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Rockefeller Medicine MenMedicine and Capitalism in Americaby E. Richard Brown
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Rockefeller Medicine MenMedicine and Capitalism in America

by E. Richard Brown

Excerpts from Abraham Flexner, Abraham Flexner: An Autobiography, copyright 1940 by Abraham Flexner and 1960 by Jean Flexner Lewison and Eleanor Flexner, reprinted by permission of Simon & Schuster. University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England Copyright 1979 by The Regents of the University of California First Paperback Printing 1980 ISBN 0-520-04269-7 Library of Congress Catalog Card Number: 78-65461 Printed in the United States of America

CONTENTSPreface Introduction Doctors Other Interest Groups Foundations and the State 1. "Wholesale Philanthropy": From Charity to Social Transformation Creating Private Fortunes and Social Discontent Driving the Reluctant Poor from Poverty Training Scientific Heads to Direct America's "Hard Hands" Carnegie's Gospel of Wealth" Reverend Gates Introduces "Wholesale Philanthropy" Rockefeller to

The Reverend Frederick T. Gates: The Making of a Rockefeller Medicine Man The General Education Board: S129 Million for Strategic Philanthropy Social Managers for a Corporate Society

2. Scientific Medicine I: Ideology of Professional Uplift American Medicine in the 1800s Incomplete Professionalization Medicine as Science Gaining Public Confidence Reducing Competition Technical Requirements of Scientific Medical Education "Nonsectarian" Medicine Undermines the Seels Specialization: Less Competition for the Elite Gains and Losses 3.Scientific Medicine 11: The Preservation of Capital Medical Technology and Capital Welch: A Rockefeller Medicine Man Rockefeller Money and Medical Science: A Social Investment Homeopathy: The Conflict Simmers Scientific Medicine and Capitalist Gates Healthier Workers Ideological Medicine

Gates' Digression 4.Reforming Medical Education: Who Will Rule Medicine? Practitioners Gain a Foothold Council on Medical Education Money for Medical Education: Who Will Pay? Help from the Carnegie Foundation The "Flexner Report" The General Education Board: Education Gets a Different Drummer Full Time: "Gold or Glory" Selling the Full-Time Proposal Boston Brahmins Resist Fear and Trembling in the Board Room Slate Universities: Professionals, the State, and Corporate Liberalism Summing Up 5.Epilogue: A Half-Century of Medicine in Corporate Capitalist Society Frederick T. Philanthropies Gales and the Rockefeller Medical

RATIONALIZING THE MEDICAL MARKET The Committee on the Costs of Medical Care Doctors and the Capita I-Intensive Commodity Sector The Slate: Rationalizing the Private Market The Growth of Capital-Intensive Commodities The "Corporate Rationalizers" The Stale and Capitalist Medicine Up Against the Medical Market National Health Insurance: More of the Same TECHNOLOGICAL MEDICINE Scientific Medicine: Beliefs and Reality Life, Death, and Medicine Tapping the State Treasury A "Superacademic General Staff" The Corporate Class The Medical-Industrial Complex Technology in Crisis Blaming the Victim: New Prominence for an Old Ideology Notes Index

PREFACE

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 xxx 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 I argue that, although medicine's new found 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 add 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

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