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Settling Down in Europe

Gunn returned to Paris in June 1922 where he established his residence until his departure for China some ten years later. He quickly found a “very pleasant apartment with lots of air and sunlight and running hot water in Neuilly, which is located within 20 minutes from our present office in Paris”. His hopes for being able to keep his family together, however, did not materialize. Within a year he informed Vincent that he had made plans “to keep his family in the South of France” where he intended to “visit them frequently.”  For health reasons, he moved them to Cannes where, given his incredible travel schedule, they probably saw him as much as they had when they were living together in Paris.

In the 1922 Annual Report, Gunn is listed as a special staff member assigned to in public health administration in Czechoslovakia as well as being a member of the Commission for the Prevention of Tuberculosis in France. In 1923, he was made Director of the Paris Office (22 Rue de l’Elysée), a position listed under the International Health Division, which was now headed by Fred Russell.

While under Rose’s directorship, Gunn probably did not feel his not being a medical doctor was a disadvantage, as Rose, like him, was not a medical man. Furthermore, their extensive correspondence while Gunn was stationed in Prague demonstrates a strong mutual respect and the presence of a belief in the value of public health education, a belief not often shared by his medical colleagues.

Gunn was one of the very rare non-medical officers in the IHD; he was also nearly unique in having bypassed being involved in hookworm campaigns before being engaged by the Foundation. It is highly doubtful that had Russell been in charge when Gunn decided he had to leave Prague that Russell would have kept him on. Russell had little respect for non-medical doctors and even less respect for a ‘health educator’. Under Russell’s leadership, the importance of team work, which was almost an obsession with Vincent, was not particularly stressed. As well, Russell liked to run his office in a military style, as befitted his military background. Vincent, on the other hand, saw the organization not as a “military bureaucratic regime in which each person tries to protect himself” but as “a cooperation of colleagues … in which each should feel both the right and obligation to criticize or make constructive suggestions though the appropriate channels not only in his own field but with respect to any other unit or agency which bears the R. name or influence”.

While stationed in Prague, Gunn visited nearby countries including Poland, Romania and Hungary. Now he found himself making extensive visits to a good number of new countries, sometimes more than once, as shown in this listing, which is far from complete:

1922: Ireland

1923: Bulgaria, Ireland, Sweden, Yugoslavia

1924: Romania, Yugoslavia, Hungary, Denmark, Ireland, Algeria

1925: Yugoslavia

Nearly every one of the reports that Gunn wrote following a visit were lengthy – more often than not, more than 200 pages long, replete with information on all aspects of the country –social and economic, supplemented by photographs of rural life, central buildings, etc. These documents, unfortunately, have never been made public. They remain in archives for the eyes of visiting researchers only.

Gunn did not carry out an in depth survey of Poland in 1921 during his short visit there. He relied mostly on what he learned from Rajchman, “a very energetic and clever man who has done a wonderful piece of work…” Rajchman’s top priority was the creation of a school of hygiene that would house laboratories, a hygienic museum, lecture and demonstration rooms, a plant for the scientific testing of apparatus, a library and a workshop. Training would be given to sanitary inspectors, health visitors (nurses), health officers and health department secretaries. Sanitary inspectors would not be expected to have degrees but would have taken secondary school courses. They would act as the “executive officers of the Health Officers in all routine matters as disinfection, placarding, sanitary inspection, etc.” Health visitors would probably have standards that for some time “would be lower than those in the United States for public health nurses.” Health officers would be offered two possibilities, a public health diploma course of 6 months and a shorter course of one month. All health officers would be required to take one or the other. Secretaries would serve as clerks capable of handling statistical material and public health legislation among other matters. “Women would be favored for this training.”

Gunn found this program to have a “certain British flavor” which was not surprising given Rajchman’s earlier contact with the Royal Sanitary Institute. He thought that “it must be conceded that in general his plan is a good one.” Rajchman was “very solid with the Minister of Health” but suffered “an enormous prejudice against him on account of his being a Jew.” While funding for his program was well advanced, a good deal more would be forthcoming if the IHD expressed interest in his program, or so Rajchman indicated to Gunn, who continued, “you will gather perhaps that Rajchman is a canny man and has the characteristics of his race.” He ended his letter to Rose with another sweeping observation, “the educated Poles are certainly more polished than the Czechs but they have had better opportunities to become so.”

The American Press was informed of the Foundation’s efforts in Poland, as announced in the Nebraska State Journal, on 19 July 1922:

Six medical students from Polish universities have been selected to go to America to finish their studies preparatory to entering the new institute of hygiene recently established here by the Rockefeller foundation. Professor Selskar Gunn, representing the Rockefeller interest, has made the final choice of the students after a competitive examination organized by the Polish ministry of health. An endowment of $250,000 has been given for the establishment of the institute by the Rockefeller Foundation.

Almost from the time that Gunn took over the responsibility of the Paris Office, he became the intermediary between Rajchman and the New York office.  They developed a close friendship, and, like with Štampar, that relationship helped further shape Gunn’s understanding of the European approach to public health, namely that of social medicine.

After spending several days in Geneva in December 1923 Gunn wrote Russell, “I have a better idea of the League of Nations than I ever had. I may say also that my enthusiasm for the League has increased.” From this point on one senses in Gunn’s letters to Russell a more positive attitude with greater attention paid to the various ideas that he had explored with Rajchman obviously with the latter’s intent of gaining the interest of the Foundation. Various new initiatives emerged in this manner, e.g. the interchange of Medical Officers of large urban areas with the idea of studying the “tremendous problem” of improving housing conditions. On this occasion Gunn added, “As you know I am tremendously impressed with the value of this kind of activity and believe that the League of Nations is spending our money extremely wisely.”

Gunn favored Rajchman receiving ‘a lump sum annually for a number of years for the general purposes of the work of the Health Section but without it being earmarked’, a practice that Russell abhorred. While expressing support of the League’s health activities, Russell wished to see a clear intent on the part of the countries involved eventually to take over from the IHD the costs of any program initiated. As early as March 1924 he wrote Gunn concerning the Interchange program, “The question therefore arises whether our main purpose in making this grant is not already achieved and whether we should not look to the member governments for the expansion and further support of the work.” Russell was of the opinion that the IHD should help the League “develop one department after another until they are able to assume the expense themselves or until it is clear that they cannot.” Also, “we might arrange for an occasional international conference.” Gunn agreed in principle but questioned “if the time limits set in the contract are too short and if the credits voted are too small,” adding further, “I believe that the IHD should be liberal in this whole matter.”

Russell was willing to consider the possibility of funding the Interchange program as part of their Fellowship program but as concerned the Epidemiological Intelligence Service, he was waiting to see what the League would do given that the Division established by Sydenstricker was “already fairly well established,” i.e. could Rajchman guarantee that the program was viable if the IHD decided to withdraw gradually its financial support. Gunn replied with excerpts from a letter that he had received from Rajchman that it was an “undoubted fact” that the Service would receive “definite financial support” from the League, but then went on to point out that Europe was “still passing through a very severe financial crisis.” In any case, Rajchman was more concerned with the future of the Interchange, as this was the instrument for “bringing about a permanent ‘change of heart’ in the ranks of Public Health Services.” (May 2, 1924)

Sydenstricker was ???

Gunn took a special interest in the activities of the LNHO concerning malaria which at the time was considered by many “to be perhaps the most urgent health problem in Eastern and South-Eastern Europe.” (October 12, 1923) Initial efforts focused on the question of why malaria had disappeared in some countries, e.g. Denmark and Holland, and not in others. Gunn thought that it had been due to “the almost complete use of land for agricultural purposes, combined with high intelligence on the part of the people,” while adding, “there may of course be other important reasons.” Rajchman wanted to go further. Such studies will not assist countries in controlling malaria. He wanted the League to carry on some malaria control work while suggesting to Gunn that the IHD assist Greece in the malaria campaign. He also pressured the IHD to make Hackett a member of the Commission.

Hackett could not be made a member of the Commission under IHD rules but he could actively participate in its work as an observer. This proved critical in helping Rajchman overcome the conservative position of members led by Col. James who in March 1930 had prepared what Rajchman judged to be “a hopeless document” which if adopted “would probably have resulted in almost complete stagnation in anti-malarial work in Europe.” Gunn pointed out to Russell that had it been adopted “it would have made it impossible for Štampar to continue the kind of malaria work in which he is now engaged.” (March 30, 1925) Russell pointed out in his reply that “Hackett deserves a good deal of credit for analyzing the situation at an early date, which permitted everyone to have knowledge of the danger and to take some steps at least to correct the errors. It means a good deal to have brought about a reconsideration of the old formula for the eradication of malaria, and this we have in some measures been able to do so during the past year. (April 13, 1925)

Similar exchanges continued to take place over the years that followed. Although Russell constantly reminded both Gunn and Rajchman that an ever increasing contribution on the part of the IHD was contrary to practice, he was equally constant in his support of the work of the League and managed to present new requests successfully to the Board overseeing the work of the IHD.

Gunn and Rajchman saw each other quite regularly, either in Geneva, where Rajchman was based, or in Paris. Their discussions centered on the subjects that were currently under review by the LNHO, and which no doubt Rajchman hoped to obtain additional funding from the Foundation. Those subjects that Gunn judged to be of greatest importance included popular public health education; health problems in connection with maternity, infancy and preschool children; the health of children of school age; tuberculosis; and venereal diseases, mostly fields that Russell did not particularly want the Foundation to addressed, thus possibly making them more attractive for funding purposes.

For a while the Foundation’s involvement with the League was taken as evidence that America might yet join. This proved to be an illusion. However, as already noted, this did not prevent America from participating in the work of the LNHO through the presence of Hugh Cumming on the LNHO’s Health Committee. Unfortunately, Cumming disapproved of Rajchman’s efforts to make the LNHO a truly international agency, i.e. one that moved into the American continents which Cumming believed ‘belonged’ to the United States. Cumming, in his capacity as Surgeon-General was also head of the Pan-American Sanitary Bureau. As such, he was concerned with the League extending its activities around the world. He interpreted any LNHO activity in the American region as an attempt to “lessen the prestige” of the PASB.

When Rajchman moved to takeover some of the work of the OIHP, an 18 May 1926 headline of the New York Times read “Cumming Protests League Methods.” Cumming called the effort of the League to take over the work of the OIHP as “highly injudicious.” When advocates favoring the position of the League pointed out that the League was receiving large financial support from the Rockefeller Foundation, Cumming replied, “The American Government was not concerned with what private American organizations did with their money.”

Real tensions existed between Rajchman and Cumming. One incident particularly upset both of them. This arose during a visit of health officials to various countries organized by the League in early 1925. The officer responsible for organizing and guiding the visit was Destouches. As described by Gunn to Russell, “Rajchman and the officials in the League are very sore about it. Rajchman stated that when President Coolidge received the men, he asked who had sent them on their study trip and that the President was informed that they were sent by the Pan-American organization.” Gunn went on to note that Rajchman was also sore that “Cumming never acknowledged any of the letters sent to him with regard to the meetings of the Health Committee which have just taken place in Geneva. There certainly appears to be a feeling over here that Cumming does not do very much to push the League, although he is a member of the Health Committee.”

Unfortunately Cumming, who was both socially and politically conservative, did not appreciate Rajchman’s “social radicalism” and actively contributed to Rajchman’s eventual departure in 1939. Despite the disapproval of Cumming and other conservative members of the Health Committee, the Foundation remained supportive of the LNHO until the end of the 1930s, when League activities, for all intents and purposes, came to a halt.

Gunn’s report on the situation regarding IHD work in Europe at the end of 1924, for obvious reasons, began with France, where the earlier anti-tuberculosis work had been transferred to the Comité National. As development of cooperation with the central health authorities of France had been ‘very slow’, a cooperative program had been initiated with one of the Departments, that of Hérault, where it was judged that in five years’ time Hérault would have a ‘modern health services’. Gunn also expressed the hope that a project would be developed for the creation of a school in Paris for the training of health personnel closely related to the Faculty of Medicine of Paris, under a special board of directors for the ‘post-graduate work, with special courses for non-medical personnel’. Although not mentioned in this paper, Gunn helped in the creation of a national office of social hygiene, which resembled of Czechoslovakia in many ways.

The other countries reported on were England, Ireland, Denmark, Norway, Sweden, Austria, Czechoslovakia, Hungary, Poland, Yugoslavia, Turkey, Greece, Albania, Bulgaria, Romania, and Algeria. Several other countries were included, e.g. Russia, Belgium, and Germany, where no concrete action had yet been taken. With respect to Czechoslovakia, despite expressing that he was “somewhat discouraged”, Gunn voiced the opinion that it was “bound to be one of the most progressive and important countries from the point of view of public health in Central Europe”. He was also upbeat concerning prospects in Hungary, Poland, and Romania, but it was Yugoslavia that he found “the most interesting in Europe today”.

Both Gunn and Russell had visited Yugoslavia in 1923 by which time Russell had become Director of the IHD. Both were much impressed by the program led by Dr Andrija Štampar, Director of the Division of Hygiene of the Ministry of Public Health. Gunn returned in the spring of 1924 where Štampar accompanied him during most of his visit. Based on what he saw, Gunn concluded that: without any assistance from outside and with limited and inadequately trained personnel they have been able to accomplish much within a short period of time. In fact, he doubted if there was any country in the world in which such strides had been made in ‘so short a period of time.

As Gunn understood it, this was exactly the kind of situation the Board was looking for, “to help those countries which are both anxious and capable of helping themselves’. Without such help Yugoslavia would continue on its path but with help ‘we can accelerate it very materially”. Of perhaps even greater importance was the fact that “by showing our interest in a material way we can undoubtedly assist in stabilization of the whole public health program”.

Although his views were made three years later, it is remarkable how Gregg’s impressions reinforced those of Gunn:

We have:

  • helped an extraordinary group of men to see clearly and begin wisely a very large undertaking;
  • through fellowships and buildings we have kept this group to their undertaking which has prospered and grown  amazingly, and we are now at the beginning of the third stage, i.e.
  • upholding through moral support during a period of 3 to 5 years the early life of hygiene in Yugoslavia. This can be done by means of help scaled off in rapidly-diminishing amounts. In general, I think that it is true there are few places where enthusiasm, energy and local support, together with aid from the Rockefeller Foundation, have accomplished so much or where we can relinquish active support and yet be as sure of the job as in Yugoslavia.
  • The political situation of Yugoslavia was complex and potentially explosive. There were political parties that wished to develop the country into a “greater Serbia”. Another favored the monarchy, while still others wished for the autonomy of Croatia or favored the special interests of the clerics, the Mussulmen, the Germans and the Hungarians. The border with surrounding countries was still in dispute and sometimes difficult to protect, especially the one with Albania:
  • The difficulties… have mostly to do with bandits who, unlike the political bandits on the Bulgarian frontier, are ordinary robbers. According to Dr. Štampar, banditry in Albania is a symptom of malaria. The Albanians, who suffer enormously from this disease, are unable to raise sufficient crops, and after a summer of fever, the easiest way in which to make a living is to go out and rob. Unfortunately, these robberies are often associated with murder…

Gunn identified some weak spots: vital statistics, sanitary engineering, and difficulties in controlling malaria. But Štampar’s list was an inclusive one; no area of activity was left out:

  • Traveling and resident fellowships
  • Sending some of the higher officials on study missions to the United States and elsewhere
  • Assistance towards the building of the School of Public Health in Zagreb
  • Assistance towards the development of the training of Public Health Nurses in the Belgrade School of Nursing
  • Assistance towards finishing the equipment of the Institute of Tropical Medicine in Skoplje
  • Assistance towards completing the equipment of the Central Epidemiological Institute in Belgrade
  • Assistance in the erection of School Clinics in Serbia
  • Assistance towards the erection of ten public health centers in ten villages in Macedonia, with financial aid for one-half of their maintenance during the first year of their existence
  • Assistance towards building an Epidemiological Institute in Catinje, Montenegro
  • Assistance for a period of two years to make it possible for the Ministry to employ two tri-lingual stenographers.

Gunn made sure that Russell was kept well informed of each new development in Yugoslavia, often adding favorable comments. In July 1925, for example, he said, “I am more than ever convinced that Dr. Štampar is going to have an extremely interesting school”. In the meantime, Stampar, who had prepared an album to celebrate five years of activity at his Ministry, sent him a copy with a note that read:

Never shall I endeavor to forget your precious friendship and assistance, which you have displayed to me in the most painful hours. Accept this gift as a kind remembrance of a beautiful époque, when we fought in common for the general welfare of people. In a common striving towards a fair cause two men have met as friends, which though strangers by blood and nation are brothers by ideas.

The album in question was Five Years of Social-Medical Activities in the Kingdom of Serbes, Croats and Slovenes, Institute of Social Medicine, 1920-1925. Readers of Štampar’s book, for it was he who was in charge of the Institute of Social Medicine in Zagreb, would have found a more elaborate explanation of the underlying social medicine ideas that Štampar was promoting:

  • It is more important to enlighten the people than to impose laws.
  • It is most important to prepare the ground in a certain sphere and to develop the right understanding for questions of hygiene.
  • The question of public health and its improvement must not be monopolized by medical authorities, but has to be cared for by everybody, for only by joint work can the progress of health be obtained.
  • First of all the physician must be a social worker; by individual therapy he cannot attain much, social therapy is the means of success.
  • Economically the physician must not be dependent on his patient, because it hinders him in the accomplishment of his principle tasks.
  • In matters of national health no difference is to be made between the rich and the poor.
  • It is necessary to form a health organization, in which the physician will seek the patient, not the patient the physician; for this is the only way to gather an ever increasing number of those whose health we have to care for.
  • The physician has to be a teacher to the people.
  • The question of national health is of greater economic importance than humanitarian importance.
  • The principal fields of action of a physician are human settlements and not laboratories and consulting rooms.

This list may strike some as being a bit paternalistic. What is missing is the manner in which Štampar ‘delivered’ his messages, which Adamic in his book about Yugoslavia described as follows:

Although, as I have suggested, a colossal personality, he is essentially a simple man, utterly free of pretense, basically a peasant. Speech comes out of his mouth in a rhythmic roll with beautiful cadences. Talking even with an educated person, he seldom uses a word that the most backward peasant cannot understand.

Stampar was opposed by some in his country for having accepted the financial assistance of the Foundation for the development of his School of Public Health. He rejected this stand, using the argument that:

If so many countries richer both by tradition and wealth, could have built their most important institutions with the support of the Rockefeller Foundation, why should not our country have done the same, the more so because it has probed in the course of time that the School of Public Health can for the most part support itself by its own revenue, and it is very likely that in time it will be able to cover all its expenses.

 

Gunn did not hesitate to intervene politically on Štampar’s behalf during his visit to Yugoslavia, especially as he was well aware of how strongly the medical profession opposed Štampar’s ideas. He used courtesy calls to members of the Royal family to extol the virtues of Štampar’s program whenever he could. During his visit in late 1926, for example, he “congratulated” Prince Paul (brother of King Alexander) and his wife Princess Olga, “on the advanced position of public health” in their country.

Rajchman shared Gunn’s enthusiasm for the work of Štampar. Following a tour of Yugoslavia in October 1927 Rajchman telephoned Gunn to tell him how “inspiring” he found it: While he (Rajchman) had always appreciated Štampar’s energy and genius, he confessed he never expected to see such great progress accomplished during the last three and half years.

In time, Yugoslavia would receive significantly more funding than any other European country that Gunn was actively involved with. In comparison, requests from the other countries visited during this period were not as comprehensive, although all shared in their desire for fellowships and study missions. Armed with his experience in Czechoslovakia and his knowledge of what Štampar was doing in Yugoslavia, Gunn was able to assess the needs of other countries quickly and with confidence. No doubt he influenced was countries asked of the RF. For example, following his visit to Hungary in the summer of 1924, during which time he met with leading figures in government and visited several provinces, he reported that the Hungarian Ministry wished to develop a Sanitary Reform Bureau similar to the one that he had helped establish while in Prague. He said that they had “watched with interest” what the Czechs were doing and concluded that they could benefit from such an idea. The Minister was “enthusiastic” and Gunn recommended that “an appropriation not to exceed $5000.00 be made available” during 1925. Dr Béla Johan was chosen as the first director of the institute. Johan would go on to become one of Europe’s leading figures in public health; the Rockefeller Foundation considered him the “best public health administrator in Europe”. When Russell visited Hungary in 1928 he judged Budapest’s Health Institute to be “first-class”.

During his visit to Rumania in 1925 Gunn learned that the Government hoped to obtain assistance on many fronts including to “insure permanently the instruction and public health education of doctors in the country itself”, which would involve “the application of medical science to sanitary organisation, to studies of sanitary reform and the practical application of public health medicine”. These “ends would be attained by the creation of an Institute of Hygiene”, or so proposed the Secretary General of the Ministry of Health, Dr Cané.

Gunn proposed fellowships, invitations of certain health officials for short visits to other European countries, and that the Division of Studies undertake studies concerning nursing. Gunn believed that there might be an opportunity “in the future” to help in the development of a School of Public Health “to assist in the development of certain services in the Ministry of Health”, such as helping in the elaboration of county health demonstrations and the campaign against malaria, all of which eventually came to pass. But why Gunn neglected the call for help in “educating doctors in the country”, an issue that he felt strongly about when serving in Czechoslovakia, is not clear. It is possible that he may have wished to avoid subjects that he was beginning to realize were ones that Pearce did not wish to engage, as discussed in more detail below. Alternatively, as Gunn was to learn during his next visit in late 1926, “all professors in Medical School and most doctors in Rumania think they are public health experts”, which he noted “makes for complication”. Also, Rumania “has a poor press in USA”, which did not prevent him from continuing IHD support to fellowships, but only to “leaders”.

Haven Emerson (1874-1957), first Director of Columbia’s DeLamar Institute of Public Health, visited Gunn in November 1927 and asked him for suggestions for a special issue concerning public health in Europe. Gunn suggested several possible writers for the various subjects that Emerson proposed:

  • Rural hygiene in Yugoslavia, by Stampar
  • Maternity and Infancy work in England, by ?
  • School of public health in Warsaw, by Chodzke
  • Hungarian National Public Health Laboratory, by Johan
  • Departmental Health Work in France, by Aublant
  • Anti-malaria work in Italy, by Missiroli
  • Campaign against endemic syphilis in Bulgaria, by Gelesmanoff
  • Role of Volunteer National Public Health Agencies in the Scheme of National Public Health Services, by Pelc
  • School Health Education inn Belgium, by ?
  • The New Organization of Public Health and Practice of Medicine in Turkey, by ?
  • Public Health Institutes in Europe, by ?
  • Article on some phase of Public Health in Denmark, by ?

Louis Aublant was the medical inspector of the department of Hérault (Montpellier) in the early 1920s, and was much appreciated (and financed) by the RF; later he became président of the Syndicat des médecins-hygiénistes de France. Chodzke was ???; Missiroli was ??? and Gelesmanoff ???

Gunn’s almost frenetic pace hardly slowed down as time passed. As well, he was stressed with the poor health of both his wife and their daughter, After a few days spent in Cannes with them, he wrote Russell that his wife was having “a good many attacks of internal pain” and that his daughter, while looking better, was “obviously a delicate and nervous child”. In time both moved back to the United States and were absent from any further references either on Gunn’s part or from any other source, archival and otherwise.

Russell tried to put a break on Gunn, but with only partial success.

In September 1925 Gunn wrote Russell to inform him of his forthcoming travels:

I am leaving the office on the 15th September for Norway, via England, and in London I shall see Dr. Stephenson, of Dublin and Dr. Belfour. In Cale I shall hope to arrange the final details with regard to the Institute of Hygiene there and get the additional information which you have asked for. In Copenhagen I am especially anxious to see Dr. Tryde and find out if we can solve the difficulty which exists concerning their statistical service. I shall then stop off for a day or two in Hamburg to see Nocht and determine whether there is any possibility (or desirability on our part) of helping Nocht in connection with his Institute with special reference to malaria courses. I shall then return to Paris for a day or two and leave for Rome, for the malaria congress. I am particularly anxious to see Hackett as we have rather a large number of things to talk over. From Rome it is highly probably that I shall go directly to Prague via Vienna. The Institute of Hygiene in Prague will possibly be opened about the 11th October, and I think it would be considered discourteous if I did not go. (September 2, 1925)

In this same letter Gunn noted that he was expected to return to the United States for three months leave. He assured Russell that “it would be impossible for me to do nothing for three months”, and instead proposed that he take one month off and then “spend time in the New York Office and visit one of the county health work in the south”

Within a month Russell wrote:

There are three new countries in Europe which you have recently been invited to visit, – Sweden, Finland, and Belgium. You will of course choose your own time to make a study of the public health situation of these countries. I am writing now to say that even though something very desirable might develop in one of them as a result of your visit, we do not feel at all sure that we could undertake any program involving a considerable expenditure at this time. We could, if it were desirable, grant a limited number of fellowships to each of these countries. Beyond that, it is not clear that there is anything that we could do now…

I think it is extremely desirable that we should bring to completion some of the projects already under way before starting new ones, and that requires a lapse of time. Furthermore, I do not believe that either your office or this office is able to administer satisfactorily with its present limited staff, additional projects that call for close attention. The development of the departmental health organizations in France will require an increasing amount of your time, and in my judgment there is no more important piece of work anywhere under way than that.

It is difficult to imagine what projects Russell thought should be brought to completion, as almost every time Gunn visited any country new requests were almost certain to result. Public health was a long term affair. It is true that the construction of buildings must come to an end at some point, but all of the other types of activities that Gunn was engaged in – strengthening institutions, educating the public, increasing the availability of public health services – these never ended, as a brief review of some of the other countries in which Gunn was involved well illustrates. However, Gunn fully agreed with Russell concerning France. As for the other visits, after acknowledging that he had understood Russell’s message, he curtly went on to say, “I am looking forward to our discussions when I come to America next year.” He probably hinted to what he had in mind for these discussions when he went on to say:

I am more than ever convinced of the necessity of our having enough men in the field to really give close attention to our various activities. Very often an activity involving a relatively small sum of money takes much more time and requires very much greater thought and attention than some large proposition involving building, for example.

Russell, although indicating that he was ‘glad’ to learn that Gunn planned to send summaries of work carried out in other countries, went on to remind Gunn that ‘not all the desirable and needed public health activities in the countries of Europe can be started or developed by us at once. I hope you will not permit the pressure of urgent needs to interfere with your vacation. When do you plan to take it?’ While one might read into this an insulting attitude on the part of Russell, I believe that there was real concern in New York about Gunn’s health owing to his workaholic ways and his having been treated for tuberculosis in early 1920 in a TB sanitarium in the States for several months, as already noted.

Despite some reservations, Russell was pleased with how matters had developed in Europe. During a discussion in early 1924 involving senior officers of the various Foundations run by the Rockefeller family, he noted (favorably) how the IHD program in Europe had started “with a single item of tuberculosis control and has now grown to a generalized program in public health throughout the continent”. Nevertheless, there were some basic differences basic differences between Gunn and Russell as can be seen in Russell’s detailed response to Gunn’s proposals for Czechoslovakia for 1927, which included Russell’s observation that “probably until there are some results from the health demonstrations, we should not be inclined to grant funds to develop a central bureau of public health education. The demonstrations themselves should have greater educational value than any other propaganda measure”. The technical services of the Ministry of Health that Russell thought the “Board would be most likely at this time to be interested in” were vital statistics, epidemiology, sanitary engineering and public health nursing. Missing from this list was Gunn’s desire to create a central bureau of public health education. More importantly was the absence of any item concerning strengthening the social medicine aspect of medical education, something that Gunn was in favor and with the example of Stampar could now push for it with greater confidence.

It was through Štampar that Gunn extended his understanding of the intimate links between social and economic conditions of the rural poor and their health. This reinforced the conclusion that he had already reached while working in Czechoslovakia on the importance of undergraduate training in public health in medical schools. Štampar believed that the development of public health services “required a great number of properly trained physicians”. In his opinion the separation of undergraduate and postgraduate training in public health was “not a good thing”. Furthermore, undergraduate training was “more important and the postgraduate training should be only a continuation of the former and confined mostly to the doctors who have shown a great deal of interest in public health matters during their undergraduate studies”.

To what degree did Gunn appreciate how different Stampar’s set up was from that which was favored in America is difficult to judge as he had so many tasks to perform during the critical period (1914-1917) when Sedgwick was left out of the discussions concerning what a model public health school should look like.

These discussions took place in 1914 and were led by Alexander Flexner, Secretary of the GEB. Flexner’s task was to consider the desirability of improving medical education in the United States with a view to the training of men for public health service.[i] He organized a meeting in October 1914 to which were invited representatives of a small number of medical schools (Columbia, Harvard (Rosenau and Whipple) and Hopkins (Welch)), several senior public health men, including Biggs (now New York State Public Health Commissioner) and Winslow (New York State Department of Health), and representatives of the Rockefeller Foundation, most importantly Rose. Sedgwick was not invited. Although Flexner later excused himself, when Sedgwick was not invited for the second round of discussions, it seems clear that Flexner did not want to have to contend directly with an alternative model of how public health training might be organized.

That model was conceived by Sedgwick during the time that Gunn was still at MIT. His educational strategy called for the development of two practitioners, one in medicine, the other in the science and arts of public health. His so-called Y plan had both students together for preclinical instruction before dividing, one leading to a degree of Doctor of Medicine, the other a Doctor of Public Health. The joint course for a Certificate in Public Health, which bore the seals of both Harvard and MIT, represented a first step towards this goal.

Despite the absence of Sedgwick the question whether or not health officers should have a medical degree was central to those present; opinions differed greatly. Welch visualized a qualified health officer as “a doctor of medicine with a hospital internship and two years of special training that would make him also a doctor of public health”.[ii] Flexner, having a similar model in mind, believed that a school of public health needed to have a strong relationship with a medical school, as public health officers had to deal with the prevention and management of disease, which they only could come to understand “in the laboratories and hospitals of a medical school”.

Biggs argued against the requirement of a medical degree. Rosenau, not surprisingly, given his relationship with Sedgwick, went so far as to argue that public health was a distinct profession, separate from the practice of medicine and that the program should be coordinate by not subordinate to the medical school. Winslow, too, believed that public health was “not a branch of medicine or engineering … the ideal school of public health should train all the various grades of sanitary workers from the highest to the lowest. Public health nurses, sanitary inspectors, and health officers for small towns are far more urgently needed than high-trained medical officers of health”. Rose ended the meeting with a vision of training that seemed to please everyone present. He described a system of training in public health services for the country as a whole, which involved one or more central institutions that covered the whole field of public health instruction, using for their laboratories, the state health organizations, city health organizations, and actual field work.

Rose and Welch were assigned the task of writing the report of the meeting. Rose wrote the first version, which was then rewritten by Welch. Whereas Rose’s plan called for a “national system of public health training, with a central school of public health as the focal point of a network of state schools”, Welch’s version dropped Rose’s system of state schools, practical demonstrations, and extensions courses, leaving in its place a “center for scientific research and the production of knowledge”.

Johns Hopkins, the clear choice of Flexner, was chosen for the new institute, with the understanding that Welch would be its director. In June 1916 the Executive Committee of the Rockefeller Foundation approved the plan for the School of Hygiene and Public Health. No budget for practical training was included, i.e. no links with state or local organizations, no extension courses, no demonstrations. This was consistent with Welch’s belief that “the school…must not feel directly and immediately responsible for public health administration or for knowledge of public health matters throughout the nation… ”. Only when the Foundation pressured Welch did he move to add staff that had any practical public health experience. At one point Biggs was offered an appointment in public health administration, which he did not accept, possibly because “he may have viewed the research-oriented Welch school as largely irrelevant to the pressing needs of public health practice”. The school opened in October 1918 with Welch in charge, a position he retained until 1926.

In the spring of 1920, Winslow, who at the time was chairman of the APHA Committee for standardizing public health education, wrote Gunn: “The committee agreed to give a certificate for one year’s work to college graduates, but required a medical degree, plus two years of graduate work for the doctor of public health. I do not know whether we are right to do this or not, but it seemed to me the more conservative and the wiser course to follow. The APHA will have to leave the question of the MD requirement optional, as many schools, like Michigan, would not agree at present to follow this rule”.

Stampar’s model differed significantly in one major way; it called for the public health school to have an intimate relationship with the national health system, something more in tune with Rose’s initial ideas than those of Welch. When Welch attended a conference organized by the LNHO in Zagreb in early October, 1927 in association with the official opening of the School of Public Health, he had intended to protest against the Zagreb school; instead he thought that England, America and other countries “might study the system here”. He even went so far as to indicate felt that is was too soon to set down rules, nor was it desirable to fix a standard. Experiments should be tried and later there may develop a “unanimity of opinion”. Those attending also included Gunn, Rajchman, Stampar, Pelc, Johan, Chodzko, de Souza, and Grotjahn.

On the conclusion of the discussions, Welch stated that was a need for “permeation of public health idea in schools of medicine”. Hopkins had come to realize that a department in the medical school could never cover the field of hygiene today. No one professor could cover statistics, sanitary engineering, medical zoology, epidemiology, etc. The collaboration of all in one school seemed to him necessary.

Gunn became more and more convinced that the lack of discussions inside the Foundation that explored alternative approaches medical education was due to the existing division of labor between the IHD and the DME. In a long letter to Russell written in April 1925, He noted that the teaching of preventive medicine in the medical schools in Europe ‘has been very poor in the past … and … remains so in most of the medical schools’. Gunn judged the ‘whole matter’ to be of ‘very considerable importance’. Gunn described the rising importance of the professor of hygiene and the efforts being made in various places to improve the laboratories for the practical teaching of the subject. He introduced the question of the relationship of the Chair of Hygiene to postgraduate courses and special courses in public health, concluding that, despite the fact that there were some exceptions, it was ‘more logical that the postgraduate and special courses should be also tied up in some way with the Institute of Hygiene of the Medical Faculty’. He observed that the programme of the DME had, until then, been essentially ‘of an emergency character’ but that this was drawing to an end. There was ‘already a tendency – as for example in connection with the development of the teaching of hygiene in the medical schools – for the DME to develop a constructive program’. As events would shortly demonstrate, Gunn was somewhat over-optimistic in reaching this conclusion.

Gunn discussed this question with Pearce during the latter’s visit to Paris. Gunn reported to Russell that he and Pearce had concluded that it would be wiser if the undergraduate teaching of hygiene in the medical schools was transferred from the DME to the IHD. This would lead to a more unified programme of public health in a given country. A similar case was made for public health nursing, which Gunn thought should also be moved into the IHB from the DS, whose responsibilities included nursing education, dispensaries and some aspects of mental hygiene. Gunn ended his letter with Pearce’s suggestion that the three divisions represented in Paris make a joint report on new countries which were to be surveyed as well as a similar report for countries in which the Foundation was already operating. Russell’s reaction was clear, as indicated by his note in the margin: reports should be made after instructions from NY. Joint action to be in NY (emphasis added). Clearly, Russell was not about to delegate any of his authority to the Paris Office or to share it with Pearce, with whom he neither collaborated nor had a friendly relation. Simon Flexner, one of the Board of Directors of the IHD, had occasion to write of the ‘friction’ between Russell and Pearce, that occasionally led Russell to lose his temper.

There is a bit of history that suggests that Russell was in fact in favor of Gunn’s ideas but was stymied by Pearce’s opposition. In September 1923 when David Edsall, Dean of the Harvard Medical School, sought funds from the Foundation for a plan to improve the teaching of the preventive aspects of medicine during the course of the regular teaching in several departments of the medical school, Russell and Vincent replied that they saw this project as “one of great fundamental importance and distinctly one in which our Board might interest itself’”. Furthermore, they understood it to be “the connecting link” between the activities of the Foundation in the development of medical education and of the IHB in the development of public health.

That Pearce thought differently can be seen from his reaction to Gregg’s expressed interest in the undergraduate medical education. This evoked a clear response from Pearce: he (Gregg) “should not be obsessed with the idea of helping medical students only in the undergraduate school. We inherited this idea when the Division started, from work that had gone on before in other groups of Rockefeller Boards. There is no reason now why we should not get away from it to a large extent”. Gregg later (circa 1950) lamented that “Pearce did not want undergraduates in public health”, adding that “this seems to have been an example of blindness on the part of Rose and Russell; they had a graduate school for a subject in which there was no undergraduate course. It was not possible to influence capable students during their undergraduate course and Rose was throwing away his best source of new material”.

Pearce kept Gregg under tight control; one method was to use his comments on Gregg’s office diaries entries! For example, when Gregg noted in his diary that “we [i.e. DME] could consider” a proposal for aiding post-graduates in Hungary who were preparing themselves to join Johan’s teaching staff, Pearce replied:

[This] request is the same old request for aid to post-graduate education. We have declined to help him several times, and I do not understand the last sentence in your memorandum in which you state we could consider aid for resident fellows who are preparing themselves to join Johan’s teaching staff. I know of no such item in our budget which would cover this. We are planning to limit the development program to France, Italy, Spain and Portugal. You may have something in mind which escapes me for the moment.

Much later Gregg was to say that he had had “a nice relationship” with Pearce, one in which he felt he had Pearce’s confidence. Still, it is difficult to believe that Gregg was not somewhat frustrated, if not by Pearce’s manner of control, then by his much narrower scope of interests, as judged by the subjects Gregg chose to write about in his diaries that he was not able to act on in the normal course of his work under Pearce. Another example is a diary note that Gregg made in 1922 following lectures given at the New York Academy of Medicine concerning the Relation of Mind to Medicine:

Papers dealt with evidence that a new era is coming in medicine which increased interest in patient as an integral problem in relations of physician to the community. Doctor’s enthusiasm has been too much for the disease and too little for the patient who has the disease. Sydenham’s influence in considering disease as an entity has developed to such an extent that we now consider a patient as though he were the carrier of some curiously wrapped and interesting package which he submits to the doctor for investigation – the doctor unwraps, unties, names and hands back to the patient.

It’s not surprising that given his early appreciation of this basic principle of preventive (social) medicine that he was favorably impressed by Stampar’s program and ideas. Following a luncheon with him in July 1925 he noted that Stampar was pushing the idea of preventive medicine “to its limits – distributes beds as part of the plan to families that are sleeping two and three to a bed – Is organizing domestic science classes for mothers and has other plans of a similar nature – Has reached a point where the need for trained personnel is becoming a serious limitation. He described Štampar as having a striking personality; his enthusiasm was contagious; he has imagination, energy and temperament with all the advantages and some of the disabilities involved. A thoroughly fascinating and compelling man – “One can understand the enthusiasm of SMG” (Selskar Mike Gunn).

Ironically, it was Pearce who had funded Štampar’s “new method” of teaching hygiene to medical students by enabling them to get direct field experience of public health work in the villages under expert direction.

Gunn’s memo did provide a reason for Vincent to call a conference of officers in May 1925 to discuss the teaching of hygiene, closer cooperation between the IHD, DME and the DS in working out plans in a given country, nurse training (division of labor), and the administration of the Paris Office. Hardly anything emerged from this meeting because after expressing dissatisfaction with the present arrangement, which was that of Gunn conducting ‘complete surveys’ of public health because Pearce did not believe that Gunn was likely to send in reports on undergraduate education “unless he is held directly responsible for such reports”, Pearce went on to point out that this would “interfere enormously…with the development of the medical curriculum”, for which he was responsible! On the way to coming to this conclusion Pearce did point out that one solution could have been turning all hygiene, graduate and undergraduate over to the IHD, which he then went on to reject. In the end, it was agreed that the unity of the undergraduate medical education should be preserved, and that the IHD had the responsibility “on the educational side only for the special training of health officers”, i.e. nothing changed as far as Gunn was concerned.

The meeting in New York did lead to Gunn being designated as the administrative head of the Paris Office, and a clarification of lines of communication, including the decision that “the different members of the Paris group should always inform each other of their own activities, especially where a matter of precedent or future policy that might affect all the Boards are involved”. Also, programs recommended by Paris officers to their “proper chiefs in New York” should be “accompanied by the expression of opinion on programs by other members of the Paris office group written similarly to their own chiefs in New York”. Vincent added, however, that “any unified programme of the IHD, DS and DME will have an especially strong appeal to the officers in New York and the Trustees”.

A new avenue of making his opinion known arose during the early stages of the reorganization of the Foundation, which is discussed in greater detail in the following chapter. Raymond Fosdick was in charge of this. In a confidential letter dated 19 April, 1926, he asked Gunn to give his views concerning a wide range of issues relating to the working and administration of the various Boards which the Foundation ran. Gunn delayed his reply until October, for reasons that he did not make clear.

Referring to the ‘policies’ of the IHD, about which “a great deal is said”, he thought their inflexible policies to be “most unwise”. The IHD would be better served by an ‘opportunistic attitude’, one that would allow different types of work to be carried out in different countries (or even in different parts of the same country)’. Furthermore, he was not convinced that ‘American methods in public health work are necessarily the best for European countries…, (especially as) there exist men and women who have a better understanding of the local problems and the means to be used to meet them than we have’. Gunn found the IHD program to be too narrow. Policies were inflexible; there was an unwillingness to recognize that what works for one country may not work for another, and there was a tendency to force countries to adopt American methods in public health work. These points made it “quite plain that a serious difference of opinion exists” between himself and Russell. In fact, Gunn concluded: I sometimes wonder if our organization is not a bit conceited about itself. Even if the IHD did not exist, progress in public health would continue. Our organization makes it possible to telescope time, to help in the avoidance of mistakes and to avoid crystallizations of organization on wrong lines.

Fosdick does not seem to have replied to this memorandum, so Gunn ended up dealing directly with Vincent, with whom by all indications he had a strong working relationship. Vincent was obviously sympathetic to Gunn’s views; he noted them carefully in his diary. They both believed in what Vincent called “team work”. Vincent too wished to broaden the work of the Foundation by bringing together its diverse elements under a more holistic frame. That Vincent, during his visits to Europe spent time with Gunn while the latter was on vacation, suggests that they were friends as well.

Vincent favored reducing the powers of the New York directors in charge, even going so far as to suggest that the notion of divisions be abandoned. Without waiting to see what structure would emerge from the reorganization that Fosdick was directing, he established an office of Vice-President for Europe. Two names were considered, Gunn and Gregg, with Gunn to be approached first.

Pearce told Vincent that Gregg “would make an admirable V.P. if SMG declines.” Russell and Vincent discussed the matter on the same day, but if Russell had anything to say, Vincent did not note it in his diary. Vincent discussed this question with Fosdick two days later at which point he indicated that Gunn’s salary would be higher given his “experience (and) training.” He lunched with Gunn that day to explain “the organization in theory and in practice” noting that Gunn “shows some interest and seems inclined towards favorable consideration” but wanted to consult with others before making up his mind. Vincent assured him that no effort would be made to “overpersuade (sic)” him. Three days later Gunn indicated his willingness to have his name presented for the post of “European Vice-Presidency.” No doubt, given their friendship, Gunn sought the advice of Gregg, but whether either one knew that the other was under consideration for the same post is not clear but probably doubtful, given the care with which Vincent managed the whole matter.

The appointment of Gunn as Vice-President for Europe was accompanied by the Foundation purchasing two top floors of a newly constructive seven-story building at 20, rue de la Baume, a quiet street in the Eighth Arrondissement just off the Boulevard Haussmann. That same year, Embree’s Division of Studies was dissolved, and “all operative functions” were assigned to the IHD and DME.

Russell and Pearce were informed of Gunn’s acceptance and the matter was put to the Board later that month. It was this Board meeting that the IHD was officially transformed to the IHD and Gregg was named Associate Director of the Division of Medical Education “with the same salary and terms of appointment as at present.” (Feb 25, 1927) One other post of VP was created, Embree was named VP “stationed in the Home Office.”

It was decided that “no immediate publicity” would be given to these changes. Gunn was free to explain it “to friends.” The relationship between the Vice-President and the other officers required clarification. This statement was issued:

Relations of Vice-President and President – field staff directly responsible to directors in the Home Office – Vice-President in the field confers with the directors and works in group with them. they take their instructions from home – at the same time Vice-President is in close communication with them and familiar with plans and is in conference – if there are suggestions with respect to the work of either of the Divisions any recommendations come directly through the representative in the field to the director in the Home Office – at the same time the Vice-President communicates directly with the President on any question – it is the responsibility of the President to bring up anything with the directors – no direct dealing of Vice-President with director in Home Office unless requested by the director – communications from the Home Office to the Vice-President – Vice-President communicates with director in response to a definite understanding and request – corresponds with the President on any subject – Field men supply the Vice-President in their section with copies of important letters for his information – Vice-President shall also supply field men with material in the discretion of the former.

One can see the hands of both Russell and Pearce in such a contorted memorandum. What was clearly being excluded was Gunn working directly with the field staff in the Paris Office to concoct something behind the backs of the Home Office directors. On the other hand, Gunn was free to exchange ideas with Vincent on any subject of his choosing and vice-a-versa.

2 Comments

  1. MURARD Lion

    Dear Socrates,
    Still enthusiastic with your Gunn’s biography you must perform and achieve. I do like reading you…
    One detail : you don’t mention Mike’s visit to Turkey, may 1925. Did you peruse his diary for the period, which is not digitized? As I am currently working on Greece, I am longing for comparisons with Turkey…
    Hoping that this short message finds you in good shape,
    Best, Lion

  2. socco

    Dear Lion,

    My memory is collapsing so I don’t know if I replied to this message or not!
    Either way,
    Warmest regards, Socrates