Health Gulf
Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present
by Harriet A. Washington
Doubleday. 501 pp. $27.95
American blacks have long suffered from health adversities not shared by whites, and the problem persists even today, decades after the end of state-sanctioned racism. As Harriet A. Washington writes in her new book, Medical Apartheid, the “racial health divide confronts us everywhere we look, from doubled black-infant death rates to African-American life expectancies that fall years behind whites.” To the question of how this disparity came to be, she provides a provocative answer.
Though slavery and segregation form the backdrop of her analysis, Washington believes that a very specific aspect of past discrimination against blacks explains the unequal levels of treatment and health that are still with us. Her focus is on the long history of medical experiments of which American blacks were the unwilling or unwitting subjects. These past injuries, Washington argues, have “played a pivotal role in forging the fear of medicine that helps perpetuate our nation’s racial health gulf.” Long after the events themselves, she believes, the memory of abuse has remained.
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Medical Apartheid covers a great deal of historical ground, from the antebellum plantation era to present-day controversies over diseases that especially afflict blacks. Some of the material Washington covers is familiar, like the infamous Tuskegee study (1932-72) in which African-American sharecroppers suffering from syphilis were observed in a research study by the U.S. Public Health Service and ultimately prevented from receiving the penicillin that might have cured them.
Other episodes are more obscure but no less chilling. Washington describes, for instance, the purchase of slaves solely for purposes of experimentation and the routine display in the 19th century of black subjects—sometimes alive, sometimes after taxidermy—as curiosities at fairs, museums, and zoos, often as part of a pseudo-Darwinian justification for racial discrimination. She suggests, too, that blacks have been especially harmed by dangerous research involving everything from burns and radiation exposure to blood transfusions.
An especially vivid example of such supposed exploitation, to which Washington refers throughout the book, is the work of Dr. J. Marion Sims, a mid-19th-century Alabama surgeon who developed the first successful technique for the repair of gynecological fistulae—abnormal passageways that sometimes develop between the bladder and the vagina as a result of prolonged labor. In afflicted women, the condition is marked by pain, disfigurement, and chronic infection, as well as by the continuous leakage of urine.
In the years 1845-49, Sims conducted experimental operations on slave women brought to him for treatment by their owners. He did not use anesthesia on them during surgery and yet, curiously, gave them opium over the course of their recoveries. “The most logical explanation” for this drug regimen, Washington writes, “had more to do with controlling the women’s behavior than controlling their pain, because the addiction weakened their will to resist repeated procedures.”
Washington acknowledges that African Americans were by no means the only group exposed to such practices in the early history of American medicine. Other captive and vulnerable populations, like prisoners, soldiers, orphans, and the mentally ill, often served as subjects too. But, as she interprets it, the combination of pervasive racism and powerlessness inflicted greater harm on blacks.
As for the health status of blacks today, Washington recognizes that it is affected by a complex amalgam of social and economic variables. But the most important factor, she argues, is distrust, which leads to the avoidance of care and to poorer health. That distrust, in turn, is a direct result of the history she recounts in such excruciating detail.
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Many sections of Medical Apartheid are fascinating, and Washington—a former medical social worker who wrote this book while on an ethics fellowship at Harvard medical school—draws on a vast range of archival material, journal articles, legal documents, and reports. The narrative is well paced and written, and her accounts of several complicated episodes like the Tuskegee study are accessible and presented in useful historical context. She also deftly covers such modern-day controversies as race-based pharmacology and the effects of maternal cocaine use on developing fetuses.
But Washington’s account is marred by frequent distortions and inaccuracies. She lends credence to several claims about racial bias in current medical practice that are either demonstrably false or hotly debated, like the notion that discrimination is a significant cause of hypertension in blacks, or the charge that African-Americans are, because of their race, less likely than whites to receive kidney transplants and high-tech cardiac intervention. Elsewhere, Washington contradicts herself. She deems “repressive,” for example, a New York State regulation requiring physicians to report the names of HIV/AIDS-positive patients to the authorities so that their sexual partners can be notified, and yet she condemns the Tuskegee researchers for not taking similar measures to contain disease with the sharecroppers under their care.
Worse, Washington often excludes details that undermine her argument. She presents Dr. J. Marion Sims as the embodiment of a callous physician-experimenter, but other historians of 19th-century American medicine provide a very different picture. According to L. Lewis Wall of the Washington University school of medicine, Sims wrote multiple accounts of his operations, and claims to have described the procedure to his subjects and obtained their permission. Nor did Sims selectively withhold anesthesia from black women, as Washington suggests. He treated his white patients the same way, and resorted to post-operative opium not to subjugate them further but rather to keep them prone and relaxed, thus ensuring that their wounds healed well.
As for Washington’s overarching argument about the historical roots of contemporary blacks’ distrust of the medical system, it simply is not persuasive. The medical literature reveals: (1) that experimental abuses commonly occurred in the past; (2) that, when surveyed today, African-Americans express low levels of trust in both physicians and the health-care system; (3) that blacks enjoy less access to health-care than do whites; and (4) that they are less healthy. Washington contends that there is a tight causal relationship among these observations, but the thesis is neither explained nor defended.
How much awareness of past abuses is there among American blacks? To the extent that such awareness exists, what role does it play in keeping blacks from obtaining care? Such questions are never critically addressed. There may well be some residue of distrust among American blacks, but it hardly seems decisive in their attitudes toward medical care. A far more important factor in why many Americans, black and white, have limited access to quality care is economic class. To the extent that health care does vary by race in America, it is because income and wealth vary by race too.
Washington’s ultimate reason for writing Medical Apartheid is to improve the health status of blacks living today. But by presenting a selective picture of the past involvement of African-Americans in medical research, and by claiming, despite ample evidence to the contrary, that they are currently discriminated against by health professionals, she may achieve the opposite of her intended effect. Sowing still more distrust and alienation, her book stands to widen the very “health divide” that she seeks to repair.
