Opinion
VIEWPOINT
David J. Hunter, MBBS, ScD Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Julio Frenk, MD, PhD Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
Related article page 1172
Corresponding Author: David J. Hunter, MBBS, ScD, Office of the Dean, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115 (dhunter@hsph .harvard.edu).
The Birth of Public Health Education ease hospital,” and city and state departments of health, as well as the Federal Public Health Service. These are essentially the same institutional attributes that the Welch-Rose report recommended. However, Rosenau based his recommendations not on abstract ideas but on the certificate, degree, and institutional structure at the existing Harvard–Massachusetts Institute of Technology (MIT) School for Health Officers that he co-founded in 1913 with William Sedgwick, professor of biology at MIT, and George Whipple, professor of sanitary engineering at Harvard. Given what seems to be broad agreement between the principal recommendations of the Rosenau article and the Welch-Rose report, it may seem surprising that there were substantial underlying tensions in the approach to the future of public health education between these leading scholars. As documented by Greer Williams5 and Elizabeth Fee,3 these differences were both tactical and philosophical in nature. The tactical elements focused on which institution would receive the initial funding from the Rockefeller Foundation to endow a School of Public Health. As Fee documented, Harvard University representatives thought that they had already established the model with the Harvard–MIT School for Health Rosenau advocated for a public health Officers; Columbia University made a proposal to the Rockefeller Foundation faculty independent of other university with an emphasis on the social as well as faculties but with close ties to schools engineering and medical sciences; and such as medicine, dentistry, Rose had already proposed in May 1914 a central research-intensive school of engineering, and law. public health linked to smaller schools in contemporaneously published document from one each state in order to train a large public health workof the participants in the meeting that led to the force. After much jockeying and visitation by a commitWelch-Rose report. In fact, the Welch-Rose report ap- tee composed of Flexner, Rose, and Jerome Greene (secpears to have been available only in the Rockefeller retary to the Rockefeller Foundation) to the candidate Archives until it was published in 1992 on the occasion cities, which also included Philadelphia and Baltimore, of the 75th anniversary of the Johns Hopkins School of Maryland, the committee recommended Johns Hopkins Hygiene and Public Health. University. In June 1916, Rockefeller made an award of Rosenau, Rose, and Welch, along with other lead- $267 000 for the founding of the Johns Hopkins School ers in the public health movement from Philadelphia, of Hygiene and Public Health, with William Welch as its Pennsylvania; Chicago; New York, New York; and Boston, first dean. Massachusetts, were attendees at a meeting in New York There were also some substantial differences in unCity on October 16, 1914, convened by the General derlying philosophies. In Rose’s original draft of the reEducation Board of the Rockefeller Foundation, which port, he made it clear that he had in mind a school that was considering proposals to fund the establishment of would support his vision of a network of schools in each one or more schools to address the need for training of state. The school would be “an integral part of a system professionals in public health. This meeting was orga- which shall be national in scope.”6 In the final version of nized by Abraham Flexner, a member of the General the Welch-Rose report, this section was truncated and Education Board, and concluded with Welch and Rose replaced with a description of the 2 contrasting models being asked to “work out a plan for the new school.”3 of public health training from Britain and Germany. The Rosenau4 advocated for a public health faculty in- British model emphasized public health administradependent of other university faculties but with close ties tion, with a focus on implementing improvements in to schools such as medicine, dentistry, engineering, and sanitation, clean water, and infectious disease control law. He emphasized connections to a “contagious dis- that had already been proven beneficial. Research was The modern era of medical education in the United States is usually attributed to the report by Abraham Flexner, commonly known as the “Flexner Report” of 1910,1 and the analogue role for public health education is generally credited to the report by William Welch and Wickliffe Rose, commonly known as the “Welch-Rose report,” 2 submitted to the General Education Board of the Rockefeller Foundation on May 27, 1915. 3 Welch became the first dean of the Johns Hopkins School of Medicine; Rose was an educator who became the administrative secretary of the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease. Interestingly, prior to the submission of the Welch-Rose report, the March 6, 1915, issue of the Journal of the American Medical Association included an article titled “Courses and Degrees in Public Health Work” by Milton J. Rosenau,4 professor of preventive medicine at Harvard University, which contained almost all of the key recommendations present in the Welch-Rose report. This JOURNAL article was read at the 11th Annual Conference on Medical Education held in Chicago, Illinois, February 16, 1915. It appears to be the only
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Opinion Viewpoint
conducted at institutions that were mainly “governmental or independent.” In the German model, departments or institutes of hygiene were university-based where “the science is advanced by research.” Although the Welch-Rose report advocated learning lessons from both systems, it seems clear that Welch’s sympathies were much stronger for the “institute of hygiene” model, and the analogy with Flexner’s university-based integration of scientific research into medical schools is also clear. Some indication of the difference in emphasis in Welch’s thinking can be seen in his description of the organization of the proposed school into chemical, biological, engineering or physical, and statistical divisions, with a single division of general hygiene and preventive medicine encompassing epidemiology, industrial hygiene, the principles of public health administration, “and other subjects not embraced under the previous captions.” In contrast, the Rosenau article placed a greater emphasis on practical instruction. For instance, each candidate for the 1-year cerARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: We thank Emily Harrison for her comments on a draft of the manuscript, for which she received no compensation. REFERENCES 1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. http://archive .carnegiefoundation.org/publications/medical
1106
tificate in public health was required to conduct a sanitary survey of a city or town, a subject on which he opined at greater length in the context of the teaching of hygiene in the medical school curriculum in another article published in THE JOURNAL in July 1915.7 With the celebration this year of the centenary of the Welch-Rose report, the prior publication in THE JOURNAL of the Rosenau article is a reminder that this report was the product of a consultative, and somewhat disputative, process. The fact that the Rockefeller Foundation made its first award to Johns Hopkins University led by William Welch, and the eponymous nature of the report that led to the award, has tended to obscure the contributions of many others, of which the first one to be found in the published literature was Rosenau. These and other authors went on to publish a series of articles documenting the need to standardize the various degrees in public health that emerged from multiple institutions.8 The 1915 article by Rosenau is one of the founding documents of the era that led to the creation of schools of public health in the United States and around the world.
-education-united-states-and-canada -bulletin-number-four-flexner-report-0. Accessed February 19, 2015.
5. Williams G. Schools of public health—their doing and undoing. Milbank Mem Fund Q Health Soc. 1976;54(4):489-527.
2. Welch WH, Rose W. The Welch-Rose Report: a public health classic. Delta Omega Honorary Public Health Society. http://rockefeller100.org /items/show/4678. 1992.Accessed December 27, 2014.
6. Rose W. School of Public Health. New York, NY: Rockefeller Foundation International Health Board; 1915.
3. The Welch-Rose Report: A Public Health Classic. Delta Omega Honorary Public Health Society. http: //www.deltaomega.org/documents/WelchRose .pdf. 1992Accessed December 27, 2014. 4. Rosenau MJ. Courses and degrees in public health work. J Am Med Assoc. doi:10.1001/jama.1915 .02570360010003.
7. Rosenau MJ. The value of a sanitary survey in the teaching of hygiene. J Am Med Assoc. doi:10.1001 /jama.1915.02580040031010. 8. Abbott AC, Boyd M, Bristol LD, et al. Standardization of public health training: report of the Committee of Sixteen. Am J Public Health (N Y). 1921;11(4):371-375.
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VIEWPOINT
David J. Hunter, MBBS, ScD Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Julio Frenk, MD, PhD Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
Related article page 1172
Corresponding Author: David J. Hunter, MBBS, ScD, Office of the Dean, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115 (dhunter@hsph .harvard.edu).
The Birth of Public Health Education ease hospital,” and city and state departments of health, as well as the Federal Public Health Service. These are essentially the same institutional attributes that the Welch-Rose report recommended. However, Rosenau based his recommendations not on abstract ideas but on the certificate, degree, and institutional structure at the existing Harvard–Massachusetts Institute of Technology (MIT) School for Health Officers that he co-founded in 1913 with William Sedgwick, professor of biology at MIT, and George Whipple, professor of sanitary engineering at Harvard. Given what seems to be broad agreement between the principal recommendations of the Rosenau article and the Welch-Rose report, it may seem surprising that there were substantial underlying tensions in the approach to the future of public health education between these leading scholars. As documented by Greer Williams5 and Elizabeth Fee,3 these differences were both tactical and philosophical in nature. The tactical elements focused on which institution would receive the initial funding from the Rockefeller Foundation to endow a School of Public Health. As Fee documented, Harvard University representatives thought that they had already established the model with the Harvard–MIT School for Health Rosenau advocated for a public health Officers; Columbia University made a proposal to the Rockefeller Foundation faculty independent of other university with an emphasis on the social as well as faculties but with close ties to schools engineering and medical sciences; and such as medicine, dentistry, Rose had already proposed in May 1914 a central research-intensive school of engineering, and law. public health linked to smaller schools in contemporaneously published document from one each state in order to train a large public health workof the participants in the meeting that led to the force. After much jockeying and visitation by a commitWelch-Rose report. In fact, the Welch-Rose report ap- tee composed of Flexner, Rose, and Jerome Greene (secpears to have been available only in the Rockefeller retary to the Rockefeller Foundation) to the candidate Archives until it was published in 1992 on the occasion cities, which also included Philadelphia and Baltimore, of the 75th anniversary of the Johns Hopkins School of Maryland, the committee recommended Johns Hopkins Hygiene and Public Health. University. In June 1916, Rockefeller made an award of Rosenau, Rose, and Welch, along with other lead- $267 000 for the founding of the Johns Hopkins School ers in the public health movement from Philadelphia, of Hygiene and Public Health, with William Welch as its Pennsylvania; Chicago; New York, New York; and Boston, first dean. Massachusetts, were attendees at a meeting in New York There were also some substantial differences in unCity on October 16, 1914, convened by the General derlying philosophies. In Rose’s original draft of the reEducation Board of the Rockefeller Foundation, which port, he made it clear that he had in mind a school that was considering proposals to fund the establishment of would support his vision of a network of schools in each one or more schools to address the need for training of state. The school would be “an integral part of a system professionals in public health. This meeting was orga- which shall be national in scope.”6 In the final version of nized by Abraham Flexner, a member of the General the Welch-Rose report, this section was truncated and Education Board, and concluded with Welch and Rose replaced with a description of the 2 contrasting models being asked to “work out a plan for the new school.”3 of public health training from Britain and Germany. The Rosenau4 advocated for a public health faculty in- British model emphasized public health administradependent of other university faculties but with close ties tion, with a focus on implementing improvements in to schools such as medicine, dentistry, engineering, and sanitation, clean water, and infectious disease control law. He emphasized connections to a “contagious dis- that had already been proven beneficial. Research was The modern era of medical education in the United States is usually attributed to the report by Abraham Flexner, commonly known as the “Flexner Report” of 1910,1 and the analogue role for public health education is generally credited to the report by William Welch and Wickliffe Rose, commonly known as the “Welch-Rose report,” 2 submitted to the General Education Board of the Rockefeller Foundation on May 27, 1915. 3 Welch became the first dean of the Johns Hopkins School of Medicine; Rose was an educator who became the administrative secretary of the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease. Interestingly, prior to the submission of the Welch-Rose report, the March 6, 1915, issue of the Journal of the American Medical Association included an article titled “Courses and Degrees in Public Health Work” by Milton J. Rosenau,4 professor of preventive medicine at Harvard University, which contained almost all of the key recommendations present in the Welch-Rose report. This JOURNAL article was read at the 11th Annual Conference on Medical Education held in Chicago, Illinois, February 16, 1915. It appears to be the only
jama.com
(Reprinted) JAMA March 17, 2015 Volume 313, Number 11
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Otterbein University User on 06/01/2015
1105
Opinion Viewpoint
conducted at institutions that were mainly “governmental or independent.” In the German model, departments or institutes of hygiene were university-based where “the science is advanced by research.” Although the Welch-Rose report advocated learning lessons from both systems, it seems clear that Welch’s sympathies were much stronger for the “institute of hygiene” model, and the analogy with Flexner’s university-based integration of scientific research into medical schools is also clear. Some indication of the difference in emphasis in Welch’s thinking can be seen in his description of the organization of the proposed school into chemical, biological, engineering or physical, and statistical divisions, with a single division of general hygiene and preventive medicine encompassing epidemiology, industrial hygiene, the principles of public health administration, “and other subjects not embraced under the previous captions.” In contrast, the Rosenau article placed a greater emphasis on practical instruction. For instance, each candidate for the 1-year cerARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: We thank Emily Harrison for her comments on a draft of the manuscript, for which she received no compensation. REFERENCES 1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. http://archive .carnegiefoundation.org/publications/medical
1106
tificate in public health was required to conduct a sanitary survey of a city or town, a subject on which he opined at greater length in the context of the teaching of hygiene in the medical school curriculum in another article published in THE JOURNAL in July 1915.7 With the celebration this year of the centenary of the Welch-Rose report, the prior publication in THE JOURNAL of the Rosenau article is a reminder that this report was the product of a consultative, and somewhat disputative, process. The fact that the Rockefeller Foundation made its first award to Johns Hopkins University led by William Welch, and the eponymous nature of the report that led to the award, has tended to obscure the contributions of many others, of which the first one to be found in the published literature was Rosenau. These and other authors went on to publish a series of articles documenting the need to standardize the various degrees in public health that emerged from multiple institutions.8 The 1915 article by Rosenau is one of the founding documents of the era that led to the creation of schools of public health in the United States and around the world.
-education-united-states-and-canada -bulletin-number-four-flexner-report-0. Accessed February 19, 2015.
5. Williams G. Schools of public health—their doing and undoing. Milbank Mem Fund Q Health Soc. 1976;54(4):489-527.
2. Welch WH, Rose W. The Welch-Rose Report: a public health classic. Delta Omega Honorary Public Health Society. http://rockefeller100.org /items/show/4678. 1992.Accessed December 27, 2014.
6. Rose W. School of Public Health. New York, NY: Rockefeller Foundation International Health Board; 1915.
3. The Welch-Rose Report: A Public Health Classic. Delta Omega Honorary Public Health Society. http: //www.deltaomega.org/documents/WelchRose .pdf. 1992Accessed December 27, 2014. 4. Rosenau MJ. Courses and degrees in public health work. J Am Med Assoc. doi:10.1001/jama.1915 .02570360010003.
7. Rosenau MJ. The value of a sanitary survey in the teaching of hygiene. J Am Med Assoc. doi:10.1001 /jama.1915.02580040031010. 8. Abbott AC, Boyd M, Bristol LD, et al. Standardization of public health training: report of the Committee of Sixteen. Am J Public Health (N Y). 1921;11(4):371-375.
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Copyright 2015 American Medical Association. All rights reserved.
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