American Foundations: Roles and Contributions

6. Foundations and Health: Innovation, Marginalization, and Relevance since 1900

120 6 Foundations and Health: Innovation, Marginalization, and Relevance since 1900 daniel m. fox The ideas, political skills, and cash of the donors, directors, and staff of American philanthropic foundations have affected the health status of millions of people during the past century. Foundations in health have innovated and temporized. They have sustained some organizations, promoted radical change in others, and helped to invent more than a few. They have embraced public advocacy and avoided it. In doing their work in health, foundations have collaborated as well as contended with leaders in government, universities, hospitals , and the medical profession. A history of health services and policy from the point of view of foundations would, however, exaggerate their importance, even though health has been second only to education among foundations’ expenditures. Most foundations have been passive donors to health care organizations. They mainly responded to proposals to meet the immediate or short-term needs of medical schools, research organizations, hospitals, and, in the first four decades of the twentieth century, patients. Moreover, as the health sector grew to become the largest in the American economy, foundation giving declined in relative importance to spending by government, employers, and individual consumers. A few numbers illustrate foundations’ involvement in health. In 1936 Eduard C. Lindeman published a study of spending by one hundred foundations and community trusts between 1921 and 1930.1 Most of what these foundations 1. Lindeman (1936). foundations and health 121 spent for health had modest contemporary impact or historical significance. Similarly, most of the almost four hundred contemporary foundations whose grants are recorded in the electronic database maintained by Grantmakers in Health help individuals and organizations but are tangential to major issues in health policy.2 This chapter assesses the influence of leading foundations on health policy and practice rather than the overall significance of foundation spending for health. I define leading foundations as those whose trustees, staff, and money had, at least for some years, effects that can be documented on significant issues in health affairs, nationally as well as internationally. Some of these foundations have been among the largest endowments, others middle sized; a few have been relatively small. The history of leading foundations in health during the past century can be summarized (though thereby necessarily distorted) in three words: innovation, marginalization, and relevance. From the early twentieth century through the 1920s, leading foundations collaborated on innovation with central actors in health policy and practice. They planned and implemented new ways to organize education for the health professions, basic and clinical research, and the delivery of services in hospitals and ambulatory settings. From the early 1930s through the 1980s, the work of leading foundations, though respected by central actors in health policy and practice, was marginal to the major issues that preoccupied them. Since the early 1990s, the work of leading foundations has been consistently relevant to major issues in health policy and practice in the United States and of growing importance in the area of global health. An Overview of Foundations and Health Affairs Since the 1890s, foundations have participated in changes in health affairs that have had enormous significance for Americans’ lives. The most important of these changes have been advances in biomedical science and technology and their translation into clinical and public health practice, the increasing prestige of the medical profession and, as a result, its domination of the allocation of funds to maintain and improve health, and vast expansion in access to health services accompanied by political conflict. Significant consequences of these changes include increasing life expectancy and the problem of managing serious chronic disease for growing numbers of people; optimism about the conquest of infection and the subsequent realization that it was exaggerated; the dominance of clinical models of prevention, diagnosis, and treatment in public policy rather 2. Grantmakers in Health, Resource Center for Health Philanthropy (www.gih.org [April 2007]). Access to the Resource Center requires registration. 122 daniel m. fox than broader determinants of health; and disparities in health services and health status by race, income, and social class, despite economic growth and increased protection of civil rights. The histories of foundations and of the health sector converged at the beginning of the twentieth century because of changes in fundamental assumptions about the organization of both philanthropy and activities to improve health. New York state was the first to enact a...