Besides these interest groups, two other forces —the government and foundations—have exerted a powerful influence in favor of rationalizing medical care. Although the government has been the dominant influence since World War II, foundations were the major external influence on American medicine in its formative period from 1900 to 1930. Their source of power has been the purse, generously but carefully applied to specific programs and policies. Neither foundations nor the government has operated as an interest group in the manner of doctors, hospitals, insurance companies, medical schools, and the drug and hospital supply industries. The enormous sums they expended—from foundations some $300 million from 1910 through the 1930s and from the federal government many billions of dollars since World War II, for medical research and education alone —have not been for their own financial enrichment.
The argument developed and supported in this book suggests that both foundation policy and government policy have served the interests of certain medical groups but only because the interests of these groups coincided with those of the larger corporate class. As evidence from the historical record will show, the programs of foundations earlier in this century were explicitly intended to develop and strengthen institutions that would extend the reach and tighten the grasp of capitalism throughout the society.
In medicine the major objectives of foundations were: to develop a system of medicine that would be supportive of capitalist society; and to rationalize medical care to make it accessible to those whom it was supposed to reach but at the least cost to society’s resources. These objectives created their own contradictions. At first, foundations aligned themselves with the aims and strategies of the medical profession, but they soon rejected the narrow interests the profession wished to serve and moved quickly to expand the roles of medical
schools and hospitals and to support their dominance over all medical care. By World War II, when the role of the State* in governing the capitalist economy was fully established, the federal government took over the foundations’ leading role in medicine, continuing the basic strategy adopted by the foundations more than two decades earlier and opening the floodgates of the treasury to implement it.
'Throughout this book, capitalized “State” refers to the political institutions and agencies of government which embody society’s political authority. Uncapitalized “state" refers to the individual states in the United States.
In the first chapter, we will see how philanthropic foundations emerged from several parallel developments of capitalist society in the latter nineteenth century. While many members of the new wealthy class were supporting charities to ameliorate the disruptions and deprivations imposed on large numbers of people by capitalist industrialization, others recognized the need for technically trained professionals and managers and supported the development of universities and professional science. Just after
the turn of the century men of great wealth, like John D. Rockefeller and Andrew Carnegie, created philanthropic foundations with professional managers in charge of their charitable fortunes. With the Rockefeller philanthropies in the lead, these foundations developed strategic programs to legitimize the fundamental social structure of capitalist society and to provide for its technical needs.
Chapter 2 traces the social and economic role of scientific medicine in the history of the American medical profession.
Modern scientific medicine was not merely a “natural” outcome of combining science and medicine in the nineteenth century.
Apart from the concrete scientific developments that permitted the application of scientific thought and investigation to problems of disease, scientific medicine had equally important social and economic origins. It was an essential part of a strategy articulated by reform leaders of the medical profession to enhance the profession’s position in society, and it succeeded
because it won the support of dominant segments of the American class structure.
Scientific medicine gained the support of the American medical profession in the late nineteenth century because it met the economic and social needs of physicians. By giving doctors greater technical credibility in society, it saved them from the ignominious position to which the profession had sunk. Moreover, scientific medicine became an ideological tool by which the dominant “regular” segment of the profession restricted the production of new doctors, overcame other medical sects, temporarily united leading medical school faculty and practitioners, and otherwise reduced competition.
Despite its appeal for the medical profession, scientific medicine would have accomplished little for doctors if it had not had the support of dominant groups in American society. In Chapter 3 we will see the reasons for this capitalist support, especially through the thinking of Frederick T. Gates, for more than two decades the chief philanthropic and financial lieutenant
to John D. Rockefeller and the architect of the major Rockefeller medical philanthropies.
As an explanation of the causes, prevention, and cure of disease that was strikingly similar to the world view of industrial capitalism, scientific medicine won the support of the classes associated with the rise of corporate capitalism in America.
Capitalists and corporate managers believed that scientific medicine would improve the health of society’s work force and thereby increase productivity. They also embraced scientific medicine as an ideological weapon in their struggle to formulate a new culture appropriate to and supportive of industrial capitalism. They were drawn to the profession’s formulation of medical theory and practice that exonerated capitalism’s vast inequities and its reckless practices that shortened the lives of members of the working class. Thus, scientific medicine served the interests of both the dominant medical profession and the corporate class in the United States.
Nevertheless, a contradiction emerged between the interests of the medical profession and those of the corporate class. As we will see in Chapter 4, the private practice profession and the corporate class clashed over attempts to reform medical education. The financing of scientific medical schools required tremendous amounts of capital from outside the medical profession.
Those who provided the capital had the leverage to impose policy. The lines of the conflict were clearly drawn: Was medical education to be controlled by and to serve the needs of medical practitioners? Or was it to serve the broader needs of capitalist society and be controlled by corporate class institutions?
The Flexner report, sponsored by the Carnegie Foundation, tried to unify these interests by centering its attack on crassly commercial medical schools. However, the Rockefeller philanthropies, substantially directed by Gates, exposed the contradiction by forcing a full-time clinical faculty system on recipient schools against the interests and arguments of
private practitioners. Gates made it clear that medicine must serve capitalist society and be controlled—through the medical schools that reproduce its professional personnel and innovate its technique—by capitalist foundations and capitalist universities. By 1929 one Rockefeller foundation, the General Education Board, had itself appropriated more than $78 million to medical schools to implement this strategy, and Gates’ perspective was firmly established.
Gates was adamant about keeping his strategy free of involvement with the State by not giving money to state university medical schools. However, within the Rockefeller philanthropiesas within the largest industrial and financial corporations generally, most officers and directors had come to see the State as a necessary aid in rationalizing industries, markets, and institutions.
The course that Gates and his contemporaries initiated continued to develop during the next half-century, but with the State assuming the
dominant financial and political role in rationalizing medical care and developing medical technology. As we will see in Chapter 5, the State’s emphasis on technological medicine ignored some of the most important determinants of disease and death while the economic and political forces of capitalist society assured that rationalization would not eliminate the developing corporate ownership and control over the medical market. How medicine will be contained and rationalized in this private market system is a contradiction that now plagues the
State and the corporate class as the demand for national health insurance grows. How medical resources can be transformed into effective instruments for improving the population’s health is a contradiction imposed on the entire society. These contradictions and their resulting crises are the legacy of medicine’s development in capitalist society.
CHAPTER I