Gunn’s Rural Reconstruction Program

In December 1934, the long-awaited report of the Committee on Appraisal and Plans appeared. Its 113 pages dealt with the whole of the Foundation, as it represented an attempt to re-think its work in light of developments since the reorganization that had taken place in 1929. The Committee expressed its confidence in the program of psychiatry under Gregg’s direction. It also took note of “a minor activity” that he had initiated concerning the teaching of public health to medical students!

Slightly more than 3 pages were dedicated to “Mr Gunn’s Program for China”. There was “little question” that his program represented “a realistic approach to present difficulties in China”. The “plastic condition of her life and institutions” was “an inviting challenge to a positive kind of service. Indeed there is a sense in which China might become a vast laboratory in the social sciences, with implications that would be international in scope”. The suggested program “helps to conserve and revivify the work” that has already been done through the PUMC.

The lack of time limitations was recognized. “If we embark, we embark for the voyage, and we must contemplate a trip of considerable duration if any significant contribution is really to be made”. This could be seen as a “conclusive argument against the project”. Furthermore, “some kind of integration, or at least a carefully matured understanding” between the program in Peking and that of Shanghai, was desirable and necessary “if some degree of uncertainty and perhaps confusion” was to be avoided. The fact that this was a different technique for approaching public health was recognized, although not made explicit, as one might read into this ‘difference’ opposing views on medical education as well as public health. Finally, the question was raised as to whether China was the best place in the world for the Foundation to engage “to push our attack”. The committee made no recommendation on this latter point but did propose Mexico, India the South American countries as presenting “an inviting field”.

Despite these questions, reservations and doubts, the Board of Trustees endorsed the program. They voted to appropriate US$ 1 million for a three-year experimental program in rural reconstruction to begin July 1935. Grant, who was still employed by the IHD, was placed under Gunn’s full responsibility.

Gunn, who had been absent from China for nearly a year, returned in high spirits. He traveled with Grant, as well as with Fosdick, who was sent to try to appease the PUMC Board of Trustee’s anger at Greene’s dismissal. Although Greene had been removed from office, the protest that it had raised in China led to him staying on until April 1935 when he resigned. By March, Gunn was able to report that he and Grant had made much progress and were “very keen about the new program…,” and that they were “going to make a pretty good team”. Gunn was going to make Grant the “detail” man, which would relieve him of “unnecessary and long conversations,” while providing Grant the possibility of not having to agree before consulting with Gunn, who Grant could portray as being “very hard-boiled” if necessary.

Grant had already laid out some of the principles of their program in his long letter to Grant referred to earlier. He identified the “essential problem” that he found to be the lack of a “marketing policy” in the “social fields of medical, agricultural and economic protection”. Man has progressed in the production of knowledge, “but has learned very little of the technique of its marketing”. The impracticality of someone who proposed, for example, to “protect against community ignorance without the organization now known as primary and secondary education with its primary and secondary schools” would be derided. Even more so if that someone were to work “only through personnel limited to university graduates instead of normal school products specifically trained to meet the institutional demands of organized perfection against ignorance”. And so it was with medicine where “there has been an almost entire lack of thought even to a marketing policy, much less of technical personnel”.

Grant referred to welfare centers that had been created as an outcome of Štampar’s visit to help create a demand “for the utilization of scientific knowledge in the daily life of the villager” related to medicine, education, agriculture and economics, yet “in all of China there is not a single agricultural, medical or economic institution able to train personnel competent to undertake such ‘primary’ duties and responsibilities, should such a demand be created”. What institution, for example, could provide a “medical officer to receive not more than $50 a month and able to discharge the demands that a system of primary medical protection would involve?”

In March Grant formulated a ‘tentative’ set of principles for the China Program which Gunn sent on to Mason. It contained many of the same points that Grant had sent to Gregg earlier, but ‘packaged’ in a more programmatic fashion, beginning with the “definition” of the China program, which was:

The advancement of knowledge through research, education and demonstrated application, for the purpose of solving definite problems which may result in improvement in the conditions of life and community welfare.

The attack, in whatever social field chosen to “make available to individuals in the community the advances made in knowledge and to secure utilization of this knowledge for the general good”, “should be the long range one of organization and method”. In medicine, for example, “the prime importance would be that of organization and methods of medical protection as a whole”. At this point Grant took on the whole history of the IHD by proclaiming that such an attack “would ultimately be more effective in dealing with such individual problems as hookworm and malaria and their control”!

This audaciousness was already in evidence in his opening paragraphs, where Grant took on the whole of the Foundation:

The five major but diverse interests of the RF have been carried on for the most part entirely separate from each other. It has long seemed to me desirable to break down the walls of the practically water-tight compartments in which these have been carried on, but thus far it had not been possible in the China program to demonstrate the practicability of coordinating these interests in a single objective to which each would make its distinctive contribution but in which there would be a certain uniformity of approach and method, which would increase the effectiveness and significance of the contribution of the RF to ‘human welfare’.

Also new in this formulation was the importance given to the “simultaneous development” of the various constituent functions and factors that contribute to human welfare. Functions included funds, personnel, organization and methods, while factors covered the whole range of social and economic sectors involved in development.

Finally, Grant indicated the desirability of carrying out experiments in the same region, so that “eventually there may be a demonstration in a single area of the essential interdependence of the various social functions and of their effective coordination for the good of the community”. This would also “centralize all the training of personnel for the various social fields”.

Gunn, in his letter dated March 23, 1935 to Mason, attached Grant’s “statement” and went on to identify Tinghsien as being the “most significant piece of work going on in China at the present time in connection with reconstruction” and where the Foundation could train  “personnel for reconstruction programs”. Tinghsien was already cooperating with Nankai and Yenching Universities while both Tsing Hua and Nanking Universities were cooperating along certain technical lines. At this point (March 1935) Gunn was only asking funds for one year as an experimental period. If successful, “we shall undoubtedly ask for funds for the two following years”. Tsing Hua University was located in Beijing and was known for its agricultural research.

One can easily imagine that those not use to this kind of heavily jargonized approach to development might be put-off, especially in an organization where very few other staff members spoke the same language! The reaction of Russell, in particular, is very revealing in this regard. He found Grant’s principles to “be very general and because of that … difficult to criticize, except in the most general terms”, which he then proceeded to do in a memorandum to Mason.

Grant’s assertion that methods and personnel are dependent on the type of organization seemed to Russell to be “completely erroneous. It dignifies organization with an importance which it does not deserve. Organization in any wide-awake and progressive group is dependent upon the type of personnel. The Foundation since I have known it has changed its type of organization several times and any other progressive group will outgrow any organization”.

Concerning public health training to be carried out in Nanking, Russell expressed the feeling “that our money should not be expended in any schemes, the object of which is quantity production, which apparently this is”. On the other hand, he continued, “we have no right to object to any plans the Chinese Government may have for training its personnel, but the subsidy which we grant to any such scheme should, in my opinion, be limited to such parts of the project as provide for improving the quality of the instruction without any reference to the quantity production of graduate”.

Russell took the occasion to explain to Mason that the IHD plan of attack had always been different from this:

Our plan has been to set up on a small scale an experimental organization which by trial and error, under the direction of excellent men, can gradually work out a system suitable to the local conditions and that after this has been done extension can be made by copying the satisfactory elements of the experimental program, that the whole emphasis is placed on working out a program which is within the means of the community to support, always with a provision that nothing will be done in the absence of well-trained personnel. In other words, we have always emphasized quality and never quantity in our program.

Mason, while sharing Russell’s concern with the meagerness of Grant’s description, concluded, as regards the issue of quantity versus quality, the “question is academic. I am sure there would be no tendency to support a properly conceived organization if it were in the hands of inadequate personnel and that we should demand both excellent personnel and proper organization”.

 

 

The positive result of the Hsiang-Ya conference on Experimental Medical Curriculum, discussed earlier, opened up a new possibility for linking “medical development” with “social reconstruction” as there existed a provincial health administration project, Farmers Cooperative that would welcome medical cooperation, and “many local social reconstruction projects” that had already started, one example being the Nanshao Rural Reconstruction experiment where health was part of the program and in which Hsaing-Ya was cooperating.

An Important Shift in Gunn’s Strategy

A few months later, following a visit to Tinghsien, Gunn wrote Mason:

Doctor Grant is up in the North, and he writes me very interestingly concerning the progress which is being made in bringing together Yenching, Nankai and Tinghsien. It looks as if we may be able to report later on that a really concrete beginning has been made towards providing the Social Sciences of two universities concerned with community laboratory facilities controlled in a manner not dissimilar to that used by the Natural Sciences in teaching and research. The significance of this may prove to be really important.

The notion of a ‘community laboratory’ which Grant had used several years earlier and which Gunn used when he was in Europe, was common in colonial circles. ???

Gunn’s list of appropriations made during the first months following his arrival at the end of 1934 totaled just over US$300,000. Leading the list was the MEM (75,000), followed by grants to the National Health Administration (44,000), University of Nankai (42,000), and fellowships in China (38,000). Grants to other rural development activities included Yenching University (30,000), the Institute of Economics at Nankai (19,000), the National Central University (17,000), and the National Agricultural Research Bureau (17,000). The only possible “new items” that Gunn could foresee at that point were “a small appropriation for Lingnan University, and an increase in the appropriation for Yenching”. Concerning the Natural Sciences, Gunn had decided that the Universities “should and could take care of these items in the future”.

The hopes expressed by Gunn for building his project around Tinghsien proved to be overly optimistic. Within a few months he was lamenting that “Doctor Grant and myself have had a good deal of difficulty in getting the Chinese in these three institutions to cooperate as we had anticipated. These people are highly individualistic and we found that real cooperation was much more difficult to obtain than the ‘lip service’ which was given to the word ‘cooperation’ prior to our actual grants”. Yen, in particular, was disinclined to yield to the opinions of others. While he was “always warm, regardless of any differences of opinion,” he “was inclined to dogmatism (believing) that his philosophy had all the answers…. Perhaps it is natural that Jimmy Yen, who has been ‘going it alone’ for so many years finds it a bit irksome to have men from other institutions putting their fingers into his private pie. As a matter of fact, the weakness of Yen’s work has been largely due to his lack of desire to give too great a prominence to men who have not been connected with his Movement”.

These sentiments led Gunn to indicate to Mason that it was “time for us to make hay slowly”. While he was “naturally perturbed about the situation” which was facing them, he had not come to feel “that we are facing failure in our Chinese venture”. A more conservative approach was needed. He abandoned the idea of extensive visits to other areas because of the difficulties involved in making such visits without getting involved in ultimate financial assistance. Rather than focusing on “the more revolutionary concepts of the Tinghsien experiment”, the objectives of the program could be “better obtained through a concentration on University investigation and training into the community field”.

Since ongoing projects had only been funded for one year, Gunn proposed that he attend the meeting of the Trustees, scheduled for April 1936, to explain in more detail his ideas concerning the role of the Universities. Mason cabled acceptance on 17 October.

Essentially this new direction moved the focus of the project from Tinghsien to the universities. By supporting Nanking University, for example, Gunn hoped to obtain “a coordination of policy” amongst its agricultural institutions, one “which has been hitherto lacking”. Professor Buck, who helped make Nanking’s program in agricultural economics “become pre-eminent in China,” was working half time at the National Agricultural Research Bureau, which had been created in early 1934 and which then had “made very great strides.” National Central University, which was also located in Nanking, was responsible for Animal Husbandry and Veterinary Medicine, but whose training to date was “much below professional standards,” and in need of correction. Gunn expected that this University would “occupy an increasingly dominant place in professional education due both to its location in the capital and to local educational circumstances”. The major portion of the grant offered was for demonstrating satisfactory development of hog-raising as an important major field of animal husbandry. Another new direction outlined by Gunn was aimed to develop effective control of insects, a direction that had only received little attention to date in China.

Gunn had to pressure the Nanking agricultural institutions to cooperate with each other. As he reported to Mason in March 1935 “some of the Nanking University crowd … are not very keen toward cooperating with the Government [and] would like to see us finance their institution so that they could go ahead without any particular relationship to the National Central University Agricultural College or the National Agricultural Research Bureau”. He concluded that the “best thing the Rockefeller Foundation could do in Nanking was to force the three institutions to work together”.

Working with individual institutions proved less complicated as witness Gunn helping Yenching University to develop a program for training personnel needed for reconstruction, although, earlier, he had had “some doubts” as to their sincerity, suspecting that their “swing” in favor of rural reconstruction “was motivated by the hope of getting money”. He was now convinced of the “sincerity” of its President, J Leighton Stuart, and the leading members of the various faculties of the University.

As it had become “apparent … that an effective coordinated program must be still broader in scope than is possible within one single private organization [i.e. the MEM]”, council was developed in the fall of 1936 that brought together all of the interested parties – the North China Council of Rural Reconstruction. This was a cooperative organization whose participating members were:

• National Tsing Hun University (Public Works)
• Nankai University (Economics and Local Government)
• Yenching University (Education and Sociology)
• Peking Union Medical College (Medicine)
• University of Nanking (Agriculture)
• The Chinese National Association of the Mass Education Movement

The purpose of the Council was “to develop a correlated community program of rural reconstruction through which controlled field facilities and services for applied training and research in the social sciences may be made available to its constituent institutions”. It was hoped by these means “to play some part in providing personnel of high quality to the various enterprises for social reconstruction in China which now are in so great need of well-trained workers”.

There is some irony in the fact that the emphasis was placed on personnel of “high quality” following a long period where lower quality in the field of medicine seemed to be required to meet the health needs of the vast under-served population of China. One can easily imagine Gregg and Russell saying ‘we told you so’!

Grant was the only Western member on the council, which totaled 13 members. The other included Yen, who also served as Chairman of the Executive Committee; Chen, who represented social medicine; Robert Lim of the PUMC; Ho, who chaired the committee on training and research; and Chu, who served as secretary.

Among the various courses that were announced three addressed social medicine and were described as follows:

• Social Medicine I   Dr Chen

This course consists of ten hours of classroom discussion and three days in field observation. It is intended for medical students who have completed their second or third year of a university medical curriculum. The principal idea of this course is to help medical students (undergraduates) become familiar with the problems and possibilities of socializing medicine.

 

• Social Medicine II  Drs Chen, Moe and Chow

This course lasts one month during which 4^th and 5^th year medical students of university standard will avail themselves of the facilities in Tinghsien. In addition to weekly individual conference, each student shall be asked to report on assigned readings, independent field observations and active participation in the various phases of the existing organization.

 

• Social Medicine III  Drs Yu, Chow and Moe

This is a two year course organized for graduates of provincial medical schools of Chuan Ko standard. The first year is composed of one month of didactic instruction, one month in aseptic discipline, four months in review of general medicine and five months in practical work under supervision at health stations. Monthly written reports are required.

The second year gives students an opportunity to demonstrate their practical intelligence by participation with responsibility. They will work five months in the District Health Center and six months in one of the stations. They are required to attend all staff meetings and, whenever necessary, to report on their experiences. Besides, they will be in this country such as Kiangning, Nanchi, Cheuping and Kiangse, thus affording them the opportunity for comparative studies.

A “controlled community facility” was one where one or more of the participating institutions would address specific rural problems in specific communities as part of their training and research program. The Council had been given a broad political mandate that permitted them to make such arrangements with individual communities. Great political sensitivity surrounded such an arrangement. On one hand, the whole of north China was under constant threat of military action by the Japanese, as noted by the American Ambassador, Nelson Johnson, in a confidential letter to Roger Greene: In North China there is an alien force that is endeavoring to displace the state of directing the so-called growth of Chinese living in North China. It is my opinion that the Rockefeller Foundation will be well advised to consider this aspect of the situation before assuming financial responsibility for an institution of this kind in an area where there is sure to be political competition for the control of the social future of the local people.

Greene raised a different concern with Gunn: Aren’t you on a rather dangerous ground in this North China Socio-politico-economic program? In these uncertain days one of your workers who is trying to reform rural China by political as well as economic and educational means might someday find himself labelled as a communist and disappear altogether.

Gunn does not seem to have replied to these concerns. It was Grant who found himself in a political debate when he asked Stacy May, who had taken over from Day the position of Director of the Foundation’s Division of Social Studies, about experiences of US Universities in the field of public administration. Grant was particularly interested in learning about how Universities set up their laboratory for graduate students. Grant, not finding what he hoped to find in the documents that May sent him, expressed surprise at the fact that the Universities were working with State Administrations rather than communities. Concerning the program in Minnesota, he suggested that their laboratory should be a “community in which the public services are controlled by the academic authorities in order to permit supervised practice for the students being taught and controlled research conditions in practical fields for the teachers themselves”.

Grant’s reply set May “back on [his] heels in very forthright fashion”. Was Grant “urging that a Chian Kai-shek-Kemal Attaturk-Hitler-Musuolini-Stalin procedure be adopted generally in America…”? He suggested that the word “laboratory” be avoided! It would seem that May had not realized the central place that this term had been given in the report prepared by Fosdick’s appraisal committee 2 years earlier. This exchange, however, did not prevent Grant from having “an excellent talk” with May when he visited New York in November 1937, nor from him subsequently writing to May about how the North China Program through its “all university council” was provided the opportunity of “translation of theory into practice through controlled communities”!

China had travelled an enormous distance between 1930, when Faber carried out his study of medical education, and 1936 when Chen had gained such prestige as to lead almost by subterfuge a revolution in both medical education and health care. Had he graduated from the PUMC 4 or 5 years earlier, much of the internal battles that ensued might not have occurred, but such speculation is really outside the aim of this book, as there are so many others that one might imagine, e.g. what if Vincent could have stayed on as President for another 5 years?

Gunn may or may not have known about the sometimes acrimonious exchanges surrounding Grant’s work, but if he did he managed to play them down. Either way, in his first major progress report, which covered the period July 1, 1935 to February 15, 1937, i.e. just a few months before Japan attacked, Gunn described the progress of the program in rather rosy terms:

It will be recalled that the basis of the China Program was twofold. The major interest was to be in rural reconstruction and as a minor objective it was hoped that the China Program might help to guarantee a greater return on the Foundation’s previous large financial investments, particularly in connection with those made to the Peking Union Medical College. It is fair to state that both these general objectives are in the process of accomplishment.

At the outset there were found to be numerous uncoordinated activities in rural reconstruction. These lacked, however, an adequate definition either of the problem of rural reconstruction or the steps necessary for their solution. The Foundation Program has stimulated Chinese leadership to define these fundamentals.

While the government’s program in rural reconstruction was likely to be “quantitative rather than qualitative in character,” ultimate success would depend on qualitative work. This, in turn, would depend on the availability of trained leadership. Here was where “Foundation assistance may be crucially important”. The word “laboratory” was avoided.

In the area of public health and medicine, the Foundation was working on two fronts. First, it was cooperating with the aim of “intensifying the quality of the courses as well as enabling the establishment of such new courses as were demanded by national needs”. Secondly, it had helped in the development of the Commission on Medical Education, a development which they were “particularly satisfied with”. This development had materially improved the “opportunities” of the PUMC to “maintain and develop its scientific and moral position in medical and public health matters”.

The experience of the last two years had demonstrated that the importance of the Foundation’s contributions lie in “its qualitative character”. The Chinese government was recognizing the weaknesses of its quantitative program and was “beginning to take counsel from the organization” that the Foundation was building up. This allowed Gunn to propose that future financial assistance would be “for a limited period and on a tapering basis”.

In early February 1937 Madame Chiang Kai-Shek wrote a personal letter to Gunn to inform him how much “the Generalissimo and [her] self” appreciated his efforts in the field of rural reconstruction. His “enlisting the interest of leading universities in a well-chosen training program will widen and deepen this work through providing leadership”.

Measured by expenditure, the China Program was on target at the time Gunn made his report in February 1937. The Trustees had originally approved a budget of $1,000,000 for a three-year period. In the first two years some $575,000 had been allocated and the new proposals for 1937 were for a total of $350,000. A total of 429 local fellowships had been awarded along with 16 foreign ones. This marked a dramatic shift from the past when foreign fellowships dominated. The majority of local fellowship aimed to provide training that would trainees to “occupy positions of responsibility in different fields of rural reconstruction”. Thirty-six research and development grants were made mostly to projects “which have a direct relation to some phase of rural reconstruction and where there seems to be an opportunity to anticipate a practical result within a reasonably short period of time”. As of the writing of this report no evaluation of results was yet possible.

How any form of evaluation might have been conducted is not at all obvious, as can be seen from the work of Shen Zonghan, a leading scientist with the National Agricultural Research Bureau (NARB). ???

Changing of the Guard in New York

Russell retired in 1935 and was replaced by Wilbur Sawyer, “whom Russell had groomed for the job, fearing that his numerous critics would try to reverse the changes that Russell had made”. A Harvard medical school graduate, he was described by some of his colleagues as “cold, uninspiring and meticulous, conscientious,” and even as “ruthlessly ambitious”, an image that does not come across in the exchanges that he had with Gunn.

As Grant was still being paid by the IHD Sawyer wrote ‘Mr’ Gunn to ask him to provide a “clearer idea than [he] had now” of Gunn’s plans for public health work in China and “your desires for cooperation” from the IHD. Gunn’s reply (Dear Doctor Sawyer) was extremely warm; he noted that in the past he had the impression that the IHD “interests in China were rather lukewarm”. Gunn was probably ignorant of the efforts that Russell had made to get Grant to initiate ‘real’ IHD projects, i.e. aimed at specific diseases. In any case, Gunn suggested that his visit to New York in the spring of 1937 be used to carry out a “thorough discussion” of the relationship between the China program and the IHD.

 

Sawyer visited China in ???? and reported to Fosdick that the health program in China had “made a very favorable impression.” PUMC graduates or holders of IHB fellowships were in key positions “and it was encouraging to see how freely they consulted each other and Dr Grant.” He expressed the “highest regard” for the Commission on Medical Education and for its Secretary, Chu. It could hardly fail “to have a very desirable effect in bringing up the standards of the lower grade provincial medical schools.” On the other hand, he observed that the problem of “high-grade post-graduate instruction for medical men from the provinces” had not been solved. There was a “hint” that the Chinese Ministry of Education might give financial assistance. In any case, the IHD “might also be interested.” He advised that the teaching would have to be in Chinese and “the best place would be at the PUMC.” Whether or not Sawyer realized that he was touching on highly sensitive issues is not clear, especially as his most recent assignment had been with ????.

Sawyer was, however, a bit “apprehensive concerning the tendency to emphasize medical care and to “restrict” public health activities to those that can be carried on through the treatment of individuals.” Epidemiology and environmental sanitation, in particular, needed stimulation otherwise they would “fall behind in the program.” He referred to the “hopeless attitude towards malaria” in some districts to illustrate this point.[1]

That Sawyer would mention environmental sanitation is not surprising. Russell had stressed its importance when Grant expressed his hopes that China would develop a School of Hygiene and Public Health “of some kind». He proposed five chairs to cover epidemiology, statistics, public health administration, physiology, physiological hygiene, bio-chemistry, and nutrition. Russell suggested in reply that “more important than some of these would be a chair on sanitary engineering, since China is a backward country and the first thing to do was to improve environmental sanitation».[2]

Writing directly to Grant, Sawyer indicated that he was looking for projects that were “new and of pioneering and exploratory nature rather than for continuing support,” adding that New York was “anxious”… that the program in China should not be diffuse and that our representatives should deal scientifically, objectively, and intensively in their special fields. Direct publicity should be avoided and propaganda minimized. Our field is public health and our service is objective and investigational.”[3] At the same time, Gunn asked Grant to “get busy” in preparing the IHB program for 1938,[4]

Here again, Grant must have been reminded of his visit to New York when Russell recorded in his diary that he had told Grant that he “had not seen any reports from the PUMC health district”, that he “did not know whether he was making any studies of public health problems or not”, and that he “hoped in the future he would inaugurate whatever studies he could because after all that was the main way to make progress in public health».[5]

As already noted, Mason retired in 1936 and was replaced by Fosdick, the long-standing officer for the Foundation and close friend of the Rockefeller family. One suspects that after the difficulties that JDRjr had with Mason, the choice of Fosdick became a necessity. In any case, Gunn and Fosdick knew each other well and from their exchanges of letters one senses an ease in communication. Unlike Mason, Fosdick wanted to be briefed well and regularly.

In a letter to Fosdick, dated 23 February 1937, Gunn provided what he called a “general statement concerning the political situation in China”. In it he made clear just how difficult the prospects for “national unity” were, although the “sense of China being a nation” was growing among the people. Blocking such unity was the “deep conflict of interest” between what he called the “Western” Chinese and “Chinese” Chinese, the latter being the ones who make up the “backbone, power, and authority of the large part of China, including the entire rural regions where 85% of the people live”.

The “landlord, gentry, usurer Chinese in the country are opposed to the ‘Western’ Chinese with their ideas of industrialization, technical development, enlightenment of the masses, etc. This ‘Chinese China group sees no advantage to themselves in increasing the purchasing power of the farmers. A debt-free rural population would be to them a great disaster. The tenancy crop-sharing system is their desire and their prosperity. This old system, of course, plays into the hands of the Communists, who are the arch-enemies of the landlord, gentry, and usurer group. Communism … represents a great power, and the childish reference of the National Government to the ‘remnant Reds’ are preposterous when one considers the size of the Soviet China, its large well equipped army, and the genuine patriotism and self-sacrificing fervor of the people who live under its regime”.

What concerned Gunn, in terms of the China program, was “to arrive at a conclusion as to the real honesty of the Chinese Government in connection with its National Reconstruction program”.

Gunn’s concern was made academic when Japan initiated hostilities in early July of that year. Despite open warfare in the North and later that year in Shanghai, reports from Gunn and Grant continued as if their China program would survive. At first Grant advised Gunn that the Council should close out its work in Tinghsien “in one year instead of two years”, and “any capital investments in Tsining should be suspended pending conclusion of the political situation”. Grant’s memos to Gunn, who had left China to participate in an LNHO meeting in Indonesia (3-13 August), suggest an unwillingness on his part to imagine that what he had working for over the previous 16 years was about to collapse. For example, in late July he was still writing about “a medical program that called for undergraduate university training of a minimum standard in sufficient institutions to meet effectively the problem of numerical sufficiency of trained personnel”! Several weeks later, however, in a letter to Sawyer, he admitted that the most probable future was one that included both localized fighting and some nation-wide fighting. The safest place to be, according to Grant, was in Peking. Houghton soon confirmed this in his cable to New York:  College session began as scheduled. Sixty-five percent of the students present from all parts of China. More are on the way. Excellent morale. Good local cooperation.

Writing from Indonesia, Gunn informed Fosdick that his staff in Shanghai had been evacuated to Manila. As for Grant, he had no idea where he was – “probably Peking. Why he went there is likewise obscure but possibly it was something urgent with regard to his wife”. He indicated that he was leaving for Singapore on the 19^th on his way to Hong Kong. Gunn knew that the Japanese had totally destroyed Nankai but like Grant and Rajchman believed that hostilities would be confined to the North as China “would not and could not engage in a major war with Japan”.

A month later, Gunn reported from Hong Kong that he had heard from Grant, who had returned to Shanghai where he expected to see him in a few days. Otherwise, his correspondence was largely taken up by reports concerning Chinese friends and fellows, especially those who were forced to flee, many of whom left China.

Gunn forwarded to Fosdick a letter that he had received from Borčić, which contained depressing news as well as what one might call gossip, e.g. that Ho was “very angry” with Hsu, who had left for America for the purpose of “raising contributions among the Chinese to buy planes with”. He did not explain what the source of his anger was, his departure or his seeking contributions! Hsu met with Stacy May while in America; May reported his impressions of Hsu to Gunn: “full of confidence in the eventual outcome”; “full of confidence in the Generalissimo; and “so much more western than the westerners”.

Training was still going on, but it was all in relation to meeting the “needs of the war medical services”. From Borčić he learned that the PUMC had decided to open the school and were urging students “all over the country to come to Peking much to the disapproval of the authorities in Nanking”. In Borčić’s letter, which was addressed to Rajchman, one learns that PUMC fellows, who were on their way to the USA, have been ordered back as were League Fellows.

Rajchman’s letter to Gunn was full of dramatic news. Written from Nanking, he described seeing more than 50 Japanese bombers that dropped about 200 bombs on the city. Eleven bombs had fallen during the day before, heavily damaged LNHO facilities, killing two and wounding six people. Cholera had appeared among the wounded and hospitals were overrun. After these details, Rajchman wanted to know if the Foundation would be interested in collaborating in medical education during this “emergency period”. He had in mind “a couple of provincial schools to replace those that were out of operation”. CK Chu and Robert Lim were involved in this activity.

Towards the end of the year, Fosdick advised Gunn that following his expected return to the States in the spring of 1938 that it would “not be necessary” for him to give his whole time to China. He had no desire to “condemn” Gunn to serve the rest of his life in China as “there are more significant things that you could do for the Foundation”. Concerning Grant, who was also expected to return to the States, Fosdick indicated that they were “conscious, of course, of Grant’s tendency to get involved in Chinese affairs [but] we know Grant well enough to make the necessary discounts in relation to his enthusiasm”.

Grant’s enthusiasm seems to have known no boundaries as suggested by his informing EC Lobenstine, Chairman of the CMB in later 1937 that of the three options that he saw for the future of the PUMC – it becoming the medical school in the Japanese university; withdrawing altogether from Peking; or selling out to the Japanese and going elsewhere – he indicated that the “sounder policy was to connect the PUMC with the Imperial University”! That Grant had probably discussed this issue with governmental representatives and was thus again seen to be overstepping the boundaries of acceptable behaviour is suggested by a memorandum that Fosdick sent to him, which concluded: It seems to me to be important, therefore, that the representatives of the Foundation in the Far East, in their discussion with either Chinese or Japanese officials, should rigidly refrain from comment relating to the PUMC.

Gunn, who was clearly unaware of most of what Grant was doing, returned to Shanghai with his wife for 8 days before returning to Hong Kong for Christmas. He let go his secretary as he expected to be leaving for the States in the coming months. His conversations with American and British friends showed a “unanimous condemnation of the Chinese”. Even “our Chinese medical friends came in for pretty serious criticisms … lack of patriotism, callousness, personal ambitions, and worse”. The Chinese military were similarly found wanting in their inability to be a credible force. Nanking was the site of “horrible scenes” enacted first by the departing Chinese troops and then the victorious Japanese troops.

The destruction of Nankai forced the Foundation to reconsider its “future relations with countries whose political and social policies seem to clash with those widely accepted in this country”. The Foundation had contributed roughly $200,000 towards Nankai University over fifteen years, and had become one of the important centers in Gunn’s program. The same day that Nankai was bombed the “Treasurer’s office of the Foundation wrote a check for $74,000 toward our pledge of $1,000,000 for the new Public Health Institute in Tokyo”. This was not a new situation for the Foundation, as it already had had a long record of cooperation in Italy, much of it under the Fascist regime.

Grant learned from Fosdick during his visit to New York that a “formula will be devised to postpone” consideration of an additional grant to the Tokyo Institute for at least one year. During WWII, the Institute became a military headquarters. In this same letter to Gunn, Grant reported that he had an excellent talk with Stacy May on the subject of public administration and that he would try to visit Charlottesville, Washington, Syracuse and Harvard, in that regard.

Public administration was one of the new programs that the Social Sciences had begun several years earlier. It was chiefly directed “toward bringing about a closer, and more mutually helpful, relationship between practical administrators in the government service and social scientists in the universities”. Harvard was one of the centers being supported. ??? what did Grant find?

At this point (end of 1937) Gunn judged the outlook for the China Program to be “pretty wretched”, but one year later he wrote Fosdick: In general I am highly pleased with the situation and feel that the Chinese despite all of the tremendous difficulties which that have gone through are to be sincerely congratulated in having prevented the Chinese program from complete disintegration”. As reported in the Foundation’s annual report for 1939:

As the cooperating institutions had made much progress in the brief interval of normal operation, the Foundation continued its aid in the emergency so that personnel and institutions might be held together.

Many of the institutions, however, had removed themselves to safer areas in China or simply be abandoned. The North China Council, for example, after moving its Rural Service Training Institute to Tingfan county, decided that “Tingfan’s considerable lag in culture and education, and its bi-racial character made it practically impossible to secure enough local leaders to lay a foundation for the more intensive work required to provide university training at a postgraduate level”. Nankai University merged its undergraduate teaching in the National Southwestern Union University; the University of Nanking was transferred to western China; and the research of the insect control program of the National Agricultural Research Bureau continued in the southwestern and western provinces of China.

Gunn, himself, took several months of vacation in Connecticut following the April 1938 Trustee meeting, before leaving for Paris in September where he was placed in charge of the Foundation’s European program, although he was still listed as Vice-President under the China Program in the Foundation’s reports. Whether Europe was where Fosdick had imagined Gunn going to is not clear; one suspects that it was more Gunn’s choice than his.

Grant remained in China until July 1939 when he moved to India.

Marshall C Balfour replaced Grant in China. He cabled Gunn in October 1939 proposing that he return to China for a visit to the interior. His proposed itinerary was as follows:

1st day   in Kunming	Visit Southwest   Union University See Mei Yichi,   Chiang Mon-lin and Chen Chu-chin
2nd day   in Kunming	HY Yao – provincial   health commissioner and YT Yao – Director of Yunnan Malaria research Station
3rd day   by car to Kweiyang
4th day   Reach Kweiyang	YS Tsur, Provincial   Commissioner of Finance Ho Chi-wu and CK Chu   of Provincial Health Board
5th day   Visit Tingfan in morning	Chu Shu Ying –   Director of NCRR
6th day   In Kweiyang in   afternoon   Visit Tuyuinkwan	Visit Hsiangya   Medical College on way back from Tingfan Visit Public Health   Training Institute, National Kweiyang Medical College and Central Field   Health Station Robert Lim, Red   Cross Medical Relief Commission Provincial   Agricultural Bureau
7th day   By car to Chungking
8th day   Stop at Tungchih	See Tungchih Highway   Health Station
9th day   Reach Chungking	See Drs FC Yen and   PZ King Franklin Ho,   Chairman and HD Fong Secretary of NCRR
10th day   in Chungking	James Yen MEM; Hsieh   Chia-seng Agricultural Research Bureau; Chu Chia-hua and Han Lih-wu, Boxer   Indemnity Board
11th day   in Chungking	HH Kung, Executive   yuan; Wong Wen-hao, Department of Political Affairs; Nelson Johnson, American   Ambassador
12th day   in Chungking	Central University;   on way back to city, call on Chang Po-lin
13th day   Fly to Chengtu
14th day   in Chengtu	CC Chen, Szechuen   Provincial Health Commissioner, SN Cheer, Central University Medical College;   Chen Yu-kwang, Nanking University
15th day   Fly back to Chungking
16th day   in Chungking
17th day   Fly back to Hong Kong

 

Gunn wrote Fosdick after “giving a good deal of thought to this whole matter of my visiting China”. He was inclined to “to believe that it might not be essential” as he had full confidence in Balfour. Furthermore, as ready as he was to go, if Fosdick thought it necessary, such a trip “would be pretty strenuous to me. I don’t have quitze the same confidence in my physical resistance that I had when I was, for example, Balfour’s age”. Balfour was ??? Fosdick, who Gunn met in January 1940, “saw no reason for SMG going to China at this time”.

John Gunther, in his 10 June, 1939 Nation article Stalemate in China described the situation as a “complete stalemate which may persist a long time. The Japanese are not strong enough to push the Chinese into Tibet; the Chinese are not strong enough to push the Japanese into the sea. The Japanese – if they maintain their present strength – may follow their invention of the concept of undeclared war by making an undeclared peace”.

The Japanese closed PUMC in 1942; however, the majority of the former PUMC community remained in Peking, Shanghai, or Tientsin throughout the war. Some alumni joined the staff of local hospitals while others retreated into private practice or research.

Gunn Visits the Soviet Union

Early requests for aid to Soviet institutions were declined following heated debates within the Organization. Pearce, however, endorsed the idea of assisting scientists, who had remained in the Soviet Union; they were already receiving emergency help from the LSRM mostly during the early years of the 1920s. This led to him sending Gregg on a three-week site visit to Russia in 1927 during which he focused on medical education. He observed the prominence given to prevention in Soviet medical training and health care, describing the curriculum as being “saturated with hygiene and preventive medicine”, while at the same time noting that some Soviet doctors complaining that the focus on hygiene was “robbing the clinical courses”. While appreciative of the Soviet efforts “to improve medical care, reform agriculture, increase production, and improve literacy”, the visit had reinforced his belief in liberty (“too precious an ideal to be abandoned…”) and in a “liberal … benevolent society”.

Gunn, too, expressed similar thoughts concerning the lack of freedom following his “very short” visit – 24 June to 9 August, 1936. While seeking fairness in his comments he had to admit that he left the country “with a general adverse opinion despite the fact that there are so many activities being undertaken … which present admirable aspects and call for praise”. His appreciation of the great advances made there was always “marred by a feeling of disapproval of the political and police measures which the authorities see fit to employ in order to accomplish their objectives. Programs designed to raise the social and economic level of the masses and bring about a fairer and more equitable distribution of health, prosperity and happiness appeal to me with greater force than ever, and I find myself more and more convinced that democratic government represents the best method of approach without being content with the results attained up to date. Indeed I am far from satisfied and I am hopeful that the future will show democratic government in various parts of the world to be much more progressive than has been the case in the past.”

In his report Gunn took note of many features of the Soviet society, some positive, some less so. He was impressed with the fact that practically everyone had numerical answers to all questions, even if the figures given on occasion were so absurd that they were ludicrous. So much emphasis has been given to quantity that quality has suffered, and it was only recently that the authorities and public alike were beginning to realize it.

Gunn found social insurance to be the bed-rock of the system. But while the authorities pointed with pride that workers did not have to contribute anything from their salaries to the scheme, Gunn found this to be a “fiction” since it was merely a matter of bookkeeping as to who pays the actual money, given the fact that the employer is the State. He calculated that the benefits under the social insurance scheme amounted to at least 18% of the worker’s salaries.

While the cities seemed to abound with health centers, crèches, sanitaria, etc., sanitation, particularly in the rural regions had been very largely ignored, something the authorities were aware of. While the number of hospital facilities was steadily growing, Gunn learned from his observations and those of visiting doctors of the League of Nations, that the quality of care in some instances was distinctly poor, and in some cases to be highly dangerous.

Nevertheless, Gunn concluded that any “fair-minded person must come to the conclusion that a large number of workers and peasants and their families are receiving medical and public health benefits which they never had before, and the constant spreading of the various services and the improvement in their quality must redound to the physical wellbeing of the people.

Another feature of the Soviet Union that pleased Gunn was the work being done in city and country for children. Everywhere he went he was greatly impressed with the quality and quantity of the efforts being carried out for the physical and mental welfare of the coming generation – an abundance of crèches, kindergartens and schools, playgrounds, camps and institutions for children in the country and at the seashore.

On the negative side, Gunn believed that the principles of ‘social equality and a classless society’ were suffering a marked deterioration, as there appeared to be an increasing material and social inequality, one driven by the growing importance being given to money and brains, as witness the fact that engineers were now considered superior to mechanics, although the reverse was true only a few years earlier.

Gunn concluded his report:

The USSR is a confusing country – certainly the most difficult one to appraise that I have ever had anything to do with. It is impossible for me, and perhaps most people, to be completely objective in considering this country, and its accomplishments and defects. Liberty is a strong instinct in many and is too precious an ideal to be abandoned even when one considers great advances made in its complete absence. Communism may be the logical way out for the Russian people, but a liberal, intelligent, forward moving and benevolent democracy still appeals to me as the best method of government yet devised. I hope that the future of the Russian people will be bright and that happiness will be theirs, but I sincerely trust that the methods which they have used will not be needed elsewhere.

Fosdick, who had taken over the Presidency from Mason in 1936, commented favorably on Gunn’s report: it is a most interesting and valuable account of the internal situation, written without prejudice and with your characteristic detachment”. In the same letter he wrote that Sawyer was on his way to China.

The LNHO Bandoeng Conference on Rural Hygiene

Rural hygiene was “the largest and also most important project of the LNHO”. It was first addressed by the European Conference on Rural Hygiene, which took place in Geneva between 29 June and 7 July, 1931. Three issues dominated the agenda: (1) principles and methods for ensuring medical assistance in rural communities; (2) effective methods of organizing health services in rural districts; and (3) effective and cheap methods of improving rural districts through sanitation. Jacques Parisot, of the University of Nancy, was the Rapporteur for medical assistance, and Štampar, for the organization of health services.

Štampar, in his background paper, outlined the difficulties facing the Commission responsible for this agenda item – Most countries have public health organizations of long standing with definite traditions and a definite system of their own. It is not easy to ask such countries to adopt new principles and a new organization. Other countries again have not developed their health services in rural districts to any great extent, while yet others have varying administrative organizations and traditions and certain peculiar cultural and economic conditions which make it impossible to work out a system which is altogether acceptable to all these countries.[6]

Despite these reservations  he reached several conclusions including the necessity for the health service in a rural district to be “entrusted to a public health expert, who should not engage in private practice” and who should be “specially trained in health work and preventive medicine”. Furthermore, the health official in charge of the health service in a rural district “must be responsible for all health work, so that there may be unity of direction which not only makes for economy, but also for efficiency”.

Referring to work already carried out by the LNHO’s Commission on health centres, Štampar outlined the role of a primary health centre, whose “success”, although mostly confined to basic public health work, “depends largely upon suitable medical supervision”. The ideal is to have a “well paid, full-time doctor who has received a good training in hygiene and social welfare. This ideal, however, is hard to realize. Supervision of the centre must therefore in many cases be entrusted to the doctor of the commune.” Where there were not enough private doctors in a region, the centre would be expected to provide treatment “free of charge.” The “economic interests of the private doctors”, Štampar added, should be “brought into harmony with the interests of the health centre”.

In his opening comments Parisot referred to the “professional qualifications of doctors”, indicating that “practitioners must have an exact idea of the part they were called upon to play in the general scheme”. The public authorities were responsible for developing such a scheme. In doing so, “they should stimulate and coordinate the efforts of the institutions and groups concerned with medical assistance … they should aim at encouraging local initiatives and supporting it by subsidies”.

One participant noted that there “was a dangerous inconsistency” between Štampar’s notion of a health centre that allowed for the treatment of patients and that of Parisot’s where they were confined to diagnosis and prevention, and only in “special cases” would they supervise or administer medical treatment. If that practice “became general friction might develop between such centres and the local participation”. This observation reflected the “mild” controversy involving “the question, to what extent items one and two were, indeed, separate issues …” Otherwise, there “were no heated exchanges, no disagreements of principle”.

The idea of a conference for Asia was first vented by the Indian and Chinese delegations in 1932. In May 1936, the Health Committee of the LNHO accepted the invitation of the Dutch Government to hold the conference in the Dutch Indies (Indonesia today) in 1937.

The Conference approached the problems of rural hygiene from an “intersectoral and interagency perspective and focused not only on the need to improve access to modern medicine and public health but also on the fundamental challenges of educational uplift, economic development, and social advancement”. Health and medical services were brought together; the other subjects addressed were those of rural reconstruction and collaboration of the population; sanitation and sanitary engineering (housing, water supply, disposal of house refuse and other wastes, and fly control); nutrition, and measures for combatting certain diseases in rural districts (malaria as well as plague, hookworm, tuberculosis, pneumonia, yaws, leprosy and mental diseases). Each subject was dealt with by a Commission or sub-Commission.

Four background papers were commissioned by the Secretariat in support of the discussion concerning health and medical services; all favored the unitary approach, i.e. medical care and health work being carried out by the same staff. One paper was that of Chen, who unfortunately seems not to have been able to attend.

Chen noted in passing that “the concept of the medical profession in [China] has been greatly influenced by American schools, where public health is always taught as being in contrast to services in hospitals and clinics”. Believing that this separation “in the West was merely historical”, China’s National Health Administration believed that “it was wise for China to build her medical system on a coordinated basis”.

Those present knew that one of the reasons for the separation of preventive and curative work in many of the Far East countries was due to the ‘historic’ policy of the Rockefeller Foundation that separated medical education and public health education in America.

Those who prepared the agenda expressed an interest in the Conference discussing the “respective advantages” of two systems for the technical training of practitioners “in light of experiences gained”. One system was that of academic training with “equal standard to that given in the Universities of the Metropolis”, the other was “the creation of a diploma which, while conferring the right of practice, does not require such long and full study”.

Chen avoided discussing the training of physicians as it was “too involved a problem ….” Instead of rehashing China’s debates concerning the question of two ‘types’ of physicians, he concluded – “Essentially, there should be only one type of doctor, the training must be inexpensive to the students, basic for future development and practical for service in rural conditions”. Also, “medical education as a whole should be influenced by the desirability of practicing medicine under organized management by the State.”.

Not surprisingly, the Conference report recommended that “every country should, in the sphere of medical education, attain the highest scientific level of theoretical and practical training, which should include facilities and opportunities for research”. This was followed by the proviso that each country’s approach to medical education should be commensurate “with its resources and its level of general education”. Also resolved:

• Medical education has evolved from a simple beginning to a modern Western standard. This historical process of evolution should be accelerated as much as possible.
• The spirit of preventive and social medicine should permeate more and more the whole programme of medical education.