Harriet A. Washington, author of Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present and other publications, drew on her research to discuss three main topics: the history of the involvement of people of African descent in medicine, the history of people of African descent in public heath, and the history of proposed health care as a right in the United States.
This history is important because it has a bearing on health today, she said. As quoted in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Institute of Medicine, 2002, p. 6), “racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality and evidence of persistent racial and ethnic discrimination in many sectors of American life.” As she described in her presentation:
- Historical patterns of approach to “Black diseases” subtly inform today’s approach to racially disparate disease patterns;
- Abusive, stigmatizing research has fed iatrophobia (fear of doctors) by many African Americans;
- History must inform medical ethics;
- History lives in today’s issues.
The history of African American involvement in science and medicine has perpetuated many inaccuracies, Ms. Washington noted. “Science and history are both privileged disciplines and are treated as the gospel truth,” she said, “but they can be edited and curated to preserve a certain perspective.” She summarized a number of falsehoods that were presented as science-based truth. For example, a 1913 article written by the editor of Science magazine (Cattell, 1913) stated, “There is not a single mulatto who has done credible scientific work.” As another example, an organization called the American College of Ethnology developed “scientific racism” to justify slavery and profitable medical research, claiming that African Americans were a “hardy” different species than white humans. A number of imaginary diseases were ascribed to them, Ms. Washington continued, as well as a false scientific basis for traits such as low intelligence, poor judgement, poor parenting, and the inability to control “bestial sexual urges.” The U.S. Census of 1840 was purported to reveal that free Blacks suffered 11 times the insanity rate of enslaved Blacks.
Despite the myth that they could not be trusted as doctors, African American women and men had a vast amount of medical knowledge. Women were known for their skills as midwives, herbalists, and healers, including by their white enslavers. In fact, the midwives often had better outcomes than white male obstetricians.
The medical profession imposed a number of barriers to African Americans practicing medicine. When a bad outcome did occur, Black health care providers often had to provide character witnesses to avoid being accused of poisoning a patient. In the 1800s, African American men could attend medical school but not earn a degree, and the American Medical Association (AMA) designated a “C” next to the names of African American physicians to denote “colored.” In the 1850s, Harvard Medical School expelled its first three Black students because of pressure by white students. Into the 1960s, an overtly racial bar or subtler exclusion persisted at many medical schools as a way to limit the number of physicians and promote exclusivity.
As part of the impetus toward professionalism, the AMA sponsored what became known as the Flexner Report, published as a report to the Carnegie Foundation for the Advancement of Teaching in 1910. Ms. Washington refuted the argument made by some people that the AMA did not actually sponsor the report, noting that author Abraham Flexner had an office and staff at the AMA headquarters in Chicago and an AMA staff member accompanied him on his site visits to medical schools. According to Ms. Washington:
The Flexner Report is sometimes referred to as a milestone in the modernization of medicine, but for African American practitioners, it was a disaster. It recommended the closing of every Black medical school except for two. Only Howard and Meharry were left. Even worse is the language of the report, which I do not think gets as much attention as it should. Abraham Flexner, although not a physician or with a Ph.D. of any kind, had strong opinions, certified by the AMA at that time, about who should become a doctor.
The views contained in the report, Ms. Washington continued, included that African Americans should not be allowed to practice except under the supervision of whites, should not be trained in medical specialties or research, and should have sharply curtailed duties. The report acknowledged the need for some limited provision of health care by African
Americans to African American patients, primarily to keep infectious disease from white communities. (See also Chapter 5 for a discussion of the ramifications of this report).
Although the AMA did not technically discriminate against African Americans after 1847, its feeder organizations on the local level did, and membership to the national organization could only take place through membership in a feeder organization. Although African American physicians protested, including picketing at AMA conventions, many were barred from residencies and hospitals. “When [African American] physicians were barred from hospitals, the effect on African American communities was disastrous,” she said. “They could not follow their patients into hospitals. Many Black patients started to view Black physicians as inferior. Yet, white doctors often had no place for [Black patients].”
In 2008, Ms. Washington was part of an expert panel that investigated and wrote about the AMA’s past record of discrimination. After their article, “African American Physicians and Organized Medicine, 1846-1968,” appeared in JAMA (Baker et al., 2008), the AMA issued an apology. “It was important,” she said. “It was accompanied by some action and a long overdue acknowledgment.”
Despite being discouraged or barred from research, many African Americans did participate in groundbreaking research, often as uncredited contributors of teams lead by whites. “They were a shadow army of medical researchers who got no acknowledgment,” said Ms. Washington, who is currently researching their lives, some of whom were collectively known as the “Garçons” (French for “boys”). “It’s important for them to be better known, especially for African American young people, so they see that far from being an exotic or unattainable goal, it’s something we have always succeeded in,” she said. Twentieth-century examples include heart researchers Vivien Thomas and Hamilton Naki, chemist Percy Julien, and many others. Earlier examples include Onesimus, who provided Cotton Mather with knowledge about smallpox vaccinations, and James McCune Smith, who went to Scotland for his medical education and, among other accomplishments, disproved the claim from the 1840 U.S. Census about the mental health impacts of freedom for African Americans.
The belief that African Americans are “mentally inferior” or “inherently violent and unintelligent,” referred to by Ms. Washington as “hereditarian follies,” continues to lead to questioning of the qualifications of African American physicians. As recent examples, she noted several incidents on airplanes when a passenger was having a medical emergency and the flight
attendants demanded the credentials of African American female physicians who volunteered to help, while not doing the same to white male physicians.
Erroneous beliefs about African Americans have also led to situations in which they become the subjects of inappropriate or harmful medical research. Lower intelligence was supposedly “verified” in seemingly painstaking but rigged research. In a few high-profile cases, Ms. Washington said, there has been an “illusion of Black complicity”: that is, that African American physicians and caregivers were actively involved in the studies. One of the most well-known is the Tuskegee Syphilis Study conducted by the U.S. Public Health Service. Ms. Washington pointed out that Eunice Rivers, the African American woman who organized the participants, is often mentioned in descriptions of this project. In her investigation, Ms. Washington said:
I found it interesting that almost anybody who has read the study can tell you who Eunice Rivers was, but no one can name the men who were the actual architects of the study, the scientists who actually carried it out and designed it and deflected the blame on her. When the initial reports were written up, the authors were all white. When people started impugning it [the study], suddenly the papers included her as one of the authors.
In addition, a widely circulated photograph of the study team included an African American man. Ms. Washington investigated to learn that the man had nothing to do with the study. Another frequently mentioned example is Solomon McBride, who conducted abusive research studies at Holmesburg Prison in Pennsylvania, but he was a prison official and not a physician. As an example of a more recent manifestation of the tendency to devalue African Americans in research, Ms. Washington pointed to myths around epidemic management. ZMapp, a treatment against Ebola, was given to a white U.S. physician rather than Africans with the disease, including Sierra Leone’s chief virologist, Sheik Umar Khan, M.D., based on the beliefs that Africans are not intelligent enough to take the new drugs correctly or other misperceptions.
These cases have led Ms. Washington to conclude:
One area where I see a need for far more African American participation is for African American medical ethicists to promulgate their analysis and research. I see too much research being weighed, valued, and put into effect with no regard to the populations on whom it is going to resonate…. The law has changed to permit research without consent, and the people who are deciding if this is an appropriate or ethical thing to do are not the people who end up being the subjects of that research. We need someone speaking up for them. I very much hope we see more Black people going into medical ethics.
Mythologies related to medicine can also foment disparities. Historically, this is shown under slavery where fitness for work, not health, was the goal. The primary relationship, or dyad, was between the physician and the planter, rather than between the physician and the patient. Today, she said, the dyad is often between the physician and the state, and Black people are increasingly seen as research subjects or are underserved. Another tendency, she said, is medical dimorphism, or blaming the victim, rather than disparate treatment and environment, as the cause of contemporary “Black diseases”; that is, disease that disproportionately affect African Americans, such as diabetes and cardiovascular conditions.
Related to the point about African Americans as subjects of research, a question was raised about recent statements by a French scientist who wanted to experiment with COVID-19 vaccinations on Africans.1 Ms. Washington replied, “What they voiced is not novel.” She said that countries in the developing world with less oversight and regulation are becoming the “laboratory for the West.”
Dr. Bright asked about the impact of the Flexner Report on medical school admissions, such as the use of standardized tests as an important
criterion of admission. Ms. Washington noted that one goal of the report was to make medicine “exclusive,” even if “we are not necessarily careful and precise about what we exclude.” As an analogy, she said knowledge of German could be a prerequisite to exclude many candidates, yet is not one that predicts medical success. She suggested studies to show the correlation, if any, between test scores and performance in medical school and as a physician. “If the idea is to have enough doctors for the American people, we must be careful to make sure the tests that we give people are really going to be predictive of abilities as a clinician,” she said. “If there is not a correlation, we should discard them [standardized tests] and find something that does.”
In answer to a question about preparation for a career as a medical ethicist, Ms. Washington suggested fellowships for those who already have a medical background or need basic grounding, as well as master’s or Ph.D. degrees in medical ethics for those who need more depth, such as to serve as expert witnesses. In all cases, “learning about the history of medicine is important,” she said. “I am concerned that ethicists don’t have a good grounding in history.”
When a participant shared her concern that ventilators may not be made as available to Black patients suffering from COVID-19, Ms. Washington expanded the conversation to consider allocations of all scarce resources in a health care setting. “There are always criteria and policies that look neutral and may be intended to be neutral but they are not,” she said. “Clinicians follow the rules, but in the rules are judgment calls,” citing organ transplant policies as another example. Liver disease is a leading cause of death among African American men, she noted, but many are not receiving liver transplants because they are deemed not to have a social support system, which is one of the criteria in selecting who receives a new liver. Camara Jones, referring to the three principles of health equity she identified in her talk (see Chapter 2), said she has concluded the best way to allocate scarce resources is through a random lottery.
Baker, R. B., H. A. Washington, O. Olakanmi, et al. 2008. African American physicians and organized medicine, 1846-1968: Origins of a racial divide. JAMA, 300(3), 306–313. doi: 10.1001/jama.300.3.306.
Cattell, J. M. 1913. Science, 39(1004), 5.
Davis, R. M. 2008. Commentary: Achieving racial harmony for the benefit of patients and communities. JAMA, 300(3), 323–325.
Institute of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press.
Washington, H. A. 2006. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Random House.