(Trigger warning: though accurate, some of the material discussed in this piece describes medical violence that some readers may find upsetting)
Medical Apartheid by Harriet Washington
In research, there is a buzz of criticism regarding the growing bureaucracy of IRB requirements. Many have argued that IRB review obfuscates our capacity for research and is inhibiting breakthroughs. I have to admit that I’ve sympathized with this sentiment in the past. I’ve wanted to bang my head against my keyboard during CITI training, and, like many of us, I’ve known the horror that hides behind the dreaded F204 form (the 2015 version, of course). For perspective, I find it useful to go back and review why we have such stringent standards for research. We often look back on the history of medical research in Nazi Germany. These examples serve as stark reminders of how humanity can spin out of control when we fail to value the right to consent. Few of us know, however, that our own country has a dark history of medical abuse and gross negligence of consent. Harriet Washington is a journalist and fellow in ethics from Harvard Medical School. Her book, Medical Apartheid, gives a historic account of the many abuses suffered by the black community in America from colonial times to the present day. As a medical student, it’s difficult to acknowledge this history and even harder to accept it as being woven into the great traditions of our professions, but it is an important reminder of the value of consent and respect for our research subjects.
A Cultural History of Exploitation
Harriet Washington begins with the story of John Brown who, as a favor, was loaned to a local doctor for experimentation. In order to study heat stroke, he forced Brown to sit naked on a stool in a pit filled with burning embers while he tested remedies like cayenne pepper tea. Later, he blistered and cut Brown’s skin to examine the depth of black skin relative to white. Similarly, James Sims, considered a medical hero to women for his contributions to gynecology, developed many of his treatments against the will of slave women. He made his mark in medicine by developing the first successful surgery to treat post-partum vesicovaginal fistulae. The method was developed by experimentation on slave women he had purchased. Despite the availability of ether, he denied them anesthesia while he tested techniques to debride and re-attach vaginal and vesicular tissue. Each time, the sutures would become infected, painfully re-opening, only to be operated on again by Sims. The technique was finally perfected with the use of silver sutures, which have antimicrobial properties. He soon made a fortune performing the technique on white women—under ether anesthesia.
White Coats
One of the hardest aspects of Medical Apartheid for me to accept was the characterization of medical education throughout American history. It’s clear from the examples in the book that medical educators have been complicit and perpetrators of serious injustices against the African-American community. In the late 18th century, the focus of medical education became more scientifically focused. As a consequence, the demand for anatomical specimens far exceeded the legal availability of cadavers. This began a long history of “resurrection men” who procured bodies for the use of medical education. Black cemeteries were an easy target since the families had fewer resources for burial and fewer legal protections. Additionally, white leaders considered the illegal selling of black cadavers a necessary evil to prevent the resurrection men from moving on to white gravesites. The history of selling black bodies touches almost every medical school with a history dating back to the 1800s. Anatomical specimens still in possession at the Medical College of Georgia were found to be overwhelmingly provided by black donors. Columbia University, NYU, and Rush University all have been implicated throughout history in procuring cadavers through illicit sources. Such donors were often exposed to humiliating desecration and used for scare tactics. One of the first African-American medical students at Harvard, Louis Tompkins Wright, walked into his first anatomy class in 1912 to find the cadaver of a black donor swinging in front of the room, strung by ice tongs in his ears. Even as laws protecting donors started to develop, they often allowed for the donation of unclaimed bodies, often resulting in donations from facilities that treated black communities. After the 1968 Uniform Anatomical Gift Act was implicated, tissue donations of unclaimed homicide victims were still permitted for donation, a population that disproportionately included the black community. Black patients were also used as a marketing ploy for southern medical schools. The promise of plentiful “clinical material” made available from the charity wards across the south were promoted to bring students to their institutions. Black subjects, forfeiting their right to consent in hopes of treatment, were subjected to experiments as fodder for publication. Washington shares the story of a young South Carolina boy who presented for surgery following lacerations to his genitals. The attending surgeon repaired the lacerations but also removed one of the boy’s testicles—he later published an article on the use of chloroform in the case of castration. In the antebellum south, slaves were treated for free as an incentive to fill the medical schools with interesting cases and opportunities to practice clinical procedures. As despicable as this is today, I wonder if there isn’t an artifact of this in modern medicine. I admit to being guilty of preferring clinical experiences within the underserved community where the patients are less inclined to object to a medical student, perhaps because their care is provided at a reduced cost.
These summaries represent a snapshot of the dark history of our treatment of African Americans within medicine. However, it’s important to remember that the foundation of today’s procedures for experiment and consent are codified in an effort to prevent and correct a dark history of abuse abroad and in our own country. Extending beyond race, it’s also worth noting that as we experience the current events of race relations—like the anniversary of Ferguson, Missouri—we medical professionals have a responsibility to recognize that there is a deserved mistrust of physicians within the black community. It also helps to illuminate the history of systemic oppression that has plagued the black community that is central to any conversation about race today.
This is a very broad topic, and this article barely scratches the surface. If you are interested in more detail, I would suggest looking up topics like Mississippi appendectomy, “hottentott,” and racial bioterrism in South Africa, or just reading the book.
Jonathan Cagle has a BA in Spanish from Southern Illinois University. Before studying medicine, he worked in politics and the non-profit sector. He is one of the student co-leaders of the Medical Ethics Interest Group.