“For the welfare of mankind”. The Commonwealth Fund and American medicine

A. McGEHEE HARVEY ans SUSAN L. ABRAMS, "For the welfare of mankind". The Commonwealth Fund and American medicine, Baltimore, Md., and London, Johns Hopkins University Press, 1986, 8vo, pp. xiii, 696, £26.50. Histories of philanthropic bodies are notoriously difficult to produce without being boring to all those not directly concerned, such as trustees, staffs, advisers, and, ofcourse, recipients ofthe largesse dispensed. The purposes of foundations are invariably drawn so widely that it is tempting for authors to notice only those activities demonstrating successes that have been attested by the good and the great, and to pass quickly over the inevitable failures. What marks the important difference from the annual report, is that a history allows for an assessment of the end-results of particular actions, and not the intention. For the more sophisticated student of foundations and their possible influence on western society, it is possible from histories to trace the development and common strands of policies adopted by successive generations of trustees and professional staffs, and to match achievement against the foundation's perception of contemporary problems. It would, of course, be of even greater interest to get behind the faQade to discover how decisions have been reached to achieve the ends that have resulted in success or discreet failure: but for this, one needs access to sources illuminating the actions of the permanent professional staffs (and their relationship with the trustees who are ultimately responsible) who develop the policies governing the making of allocations and grants; and that is not easy without sight of essentially private and possibly libellous documents. This is therefore an important book, for it does to some extent lift the veil on how the Commonwealth Fund arrived at certain of its decisions in respect of an important sector of its purposes. It is extremely difficult, if not impossible, in a short review to discuss sensibly the value of the actions taken in the field covered, since these reflect the bewilderingly complicated arrangements necessary for health care in modern society. At a fundamental level, health care involves the education of an enormous range of professional groups, with the medical profession pre-eminent, but each with its own standards of quality and ethical behaviour; and this has been an important area ofthe Fund's work. The problems of a loosely adhering, unco-ordinated, but still a health care system of sorts, in the richest country of the West, are interwoven with the Fund's policies over the years. This brilliantly presented account of its approach to the multi-faceted aspects ofAmerican medicine makes it even more difficult to do the book justice. I can only urge all who are interested in examining the universal problems of modern medicine in the contemporary world to get a copy and read it. The ceaseless search for quality in all respects, which features strongly in the account, is not always fully understood or appreciated in Europe as a major concern of American medicine. What will, however, be of special interest not just to the historian but to the social observer, are the throw-away, frequently dry comments made more telling by occasionally being direct quotes from a wide range of individual advisers, some still alive, who are experts on the many aspects of the American health scene. These give insights on how that phenonemon, possibly in the long run unique to the twentieth century, the independent private foundation, operates in a world in which there is a confusing mix of advice, as well as resources, available from private, public, and semi-public bodies, pursuing not dissimilar purposes. Here are set out the reactions and beliefs of the main people concerned in advising on, making, and taking grants. Here is indicated (without comment but laconically put in context) the influence of founders, sometimes direct, sometimes perhaps spiritually embroidered at second, occasionally at third hand, through the mouths of erstwhile disciples and friends. Here are displayed the gobbets of advice not likely to be universally acclaimed, but doubtlessly well motivated, from reputable advisers, and what is done about them. This is an impressive book revealing more than the somewhat off-putting cliche of its title would suggest.