On July 24, 1910, the New York Times dropped a bombshell in the form of a report that would rock the education system and health care around the world for the next 100 years.
In two pages, the article "Factories to train ignorant doctors"2 summarized the study "Medical Education in the United States and Canada - A Report to the Carnegie Foundation for the Advancement of Teaching"1.
Drafted by the controversial and ambitious educator Abraham Flexner, the "Flexner Report", as it came to be known, would become the most cited publication on medical education in history. He is considered to be largely responsible for the biggest medical school reform of all time.
Yes, it has determined how you have looked after your health to date.
For this reason, and because it is the pivot of intricate conspiracy theories circulating around the world wide web, it is worth investing a few minutes of your day to understand its context and its impacts.
Ready to take the red pill?
The infamous report
In 1909, commissioned by the Carnegie Foundation, Abraham Flexner visited 155 medical schools in North America in 180 days. Even with a short visit to each establishment, he was categorical in his diagnosis: the vast majority should close.
The document pointed to an excess of private and commercial medical schools on the market, which only existed to make money for their owners, resulting in unprepared doctors who were pouring out millions of wrong diagnoses and inadequate therapies, damaging the health of the population.
Faced with this situation, the Flexner Report proposed major reforms in medical education, including higher admission standards, more training time, adherence to the scientific method in research and practice, and supervision by state licensing boards. It also established, as a general rule, a much smaller number of better equipped and run medical schools. And fewer doctors graduating each year, better educated and better trained.
The motivations that led to the creation of the document are among the most intricate conspiracy theories on the internet. One of the factors for this is that the report was widely disseminated by the media of the time, which was supported by advertising from large companies, which were also investors in the growing pharmaceutical industry.
Another controversial factor is that technical journals were subsequently created, also supported by advertising, which gave the spotlight to scientific studies focusing on allopathy and synthetic medicines. These reviews fed back into the curriculum of medical schools, which became focused on treating established diseases rather than preventing them.
Analyzed in today's context, it's possible to be suspicious of the reasons that led the report to go viral. But at the beginning of the 20th century, the context was ideal for it to explode.
Bitter medicine and some side effects
In some ways, the Flexner Report was a cure.
From the middle of the 19th century, small "commercial private schools", not affiliated to universities and made up of groups of 8 to 10 teachers, multiplied. Teaching was based on textbooks and theoretical classes, and their curricula and educational objectives were general and non-standardized.
Medical training was already being discussed behind the scenes in the academic community, but Flexner's article - and its widespread newspaper coverage - involved public opinion and generated a broad social discussion.
The public responded by increasing donations and politicians created taxes to fund medical education. In addition, a public outraged by Flexner's description of existing private schools pressured and accelerated regulatory changes and oversight.
As a result, of the 148 American medical schools, only 66 remain.
Since the report, medical training has gone from four years, largely based on study and theory, to eight years, as well as including a compulsory internship for clinical practice. Medical quality increased significantly, and protocols, both for scientific research and for care and prognosis, were standardized.
The approval of new medical schools became stricter, with the need for links to hospitals and universities, and the American Medical Association began to supervise all medical schools to maintain high standards.
Life expectancy has risen from 50 years in 1910 to 80 in 2020. Several factors have influenced this, but undoubtedly the evolution of medicine has been decisive.
But there were serious side effects.
Medicine became a lucrative and well-respected profession - and it became much more elitist.
Of the seven schools that trained black doctors, five were closed. The American Medical Association used the report to demand the same standard as the elite universities, and the wealthy society of the time did not allocate funds for these schools to maintain or update their equipment and facilities.
Without access to a decent high school education and without the income or support to attend a public university, the training of black doctors virtually ended. And this effect persists to this day: about 4% of American doctors are black - and 80% of them studied at Meharry Medical College or Howard University, the two schools that survived the Flexner era. In 2008, almost a century after the Flexner Report, the AMA formally apologized for "its past history of racial inequity toward African-American physicians".
If the report sacrificed the schools that closed and the less well-off in the name of protecting the health of the population, its author, at the time a relatively obscure educator, gained international fame.
He ended up producing another report, on medical education in Europe, in 1912; the same year he received an invitation to join the Rockefeller Foundation's General Education Council. In 1930, he founded the Institute for Advanced Study at Princeton, which he directed until 1939, when he hired Albert Einstein.
Out go the plants, in come the capsules.
Another effect was the demonization of natural treatments.
Druids, shamans and gurus have always existed. At the beginning of the health sciences, the role of the priest included the doctor, the pharmacist and the psychologist, among others. Medicine was based on herbal medicines, many inherited from ancient traditions and translated by oral tradition, later organized into books.
There are records of the manufacture of medicines from plants dating back more than 2,600 years in China. In India, the Brahmins developed remedies from 600 different types of medicinal plants. Hippocrates, who lived at the end of the 5th century BC, mentioned around 400 medicinal plants in his writings. The Bible lists nearly 30 medicinal plants
Pharmacy, as an activity, appeared in Alexandria after a period of instability marked by wars and epidemics. The first school of pharmacy was founded in Baghdad in 754. In 1240, pharmacy was officially separated from medicine by an edict from Frederick II, Emperor of Prussia, which established the first code of professional ethics.
In 1887, practitioners of alternative medicine compiled the Homeopathic Pharmacopoeia of the United States. Thus, estimates indicate that around half of American doctors and medical schools practiced holistic medicine in 1910, using knowledge from Europe and Native Americans and prescribing herbal medicines.
This practice reinforced the perception that there was a lack of scientific standards and evidence, and that small private schools were based on belief and superstition.
And although most of the medicines of the time, such as opium and morphine, were extracted from plants, science - based on observation, experimentation, publication and reproduction - was taking its first steps.
The period from 1870 to 1910 is called the second technological revolution (Pochmann, 2003), which coincides with the discovery of new materials such as steel, oil and electricity, as well as inventions such as the engine, combustion, the telegraph, the telephone, the X-ray, among others.
Chemistry was evolving fast. In 1897, the German Felix Hoffman tested willow bark extract to fight infections. In the first tests, the pill synthesized from salicin - the plant's active ingredient - didn't achieve good results, but it did reduce fever. To prevent the medicine from causing burning in the stomach, he added the substance acetyl to the formula. Thus was born acetylsalicylic acid, which Bayer popularized as Aspirin.
It was followed by hundreds of synthetic drugs.
The scientific method demanded stability, and the standardization of research-based protocols became a perfect backdrop for the growing pharmaceutical industry of synthetic drugs, which funded most of these studies, strengthening the more reductionist paradigm of the Flexner Report and decisively influencing the school curricula and medical protocols of the 20th century.
With industrialization, the cost of synthetic drugs fell. Industrialization allowed for scale, which reduced costs and gave the population access to allopathic medicines. Their mass adoption was only a matter of time.
Thus, some more effects derived from the article were the definitive separation of the pharmacist and the doctor, the strengthening of the role of the prescription of synthetic drugs in the practice of medicine and the reduction of the role of nutrition, exercise, sleep and psychological well-being and alternative therapies in American medical training.
With a more reductionist and specialized focus on the disease and its corrective treatment, prevention took a back seat. And herbal medicines would be discredited in medical literature for decades.
Pajé with a PHD
If you scroll through Netflix, you'll come across documentaries such as "What the Health", "Take your pills", "The Pharmacist" and "Cowspiracy". They expose a deep and growing distrust of the health system inaugurated by the Flexner Report.
There is a growing collective awareness that the scientific and reductionist paradigm has had its merits, but it has passed the point. You can't treat the heart, spine or skin in isolation without treating the mind, spirit and social relationships together.
In 2016, the WHO found that around 80% of chronic diseases are caused by lifestyle. In other words, by taking care of their diet, exercise, sleep and emotional well-being, 4 out of 5 people would not be ill today.
But even so, medical education is still very much influenced by the Flexnerian model. Integrative medicine, which works on prevention, for example, is still not recognized by medical councils in much of the world, including Brazil.
Despite this, many doctors are preparing themselves and learning about nutrition, lifestyle and integrative therapies - even outside of university.
At the Institute of Lifestyle Medicine, linked to Harvard Medical School, one of the most popular courses is "Clinicians in the Kitchen", a cooking course aimed at doctors. All the recipes taught are vegan.
Alternative therapies are also growing steadily, and not just in sophisticated spas. In 1995, the National Policy for Integrative and Complementary Practices was instituted in Brazil, which included 29 alternative therapies in the Unified Health System. In 2017, therapies such as Ayurveda, Circular Dance, Naturopathy and Reiki were incorporated. In 2019, the SUS carried out around 500,000 auriculotherapy sessions, for example.
There is a quest to return to nature and the natural, and this time it is anchored by advances in genetics, precision agriculture and a lot of science.
The global medical cannabis market in 2021, for example, is projected at US$16 billion, and should reach US$46 billion by 2026. In the US, it is estimated that around 50% of the market for synthetic opioids focused on pain - which have many side effects - will migrate to cannabis, which, despite being natural, is genetically controlled to maintain standards and precision in prescribing.
Science combined with nature is also revolutionizing our table.
Chilean foodtech NotCo was recently valued at US$1.5 billion, with contributions from Roger Federer and Jeff Bezos. NotCo's focus is to produce plant-based foods with the same taste and texture as traditional ones. Egg-free mayonnaise, dairy-free ice cream, plant-based milk and non-animal meat. All the items are made using artificial intelligence (AI) and algorithms.
And even giant vegetable protein producers like JBS and BRF are manufacturing vegetable meat in industrial volumes.
These movements come at a time of growing health awareness and new generations engaged with social causes and the planet, as well as the rise of the ESG agenda.
A survey carried out by Ibope and commissioned by the Good Food Institute Brazil, for example, revealed that almost half (47%) of Brazilians reduced their meat consumption in 2020. This accelerates a trend detected by Ibope itself in 2018, when 14% of the population declared themselves vegetarian - an increase of 75% compared to 2012, when the same survey indicated 8% of Brazilians were vegetarian or vegan.
In addition, 55% of the population said they would be willing to consume more vegan products if they were better indicated on the packaging or if they were the same price as regular products.
We have reincorporated old habits that were inherited from our ancestors and forgotten for a century, but this time repackaged by technology.
Yes, the same science that expelled nature from medical schools in 1910 is rescuing integral health - physical, mental, spiritual, social and environmental.
Finally the Pajés are back - and now with a PHD in technology.
Our health thanks you.
High-tech nature
I once spoke to a police officer who explained the difference between the civil and military police very simply: "The military acts to prevent crime. The civilian police come in to investigate and solve the crime after it has already happened".
It's a good analogy for health. Prevention and correction require different troops.
In the midst of a crisis, you can't wait for the body's natural response, or just change your diet or improve your sleep. These are preventative measures. Once the disease is established, you need to use the medicines available, even if they are synthetic.
On the other hand, science has been understanding, explaining and making accessible the best that the forest can offer us. And we have incorporated new habits, inherited from our ancestors, but revamped by technology. These resources, which are increasingly personalized and guaranteed to be safe, are excellent for preventing illness and, above all, maintaining good health.
The idea that a natural, organic, vegan and sustainable product is better for your health than its processed and industrialized substitutes is no longer a niche thought. It has become popular wisdom.
My grandfather was a pharmacist in the interior of São Paulo at the end of the 1940s. At that time, there weren't many doctors in the region. There was no hospital in the city. That's why he repeated a pattern of the healers of antiquity: he was half doctor, half chemist, half shaman.
I'm glad that, almost 70 years after he closed his pharmacy, his role is being revived.
Our health thanks you.
