American patronage and French Medicine : from the Rockefeller philanthropy to Inserm
Jean-François Picard (I.R. CNRS)
Talk given at the John Shaw Billings Society for the History of Medicine, UIPUI (sept. 1995)
Two convergent trends have defined medicine at the end of the twentieth century: clinical practice and biology. This convergence has only partly been the result of scientific logic (such as the convergence of biology and chemistry which produced molecular biology). It has also been the result of concerted efforts to unify the work of doctors and biologists. Among other things, it has required overcoming the reticence of doctors who resisted the condescendence of biologists who questioned their scientific competence.This convergence occurred first in Germany, then in the United States, in this country thanks in large measure to the work of foundations supporting scientific research. In France, the meeting of medicine and biology owed much to the Rockefeller Foundation. There were, in fact, two decisive interventions by the Rockefeller Foundation into the organization of French medicine: first, the creation of a public health administration during the First World War beginning with a campaign against tuberculosis; the second in the 1940's which saw the creation of modern biomedical research based on molecular biology.
1.Was the French Medicine Backwards?
France has held an important place in the history of medicine. For example, at the beginning of the nineteenth century, French doctors created the modern clinic with patient care in the hospital bed. Another invention in the first half of the 19th century by a French doctor, the stethoscope, permitted great advances in diagnosis. Later in the century Claude Bernard a doctor in a Paris hospital, discovered the connection between human physiology and therapy, amd also introduced the concept of experimental medicine. Shortly thereafter, a French chemist, Louis Pasteur, coined the term "microbe" to describe the microscopic organisms responsible for many of the diseases that had plagued humankind since time immemorial. In fact, Pasteur has a legitimate claim as one of the handful of architects of modern laboratory medicine, including two of its most effective treatments: antisepsis and vaccination. Despite these major innovators, one could argue that the general practitioners of French medicine were late in following these discoveries that were making medicine more scientific. Take as an example, microbiology. Even though during the last 20 years of the 19th century, this new field was at the base of the creation of the Pasteur Institute in Paris (1888), there was no instruction of microbiology at the Medical School of Paris until the First World War. During this time these same doctors also passed resolutions against the obligatory declaration of contagious diseases such as tuberculosis, in the name of confidentiality. And opponents of obligatory vaccination against diphtheria used as an argument that the discoverer of the vaccine, Gaston Ramon at he Pasteur Institute, was a veterinarian by training. (Ramon memo 14 fev. 1939; Doss. Ramon, Acad. des Sci.). The reasons for the decline of French medicine are multiple and complex. Among them are the desire to retain a humanistic view of medicine. Thus, as late as 1954, one French doctor argued in a journal devoted to the reform of medical studies. It is important not to confuse the science of medicine with the art of medicine....One should not be substituted for the other.... Biology may reign absolute from now on, (but) is it necessary for our French medicine to lose its character of individual, humanistically inspired medicine; that it cease not to be a close interchange between a patient and his doctor... In order not to be mistaken, science should never confuse the principle of physical integrity with the sacred integrity of the human being. (G. Dreyfus, "Le point de vue du clinicien," La Nef, 1954/2.)
2.The introduction of scientific medicine in America
It is a well known story that I will only summarize for comparison to what happened in France. Johns Hopkins Medical School was the first institution to establish full-time clinical teaching, with special attention to research. The two persons largely credited with the innovation were William Osler and William Welch, a British and an American physicians, both of them trained in Germany. (German training was not unusual for Americans at the end of the 19th and beginning of the twentieth century. According to Rosemary Stevens, over 15,000 Americans studied medicine in Germany between 1870 and 1914.) The organizing principles of scientific medicine are simple (in theory). They consist in uniting under one roof:
1) Treatment (care of patients)
2) Training of doctors (bedside teaching)
3) Laboratories for clinical and basic research
These were, in fact, the principle conclusions of the famous report from the Carnegie Foundation, by Abraham Flexner in 1910, on medical instruction in Europe and North America.
The most remarkable thing about the American response to the report is that contrary to Europe, where it was the individual universities and public authorities who responded. Private foundations took the initiative of reforming the American medical teaching system. Flexner's elder brother Simon, had the charge of the newly created Rockefeller Institute for Medical Research in New York which followed the treatment-research model. The Rockefeller Foundation was also interested in public health, another crucial problem of medicine at the turn of the century. In 1909 a Sanitary Commission of the Rockefeller Institute was created for an initial project to eradicate hookworm disease (commonly called then "the germ of laziness"). This parasitic disease afflicted the southern U.S., and the director of the project was Wickliffe Rose who later became head of the General Education Board at the Rockefeller Foundation. (4) This one was created in 1911 as an organization which would become one of the principle proponents of scientific medicine, not just in the United States, but also throughout the world.
3. Organizing public health in France (1917-1930)
It did not take long for the impact to be felt outside the U.S., thanks to the outbreak of the world war. In France, for example, the mobilization for the war revealed the deporable health conditions of recruits. Ten per cent of all deaths in France were from tuberculosis, compared to 8% in Germany and 7% in Great Britain. When the United States entered the war in 1917, the Rockefeller Foundation decided to launch a program of preventative medicine in France, in part for the selfish reason of protecting American soldiers who would soon be arriving in France from the ravages of venereal disease and tuberculosis, but also to help the French themselves to organize an effective civilian public health administration. The Americans were careful not to ruffle the feathers of the proud French cock. As Wickliffe Rose wrote to the Medical Advisory Council, "It is not necessary to import scientific knowledge to the country of Pasteur, but rather to demonstrate the virtues of an efficient sanitary organization." (Rose to Medical Advisory Committee of War Council, Sept. 1917). Proof that this was a long-term commitment by the Rockefeller foundation comes from the fact that the emergency war-time relief program was converted into a National Committee for Defence against Tuberculosis in 1919, with substantial funding from the American foundation. Moreover, the program was modeled on the hookworm campaign in the U.S., with a triple objective of:
1) Anti-tuberculosis prevention propaganda
2) Screening (with protocols established in two provincial departments of France and one Parisian district)
3) Creation of a training program for visiting nurses and public health doctors.
(The impact of the program were far-reaching. For example, Jacques Parisot, who became Dean of the Medical School of Nancy and eventually the President of the National Institute of Hygiene in 1956, began his career as a doctor in the Rockefeller tuberculosis mission in 1920). In 1924 the Director of the Rockefeller International Health Board in Paris, Selskar M. Gunn (a public health official from Massachsusetts), met the French Minister of Labor and Health Justin Godart. They two men agreed to create alongside the tuberculosis organization, a National Office of Social Hygiene, a French government agency directly inspired by the Rockefeller Foundation. One measure of the influence of the Foundation in the creation this French public health administration is the fact that 3/4 of the budget of this governmental agency came from the Americans.(6) (The International Public Health Board spent over 2.5 million dollars in the five years of the tuberculosis campaign, which was 1/4 of its total budget). Thus, the Rockefeller Foundation did more than simply give a jump start to this program -- its normal practice -- it created a whole organization, which prompts the question of its ultimate effect. But the National Social Hygiene Office did not last more than a decade, thanks to budget cuts prompted by the Depression. It was revived, however, in 1941 during the Vichy regime under the name of National Institute of Hygiene.
4. The Great Transformation of Medicine - from Public Health to Molecular Biology - is also one of the result of a scientific policy conducted by the Rockefeller Foundation
In 1932 the mathematician Warren Weaver was named head of the Natural Sciences division which represented a major change in the history of the Rockefeller Foundation. In effect, Weaver's goal was
1/ Drive the Rockefeller Foundation to the endowment of more basic research
2/ To place physics and chemistry in the service of a new biology, because these sciences offered the means to a new understanding of the mechanisms of life. Even if the applications to medicine still seemed remote, the underlying idea of the Rockefeller project, as with other scientific institutes in the world, was cancer research. In fact, it was the beginning of a new science : cell (later molecular) biology. (7)
The way in which Weaver proceeded was instructive of modern science policy. While continuing to offer support for young researchers ( the traditional Rockefeller fellowships), he began to support programs of research in the new biology, for exemple by allowing American and foreign laboratories to purchase new types of equipment (spectrophotometers, ultracentrifuges, etc.). In Paris, the Rockefeller Foundation lent its support to the Institute of Physico-chemical Biology, an organization created in 1928 by the physiologist Andre Mayer, thanks to the support of Baron Edmond de Rothschild. Based on the Rockefeller model, the French institute offered fellowships to researchers from different disciplines and it created laboratories to study living organisms at the molecular level. The idea of the philanthropist Baron de Rothschild (who liked to cite Claude Bernard) was to combat major diseases such as cancer. In 1945 Rapkine (a former Rockefeller fellow in the parisian IBPC) who had spent the war in the United States where he had increasing contact with the Rockefeller, convinced the Foundation to resume its research support in France. This time, however, the Americans were asked to support a new public organization which the French had established just before the war: the National Center for Scientific Research (CNRS, in French). Working directly with a foreign government agency, however, raised some difficulties, as the President of the Rockefeller Foundation, Raymond Fosdick noted. General support of the CNRS contradicted the foundation's policy of selecting the fields and researchers to support. But Weaver was a supporter of the French research and obtained $250,000 for operating expenses which, in fact, were mainly used to publicize the findings of the new biology. It has been argued that the Rockefeller policy of supporting the CNRS served more to help already established scientists and the question is how the foundation modernized French medical research?
5.Modernization of French Medicine (after 1945)
In the aftermath of the Second World War in France, the main question asked about medical research was - as it has been posed in the US half a century earlier - who should direct it: biologists or doctors? The general answer is that the latter were displaced by the biological researchers who were greatly alarmed at the technical backwardness of French medicine. Thus, André Lwoff of the Pasteur Institute (Who will be Nobel prize awarded for his research on genetics) wrote in a note to the CNRS at the time, "For obvious reasons it should make no sense to consider the scientific study of the agents of human infectious diseases as a branch of medicine.... [In France] the fact that microbiology is not taught in schools of science but rather in medical schools by professors who are not specialists, has resulted in a very serious crisis for microbiology. (Lwoff, note dec. 1944, CNRS 80284). Briefly, according to those at the Pasteur Institute, medical research (some will soon call it biomedicine) was too complicated to be left in the hands of doctors; while for the same reasons they hesitated to integrate medical research into the scientific programs of the CNRS. Those at the Pasteur Institute did not hesitate to point out that their organization was run by researchers who were not doctors, beginning with Pasteur himself, but also in 1945 the director was the biochemist Jacques Trefouel, one of the discoverers of sulfamide. In the end, the first French medical organization to take up this new research challenge was the National Hygiene Institute which had been created during the war. In 1946 a new director was named: Louis Bugnard, a doctor and graduate of the Ecole Polytechnique, but also a former Rockefeller fellow and a specialist in medical physics (encephalography, radio-therapy). Bugnard was determined to encourage the practice of scientific medicine. He therefore wrote Alan Gregg, responsible of the division of medicine in the Rockefeller Foundation, "The INH which has begun to support certain laboratories is now also in charge of organizing medical research in France. I hope to obtain from the French government a budget which will allow a good start" and Bugnard added a request more in keeping with the Rockefeller tradition, "Could the Foundation also support fellowships for French [practicioners] I would like to send to the United States?" (Bugnard to Dr. Allan Gregg, 28 Aug. 1946, Papiers Bugnard). Thanks to American support, an Allis-Chalmers Betatron was installed at the cancer research center of Villejuif in Paris in 1948, close to one of the first clinical lab installed in a French hospital. But above all, the fellowships allowed French young doctors (Alexandre Minkowski, Maurice Tubiana, and many others) to complete their training at the medical schools of the large East Coast American universities, from which they returned with new techniques for treatment in cancer and obstetrics/gynecology. In truth, one can say that a new generation of French practitioners was trained to scientific medicine in American methods. In the mid 1960's, the National Hygiene Institute begin supporting biomedical research in addition to public health work, an evolution which culminated in 1964 with its transformation into the National Institute for Health and Medical Research. The INSERM of today counts more a hundred laboratories, mainly in public hospitals, covering all disciplines from classic clinical research to medical genetics, even including social sciences applied to medicine.
6. Does Modernization means Americanization in French Medicine?
In reality , and despite some concerns, the two phenomenon (modernization and Americanization) seem linked. Thus, the pediatrician Robert Debre, one of the main architects of this modernization, was undoubtedly an ardent patriot who regretted to see certain of his students go permanently to America, such as the cardiologist Andre Cournand who received the Nobel Prize in 1956 (10); but he knew well enough that American methods were the best that he introduced them into France. When the reform of the hospital system occured in France in 1958, Debre did not hide the fact that the new Centres Hospitaliers Universitaires (CHU) were directly inspired by the famous Abraham Flexner Report. So the Final question is : why did French Medicine wait 50 years before Modernization on the American Model? It seems to me that one answer is tied to the historical relationship between medicine and politics in France. The fact is that French physicians were (and still are) more active in politics than their American counterparts. Their presence in significant numbers in the National Assembly and ministerial cabinets seems first to be linked to a strong sense of their role as social agents. Second is their desire to defend the so-called "liberal" practice of their art and profession.(12) This explains the creation of the "Ordre national des medecins" (the French Medical Association) during the Vichy period, and the decision to support quotas on Jewish doctors. Before the Second World War it is difficult to find a physician such as Robert Debre who wished to use political influence for the modernization of medicine. Doctors were more concerned with their political careers than a science policy.
(1) M. Foucault, Naissance de la clinique, Paris Gallimard 1976
(2) in Picard in Sciences Sociales et Sante, "Contributions a l'histoire de la recherche medicale en France au XXe siecle". 10. 4. 1992
(3) in Fisher, Donald, "The Rockefeller Foundation and the Development of Scientific Medicine in Great Britain," Minerva, 16. 1978
(4) Brown, E.Richard "Public Health in Imperialism : Early Rockefeller Programs at Home and Abroad" American Journal of Public Health. 66. 9. 1976
(5) in Murard, Lion et Zylberman, Patrick, La mission Rockefeller en France et la creation du comite national de defense contre la tuberculose (1917-23). Revue d'histoire moderne et contemporaine, 34. 1987
(6) Schneider, William H., Quality and Quantity. The Quest for Biological Regeneration in Twentieth Century France, Cambridge University Press. 1990
(7) Kohler, Robert E., Partners in Science: Foundations and Natural Scientists. Chicago University Press, 1991
(8) Abir-Am, Pnina, "the Discours of Physical Power and Biological Knowledge in the 1930s : A Reappraisal of the Rockefeller Foundation's 'Policy' in Molecular Biology, Social Studies of Science, 12, 1982
(9) Burian R., Gayon J., Zallen D.T., "The singular Fate of Genetics in the History of French Biology, 1900-1940", Journal of the History of Biology, 21, 1988. Morange M., Histoire de la biologie moleculaire, Paris, La Decouverte, 1994
(10) Zallen, Doris T., "Louis Rapkine and the Restoration of French Science after the Second World War", French Historical Studies, 17. 1. 1991
(11) Debre, Robert, L'honneur de vivre, temoignage. Paris, Hermann, 1974