Todd L. Savitt

African American Physicians and Organized Medicine, 1846-1968: Origins of a Racial Divide

Like the nation as a whole, organized medicine in the United States carries a legacy of racial bias and segregation that should be understood and acknowledged. For more than 100 years, many state and local medical societies openly discriminated against black physicians, barring them from membership and from professional support and advancement. The American Medical Association was early and persistent in countenancing this racial segregation. Several key historical episodes demonstrate that many of the decisions and practices that established and maintained medical professional segregation were challenged by black and white physicians, both within and outside organized medicine. The effects of this history have been far reaching for the medical profession and, in particular, the legacy of segregation, bias, and exclusion continues to adversely affect African American physicians and the patients they serve.

Creating a Segregated Medical Profession: African American Physicians and Organized Medicine, 1846-1910

An independent panel of experts, convened by the American Medical Association (AMA) Institute for Ethics, analyzed the roots of the racial divide within American medical organizations. In this, the first of a 2-part report, we describe 2 watershed moments that helped institutionalize the racial divide. The first occurred in the 1870s, when 2 medical societies from Washington, DC, sent rival delegations to the AMAs national meetings: an all-white delegation from a medical society that the US courts and Congress had formally censured for discriminating against black physicians; and an integrated delegation from a medical society led by physicians from Howard University. Through parliamentary maneuvers and variable enforcement of credentialing standards, the integrated delegation was twice excluded from the AMAs meetings, while the all-white societys delegations were admitted. AMA leaders then voted to devolve the power to select delegates to state societies, thereby accepting segregation in constituent societies and forcing African American physicians to create their own, separate organizations. A second watershed involved AMA-promoted educational reforms, including the 1910 Flexner report. Straightforwardly applied, the reports population-based criterion for determining the need for phySicians would have recommended increased training of African American physicians to serve the approximately 9 million African Americans in the segregated south. Instead, the report recommended closing all but 2 African American medical schools, helping to cement in place an African American educational system that was separate, unequal, and destined to be insufficient to the needs of African Americans nationwide.

Medical readers' theater as a teaching tool.

Readers’ Theater (RT) is a unique vehicle for introducing ethical, cultural, and social issues in medicine to academic, professional, and community audiences. It brings alive the characters in a story in a way that silent reading or reading a story aloud cannot. Audience members experience what is, in essence, a case report acted out “on stage” rather than reading or hearing someone report on a situation second hand. RT has an immediacy about it, a compelling aspect, that makes listeners pay attention and mentally participate in the action. It draws people into the story, engages them. The oral reading and subsequent open discussion combine to educate audience members about the topic of the story and the variety of ways one can interpret the story’s message. This article describes the long-standing RT program at the Brody School of Medicine (BSOM) at East Carolina University (ECU) and some of variations on RT that people have developed around the country.

An Exploratory Study of Stress Coping and Resiliency of Black Men at One Medical School: A Critical Race Theory Perspective

Black men have reported a number of stressful experiences during medical school training. Guided by Critical Race Theory, the authors examined the survey responses of 16 Black men who matriculated at one medical school to assess perceptions of medical school stress. The researchers identified several themes: (1) perceived academic inequities created tension between Black and non-Black medical students but provided bonding opportunities among Black male medical students, (2) stress negatively impacted academic performance and personal health, and (3) use of social support and spirituality contributed to coping and resiliency. For Black male medical students, the general stress of medical school can be compounded by additional race-related stress. Supporting the success of Black male medical students requires understanding perceived stressors, a focus on helping Black men build social and spiritual connections that contribute to resiliency, and active efforts at the organizational level to address perceptions of academic inequity.

Early radiology and early African American physicians.

Readers of Dr Oestreich’s article on early radiology and the National Medical Association (NMA) might wonder why a historian would track the acceptance and use of radiographic techniques specifically among black physicians. To answer that question we must first recognize the significance to medicine of the discovery of x-rays. Consider the problem healers have faced since time immemorial: Caring for and curing patients depends in part on knowing what is occurring within the body. How can healers learn what is happening when someone is sick, without actually opening the body and looking? Before Roentgen, unless the healer was a shaman practicing in a culture where disease was believed to be the result of spirit intrusion or other supernatural causes and therefore did not need to look within the body to cure the patient, healers relied on indirect clues. They noted, for example, patients’ symptoms, visible or palpable changes detectable on the body’s surface, alterations in pulse, and the state of whatever came out of or could be removed from the body, for hints about what was occurring. They observed, smelled, and touched, as appropriate, discharges from all orifices, and inspected the blood removed in venesection. Physical diagnostic techniques provided only indirect information as well. It is telling that the name French physician Rene Laennec gave to the tool he invented in 1816 to improve immediate auscultation (ear-to-chest) was stethoscope, a word meaning “to see into the chest or chest viewer.” The various sounds transmitted through this new instrument (mediate auscultation), correlated with the autopsy findings from patients who, in life, produced similar sounds, allowed physicians to “see”—in a sense—what was happening in the body without actually opening it. Other physical diagnostic methods developed around that time, such as percussion and reflex testing with the reflex hammer, also helped. These were still indirect methods of viewing the body’s activities. The x-ray, however, was different. It allowed, for the first time, direct visualization of some tissues within the body. Physicians and laypeople alike celebrated x-rays as an amazing tool and a great breakthrough in medicine. It was important for African American doctors in the late 19th and early 20th centuries to keep up with this latest advance in medicine if they were to show themselves competent practitioners. Dr Oestreich’s article illustrates that early black physicians were aware of and users of x-rays. Physicians of color did not enter the profession in any numbers until the early 1870s, a few years after Emancipation and just 25 years before the discovery of x-rays. Black doctors had to prove to their current and potential white and black patients and to their white colleagues that they were capable of mastering the body of knowledge and techniques necessary for the practice of medicine. Formal education had not been an option for black people during slavery times. Further, most white Americans believed that men and women of African descent were not educable beyond a very basic level. The small group of black physicians who practiced in the first decades after Emancipation organized themselves in 1895 for mutual support in the face of blatant racism and exclusion from the rest of the medical profession. The NMA was founded (November 1895) just a month before Roentgen announced his discovery of x-rays (December 1895), so both were new to American society. Oestreich’s research indicates that black doctors such as Marcus Wheatland quickly adopted x-rays as part of their practice and used the NMA annual meetings to promote their use. The Journal of the National Medical Association, founded in 1909, almost 15 years after its parent organization, also served as a vehicle to keep black doctors abreast of x-rays and other new tools of the trade. The first article on roentgenology appeared in volume 3 (1911). That article, by a Chicago radiologist of color, Claudius D. Bell of Provident Hospital, sought to reinforce the value of x-rays to fellow African Author Affiliation: Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine at East Carolina University, Greenville; JNMA Editorial Board, Silver Spring, Maryland. Correspondence: Todd L. Savitt, PhD, Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine, East Carolina University, 600 Moye Blvd, Greenville, NC 27834 (savittT@ecu.edu).

The Journal of the National Medical Association 100 Years Ago: A New Voice of and for African American Physicians

Volume 1 of the Journal of the National Medical Association (JNMA), published quarterly during 1909, included a good deal of space devoted to 2 key concerns: (1) building and unifying black health professionals in medicine, surgery, dentistry, and pharmacy; and (2) providing a voice for these African American health professionals to the often-hostile and racist larger world of medicine. The Journals editor, Charles Victor Roman, and associate editor, John A. Kenney, were well suited to the task. They promoted membership in the National Medical Association (NMA), attendance at NMA annual meetings, and cooperation among the health professions. They also used the pages of the JNMA to firmly respond to the negative articles and biased, even hateful, attitudes expressed by white medical and lay people. The JNMA has continued to speak for the black medical profession over the subsequent 100 years.

Sickle Cell Issue Editorial

The year 2010 marks the 100th anniversary of the first case of sickle cell disease (SCD) reported in the medical literature: James B. Herrick’s landmark article, “Peculiar elongated and sickle-shaped red blood corpuscles in a case of severe anemia,” appeared in the November 1910 issue of the Archives of Internal Medicine. In recognition of this significant event, the National Medical Association is dedicating the entire November issue of its journal to this important disorder, which continues to wreak havoc on the lives of SCD patients and their families. Having learned much during the past 100 years, medical researchers and practitioners have developed many helpful interventions. The continuing toll in human suffering highlights the fact that much more remains to be done. It should be noted that 1910 merely marks the year Western medicine recognized the disease—not the year SCD made its appearance on this planet. As pointed out in both Savitt’s and Ballas’ articles in this issue, people in West Africa knew of the disease, though by different names, and suffered from it for centuries before 1910. Permit us editorial prerogative to speculate for a moment about the relationship between the African slave trade and SCD in West Africa. In the many recorded accounts of the slave trade along the west coast of Africa from Senegambia to present-day Angola, there were 2 methods of “warehousing” slaves for trans-Atlantic shipment after they had been captured/collected from inland: (1) fort trade (in fixed fortifications), which was conducted on land such as at the famous Cape Coast Castle on the Gold Coast (present-day Ghana), in which European traders sold their slaves to ship captains; and (2) boat trade, which took place where there were no forts and slaves were ferried out to a ship via canoes or longboats and traded on the main deck of a slave ship. This was also referred to as the black trade because it was controlled largely by African merchants from the traditional trading states. In either venue, captives often lived in horrible conditions for many weeks until the ocean-going slave ship had acquired a full cargo and could begin its journey across the ocean. Even at anchor, there was little ventilation, a restricted water supply, and a meager subsistence diet. Although many prisoners fell victim—both before and during the Middle Passage—to disease, starvation, and depression/psychoses, it is also likely that a small number of these newly enslaved males and females, not noticed as sickly or weak, were sufferers of SCD and died in sickle cell crisis while confined in their contained and unventilated spaces characterized by increased carbon dioxide and reduced oxygen content. Those healthy captives who were unknowing carriers of the sickle cell gene took that gene with them to North and South Americas where, if they mated with another carrier, created offspring with SCD. Much progress has been made in the scientific understanding and management of SCD since its discovery. One of the latest and most promising advances has been the development of hematopoietic stem cell transplantation. Though it offers a cure and has been used successfully in a small number of patients, this treatment is associated with significant morbidity and mortality and requires further refinement. We would like to pay homage to Dr Roland B. Scott, director of the Comprehensive Sickle Cell Center at Howard University, Washington, DC, for many years, who was instrumental in bringing this disease to the attention of the entire nation in the early 1970s. One product of his efforts was the creation of 10 National Institutes of Health– mandated comprehensive sickle cell centers across the country that were in existence for more than 30 years. Sadly, this mandate expired, although many of the original centers continue to maintain centers of excellence in SCD with institutional, governmental, and private funding. Until there is a cure for SCD, perhaps Congress and the National Institutes of Health should revisit this decision. In our special sickle cell issue of the JNMA, we present historical perspectives on the disease and its discovery as well as reports of scientific advances and new work in diagnosis, management, and psychosocial concerns. We hope that these articles will provide readers with a sense of the progress made in managing SCD patients over the last 100 years and, perhaps, a glimpse into the future as it might unfold for both patients and providers.

American Social and Political Thought and the Federal Role in Child Health Care

The twentieth-century history of federal involvement in children’s health affairs has followed an interesting pattern: from little concern to deep commitment and then to reluctant participation. Ann Wilson has shown how between 1906 and 1912 Theodore Roosevelt’s administration prodded Congress to establish a Children’s Bureau to determine children’s and parents’ medical and other needs; how Congress backed away from that commitment in the 1920s; how, during the Depression of the 1930s, President Franklin Roosevelt and Congress joined together to pass social legislation to help those in need, including children; and how the current Reagan administration, despite such actions as the “Baby Doe” regulations, has sought to reduce federal involvement in health care financing, Congress’ wishes notwithstanding [5]. Though the three presidents mentioned — Theodore and Franklin Roosevelt, and Ronald Reagan — engineered these changes in government policy, they did not act in a vacuum. The general mood of the country, economic conditions, and political philosophy all played a role. To some extent, the medical profession also influenced public policy in this area.