Ghosts from the PastGhosts from the Past

An African American An African American Perspective on the History Perspective on the History

of Medicineof Medicine

Dr. Tochi M. Okwuosa

Case 1Case 1A 45 yo AA female without any significant A 45 yo AA female without any significant past medical history presented to the past medical history presented to the Emergency department with complaints of Emergency department with complaints of generalized fatigue and immense generalized fatigue and immense shortness of breath – worsening in the shortness of breath – worsening in the past 1 month. She denied having similar past 1 month. She denied having similar symptoms in the past.symptoms in the past.

Labs revealed leukopenia, anemia and Labs revealed leukopenia, anemia and thrombocytopenia (pancytopenia)thrombocytopenia (pancytopenia)

Chest X-Ray revealed axillary and Chest X-Ray revealed axillary and mediastinal lymphadenopathymediastinal lymphadenopathy

Case 1 Cont’dCase 1 Cont’dChest CT confirmed the axillary LAD was Chest CT confirmed the axillary LAD was accessible by fine needle aspirationaccessible by fine needle aspirationPatient was also found to be B12 deficient Patient was also found to be B12 deficient and was started on B12 replacement Txand was started on B12 replacement TxB12 deficiency could have been the B12 deficiency could have been the etiology of her anemia and etiology of her anemia and thrombocytopenia, however…thrombocytopenia, however…In order to further workup the patient’s In order to further workup the patient’s lymphadenopathy and leukopenia, she lymphadenopathy and leukopenia, she was approached for a consent on a fine was approached for a consent on a fine needle aspiration with possible needle aspiration with possible subsequent bone marrow biopsy, subsequent bone marrow biopsy, BUTBUT– Patient refused saying she “does not want to Patient refused saying she “does not want to

be used for an experiment”be used for an experiment”

Case 2Case 2A 39 yo AA male with history of HIV – A 39 yo AA male with history of HIV – known to have refused treatment in the known to have refused treatment in the past - presented to the emergency past - presented to the emergency department with complaints of cough, department with complaints of cough, shortness of breath, pleuritic chest pain, shortness of breath, pleuritic chest pain, fever/chills and generalized fatigue.fever/chills and generalized fatigue.Oxygen saturation of 85% on RA in the ED Oxygen saturation of 85% on RA in the ED improved with 4LNC oxygenimproved with 4LNC oxygenChest X-Ray revealed a diffuse interstitial Chest X-Ray revealed a diffuse interstitial pulmonary processpulmonary processRecent labs revealed a CD4 count of 154, Recent labs revealed a CD4 count of 154, now giving the patient a diagnosis of AIDSnow giving the patient a diagnosis of AIDSHis LDH was also elevatedHis LDH was also elevated

Case 2 Cont’dCase 2 Cont’dAdmitted to general medicine on bactrim, Admitted to general medicine on bactrim, avelox and airborne precautions for his avelox and airborne precautions for his pneumonia – most likely Pneumocystis pneumonia – most likely Pneumocystis cariniicarinii (PCP) vs community acquired vs (PCP) vs community acquired vs TuberculosisTuberculosisSputum cultures later confirmed PCP, no TBSputum cultures later confirmed PCP, no TBTreated with bactrim and much improved Treated with bactrim and much improved by time of discharge 3 days laterby time of discharge 3 days laterPt later approached about considering Pt later approached about considering treatment for his HIV/AIDS, BUT STATEStreatment for his HIV/AIDS, BUT STATES– ““Never. I don’t trust you doctors. Y’all Never. I don’t trust you doctors. Y’all

gave it to me… now you wanna kill me? gave it to me… now you wanna kill me? I’ll be fine by myself. I don’t need your I’ll be fine by myself. I don’t need your treatment”.treatment”.

Gomes and McGuire, 2001

Sources of HealthCare DifferencesAnd Disparities: Populations with EqualAccess to Healthcare

SERIES OF SERIES OF BAD BLOODBAD BLOOD

THE TUSKEGEE SYPHILIS THE TUSKEGEE SYPHILIS EXPERIMENTEXPERIMENT

Called the “The Called the “The Tuskegee Study of Tuskegee Study of Untreated Syphilis in the Untreated Syphilis in the Negro Male”Negro Male”

Also known as the Also known as the ‘longest non-therapeutic ‘longest non-therapeutic experiment in human experiment in human history’history’

Conducted by the US Conducted by the US Public Health Service Public Health Service (PHS)(PHS)

In The Days of Tuskegee...In The Days of Tuskegee...Syphilis was more prevalent in urban Syphilis was more prevalent in urban than rural communitiesthan rural communitiesBlacks more prevalent in rural Blacks more prevalent in rural communities, however…communities, however…In rural communities, incidence of In rural communities, incidence of syphilis in blacks greater than whites syphilis in blacks greater than whites by a ratio of 6:1by a ratio of 6:1– National black:white prevalence ratio National black:white prevalence ratio

was was 11.6:111.6:1Mostly an issue of financial and social Mostly an issue of financial and social classclass

In The Days of Tuskegee...In The Days of Tuskegee...

In those days, syphilitic treatment was In those days, syphilitic treatment was a chaos of different regimensa chaos of different regimens– Many piecemeal case studiesMany piecemeal case studies

In 1929, PHS sponsored the creation In 1929, PHS sponsored the creation of the Cooperative Clinics Group (CCG)of the Cooperative Clinics Group (CCG)– Five leading research-oriented venereal Five leading research-oriented venereal

disease clinics: Western Reserve, Johns disease clinics: Western Reserve, Johns Hopkins, U Michigan, U Penn and MayoHopkins, U Michigan, U Penn and Mayo

Need for a multicenter trialNeed for a multicenter trial

In The Days of Tuskegee...In The Days of Tuskegee...RetrospectiveRetrospective Scandinavian study by Scandinavian study by Bruusgard Bruusgard et alet al of 309 pts found of 309 pts found spontaneous remission in 43% of syphilis spontaneous remission in 43% of syphilis patientspatientsBetween 1932 and 1946, other studies Between 1932 and 1946, other studies concluded that treatment improves concluded that treatment improves eventual course in syphilis in a minority of eventual course in syphilis in a minority of patientspatientsThe treatment of the day also were The treatment of the day also were reportedly harmful to some patientsreportedly harmful to some patients

Aim of StudyAim of StudyTo prove that spontaneous To prove that spontaneous regression in syphilitic regression in syphilitic manifestations and the disease in manifestations and the disease in general, occurred with minimal or no general, occurred with minimal or no treatmenttreatmentStudy was meant to record the Study was meant to record the natural evolution of untreated natural evolution of untreated syphilis, in the hopes of justifying (or syphilis, in the hopes of justifying (or not justifying) treatment programs in not justifying) treatment programs in blacksblacks– Initially projected to last 6 monthsInitially projected to last 6 months

Study DesignStudy Design600 black sharecroppers from Macon 600 black sharecroppers from Macon county, Alabama (highest concentration of county, Alabama (highest concentration of positive serologic test for syphilis at the positive serologic test for syphilis at the time)time)399 patients had syphilis and 201 who did 399 patients had syphilis and 201 who did not have the diseasenot have the disease– Grossly disadvantaged men, making it easier Grossly disadvantaged men, making it easier

to enroll them in the studyto enroll them in the study– Told they were being Told they were being treatedtreated for “bad blood” for “bad blood”

– a local term used to describe several – a local term used to describe several illnesses, including anemia, fatigue and syphilisillnesses, including anemia, fatigue and syphilis

– Received free medical exam, free meals and Received free medical exam, free meals and burial insuranceburial insurance in exchange in exchange

Study DesignStudy Design

Study was meant to record the Study was meant to record the natural history of syphilis, in the natural history of syphilis, in the hopes of justifying treatment hopes of justifying treatment programs in blacksprograms in blacks– Initially projected to last 6 monthsInitially projected to last 6 months

The TruthThe Truth

Study lasted from 1932 to 1972Study lasted from 1932 to 1972

These men were not informed of the These men were not informed of the full nature of the experimentfull nature of the experiment

Underwent painful and potentially Underwent painful and potentially dangerous spinal tap procedures - dangerous spinal tap procedures - lumbar punctureslumbar punctures– Promotional hype to cover up the Promotional hype to cover up the

lumbar punctures: “LAST CHANCE FOR lumbar punctures: “LAST CHANCE FOR SPECIAL FREE TREATMENT”SPECIAL FREE TREATMENT”

The TruthThe Truth

The men received suboptimal The men received suboptimal treatment for their syphilistreatment for their syphilis– Syphilis treatment of the day – Syphilis treatment of the day – bismuth, bismuth,

neoarsphenamine and mercuryneoarsphenamine and mercury – given – given in such tiny amounts that only 3% of the in such tiny amounts that only 3% of the men showed any improvementmen showed any improvement

– Treatment eventually replaced by “pink Treatment eventually replaced by “pink medicine” – aspirinmedicine” – aspirin

Token medications given as good public Token medications given as good public relations to ensure nothing interfered with relations to ensure nothing interfered with the study’s aimthe study’s aim

The TruthThe Truth

Autopsies would eventually be Autopsies would eventually be required as part of the study – a fact required as part of the study – a fact that was concealed from the menthat was concealed from the men

One of the doctors involved in the One of the doctors involved in the experiment was quoted to have said experiment was quoted to have said “As I see it, we have no further “As I see it, we have no further interest in these patients until they interest in these patients until they die”.die”.

Participants - IParticipants - IUS Public Health Services (PHS)US Public Health Services (PHS)

The Tuskegee Institute affiliated hospitalThe Tuskegee Institute affiliated hospital– Study took place in the medical facility of this Study took place in the medical facility of this

black University founded by Booker T. black University founded by Booker T. WashingtonWashington

– Other predominantly black institutions and Other predominantly black institutions and local black doctors were involved as welllocal black doctors were involved as well

Surgeon General of the US Surgeon General of the US – Sent the men certificates of appreciation after Sent the men certificates of appreciation after

25years of the study25years of the study

Participants - IIParticipants - IINurse Eunice RiversNurse Eunice Rivers– A black nurse who was a central figure in the A black nurse who was a central figure in the

study for most of its 40-yr durationstudy for most of its 40-yr duration– Trusted by the men, and she seemed to have Trusted by the men, and she seemed to have

sincerely cared about their well-beingsincerely cared about their well-being– Unquestioning submission to authority Unquestioning submission to authority

obscured her moral judgmentobscured her moral judgment““we were taught that we never diagnosed, we never we were taught that we never diagnosed, we never prescribed, we followed the doctor’s instructions”.prescribed, we followed the doctor’s instructions”.

– Still felt nothing ethical was amiss even after Still felt nothing ethical was amiss even after exposure of the experiment to the publicexposure of the experiment to the public

The Tuskegee Institute Motto: Lifting the Veil

Several Treatment Efforts DeniedSeveral Treatment Efforts DeniedStudy men prevented from participating in Study men prevented from participating in several nationwide campaign efforts to several nationwide campaign efforts to eradicate venereal diseaseeradicate venereal diseasePenicillin discovered in the 1940’s was the Penicillin discovered in the 1940’s was the first real cure for syphilisfirst real cure for syphilis– These men were deliberately denied the These men were deliberately denied the

medication by PHSmedication by PHS

During WWII, 250 of the men registered During WWII, 250 of the men registered for the draft and were therefore required for the draft and were therefore required to get syphilis treatment to get syphilis treatment – All men exempted from treatment by the PHSAll men exempted from treatment by the PHS

Treatment Denial Continues….Treatment Denial Continues….In 1943, the Henderson Act (a public In 1943, the Henderson Act (a public health law) required testing and health law) required testing and treatment for venereal diseasestreatment for venereal diseases– Never happened for these menNever happened for these men

In 1964, the WHO’s declaration of In 1964, the WHO’s declaration of Helsinki specified that “informed Helsinki specified that “informed consent” was needed for any consent” was needed for any experiment involving human beingsexperiment involving human beings– These men were still never consentedThese men were still never consented

It all comes out in the openIt all comes out in the openJuly 25, 1972 – an article in July 25, 1972 – an article in Washington Washington StarStar by Jean Heller of the Associated Press by Jean Heller of the Associated Press

Source: Peter Buxtun – a former PHS Source: Peter Buxtun – a former PHS venereal disease interviewervenereal disease interviewer

Carried by the New York Times as wellCarried by the New York Times as well

Ad Hoc advisory panel of 9 professional Ad Hoc advisory panel of 9 professional members appointed to review the study by members appointed to review the study by the Assistant Secretary for Health and the Assistant Secretary for Health and Scientific AffairsScientific Affairs

Findings of the PanelFindings of the PanelThe men freely agreed to be studiedThe men freely agreed to be studiedHad been misled and had not been Had been misled and had not been informed of the real purpose of the studyinformed of the real purpose of the studyHad not been given all the facts required Had not been given all the facts required to provide informed consentto provide informed consentHad not been given adequate treatment Had not been given adequate treatment for their diseasefor their diseaseHad not been given the option of quitting Had not been given the option of quitting the studythe studyStudy was ethically unjustifiedStudy was ethically unjustified

Study Ends….Study Ends….October 1972, panel advises stopping the October 1972, panel advises stopping the study at oncestudy at once

One month later, US Assistant Secretary One month later, US Assistant Secretary for Health and Scientific Affairs announced for Health and Scientific Affairs announced the end of the studythe end of the study

Later statement by one of the study Later statement by one of the study participants participants “…nothing learned will “…nothing learned will prevent, find, or cure a single case of prevent, find, or cure a single case of infectious syphilis or bring us closer to our infectious syphilis or bring us closer to our basic mission of controlling venereal basic mission of controlling venereal disease in the United States”disease in the United States”

Repercussions….Repercussions….By the end of the By the end of the experiment,experiment,– 28 of the men had 28 of the men had

died directly of died directly of syphilissyphilis

– 100 were dead of 100 were dead of related complicationsrelated complications

– 40 wives were 40 wives were infectedinfected

– 19 of their babies 19 of their babies were born with were born with congenital syphiliscongenital syphilis

Reparations….Reparations….

Summer 1973, NAACP files a class action Summer 1973, NAACP files a class action law-suit that resulted in an out of court law-suit that resulted in an out of court settlement of approx. $10 million total settlement of approx. $10 million total ($37,500 each) for the Tuskegee study ($37,500 each) for the Tuskegee study menmen– In addition, Tuskegee Health Benefit Program In addition, Tuskegee Health Benefit Program

established by US government to provide free established by US government to provide free medical and burial services for all living medical and burial services for all living participantsparticipants

– Health benefits to infected wives, widows and Health benefits to infected wives, widows and childrenchildren

– The CDC was responsible for this program The CDC was responsible for this program which remains today at the National Center for which remains today at the National Center for HIV, STD and TB preventionHIV, STD and TB prevention

Clinton ApologizesClinton Apologizes““It is not only in remembering that It is not only in remembering that shameful past that we can make shameful past that we can make amends and repair our nation, but it amends and repair our nation, but it is in remembering that past that we is in remembering that past that we can build a better present and a can build a better present and a better future”.better future”.

Former President Clinton (May 16, 1997)Former President Clinton (May 16, 1997)

8 survivors of the Tuskegee study; 8 survivors of the Tuskegee study; five were in attendance, the others five were in attendance, the others had 3 family representatives.had 3 family representatives.

Later Repercussions….Later Repercussions….

AAs are wary of physicians (especially AAs are wary of physicians (especially of the Caucasian race)of the Caucasian race)– sub-optimal medical treatmentsub-optimal medical treatment

Lack of participation of AAs in Lack of participation of AAs in researchresearch– Difficulty in addressing diseases most Difficulty in addressing diseases most

prevalent among blacks e.g. HIV/AIDSprevalent among blacks e.g. HIV/AIDS– AAs receive drugs proven by research to AAs receive drugs proven by research to

be beneficial in the Caucasian populationbe beneficial in the Caucasian populationMay no necessarily be optimal for AAs (A-heft May no necessarily be optimal for AAs (A-heft & V-heft)& V-heft)

Criticisms of the StudyCriticisms of the Study1.1. Men did not receive PCN when it became Men did not receive PCN when it became

available as a definitive CURE for the diseaseavailable as a definitive CURE for the disease2.2. Men did not receive informed consent even Men did not receive informed consent even

when this became a lawwhen this became a law3.3. Men were not given the option of quitting the Men were not given the option of quitting the

studystudy4.4. Of note, all the manifestations of the disease Of note, all the manifestations of the disease

(both primary, secondary and tertiary) were (both primary, secondary and tertiary) were well known at the timewell known at the time

5.5. For full comparison, whites should have been For full comparison, whites should have been included in the study as controlsincluded in the study as controls

6.6. Venereal disease laws were broken in not Venereal disease laws were broken in not treating these men (or the men were exempted treating these men (or the men were exempted from being bound by them) from being bound by them)

Critics of the CriticismsCritics of the Criticisms1.1. No one was sure about treatment with PCN, best No one was sure about treatment with PCN, best

route of administration or duration of treatmentroute of administration or duration of treatment2.2. Administration of PCN would have defeated the Administration of PCN would have defeated the

aim of the studyaim of the study3.3. By the time PCN was discovered, most of the By the time PCN was discovered, most of the

men were in the tertiary stage and could not men were in the tertiary stage and could not have been curedhave been cured

4.4. The researchers were projected as being “truly The researchers were projected as being “truly interested” in the effects of syphilis in black interested” in the effects of syphilis in black peoplepeople

5.5. Inclusion of patients who had exceeded their Inclusion of patients who had exceeded their mean life expectancy shows the study was not mean life expectancy shows the study was not expected to last so longexpected to last so long

6.6. How could informed consent be obtained from How could informed consent be obtained from illiterate men?illiterate men?

A Legacy of DistrustA Legacy of Distrust

?Father of Gynecology??Father of Gynecology?Dr. J. Marion Sims (1813-1884)Dr. J. Marion Sims (1813-1884)1845 – 1849: He initiated and perfected 1845 – 1849: He initiated and perfected the surgical treatment of vesico-vaginal the surgical treatment of vesico-vaginal fistula by experimenting on black slave fistula by experimenting on black slave women women All surgeries on black women done without All surgeries on black women done without anesthesiaanesthesiaHe finally perfected the procedure after he He finally perfected the procedure after he had carried out surgery on his first had carried out surgery on his first experimental slave patient - Anarcha - for experimental slave patient - Anarcha - for the 30the 30thth time!!! time!!!

An original painting by Robert Thom depicting the event with some artistic license 100 years later (commissioned by the Parke–Davis Co., from A history of medicine in pictures, edited by Bender GA, 1961).

?Father of Gynecology??Father of Gynecology?Later (after perfecting the Later (after perfecting the procedure), he performed surgery on procedure), he performed surgery on the white female counterparts with the white female counterparts with anesthesiaanesthesiaRegardless of his exploits, he went Regardless of his exploits, he went on to become president of the AMA on to become president of the AMA in 1875 in 1875 andand got the title of Father of got the title of Father of Gynecology.Gynecology.His statue stands in central park, His statue stands in central park, New YorkNew York

From Sims' original text, Silver sutures in surgery, 1858

Sims Speculum Sims Position

Medicine and Slavery Medicine and Slavery in the 19in the 19thth Century Century

Due to high mortality rates for minor Due to high mortality rates for minor surgeries in Louisiana, physicians surgeries in Louisiana, physicians perfected their C-section techniques on perfected their C-section techniques on black women first before applying it to black women first before applying it to white womenwhite women

Despite state laws banning the dissection Despite state laws banning the dissection of human bodies after death, white of human bodies after death, white medical students stole black bodies from medical students stole black bodies from graves to learn surgery since black bodies graves to learn surgery since black bodies were not ‘protected by law’were not ‘protected by law’

The Psychiatry of SlaveryThe Psychiatry of Slavery

DrapetomaniaDrapetomania: : a a mental illness mental illness (credited to Dr. (credited to Dr. Sam Cartwright in Sam Cartwright in the 19the 19thth century) century) that caused black that caused black slaves to run away slaves to run away from plantationsfrom plantations– ““Cured” by Cured” by

repeated whippingsrepeated whippings

The Psychiatry of SlaveryThe Psychiatry of Slavery

DysaethesiaDysaethesia aethiopicaaethiopica:: caused blacks to caused blacks to suffer from sleepiness, dry skin, lesions, suffer from sleepiness, dry skin, lesions, insensitivity to pain, mischievous insensitivity to pain, mischievous behavior behavior

The Physiology/Anatomy of SlaveryThe Physiology/Anatomy of Slavery

During the chattel slavery era, During the chattel slavery era, physicians claimed that blacks had physicians claimed that blacks had some physiologic and anatomical some physiologic and anatomical features that made them better features that made them better suited to be both slaves and medical suited to be both slaves and medical research subjectsresearch subjects– Small brains, thick lips and thick skin Small brains, thick lips and thick skin

giving them high tolerance for heat, sun giving them high tolerance for heat, sun and painand pain

World War IIWorld War II

Blood of black soldiers were Blood of black soldiers were segregated from that of white segregated from that of white soldiers in order to maintain racial soldiers in order to maintain racial separationseparation– Jeopardized lives of black soldiers Jeopardized lives of black soldiers

(drafted to go to war) who were in need (drafted to go to war) who were in need of transfusionof transfusion

HeLa Cells • Henrietta Lacks: AA Henrietta Lacks: AA female from Baltimore female from Baltimore whose cancer cells were whose cancer cells were harvested in 1951 harvested in 1951 (without her knowledge (without her knowledge or the knowledge of her or the knowledge of her family members) for the family members) for the study of cancerstudy of cancer

• Financial gain for Financial gain for some researchers some researchers distributing her cells distributing her cells while her family was while her family was kept in the darkkept in the dark

Eugenics MovementEugenics MovementA movement introduced by American Scientists A movement introduced by American Scientists in the late 19in the late 19thth century that initially involved century that initially involved people who had developmental disabilities, people who had developmental disabilities, mental illness or were criminals mental illness or were criminals

Carried out in about 30 states within the US Carried out in about 30 states within the US from 1929; and lasted 45 yearsfrom 1929; and lasted 45 years

An extension of this program in N. Carolina An extension of this program in N. Carolina (after 1945) mandatory sterilization procedures (after 1945) mandatory sterilization procedures in black women (sometimes unbeknownst to in black women (sometimes unbeknownst to the black women), to avoid passing on their the black women), to avoid passing on their progenyprogeny

Program finally ended with anti-eugenics Program finally ended with anti-eugenics movements in the late 1970smovements in the late 1970s

Gains from the RuinsGains from the RuinsVery tight government regulations on Very tight government regulations on studies involving human beings.studies involving human beings.Informed consent from patients Informed consent from patients undergoing research or surgical undergoing research or surgical proceduresproceduresSims speculum and sims position for Sims speculum and sims position for gynecologic exam and surgerygynecologic exam and surgeryHeLa cells pivotal in the study of Polio and HeLa cells pivotal in the study of Polio and its vaccination its vaccination HeLa cells also fundamental in the study of HeLa cells also fundamental in the study of cancercancer– > 50 years after her death, HeLa cells are still > 50 years after her death, HeLa cells are still

used all over the world in cancer researchused all over the world in cancer researchAwareness of potential fallacies in Awareness of potential fallacies in medicinemedicine

What about Black Physicians?What about Black Physicians?BlacksBlacks HispanicsHispanics AsiansAsians Native Native

AmericanAmerican

Percentage of Percentage of Physicians (2004)Physicians (2004)

2.3%2.3% 3.2%3.2% 8.3%8.3%

Increase in medical Increase in medical school applications school applications (1974 – 2004)(1974 – 2004)

22%22% 200%200% 450%450%

Increase in number Increase in number of black medical of black medical school graduates school graduates (1980 – 2004)(1980 – 2004)

35%35% 118%118% >650%>650% 200%200%

Increase in number Increase in number of female black of female black medical school medical school graduates (1980 – graduates (1980 – 2004)2004)

126%126% 422%422% >1800%>1800% 717%717%

AAMC, Minorities in Medical Education, Facts & Figures, 2005

The History of Black Medical The History of Black Medical CollegesColleges

The first black medical college – Howard The first black medical college – Howard University – was founded in 1868University – was founded in 1868By 1900, there were about 10 black By 1900, there were about 10 black medical collegesmedical colleges– More had opened prior to this, but had quickly More had opened prior to this, but had quickly

closedclosed– Most were funded independently by religious Most were funded independently by religious

groups, and individual donorsgroups, and individual donors– Only Howard university had congressional Only Howard university had congressional

backingbacking

By 1923, only 2 black colleges were left in By 1923, only 2 black colleges were left in the countrythe country

Earlier on in HistoryEarlier on in HistoryThere was already crisis with funding and There was already crisis with funding and quality of black medical collegesquality of black medical colleges– Underserved black patients needed to be cared for, Underserved black patients needed to be cared for,

but most of the black medical school students were but most of the black medical school students were from poor backgroundsfrom poor backgrounds

Most of the staff were overworked and Most of the staff were overworked and underpaidunderpaidThey lacked adequate lab and classroom They lacked adequate lab and classroom equipments and facilitiesequipments and facilitiesBoard failure rates exceeded 20% in 1904/5Board failure rates exceeded 20% in 1904/5They had evening classes for their students They had evening classes for their students that worked full timethat worked full time

Earlier on in History (cont’d)Earlier on in History (cont’d)

? How to solve the problem?? How to solve the problem?– Increase tuition?Increase tuition?– Engage philanthropists to contribute to Engage philanthropists to contribute to

black medical education?black medical education?– Engage to government to ensure better Engage to government to ensure better

care for its black citizens by ensuring care for its black citizens by ensuring better medical education for their better medical education for their physicians?physicians?

The Flexner Report (cont’d)The Flexner Report (cont’d)

Looked at:Looked at:– Medical school entrance requirementMedical school entrance requirement– Size and training quality of the facultySize and training quality of the faculty– Size of endowment and tuitionSize of endowment and tuition– Quality of laboratoriesQuality of laboratories– Availability of teaching hospitals and their Availability of teaching hospitals and their

clinical teaching staffclinical teaching staff

Began in 1908, was completed by 1910Began in 1908, was completed by 1910

In the aftermath of the Flexner report, only In the aftermath of the Flexner report, only 2 black medical schools remained in the 2 black medical schools remained in the nationnation

The Flexner Report (cont’d)The Flexner Report (cont’d)

Until the Flexner Report, black Until the Flexner Report, black schools were never noticed in schools were never noticed in medical report, articles or medical report, articles or commentariescommentaries

The report was published in JAMA in The report was published in JAMA in 19101910

Described as harsh, frank, chiding, Described as harsh, frank, chiding, sarcastic and bitingsarcastic and biting

Some Flexner Report StatementsSome Flexner Report Statements““The negro must be educated not only for The negro must be educated not only for his sake, but for ours…. ten million of his sake, but for ours…. ten million of them live in close contact with sixty million them live in close contact with sixty million whites”.whites”.““Of the seven medical schools… five are at Of the seven medical schools… five are at this moment in no position to make any this moment in no position to make any contribution of value… sending out contribution of value… sending out undisciplined men whose lack of training is undisciplined men whose lack of training is covered up by the imposing MD degree”.covered up by the imposing MD degree”.““The negro must be educated not only for The negro must be educated not only for his sake, but for ours… to know and to his sake, but for ours… to know and to practice fundamental hygienic principles. practice fundamental hygienic principles. A well-taught negro sanitarian will be A well-taught negro sanitarian will be immensely useful”.immensely useful”.

The Flexner Report (cont’d)The Flexner Report (cont’d)

The black medical schools had 2 The black medical schools had 2 missions:missions:– To offer “the more promising of the To offer “the more promising of the

race… a substantial education in which race… a substantial education in which hygiene rather than surgery… is hygiene rather than surgery… is strongly accentuated”.strongly accentuated”.

– To “imbue these men with missionary To “imbue these men with missionary spirit so that they will look upon the spirit so that they will look upon the diploma as a commission to serve their diploma as a commission to serve their people humbly and devotedly away from people humbly and devotedly away from large cities [in] the village and [on] the large cities [in] the village and [on] the plantation, upon which light has hardly plantation, upon which light has hardly as yet begun to break”.as yet begun to break”.

History of AA Med Colleges (cont’d)History of AA Med Colleges (cont’d)

5 of the 7 medical schools closed after this 5 of the 7 medical schools closed after this reportreport– Last of them closed in 1923Last of them closed in 1923– Surviving schools: Howard and Meharry college Surviving schools: Howard and Meharry college

in Nashville, TNin Nashville, TN

NMA (an AMA sub-committee) remained NMA (an AMA sub-committee) remained silent on the Flexner reportsilent on the Flexner reportIt took a bit of cajoling for the Carnegie It took a bit of cajoling for the Carnegie Foundation and the GEB to provide the Foundation and the GEB to provide the funds to keep the 2 medical colleges funds to keep the 2 medical colleges functioningfunctioning– Flexner was instrumental in the achieving this Flexner was instrumental in the achieving this

aimaim

History of AA Med Colleges (cont’d)History of AA Med Colleges (cont’d)

Between 1932 – 1942, number of Between 1932 – 1942, number of black physicians dropped by 5%, black physicians dropped by 5%, while the number of white physicians while the number of white physicians rose by 12%rose by 12%It was not until 1966 that another It was not until 1966 that another black college was founded – Charles black college was founded – Charles Drew medical school in L.A.Drew medical school in L.A.– Morehouse medical college in Atlanta, Morehouse medical college in Atlanta,

GA was subsequently founded in 1975GA was subsequently founded in 1975

PAST ACHIEVEMENTSPAST ACHIEVEMENTS

Some AA Contributions to MedicineSome AA Contributions to Medicine

1721: 1721: OnesimusOnesimus (an (an African slave) African slave) describes the African describes the African method of method of innoculation against innoculation against small pox to Cotton small pox to Cotton MatherMather– Technique later Technique later

perfected by Edward perfected by Edward Jenner in the 1790’s by Jenner in the 1790’s by the use of a less the use of a less virulent orgvirulent org

– Used to protect Used to protect American revolutionary American revolutionary war soldierswar soldiers

Some AA Contributions to MedicineSome AA Contributions to MedicineDr. Daniel Hale WilliamsDr. Daniel Hale Williams

1891:Founded Provident 1891:Founded Provident hospitalhospital– 11stst inter-racial hospital in the inter-racial hospital in the

United StatesUnited States

1893: Performs the first 1893: Performs the first successful operation (in successful operation (in the world) on a human the world) on a human heartheart– Performed on a chest stab Performed on a chest stab

wound victimwound victim

Some AA Contributions to MedicineSome AA Contributions to Medicine

1917: 1917: Dr. Louis T. WrightDr. Louis T. Wright develops develops the intradermal technique for the intradermal technique for vaccinating soldiers against small vaccinating soldiers against small poxpox

1927: 1927: Dr. William Augustus HintonDr. William Augustus Hinton develops the Hinton test for develops the Hinton test for diagnosing Syphilisdiagnosing Syphilis– Later develops an improved version – Later develops an improved version –

the Hinton-Davies testthe Hinton-Davies test

1940:1940: Dr. Charles R. Dr. Charles R. DrewDrew, after 2 yrs of , after 2 yrs of blood research, blood research, discovers that discovers that plasma can replace plasma can replace whole blood whole blood transfusionstransfusions– Developed the concept Developed the concept

of BLOOD BANKof BLOOD BANK– Blood can now be Blood can now be

stored for longer stored for longer periods of time as periods of time as plasmaplasma

Some AA Contributions to MedicineSome AA Contributions to Medicine

1944: 1944: Vivien ThomasVivien Thomas, a technician in , a technician in the labs of Dr. Alfred Blalock at Johns the labs of Dr. Alfred Blalock at Johns Hopkins Hospital , develops the Hopkins Hospital , develops the Blalock-Taussig shunt for treatment Blalock-Taussig shunt for treatment of Tetralogy of Fallotof Tetralogy of Fallot– 1976: awarded Doctor of Laws honorary 1976: awarded Doctor of Laws honorary

degree by Johns Hopkins Universitydegree by Johns Hopkins University– 1979: post retirement, becomes 1979: post retirement, becomes

instructor emeritus of surgeryinstructor emeritus of surgery

Some AA Contributions to MedicineSome AA Contributions to Medicine

Blalock-Taussig Shunt – Developed with the help of Vivien Thomas

Some AA Contributions to MedicineSome AA Contributions to MedicineDr. Samuel L. KountzDr. Samuel L. Kountz participated in the first participated in the first west coast kidney transplant in 1959west coast kidney transplant in 19591961: Dr. Kountz and Dr. Cohn made medical 1961: Dr. Kountz and Dr. Cohn made medical history at Stanford University when they history at Stanford University when they developed a method and performed the first developed a method and performed the first transplant in which an unidentical (non-twin) transplant in which an unidentical (non-twin) donor and mother was used donor and mother was used Later, developed the Kountz’s technique for Later, developed the Kountz’s technique for detecting and treating acute rejectiondetecting and treating acute rejection– Prior to this, < 5% 2yr survival post kidney Prior to this, < 5% 2yr survival post kidney

transplanttransplant– MethylprednisoloneMethylprednisolone1964: American College of Cardiology 1964: American College of Cardiology Outstanding Investigator AwardOutstanding Investigator Award

Some AA Contributions to Some AA Contributions to MedicineMedicine

1987: 1987: Neurosurgeon Neurosurgeon Dr. Dr. Ben CarsonBen Carson, leads , leads a seventy-member a seventy-member surgical team at surgical team at Johns Hopkins Johns Hopkins Hospital to Hospital to separate Siamese separate Siamese twins joined at the twins joined at the craniumcranium

Some AA Contributions to MedicineSome AA Contributions to Medicine

1991: 1991: Dr. Vivian PinnDr. Vivian Pinn - the first - the first female (and first African-American female (and first African-American female) Director of the Office of female) Director of the Office of Research on Women's Health, Research on Women's Health, National Institutes of Health National Institutes of Health

1997: 1997: Dr. Donna Christian-Dr. Donna Christian-ChristensenChristensen - - the first female the first female physician (and first African-American physician (and first African-American female physician) in the U.S. female physician) in the U.S. Congress Congress

HEALTH DISPARITIES:HEALTH DISPARITIES:To Think About…To Think About…

Physician Disparities: StatisticsPhysician Disparities: StatisticsNationwide in a population of about 28% Nationwide in a population of about 28% minority population, only 5% make up the minority population, only 5% make up the physician population and 3%, the medical physician population and 3%, the medical school facultyschool facultyMinorities spend more time with students Minorities spend more time with students and patients, and less time on research; and patients, and less time on research; yet, much less likely to achieve faculty yet, much less likely to achieve faculty promotionpromotion98% of senior leaders in health care 98% of senior leaders in health care management are whitemanagement are white

- (ACP Position Paper, 2004)- (ACP Position Paper, 2004)

Physician Disparities: StatisticsPhysician Disparities: Statistics

Black patients saw white physicians Black patients saw white physicians 22% of the time VS white patients who 22% of the time VS white patients who saw black physicians 1% of the timesaw black physicians 1% of the time

77% of white physicians believed that 77% of white physicians believed that disparities in healthcare related to race, disparities in healthcare related to race, ethnicity or educational status, rarely or ethnicity or educational status, rarely or never happenednever happened

80% of black physicians reported the 80% of black physicians reported the opposite – there were differencesopposite – there were differences

– (Kaiser Family Foundation, 2001)(Kaiser Family Foundation, 2001)

Physician Disparities: StatisticsPhysician Disparities: StatisticsPhysicians who treat African Americans are Physicians who treat African Americans are less likely to be board-certified, and less able less likely to be board-certified, and less able to refer patients to specialists than physicians to refer patients to specialists than physicians who treat white patientswho treat white patients77% of physicians practicing in black 77% of physicians practicing in black neighborhoods are board certified in their neighborhoods are board certified in their

primary care specialty primary care specialty VSVS 88% of physicians 88% of physicians practicing in white neighborhoodspracticing in white neighborhoods28% of physicians treating blacks said they 28% of physicians treating blacks said they could not provide high quality healthcare to could not provide high quality healthcare to

their patients their patients VSVS 17% of physicians treating 17% of physicians treating whiteswhites

– (NEJM, 2004)(NEJM, 2004)

Whites live significantly longer Whites live significantly longer than blacks…than blacks…

Black male68.6

White male, 75

Black female75.5

White female80.2

62

64

66

68

70

72

74

76

78

80

82

RACE

AgeInYears

- DHHS Fact Sheet, 2004

Death Rates for Diseasesof the Heart, by Race/Ethnicity, 2001

Higher Prevalence of Diseases in African AmericansHigher Prevalence of Diseases in African AmericansHeart Disease (Andrews Heart Disease (Andrews et al, et al, 2001)2001)Prostate Cancer (Reddy Prostate Cancer (Reddy et alet al, 2003), 2003)Lung Cancer (Stellman Lung Cancer (Stellman et al,et al, 2003) 2003)HIV (Torian HIV (Torian et al,et al, 2002) 2002)Stroke (Ruland and Stroke (Ruland and Gorelick, 2005)Gorelick, 2005)Renal Cancer Renal Cancer (Vaishampayan(Vaishampayan et al et al, , 2003)2003)Breast Cancer (GhafoorBreast Cancer (Ghafoor et alet al, 2003), 2003)Cervical Cancer (JemalCervical Cancer (Jemal et al,et al, 2004) 2004)Oral Cancer (ShaversOral Cancer (Shavers et al, et al, 2003)2003)Tooth loss (Gilbert Tooth loss (Gilbert et al, et al, 2003)2003)

Obesity and Diabetes Obesity and Diabetes (Cossrow and Faulkner, (Cossrow and Faulkner, 2004)2004)Chronic Asthma Chronic Asthma (Boudreaux(Boudreaux et al et al, 2003), 2003)CRC (Baquet and CRC (Baquet and Commiskey, 1999)Commiskey, 1999)Pancreatic Cancer Pancreatic Cancer (Silverman (Silverman et al, et al, 2003)2003)Lymphomas (Briggs Lymphomas (Briggs et al,et al, 2003)2003)Endometrial Cancer Endometrial Cancer (Randall and Armstrong, (Randall and Armstrong, 2003)2003)Lupus nephritis (Lea, 2003)Lupus nephritis (Lea, 2003)Hepatitis B and Syphilis Hepatitis B and Syphilis (Schrag (Schrag et al, et al, 2003)2003)Arthritis (Dunlop Arthritis (Dunlop et al, et al, 2001)2001)

… to name a few…

General Disparities in Health CareGeneral Disparities in Health Care

African Americans are less likely to:African Americans are less likely to:– Report health insuranceReport health insurance– Receive recommended immunizationsReceive recommended immunizations– Receive screening and treatment for Receive screening and treatment for

cardiac risk factors and cancercardiac risk factors and cancer

““91,000 African Americans die each 91,000 African Americans die each year because of health disparities”year because of health disparities”

Dr. Rodney Hood, National Medical Dr. Rodney Hood, National Medical AssociationAssociation

National InitiativesNational Initiatives‘‘Healthy People’ (REACH) 2010 initiativeHealthy People’ (REACH) 2010 initiative– Launched by the DHHS in 2000Launched by the DHHS in 2000– Being executed by the CDCBeing executed by the CDC

Agency for Healthcare Research and Agency for Healthcare Research and Quality (AHRQ)Quality (AHRQ)National Institutes of Health (NIH)National Institutes of Health (NIH)CDC National Immunization ProgramCDC National Immunization ProgramCMS InitiativesCMS Initiatives– ESRD Clinical Performance Measures ProjectESRD Clinical Performance Measures Project– Quality Improvement OrganizationsQuality Improvement Organizations

Kaiser and RWJ FoundationKaiser and RWJ FoundationCenters for Healthy Hearts & SoulsCenters for Healthy Hearts & SoulsDoctors back to school Program (AMA Doctors back to school Program (AMA Minority Affairs Consortium)Minority Affairs Consortium)

In Conclusion…In Conclusion…

African American patients are wary African American patients are wary of physiciansof physiciansMost of the distrust stem from past Most of the distrust stem from past exploitations of the African American exploitations of the African American community; as well as current community; as well as current disparities that exist within our disparities that exist within our healthcare systemhealthcare systemThe past cannot be altered, but the The past cannot be altered, but the bad outcomes of the seeds planted in bad outcomes of the seeds planted in the past can be remediedthe past can be remedied

In Conclusion…In Conclusion…Steps must therefore be taken to Steps must therefore be taken to recognize the mistakes of the past and recognize the mistakes of the past and make necessary efforts to eliminate make necessary efforts to eliminate continued gaps and mishaps within our continued gaps and mishaps within our healthcare systemhealthcare system

We therefore hope that we can create We therefore hope that we can create a more unified healthcare system a more unified healthcare system within which our citizens are well cared within which our citizens are well cared for, irrespective of race and ethnicityfor, irrespective of race and ethnicity