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important center for bacteriological investigation. Today the many universi-
ties in New York City have assumed the local biomedical research function.
The patient care function involves some local health agencies in medical
education, as many general hospitals are affiliated teaching hospitals of
medical schools. And local governments are able to regulate certain medical
services through zoning laws, business regulations, and the establishment of


local health and safety codes. Health promotion and patient care remain,
however, the major functions common to most local health agencies.


Although no formal assessment of the extent of documentation available
in municipal and local archives has ever been conducted, it is likely that
even fewer records relating to local health agencies have been preserved
at the local level than at the state level. In his manual for local records
officers, H. G. Jones noted that "a great majority of the political subdivi-
sions in the United States — counties, towns, cities, special-purpose dis-
tricts, etc. — remain without a[n archival] program of their own and
receive little effective assistance from professionals at a higher level of
government. "^^ The situation for health records within the few jurisdic-
tions that do maintain archives may even be worse, given the traditional
lack of interest in health records. Jones provided a brief subject analysis of
local records "most commonly of interest to researchers."'^ Health rec-
ords are not found among them.

Local authorities have traditionally drawn on three possible avenues
for preserving their records: establishing a local archives, transferring
material to other repositories, such as historical societies, and transferring
material to state agencies. In his book on local records, Bruce Dearstyne
recommends that each jurisdiction establish its own municipal or local
archives.'^ A government-maintained local archives is the most likely to
have complete holdings of local records, and preserving records in their
context is an important component of local practice. Both Baltimore and
Philadelphia, for example, have established archives rich in local health
records, reflecting the importance of American medical practice in both
cities. The records for Baltimore's Health Department date from 1798, just
five years after governmental involvement with health in the city began.
Initial governmental interest was in quarantine and infectious disease
control, but over time municipal involvement with health expanded.
During the twentieth century, the agency became responsible for inspect-
ing food, monitoring occupational safety, enforcing housing hygiene and
regulating environmental quality. Starting in the 1960s, the department
began supervising programs relating to child health, clinics, mental
health, and addictions. Philadelphia's archives contains minutes and other
records of its Board of Health and the Department of Public Health. The
records of many of the clinics and hospitals managed by the city, including
the Philadelphia General Hospital and the Philadelphia Nursing Home, are
also retained.'^


Yet, while the existence of a locality-sponsored archives may, as
Dearstyne recommends, be the best way to protect the completeness and
context of the records, the experience in Baltimore and Philadelphia
suggests that even the presence of a municipal archives may not be
sufficient to preserve records. As of 1984, the bulk of Baltimore's records
predate World War I. Twentieth-century records, the guide notes, are
"varied and small in volume." In Philadelphia the situation is similar.
Although records for the early period of the city's history are relatively
complete, record schedules for modern records may be outdated, placing
the bulk of modern city records at risk. Fortunately, Philadelphia will
shortly begin a grant-funded reevaluation of city record schedules, and
new schedules that better reflect the nature and importance of modern
records will be established. "^^

Baltimore City has also transferred medical records to other institu-
tions or agencies. The records of the city's infectious disease hospital,
Sydenham Hospital, for example, are housed at the National Library of
Medicine. Because the collection was too large to preserve in its entirety,
a sample of every tenth patient register volume was made. This example
illustrates the danger of transferring records to other agencies or reposito-
ries: there is no assurance that the collection will be retained as a whole.
Transferring records to either a state or private repository may be accept-
able if the alternative is destruction, but if possible, it should be avoided.

The examples of Baltimore and Philadelphia indicate the weaknesses
of even the best local records programs. Local records are invaluable as
sources for documenting public health efforts, and selected records are
worthy of preservation. Jones and Dearstyne have attempted to draw the
attention of local government officials to the importance of these records,
and it is hoped that local records will in the future receive more of the
attention they deserve.


A foundation is defined by the Foundation Center as a "nongovernmen-
tal, nonprofit organization with its own funds (usually from a single
source, either an individual, family, or corporation) and a program man-
aged by its own trustees and directors, which was established to maintain
or aid educational, social, charitable or other activities serving the com-
mon welfare, primarily by making grants to other nonprofit organiza-
tions.'"^^ The first charitable foundation in the United States was estab-
lished in 1867, when George Pcabody established the Peabody Fund. The
period since World War II has seen an explosive growth in their numbers.



FIGURE 3-2 Headquarters of the Howard Hughes Medical Institute, the
world's largest private charitable organization, in Chevy Chase, Maryland, 1993.
Source: Howard Hughes Medical Institute; William K. Geiger, photographer

Today there are over 31,000 private foundations, ranging in size from
large national foundations such as the Ford, Rockefeller, and Carnegie
foundations to small local foundations. In interest and scope of activity
they are similar to governmental agencies because foundations, too, act
on national, state, and local levels. The Foundation Center distinguishes
four common types of foundation:

• Independent foundations, usually established by an individual or
family and operating with a broad charter;

• Community foundations, publicly supported organizations that
derive their funds from many donors and that usually limit their
giving program to their immediate area;

• Corporate foundations, established by corporations to distribute tax-
free up to 10 percent of their profits; and

• Operating foundations, designed primarily to operate a specific
research, social welfare, or other program.

Foundations with a special interest in health and medicine compose a
large percentage; of the 31,000 foundations in the United States, more
than 2,500 have a history of awarding grants relating to health matters. In
1991 almost 16 percent of all foundation grants were for health care


programs or for the education of hiealth professionals, the second largest
expense category after support of schools and colleges.'*^ The largest
private charitable organization in the world is the Howard Hughes Medi-
cal Institute, with assets of over $6.4 billion.'*^ The W. K. Kellogg Founda-
tion, with assets of $4.2 billion, and the Robert Wood Johnson Founda-
tion, with assets of $2.6 billion, are two other prominent foundations
primarily interested in medical topics. The Rockefeller Foundation and
the Commonwealth Fund, established in 1918 by the Harkness family, are
two foundations that are historically important in funding aspects of the
U.S. health care system.'*^


The primary activity of a foundation, as noted in the previous section, is to
make grants to other nonprofit institutions. Foundations provide the
money to maintain and support institutions active in all functions of the
U.S. health care system and at one time were even active in performing
those functions themselves. Many foundations, for example, were ini-
tially established to provide patient care to the community's indigent. This
was usually accomplished by funding a local hospital or clinic, although
occasionally a foundation might have employed its own physicians to
provide patient care. On the national level, the Commonwealth Fund
funded the construction and maintenance of hospitals in some rural areas.
Through the use of demonstration projects, other foundations supported
the development of local health units, resulting in a concomitant im-
provement in the health of the surrounding population.

Over time, however, the involvement of foundations in direct patient
care has decreased. In many instances when clinics and demonstration
projects begun by a foundation proved to be beneficial, governmental
agencies developed the programs further. The Commonwealth Fund's
support of rural hospitals, for example, served as a model for federal
involvement in rural hospital construction with the Hill-Burton Act of
1946.'*5 The great remaining challenge in patient care — providing patient
care to the indigent or uninsured — is, however, beyond the resources of
even the richest foundations. Only a few foundations still fund innovative
demonstration programs in patient care, while most have shifted their
emphasis to health promotion or policy analysis.

Many of the resources that foundations once committed to direct
patient care have instead been spent on funding health promotion. Health
promotion itself has always been an important function of health founda-
tions. The eradication of hookworm in the South, for example, was primar-


ily a result of the sanitary efforts of the Rockefeller Foundation.'*^ More
recently, the Robert Wood Johnson Foundation and the Kaiser Foundation
have sponsored reporting on health care issues in the news media.

Foundations have historically had a major influence on biomedical
research. Early in this century, before the funding of biomedical research
was an accepted governmental function, foundations played an important
role in the scientific advance of medicine.'*^ Of course, the scale of founda-
tion support for both is small in comparison to governmental support. In
1989, for example, the Howard Hughes Medical Institute expended $197
million for biomedical research and private foundations another $82
million, whereas the NIH spent over $6.7 billion on health research and
development.'*^ Nevertheless, the contribution to biomedical research of
foundations like the Hughes is important. The Howard Hughes Medical
Institute, for example, provided seed money to support early efforts to
map portions of the human genome; only after their efforts helped build
support for the project could NIH get budgetary authority for the project
and establish the National Center for Human Genome Research.'*^ Other
foundations have given similar support to early fundamental work in the
basic life sciences.

Medical education is the area where foundations have perhaps had the
greatest influence. No foundation maintains its own medical school, and
the funding of training for individuals is limited. But foundations have
initiated a number of studies that have fundamentally changed the nature
of medical education in this country. For example, the Flexner report on
medical education (I9I0), which set out standards for modern medical
education in the United States, was funded by the Carnegie Foundation;
and the Rockefeller Foundation, through its General Education Board,
provided the funds that enabled a number of universities to implement
the recommendations embodied in the report. More recently, foundations
have supported studies on reform of medical school curricula. The Alfred
P. Sloan Foundation and the Josiah P. Macy Jr., Foundation in particular
have worked to increase educational opportunities for minorities in
health care fields.

In sum, foundations, like federal, state, and local agencies, provide
funding to purchase equipment and to construct, renovate, or expand
health care facilities; provide operating expenses or emergency funds;
support research; and educate health personnel through scholarships,
in-service education programs, on-the-job training, and exhibits. The
importance of foundations and the reason why their records are of
particular interest to historians is the pioneering role played by founda-
tions in all these areas. Foundations have historically had the flexibility to


respond quickly to innovative ideas through the development of pilot
studies or demonstration projects. Successful approaches have then been
replicated on a broad scale, usually by a governmental agency.


As with any institutional archives, foundation records document the
activities of the sponsoring organization. In addition, the records of health
foundations contain important information about individuals and other
groups and organizations. As Kenneth W. Rose noted, foundation records
may contain "important and often difficult-to-find information about a
variety of other institutions and organizations which too often disappear
without leaving any paper trail of their own. Since applicants for financial
support have to explain themselves, their backgrounds, and their needs to
their founders, foundation records are rich in the details of the histories of
other organizations. "5°

Unfortunately, Rose's survey of the records of all foundations suggests
that foundation records may be at risk. Of the 1,000 largest foundations
contacted for the survey, only 394 foundations chose to respond. Of those
394, only 43 (35 percent) had deposited their records in either an in-
house or external archives. The situation is even worse for foundations
that fund health care activities. Of the 140 foundations identified in the
survey as having a historical interest in health care, only 21(15 percent)
have formal internal or external archives programs. Six of these 21 are
found at the Rockefeller Archives Center; without the efforts of this one
repository, the picture would be even more bleak.

Many of the foundations that have not established formal internal or
external archives programs did report that archival records are found in
the general records of the foundation. Yet the completeness of these
records is in question. The Josiah Macy, Jr., Foundation, for example, one
of the most important foundations in the history of health care in this
country, reported having administrative and correspondence files only
since 1976, although it was founded in 1930. Other foundations impor-
tant to the development of health care, including the W. K. Kellogg
Foundation, the Alfred P. Sloan Foundation, and the Pew Charitable
Trusts, did not grant permission to have their responses to the survey
published in the volume, suggesting that they are unwilling to allow
researchers access to their records.

Fortunately, the work of Rose and others at the Rockefeller Archives
Center is an important first step in alerting foundations to the importance
of their records, and the center itself is an excellent model of a well-run
foundation archives. Since the publication of the survey, other founda-


tions interested in health care have either deposited records in external
repositories or have established their own archives programs. The Albert
and Mary Lasker Foundation, for example, deposited the records relating
to the Lasker Award, the premier American award for medical research, in
the National Library of Medicine. Perhaps more important, the People-to-
People Foundation, Inc., the sponsor of Project HOPE, has established an
internal archives at its headquarters in Millwood, Virginia. With the
assistance of a National Historical Publications and Records Commission
grant, the foundation has organized its 381 cubic feet of records and
published a guide to its holdings. The guide is a model for other founda-
tions interested in establishing archives. ^^ One hopes that the Rockefeller
Archives Center's example, the People-to-People Foundation's guide, and
this volume, will encourage more foundations to establish active archival


1. Professional and voluntary associations also perform many of the same
funaions as health care agencies and foundations. Their contributions are
considered in Chapter 6.

2. The term "agency" frequently has a specific meaning for federal, state, and
local governments, designating a governmental unit at a distinrt level in the
government hierarchy. In this chapter it is used generically to refer to any
governmental unit (department, agency, office, branch, division, etc.).

3. National Center for Health Statistics, Health: United States, 1991, and Prevention
Profile (Hyattsville, Md.: National Center for Health Statistics, 1991), 274.

4. Ibid., 277.

5. Charles Brecher, "The Government's Role in Health Care," in Anthony R.
Kovner and contributors. Health Care Delivery in the United States, 4th ed. (New
York: Springer Publishing Company, 1990), 297.

6. The lack of consistency in agency functions from state to state was one of the
driving forces behind the creation of the RLIN Seven States Project, which
tried to provide access to archival collections according to functional criteria
rather than by office of origin. On the Seven States Project and its functional
organization, see David Bearman, "Archives and Manuscript Control with
Bibliographic Utilities: Opportunities and Challenges," American Archivist 52
(Winter 1989): 26-39; Robert Sink, "Appraisal: The Process of Choice,"
American Archivist 53 (Summer 1990): 452-58; and Research Libraries Group,
Government Records in the RUN Database: An Introduction and Guide (Mountain
View, Calif.: Research Libraries Group, 1990).

7. Robert Straus, Medical Care for Seamen: The Origin of Public Medical Service in the
United States (New Haven: Yale University Press, 1950). Other discussions of
the origins of the Marine Hospital Service and its mandate to treat sailors are


found in Bess Furman, A Profile of the United States Public Health Service.
1798-1948 (Bethesda, Md.: National Library of Medicine, 1973) and Ralph
Chester Williams, The United States Public Health Service, 1798-1950
(Washington, D.C.: Commissioned Officers Association of the United States
Public Health Service, 1951).

8. A Common Thread of Service: An Historical Guide to HEW (Washington, D.C.:
Department of Health, Education, and Welfare, 1973).

9. The categorical institutes constituting the National Institutes of Health and
located on the Bethesda campus of NIH are devoted to the following subjects:
Aging; Alcohol Abuse and Alcoholism; Allergy and Infectious Diseases;
Arthritis and Musculoskeletal and Skin Diseases; Cancer; Child Health and
Human Development; Deafness and Other Communication Disorders; Drug
Abuse; Dental Research; Diabetes and Digestive and Kidney Diseases; Eyes;
General Medical Sciences; Heart, Lung and Blood; Mental Health;
Neurological Disorders and Stroke; and Nursing Research. The National
Institute of Environmental Health Sciences, also a component part of the NIH,
is located in Research Triangle Park, North Carolina.

10. Several efforts are under way to document the human genome project,
supported by funds from the National Center for Human Genome Research at
NIH and the National Science Foundation. The Beckman Center for the
History of Chemistry has begun one such effort, and the bioethics library at
Georgetown University has begun another.

1 1 . Mark Walter, "Pharmaceuticals: An Industry Ripe for Automation," in The
Seybold Report on Publishing Systems 22{\2) (March 8, 1993), 3-12.

12. National Center for Health Statistics, Health: United States, 1991, 294, 297.

13. Brecher, "Government's role," 309.

14. Professional standards review organizations and their impact on hospitals are
discussed in more detail in Chapter 2.

1 5. Brecher, "Government's Role," 311.

16. Joel Howell, "Preserving Patient Records to Support Health Care Delivery,
Teaching, and Research," in Nancy McCall and Lisa A. Mix, eds.. Designing
Archival Programs to Advance Knowledge in the Health Fields (Baltimore: Johns
Hopkins University Press, 1994).

1 7. The United States Cadet Nurse Corps and Other Federal Nurse Training Programs
(Washington, D.C.: Public Health Service, 1950), 78. See also Philip A.
Kalisch and Beatrice J. Kalisch, The Federal Influence and Impact on Nursing
(Hyattsville, Md.: Bureau of Health Professions, Division of Nursing, 1980)
(NTIS doc. HRP-0900636).

18. Lauren LeRoy and Philip R. Lee, Deliberations and Compromise: The Health
Professions Educational Assistance Act of 1976 (Cambridge, Mass.: Ballinger, 1977).

1 9. Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic
(New York: St. Martin's Press, 1987), 54.

20. Federal Records Act, 44 U.S. Code 3101.

2 1 . An overview of the programmatic activities and expenditures of each state
health agency is provided in the Public Health Foundation's annual survey of
public health agencies.


22. Public Health Foundation, Public Health Agencies 1991: An Inventory of Programs
and Block Grant Expenditures (Washington, D.C.: Public Health Foundation,
1991), 1.

23. Ibid., 3.

24. The increased incidence of antibiotic-resistant tuberculosis in the United
States may lead to the revival of tuberculosis sanatoria.

25. In some other states, such as Georgia, hospitals are operated by separate
hospital authorities outside of the supervision of the state health agency.
Public Health Agencies 1991, 7.

26. Arizona, the last state to join the Medicaid program, signed on in 1982.

27. NIH Data Book: Basic Data Relating to the National Institutes of Health (Bethesda,
Md.: National Institutes of Health, 1991), 2.

28. An interesting analogy from the world of physics is found in Utah, where
much of the recent work on cold fusion was funded by the state government.

29. Committee on the Records of Government, Report (Washington, D.C.:
Committee on the Records of Government, 1985), 71.

30. Ibid., 20. On the poor state in general of state archives, see also Lisa B. Weber,
ed.. Documenting America : Assessing the Condition of Historical Records in the States
(Atlanta: Conference of the National Historical Publications and Records
Commission Assessment and Reporting Grantees, 1984).

31. Roland M. Baumann, "The Administration of Access to Confidential Records
in State Archives: Common Practices and the Need for a Model Law,"
American Archivist 49 (1986): 361-363.

32. In addition to the Baumann work cited above, see also McCall and Mix,
Designing Archival Programs.

33. C. A. Miller et al., "A Survey of Local Public Health Departments and Their
Directors," American Journal of Public Health 67 (October 1977): 931-99.

34. Public Health Agencies 1991, 1.

35. Haven Emerson, Local Health Units for the Nation (New York: Commonwealth
Fund, 1945).

36. H. G. Jones, Local Government Records: An Introduction to Their Management,
Preservation, and Use (Nashville, Tenn.: American Association for State and
Local History, 1980), 19.

37. Ibid., 136.

38. Bruce W. Dearstyne, The Management of Local Government Records: A Guide for
Local Officials (Nashville, Tenn.: American Association for State and Local
History, 1988), 110-1.

39. William G. Le Furgy, The Records of a City: A Guide to the Baltimore City Archives
(Baltimore, Md.: City Archives and Records Management Office, 1984), 36,
and John Daly, Descriptive Inventory of the Archives of the City and County of
Philadelphia (Philadelphia: Department of Records, 1970).

40. Ibid., 37; telephone conversation with David Weinberg, Philadelphia City
Archives, 27 June, 1993.

41. National Data Book of Foundations, 1991 (New York: Foundation Center, 1991),
v. The Foundation Center, a nonprofit organization founded and supported
by foundations "to provide a single authoritative source of information on


foundation giving," is the best source of information on foundations (also

Online LibraryJoan D KrizackDocumentation planning for the U.S. health care system → online text (page 8 of 26)