A Program in The Medical Sciences by Alan Gregg (Excerpt from Trustees lirlonthly report April 1, 1950) 1 1 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 " 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 / 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 i 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, '3 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 -'& ToLC -0 54 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 I1 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.