Pivotal to Asia’s future will be the robustness of its medical universities. Lessons learned in the past and the challenges facing these schools in the future are outlined in this collection, which offers valuable insights for other medical education systems as well. The populations in these rapidly growing countries rely on healthcare systems that can vigorously respond to the concerns of shifting demographics, disease, and epidemics. The collected works focus on the education of physicians and health professionals, policy debates, cooperative efforts, and medical education reform movements.
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About the Author
Lincoln C. Chen is President of the China Medical Board and Chair of the Board of BRAC USA.
Michael R. Reich is Taro Takemi Professor of International Health Policy at the Harvard School of Public Health.
Jennifer Ryan is a Program Manager at the China Medical Board.
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Medical Education in East Asia
Past and Future
By Lincoln C. Chen, Michael R. Reich, Jennifer Ryan
Indiana University PressCopyright © 2017 Indiana University Press
All rights reserved.
The China Medical Board in East Asia, 1950–2000
Jennifer Ryan and Mary Brown Bullock
The China Medical Board was instrumental to the twentieth-century development of medical education, not only in China, as its name would suggest, but in a total of seventeen countries outside the United States, including all of the countries in East Asia. This chapter on the institutional history of CMB describes how it expanded its mission after the Peking Union Medical College (PUMC) was nationalized and the American foundation was forced to pull out of the newly established People's Republic of China. Turning this exodus into an opportunity, the foundation made adjustments and strategic investments to maximize impact where its philanthropic mission could best serve the needs of the "Far East," as the region was known at the time. Indeed, the region was in great need of reconstruction after the damages of the wartime years. During its thirty years outside China, CMB continued to make a significant impact by funding strategic projects as it recognized specific country needs. The foundation funded reconstruction projects, granted institutional matching endowment funds, and supported hundreds of individuals with travel fellowships and exchange programs. Although they were less well-known than these long-term impact grants, CMB made other unique contributions to the development of medical education in Asia — including small but singular achievements such as building and stocking the first and only medical library in the Philippines and translating the first textbooks on nursing into Chinese.
Over the course of a century, by building medical institutions in China and neighboring Asian countries, CMB has given hundreds of millions of dollars in grants and technical support to strengthen education and research in medicine, nursing, and public health, all aimed at improving health in Asia. In the first half of the twentieth century, most of CMB's resources went toward the construction and development of PUMC to establish a world-class medical school and hospital in China. Virtually all of the premier medical universities in Asia have been funded in some way by CMB, including many schools focusing on rural health in remote regions. In its one-hundred-year history, CMB has provided US $1.5 billion to more than 118 Asian medical universities, supporting young and senior fellows and funding innovations in research and education. Innovation has been a hallmark of CMB's impact in Asia, from research innovations such as the isolation of ephedrine, the discovery of Peking Man, and the first model of rural primary health care deploying "barefoot doctors" to educational innovations like the introduction and dissemination of science-based education in universities, problem-based and standardized patient learning, global minimal educational requirements, and IT-accelerated learning.
Over the course of one hundred years, CMB — one of the earliest modern philanthropic institutions to operate in Asia — has been led by eight presidents and seventy trustees, including John D. Rockefeller III, who served on the board from 1930 to 1947. Programmatic shifts reflect changing historical circumstances, while the long tenure of CMB's leadership highlights its lasting engagements with and deep knowledge of Asia over a transformative era. The institutional history of CMB that follows has been taken largely from its annual reports and archival materials from 1914 to 2014.
The PUMC Era: 1914–1950
The more than three decades between 1914 and 1950 could be dubbed "The PUMC Era." Following the recommendations of Medicine in China, a report published by the China Medical Commission of the Rockefeller Foundation, CMB was launched in 1914 as the second major program of the newly established Rockefeller Foundation. The CMB was created to put the ideas of the commission into practice, specifically to manage funding and operations for the establishment of PUMC, "the cradle of modern medicine in China." Indeed, CMB spent the next three decades constructing, staffing, and developing China's premier medical school and affiliated teaching hospital until it had to pull its operations from China when PUMC was nationalized after 1949 by the newly victorious Chinese Communist government.
CMB's mission today traces its roots to the early years of the twentieth century, when breakthroughs in science were opening a new era of science-based medicine and Abraham Flexner's path-breaking report was beginning to transform modern medical education. John D. Rockefeller Sr., the richest man of his generation, was channeling his vast wealth toward philanthropic endeavors through the newly created Rockefeller Foundation, and CMB was its second and perhaps largest-ever program.
CMB's intellectual foundations and mandate for its work in China were expressed in the ninety-eight-page commission report funded by the Rockefeller Foundation. In April 1914, the members of the commission — Harry Pratt Judson, Roger Sherman Greene, Francis Weld Peabody, and George Baldwin McKibbin — sailed to China to examine various medical schools and hospitals and report on the conditions of public health and medicine there. All in all, they surveyed seventeen medical schools and ninety-seven hospitals on their trip, which extended to eleven of China's eighteen provinces. The commission met with both government officials and those who ran the medical missionary schools. Those early decades found China at a crossroads as the collapse of the Qing Dynasty gave way to the beginning of the new Republic of China and major efforts at modernization were poised to improve the health of the country trying to shed the moniker "the sick man of Asia." The health conditions surveyed by the commission included incidences of infectious diseases such as cholera and bubonic plague, as well as tuberculosis, hookworm, and syphilis, and also assessed the state of medicine and surgery at that time, western medicine in China, and standards of medical education under missionary auspices. Through their extensive travels and observations, the commission members were convinced that the time and Chinese receptivity were ripe for the introduction of western medical teaching and practice (China Medical Commission of the Rockefeller Foundation 1914).
Recommendations included that the Rockefeller Foundation should certainly undertake medical work in China, cooperate with existing missionary institutions as far as possible, and instill the highest standards of medical instruction in English. The commission recommended that medical educational work begin in Beijing in connection with the existing Union Medical College. In 1915, the foundation purchased and assumed support of the Union Medical College, which had been founded by a group of Protestant missionaries in 1906. Construction of the physical plant took the next four years. In 1917, CMB established PUMC to expand western medicine in China, and in 1919, PUMC admitted women for nursing, becoming the first coeducational school in China. By 1921, formal dedication ceremonies were held on the campus grounds, with John D. Rockefeller Jr. declaring the intention to "make permanent on Chinese soil the best in scientific medicine that the world can offer." The first meeting of the board of trustees in September 1921 was attended by fourteen members, including Rockefeller Jr.
PUMC was a first-rate biomedical research facility, and English was the language of instruction. PUMC's research departments included anatomy, chemistry, physiology, and pathology, as well as a radiology, or X-ray, department. In 1924, PUMC scientists discovered and isolated ephedrine from the Chinese herb mahuang (Ephedra sinica). Two years later, Davidson Black discovered Peking Man and conducted paleontology studies in PUMC's Department of Anatomy. PUMC quickly became the premier medical school and hospital in China, so prominent, in fact, that China's first president, Dr. Sun Yat-sen (Sun Zhongshan), also a physician of western medicine, chose to be evaluated at PUMC before he died of liver cancer in 1925. That same year, public health pioneers John Grant and C. C. Chen established and developed the first health-field station in Beijing, which was staffed by PUMC students, and then began rural health work in Ding Xian, which eventually developed into the "barefoot doctor" model.
In 1928, the CMB received its first Rockefeller Foundation endowment of $12 million to create an independent American foundation for the continuing support of PUMC. Shortly thereafter, leading Chinese philosopher and modernizer Hu Shih joined PUMC's board, becoming Chairman from 1946-1949. Throughout both the Sino-Japanese and Chinese civil wars, PUMC's dedicated staff and leadership steadfastly continued CMB's mission. During this period, led by visionaries and medical men (both Chinese and western) such as John B. Grant and Hu Shih, and others such as C. U. Lee, Roger Greene, and Henry S. Houghton, PUMC doctors and nurses cared for wounded soldiers during Japanese invasion. When PUMC was taken over during World War II, the Japanese interned Director Henry Houghton, who remained captive for four years (1942-1946).
With the outbreak of war with Japan in 1941 and the occupation of PUMC by Japanese troops, CMB redirected PUMC students it supported to continue their studies at other medical schools. PUMC reopened in 1947 with twenty-two medical and sixteen nursing students, led by C. U. Lee, its first Chinese director. Yet, the resumption of full-scale operation of the college was not possible.
With the success of the Communist Revolution in 1949, conditions began to change. The CMB planned to continue work in the People's Republic of China, but the advent of the Korean War and worsening relations between the two governments made this impossible. In January 1951, PUMC was nationalized and all funds for China were frozen by the US government. CMB, under Director Harold Loucks, withdrew from the newly formed People's Republic of China and would not return for almost thirty years. At the same time that CMB was forced to leave the mainland, PUMC graduates and former staff members who left with the Chiang Kai-shek's Nationalists joined together and formed the National Defense Medical Center in Taiwan for the training of medical students there.
By 1951, PUMC faculty and graduates had founded many key clinical specialties in China and developed innovations such as a three-tiered rural health system. The knowledge generated by PUMC helped usher in a revolution in the understanding and practice of medicine in China that catalyzed dramatic health progress, and its graduates, including Huang Jiasi and Wu Jieping, have made enduring contributions to China's health care system.
CMB Extends to East and Southeast Asia: 1951–1980
Political change in China interrupted CMB's work on the mainland for three decades and prompted CMB's extension throughout Asia in the 1950s. Since CMB could no longer continue its support of PUMC, in 1951 it began to expand its program to medical and nursing schools to the limits permitted by its charter to "the Far East and the United States of America." In a time of stress and uncertainty, CMB's board of trustees widened their field of activity, entering new geographies with a new program strategy. The year 1952 marked CMB's first grants in new territories. Support went first to Japan and Taiwan in 1952, next to Korea, Hong Kong, and Thailand in 1953, and ultimately, over the following three decades, to medical institutions in fourteen countries and regions outside the United States and China, including medical schools in the Philippines, Indonesia, Ceylon (Sri Lanka), Malaya (Malaysia), Burma (Myanmar), Singapore, and Vietnam.
Table 1.1 shows the number of grantee schools and total funding in East Asia over three decades. A full listing of grantee schools from Table 1.1 can be found in the annex at the end of this chapter. Among this group, South Korea received the most funding, with $9.1 million, followed by Taiwan, Japan, and Hong Kong. It is interesting to note that, while the number of grantee schools in Japan (forty schools) far exceeded any other country, the overall level of funding to the country was much lower compared with countries with fewer number of schools (in the case of Hong Kong, only one school). This kind of differentiated grant making by the CMB board was in response to local schools' needs and strengths and changing socioeconomic conditions within the region.
During these thirty years, CMB's program outside mainland China funded a wide swath of projects as it recognized needs in specific countries. This was of particular value in light of in-country reorganization and reconstruction efforts during the postwar years. In the early days of CMB's new program in the Far East, the projects aided by its grants fell into the following four major categories: fellowships, visiting professorships, medical libraries, and equipment for laboratories. Individuals sponsored by CMB fellowships and visiting professorships crisscrossed the globe — Asian physician-teachers traveled to US institutions for educational exchanges while American professors taught as medical faculty in Asian institutions. Institutions sponsored by CMB were able to rebuild and stock libraries and equip their schools to carry out research and teaching activities.
For over twenty years, CMB made individual fellowship grants to medical and nursing schools in the region. It considered its fellowship program for study and travel in the United States one of its most important contributions to medical education in the Far East. Study fellowships provided for one year of study, usually in the United States or occasionally in Europe, while travel fellowships would enable those with an already established scientific reputation to bring themselves up to date with developments in their field of interest. Most recipients would travel to the United States for a period of about three to six months to visit American schools and hospitals to observe their operations. During the first year of the fellowship program (1952), funds were given to thirteen medical schools for sixteen fellowships.
It was CMB's view that the fellowship program was to improve medical education in the recipient's home country, not just enhance his or her personal career. Concerned that these not contribute to "brain drain" in the medical sciences, CMB granted fellowships with the expectation that the individual was to return to his or her school after completion.
Japan, a CMB grant recipient until 1974, received the highest number of fellowships, with a total of 186, with Taiwan right behind with 185, followed by Thailand and Korea with 106 and 100, respectively. Of the total number of fellowships, study fellowships made up the bulk of the total at 78 percent, with travel fellowships at 22 percent (see Table 1.2). Support was given to various disciplines, including: clinical sciences, basic sciences, medicine, surgery, public health, libraries, obstetrics and gynecology, pediatrics, hospital administration, and radiology.
The fellowship program ramped up gradually and was in operation through 1973, by which time it was granting approximately fifty fellowships per year. The reason for ending the fellowship program was two-fold. Under new CMB president Dr. Patrick Ongley, the foundation set new goals in 1973, specifically with a sharper focus on empowering Asian institutions. At the same time, IRS tax rules in the United States changed, no longer allowing the "return home" provision. With concern over contributing to brain drain in regards to the overall objectives of the fellowships, Ongley modified the program and eventually moved the funds to block grants and matching grants.
Visiting professorships were funded to foster mutual understanding between East and West, as well as the progress of medicine. Professors of a variety of specializations — medicine, pathology, orthopedic surgery, parasitology, physiology, public health nursing, bacteriology, and pharmacology — were sponsored to spend short (two- to six-month) or longer (two- or three-year) periods of time in residence in an Asian university's faculty of medicine. CMB sponsorship of visitors in the Far East started in 1952, with the first three visiting professors going to three medical schools in Taiwan, the Philippines, and Singapore. In 1957, the first year CMB annual reports began to list fellows and visitors by name and institutional affiliation, ten professors were visiting at faculties of medicine and schools of nursing throughout the region — including the Philippines, Japan, Taiwan, Thailand, Hong Kong, Burma, and Indonesia. As with the fellowship program, 1973 was the final year of the visiting professor program.
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Table of Contents
Preface: Mary Brown Bullock
Foreword: Bong-Min Yang, Keizo Takemi, and Ke Yang
Part I. Overview and US-Asia Engagement
History and Development of Medical Education in East Asia: An Overview / Lincoln C. Chen, Michael R. Reich, and Jennifer Ryan
1. The China Medical Board in East Asia, 1950-2000 / Jennifer
Ryan and Mary Brown Bullock
2. American Medical Education and US Engagement in East Asia, 1950-1970 / Jesse B. Bump and Paul J. Cruickshank
Part II. Country Cases: China, Japan, and South Korea
3. Medical Education in Contemporary Mainland China / Daqing Zhang
4. Mission and Modernity: The History and Development of Medical Education in Taiwan / Ming-Jung Ho, Kevin Shaw, Julie Shih, and Yu-Ting Chiu
5. A Brief History of Medical Education in Hong Kong / Gabriel M. Leung and N. G. (Niv) Patil
6. The Roots of Modern Japanese Medical Education in Japan / Kenichi Ohmi
7. Western Influences on Health Science Education in Korea: Medical, Nursing, and Public Health Education / OkRyun Moon
Part III. Future Challenges
8. Burden of Disease: Implications for Medical Education in East Asia / Stuart Gilmour, Yusuke Tsugawa, and Kenji Shibuya