A Program in The Medical Sciences

          by Alan Gregg
(Excerpt from Trustees lirlonthly report April 1, 1950)

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THE PROGRAM IN THE MEDICAL SCTENCES

A Statement by Alan Gregg

A program, especially if it involve policy consideration, can be

presented in two parts:

the first section being devoted to the arrangement

and presentation of its component items, the second section being devoted

to general comments or interpretations of the program as a whole.

procedure will be followed in outlining the present program of the Mdfeal

This

Sciences, Under Section I are set forth, not any individual projects, but

the principal areas of Medical Sciences activity - the mpd !`activity"  com-

prising the officers1 reading, intervims, visits, reports, and negotiation8

involved in making recommendations, extensions, renewals, and other types of

admini st rat fve work

I

/ /

Psychiatry and Neurology,

lbphasis on these subjects began in

1933.
in medicine on a reformed and solid foundation,
were depression years, five to six were years of war9  and the last five
have witnessed a progressive loss in the dollargs purchasing value.
program in behalf of psychiatry can reasonably claim special consideration
because of` these handicaps,  Consequently, there is no clear case for giv-
ing up completely or hurriedly our present interest Cn psychlatrf-and

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neurology and their underlying sciences such as neurophpiology,  neuro-
pathology, and psychology, Indeed, if the Foundation were to announce
that it was no longer interested in psychiatry,  such a declaration would
be interpreted very widely as evidence of the Foundation's disillusionment
with the possibility of progress in this field,

Seventeen years might be assumed to be enough time to put any field
                        Four of the past 17 years

The

       Much still needs to be done ir, the study of psychotherapy and
the criteria of successful therapy, in the aevelopent of psgchiatry in
other countries, in the support of psychology both in North America and
in Europe, and in the support of basic studies in histologyp biochemistry,
biophysics, physiology, pathology and genetics of the nervous system,
OppoPtuntties in these fields will continue to be given careful attention
and support,

It does not seem reasonable, now-ever, for the Foundation to

undertake any new projects involving general support to departments of
psychiatry in North American medical schools,  nor to continue for mope
than a minimum period existing projects of this kind,
government aid must shoulder such costs eventually now that psychfatry is
fairly well taught in some schools,

Local or federal

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Preventive Medicine and Public Health,

In most countries pre-

ventive medicine and public health depend upon the level of general educa-
tion, on the quality of medical education and on political and economic
factors, With the last two factors the Foundation can have little to do,
But any improvement in the teachicg of preventive medicine and public
health ___" -.- to the doctors of the future is lik%~~~o~F%E"e sta66s of
the public health and the advance of preventive medicine,  The officers
of the International Health Division stationed in other countries usually
agree that any favorable long-term predictions one could make about the
public health in any country call for improvements in its medical educa-
tion, including especially the- teaching cG?public health"%ome&al stu-
dents .,

When all our medical schools are full and ovep-applied for,  the
                               Obviously

                   In any case) not many of the

graduate Schools of Public Health are still far from full,
something is wrong,  The public seems to hold an ignorant, underestimate
of the value of public health officers.
ablest medical students head for public health,

Meanwhile the service of the doctor to our society seems to be

changing. Oroup practice becomes more commono Prepayment schemes for
physicianst services are growing,
to be considered a desirable basis for organizing the practice of the
future,
health and preventive medicine in medical schools -. here and in other coun-
ries, "'Activity fn this' teaching    be one of the fields of interest
to the Medical Sciences.
within the  field of the International Health Division as they have been
in the past,

The need for medical care is beginning

This will call for extensive Cevj.sia&.p_f_ og,r-,t,each%ing, of public

The graduat,e Schools of Public Health remain

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Endocrinology,

News can be spread through tom over telephone

wires or by persons circulating from house to houseo Similarly in the
body, different organs can be reached by messages coming over the nervous
system, or they can be reached by substances that profoundly affect the
growth and function of different tissues such as skin, hair, cartilage,
muscle, etc,  Most readem are familiar with the names of such internal
secretions as insulin and adrenalin, and with the fact that the pituitary,
the thyroid, the adrenals (and other endocpine glands) produce internal
secretions that are ,small in amount but large in effects and complicated
in both structure and action,

     So complicated is the subject of endocrinology that the Medical
Sciences has chosen to give long-continued support to a few investigators
possessing an unusual blend of chemical knowledge, tenacity of purpose,

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29.

enthusiasm and critical judgment,  The recent discoveries of the physiologi-
cal effects of ACTH and cortisone (both substances related to the internal
secretion of the cortex or rind of the adrenals) have called for and secured
research grants from government in amounts far larger than the Medical Sci-
ences could have supplied,  Now that ACTH and cortisone have reached elini-
cal use and commercial production, our best policy will be to find a few
interested and cmpetent physiologists and clinicians and support them,,

human identic 2 wins, the Medical Sciences has kept a steady interest in
what is sometimes called medical genetics,
this field,  Hereditary traits show best where there is close inbreeding,,
The number of closely inbred populations is diminishing,
are always isolated and hard to get to,
function are popularly interpreted in most parts of the world as evidence
of divine punishment or displeasure, and therefore are hidden or lied about,
Experimental genetics is growing rapidly in the hands of biologists working
with plants and insects*
comparable to the geneticist's experimental crosses,  and no one student of
human heredity muld be likely to live long enough to be able to study as
many as four generations of human subjects.

Human Iieradit ,

Beginning in1932 with grants for the studies of

          Progress is necessarily slow in

Such populations

Inherited defects of structure and

Human matings are not controllable in any way

     Despite these numerous and heavy limitations, progress can be
made.  Certainly compared with what we now see that heredity determines
in plants and animals, we 4ave given environment more than its due share
of attention in OUF studies of mano  Manls nature has been ignored,  his
nurture receiving most of the scientists' attention, Psychiatry and psy-
chology could both gain from and give to the intensive study of human
heredity,,

     The real meaning of some population problems varies more with the
kind of people produced than with the number merely,
study of population growth could neglect the factor of human heredity,  even
though at present our knowledge of the lam and nature of human heredity is
scant, to say the least. The mainpontributions the Medical Sciences divi-

r,""c& sion can make to the study of population problems will be through the
      National Research Council Committee on Research in Problems of Sex, through
      studies of the physiology of human reproduction, and through studies of
      human heredity,

No really adequate

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ToLC -0

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Medical Education. There is considerable evidence that the

foundations, the science writers9 various successful researches during
the war (notably the Manhattan project), and the change in disease rates
and consequent increase in longevity that characterize the last 50 years9
have all had a share in making the American public aware of the immense
value of scientific research.  Not only aware of the value of research but
in medicine insistently pushing the federal government to support research
over a wide range.,
researchers, grants in aid of research, buildings to house research - all
these are available from Government in numbers undreamed of 30 pars agoo
It should be added that a well-known leader at California Institute of
Technology recently expressed himself in private as being willing to trade

Scholarships and fellowships to recruit the ranks of

nine dollars of government research grant money for one dollar of Rocke-
feller Foundation research grant money because the latter was so much mope
w5sely planned and given.
present, very large - resources for supporting research work,
creation of a National Science Foundation,  the furtherance of medical re-
search is no longer so largely the privilege of universities and founda-
tions.

None the less, the Covement has large - at
                          With the

Meanwhile the medical schools9 especially those in our endowed

          In the thirties the average drop in endowment

universities, have begun to deteriorate, Their effective income is about
half what it was in 1930,
income rate was from 5% to 305% - about a 30% loss in endowment income,
Then came the loss of teachers and the interruption of tyaining and re-
cruitment of teachers during the war,
power of the dollar and consequently the loss of young teachers who would
not live on niggardly salaries when the practice of medicine paid very
well. The financial straits of our medical schools threaten the recmit-
ment and training of research men in biological science as well as medicine,

Then came the loss in the purchasing

     Mor is the present difficulty merely financial,
school authorities are not prepared - in most instances - to decide,  and
persuade their colleagues to accept9 the changes in objective and in method
which are appropriate to the teaching of medicine in 19506
entire difficulty is merely financial .

The medical

They think the

Obviously neither the division of Medical Sciences nor even all

the Fourdationl s income could make much impression on the financid  need
of 78 schools,
them efficient as judged by the standards of a decade agoo
be much interest or any justification for a foundation simply supplying
funds to carry or salyage medical schools to perpetuate teaching methods
they have been using since 1929 with gradually decreasing effectiveness,

This need is estimated at $1~,OOO,OOO annually just to keep
                               Nor would there

     It may not be unreasonable to suggest that the senior officer of
the division of Medical Sciences during the five years remaining to him in
the sedce of The Rockefeller Foundation has more to offer out of thirty
years of contact with public health field work, research institutes, hospi-
tals and medical schools as a critic and adviser of medical education than
in any other capacity.
need of the medical sciences today, the reply would suggest a series of
three or four monographs on the purposes and methodsg the problems and the
circumstances, the present and the future of research, teaching and medi-
cal practice and the preparation for them, v:ritten by a person, not by a
committee, and without any more to commend it than its own quality,

Were his own judgment to be asked as to the major

One more point under the general heading of medical education.

The divfsion has paid for the pioneering expenses in other fields than
psychiatry and neurology,  The Department of the History of Medicine at
Johns Hopkins, the Chair of Clinical Science at University College,
Londony the Departanent of Legal Medicine at Harvard and the Departments
of Dermatology at Harvard and at Pennsylvania are examples,

It might be

that some other subject, eogog human reproduction, or human ecology, might
be aided in the future as a qualitative addition to medical education,,

Miscellaneous,

              The classification %niscellaneousw is necessary
because occasionally a request demands favorcable action because it is the
inescapable result of some project begun by the Foundation and morally its
responsibility,  Since the Foundationts interests have been both numerous
and varied in the general field of medicine, a good many apparently incon-
gruous items appear and will continue to appear under ~'misce1laneous.f~

       On more than one occasion the rubric l1miscel1aneousw has contained
growing edges or budding points of the divisionPs interest.  Such, for exam-
ple, ms the first project in the field of the distribution of medical care,
It would be irony to insist that any division concerned with research be
expected to delimit or define the extent of its interest in events still
unfolding, So into llmiscellaneousll sometimes fall projects of unimagined
characteristics and unforeseen excellence,

Finally, there are a few types of activity that could better be

called 1Igeneralt1 than "miscellaneousf8 since they usually contribute to the
other programs even though having an individual raison d7etm,
ship program exemplifies such a general program,  Since the mere size and
duration of the fellowship program fivite challenge to our continuing it,
it might be appropriate to note that our satisfactoPy contacts jn every
country including our own are due more to the fellowship program than to
any other activity,

The fellow

And soy as above noted, the progmm of" the Medical Sciences divi-

sion is spread over six main headingso,

1,

Psychiatry (including neuroanatmy, qeurophysioIogy, neuro-
chemist ms clinical neurol ogy9 neurosurgery, psychology,
clinical psychology, child guidancep etc , )

2.

Public Health and Preventive Medicine (as presented to

medical students )

3

Endocrinology (with possible later relationships to con-
stitution and character and certain present beaPing on
large areas of physiology)

Human Heredity (genetics as applied to human indidduals

and populations)

50

Medical Education (the training of fiturn practitioners9

teachers and investigators in the medical sciences
and the clinical subjects)

60 Miscellaneous (general programs such as fellowships, New

and exploratory itas,
f~an earlier projects,)

Occasional moral responsibilities

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The first comment on the program of the Medical Sciences as out-

lined above is that the Federal Government now has funds for trafning and
research work in the medical sciences and clinical medicine in amounts and
for purposes not available (nor even imagined) before Wmld War II,
for direct aid to medical education is now in Congress,
cussion of the so-called National Science Foundation, with possible legis-
lative action in the next year,  It would probably be no exaggeration to say
that the existent enormous changes in tax-supported maintenance of research
and training justify a thorough review of the policy of the hEedical Sciencesu

         A bill
There rdll be dis-

      The Federal Govement,, like the private foundations9 spends most
of its money in the medical field in the form of grants for trainfng person..
ne1 and in shorbterm research grants,
Federal f'mds and Rockefeller Foundation funds that buildings and endowment
are given Kith reluctance to universities if they are gr-ren at all;  and that
preference is given to grants in aid and fellowships, usually on relatively
short-term commitments,  In effect the policies of the Fcuridatioc have beer.
imitated by agencies of the Federal Government (United SCuates Public Health
Service, Veterans Administration and Atomic Energy Commission)   In quanti-
tative terns the Federal Government completely outstrips the  resources and
the'activities of The Rockefeller Foundation in medicine,
what the Federal authorities canvt do - dogoy long-term grants or endoments
or special experiments in %efl fields - can the Foundation avofd quantita-
tive comparisons with a now far more powerftil competitor,  I would think
that in the Medical Sciences it would be wfse to keep a close control of
small and short-term grants,,  and therefore not increase our staff but favor
long-term grants and endowment,

In the main it is ROW true of both

Only by doing

      The fact is that the present level of government spending in re-
search ad the likelihood of a National Science Foundation being created in
the near future call for a re-examination of our policy and especfally the
attitude toward endowment,  Endowment now becomes the one type of valuable
aid which the Government cannot give,  F'urthemore, endowment gives an in-
stitution independence of government::  fndeed,  it could be claimed that ade-
quate endoment of a private institution not onlymakes it independent of
government - it makes government dependent on the private institution's
dependable resources,
ment are hunting for places stable enough to accept government help would
continue an old policy in changed circumstances,
ment means but, little nowadays brings to mind the source of the Foundationos
current incame.

Refusal to endow when maintenance grants Pram govern-

The argument that endow

The above comment obviously concerns principally the activities

                                        the situa-

of the Medical Sciences in the United States,
interests in other countries (especially, in medical education)
tion is somewhat unusualo

In point of Medical Sciences

If the foundation that leads all other Amerfean crganizations in

its reputation for tac6ful and helpful relations Kith both the people and
the officials of other nations were to choose this time to withdraw its
representatives from abroad, it would add a strange flavor to the expecta-
tions in various countries of American collaboration at technical rather
than political levels,  Such a decision would be incomprehensible abroado
On the other hand, it would give Medical Sciences officers satisfaction if9
in the interests of medical education, the Medical Sciences em place two
or three representatives abmad for periods of three .to five pars,  OP be
of further assistance to International Health Division represen2atives a-
ready resident in foreign countrieso It ~0~l.d~ howevep, be mistaken to
embark upon the support of program in medical education on at: international
basis unless the Trustees have convictions that would be likely to outlast
the remaining period of semice of the present director,  The Fonndation
needs no repetition of the disappointment and discouragement in South AfdcaS
South America and the Fap East on the ternination in 1929 of %he Focndationls
interest in mecllcal education.