The report of Dr. George E. Vincent, President of the Rockefeller Foundation, for the year 1921 gives a detailed account of what is surely the most outstanding achievement of any one organization in the history of medicine. The map of the world-wide activities of the Rockefeller Foundation which appears at the beginning of the report shows that there is hardly a country, with the exception of northern Asia and Africa, where the name of Rockefeller is not known.

During the year 1921 the Rockefeller Foundation continued a quarter-million dollars annual appropriation to the School of Hygiene and Public Health of Johns Hopkins University, pledged two million dollars to Harvard for a school of health, contributed to public health training in Czechoslovakia, Brazil and the United States, aided the Pasteur Institute of Paris to recruit and train personnel, promoted the cause of nurse training in America and Europe, underwrote an experimental pay clinic in the Cornell Medical School, formally opened a complete modern medical school and hospital in Peking, assisted twenty-five other medical centres in China, promised a million dollars for the medical school of Columbia University, contracted to appropriate three and one half million dollars for the rebuilding and reorganization of the medical school and hospital of the Free University of Brussels, made surveys of medical schools in Japan, China, the Philippines, Indo-China, Straits Settlements, Siam, India, Syria, and Turkey, supplied American and British medical journals to 112 medical libraries on the continent, supplemented the laboratory equipment and supplies

of five medical schools in Central Europe, defrayed the expenses of commissions from Great Britain, Belgium, Serbia and Brazil, provided 157 fellowships in hygiene, medicine, physics and chemistry, to representatives of eighteen countries, continued a campaign against yellow fever in Mexico, Central and South America, prosecuted demonstrations in the control of malaria in ten states, co-operated in hookworm work in nineteen govermental areas, participated in rural health demonstrations in seventy-seven American countries and in Brazil, neared the goal of transferring to French agencies an anti-tuberculosis organization in France, provided experts in medical education and public health for counsel and surveys in many parts of the world, and rendered sundry minor services to governments and voluntary societies. These were done in part by the Foundation directly, but chiefly through its departmental agencies the International Health Board, the China Medical Board, and the Division of Medical Education.

a

TELESCOPE AND MICROSCOPE.

« Cure looks through the microscope, prevention through the telescope », is the saying of a successful American health officer. There has been and still is marked difference between the average physician's point of view and that of the medical officer of health. The former deals with disease which has manifested itself; the latter seeks to foresee and to forestall its occurrence. The one thinks of the individual patient, the other of the community as a whole.

But the leaders of the medical profession have not taken the myopic view. As a matter of fact they have been the very prophets and promoters of preventive medicine. The men who have done most to introduce the telescope have, with certain notable exceptions, been trained primarily to concentrate upon the microscope. With them cure and prevention have been not sharply contrasted but closely related ideas. They have increasingly regarded experience with disease in individuals as a means of protecting the community against it.

The progress of public health depends upon the appreciation, sympathy and support of the medical profession, Doctors will gradually come to think of themselves and to be regarded by the public as primarily resoponsible for keeping people well. Periodic physical examinations, the early discovery of incipient maladies, warnings against environmental dangers, the wise control of diet, insistence on appropriate exercise, suggestions about personal and social life, will in increasing measure replace medicines, hospitals and sanatoria, and may even reduce the demand for surgical service. Who knows but that the doctor of the future, receiving an annual retaining fee from his clients, will feel no embarrassment in taking the initiative and in keeping a watchful eye upon them? Then a case of illness would be not the physician's opportunity but reflection upon his vigilance.

PROGRESS IN PREVENTION

a

Jenner's discovery of vaccination for smallpox, Pasteur's researches in the causation of various diseases by bacteria and microbes, the use of vaccines and sera, Lister's introduction of antiseptic surgery, are striking illustrations of the scientific knowledge of the origin, spread and prevention of certain maladies which has been made available since the end of the eighteenth century, and especially during the last fifty years.

The presence of smallpox is now a disgrace to any civilized community or country; cholera and plague have disappeared from the leading nations ; typhoid fever has been enormously reduced; mala

ria and hookworm disease are giving ground; yellow fever is being narrowly restricted; typhus is practically unknown among a cleanly people; the fear of diphtheria has been largely allayed. But it is too early to feel complacent. Only a beginning has been made. Many diseases still baffle the health authorities.

Stages in the progress of preventive medicine are distinguisable. First comes control of physical environment through pure water, milk, and food supplies, adequate sewerage and refuse disposal systems, improved housing, heating and ventilation. Then follows control of diseases other than those whose causes are water and food borne. Various forms of occupational hazards and maladies are also attacked. Concern for the welfare of mother and child is a prominent feature at this stage. The third stage emphasizes the vital part which personal hygiene plays. It is roughly estimated that 80 per cent of the maladies which produce the total death rate cannot be directly controlled by the sanitarian. He must persuade individuals to conform to the laws of health and to report promptly the first sign that anything is amiss.

A fourth phase just beginning to emerge has to do with economic, social and mental influences. Income, standard of living, opportunities for social intercourse and recreation, all have important relations to individual and community health. Mental hygiene, which is coming to be recognized as a part of public health, deals with problems of defects and delinquency in children and criminality in adults, with nervous and mental disorders, with the classification, treatment and custodial care of the feeble-minded and insane and related questions. To the support of the work of the National Committee for Mental Hygiene the Rockefeller Foundation contributed during 1921, $ 86,370,57.

CHANGING IDEALS OF HEALTH.

Advances in the cure and prevention of disease reflect a shifting of emphasis and a gradual revision of the idea of health itself. There is a tendency

The future of preventive medicine depends upon drawing first-class men and women into the profession and giving them efficient, modern, specialized training and supervised practical experience.

The International Health Board of the Rockefeller Foundation realized early in its history that a chief problem in disease prevention would be to find men qualified both scientifically and practically to do the work. An ordinary medical school education is not enough. There must be special training in the scientific principles, the administrative methods, and the point of view of preventive medicine and public health. So the Board decided to establish a school of health under the auspices of a university, but at the same time a separate institution with its own buildings and equipment, its own teaching staff, its own professional aims and its own esprit de corps. In 1918 the new School of Hygiene and Public Health of Johns Hopkins University opened its doors, the Rockefeller Foundation having supplied the sum neccessary for building, equipment and annual maintenance. Courses of study leading to the degrees of Doctor of Public Health, Doctor of Science in Hygiene, Bachelor of Science in Hygiene, and to the certificate in Public Health were offered. For the academic year 1920-1921 the faculty numbered forty and 122 students were registered. The investigative work of the School has covered a wide range of problems, and the American Journal of Hygiene is published under its auspices.

In addition, the Rockefeller Foundation appropriated $1,660,000 towards the work of transforming the course in public health at Harvard Medical School into a separate school of health, with its own headquarters and teaching staff. This division of the Harvard Medical School has already done important work in the field of industrial hygiene and the Journal of Industrial Hygiene is published under its auspices.

The Foundation also contributed $35,000 towards an extension of the buildings of New York University, a large part of which is to be used by

The Pasteur Institute in. Paris, as a result of the war, was seriously threatened not only with curtailment of its activities but with a lack of new workers who should receive training, engage in research and thus be prepared gradually to assume responsibility for the future of this world-famous centre and its several branches. To supply fellowships for a transition period and to help defray the costs of training assistants, the Foundation gave $30,000 in 1921 and pledged other sums on a diminishing scale for the next two years.

In Czecho-Slovakia the Foundation has promised to supply $378,000 towards the erection of an institute of public health. For two years the International Health Board has had a resident representative in Prague and has provided fellowships for health training in the United States.

During 1921 the Board continued to contribute towards the maintenance of a department of hygiene in the medical school of Sao Paolo, Brazil.

In June, 1921, a Royal Commission recommended the establishment of a central school of public health in London, preferably in affiliation with the University of London, and a request was made by the British Ministry of Health for the co-operation of the Foundation. At the time this report was written negotiations were still in progress.

THE TRAINING OF NURSES.

In 1919 the Foundation invited a group of persons who are most familiar with nursing problems to a conference which nominated a survey committee, under whose auspices a study of the exact functions of bedside and public health nurses and the kind and length of training they should receive has been carried out. Their report has recently been issued and will be reviewed in the next number of The World's Health. The expenses of the survey were met by the Foundation.

During 1921 the International Health Board contributed towards short courses for training nurses in New York State. Four nurses' training centres were aided in France. The Cavell-Depage Memorial School of Nursing in Brussels will be an integral part of the reorganized hospital and medical school to which the Foundation is contributing a large sum. It is co-operating with the government of Brazil in developing a public health nursing service, and it supports a nurses' training school in connexion with the Peking Union Medical College. A survey of the training of nurses in Great Britain and on the continent has been authorized, and scholarships were granted to four Polish nurses for study and training in the United States.

A demonstration paying clinic for persons of moderate means, in connexion with Cornell University, is supported by the Rockefeller Foundation. On the day the clinic opened 700 persons presented themselves and there has been a steadly growing patronage every since.

DEDICATION OF PEKING

UNION MEDICAL COLLEGE.

On September 19, 1921, the Peking Union Medical College was officially opened in a new setting and with enlarged resources. All the essential laboratories and lecture rooms, a hospital of 225 teaching beds and an outpatient department are provided. The entire plant covers twenty-five acres and includes fifty-nine buildings. The student registration for 1921-1922 showed fifty-two in the pre-medical school, twenty in the medical school and eleven in the nurses' training school. The fact that only a small number of preparatory schools and colleges can meet the entrance standard, the length and cost of the medical course and the popular ignorance of modern medicine are obstacles to be slowly overcome. The work in China is administered unde the auspices of the China Medical Board of the Rockefeller Foundation.

MEDICAL EDUCATION IN MANY LANDS.

Columbia University, in New York, is planning to build a combined medical school and hospita1, towards which the Foundation has agreed to contribute $ 1,000,000.

In connexion with the University of Brussels, the Foundation is giving $ 3,500,000 towards the cost of rebuilding the medical laboratories and the antiquated hospital of St. Pierre. The Cavell-Depage Memorial Nurses' Home and Training School will be part of this project.

Medical education in Canada was further helped during 1921 to the extent of $ 5,000,000 through the Universities of Dalhousie, Montreal, Alberta and McGill.

With the object of gathering accurate data about medical education in many countries, representatives of the Foundation made surveys of medical schools in Japan, China, Hong Kong, the Philippines, Siam, Indo-China, Straits Settlements, Java, Egypt, Syria and Constantinople.

The Foundation granted 157 fellowships in public health or medical education during the year, distributed by countries as follows: seventy-one Americans, one Belgian, seven Brazilians, eleven Canadians, one Singhalese, seventeen Chinese, one Colombian, two Costa-Ricans, nineteen Czechs, seven British, four French, one Guatemalan, one Mexican, two Nicaraguans, seven Poles, two Salvadoreans, two Syrians and one Norwegian.

OTHER ACTIVITIES.

The Foundation has actively continued its campaigns against yellow fever, malaria and hookworm, which have been described in a previous article. (1).

The special Commission which in 1917 was sent to France under the auspices of the International Health Board to help in the creation of a nationwide anti-tuberculosis organization (2) was formally disbanded on June 30, 1921. Certain representatives of the Board remained in France to complete arrangements for the final transfer of the Commission's functions to Franch agencies. This project was undertaken as a demonstration of a system of organization, of special training, of popular education and of extension methods, and up to the end of 1921, $ 2,000,000 had been spent upon the cam

paign. The response of the French people has been remarkably gratifying.

The outlines of a world-wide campaign for health are beginning to emerge. Scientific research workers in many national centres are in constant communication, and knowledge is being applied more effectively to the problems in the field. All this is being helped on by many methods and agencies, such as working agreements between governments. the Health Section of the League of Nations, and the League of Red Cross Societies. It is hardly possible to estimate the full value of the part played by the Rockefeller Foundation in this world-wide team-work for the prevention of disease.