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.The Role of TrainingBy the early 1920s, the IHB was running hookworm, yellow fever, and malariacampaigns throughout Latin America and the Caribbean and in the Far East,and expanding its research and application capacities in several other areas.Closely linked to these public health campaigns was the RF s role in graduatepublic health education, a realm of training which the RF itself had essentiallyfounded.The lessons of the Sanitary Commission had been clear: there existedno pool of health officials prepared to garrison the front lines of public healthin the South of the United States.Rose had found that most local health officerswere untrained, part-time political appointees who were primarily concernedwith curative medical care.He concluded that for the IHB to operate success-fully, it needed to create a new profession of public health with institutions thatwere independent from those of clinical medicine.In the 1910s, the RF had begun funding the modernization of medical trainingin the United States, acting on the findings of the 1910 Flexner Report. Southerneducator Abraham Flexner (brother of Rockefeller Institute scientist Simon), in areport written for the Carnegie Foundation for the Advancement of Teaching, hadcalled for a transformation of medicine following the principles of a full-time,research-oriented faculty, close ties to a university and hospital, adequate labora-tory facilities, and a scientifically prepared student body.57 The RF offered gener-ous grants to so-called A-schools, such as Harvard and Johns Hopkins, to adapt tothese principles, leaving many other medical schools to wither.In late 1913, Abraham Flexner, who served as secretary of the RF s GeneralEducation Board, was asked to head an RF committee on public health educa-tion.After several years of debate and discussion among Flexner, Rose, and ahandful of other leaders in the fields of sanitation, preventive medicine, andphilanthropy, including Dr.William Welch, dean of Johns Hopkins MedicalSchool and an IHB trustee, in 1916 the RF chose to back the Johns HopkinsUniversity as the site of the first school of public health in the U.S.RF donationsenabled the founding of similar schools at Harvard in 1922 and the Universityof Toronto in 1925 (opened in 1927).These three schools trained the vastmajority of IHB/D officers as well as hundreds of Latin American public healthand nursing fellows whom the RF sponsored over the decades.Despite Rose s intention to separate and elevate the status of public health, itsrole relative to medicine remained ambiguous, and the organization of both theRF and the new schools of public health reflected these tensions.The flagshipJohns Hopkins School of Hygiene and Public Health like the schools that fol-lowed emphasized medically-oriented research rather than combining theg' 30 a match made i n heaven?g'social and medical sciences; early on, more practice-based units in areas such ashealth education, epidemiology and public health administration were far out-numbered by laboratory-oriented pathology and physiology departments whichemphasized disciplines such as helminthology, parasitology, bacteriology, andchemical hygiene.This organization along medical science specialties seemed tosuggest that public health was subsidiary to medicine.58The relationship between medicine and public health was ill-defined in boththe RF s New York office and in the field.The IHB/D relied on the existence of trained medical men in the countries where it operated, yet it was organ-izationally separate from the RF s Division of Medical Education until 1951 whenthe two entities were merged into the Division of Medicine and Public Health.59As evidenced in Latin America, field officers often complained about the dearthof well-trained medical graduates, but the IHB/D sought to distance itself frommedical education concerns, concentrating instead on those competent gradu-ates eligible for its own fellowships.60 Still, at least some RF leaders held thatreceptivity to public health measures might be stabilized through improve-ments in medical education in Latin America.61Beginning with RF officer Richard Pearce s survey of Brazilian medicalschools in 1916, visiting RF experts made periodic assessments of medical edu-cation in a variety of Latin American countries.62 Although officers Pearce, AlanGregg, and their colleagues wrote detailed accounts of their visits critiquingheavy reliance on clinicians as medical school faculty members, overcrowdedclassrooms, excessive French influence, and an insufficient role for experimen-tal research the RF s involvement in Latin American medical educationremained circumscribed until after World War II.The only Latin American med-ical school that the RF deemed worthy of assistance before this time was SãoPaulo s.Because São Paulo was, according to RF President Raymond Fosdick(1936 48), progressive, likely to maintain improvements, and blessed withable leadership, it received a grant of nearly $1 million ($5.3 million in 2004dollars) in the 1920s to carry out Flexnerian reforms.63The RF s limited engagement was justified ex post facto by RF officer RobertLambert s 1943 assessment that Latin Americans were already universally accepting of Western medicine and needed only to improve their medicalschools quality of teaching, facilities, and institutional affiliations.There was noneed to eliminate proprietary, diploma mill medical schools because thesewere virtually nonexistent in Latin America.64 Lambert was implicitly comparingthe situation in Latin America to China, where the RF invested $45 million (wellover $600 million in 2004 dollars) in the Peking Union Medical Collegebetween 1915 and 1949 to introduce Western medicine to a pre-scientific country.65 Though no other institution in the world reached the same level ofsupport, many North American, European, South Pacific, and Southeast Asianmedical schools received RF funding while most Latin American schools wereneglected. a match made i n heaven? 31Lambert s line of reasoning might have led the RF to invest in Latin Americanschools of public health instead of medical schools, but it supported only onesuch effort (although it did provide support to schools of nursing in Venezuelaand Brazil).66 Of the twenty-one schools of public health the RF sponsored out-side North America, almost all were in central and western Europe (includingthe London School of Hygiene and Tropical Medicine, which trained healthprofessionals from throughout the British Empire),67 with São Paulo againselected as the lone Latin American site.68 Marcos Cueto has argued that Brazilwas selected over the more scientifically advanced Argentina because the RFpreferred a country where there were fewer obstacles to the implementation ofpublic health measures and where government institutions and medical eliteswould be most receptive.69 RF officials also hoped that strengthened medicaland public health schools in some Latin American countries would serve as mag-nets for students from neighboring countries; however, it soon became apparentthat most students pursuing advanced training chose to go to the United States(where fellowships were available) rather than to neighboring countries.70But the RF did not ignore Latin American public health training: it orientedits investment to individuals rather than to institutions
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