In 1910, a man named Abraham Flexner published a report. He had no medical degree. He had never treated a patient. He had no background in public health, no training in pharmarmacology, no experience running a hospital or managing a clinical practice. He was an educator, a school master from Louisville, Kentucky, who had spent his career thinking about pedigogy and curriculum design.

 That report, commissioned by the Carnegie Foundation and funded in part by John D. Rockefeller destroyed over half of the medical schools in the United States within a decade. It ended the careers of thousands of practitioners. It eliminated entire traditions of healing that had existed in America for generations.

 And it handed control of American medicine to a small group of men whose primary interest in medicine was not healing, but profit. The American medical system you interact with today, the one that costs more per capita than any other system on Earth while producing worse outcomes than most of its peers, the one where a single hospital stay can bankrupt a family.

 The one where pharmaceutical companies set the research agenda and insurance companies make clinical decisions. That system was not the result of medical science improving and medicine naturally consolidating around what worked. It was the result of a deliberate, documented, well- financed campaign to eliminate competition and establish a monopoly.

And the man who fired the first shot was a school teacher with no medical training, carrying a report written on behalf of men who had already decided what conclusion they wanted. That is where we are going today. We are going to follow the money and read the primary sources and show you exactly what was destroyed, who destroyed it, why they destroyed it, and what it cost.

 because the cost has been enormous and it is still being paid. To understand what the Flexner report destroyed, you have to understand what American medicine looked like before 1910. And to understand that, you have to let go of the story you were probably told, which is that preflexer American medicine was a chaos of quax and snake oil salesman.

 And that the Flexner report was the dawn of real scientific medicine in a country that had previously been fumbling in the dark. That story is not just incomplete. It is in its essential structure a piece of propaganda produced by the people who benefited most from the destruction of the old system.

 And it has been repeated so many times in so many medical school curricular and history textbooks and documentary films that it has acquired the status of obvious truth. The actual picture is more complicated, more interesting, and considerably more damning. Before 1910, American medicine was genuinely pluralistic. There were multiple competing traditions, each with its own theoretical foundation, its own clinical practices, its own schools, its own professional organizations, and its own patient base.

These traditions were not uniformly effective, and some of them were indeed fraudulent. But the dominant traditions, the ones that had the largest patient populations and the most established schools and the most robust professional networks, were not the fraudulent ones. They were traditions with serious intellectual foundations and documented clinical records.

 The largest of these after what was called regular or alipathic medicine was eclectic medicine. Eclectic medicine was a tradition founded in the 1820s by Worcester Beach, a physician who had trained in both European medicine and in the plant-based healing practices of indigenous North American and African-American communities. The eclectics believed that effective medicine should be drawn from whatever sources produced results and their tradition incorporated a vast pharmacaper of plant-based remedies, many of which are now recognized by

modern pharmacology as containing active compounds with genuine therapeutic value. By 1900, Eclectic Medicine had its own medical colleges, its own professional journal, the Eclectic Medical Journal, its own licensing standards, and its own clinical hospitals. The Eclectic Medical College of Cincinnati, founded in 1845, was one of the oldest continuously operating medical schools in the United States.

Eclectic practitioners were not fringe figures. They were licensed physicians operating within a recognized professional framework treating hundreds of thousands of patients. The second major alternative tradition was homeopathic medicine. Homeopathy had been introduced to the United States in the 1820s and 1830s and had grown rapidly to become one of the most popular medical traditions in the country by the mid-9th century.

 By 1900, there were 22 homeopathic medical colleges in the United States and homeopathic physicians treated a significant fraction of the American population. The Boston University School of Medicine was for much of the 19th century and a homeopathic institution. The University of Michigan’s medical department had homeopathic professors.

Homeopathy was not a fringe practice. It was mainstream medicine for a substantial portion of the population. The third tradition, and the one that would be most thoroughly erased by the Flexner report, was osteopathic medicine, at least in its original form. Andrew Taylor still the founder of osteopathy had developed his system in the 1870s after the deaths of three of his children from spinal menitis.

 Still believed that the body had an inherent capacity for self-healing and that the role of the physician was to remove the structural obstructions that prevented that capacity from functioning. The original osteopathic tradition emphasized hands-on manipulation, lifestyle, and nutrition and was deeply skeptical of pharmaceutical intervention.

 There were also naturopathic practitioners who emphasized the healing power of nature through nutrition, water, air, and light. There were chiropractic practitioners whose tradition had been founded in 1895 by DD Palmer and who focused on the relationship between the spine and the nervous system. They were practitioners of what was called physioomedicalism, a tradition that combined botanical medicine with principles drawn from vitalist physiology.

 And then there was regular or alopathic medicine, the tradition that would become the only legal form of medical practice in the United States after 1910. In 1900, regular medicine was not the dominant tradition by any obvious measure. It had the most institutional prestige and the most political connections, but its clinical record was by many measures not better than its competitors.

 In some areas, it was worse. Regular medicine in 1900 still relied heavily on interventions that we now know were actively harmful. Bloodletting, while declining, was still practiced. Calamel, a mercury based compound used as a perive was still in the regular pharmarmacapua and was causing mercury poisoning in patients across the country.

 The germ theory of disease had been established by Pastor and Kirk in the 1860s and 1870s. But the therapeutic implications of germ theory, meaning effective treatments for bacterial infections, would not be realized until the development of sulfur drugs in the 1930s and penicellin in the 1940s. In the intervening decades, regular medicine had a theoretical framework that was scientifically correct, but relatively limited effective treatments to offer.

 What regular medicine had that its competitors lacked was a relationship with the emerging pharmaceutical and chemical industries. Understand this relationship and you understand everything that follows. The late 19th century saw the emergence of the modern pharmaceutical industry built primarily on the chemistry of colar derivatives.

 These were synthetic compounds produced in laboratories with no history of traditional use and no accumulated body of empirical knowledge about their long-term effects. The early pharmaceutical industry concentrated largely in Germany and Switzerland needed medical systems that would use their products. A medical tradition based on botanical remedies that could be grown, harvested, and prepared without industrial intermediaries was and from the perspective of the pharmaceutical industry, a competitive threat.

 The major American industrial fortunes of the late 19th century, most prominently those of John D. Rockefeller and Andrew Carnegie, were themselves built on the chemistry of petroleum and steel. Rockefeller’s Standard Oil was not just an oil company. By the early 20th century, it was also a major producer of pharmaceutical precursor chemicals.

Rockefeller had already understood from his experience in oil refining that the most profitable position in any industry is not production but control of the infrastructure through which production flows. The infrastructure of medicine was medical education. Control what was taught in medical schools and you controlled what was practiced in doctor’s offices.

control what was practiced in doctor’s offices and you controlled what patients received. Control what patients received and you controlled a market worth hundreds of millions of dollars annually. A market that was by its nature inelastic because sick people will pay whatever they have to pay to get well.

 Rockefeller through the general education board and the Rockefeller Institute for Medical Research had already been funding medical education reform before the Flexner report was commissioned. Carnegie through the Carnegie Foundation for the Advancement of Teaching was the institutional vehicle for the report itself.

 The two foundations were not independent actors pursuing parallel agendas. They were coordinated instruments of a shared strategy and the men who ran them were in regular communication about that strategy. This is not speculation. It is documented in the correspondence archives of both foundations, in the personal papers of Frederick Gates, the Baptist minister, who became Rockefeller’s chief philanthropic adviser, and in the institutional histories written by people who had access to those archives and either did not recognize the significance of what they were reading

or chose not to emphasize it. Frederick Gates, whose background was in theology rather than medicine, became convinced after reading William Oller’s Principles and Practice of Medicine in the 1890s that American medicine was in crisis and that Rockefeller money could solve that crisis by reorganizing medical education around a German university model.

 The German model developed at institutions like the University of Berlin and the University of Leipig emphasized laboratory science controlled clinical trials and pharmaceutical intervention. It was a model that was genuinely scientifically rigorous but it was also a model that was specifically compatible with an industrial pharmaceutical economy.

Gates wrote a famous memo to Rockefeller in 1897 describing American medicine as a vast unscientific mass of hug and proposing that Rockefeller fund the creation of a new kind of medical education. This memo is quoted in virtually every history of the Rockefeller philanthropies. What is less frequently noted is that Gates was writing about a crisis in regular alipathic medicine specifically.

He was not writing about the eclectic or homeopathic traditions which had their own institutional structures and which Gates had not studied. His prescription for regular medicine was then applied through the Flexner process to all of American medicine. Abraham Flexner was hired by the Carnegie Foundation’s president Henry Pritchette in 1908.

 His assignment was to visit every medical school in the United States and Canada and assess their facilities, curriculum, faculty, and student admission standards. Flexner spent approximately 2 years doing this, visiting approximately 155 schools over the course of his tour. The report he produced in 1910 titled Medical Education in the United States and Canada is a remarkable document.

 It is well written, clearly argued, and in many of its specific criticisms, accurate. Many of the schools Flexner visited were in fact poorly funded, inadequately staffed, and insufficiently rigorous in their admission standards. This was true of regular schools as well as eclectic and homeopathic ones.

 But the report was not designed to improve medical education across all traditions. It was designed to establish a single standard, the German university model with its emphasis on laboratory science and pharmaceutical therapeutics as the only legitimate form of medical education and to eliminate every institution that did not meet that standard.

 The standard was also not coincidentally a standard that the schools connected to Rockefeller and Carnegie funding already met or could rapidly be brought to meet while the schools of the competing traditions could not meet it without funding they would not receive because the funding was controlled by the same foundations whose standard they were being asked to meet. This is a closed loop.

 It is worth sitting with that for a moment. The foundations set the standard. The foundations controlled the funding required to meet the standard. The schools that received the funding could meet the standard. The schools that did not receive the funding could not. The schools that could not meet the standard were condemned in the Flexner report.

The condemnation of the schools in the Flexner report was used to justify the withdrawal of state licensing from their graduates. And the withdrawal of state licensing destroyed the schools. It did not happen overnight, but it happened with remarkable speed. In 1900, there were approximately 160 medical schools in the United States.

 By 1920, there were 85. By 1930, there were 76. The reduction was not random. The schools that survived were overwhelmingly. Be the regular alipathic schools affiliated with universities that had received Rockefeller or Carnegie funding. The schools that closed were disproportionately the eclectic and homeopathic schools, the schools for African-American physicians, and the schools that had admitted women in significant numbers.

 The racial dimension of the Flexner report’s impact deserves particular attention because it is one of the most consequential and least discussed aspects of the story. In 1900, there were approximately seven medical schools that specifically served African-American students. These schools existed because the regular alipathic medical establishment had excluded black physicians from its institutions.

The Howard University College of Medicine and the Mihari Medical College were the two largest and most established of these schools and both survived the Flexner purge, but five others did not. The closure of those schools meant that the already limited pipeline of black physicians into American medicine was further constricted at precisely the moment when the overall number of medical schools was being cut in half.

 Flexner’s own descriptions of the black medical schools in his report are worth reading. Not because they are useful as medical assessments, which they are not, but because they reveal the racial assumptions built into the entire enterprise. Flexner argued that black physicians should be trained primarily to serve black communities in the south and that their training should therefore be calibrated to that purpose.

The notion that a black physician might practice general medicine, treat patients of any race, operate in any region of the country, must or contribute to medical research simply does not appear in Flexner’s analysis. The women’s schools faced a different but related dynamic. Several of the women’s medical colleges that had been founded in the mid-9th century, including the Women’s Medical College of Pennsylvania, were specifically targeted for criticism in the report or were pressured to merge with co-educational

institutions on the theory that a separate institution was no longer necessary. What happened in practice was that many of the co-educational institutions that absorbed women’s medical colleges then reduced their admission of women’s students. The overall number of women in American medical schools declined significantly in the decades after Flexner.

 Now let us talk about what was lost. The eclectic traditions pharmarmacapier is perhaps the most concrete example of what the flexner purge cost American medicine in purely therapeutic terms. The Eclectics had spent 75 years systematically documenting the therapeutic properties of North American plants, drawing on indigenous knowledge, African-American healing traditions and their own clinical experience.

 By 1900, the eclectic pharmacapua contained descriptions of several hundred plant-derived remedies, many of which had been subjected to what we would now recognize as clinical observation, tracking which remedies produced which outcomes in which patient populations. Several of the plants in the eclectic pharmacapoya have since been validated by modern pharmacological research.

Ekania which the eclectics used extensively for infections is now one of the most studied medicinal plants in the world with evidence supporting its immunomodulatory properties. Cascara sagrada used by the eclectics as a laxative became a standard pharmaceutical product. Labilia inflatter used for respiratory conditions contains alkoids that modern pharmarmacology recognizes as having genuine broncoilatory properties.

Golden seal used for mucous membrane infections contains bourberin an alkoid with documented antimicrobial activity. These were not folk remedies preserved by tradition without rational basis. They were the product of systematic clinical observation over generations encoded in the professional literature of a recognized medical tradition.

 And that literature was largely lost or rather deliberately marginalized when the schools and journals and professional organizations of the eclectic tradition were destroyed. The destruction happened through a mechanism worth understanding in detail because it was elegant in its simplicity. Medical licensing in the United States was in 1900 controlled at the state level by state medical boards.

 The composition of those boards was in most states dominated by regular alipathic physicians reflecting the political influence of the American Medical Association which had been reorganized and reinvigorated in 1901 specifically to consolidate regular medicine’s political position. After the Flexner report was published, state medical boards began requiring that applicants for medical licenses have graduated from an approved medical school.

 The list of approved schools was in most states uh effectively determined by the American Medical Association’s Council on Medical Education, which had been working closely with the Carnegie Foundation and the Rockefeller Foundation since before Flexner’s tour began. Schools that were not on the approved list had their graduates denied licenses.

 Schools that could not obtain approval lost their students. Schools that lost their students closed. The entire process was driven not by any democratic deliberation or legislative process, but by the coordination of private foundations, a professional association, and the state regulatory apparatus. This was regulatory capture executed with textbook efficiency.

 The regulated industry controlled the regulators, used the regulatory process to eliminate competition, and presented the entire operation as a public health measure. It worked. By 1930, Pluralistic American Medicine was dead. The Eclectic Medical College of Cincinnati, the oldest continuously operating alternative medical institution in the country, closed in 1939, 94 years after its founding.

 The last homeopathic medical colleges were absorbed into alipathic institutions or closed by midentury. The original osteopathic tradition was gradually absorbed into mainstream medicine with osteopathic physicians receiving training almost identical to alipathic physicians retaining the DO degree as a credential but largely abandoning the original philosophical orientation of Stills system.

 What replaced pluralistic medicine was not simply better medicine. What replaced it was a medical system specifically designed around pharmaceutical intervention, most specifically aligned with the industrial interests of the chemical and pharmaceutical industries and specifically organized to maximize the volume of pharmaceutical products consumed by the American population.

This is not to say that pharmaceutical medicine has not produced genuine benefits. It has. The development of antibiotics, vaccines, insulin, chemotherapy agents, and countless other pharmaceutical interventions has unquestionably saved lives and reduced suffering on an enormous scale. The germ theory framework that underlay the Flexner model was in its essentials correct.

 Laboratory science has contributed enormously to human health. But the question is not whether the Flexner model produced any good outcomes. The question is whether the elimination of all competing traditions was a necessary precondition for those good outcomes. And the answer to that question is almost certainly no. There is no reason why a rigorous scientific standard for medical education could not have been applied in a way that preserved and validated the best of the eclectic traditions botanical farmer while improving its clinical training

and research methods. There is no reason why homeopathic schools that were willing to incorporate laboratory science could not have been funded to do so while retaining their distinctive clinical approaches for investigation rather than elimination. There is no reason why the traditions that emphasize nutrition, lifestyle, and the body’s inherent healing capacity had to be destroyed rather than integrated into a broader scientific framework.

Those things did not happen because the people who designed the Flexner process did not want them to happen. They wanted a medical system based on pharmaceutical intervention because they had invested in the pharmaceutical industry and because they understood correctly that a medical system based on botanical remedies, lifestyle modification, and the body’s self-healing capacity was not a medical system that would generate large pharmaceutical revenues.

 The cost of that choice is visible in the epidemiological record of the 20th century. The United States, despite its enormous per capita health expenditure, W has worse health outcomes on most standard measures than other wealthy countries that spend significantly less. American life expectancy at birth is lower than in most comparable countries.

Infant mortality is higher. The rates of chronic disease, including diabetes, cardiovascular disease, obesity, and autoimmune conditions, are among the highest in the industrialized world. These are not outcomes that can be attributed to a failure of pharmaceutical medicine to deliver its promised interventions.

Americans take more pharmaceutical drugs per capita than people in virtually any other country. The problem is not a shortage of pharmaceutical intervention. The problem is that a medical system built entirely around pharmaceutical intervention is not a medical system designed to keep people healthy.

 It is a medical system designed to treat illness and specifically to treat illness with interventions that must be repeatedly purchased. A medical tradition that emphasized nutrition, botanical medicine, and the body’s self-healing capacity would not necessarily have prevented all of these outcomes, but it would have offered a different set of tools.

 It would have maintained a different set of questions and it would have been far less easily captured by the financial interests of the industries whose products it relied upon. The Flexner report foreclosed that possibility, not because the science required it, but because the money wanted it.

 Here is what is worth noting about the present moment. Flexner’s framework is now over a century later beginning to crack around its edges. The rise of integrative medicine, functional medicine, and evidence-based naturopathy represents a partial rehabilitation of approaches that were destroyed or marginalized after 1910. The NIH established a national center for complimentary and integrative health in 1999 acknowledging that there are therapeutic approaches outside the pharmaceutical model that merit scientific investigation.

The field of psychonuroimmunology which investigates the relationship between psychological states, the nervous system and immune function is rediscovering theoretical ground that the osteopathic and eclectic traditions occupied a century ago. But the institutional legacy of Flexner is still overwhelmingly intact.

 American medical education is still dominated by pharmaceutical medicine. American medical research is still funded primarily by pharmaceutical companies, which means the research agenda is still determined by what is patentable and profitable. The American Medical Association still has significant influence over medical licensing and medical school accreditation.

And the fundamental economic structure of American medicine organized around the sale of pharmaceutical interventions and reimburseable procedures remains essentially what it was in 1930. The schools are gone. The traditions are marginalized. The pharmacapier is lost. And the system that replaced them costs three times what comparable systems in other countries cost while delivering worse outcomes.

 This is the medical system that a school teacher with no medical degree built on behalf of men who wanted to sell petroleum derivatives to sick people. Abraham Flexner, for what it is worth, appears to have been a sincere man who genuinely believed he was improving American medicine. His 1910 report was his most significant professional achievement, and he spent the rest of his life working in educational reform, largely moving away from the medical field.

 Whether he understood the full implications of what he had been hired to produce, whether he knew that the standard he was applying had been designed to deliver a predetermined outcome is a question the historical record does not definitively answer. What the historical record does definitively answer is that the people who commissioned the report knew exactly what they wanted.

The correspondence of Frederick Gates and the institutional records of the General Education Board make clear that the goal was not to improve the median quality of American medical education. The goal was to consolidate American medicine around a single model, the pharmaceutical model, and to eliminate the institutional infrastructure of every tradition that offered an alternative. They succeeded completely.

The question worth asking 115 years later is whether that success has been good for the health of the American people. The data says no. The pharmaceutical industry’s revenues in the United States currently exceed $500 billion annually. The United States spends approximately $4 trillion a year on healthcare.

 Americans pay more for prescription drugs than people in any other wealthy country. sometimes 10 or 20 times more for identical molecules. Chronic disease management, meaning the ongoing pharmaceutical treatment of conditions like diabetes, hypertension, and depression, represents the largest and most stable segment of pharmaceutical revenue.

 A medical system optimized for the sale of chronic disease management products is a medical system with a financial interest in chronic disease. This does not mean that the pharmaceutical industry manufactures disease. It means that the pharmaceutical industry has no financial incentive to prevent it and has actively shaped the research agenda, the regulatory environment and the clinical training of physicians in ways that minimize the role of prevention and maximized the role of ongoing pharmaceutical intervention.

That shaping began in 1910 with a report written by a man who had never treated a patient, commissioned by foundations controlled by men who had already decided what conclusion they needed. The traditions that would have asked different questions that would have built different tools that would have trained physicians to think about health rather than disease management were destroyed before they could develop into a mature alternative.

 Their schools were closed. Their journals ceased publication. Their pharmic peers were dismissed as folklore. their practitioners were denied licenses and driven out of practice. What was lost was not just a set of therapeutic techniques. What was lost was a set of questions. Questions about what maintains health rather than simply suppressing symptoms.

 Questions about the relationship between the environment, the diet, the emotional state, and the body’s capacity for self-repair. questions that the eclectic physicians and the original osteopaths and the naturopaths were asking in their different ways and that American medicine officially stopped asking for the better part of a century.

Those questions are only now beginning to be asked again cautiously in the margins of a medical system still organized around the answers that Flexner’s patrons had already decided they wanted. History in the long run asks its questions whether you want it to or not. The Flexner report is still cited in medical school curriculara as the foundational document of modern American medicine.

 It is presented as the moment science defeated quackery. Students are not typically told who paid for it. They are not told what was destroyed and they are not asked to consider whether a system designed to serve the interests of industrial capital is the same as a system designed to serve the interests of patient health.

 Those are the questions worth asking. 115 years late but still worth asking. If questions like this keep you awake the same way they keep us awake, subscribe and hit the bell. We follow the money, read the primary sources, and ask what was there before every week. See you in the next one.