The evolution of American medicine and the Duke Endowment Health Care (Hospital) Division since 1924.

I have been associated with The Duke Endowment since 1963—first as a new medical Dean at Duke University, the Endowment’s major beneficiary, and then, in the last decade, as a trustee of the Endowment and a member of the Health Care Committee. Since 1963, my friends and colleagues have been Marshall Pickens1, Jim Felts, Tom Perkins1, Dick Henney, and Mary Semans1—all trustees of the Endowment. In 1924, when James B. Duke signed the indenture creating The Duke Endowment, healthcare in America was at a turning point. Hospitals were changing from a place to go to die to a place to go for a possible cure. The cost of hospitalization was $3.00 a day, which led to Mr. Duke’s decision to contribute $1.00 a day for the care of indigent patients in North and South Carolina. Pernicious anemia was still incurable; in fact, Mr. Duke died of the disease ten months after signing the Indenture, shortly before the discovery of the intrinsic factor that would cure the disease. Banting and Best had just discovered insulin, and diabetes was finally changing from a lethal disease to one that was at least partially manageable. Heart disease, hypertension, stroke, cancer, accidents, and infectious diseases (including tuberculosis and pneumonia) were major killers. Private foundations in the health field supported fragments of research in medical institutions. Some of the leading philanthropic foundations, including the Rockefeller Foundation, were concerned about the shortage of physicians that followed the Flexner Report of 1913 and the subsequent closing of many medical schools in the United States that were essentially “diploma mills.” The input of these foundations led to the creation of new schools attached to universities, such as the University of Rochester and, in 1930, Duke Medical School. In the early 1930s, there was no health insurance, so in North Carolina Dr. Wilburt C. Davison (Duke Medical School’s founding Dean) and Mr. George Watts Hill, Sr. (a successful business man) sponsored the founding of North Carolina Blue Cross and North Carolina Blue Shield. Davison and Hill were regarded as “socialists” for endorsing such a move. Then came the control of infections through the development of antibacterials and antibiotics. In the mid-thirties, sulfanilamide (Prontosil) was discovered by the Germans. On a personal note, its introduction coincided with my being a ten-year-old with lobar pneumonia; I was one of the first patients to receive the drug, and I survived. Penicillin was discovered in 1942 by Fleming and Flory at Oxford University. Like many major medical discoveries, it was serendipitous and almost accidental. Penicillin was a major life-saver from infected wounds during World War II. Immediately after World War II, Waksman discovered streptomycin. The successful war against tuberculosis began, and, within a decade, sanatoria were being emptied. In 1948, the social environment of hospitals was to change also; in parallel, The Duke Endowment made major policy changes. The Hill-Burton Act was passed, providing federal funds to build and renew small rural hospitals so that Americans would not have to travel long distances to get inpatient care.2 The trustees of the Endowment directed funds to help the rural hospitals in North and South Carolina achieve these goals. Senator Lister Hill of Alabama (named by his father in honor of Lord Lister, the architect of antiseptic surgery in the late nineteenth century) went on to a lifetime of distinguished achievements in support of the health field. At about the same time, the Veteran’s AdminThe Evolution of American Medicine and The Duke Endowment Health Care (Hospital) Division Since 1924