Rockefeller Medicine Men

by E. Richard Brown – Unbekoming Book Summary

Today’s global medical system was developed and sculpted by Anglo-American Oligarchs and their “Foundations” and then exported to the world.

Just like their beloved Virology and Cancer Cartels, it has mutated and metastasized into the vile, putrid and predatory corruption that delivered us Covid, Lockdowns and Vaccines.

This global “One Health” system, is the ring that rules them all.

It’s largely forgotten history. But there was a time when people knew what was going on, and wrote about it, in great detail.

This is one of those books.

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Rockefeller Medicine Men By E

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Rockefeller Medicine Men: Medicine and Capitalism in America (1979)

by E. Richard Brown

Question 1: What role did scientific medicine play in the professionalization of American physicians in the late 19th and early 20th centuries?

Scientific medicine played a crucial role in the professionalization of American physicians by providing a basis for the reform of medical education, increasing the technical effectiveness of doctors, and helping to undermine competing medical sects. It allowed elite practitioners to raise standards, reduce competition, and elevate the social status of the profession.

Question 2: How did the Rockefeller and Carnegie philanthropies influence the development of medical education in the United States?

The Rockefeller and Carnegie philanthropies, particularly the General Education Board (GEB) and the Carnegie Foundation for the Advancement of Teaching, heavily influenced medical education by providing large sums of money to support the reform of medical schools along the lines of scientific medicine. They promoted higher admission standards, laboratory-based instruction, and the integration of medical schools into research universities.

Question 3: In what ways did the rise of industrial capitalism shape the emergence of scientific medicine?

Industrial capitalism shaped scientific medicine by creating a demand for a healthy and productive workforce, and by providing the wealth and resources necessary to support medical research and education. Capitalists and corporate managers saw scientific medicine as a valuable tool for legitimizing the existing social order and deflecting attention from the negative health impacts of industrial working conditions.

Question 4: How did medical sects like homeopathy and eclecticism compete with the regular medical profession in the 19th century?

Homeopathy and eclecticism competed with the regular medical profession by offering alternative theories of disease and treatment that appealed to many patients dissatisfied with the harsh and often ineffective methods of conventional medicine. They maintained separate medical schools, professional organizations, and licensing examinations, and had a significant following among the public.

Question 5: What strategies did elite physicians employ to reform medical education and reduce competition within the profession?

Elite physicians worked to reform medical education by advocating for higher admission standards, longer and more rigorous training, and a greater emphasis on laboratory science. They also sought to reduce competition by working with state licensing boards to close down proprietary medical schools and by encouraging the consolidation of medical schools into fewer, more prestigious institutions.

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Introduction

The crisis in today's health care system is deeply rooted in the interwoven history of modern medicine and corporate capitalism. The major groups and forces that shaped the medical system sowed the seeds of the crisis we now face. The medical profession and other medical interest groups each tried to make medicine serve their own narrow economic and social interests. Foundations and other corporate class institutions insisted that medicine serve the needs of "their" corporate capitalist society. The dialectic of their common efforts and their clashes, and the economic and political forces set in motion by their actions, shaped the system as it grew. Out of this history emerged a medical system that poorly serves society's health needs.

The system's most obvious problems are the cost, inflation, and inaccessibility of medical care in the United States. Total health expenditures in this country topped $200 billion in 1979, nearly $1,000 for every woman, man, and child. Far more of society's resources now go into medical expenditures than ever before; twice the portion of the Gross National Product was spent on medical care in 1980 than in 1950.

We pay for these costs through our taxes, health insurance premiums, and directly out of our pockets. Public expenditures— four out of every ten dollars spent on personal health services — come out of our taxes. Private health insurance and direct out-of-pocket payments each account for about three out of every ten dollars. No matter what form it takes, the entire $200 billion originates in the labor of men and women in the society. President Carter estimated that the average American worker works one month each year just to pay the costs of the medical system.'

Most people feel they should be getting a lot for this money, but instead they find that it is difficult even to get the care they need. Primary care physicians — general practitioners, pediatricians, internists, and gynecologists — are scarce. Doctors and hospitals are clustered in the "better" parts of our cities and largely absent from the poorer sections and rural areas of our country. For the millions of Americans covered by Medicaid (the government subsidy program for the public assistance-linked poor), the coverage has been as sparse and degrading as the demeaning clinics it was supposed to replace. The middle class and the poor share at least long waiting periods for doctors, one of the most common constraints on the accessibility of physicians. Instead of creating a humane and accessible medical care system, Medicare and Medicaid have helped fuel inflation in medical costs by dumping new funds into a privately controlled system ready to absorb every penny into expansion, technology, high salaries, and profits.

A second, somewhat less widely discussed, problem is the relatively small impact medical care makes on the population's health status. Despite a plethora of new diagnostic procedures, drugs, and surgical techniques, we are not as healthy as we believed these medical wonders would make us. Some critics, like social philosopher Ivan Illich, accuse medicine of making us sicker — physically, politically, and culturally — than we would be without it. Many analysts have documented the medical profession's social control functions, medical technology's frequently adverse effects on our health, and medicine's neglect of important physical and social environmental influences on our health. Instead of medicine liberating us from the suffering and dependency of illness, we find that its oppressive elements have grown at least as rapidly as its technical achievements.

Why has medical care grown so costly so rapidly? Why is it so plentiful and yet so inaccessible? How did medicine become technically so sophisticated but remain socially unconcerned and even repressive?

A popular but too facile answer is that such problems are characteristic of technology and industrialized societies. According to this argument, technology and industrialization impose their own limits on forms of social organization and produce similar kinds of problems that call forth similar solutions. Medical sociologist David Mechanic finds problems of cost, organization, and ethical dilemmas in medicine widespread among industrialized countries and concludes that "the demands of medical technology and the growth of the science base of medical activity produce pressures toward common organizational solutions despite strong ideological differences.'" Illich asserts that "pathogenic medicine is the result of industrial overproduction." In this view, technology has a life of its own, imposing its imperatives on individuals and social organization. By focusing on widespread patterns of industrial organization and technological development, these analysts conclude that technology and industrialization are universal determining forces.

Such technological determinism ignores the particular history in which society and technology interact. In the Marxian view, technology and economic organization constantly shape each other in a dialectical process. Individuals and groups who own the resources and control the organization of production, far from being at the mercy of "neutral" technology, introduce innovations that serve their own ends and oppose those that would serve other interests than their own. These innovations may neglect broader community needs and may hurt the interests of others. Machines and factories undermined the autonomy and even the economic existence of independent craft workers. Hospitals and their expensive equipment may tie many health workers to monotonous jobs and use funds that might otherwise go for more widely distributed community clinics. Those affected by these technological developments may resist them and force their modification. Workers may organize into unions and gain some control over the relations of production. Communities may organize to block hospital expansion and force development of more community-based clinics. In sum, the political-economic organization of society generates certain types of technological innovation and not others, and these innovations generate new social forces that modify technology and political-economic relations.

This book sees scientific, technological medicine not as the determining force in the development of modern health care but as a tool developed by members of the medical profession and the corporate class to serve their perceived needs. Individuals and groups who possess needed resources can apply them to develop certain types of technological innovation in medicine. Those who have the requisite resources can also apply the resulting technological innovation to serve their economic and social needs.

In the United States medicine came of age during the same period that corporations grew to dominate the larger economy. As corporate capitalism developed, it altered many institutions in the society, medicine among them. Its influence was created not simply through cultural assimilation or the demands of industrial organization but by persons who acted in its behalf. This interpretation does not suggest that history is made by dark conspiracies. Rather, it argues that the class that disproportionately owns, directs, and profits from the dominant economic system will disproportionately influence other spheres of social relations as well.

Members of the corporate class, including those who own substantial shares of corporate wealth as well as the top managers of major corporate institutions, naturally try to ensure the survival of capitalist society and their own positions in its social structure. In the case of medicine, members of the corporate class, acting mainly through philanthropic foundations, articulated a strategy for developing a medical system to meet the needs of capitalist society. They believed their goals for medicine would benefit the society as a whole, just as they believed that the private accumulation of wealth and private decisions about how to use that wealth and its income were in the best interests of society. In this book, we will examine the strategies they developed during the Progressive era and the reasons for their actions, leaning heavily on the public and private thoughts of some persons centrally involved in these efforts. We will describe and analyze the interests and strategies of the medical profession and of the corporate class as they developed independently, coalesced, and then clashed. We will also see that the government has increasingly taken over the strategies and struggles begun by the corporate class.

The corporate class influenced medicine, but it could not control it absolutely. The market system in medical care provides special interest groups — today including doctors, hospitals, insurance companies, drug companies, and medical supply and equipment companies — ^with the opportunity to develop their own bases of economic power, enabling them to carve out and defend their turfs in the marketplace. The larger business class stands "above" these interest groups, trying to tame and coordinate the leviathan but nonetheless committed to private ownership and control and also enjoying medicine's legitimizing and cultural functions. The relationships and the contradictions that emerged among the corporate class and these medical interest groups profoundly influenced the organization and content of today's medical system.

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Question 6: How did the American Medical Association (AMA) evolve into a powerful political force for the medical profession?

The AMA became a powerful political force by reorganizing itself into a national body with a strong central leadership and close ties to state and local medical societies. It lobbied for stricter licensing laws, worked to discredit competing medical sects, and promoted the interests of physicians in national policy debates.

Question 7: What was the significance of the Flexner report in reforming American medical education?

The Flexner report, commissioned by the Carnegie Foundation, provided a comprehensive and highly critical assessment of American medical schools and recommended sweeping reforms based on the model of scientific medicine. It helped to accelerate the closure of weak proprietary schools, raised admission and curriculum standards, and channeled philanthropic support to a select group of research-oriented medical schools.

Question 8: How did Frederick T. Gates and the Rockefeller philanthropies view the role of medicine in supporting industrial capitalism?

Gates and the Rockefeller philanthropies saw medicine as a key pillar of industrial capitalism, essential for maintaining a healthy and productive workforce, legitimizing the existing social order, and promoting American interests abroad. They believed that by investing in medical research and education, they could help to create a more stable and prosperous society while also advancing their own business interests.

Question 9: In what ways did the General Education Board (GEB) and other Rockefeller philanthropies shape the direction of medical education reform?

The GEB and other Rockefeller philanthropies shaped medical education reform by providing large grants to medical schools that agreed to adopt their preferred model of scientific medicine, which emphasized laboratory research, full-time faculty positions, and close integration with university-based science departments. They also worked to standardize medical education through the development of national accreditation bodies and licensing exams.

Question 10: How did the "full-time plan" for clinical faculty impact medical education and the medical profession?

The "full-time plan" required clinical faculty to devote themselves exclusively to teaching and research, rather than maintaining private practices. It helped to integrate clinical training more closely with basic science instruction and research, but also created tensions between academic physicians and private practitioners, who resented the loss of income and prestige associated with medical school appointments.

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DOCTORS

From our vantage point today it is difficult to believe that in the late nineteenth century the medical profession lacked power, wealth, and status. Medicine at that time was pluralistic in its theories of disease, technically ineffective in preventing or curing sickness, and divided into several warring sects. Existing professional organizations had virtually no control over the entry of new doctors into the field. Physicians as a group were merely scattered members of the lower professional stratum, earning from several hundred to several thousand dollars a year and having no special status within the population.

By the 1930s, however, medicine was firmly in the hands of an organized profession that controlled entry into the field through licensure and accreditation of medical schools and teaching hospitals. The profession also controlled the practice and economics of medicine through local medical societies. "Medicine" had come to mean the field of clinical practice by graduates of schools that followed the scientific, clinical, and research orientations laid down by the American Medical Association (AMA) and by Abraham Flexner in a famous report for the Carnegie Foundation. All other healers were being excluded from practice. Physicians were increasingly drawn only from the middle and upper classes. The median net income for nonsalaried physicians in 1929 was $3,758, above the average for college teachers but below the faculty at Yale University and below the average for mechanical engineers." Overall, doctors were rapidly rising in income, power, and status among all occupational groups.

In the 1970s physicians have continued to climb to the top rungs of America's class structure. The" median net income of office-based physicians — $63,000 in 1976 — places them in the top few percentiles of society's income structure. In 1939 the average earnings of doctors were two and a half times as great as those of other full-time workers, but by 1976 the gap had increased to five and a half times. Doctors rank with Supreme Court justices at the top of the occupational status hierarchy. And in recent public opinion polls, more Americans said they trusted the medical profession than any other American institution — including higher education, government (of course), and organized religion.

Rising "productivity" has been an important factor in physicians' efforts to raise their incomes, status, and power. The medical profession has drastically controlled the production of new physicians and has delegated to technicians and paraprofessionals below them the tasks they no longer find interesting or profitable. With rapidly expanding medical technology, more and more tasks were shifted down the line to a burgeoning health work force. At the beginning of this century two out of every three health workers were physicians. Of the more than 4.7 million health workers today, only one in twelve is a physician. Thus, doctors have increasingly become the managers of patient care rather than the direct providers of it.

As medical managers, physicians have found themselves drawn out of private practice into employment in hospitals, research, teaching, government, and other institutions. Today four in ten doctors are employed in such institutions, compared with one in ten in 1931 . These physicians have had fewer material interests in common with private practitioners and have shown little political support for the AMA.

Physicians entered a struggle to maintain their position at the top of the medical hierarchy soon after that position was won. The challenge has not, for the most part, come from below, except for recent attempts by nurses to increase their authority in patient care. Doctors have found themselves in a struggle with hospitals, insurance companies, medical schools, foundations, government health agencies, and other groups with an interest in a more rationalized health system — one in which the parts are more coordinated hierarchically and horizontally and in which more emphasis is given to capital-intensive services. The conflict has emerged between organized practitioners as one interest group, what Robert Alford calls "professional monopolizers," and all the groups seeking to systematize health care according to bureaucratic and business principles of organization, what Alford calls "corporate rationalizers.'"'

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Question 11: What role did state licensing boards play in the reform of medical education and the consolidation of professional power?

State licensing boards, often controlled by medical society representatives, played a key role in reforming medical education by setting higher standards for licensure and closing down proprietary schools that failed to meet those standards. They helped to reduce competition within the profession and to establish the dominance of scientific medicine over alternative approaches.

Question 12: How did the rise of medical specialization affect competition within the medical profession?

The rise of medical specialization initially created tensions within the profession, as specialists competed with general practitioners for patients and prestige. However, over time, specialization helped to reduce overall competition by creating a more hierarchical and differentiated structure within medicine, with specialists commanding higher fees and greater social status than primary care physicians.

Question 13: In what ways did the corporate class benefit from the development of scientific medicine?

The corporate class benefited from scientific medicine in several ways: by gaining access to a healthier and more productive workforce; by using medical science to legitimize the existing industrial order and deflect attention from the negative health impacts of working conditions; and by profiting from the sale of medical products and services, including pharmaceuticals, medical devices, and health insurance.

Question 14: How did the Rockefeller Institute for Medical Research and other research institutions contribute to the growth of medical science?

The Rockefeller Institute and other privately funded research institutions contributed to the growth of medical science by providing laboratories, equipment, and salaries for elite researchers to conduct cutting-edge investigations into the causes and treatments of disease. They helped to establish the United States as a world leader in biomedical research and to transform the culture of medical education around scientific investigation and experimentation.

Question 15: What was the significance of the conflict between private practitioners and academic physicians in shaping the direction of medical education reform?

The conflict between private practitioners and academic physicians reflected a deeper tension within the profession over the relative importance of clinical experience versus scientific research in medical training and practice. Private practitioners often resented the growing influence of academic physicians and the emphasis on laboratory science in medical education, while academics sought to establish their authority over the direction of the profession through their control of research and training.

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OTHER INTEREST GROUPS

In challenging the power of organized medicine to protect its interests, hospitals, particularly through the American Hospital Association (AHA), have tried to appear the "logical center" of any rationalized health system.' In their transformation and growth from asylums for the sick and dying poor to their twentieth-century role as the physician's workshop, hospitals developed a powerful position in modern health care as the major locus of medical technology. Because of physicians' growing reliance on technology, hospitals were absorbing an increasing share of dollars spent on medical care. Public and private health insurance (really, medical care insurance) developed as a stable source of income, enabling hospitals to expand their facilities. Collectively, hospitals have become a major force in the medical system, consuming 40 percent of the nation's annual health care expenditures. Blue Cross and Blue Shield (the "Blues"), created in the 1930s and 1940s by hospital associations and medical societies, respectively, together with commercial insurance companies now control 30 percent of medical care expenditures, mostly emphasizing hospital-based technical care. They have developed economic and political clout commensurate with their dominating fiscal role.

While the insurance industry is a new voice in the chorus of corporate rationalizers, medical schools have been in the vanguard for more than half a century. Although run by physicians — for the reproduction of health professionals and as the research and development arm of the medical industry — medical school interests have often conflicted with the interests of practitioner dominated medical societies. In the nineteenth century, medical schools were generally run by small groups of doctors for their own financial benefit. During most of the twentieth century, medical schools have been university-controlled and responsive to the interests of foundations and, since World War I, government funding sources. For the brief period from about 1900 to World War I, science-oriented medical schools and the AMA joined forces to press for the acceptance of scientific medicine. Since that time they have gone their separate ways — the AMA struggling to preserve the dominance and incomes of private practitioners, and medical schools fostering more rationalized medical care, usually with physicians as top management.

Hospitals, insurance companies, and medical schools all have a relatively greater interest than doctors in promoting capital intensive, rationalized medical care. While expanding medical technology helped doctors increase their status and incomes, it has been the raison d'etre of hospitals, medical schools, and even insurance companies. Medical technology's demands for heavy capital investment also encourage rationalization of medical resources— centralization and coordination of capital, facilities, expenditures, income, and personnel.

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Question 16: How did the American Medical Association's Council on Medical Education work to standardize and reform medical schools?

The AMA's Council on Medical Education worked to standardize and reform medical schools by conducting inspections and evaluations of existing programs, establishing minimum standards for admission and curriculum, and encouraging state licensing boards to close down schools that failed to meet those standards. It also worked to promote the model of scientific medicine and to align medical education more closely with the needs of research universities and teaching hospitals.

Question 17: In what ways did the Rockefeller philanthropies use medicine as a tool for extending American influence abroad?

By establishing medical schools, research institutions, and public health programs in countries throughout the world. They saw medicine as a way to promote American values and interests, to build good will toward the United States, and to create markets for American products and services.

Question 18: How did the Carnegie Foundation for the Advancement of Teaching contribute to the reform of medical education?

The Carnegie Foundation contributed to the reform of medical education by commissioning Abraham Flexner to conduct a comprehensive survey of American medical schools and by publishing his highly influential report in 1910. The Flexner report provided a blueprint for reforming medical education along the lines of scientific medicine and helped to channel philanthropic support to a select group of research-oriented schools.

Question 19: What role did industrial philanthropy play in shaping the development of hospitals and clinical care in the early 20th century?

Industrial philanthropy, particularly from the Rockefeller and Carnegie foundations, played a major role in shaping the development of hospitals and clinical care in the early 20th century. Philanthropic grants helped to finance the construction of new hospitals and clinics, to establish training programs for nurses and other health professionals, and to promote the integration of scientific medicine into patient care. At the same time, philanthropic support also served to legitimize the authority of medical elites and to reinforce the hierarchical structure of the healthcare system.

Question 20: How did the Committee on the Costs of Medical Care (CCMC) address issues of access and cost in the American medical system?

The CCMC, a privately funded group of physicians, economists, and public health experts, conducted a major study of the American medical system in the late 1920s and early 1930s. It documented widespread inequalities in access to care based on income and geography, and recommended a series of reforms to improve the organization and financing of medical services, including the development of group practice models, voluntary health insurance plans, and increased government support for public health programs.

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FOUNDATIONS AND THE STATE

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 [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 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.

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, Uke 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 philanthropies as 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.

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Question 21: In what ways did the rise of medical technology contribute to the growth of a "medical-industrial complex"?

The rise of medical technology, including new diagnostic and therapeutic devices, pharmaceuticals, and hospital equipment, contributed to the growth of a "medical-industrial complex" by creating profitable new markets for the sale of medical products and services. It also reinforced the cultural authority of scientific medicine and the economic power of medical elites, who controlled access to these technologies and benefited from their use.

Question 22: How did the development of health insurance, both private and public, shape the American medical care system?

The development of health insurance, both private plans like Blue Cross and Blue Shield and public programs like Medicare and Medicaid, played a major role in shaping the American medical care system in the mid-20th century. Insurance helped to finance the expansion of hospitals and medical technologies, while also increasing access to care for many Americans. However, it also contributed to rising costs and reinforced the fee-for-service payment model that incentivized the overuse of medical services.

Question 23: What role did the state play in the rationalization of medical care in the United States?

The state played an increasingly important role in the rationalization of medical care in the United States throughout the 20th century, particularly after World War II. Federal and state governments provided funding for hospital construction, medical research, and public health programs, while also establishing regulatory agencies to oversee the safety and efficacy of drugs and medical devices. However, the state largely avoided direct involvement in the financing or delivery of medical services, leaving those functions to the private sector.

Question 24: How did the development of capital-intensive medical technologies affect the organization and cost of medical care?

The development of capital-intensive medical technologies, such as advanced imaging devices and surgical robots, had a major impact on the organization and cost of medical care in the late 20th century. These technologies required significant investments in equipment, facilities, and specialized personnel, leading to the consolidation of medical services in large hospitals and academic medical centers. They also drove up the cost of care, as providers sought to recoup their investments through higher fees and increased utilization.

Question 25: In what ways did the growing influence of corporate and philanthropic interests in medicine conflict with the autonomy of the medical profession?

The growing influence of corporate and philanthropic interests in medicine, particularly in the areas of medical research and education, created tensions with the autonomy and authority of the medical profession. Some physicians feared that outside funders would dictate the direction of medical science and practice, while others welcomed the resources and prestige that came with corporate and philanthropic support. These tensions reflected a broader struggle over the control and purpose of medicine in an increasingly complex and commercialized healthcare system.

Question 26: How did the American medical care system come to be organized around private, market-based principles rather than as a public service?

The American medical care system came to be organized around private, market-based principles rather than as a public service for several reasons. These included the early development of a fee-for-service payment model that rewarded entrepreneurial physicians, the lack of a strong labor movement or socialist tradition in the United States, and the opposition of organized medicine to government involvement in healthcare. The dominance of private insurance plans and the limited nature of public programs like Medicare and Medicaid also reinforced the market orientation of American medicine.

Question 27: What factors contributed to the growing dominance of specialist physicians over primary care providers in the 20th century?

Several factors contributed to the growing dominance of specialist physicians over primary care providers in the 20th century, including the increasing complexity and technological sophistication of medical science, the financial incentives for specialization created by fee-for-service payment models, and the cultural prestige associated with advanced training and expertise. The emphasis on specialty care in medical education and the growth of referral networks among physicians also worked to marginalize primary care.

Question 28: How did the distribution of medical services and resources reflect broader social and economic inequalities in American society?

The distribution of medical services and resources in the United States reflected and reinforced broader social and economic inequalities, particularly those based on race, class, and geography. Poor and minority communities often lacked access to high-quality medical care, while wealthy and predominantly white areas enjoyed a disproportionate share of healthcare resources. The concentration of medical facilities and personnel in urban centers also left many rural areas underserved.

Question 29: In what ways did the American medical profession resist efforts to establish a national health insurance program in the 20th century?

The American medical profession, led by the American Medical Association (AMA), strongly resisted efforts to establish a national health insurance program throughout much of the 20th century. The AMA used its political influence and financial resources to oppose legislation that would have expanded government involvement in healthcare, arguing that such programs would lead to "socialized medicine" and undermine the autonomy of physicians. Instead, the AMA supported the growth of private insurance plans and worked to limit the scope of public programs like Medicare and Medicaid.

Question 30: How did the Gates and Rockefeller philanthropies' approach to medical education reform differ from that of the Carnegie Foundation?

The Gates and Rockefeller philanthropies took a more hands-on approach to medical education reform than the Carnegie Foundation, using their financial leverage to encourage schools to adopt specific policies and practices. For example, the Rockefeller-funded General Education Board required schools to adopt a strict full-time system for clinical faculty as a condition of receiving grants, while the Carnegie Foundation focused more on conducting studies and making recommendations for reform. The Rockefeller philanthropies also tended to have a more explicit focus on aligning medical education with the needs of industrial capitalism and American foreign policy interests.

Question 31: What role did the Flexner report play in consolidating the dominance of allopathic medicine over alternative medical sects?

The Flexner report played a significant role in consolidating the dominance of allopathic medicine over alternative medical sects by establishing a new set of standards for medical education based on the principles of scientific medicine. The report was highly critical of many proprietary and sectarian schools, arguing that they lacked the necessary facilities, faculty, and research capabilities to train effective physicians. Its recommendations helped to accelerate the closure of these schools and the marginalization of alternative medical approaches, while channeling philanthropic support to a select group of allopathic institutions.

Question 32: How did the "medicalization" of social problems serve to legitimize industrial capitalism and deflect attention from structural inequalities?

The "medicalization" of social problems, or the tendency to define and treat issues like poverty, crime, and unemployment as medical conditions rather than as products of social and economic inequalities, served to legitimize industrial capitalism in several ways. By locating the causes of social problems within individuals rather than in the structure of society, medicalization deflected attention from the systemic inequities and exploitative practices of capitalism. It also reinforced the idea that social ills could be solved through technical interventions rather than political or economic change, and that the appropriate experts to address these problems were physicians and other medical professionals rather than social reformers or activists.

Question 33: In what ways did the critique of scientific medicine and the "medical-industrial complex" challenge the dominant model of American health care?

The critique of scientific medicine and the "medical-industrial complex," which emerged in the 1960s and 1970s, challenged the dominant model of American health care in several ways. Critics argued that the narrow focus on biological mechanisms and technological interventions neglected the social, economic, and environmental determinants of health, and that the profit-driven nature of the medical system led to the overuse of expensive and often unnecessary treatments. They called for a greater emphasis on preventive care, community-based services, and patient empowerment, as well as for more public control over the allocation of healthcare resources. While these critiques did not fundamentally transform the American medical system, they did contribute to the development of alternative models of care and to a greater recognition of the limitations of the biomedical approach.

CONCLUSION

American society is faced with a health system that is at once expensive and incapable of serving the important health needs of the population. Despite many decades of efforts to make medicine more effective and improve its accessibility, the system seems to remain impervious to fundamental change. The reform efforts, however, are themselves fundamentally flawed.

From the early Rockefeller medical philanthropies to the opening of the federal treasury to the health sector, the major strategy for making medicine more effective has been biomedical research and the development of technological medicine. Technical advances have been very great, but the results have not been distributed equitably, coordinated rationally with needed primary care, or matched with support for improvements in the physical and social environments. Technique has also increasingly replaced personal caring and emotional support in doctor-patient relationships. As we have seen, these emphases have had only a limited positive impact on the health of the population. The persistence of such narrowly technical approaches is due to their usefulness to powerful classes and interest groups. For members of the corporate class, technological medicine has legitimized their economic and political dominance by diverting attention from the consequences of their control — that is, from such "social costs" as class inequalities, domination based on race or sex, occupational hazards, and environmental degradation. For the medical profession, the knowledge generated by medical science and the techniques of medical technology provided the basis for physicians' claims to a monopoly of authority over the practice of medicine. Over the last few decades medical technology has been the foundation of a whole new industry, an interest group that directly profits from the emphasis on technical approaches to health problems. Technological medicine has benefited all these groups, and they have, in turn, supported its expansion.

The Rockefeller philanthropies also began the long process of rationalizing medical care. This campaign has been joined by groups in and outside the health sector and has been increasingly supported by the State over the last several decades. The political power of the medical profession was strong enough to block early efforts at subordinating all elements of the system into a hierarchy of organizational authority. So pieces of the rationalizing strategy were implemented where there was least resistance. Voluntary health insurance programs — private and later public ones — were developed mainly around hospital care, financing the expansion of high technology medicine with the hospital at its center. The rationalizing of the private medical market helped the growth of the capital-intensive medical commodity sector, which has a major stake in technological medicine. The private control of this market, the emphasis on medical technology, and the socializing of costs by third-party payers combined to make expenditures soar, compounding government fiscal problems and draining ever-increasing amounts of money from the economy.

Medicine's upper-class reformers, from Gates and his foundation colleagues to present-day officials of the State, have been unwilling to oppose the private market in its entirety, producing a profound contradiction in their struggles to rationalize medicine. They favored the development of the private market with legislative and financial support in lieu of nationalizing medical care. The present crisis is a result of this political-economic process. It was an inevitable outcome only in that those who shaped the system believed in, or at least accepted, the needs and constraints of capitalist economic and social relations. If Gates and subsequent foundation and government leaders in the field of medicine had been committed to making health care serve the needs of the majority population rather than the needs of capitalism and the interests of the corporate class, a different course would have been followed. Even today a comprehensive, centrally planned nationalized health service could effectively control cost and provide equal care for the whole population. Health care could be more effective in improving health if its research and action were directed at environmental conditions in about the same proportion that those conditions contribute to sickness and death.

But health policy makers cannot be counted on to make these fundamental changes. As members of the corporate class or identified with its interests, they believe, to paraphrase Charles Wilson's audacious aphorism, "what's good for business is good for America." Furthermore, the capitalist sector of medicine has grown rich and powerful, bringing the economic and political influence of insurance companies, banks, and industrial corporations into active support for retaining the private medical market. National health insurance is supported because it will further socialize the costs of medicine, but nationalizing medicine in a national health service is unacceptable to the powerful private market forces and therefore is ignored by health policy makers. Instead of overhauling the medical system, they put the burden of controlling costs on people who have been afflicted with disease by restricting their access to services and demanding that they improve their health by changing their behavior.

However, even a national health service would not necessarily end medicine's role of legitimizing corporate capitalist society. It would, if anything, enable these ideological functions to compete less with the needs of the marketplace. Without the access problems that remain in the present market system, the "healing ministration," as Gates called medicine, could bring individual-focused, technical perspectives and methods to the health problems of the entire population.

Health care, potentially, has a great deal to offer. We rightfully expect it to prevent sickness, diagnose our ills, relieve our pains, and, when we are sick, return us to at least our usual level of functioning. If it were not distorted by its character as a commodity and by the ideological functions demanded of it, health care might well be developed as we wish it would. It is possible to make a health care system that effectively serves the health needs of the majority classes rather than the economic and political interests of its providers and the upper classes. It is doubtful, however, that such a health care system can be realized in a capitalist society, committed as it must be to maintaining the primacy of capital accumulation. Nevertheless, the struggle for that new health system may contribute to the larger struggle for a new, more just economic and social order.

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