Welcome to Stuff You Missed in History Class, a production of I Heart Radio. Hello, and welcome to the podcast. I'm Holly Frying, and I'm Tracy P. Wilson. Uh, Tracy. One of the topics that's come up a couple of times for me in recent weeks as I've just been doing my own reading related to racial injustice is the Flexner Report. And this was a report that was issued in the early twentieth century. It is often credited with changing the medical field and shaping what medical education looks today. I also found one article that said it's the most overrated document in medical history, which made me laugh a bit um. But there are also aspects of this document that really need to be discussed in terms of how they impacted the black community. So we're going to talk about this one in three parts. First, we're going to talk about Abraham Flexner, for whom the report is named and who made the report. And then we're going to talk about the general impact of the Flexner Report on medicine. And finally we will talk about how this affected black medical schools specifically. And it is a lot to unpack, and I hope we managed to do it justice as with anything related to any of these topics, a person's biography, the history of any given field, and the history of how things impact racial injustice. Like, there are always more nuances than we could ever pack into an episode, but we're hoping we hit all of the prominent and impertinent points. Yeah, if you listen to the podcast Saw Bones, they did an episode which I guess at this point will be a few weeks ago that was about racism in medicine and it it alludes to this without going into much detail about it. So if you if you listen to our show and that show, these are sort of they'll complement one another. They do, they do. We didn't plan that, it just happened. Uh So this starts with Abraham Flexner and Abraham Flexner was born in Louisville, Kentucky, on November eighteen sixty six. His father more It's Flexner and his mother as their Abraham, were German Jewish immigrants. More It's had a hat business and Esther worked as a seamstress. The Flexner family was large. Abraham was their sixth child and they ultimately had nine. Moret's and Esther were able to build up their finances with The plan not that they would live lavishly, but that every one of their sons and there were seven of them, would attend college. But that plan fell apart when the eighteen seventy three panic hit and they lost their savings. But Abraham did manage to go to college. He attended Johns Hopkins University, and the funds came from his brother, Jacob. The span and the ages of the Flexner children meant that Jacob was already established by the time Abraham graduated from high school, and the money he was making as a drug store owner was put towards Abraham's tuition. Yeah, they definitely always prioritized education is where they put their money. Abraham earned his b a In eighteen eighty six, and his hope had been and to go into a post graduate program, but there was not enough money for that, and though he did try to secure a fellowship and non materialized, so he went home to Louisville to start his career. For the next four years, Flexner worked as a high school teacher, heading up the Latin and Greek classes at Louisville High School. But during that time he was developing another idea because he thought there was a better way to structure education, and that idea manifested as an experimental school, and Flexner founded that school in eighteen nine. That school was simply called Mr. Flexner School, and it was incredibly progressive. The structure probably seemed like no structure at all to traditional educators. Flexner did away with the idea of a set curriculum. Students did not have exams, and they did not receive grades. The vision that Flexner had for this school was custom tailored education to prepare students for higher learning, and a lot of his students got into very good schools, so this was a very successful model. The Flexner family continued to value education and help one another in that regard. One of the personal benefits for Abraham Flexner in creating his school was that he could enroll his brother Simon there and get him into JOHNS. Hopkins. He was also able to pay for Simon's tuition. Abraham also helped his sister Mary, he paid her way at Brent mar This marks an expansion of the family's plan to not only educate the men of the family, but also the women, and education for women was something that Abraham supported throughout his life. One of the former pupils in Flexner's preparatory school. A young woman named Anne Crawford also became an important part of Abraham's life after graduating and had become a teacher. She had attended Massar in which he finished those studies. She started working there at the school, and she also had started to pursue a career as a playwright. Abraham and Anne fell in love and they were married in and they eventually had two daughters, Jean and Eleanor. In nineteen o four, and adapted the novel Mrs Wiggs of the Cabbage Patch, which is a comedic story about an impoverished Southern family, into a Broadway play. Mrs Wiggs ran from September three, nineteen o four, through January nineteen o five at the Savoy Theater, and it was a success. The income from Ant's work on the show made it possible for Abraham to enroll at Harvard to get his master's degree in psychology. He closed his school to do that. He also spent a year in Germany as part of his studies, again bankrolled through his wife's success in the theater. That time spent in Germany made Flexner deeply aware of what he saw as the failings of the education system back home, and as a result, in nineteen o eight, he researched and wrote an assessment of higher education in the United States titled the American College a Criticism. Based on his work examining colleges and identifying what he saw as the problems at the single school level as well as systematically, flexnerra was commissioned by the Carnegie Foundation for an new project. He was asked by the president of the Carnegie Foundation for the Advancement of Teaching, that was Henry Smith Pritchett, to apply that same critical and analytical eye to the medical institutions, specifically in the United States and Canada. There were a hundred and fifty five medical schools in his survey. Yeah, he took two years to basically travel around and visit all these schools and do his assessment, and then in nt Flexner completed his report which was titled Medical Education in the United States and Canada. And when this report came out, it had a massive impact on medical education in North America. A lot of the schools that Flexner had found lacking closed as a consequence of its publication. Others were completely overhauled and essentially rebuilt from the ground up, and we're going to talk more about all of that in just a moment. Following the medical school report, Flexner produced a report at the behest of the Rockefeller Foundation examining the sex work field in Europe and how it was re elated. It was the first of many varied reports that Flexner would compile for the Foundation. But though he had moved on to other projects like that, Flexner did not just drop his medical report and then move on with his life. He actually dedicated himself to improving medical education, specifically, in nineteen thirteen, following his report on European sex work, Flexner became the secretary to the Rockefeller Foundation's General Education Board. During this time, in his role, he worked on a number of other research and reporting projects, as we mentioned, but he also made sure that money from private donors was allocated to medical education and improving some of the problems he had discovered while working on his nineteen ten report. In ninety one, Abraham Flexner wrote a memo for the Rockefeller Foundation's Board which was titled The Usefulness of Useless Knowledge, and this memo evolved and it became a lecture, and then, eighteen years after he initially wrote it, it was published in Harper's Magazine, And that piece of writing opens with the following paragraph quote, Is it not a curious fact that, in a world steeped in irrational hatreds which threatened civilization itself, men and women, old and young, detached themselves wholly or partly from the angry current of daily life, to devote themselves to the cultivation of beauty, to the extension of knowledge, to the cure of disease, to the amelioration of suffering, just as though fanatics were not simultaneously engaged in spreading pain, ugliness, and suffering. The world has always been a sorry and confused sort of place. Yet poets and artists and scientists have ignored the factors that would, if attended, to paralyze them. From a practical point of view, intellectual and spiritual life is, on the surface, a useless form of activity in which men indulge because they procure for themselves greater satisfactions than are otherwise obtainable. In this paper, I shall concern myself with the question of the extent to which the pursuit of these useless satisfactions proves unexpectedly the source from which undreamed of utility is derived. One of the things that Flexner touches on in this writing is the unintentional outcomes of pursuits that were of pure intent. He specifically mentions how the advancement of the cruelty of warfare was fueled by scientists who were often working they thought for the betterment of mankind. As the nineteen twenties were on, Abraham Flexner found himself at odds with other members of the education board at the Rockefeller Foundation, and this led to him ultimately being pushed out of the organization in ninety eight. In nine nine, Abraham Flexner was approached by philanthropist siblings Lewis and Caroline Bamburger. The Bamburgers thought they could use their wealth to establish a new medical school in Newark, New Jersey, and they wanted Flexner as an advisor on the project. But Flexner pointed out that Newark had neither a teaching hospital nor a top notch university, both of which were vital to the success of a medical school, and Abraham Flexner was really thinking of a different sort of project, and he was able to convince the Bamburgers that they should instead invest in his idea, and they did with a gift of five million dollars. Flexner envisioned what he would later call an educational utopia that offered the greatest minds a place where they could be driven entirely by their curiosity, and so in nineteen thirty Flexner founded the Institute for Advanced Study in Princeton, New Jersey, and served as director there until nineteen thirty nine. It's missions stated quote, the Institute is pledged to assemble a group of scientists and scholars who, with their pupils and assistants, may devote themselves to the task of pushing beyond the present limits of human knowledge, and to training those who may carry on. In this sense, Flexner was able to attract some of the biggest names to his institute, including Albert Einstein, who joined in nineteen thirty three. In the years since it's founding, the Institute has had as members or as faculty thirty four Nobel Laureates, forty two Fields Medalists, and eighteen Abel Prize Laureates. In addition to Einstein, notable names on that list include Robert Oppenheimer and previous podcast subject John von Neumann. We're going to cover the end of Flexner's life and the impact of his work on medical education, but we're due for a quick break to have a word from our sponsors. The same year that he opened his institute, Abraham also published another book about education. This time it was a comparative review of how schools ran in different countries, titled Universities American, English, German. Flexner retired as director at the institute in nineteen thirty nine after an internal conflict in which the school was accused of allowing an anti Semitic climate at Princeton, a school that they routinely worked with. They were allowing that climate to hinder the work of a lot of the professors. As tensions among the scholars and leadership war on. Flexner retired in the autumn of ninety nine. Although he was in his seventies, He stayed very busy after leaving the institute, consulting on various projects and writing several books, including his autobiography. During and after World War Two, several of Abraham's siblings died by the end of the nineteen forties. Only Abraham and his sister Gertrude were still living out of the nine Flexner siblings. At the same time, his wife, Anne had gradually developed vascular dementia in nine and had declined so seriously that she was taken to a Rhode Island sanitarium. Their two daughters frequently visited her, and they updated their father, but Abraham never saw Anne again. He had not coped with her illness well and could not bear to have the person that he had been so close to no longer recognize him. He later told friends that he had actually had a breakdown during this time. As he recovered from this significant change in his life, Flexner moved to a hotel near Central Park and enrolled in classes at Columbia. He opted for classes in literature and history. In nineteen fifty one, the New York Times read an article about the eighty five year old Flexner educational reformer taking classes alongside co Ed's, a quarter his age, and died shortly before Abraham's ninetieth birthday, which once again sent him into a dark period, and as he was slowly returning to his old self, his daughter Jeane convinced him to leave New York and moved to Falls Church, Virginia, which is where she lived so that he could be near her, and he spent two years there and doing a very active social life and visiting the museums of nearby Washington, d c. Regularly before his death on September twenty one, nineteen fifty nine. So moving on to his report about medical schools. As we mentioned, Flexner covered a hundred and fifty five schools in his nineteen ten report, and in researching that report, he had visited each school and written detailed and comprehensive notes about their entrance requirements, faculty funding, laboratories, and connections with affiliated hospitals. In the five decades before his research, massive advances in science and medicine had been made, but because there was no comprehensive guidance for how medical schools operated, a lot of them were still teaching out of date information, basically telling future doctors stuff that wasn't believed to be true anymore. This was in large part because the faculty at many medical schools consisted largely of practicing physicians who were teaching exactly as they had been taught without updating that information with the changing times. Bacteriology, diagnostic developments, and surgical techniques were all rapidly changing fields, and if a school wasn't keeping up the doctors they trained, or in danger of offering their patients poor or outdated care at best and endangering their lives at worst. To compound that problem, there were a lot of new medical schools opening with totally read standards for entry. When Flexner published to study, seventy four percent of a medical schools that were open required only a high school education for admission. Some were willing to accept high school equivalency certificates, which meant that there was really no clear standard. Only a fifth of the schools required two or more years of college prior to entry. Many were essentially profit driven businesses. Abraham Flexner was also very frank in his report about how little the public really knew about the workings of any given medical school. He wrote in the introduction quote, educational institutions, particularly those which are connected with a college or a university, are peculiarly sensitive to outside criticism, and particularly to any statement of the circumstances of their own conduct or equipment which seems to them unfavorable in comparison with that of other institutions. As a rule, the only knowledge which the public has concerning an institution of learning is derived from the statements given out by the institution itself, information which, even under the best circumstances, is colored by local hopes, ambitions, and points of view. Flexner felt that this work was vital and important to be doing, writing that the information in it was of importance not just to medical practitioners, but to quote every citizen of the United States and Canada. Abraham Flexner, building on standards that were already in place in Germany, established standards of evaluation for the medical schools and his study and then judged each one against those criteria. And we should note that he was not the first person to do this. In the United States, the Association of American Medical Colleges, founded in eighteen seventy six and consisting of twenty two member schools, had agreed on curriculum standards to provide uniformity in medical education that had happened after an assessment of the state of medical education. The a a m C continued to grow and reevaluate in the years between its founding and flex Nurse Report. The American Medical Association had similarly started issuing reports on the status of medical education as early as eight and some of the criteria they used were present in Flexner's evaluation system as well, but neither of these had oversight over all medical schools. It was an opt in on a set of standards. All of Flexner's work was aimed at determining, in his opinion, whether a school was able to effectively teach its students modern medicine. The model that he drew up for what this looked like included admittance requirements of college level biology, chemistry, and physics courses, a curriculum with both lecture and lab teaching of anatomy, pathology, bacteriology, and pharmacology, among other courses, access to teaching hospitals for hands on experience, salaried faculty who were exclusively working in teaching and research, not practicing doctors who just taught on the side. Flexner laid out his finding state by state and school by school. He was detailed calling out if he had found dirty labs or lacks standards. He criticized the way the days were scheduled at schools and how exhausted students were often sitting through hours of dull lectures by part time faculty. Because he was an outsider, an education reformer rather than a member of the medical community. His assessment was without preconception and it was brutally honest, offering the general public a startling look at the way people who cared for their health were being educated. Flexner advocated for state licensing boards to take a more assertive role in modernizing medicine by refusing to license graduates from schools that were not up to standards, and he believed that a lot of schools were not up to standards. In the end, he recommended that one hundred twenty of the one hundred fifty five he reviewed for the report should be closed. That recommendation was based on his assessments that their standards were very poor and that they were not keeping up scientifically and thus were creating poorly educated doctors who lacked up to date knowledge in their field, which was something he saw as a completely obvious danger to public health. Canadian schools, we should mention, fared much better than their US counterparts. Overall, only one school there made Flexner's list of closing recommendations. It was not closed, though. They did have a little bit of a review of their curriculum and their standards and changed up a little. Many of the schools in the US that he recommended be closed did close. Within a decade, there were only half as many medical schools as there had been when Flexner's report was published. Those that had remained had reformed their standards, and their courses and their lab work in clinical teaching had been significantly changed and in most cases modernized. For all of the change that was catalyzed by the report, Flexner became famous as an educational reformer. We're gonna pause here before we dig into the ramifications of Flexner's work for black medical schools specifically, so here in the meantime are some of the sponsors that keep stuff you missed in history class going. Before we talk about the effects of the Flextioner Report on the black population in the US and its medical schools, we should give a brief sense of what was going on in that space prior to nineteen. The first black man in the US to receive a medical degree was David J. Peck. He received a degree from Rush Medical School in Chicago in eighteen forty seven. As a note, he was not the first black doctor in the US that's usually cited as formerly enslaved. James Durham, who was born in seventeen sixty two and learned medicine through an apprenticeship in the thirteen years after Pack's graduation, there were a handful of other black med students who graduated with degrees. In the US, nine medical schools had established that they would admit black students by eighteen sixty, including the Medical School of Heart of Harvard University, Bowden Medical School in Maine, and the Medical School of the University of New York. In the late eighteen sixties, the first medical school for black students opened. That was Howard University Medical School in Washington, d c. And it opened in eighteen sixty eight. Eight years later, Maharry Medical College opened in Nashville, Tennessee. From eighteen seventy six to nineteen o four, another six black medical schools opened, including Lettern Medical School, which became Shaw University in Raleigh, North Carolina, New Orleans University Medical College, Knoxville College Medical Department that became Knoxville Medical College, Chattanooga National Medical College, and University of West Tennessee College of Physicians and Surgeons. The schools listed there are ones that were open when Flexner compiled the report. There had been others that had folded before the nineteen o eight research started. That included Lincoln University in Oxford, Pennsylvania, which had opened in eighteen seventy and closed four years later. Straight University Medical to Artment was established in New Orleans in eighteen seventy three, but was disbanded in eighteen seventy four. Hannibal Medical College of Memphis, Tennessee, had opened in eighteen eighty nine, but closed in eighteen ninety six. Louisville States University Medical Department ran from eighteen ninety nine to nineteen o three. Chattanooga National Medical College closed in nineteen o four after five years in operation. The Medical Society of the District of Columbia was founded in eighteen seventeen. That society was for whites only. The American Medical Association was founded in eighteen forty seven, and though black doctors applied to become members for years, they were denied entry. We're gonna come back to the A M and just a bit. The Medico Turigical Society was founded as a black medical society in eighteen eighty four because of the impossibility that black doctors faced gaining admittance to those established groups. The National Medical Association was founded in eighteen ninety five for black doctors for the same reason. It was not until the nineteen fifties that black doctors had gained admittance to medical societies in most states. In the midst of this clear division and racism, the Flexner Report was released. Flexner had often been lauded for his role as a reformer, and, as we've discussed, reform did need to happen. He was obviously blunt and often scathing in his critiques of individual schools, and the schools for black men students were no different, and his report he wrote, quote, of the seven medical schools for negroes in the United States, five or at this moment in no position to make any contribution of value. While he praised both Howard and Maharry is worth developing, the rest were deemed basically useless. This assessment did not take into account the fact that black medical schools charged much lower tuition than white schools, had fewer endowments, and were operating on much narrower margins. In his assessment, he wrote, quote, the negro needs good schools rather than many schools. He went on to elaborate eight that it was important for black doctors to be well educated. He understood that black doctors would see to the health of the black population, and since the black population was a part of the larger whole, their care was important. But the language that Flexner used throughout this section where he talked about all of this is a very mixed bag. He simultaneously speaks of the rights and contributions of black people, but also asserts that it is best if black doctors take care of their own people and offers the teaching of hygiene as one of the most important duties of black doctors and nurses, rather than life saving skills, which is just inherently racist. Every black medical college that Flexner called out as subpar closed. The first four had shut their doors by nineteen fourteen, a fifth closed in nineteen fifteen. The last from the last list, the Medical Department of the University of West Tennessee, lasted until Howard and Maherry remained and they still do. The tr is Our Drew Medical School in Los Angeles was the next predominantly black medical school to open. That didn't happen until nineteen sixty six. Listen to our episodes on Brown v Board Like that seems late in the creation of a medical school um, but that school was founded like specifically to respond to to medical access needs within the black community. The next was Morehouse School of Medicine in Atlanta in nineteen So the narrowing of options for prospective black doctors left a huge care gap for the black community. Many potential physicians were excluded from educational opportunities due to location, which meant that the care of black patients was often doled out by white doctors, who, even in the best of circumstances, met their duties with inherent racial bias. And as we have discussed on the show before, there were definite racist abuses of power in the medical system, and this has had far reaching and ongoing consequences. A panel was assembled by the American Medical Associate Institute for Ethics in two thousand five to examine the history of racism and the medical profession. One of their findings was that the Carnegie Foundations project for which they hired Flexner, that had been sponsored by the a m A as well, although that hadn't been disclosed at the time. Flexner's line of good schools rather than many schools, had ensured that medicine stayed segregated, and that communities who needed doctors the most were just left without them. Yeah, there are some question marks that continue about whether or not someone associated with the A m A was actually with him on some of those school visits, and at some points in history he said that that person was with him, and then later on he was like no, no, no, no, no, like they met me there, like it it shifted. So we don't really know if there was even more hands on direction of that report in that regard or not. A lecture on the now defunct Black med schools by Dr Earl H. Harley of Washington, d C. Was published in the Journal of the nation No Medical Association in September of two thousand six, and in it, Dr Harley summarized how black medical schools, which have always been smaller with a higher percentage of graduates going into medicine for underserved communities, have continued to face obstacles in the century since Flexner's report, writing quote, one of the greatest challenges of today's black medical schools is economics. Black medical schools find it difficult to compete with well funded majority universities with a long standing commitment to train African Americans, such as the University of Michigan. The result maybe the siphoning of well qualified, highly competitive African American students who choose quote rich schools for pragmatic economic reasons. This places an extra burden on today's black medical schools of appealing to a higher social calling as they seek to fulfill their historic missions. While they search for greater endowments to become more attractive, they must continue to position themselves as the training grounds for those who will serve the underserved. So those brings up a natural question. Did Flexner realize the disproportionate impact of his report on black med students and doctors and patients? He spoke at length about race throughout his life, But what were his intentions with this report? And I mean, apart from his attentions the effects that we just mentioned. Yeah, but we don't know what his mindset was. Uh, And there are different schools of thought on it. You can talk to a lot of people and they will give you completely different answers for whether or not they thought that there um was racism in the mix, or if Flexner really understood this. He did know that he was limiting the scope of black medicine. He said so in his report, although it is part of a rather idealist passage that reads, quote, the upbuilding of Howard and Maherry will profit the nation much more than the inadequate maintenance of a larger number of schools. They are, of course unequal to the need and opportunity. But nothing will be gained by satisfying the need, or of rising to the opportunities, through the survival of feeble, ill equipped institutions, quite regardless of the spirit which animates the promoters in Flexner wrote a letter to the trustees of his Institute for Advanced Studies and which he advocated against discrimination. Quote. It is fundamental in our purpose and our express desire that in the appointments to the staff and faculty, as well as in the admission of workers and students, no account shall be taken directly or indirectly of race, religion, or sex. We feel strongly that the spirit characteristic of America at its noblest, above all, the pursuit of higher learning, cannot admit of any conditions as to personnel other than those designated to promote the objects for which this institution is established, and particularly with no regard whatever to accidents of race creat or sex. It appears that Flexner's progressive ideas about equality, particularly in relation to race, probably came from his childhood in Louisville. One biographer who is very sympathetic to Flexner, Thomas Neville Honor, made the case in his book about Flexner that when Abraham was growing up in Louisville, Kentucky, it was a time when, while there was certainly nothing akin to equality, there were more services and opportunities for the city's black community than in a lot of other places. Uh there were a dozen schools for black students there when Abraham was growing up, and professional training schools and teaching, medicine, and law were available to black residents. And the Flexner's, who were not wealthy, lived in a neighborhood where they had black neighbors. Abraham noted later in his life that he and his siblings often played with the black children in their neighborhood. This experience may have left Abraham Flexner a little idealistic about the realities of life for the black families that he knew and socialized with. To him, it seemed obvious that any of the kids he played with could grow up to do the same kinds of jobs that he and his siblings could do. But it seems that he didn't really come to terms with the fact that there were plenty of other people who didn't see things this way. He acknowledged during his lifetime that he didn't realize that the black students he had known growing up were so deeply disadvantaged until later in his life when he was researching and analyzing educational institutions after his retirement from the Institute. Both before and after World War Two, Flexner was pretty outspoken against prejudice. He made a radio broadcast in which he stated his disappointment that democracy hadn't brought more equality to the relationship between races. After the war, he spoke about how far behind England the US was in terms of both religious and racial prejudice. But his feelings about prejudice are complicated. I'll also say that, um, that's an interesting note about England in the US in terms of re I feel like Flexner always compared the US to European countries he had visited, and he always found the US lacking by comparison. But some of that is definitely a rose colored glass of situation. Yeah, yeah, I don't. I don't know when he made that statement. Um, but something that is going to come up in an episode we're gonna record shortly is like about racism uh in England specifically. Anyway, back to the subject at hand, Uh, His feelings about prejudice are complicated. Although he had been raised by devout Jewish parents, Abraham and his siblings all drifted away from the Jewish faith and they considered themselves secular Jews. When he encountered anti semitism, he tended to presume the person involved was ignorant instead of malicious, and he just brushed it off and went on with his life. But he was in a position to be able to do that. Anti Semitism doesn't seem to have materially impacted his career or his life. Yeah, this is definitely one of those cases where I think he doesn't realize that he was, you know, enjoying a certain degree of privilege and being able to be like, oh, you don't like me, Okay, I still have plenty of opportunities, which is not how it works for everybody. The true depth of racism against the black community was clearly a blind spot in his work, and that left a lasting legacy on both black physicians and patients that is still felt. He just thought that medical schools and other institutions of higher learning should be admitting students regardless of their sex, color, or religion. But he didn't seem to recognize that there was a whole world of obstacles that had to be addressed to get to the point where students who weren't white or weren't male could even be applying to medical school, let alone get through the admission process. And in a way, it struck me while I was researching this that his own idealism put him in this situation not dissimilar to the scientists that he once wrote about who accidentally advanced the technologies of warfare. In his work for school reform, the already disadvantaged black schools simply could not keep pace with standards that required money and resources they simply didn't have, and white schools were still not often admitting black medical students. The debate over Flexner's intentions continues among medical historians, and if you start digging, you'll find people who think of him as everything from a benevolent but a realist. We've talked about a lot of those on the show too inherently racist, talked about a lot of those two um and this this latter part is due to the discussion of hygiene as a primary focus for black physicians. There are examples of leaders from both Maharry and Howard using similar language regarding the need for hygiene instruction as an important part of the service of black doctors. They predate Flexner's report by a couple of years, and this is on its surface inherently racist. Those leaders who also said that that was an important part of a black doctor's training we're also white. But it also suggests that Flexner's statements were echoes of the school stated missions, rather than standalone judgments that he made. And there is also an interesting possibility, as discussed in a eleven article in the Journal of the History of Medicine and Allied Sciences by Lynn E. Miller and Richard M. Weiss, that this language was actually part of carving out a public health role for the physicians from these schools in an f to garner support for the schools across racial divides. In the statements from Maherry and Howard in nineteen o seven and nineteen o eight that we're talking about those sentiments of hygiene being the highest need are followed by mentions of how obvious it is thus that these institutions should be supported. And there are some indicators that a number of medical schools, black and white. We're already in an economic tail spin before Flexner's report was released. Some of that was because there were already efforts to try to meet guidelines that had been issued by the a m A, and the financial burdens of doing that just proved to be too much to allow for sustainability. While the discussion of Flexner's intentions and the real ramifications of his work continues, the a m A, following the findings of their Ethics Council, did issue a public apology in two thousand and eight, quote for its past history of racial inequality toward African American physicians, and shares its current effort to increase the ranks of minority physicians and their participation in the a m A. The organization also announced a number of programs aimed at encouraging minorities to pursue careers in medicine. This is one of those cases where we're still untangling all the ten drills of all these influences on the medical field that will probably continue for years to come. I wanted to close with another quote from Flexner's Usefulness of Useless Knowledge. I personally remain in a state of conflict about the man and his work. Uh. It's like I want to support an idealist who wants to make things better, but not when that idealism blinds you so much that you end up hurting people. Um. But when I came across this passage while I was researching, it really hit me in its pertinence to our world today. Uh. And he wrote, quote the justified outcry of those who, through no fault of their own, are deprived of opportunity and a fair share of worldly goods, therefore diverts an increasing number of students from the studies which their fathers pursued to the equally important and no less urgent study of social, economic, and governmental problems. I have no quarrel with this tendency. The world in which we live is the only world about which our senses can testify. Unless it has made a better world, a fairer world, millions will continue to go to their graves silent, saddened, and embittered. That is the complicated Flexner report. Yeah, I think it's worth knowing that. Like there's there's a question sometimes where it seems like people are kind of asking was he racist? Or um, was he operating from best intentions? And it can be operating yet if he's operating from his best intentions, like still racist though, Like it's impossible to grow up in a position of privilege in a racist society that is threaded all through with many layers of racist of racism and like to not be racist, Like it is a lifelong effort to undo all of those thinking patterns, no matter how well intended you are. Yeah, I mean, it's it's one of those things when you read his writing, he so clearly believes that, like if we just shut down all the bad black medical schools, these two good ones are going to be so good that then we can expand from there and everything will be great. And it's like he's missing so much of the puzzle that like again in an ideal world, sure, but like, um, yeah, he's he's complicated. I have complicated feelings about him. Um, do you have a listener mail? I do. It's much less complicated. It's a very very lovely listener mail from our listener, Crystal, who writes History of Science Topics is my Jam, which I liked because it's fine too. She writes, Dear Holly and Tracy, I'm writing to say I love your podcast. I've always enjoyed learning about history, and you make it easy to listen to. Over the past few months, I've been catching up with you going through your catalog of I'm a scientist working in a lab in Canada doing research with insects, and I just love when you do podcasts on science it's related topics. I particularly like the mention of Thomas Say from the New Harmony episode, as he was an entomologist and taxonomist, and I would like to know more about the lives of these people from the past. Uh. In my work, I've been able to help digitize historical insects specimen records. This sounds so cool, uh, And I'm always amazed and I find collection labels that say the specimen was collected during World War One or World War Two. What were these scientists doing during these difficult times and why were they continuing their research and not involved in particular wartime efforts. I also thoroughly enjoyed learning about Chen Chung Woo, whom I had never heard about before. She was a pioneer in physics and has certainly inspired me as a woman. Scientists. Please share more of these kinds of stories. Lastly, I just finished listening to your episode on the discovery of helium. Again. I just love hearing about topics like this. UM. I wanted to read this in part because Uh it ties in a little bit to uh Flexner's discussion of how in that that seemingly useless knowledge becoming useful. He talks about how sometimes science just step away from the realities of current events to continue to do their work. But I can't speak specifically to those specimen collectors that got those insects, although again, that sounds super interesting. So thank you so much, Crystal. I love that you work in in science and that there's entomology happening under your hand. We appreciate it, and we're grateful to be along with you on some of that journey. If you would like to write to us, you can do so at History Podcast at iHeart radio dot com. You can also find us pretty much everywhere on social media as Missed in History, and if you would like to subscribe this super easy to do. You can do that in the I heart Radio app, on Apple podcasts, or wherever it is you listen. Stuff you missed in History Class is a production of I heart Radio. For more podcasts from i heart Radio, visit the i heart Radio app, Apple Podcasts, or wherever you listen to your favorite shows.

Welcome to Stuff You Missed in History Class, a production of I Heart Radio. Hello, and welcome to the podcast. I'm Holly Frying, and I'm Tracy P. Wilson. Uh, Tracy. One of the topics that's come up a couple of times for me in recent weeks as I've just been doing my own reading related to racial injustice is the Flexner Report. And this was a report that was issued in the early twentieth century. It is often credited with changing the medical field and shaping what medical education looks today. I also found one article that said it's the most overrated document in medical history, which made me laugh a bit um. But there are also aspects of this document that really need to be discussed in terms of how they impacted the black community. So we're going to talk about this one in three parts. First, we're going to talk about Abraham Flexner, for whom the report is named and who made the report. And then we're going to talk about the general impact of the Flexner Report on medicine. And finally we will talk about how this affected black medical schools specifically. And it is a lot to unpack, and I hope we managed to do it justice as with anything related to any of these topics, a person's biography, the history of any given field, and the history of how things impact racial injustice. Like, there are always more nuances than we could ever pack into an episode, but we're hoping we hit all of the prominent and impertinent points. Yeah, if you listen to the podcast Saw Bones, they did an episode which I guess at this point will be a few weeks ago that was about racism in medicine and it it alludes to this without going into much detail about it. So if you if you listen to our show and that show, these are sort of they'll complement one another. They do, they do. We didn't plan that, it just happened. Uh So this starts with Abraham Flexner and Abraham Flexner was born in Louisville, Kentucky, on November eighteen sixty six. His father more It's Flexner and his mother as their Abraham, were German Jewish immigrants. More It's had a hat business and Esther worked as a seamstress. The Flexner family was large. Abraham was their sixth child and they ultimately had nine. Moret's and Esther were able to build up their finances with The plan not that they would live lavishly, but that every one of their sons and there were seven of them, would attend college. But that plan fell apart when the eighteen seventy three panic hit and they lost their savings. But Abraham did manage to go to college. He attended Johns Hopkins University, and the funds came from his brother, Jacob. The span and the ages of the Flexner children meant that Jacob was already established by the time Abraham graduated from high school, and the money he was making as a drug store owner was put towards Abraham's tuition. Yeah, they definitely always prioritized education is where they put their money. Abraham earned his b a In eighteen eighty six, and his hope had been and to go into a post graduate program, but there was not enough money for that, and though he did try to secure a fellowship and non materialized, so he went home to Louisville to start his career. For the next four years, Flexner worked as a high school teacher, heading up the Latin and Greek classes at Louisville High School. But during that time he was developing another idea because he thought there was a better way to structure education, and that idea manifested as an experimental school, and Flexner founded that school in eighteen nine. That school was simply called Mr. Flexner School, and it was incredibly progressive. The structure probably seemed like no structure at all to traditional educators. Flexner did away with the idea of a set curriculum. Students did not have exams, and they did not receive grades. The vision that Flexner had for this school was custom tailored education to prepare students for higher learning, and a lot of his students got into very good schools, so this was a very successful model. The Flexner family continued to value education and help one another in that regard. One of the personal benefits for Abraham Flexner in creating his school was that he could enroll his brother Simon there and get him into JOHNS. Hopkins. He was also able to pay for Simon's tuition. Abraham also helped his sister Mary, he paid her way at Brent mar This marks an expansion of the family's plan to not only educate the men of the family, but also the women, and education for women was something that Abraham supported throughout his life. One of the former pupils in Flexner's preparatory school. A young woman named Anne Crawford also became an important part of Abraham's life after graduating and had become a teacher. She had attended Massar in which he finished those studies. She started working there at the school, and she also had started to pursue a career as a playwright. Abraham and Anne fell in love and they were married in and they eventually had two daughters, Jean and Eleanor. In nineteen o four, and adapted the novel Mrs Wiggs of the Cabbage Patch, which is a comedic story about an impoverished Southern family, into a Broadway play. Mrs Wiggs ran from September three, nineteen o four, through January nineteen o five at the Savoy Theater, and it was a success. The income from Ant's work on the show made it possible for Abraham to enroll at Harvard to get his master's degree in psychology. He closed his school to do that. He also spent a year in Germany as part of his studies, again bankrolled through his wife's success in the theater. That time spent in Germany made Flexner deeply aware of what he saw as the failings of the education system back home, and as a result, in nineteen o eight, he researched and wrote an assessment of higher education in the United States titled the American College a Criticism. Based on his work examining colleges and identifying what he saw as the problems at the single school level as well as systematically, flexnerra was commissioned by the Carnegie Foundation for an new project. He was asked by the president of the Carnegie Foundation for the Advancement of Teaching, that was Henry Smith Pritchett, to apply that same critical and analytical eye to the medical institutions, specifically in the United States and Canada. There were a hundred and fifty five medical schools in his survey. Yeah, he took two years to basically travel around and visit all these schools and do his assessment, and then in nt Flexner completed his report which was titled Medical Education in the United States and Canada. And when this report came out, it had a massive impact on medical education in North America. A lot of the schools that Flexner had found lacking closed as a consequence of its publication. Others were completely overhauled and essentially rebuilt from the ground up, and we're going to talk more about all of that in just a moment. Following the medical school report, Flexner produced a report at the behest of the Rockefeller Foundation examining the sex work field in Europe and how it was re elated. It was the first of many varied reports that Flexner would compile for the Foundation. But though he had moved on to other projects like that, Flexner did not just drop his medical report and then move on with his life. He actually dedicated himself to improving medical education, specifically, in nineteen thirteen, following his report on European sex work, Flexner became the secretary to the Rockefeller Foundation's General Education Board. During this time, in his role, he worked on a number of other research and reporting projects, as we mentioned, but he also made sure that money from private donors was allocated to medical education and improving some of the problems he had discovered while working on his nineteen ten report. In ninety one, Abraham Flexner wrote a memo for the Rockefeller Foundation's Board which was titled The Usefulness of Useless Knowledge, and this memo evolved and it became a lecture, and then, eighteen years after he initially wrote it, it was published in Harper's Magazine, And that piece of writing opens with the following paragraph quote, Is it not a curious fact that, in a world steeped in irrational hatreds which threatened civilization itself, men and women, old and young, detached themselves wholly or partly from the angry current of daily life, to devote themselves to the cultivation of beauty, to the extension of knowledge, to the cure of disease, to the amelioration of suffering, just as though fanatics were not simultaneously engaged in spreading pain, ugliness, and suffering. The world has always been a sorry and confused sort of place. Yet poets and artists and scientists have ignored the factors that would, if attended, to paralyze them. From a practical point of view, intellectual and spiritual life is, on the surface, a useless form of activity in which men indulge because they procure for themselves greater satisfactions than are otherwise obtainable. In this paper, I shall concern myself with the question of the extent to which the pursuit of these useless satisfactions proves unexpectedly the source from which undreamed of utility is derived. One of the things that Flexner touches on in this writing is the unintentional outcomes of pursuits that were of pure intent. He specifically mentions how the advancement of the cruelty of warfare was fueled by scientists who were often working they thought for the betterment of mankind. As the nineteen twenties were on, Abraham Flexner found himself at odds with other members of the education board at the Rockefeller Foundation, and this led to him ultimately being pushed out of the organization in ninety eight. In nine nine, Abraham Flexner was approached by philanthropist siblings Lewis and Caroline Bamburger. The Bamburgers thought they could use their wealth to establish a new medical school in Newark, New Jersey, and they wanted Flexner as an advisor on the project. But Flexner pointed out that Newark had neither a teaching hospital nor a top notch university, both of which were vital to the success of a medical school, and Abraham Flexner was really thinking of a different sort of project, and he was able to convince the Bamburgers that they should instead invest in his idea, and they did with a gift of five million dollars. Flexner envisioned what he would later call an educational utopia that offered the greatest minds a place where they could be driven entirely by their curiosity, and so in nineteen thirty Flexner founded the Institute for Advanced Study in Princeton, New Jersey, and served as director there until nineteen thirty nine. It's missions stated quote, the Institute is pledged to assemble a group of scientists and scholars who, with their pupils and assistants, may devote themselves to the task of pushing beyond the present limits of human knowledge, and to training those who may carry on. In this sense, Flexner was able to attract some of the biggest names to his institute, including Albert Einstein, who joined in nineteen thirty three. In the years since it's founding, the Institute has had as members or as faculty thirty four Nobel Laureates, forty two Fields Medalists, and eighteen Abel Prize Laureates. In addition to Einstein, notable names on that list include Robert Oppenheimer and previous podcast subject John von Neumann. We're going to cover the end of Flexner's life and the impact of his work on medical education, but we're due for a quick break to have a word from our sponsors. The same year that he opened his institute, Abraham also published another book about education. This time it was a comparative review of how schools ran in different countries, titled Universities American, English, German. Flexner retired as director at the institute in nineteen thirty nine after an internal conflict in which the school was accused of allowing an anti Semitic climate at Princeton, a school that they routinely worked with. They were allowing that climate to hinder the work of a lot of the professors. As tensions among the scholars and leadership war on. Flexner retired in the autumn of ninety nine. Although he was in his seventies, He stayed very busy after leaving the institute, consulting on various projects and writing several books, including his autobiography. During and after World War Two, several of Abraham's siblings died by the end of the nineteen forties. Only Abraham and his sister Gertrude were still living out of the nine Flexner siblings. At the same time, his wife, Anne had gradually developed vascular dementia in nine and had declined so seriously that she was taken to a Rhode Island sanitarium. Their two daughters frequently visited her, and they updated their father, but Abraham never saw Anne again. He had not coped with her illness well and could not bear to have the person that he had been so close to no longer recognize him. He later told friends that he had actually had a breakdown during this time. As he recovered from this significant change in his life, Flexner moved to a hotel near Central Park and enrolled in classes at Columbia. He opted for classes in literature and history. In nineteen fifty one, the New York Times read an article about the eighty five year old Flexner educational reformer taking classes alongside co Ed's, a quarter his age, and died shortly before Abraham's ninetieth birthday, which once again sent him into a dark period, and as he was slowly returning to his old self, his daughter Jeane convinced him to leave New York and moved to Falls Church, Virginia, which is where she lived so that he could be near her, and he spent two years there and doing a very active social life and visiting the museums of nearby Washington, d c. Regularly before his death on September twenty one, nineteen fifty nine. So moving on to his report about medical schools. As we mentioned, Flexner covered a hundred and fifty five schools in his nineteen ten report, and in researching that report, he had visited each school and written detailed and comprehensive notes about their entrance requirements, faculty funding, laboratories, and connections with affiliated hospitals. In the five decades before his research, massive advances in science and medicine had been made, but because there was no comprehensive guidance for how medical schools operated, a lot of them were still teaching out of date information, basically telling future doctors stuff that wasn't believed to be true anymore. This was in large part because the faculty at many medical schools consisted largely of practicing physicians who were teaching exactly as they had been taught without updating that information with the changing times. Bacteriology, diagnostic developments, and surgical techniques were all rapidly changing fields, and if a school wasn't keeping up the doctors they trained, or in danger of offering their patients poor or outdated care at best and endangering their lives at worst. To compound that problem, there were a lot of new medical schools opening with totally read standards for entry. When Flexner published to study, seventy four percent of a medical schools that were open required only a high school education for admission. Some were willing to accept high school equivalency certificates, which meant that there was really no clear standard. Only a fifth of the schools required two or more years of college prior to entry. Many were essentially profit driven businesses. Abraham Flexner was also very frank in his report about how little the public really knew about the workings of any given medical school. He wrote in the introduction quote, educational institutions, particularly those which are connected with a college or a university, are peculiarly sensitive to outside criticism, and particularly to any statement of the circumstances of their own conduct or equipment which seems to them unfavorable in comparison with that of other institutions. As a rule, the only knowledge which the public has concerning an institution of learning is derived from the statements given out by the institution itself, information which, even under the best circumstances, is colored by local hopes, ambitions, and points of view. Flexner felt that this work was vital and important to be doing, writing that the information in it was of importance not just to medical practitioners, but to quote every citizen of the United States and Canada. Abraham Flexner, building on standards that were already in place in Germany, established standards of evaluation for the medical schools and his study and then judged each one against those criteria. And we should note that he was not the first person to do this. In the United States, the Association of American Medical Colleges, founded in eighteen seventy six and consisting of twenty two member schools, had agreed on curriculum standards to provide uniformity in medical education that had happened after an assessment of the state of medical education. The a a m C continued to grow and reevaluate in the years between its founding and flex Nurse Report. The American Medical Association had similarly started issuing reports on the status of medical education as early as eight and some of the criteria they used were present in Flexner's evaluation system as well, but neither of these had oversight over all medical schools. It was an opt in on a set of standards. All of Flexner's work was aimed at determining, in his opinion, whether a school was able to effectively teach its students modern medicine. The model that he drew up for what this looked like included admittance requirements of college level biology, chemistry, and physics courses, a curriculum with both lecture and lab teaching of anatomy, pathology, bacteriology, and pharmacology, among other courses, access to teaching hospitals for hands on experience, salaried faculty who were exclusively working in teaching and research, not practicing doctors who just taught on the side. Flexner laid out his finding state by state and school by school. He was detailed calling out if he had found dirty labs or lacks standards. He criticized the way the days were scheduled at schools and how exhausted students were often sitting through hours of dull lectures by part time faculty. Because he was an outsider, an education reformer rather than a member of the medical community. His assessment was without preconception and it was brutally honest, offering the general public a startling look at the way people who cared for their health were being educated. Flexner advocated for state licensing boards to take a more assertive role in modernizing medicine by refusing to license graduates from schools that were not up to standards, and he believed that a lot of schools were not up to standards. In the end, he recommended that one hundred twenty of the one hundred fifty five he reviewed for the report should be closed. That recommendation was based on his assessments that their standards were very poor and that they were not keeping up scientifically and thus were creating poorly educated doctors who lacked up to date knowledge in their field, which was something he saw as a completely obvious danger to public health. Canadian schools, we should mention, fared much better than their US counterparts. Overall, only one school there made Flexner's list of closing recommendations. It was not closed, though. They did have a little bit of a review of their curriculum and their standards and changed up a little. Many of the schools in the US that he recommended be closed did close. Within a decade, there were only half as many medical schools as there had been when Flexner's report was published. Those that had remained had reformed their standards, and their courses and their lab work in clinical teaching had been significantly changed and in most cases modernized. For all of the change that was catalyzed by the report, Flexner became famous as an educational reformer. We're gonna pause here before we dig into the ramifications of Flexner's work for black medical schools specifically, so here in the meantime are some of the sponsors that keep stuff you missed in history class going. Before we talk about the effects of the Flextioner Report on the black population in the US and its medical schools, we should give a brief sense of what was going on in that space prior to nineteen. The first black man in the US to receive a medical degree was David J. Peck. He received a degree from Rush Medical School in Chicago in eighteen forty seven. As a note, he was not the first black doctor in the US that's usually cited as formerly enslaved. James Durham, who was born in seventeen sixty two and learned medicine through an apprenticeship in the thirteen years after Pack's graduation, there were a handful of other black med students who graduated with degrees. In the US, nine medical schools had established that they would admit black students by eighteen sixty, including the Medical School of Heart of Harvard University, Bowden Medical School in Maine, and the Medical School of the University of New York. In the late eighteen sixties, the first medical school for black students opened. That was Howard University Medical School in Washington, d c. And it opened in eighteen sixty eight. Eight years later, Maharry Medical College opened in Nashville, Tennessee. From eighteen seventy six to nineteen o four, another six black medical schools opened, including Lettern Medical School, which became Shaw University in Raleigh, North Carolina, New Orleans University Medical College, Knoxville College Medical Department that became Knoxville Medical College, Chattanooga National Medical College, and University of West Tennessee College of Physicians and Surgeons. The schools listed there are ones that were open when Flexner compiled the report. There had been others that had folded before the nineteen o eight research started. That included Lincoln University in Oxford, Pennsylvania, which had opened in eighteen seventy and closed four years later. Straight University Medical to Artment was established in New Orleans in eighteen seventy three, but was disbanded in eighteen seventy four. Hannibal Medical College of Memphis, Tennessee, had opened in eighteen eighty nine, but closed in eighteen ninety six. Louisville States University Medical Department ran from eighteen ninety nine to nineteen o three. Chattanooga National Medical College closed in nineteen o four after five years in operation. The Medical Society of the District of Columbia was founded in eighteen seventeen. That society was for whites only. The American Medical Association was founded in eighteen forty seven, and though black doctors applied to become members for years, they were denied entry. We're gonna come back to the A M and just a bit. The Medico Turigical Society was founded as a black medical society in eighteen eighty four because of the impossibility that black doctors faced gaining admittance to those established groups. The National Medical Association was founded in eighteen ninety five for black doctors for the same reason. It was not until the nineteen fifties that black doctors had gained admittance to medical societies in most states. In the midst of this clear division and racism, the Flexner Report was released. Flexner had often been lauded for his role as a reformer, and, as we've discussed, reform did need to happen. He was obviously blunt and often scathing in his critiques of individual schools, and the schools for black men students were no different, and his report he wrote, quote, of the seven medical schools for negroes in the United States, five or at this moment in no position to make any contribution of value. While he praised both Howard and Maharry is worth developing, the rest were deemed basically useless. This assessment did not take into account the fact that black medical schools charged much lower tuition than white schools, had fewer endowments, and were operating on much narrower margins. In his assessment, he wrote, quote, the negro needs good schools rather than many schools. He went on to elaborate eight that it was important for black doctors to be well educated. He understood that black doctors would see to the health of the black population, and since the black population was a part of the larger whole, their care was important. But the language that Flexner used throughout this section where he talked about all of this is a very mixed bag. He simultaneously speaks of the rights and contributions of black people, but also asserts that it is best if black doctors take care of their own people and offers the teaching of hygiene as one of the most important duties of black doctors and nurses, rather than life saving skills, which is just inherently racist. Every black medical college that Flexner called out as subpar closed. The first four had shut their doors by nineteen fourteen, a fifth closed in nineteen fifteen. The last from the last list, the Medical Department of the University of West Tennessee, lasted until Howard and Maherry remained and they still do. The tr is Our Drew Medical School in Los Angeles was the next predominantly black medical school to open. That didn't happen until nineteen sixty six. Listen to our episodes on Brown v Board Like that seems late in the creation of a medical school um, but that school was founded like specifically to respond to to medical access needs within the black community. The next was Morehouse School of Medicine in Atlanta in nineteen So the narrowing of options for prospective black doctors left a huge care gap for the black community. Many potential physicians were excluded from educational opportunities due to location, which meant that the care of black patients was often doled out by white doctors, who, even in the best of circumstances, met their duties with inherent racial bias. And as we have discussed on the show before, there were definite racist abuses of power in the medical system, and this has had far reaching and ongoing consequences. A panel was assembled by the American Medical Associate Institute for Ethics in two thousand five to examine the history of racism and the medical profession. One of their findings was that the Carnegie Foundations project for which they hired Flexner, that had been sponsored by the a m A as well, although that hadn't been disclosed at the time. Flexner's line of good schools rather than many schools, had ensured that medicine stayed segregated, and that communities who needed doctors the most were just left without them. Yeah, there are some question marks that continue about whether or not someone associated with the A m A was actually with him on some of those school visits, and at some points in history he said that that person was with him, and then later on he was like no, no, no, no, no, like they met me there, like it it shifted. So we don't really know if there was even more hands on direction of that report in that regard or not. A lecture on the now defunct Black med schools by Dr Earl H. Harley of Washington, d C. Was published in the Journal of the nation No Medical Association in September of two thousand six, and in it, Dr Harley summarized how black medical schools, which have always been smaller with a higher percentage of graduates going into medicine for underserved communities, have continued to face obstacles in the century since Flexner's report, writing quote, one of the greatest challenges of today's black medical schools is economics. Black medical schools find it difficult to compete with well funded majority universities with a long standing commitment to train African Americans, such as the University of Michigan. The result maybe the siphoning of well qualified, highly competitive African American students who choose quote rich schools for pragmatic economic reasons. This places an extra burden on today's black medical schools of appealing to a higher social calling as they seek to fulfill their historic missions. While they search for greater endowments to become more attractive, they must continue to position themselves as the training grounds for those who will serve the underserved. So those brings up a natural question. Did Flexner realize the disproportionate impact of his report on black med students and doctors and patients? He spoke at length about race throughout his life, But what were his intentions with this report? And I mean, apart from his attentions the effects that we just mentioned. Yeah, but we don't know what his mindset was. Uh, And there are different schools of thought on it. You can talk to a lot of people and they will give you completely different answers for whether or not they thought that there um was racism in the mix, or if Flexner really understood this. He did know that he was limiting the scope of black medicine. He said so in his report, although it is part of a rather idealist passage that reads, quote, the upbuilding of Howard and Maherry will profit the nation much more than the inadequate maintenance of a larger number of schools. They are, of course unequal to the need and opportunity. But nothing will be gained by satisfying the need, or of rising to the opportunities, through the survival of feeble, ill equipped institutions, quite regardless of the spirit which animates the promoters in Flexner wrote a letter to the trustees of his Institute for Advanced Studies and which he advocated against discrimination. Quote. It is fundamental in our purpose and our express desire that in the appointments to the staff and faculty, as well as in the admission of workers and students, no account shall be taken directly or indirectly of race, religion, or sex. We feel strongly that the spirit characteristic of America at its noblest, above all, the pursuit of higher learning, cannot admit of any conditions as to personnel other than those designated to promote the objects for which this institution is established, and particularly with no regard whatever to accidents of race creat or sex. It appears that Flexner's progressive ideas about equality, particularly in relation to race, probably came from his childhood in Louisville. One biographer who is very sympathetic to Flexner, Thomas Neville Honor, made the case in his book about Flexner that when Abraham was growing up in Louisville, Kentucky, it was a time when, while there was certainly nothing akin to equality, there were more services and opportunities for the city's black community than in a lot of other places. Uh there were a dozen schools for black students there when Abraham was growing up, and professional training schools and teaching, medicine, and law were available to black residents. And the Flexner's, who were not wealthy, lived in a neighborhood where they had black neighbors. Abraham noted later in his life that he and his siblings often played with the black children in their neighborhood. This experience may have left Abraham Flexner a little idealistic about the realities of life for the black families that he knew and socialized with. To him, it seemed obvious that any of the kids he played with could grow up to do the same kinds of jobs that he and his siblings could do. But it seems that he didn't really come to terms with the fact that there were plenty of other people who didn't see things this way. He acknowledged during his lifetime that he didn't realize that the black students he had known growing up were so deeply disadvantaged until later in his life when he was researching and analyzing educational institutions after his retirement from the Institute. Both before and after World War Two, Flexner was pretty outspoken against prejudice. He made a radio broadcast in which he stated his disappointment that democracy hadn't brought more equality to the relationship between races. After the war, he spoke about how far behind England the US was in terms of both religious and racial prejudice. But his feelings about prejudice are complicated. I'll also say that, um, that's an interesting note about England in the US in terms of re I feel like Flexner always compared the US to European countries he had visited, and he always found the US lacking by comparison. But some of that is definitely a rose colored glass of situation. Yeah, yeah, I don't. I don't know when he made that statement. Um, but something that is going to come up in an episode we're gonna record shortly is like about racism uh in England specifically. Anyway, back to the subject at hand, Uh, His feelings about prejudice are complicated. Although he had been raised by devout Jewish parents, Abraham and his siblings all drifted away from the Jewish faith and they considered themselves secular Jews. When he encountered anti semitism, he tended to presume the person involved was ignorant instead of malicious, and he just brushed it off and went on with his life. But he was in a position to be able to do that. Anti Semitism doesn't seem to have materially impacted his career or his life. Yeah, this is definitely one of those cases where I think he doesn't realize that he was, you know, enjoying a certain degree of privilege and being able to be like, oh, you don't like me, Okay, I still have plenty of opportunities, which is not how it works for everybody. The true depth of racism against the black community was clearly a blind spot in his work, and that left a lasting legacy on both black physicians and patients that is still felt. He just thought that medical schools and other institutions of higher learning should be admitting students regardless of their sex, color, or religion. But he didn't seem to recognize that there was a whole world of obstacles that had to be addressed to get to the point where students who weren't white or weren't male could even be applying to medical school, let alone get through the admission process. And in a way, it struck me while I was researching this that his own idealism put him in this situation not dissimilar to the scientists that he once wrote about who accidentally advanced the technologies of warfare. In his work for school reform, the already disadvantaged black schools simply could not keep pace with standards that required money and resources they simply didn't have, and white schools were still not often admitting black medical students. The debate over Flexner's intentions continues among medical historians, and if you start digging, you'll find people who think of him as everything from a benevolent but a realist. We've talked about a lot of those on the show too inherently racist, talked about a lot of those two um and this this latter part is due to the discussion of hygiene as a primary focus for black physicians. There are examples of leaders from both Maharry and Howard using similar language regarding the need for hygiene instruction as an important part of the service of black doctors. They predate Flexner's report by a couple of years, and this is on its surface inherently racist. Those leaders who also said that that was an important part of a black doctor's training we're also white. But it also suggests that Flexner's statements were echoes of the school stated missions, rather than standalone judgments that he made. And there is also an interesting possibility, as discussed in a eleven article in the Journal of the History of Medicine and Allied Sciences by Lynn E. Miller and Richard M. Weiss, that this language was actually part of carving out a public health role for the physicians from these schools in an f to garner support for the schools across racial divides. In the statements from Maherry and Howard in nineteen o seven and nineteen o eight that we're talking about those sentiments of hygiene being the highest need are followed by mentions of how obvious it is thus that these institutions should be supported. And there are some indicators that a number of medical schools, black and white. We're already in an economic tail spin before Flexner's report was released. Some of that was because there were already efforts to try to meet guidelines that had been issued by the a m A, and the financial burdens of doing that just proved to be too much to allow for sustainability. While the discussion of Flexner's intentions and the real ramifications of his work continues, the a m A, following the findings of their Ethics Council, did issue a public apology in two thousand and eight, quote for its past history of racial inequality toward African American physicians, and shares its current effort to increase the ranks of minority physicians and their participation in the a m A. The organization also announced a number of programs aimed at encouraging minorities to pursue careers in medicine. This is one of those cases where we're still untangling all the ten drills of all these influences on the medical field that will probably continue for years to come. I wanted to close with another quote from Flexner's Usefulness of Useless Knowledge. I personally remain in a state of conflict about the man and his work. Uh. It's like I want to support an idealist who wants to make things better, but not when that idealism blinds you so much that you end up hurting people. Um. But when I came across this passage while I was researching, it really hit me in its pertinence to our world today. Uh. And he wrote, quote the justified outcry of those who, through no fault of their own, are deprived of opportunity and a fair share of worldly goods, therefore diverts an increasing number of students from the studies which their fathers pursued to the equally important and no less urgent study of social, economic, and governmental problems. I have no quarrel with this tendency. The world in which we live is the only world about which our senses can testify. Unless it has made a better world, a fairer world, millions will continue to go to their graves silent, saddened, and embittered. That is the complicated Flexner report. Yeah, I think it's worth knowing that. Like there's there's a question sometimes where it seems like people are kind of asking was he racist? Or um, was he operating from best intentions? And it can be operating yet if he's operating from his best intentions, like still racist though, Like it's impossible to grow up in a position of privilege in a racist society that is threaded all through with many layers of racist of racism and like to not be racist, Like it is a lifelong effort to undo all of those thinking patterns, no matter how well intended you are. Yeah, I mean, it's it's one of those things when you read his writing, he so clearly believes that, like if we just shut down all the bad black medical schools, these two good ones are going to be so good that then we can expand from there and everything will be great. And it's like he's missing so much of the puzzle that like again in an ideal world, sure, but like, um, yeah, he's he's complicated. I have complicated feelings about him. Um, do you have a listener mail? I do. It's much less complicated. It's a very very lovely listener mail from our listener, Crystal, who writes History of Science Topics is my Jam, which I liked because it's fine too. She writes, Dear Holly and Tracy, I'm writing to say I love your podcast. I've always enjoyed learning about history, and you make it easy to listen to. Over the past few months, I've been catching up with you going through your catalog of I'm a scientist working in a lab in Canada doing research with insects, and I just love when you do podcasts on science it's related topics. I particularly like the mention of Thomas Say from the New Harmony episode, as he was an entomologist and taxonomist, and I would like to know more about the lives of these people from the past. Uh. In my work, I've been able to help digitize historical insects specimen records. This sounds so cool, uh, And I'm always amazed and I find collection labels that say the specimen was collected during World War One or World War Two. What were these scientists doing during these difficult times and why were they continuing their research and not involved in particular wartime efforts. I also thoroughly enjoyed learning about Chen Chung Woo, whom I had never heard about before. She was a pioneer in physics and has certainly inspired me as a woman. Scientists. Please share more of these kinds of stories. Lastly, I just finished listening to your episode on the discovery of helium. Again. I just love hearing about topics like this. UM. I wanted to read this in part because Uh it ties in a little bit to uh Flexner's discussion of how in that that seemingly useless knowledge becoming useful. He talks about how sometimes science just step away from the realities of current events to continue to do their work. But I can't speak specifically to those specimen collectors that got those insects, although again, that sounds super interesting. So thank you so much, Crystal. I love that you work in in science and that there's entomology happening under your hand. We appreciate it, and we're grateful to be along with you on some of that journey. If you would like to write to us, you can do so at History Podcast at iHeart radio dot com. You can also find us pretty much everywhere on social media as Missed in History, and if you would like to subscribe this super easy to do. You can do that in the I heart Radio app, on Apple podcasts, or wherever it is you listen. Stuff you missed in History Class is a production of I heart Radio. For more podcasts from i heart Radio, visit the i heart Radio app, Apple Podcasts, or wherever you listen to your favorite shows.