Alan Gregg began his long career with the Rockefeller Foundation in 1919 when he joined the International Health Board's project in Brazil, under Lewis Hackett's direction. The International Health Board (later the International Health Division) had grown out of the Rockefeller Sanitary Commission, which worked to reduce the prevalence and economic impact of hookworm disease in the American South from 1909 to 1914 (hookworm, an intestinal parasite, had afflicted 90% of the population in some areas during that period). This effort, combining treatment, sanitary improvements, public health education, and establishment of state and local public health administrative frameworks, was largely successful. Hackett had been assigned to apply in Brazil the lessons learned in the American hookworm program. Gregg was eager for exposure to a new language and culture; when Wickliffe Rose gave him a choice of assignments, Gregg recalled thinking, "which of these do I know least about?" Hackett, however, remembered Gregg's frame of mind differently: "home from the war, unsettled and deeply disturbed by what he had been through, he asked me to assign him to the wildest area and the toughest job I had, one that other doctors would be delighted to escape. I tried to do so."
After first working in a Rio de Janeiro laboratory to learn about hookworm disease and the mosquitoes that transmitted malaria, Gregg was sent to several remote back-country posts where he worked with local public health campaigns, mostly to diagnose, but also to treat villagers for hookworm infection. He recorded his observations of Brazil in letters to family and friends, as well as in a personal journal that foreshadowed the numerous country studies he would later carry out with the medical education and research divisions. Gregg also conducted research and wrote technical reports on hookworm infection and broader public health conditions during his three years in Brazil. The end of Gregg's Brazil tour overlapped with the arrival of Fred Soper, another Rockefeller officer who became a dominant figure in Latin American public health. Gregg considered Soper "too domineering" for his taste, but the two remained friends during their parallel careers with the Rockefeller Foundation.
His experience in Brazil affected Gregg's approach to medicine and his career by establishing the groundwork for appreciating different cultures, albeit somewhat ethnocentrically. "In the Brazil of that day," he later recalled, "as you drew away from the railroad you went back in time. The children's games were set to Gregorian music because the people had no more recent melodies."
Gregg also encountered rural residents' skeptical reactions to Rockefeller philanthropy. For example, when inhabitants of a remote region were reluctant to appear for medical examinations, Gregg sought advice from a local priest. The priest, originally from Poland, asked if Mr. Rockefeller was giving away money because he had led a dubious life and was making a "peace offering" to his God. Gregg replied by asking whether one needed a motive to give food or money to a weak and starving man. When the priest said the motive would then be "charity, or a sense of guilt," Gregg recalled stifling a desire to agree, but instead pointed out that Rockefeller had just given $3 million to people starving in Poland. This apparently persuaded the priest, who in turn persuaded his flock to accept the ministrations of the Rockefeller physicians.
During these years, Gregg also experienced the many frustrations of public health work. As he later recalled, the work in Brazil confirmed a colleague's evocative description of medical practice: It was like having to treat a long line of patients with sprained ankles, knowing that the sprains were caused by a hole in the sidewalk just outside, but also knowing that he would have no chance to get a shovel and fill the hole, because he was too busy treating the patients. After his service in Brazil, Gregg concluded that there were too many holes and too few shovels, and shifted his focus to medical education and research, looking for a more fundamental solution to chronic public health problems.
Gregg then worked for Richard Pearce, head of the new Medical Education Division, who had initially been recruited from the University of Pennsylvania as a consultant for the Rockefeller Foundation to evaluate the new programs in Latin America. It was in this former capacity that Pearce came across Gregg in Brazil, and with Gregg's three-year term of service coming to an end in 1922, Pearce asked him to become the division's Associate Director. Pearce had a broad mandate: the reform of medical education around the world, promoting scientific medicine and full-time teaching--as Abraham Flexner had championed in American medical schools. His duties also included oversight of the Peking Union Medical College, the institution receiving the most significant Rockefeller funding outside the United States.
Soon after Gregg became Associate Director, Pearce departed on a seven-month trip to survey medical education in Europe. Left in charge of the division in New York, Gregg embarked on a crash course in the foundation's workings, as he was expected to represent the division at officers and trustees meetings. In 1923, he also tried his hand at two country surveys of his own: one in Colombia and another in Mexico. Another important part of Gregg's responsibilities was to accompany visiting foreign medical delegations as they toured American medical schools. This duty was not a mere formality; Pearce and Gregg both realized that it would enable Gregg to observe the changes that had occurred in American medical education since he left for France in 1917.
Pearce's 1922 survey in Europe made it clear that his division's strategy for European medical education reform would require a knowledgeable and trustworthy officer permanently on the scene, and he began to arrange for such a position at the foundation's Paris office. Meanwhile, American medical school administrators had taken notice of Gregg's abilities, and when Johns Hopkins offered him a position at the end of 1923, Pearce countered by offering a post in Paris as Associate Director. Gregg accepted, with the understanding that he would first conduct a detailed survey of medical education in Italy, a country where Rockefeller Foundation officers had as yet spent little time. As he later recalled, he proposed to do an "absurdly thorough" survey that would provide a better sense of which survey data were most valuable in funding decisions. To Gregg's delight Pearce replied, "You've got plenty of time."
After a stay in Paris during the summer of 1924, Gregg, his wife, and their young son, left for Italy, renting a house on the Isle of Capri to serve as a home base for Gregg's visits to Italian medical schools. Gregg remained in Italy until May 1925, and his report on Italian medical education, based on visits to all 21 medical schools, ran to 319 pages, excluding appendices. Although surveys and site visits were a standard part of the Rockefeller funding decision process, they were either conducted from the New York office, by correspondence with the country's medical administrators, or at best, by brief visits by foundation officers or hired consultants. Gregg's Italian survey, therefore, represented a new depth of study including background history, all facets of health infrastructure, as well as medical training, number of students, hospitals, laboratories, courses, and requirements. Although never repeated in such depth, the Italian report set a standard that would guide subsequent surveys by Gregg and other foundation officers in Europe.
Back in Paris, Gregg launched a survey of Irish medical education and made regular visits to France, Germany, Scandinavia, and Eastern Europe, including a 1927 trip to the Soviet Union. In the process, he oversaw Rockefeller's emergency assistance program to medical schools (primarily for library books, equipment and new buildings), funding for full-time medical sciences faculty at European medical schools, and the extensive, ongoing fellowship program. The fellowship program alone required staying informed about both promising young medical researchers, and the best European laboratories where they could be placed for training.
After reviewing its operations in 1928, the Rockefeller Foundation reorganized, replacing the old Division of Medical Education with the Division of Medical Sciences, which would focus more heavily on research. In the short term, this shift was not a radical one, as the division had always sought to make medical education more scientific. Accordingly, the division provided funding for strengthening early instruction in basic medical sciences, fellowships for medical graduates carrying out research, and larger research projects at key institutions. Gregg preached and practiced the conduct of surveys of medical education, and focused especially on studying the broader social and historical context of each country's medical training system. Realizing that even the Rockefeller Foundation's great resources could not remedy all shortcomings everywhere, the Medical Sciences Division concentrated on centers of medical education with substantial international influence: University College London, the Paris Faculty of Medicine, Peking Union Medical College, the São Paulo School of Medicine, the All-India School of Hygiene and Public Health in Calcutta, and the American University of Beirut.
In a 1933 memorandum assessing the success of these programs during the 1920s, Gregg discussed the funding of buildings and endowments for these strategic centers, as well as fellowships and long-term research grants to "capable investigators." "Failures," he wrote in his typically frank style, "were most commonly associated with incompetent recipients, premature hopes on our part of progress in fields where no advance has taken place, and over-confidence in the social, economic, and cultural matrix in certain countries."
In hindsight, both Pearce and Gregg underestimated the long-term implications of the reorganization which, for the most part, eventually narrowed the foundation's scope to the support of shorter term research. Initially, however, the reorganization added significantly to their division's workload by giving it responsibility for the funding of American medical schools, previously carried out by the General Education Board. Adding to the complications imposed by the reorganization, Pearce's health was failing; heart problems hospitalized him in the fall of 1929, and he died soon thereafter, in February 1930. The question of his successor was further complicated by the appointment of a new president of the foundation, Max Mason, once president of the University of Chicago; it was not until the fall of 1930 that Mason offered Gregg the position of Director of Medical Sciences.