Foundation, the General Education Board and the Rockefeller Institute, and with Simon Flexner. In Brown's account, Simon proposed Abraham as director of the study. Brown's note 24 labels this sequence an inference from the available accounts.

Pritchett's introduction to the report thanks three men by name for "constant and generous assistance": William H. Welch of Johns Hopkins, Simon Flexner "of the Rockefeller Institute," and Bevan. In the spring of 1911 Gates invited Abraham Flexner to lunch and asked him, "What would you do if you had a million dollars with which to make a start in reorganizing medical education in the United States?" Flexner named Welch and Johns Hopkins. In 1913 he became Secretary of the General Education Board and directed its medical program.

Rockefeller incorporated the General Education Board in 1903. His gifts to it reached $43 million by 1907, at the time the largest gift to a philanthropic organization in American history. The Board's medical program began in 1913, three years after the Flexner Report.

The full-time plan came from Franklin Mall of Johns Hopkins, who told Flexner the money should go toward "placing upon a salary basis the heads and assistants in the leading clinical departments." Clinical chiefs then earned roughly $20,000 to $35,000 a year from consultations. Under the plan they would receive a salary of $10,000, their assistants $2,500, and all consultation fees would go to the school. Welch asked that salaried professors keep some consulting fees. The Board refused all exceptions and voted Johns Hopkins $1.5 million in October 1913.

Washington University, Yale and the University of Chicago received more than $8 million for full-time reorganization. Harvard refused the plan. Nicholas Murray Butler, president of Columbia, rejected the Board's terms as "so reactionary and so antagonistic to the best interests of the public, of medical education and of Columbia University, that they will not, under any circumstances, be approved by us." Bevan denounced the plan as "unethical and illegal" because it deprived clinical faculty of their fees. By 1926, 42 percent of the $13 million in American medical school operating expenses went to the salaries of full-time faculty.

Brown's totals for the Board's medical spending, drawn from its annual reports, are lower than the Archive Center's: more than $78 million appropriated by 1929 and more than $82 million applied by 1930. The difference reflects appropriations, disbursements and program boundaries.

The Rockefeller boards also required matching money. According to Brown, they "required virtually all recipients to raise an amount equal to, or as much as four times greater than, the grant." By 1925 the General Education Board had given $60 million to college endowments and required $140 million in matching funds.

Gates set out the purposes of Rockefeller medicine in letters to Rockefeller and in memos to the General Education Board's trustees. The purposes were a productive labor force, a medical profession that no longer set its own prices, and a medicine that located the sources of poverty, crime and vice in disease. The president of the Rockefeller Foundation described its medical work abroad in comparable terms.

George E. Vincent, president of the Rockefeller Foundation, wrote the "machine guns" sentence about a Foundation-supported hospital ship for the Moro population of the southern Philippines. A Foundation newsletter of August 1916 called the ship's work "an entering wedge for permanent civilizing influences." Brown observes that the domestic programs had "exactly the same ends, though Gates and others were far more circumspect in discussing them."

Brown reads the documents as a record of class interest. Brown, who assembled them from the Rockefeller and Carnegie archives, rejects an investment motive: "The Rockefellers did not have any significant investment in Southern textile mills. Rather their extensive and widespread investments gave them a concern for the productivity of the entire economy." The programs abroad, he writes, were not "intended to prop up specific Rockefeller investments" and were aimed at each country's work force. Brown grants that Gates had "genuinely humanitarian motivations." Brown's book is the source of every quotation in this section, and his notes give the archival locators.

Gates did not command the General Education Board. On 26 February 1925 the Board approved a University of Chicago contract that let full-time clinical faculty continue private practice outside the university's hospitals, with Gates dissenting. In September 1925 the Board's executive committee allowed Johns Hopkins, Vanderbilt, Washington University and Yale to modify their full-time contracts, and Gates asked to have his negative vote recorded. The Board also set aside his rule against funding state universities, beginning with $2.5 million toward a $4.5 million medical center at the University of Iowa. Gates resigned from the Board's executive committee in October 1925.

The founder disagreed with his managers on homeopathy. Rockefeller wrote to his staff in December 1916: "I am a homeopathist. ... I desire that homeopathists should have fair, courteous, and liberal treatment extended to them from all medical institutions to which we contribute." In 1919, while considering the $45 million gift, he wrote that "Homeopathic teaching should not be excluded ... it should be provided for, the same as Allopathic." His son and his staff replied that "scientific medicine has rendered obsolete the former distinctions between the so-called Homeopathic and the so-called regular or Allopathic schools." The gift went to the full-time plan.

The AMA and the foundations also parted. Bevan wrote to Pritchett in 1921 that the Rockefeller philanthropies had become "a disturbing influence by dictating the scheme of organization of our medical schools" and that "Their position has become a real menace to sound development." Brown's summary of the early period is that "it was the profession that defined the goals and the strategy."

The closures began before the report and continued at the same rate after it. Between 1904 and 1915, 92 schools closed or merged: 44 in the six years to 1909 and 48 in the six years to 1915. State licensing boards did the closing. Barbara Barzansky's centenary review finds that their refusal to recognize poor schools sealed those schools' fate. Foundation grants went to the schools that survived.

The General Education Board supported Meharry Medical College from 1916. Vanderbilt, the Board's "strategic point" in the South, received $17.5 million by 1960, and Meharry received less than half that sum. Through its annual grants the Board installed full-time teaching at Meharry in the 1930s, "with approved white faculty members in charge and a hand-picked white president."

Homeopathic and eclectic schools were in decline before the report. According to Miller and Weiss, their students fell from 17 percent of all American medical students in 1880 to 6 percent in 1910. Brown counts 31 homeopathic and eclectic schools in 1910, a third fewer than in 1900. Bevan recalled in 1932: "We were, of course, very grateful to Pritchett and to Flexner" for enabling "us to put out of business" the homeopathic and eclectic schools that existed in 1910.

Flexner addressed physician supply directly. Reducing 155 schools to 31, he wrote, "would threaten no scarcity of physicians until the country's development actually required more than 3500 physicians annually, that is to say, for a generation or two, at least."

The AMA's Council wrote the standards and placed its members on the licensing boards that closed schools. The Carnegie Foundation lent the Council's campaign an outside name and agreed in writing to minimize the Council's part. Rockefeller's General Education Board financed the surviving schools, bound them to its full-time plan by contract, and kept them in line afterward through the prospect of further grants.

Frederick Gates, the man who designed the Rockefeller medical program, wrote down its purposes: labor productivity in the hookworm counties, an end to physicians setting their own fees, and a medicine that located the sources of poverty and crime in disease. His board outvoted him on tactics in 1925, and the founder who paid for the program was a homeopathist. Brown judges that Gates's position nonetheless "became the established foundation direction in medicine for half a century."