In 1900 the United States had more medical schools than the rest of the world combined. Many of them were commercial institutions devoted to making profits rather than to educating men to perform competently within the medical profession. The profit incentive precipitated low educational standards and made American medical practice decidedly inferior to medical practice almost anywhere else in the civilized world. By 1900 medical education had become pernicious, threatening the health of the nation and the future of the American medical profession. This thesis discusses the efforts to reform medical education practices.

Healthcare in the United States experienced a remarkable transformation during the late 19th and early 20th centuries. While this transformation is well documented in descriptive historical accounts there are few empirical studies investigating the mechanisms through which reform was disseminated or the affects of the reform on healthcare. To this end, this dissertation examines four issues related to changes in the American healthcare industry during the early 1900's.Chapter 2 examines changes in medical education. This chapter provides a qualitative analysis of motivations behind the medical education reforms in America and an empirical analysis of the shakeout of medical schools that occurred from 1905 to 1920. Licensing laws and medical school reviews were found to have influenced exiting decisions of many medical schools. Reform of medical education in America was followed by a disproportionate decline of physician supply in rural areas. Along these lines, Chapter 3 provides a case study of the geographic distribution of physicians during the early 20th Century. Data on individual physicians was compiled to analyze variation in physician counts across counties and to investigate out-migration of rural county physicians. This analysis indicates physicians were drawn more and more to areas offering better financial opportunities, greater access to medical facilities, and more opportunity for professional contact.It is unclear to what extent patients initially benefited from the changes in medicine. Chapters 4 and 5 focus on one aspect of this issue by examining the impact of physicians on mortality rates. Chapter 4 utilizes the individual physician data from Chapter 3 to assess whether variation in physician counts explain variation in infant and non-infant mortality rates across counties. Estimates indicate that physicians were still unable to reduce mortality in the early 1920's. Chapter 5 focuses on the impact on maternal mortality resulting from the transition of childbirth during the first half of the 20th Century from the home to the hospital setting. Using hospital beds as a proxy for medical inputs, regression analysis revealed that the transition may have contributed to more maternal deaths until the introduction of sulfa drugs in the late 1930's.

O atual modelo de atenção à saúde do Brasil tem suas origens no modelo biomédico flexneriano, idealizado e implantado nos Estados Unidos por meio da ação combinada do corporativismo médico local e do grande capital. Sua importação e implantação se insere nas relações gerais de dependência econômica e subordinação política do nosso País aos interesses norte-americanos, desde as últimas décadas do século XIX até as primeiras décadas do século XX. O objetivo desta tese é identificar e analisar como as grandes fundações norte-americanas, financiadoras do modelo de atenção médica originado a partir da publicação do Relatório Flexner em 1910, mais os interesses capitalistas, tanto do grande capital internacional quanto nacionais, e o corporativismo médico brasileiro, construíram o modelo de atenção médico-hospitalar no Brasil e o moldaram à sua conveniência, de sorte a torná-lo hegemônico, preparando o terreno para a implantação da fase seguinte, a do complexo médico-industrial. Para tanto, apropriando-se do discurso dominante da ciência, deverão introduzir-se no Estado ou com ele manter estreito relacionamento, de forma a controlá-lo ou dirigí-lo ainda que parcialmente, privilegiando seus interesses, enquanto vestidos de um discurso que se pretende assistencialista, promovendo a expansão da base de assistência médica individual para cristalizar um padrão hospitalocêntrico e crescentemente tecnificado / The current model of health care assistance in Brazil stems from the biomedical Flexneriam medicine model once imagined and implemented in the United States through the combined action of the local medical corporativism and corporate class, mediated by the great philanthropies, and ultimately exported in the wake of financial capitalist expansionism, resulting in the Brazilian economical and political subordination to American interests between the late XIX and mid XX centuries. The main theme of this dissertation is to analyze how the great American philanthropic foundations, who financed the medical reform after the Flexner Report was published in 1910, combined their interests with the corporate class ones, both international and local, and, adding the support of the local medical corporativism, conformed the Brazilian health care model to its convenience, just preparing the ground for the introduction of the next phase, i.e., the medical-industrial complex. In order to succeed, and under the banner of the medical science, they either penetrated the structure of the State or maintained with it a close relationship, in order to control or at least partially steer it, always meaning its own interests while maintaining a betterment discourse, but promoting individual medical care in order to foster a hospital and technology centered pattern

O atual modelo de atenção à saúde do Brasil tem suas origens no modelo biomédico flexneriano, idealizado e implantado nos Estados Unidos por meio da ação combinada do corporativismo médico local e do grande capital. Sua importação e implantação se insere nas relações gerais de dependência econômica e subordinação política do nosso País aos interesses norte-americanos, desde as últimas décadas do século XIX até as primeiras décadas do século XX. O objetivo desta tese é identificar e analisar como as grandes fundações norte-americanas, financiadoras do modelo de atenção médica originado a partir da publicação do Relatório Flexner em 1910, mais os interesses capitalistas, tanto do grande capital internacional quanto nacionais, e o corporativismo médico brasileiro, construíram o modelo de atenção médico-hospitalar no Brasil e o moldaram à sua conveniência, de sorte a torná-lo hegemônico, preparando o terreno para a implantação da fase seguinte, a do complexo médico-industrial. Para tanto, apropriando-se do discurso dominante da ciência, deverão introduzir-se no Estado ou com ele manter estreito relacionamento, de forma a controlá-lo ou dirigí-lo ainda que parcialmente, privilegiando seus interesses, enquanto vestidos de um discurso que se pretende assistencialista, promovendo a expansão da base de assistência médica individual para cristalizar um padrão hospitalocêntrico e crescentemente tecnificado / The current model of health care assistance in Brazil stems from the biomedical Flexneriam medicine model once imagined and implemented in the United States through the combined action of the local medical corporativism and corporate class, mediated by the great philanthropies, and ultimately exported in the wake of financial capitalist expansionism, resulting in the Brazilian economical and political subordination to American interests between the late XIX and mid XX centuries. The main theme of this dissertation is to analyze how the great American philanthropic foundations, who financed the medical reform after the Flexner Report was published in 1910, combined their interests with the corporate class ones, both international and local, and, adding the support of the local medical corporativism, conformed the Brazilian health care model to its convenience, just preparing the ground for the introduction of the next phase, i.e., the medical-industrial complex. In order to succeed, and under the banner of the medical science, they either penetrated the structure of the State or maintained with it a close relationship, in order to control or at least partially steer it, always meaning its own interests while maintaining a betterment discourse, but promoting individual medical care in order to foster a hospital and technology centered pattern

Currently only 5.7% of physicians in the United States (U.S.) are Black/African American. This comprehensive analysis explores the significant underrepresentation of Black/African American physicians in the United States, a problem that has persisted for over 100 years. This investigation traces this disparity back to the Flexner report, a document that revolutionized medical education for the benefit of the white population but to the detriment of Black and other vulnerable populations. There is a critical examination of the ethical implications of the Flexner report, arguing that it has contributed to health disparities resulting in shortened lives for Black men, women, and children. Moreover, the roles played by private institutions such as the Carnegie Foundation, the Rockefeller Foundation, the Accreditation Council for Graduate Medical Education and the American Medical Association and the U.S. federal government in initiating, funding or upholding the changes resulting from Flexner’s report are delineated. Most importantly, the efforts, as a result of the formation of the National Medical Association to overcome the obstacles placed in front of Black healthcare providers in caring for people of color is revealed. In exposing the damage done to physicians and patients of color there are also proposals of solutions to reverse the ethical harm done because of the Flexner report's implementation, including reparations for Black healthcare providers and patients adversely affected by the Flexner report. In conclusion there is an in-depth analysis of the history and impact of the Flexner report, the ethical and moral imperatives of reparations, and the feasibility and potential impact of these reparations. / Urban Bioethics