Practice and Protest: Black Physicians and the Evolution of Race-Conscious Professionalism Brian W. Powers, Nancy E. Oriol, Sachin H. Jain Journal of Health Care for the Poor and Underserved, Volume 26, Number 1, February 2015, pp. 73-81 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2015.0002

For additional information about this article https://muse.jhu.edu/article/574199

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HISTORY

Practice and Protest: Black Physicians and the Evolution of Race-Conscious Professionalism Brian W. Powers, AB Nancy E. Oriol, MD Sachin H. Jain, MD, MBA Abstract: Throughout history, Black physicians have been bound by a dual obligation: to pursue excellence and success in their profession, and to leverage their professional stature to improve the condition of their communities. This paradigm of race-conscious professionalism has affected greatly the experience of Black physicians, and shaped their formulation of professional identity. This paper explores the relationship between professional life and racial activism in the Black physician community from the pre-Civil War era until the present. The nature of this negotiation has shifted according to the professional and social dynamics of the era. Before the Civil War, Black physician-activists were forced to relinquish their professional duties in order to engage in activism. In later years, activism emerged as a valuable endeavor in the Black medical community, which offered greater opportunities for activism within the profession. The implications of these findings for contemporary physicians are discussed. Key words: African American physicians, medical history, race and medicine, professional life.

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istories of African Americans in the medical profession have traditionally adhered to one of two main perspectives. One chronicles achievements, such as Charles Drew’s pioneering research on blood plasma.1,2,3 The other documents important firsts, such as the first Black graduate of an American medical college, David Peck.1,2,4 While these narratives have been essential in wresting Black physicians from historical anonymity and establishing their fundamental contributions to American medicine, a focus on discrete milestones has obscured much of the texture and historical evolution of life as a Black physician. America’s complicated and troubling history of racism and race relations has exposed Black physicians to personal and professional challenges distinct from those of their White counterparts. Historian Darlene Clark Hine has argued that across time and industry, Black professionals have been bound by a dual obligation: to pursue excellence and success in their profession, and to leverage their professional stature to help improve the condition of their communities.5 This paradigm of “race-conscious professionalism”6 has affected greatly the experience of Black physicians, shaping The authors are affiliated with the Harvard Medical School [BWP, NEO, SHJ]; Beth Israel Deaconess Medical Center [NEO]. Please address correspondence to Brian W. Powers, Harvard Medical School, 250 Longwood Avenue, Boston, MA 02115; [email protected]. © Meharry Medical College

Journal of Health Care for the Poor and Underserved 26 (2015): 73–81.

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their formulation of professional identity as early as the 1830s.7,8 Here, we explore the relationship between professional life and racial activism in the Black physician community from the pre-Civil War era until the present, outlining the evolution of race-conscious professionalism across four discrete eras—Abolitionism (1835–1865), Building Parallel Institutions (1865–1930), Civil Rights and Desegregation (1930–1965), and Disparities (1965 to Present)—and considering the implications of this relationship on contemporary physicians.*

Abolitionism (1835–1865) In the decades before the Civil War, the medical world was in a state of transition. Rather than being forced into parallel institutions, Black physicians were able to join a mainstream American medical profession that was undergoing its own debate over the nature of professionalism and, as a result, had not yet developed the mechanisms for systematic exclusion based on race.8,9 Race added a complicating factor for Black physicians navigating this tumultuous professional climate, however. At a time when the majority of African Americans were enslaved, these practitioners were well aware of the broader racial realities evidenced by their successes—they were living proof that if given equal opportunities, African Americans were capable of scientific achievement and professional advancement.8,10,11,12,13 This basic truth was the foundation of a strong link between medical practice and racial activism. An astounding proportion of early Black physicians took up practice not only as doctors, but also as ardent activists and abolitionists.8,13,14,15,16 In fact, many of the nation’s first Black physicians—such as James McCune Smith, Martin Delaney, and John Rock—are remembered more for their activities as abolitionists than their historic careers as physicians. For example, James McCune Smith** leveraged his training in science and mathematics to pen a series of influential articles that systematically dismantled pro-slavery arguments and the tenets of pseudo-scientific racism.13,17 These physicians understood that their position as exemplars combined with their scientific credibility placed them in a unique position to advocate for emancipation.8,12,13 Although a career as a physician was ideologically compatible with the themes of improvement and self-elevation that dominated Black activism of the era, sustained engagement with activism was professionally untenable for Black physicians.8 The antebellum medical climate, oversaturated and fiercely competitive as a result of weak *Given the breadth of the subject matter, this paper will focus specifically on the evolution of race conscious professionalism and, as a result, will not attempt to be a full or thorough account of the Black experience in medicine. More thorough and comprehensive treatments of the history of Black physicians can be found elsewhere (for example, see Byrd WM, Clayton LA. An American health dilemma. New York: Routledge; 2000). **James McCune Smith (1813–1865) was the first Black American to receive a M.D. degree, which he earned from the University of Glasgow in 1837. He returned to New York, NY and established a successful medical practice. Later in his life, he became a committed and vocal abolitionist. For more information please see: Cobb, WM. James McCune Smith. Journal of the National Medical Association 1952;44(2):160 and Satuffer, J. The Works of James McCune Smith: Black Intellectual and Abolitionist. Oxford: Oxford University Press; 2006.

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regulation, punished any practitioner who did not dedicate his full efforts to clinical responsibilities.8,9 Early in his career, Dr. James McCune Smith worried that spending several days to attend an antislavery conference would “inflict an injury upon [his] medical reputation which months could not remove.”18 In attempting to forge their identity as physician-activists, McCune Smith and his peers had to choose the avenue to which they would dedicate their focus. Those who engaged heavily in public protest, such as McCune Smith, John Rock, and Martin Delany, were forced to relinquish clinical responsibilities.8,16,17,18 On the other hand, practitioners who placed a premium on professional life, such as James Still and William Peter Ray, limited activism to the local level, or avoided it entirely.8,14

Building Parallel Institutions (1865–1930) The changes to American society brought forth by the Civil War fundamentally altered the nature of race-conscious professionalism. Emancipated Blacks were able to pursue education and professional advancement in a way previously impossible. Institutionalized racism and structural violence remained substantial barriers to success, but the era after the Civil War was characterized by steady growth in Black institutions within and outside of medicine, including primary and secondary schools, universities, medical schools, and Black hospitals.19,20,21 At the same time, however, the unregulated medical climate of the antebellum era was eroding. As the medical profession became increasingly consolidated, measures of institutional credibility such as degrees and licensure became requirements for practice.9 With educational institutions successfully guarding entry into the profession, systematic exclusion of African Americans based on race emerged in a way that was previously impossible.8,9 This was a critical juncture in the history of African American involvement in medicine, forcing the creation of all-Black medical institutions. Since state, local, and national medical associations like the American Medical Association (AMA) refused to accept Black members, parallel organizations such as the National Medical Association (NMA) were born. Many hospitals, especially those in the South, refused to grant admitting privileges to Black physicians, leading to the establishment of all-Black hospitals in several major cities.9,22 African Americans remained excluded from most medical colleges, directly through racist admission policies and indirectly through intentionally restrictive admission requirements, prompting the development of seven Black medical colleges in the decades after the Civil War.9,22,23 The Flexner Report* led to the closure of five of these schools by 1930, but Howard and Meharry endured as fundamental institutions for Black medical education.9,19,23,24 Parallel institutions provided new avenues for reconciling the tension between practice and protest. Instructing aspiring African American physicians at Howard, Meharry, or the other medical schools founded to train Black doctors,19 or working to *The impact of the Flexner report on the African American medical community extended beyond the closing of Black medical colleges. For a comprehensive and nuanced summary of these developments, please see Sullivan LW and Mittman IS. The State of Diversity in the Health Professions a Century After Flexner. Academic Medicine 2010;85(2):246–53.

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improve the health of Black communities by working at all-Black hospitals, addressed the conflicts of race-conscious professionalism within the professional realm, and without jeopardizing professional success. This was a drastic change from the decades before the Civil War, when the nascent Black medical profession was neither large nor consolidated enough to offer such opportunities. A prominent champion of this new model of race-conscious professionalism was Daniel Hale Williams. Not only was Williams a pioneering cardiac surgeon, but he established schools for Black nurses in Chicago and Washington, DC, founded the Provident Hospital in Chicago, and founded and served as the first president of the NMA.25 Williams was a leader in this national movement, but the call to activism took place at the local level as well. Across the North and South, Black physicians helped to train a new generation of health professionals and served to improve the health of Black communities.26,27

Civil Rights and Desegregation (1930–1964) The parallel institutions that flourished after the Civil War did more than lay the foundation for a growing Black medical community. As they matured, Black medical institutions became incubators for racial activism, and foci for organized attacks on segregation and discrimination. The NMA led several concerted, national campaigns against segregation in hospitals, within the medical corps of the armed forces, and within the AMA and state and local medical societies.28,29 William Montague Cobb, editor of the Journal of the NMA from 1949 to 1977, used the journal as a public forum to put forth the NMA’s views on civil rights. He established a regular column entitled the “Integration Battlefront” and, starting in 1957, organized a series of seven conferences on hospital discrimination and the need for desegregation, effectively bringing the issues into the public sphere.30 The focus on desegregation and inclusion by the NMA, Cobb and other Black physician-activists represented a stark shift from the parallelism that defined the activities of physician-activists in the previous era. Strategies honed during these battles over segregation in the medical arena were later used in more global fights for desegregation and equality. Black physicians assumed leadership roles in organizations such as the National Association for the Advancement of Colored People, and were instrumental leaders in catalyzing reforms such as the Civil Rights Acts, hospital desegregation rulings, the Voting Rights Act, and Medicare/Medicaid legislation.27 For example, Robert Smith, a Mississippi physician active in the NMA, formed the Medical Committee for Civil Rights (later the Medical Committee for Human Rights) during 1963 to provide physicians, both Black and White, opportunities to formally engage in civil rights activities, including the March on Washington.31 This pattern of race-conscious professionalism more closely resembled that of the decades before the Civil War. Not limiting their activities to the realm of health care, Black physician-activists focused on the systematic, societal issues that affected their communities. Just as their abolitionist peers had done before the Civil War, they used their positions of power, public stature, and knowledge to lead fights for civil rights and desegregation. But as in the years after the Civil War, a growing Black medical profession provided the venues and capacities to engage in activism without jeopardizing professional success.

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Disparities (1964 to Present) Black physician engagement in racial activism continued after the passage of the Civil Rights Act. William Montague Cobb, for example, continued to be active in the NAACP and served as its President from 1976 to 1982.29 However, as the battles over segregation and civil rights waned, race-conscious professionalism took on a new flavor, once again motivated by the contemporary concerns of the Black community. Desegregation and expanded access to medical care notwithstanding, the gap in health and health outcomes between White and Black communities persisted.30 Addressing and overcoming racial and ethnic health disparities came to define the most recent phase of race-conscious professionalism. Black physicians have been disproportionately represented in the ranks of leadership in the health disparities movement at both the local and national level. From the 1980s to early 2000s, Black physicians used their positions of power and influence to focus the attention of both the public and policymakers on pervasive racial and ethnic inequities in health and health care. During his tenure as Secretary of Health and Human Services, Louis Sullivan increased the racial and ethnic diversity of federal health departments, led a $100 million dollar minority hear care initiative, and called attention to health care disparities through the Healthy People 2000 report.32 Sullivan later chaired the Sullivan Commission, whose 2004 outlined pervasive underrepresentation of Black professionals in health care.33 David Satcher, Surgeon General from 1998 to 2002, continued to direct the federal government’s attention to describing the extent of health disparities, and with funding from Congress and President Clinton led the Initiative to Eliminate Racial and Ethnic Health Disparities.34 The work of these individuals, and others, formed the foundation of the 2002 Institute of Medicine report Unequal Treatment, a definitive and authoritative volume on the extent of disparities in health care, co-authored by several leading Black physicianactivists.35 More recently, Black-physician activists have focused on ameliorating health care disparities. The NMA continues to be a national leader in the disparities movement, most notably through the research and policy recommendations of the Cobb Institute. Hospitals and health systems around the country have created institutes and centers, many of which are led by Black physicians, aimed at reducing disparities. Additionally, individuals such as Risa Lavizzo-Mourey, CEO of the Robert Wood Johnson Foundation, are using their positions power and influence to direct efforts and resources on improving equity in health and health care. This level of engagement parallels the disproportional engagement in racial activism seen among Black physicians in the fights for emancipation and civil rights, and speaks to the enduring, and evolving, influence of race-conscious professionalism in the modern era. Whereas most physicians and physician-groups object to disparities on moral grounds, for many Black physicians the issue is personal. Through their own experiences and those of their friends, families, and communities, many Black physicians have felt the sting of health inequity first hand. These personal trials alter the pull between professional life and racial activism, and result in a stronger draw toward activism than for many of their peers.

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The Future of Race-Conscious Professionalism Several contemporary trends are likely to shape the continued evolution of the role of race-conscious professionalism in the lives of African American physicians. Most notable is the persistence of severe race/ethnicity-related health disparities and underrepresentation of African American students in the health professions. Whereas most other minority groups have seen an increase in representation in recent years, African Americans enrollment has remained stagnant.36 When only 6.3% of the physician workforce in the United States is African American, despite constituting over 13% of the total population, Black physicians are reminded of their exceptionalism almost daily.37 This renders Hine’s “dual obligation” increasingly acute, and introduces concerns and motivations that lie outside the realm of traditional medicine and professional advancement. Amidst thee dynamics, there is likely to be a continued pressure to reconcile clinical practice with political and social activism. At the same time, other forces may attenuate the draw to activism. Recent studies have shown that African Americans graduate from medical school with significantly more debt than their counterparts of other races and ethnicities.37 This financial burden could increase the draw to lucrative subspecialties, and make it more difficult to dedicate time and efforts to non-remunerated activities in the realm of social activism. At this point it is remains unclear exactly how these and other dynamics will impact the lives of aspiring Black physicians, but the nature of race-conscious professionalism will continue to evolve with the professional and social dynamics that underlie the African American experience in medicine.

Conclusion and Implications For over 150 years, race-conscious professionalism has defined the experience of Black physicians, pressuring them to reconcile the competing demands of professional life and racial activism in forging their professional identities. Understanding these tensions can help appreciate the experience of contemporary Black physicians, especially doctors in training and young physicians who are refining their sense of professional identity and career trajectory. This is important context for current initiatives that aim to reverse medicine’s ignoble trend of racial exclusion not only in the ranks of the profession, but in perpetually underrepresented domains such as biomedical research and academic leadership. For these programs to be successful, they must entertain and address the realities of the Black experience in medicine. Furthermore, appreciating the complex relationship between practice and protest as it manifests for Black physicians brings important clarity to the competing motives that other physicians sometimes face. Race-conscious professionalism is not a uniquely Black phenomenon; physicians from any minority background are exposed to the same tensions. Nor is the relationship between practice and protest predicated solely on issues of race and racism. Throughout most of the struggles discussed above, White physicians stood by their Black colleagues in advocating for abolition or civil rights. Today, physicians continue to assume leadership positions in efforts to reduce inequal-

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FIGURE 1.

ity within and outside of health care. It should be no surprise that, in a professional founded upon alleviating human suffering, many physicians will feel a dual obligation between the practice of medicine and social justice.

Acknowledgments The Authors gratefully acknowledge the contributions and guidance of Patrick Rael, PhD, from the Departments of History and Africana Studies at Bowdoin College. Funding/Support: None. Other disclosures: The authors have no potential conflicts of interest to disclose. Disclaimers: The views expressed in this article represent the authors’ views and not necessarily the views or policies of their respective affiliated institutions.

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References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Morias HM. The history of the Negro in medicine. New York, NY: Publishers Company, 1967. Bousfield MO. An Account of Physicians of Color in the United States. Bulletin of the History of Medicine. 1945;17:61–84. Cobb WM. The Black in American Medicine. Clinical Orthopaedics and Related Research. 1999 May;362:12–21. http://dx.doi.org/10.1097/00003086-199905000-00003 Harris MJ. David Jones Peck, MD: A Dream Denied. J Natl Med Assoc. 2010 Oct;102(10):954–5. Hine DC. Speak truth to power: black professional class in United States history. Brooklyn, NY: Carlson Publishers, 1996. Wilkins DB. Identities and roles: race, recognition, and professional responsibility. Maryland Law Review. 1998;57: 1502–95. Morias HM. The history of the Negro in medicine. New York, NY: Publishers Company, 1967. Powers BW. Free Black Practitioners and the Rise of the Medical Profession. Presented at: 32nd Annual Meeting of the Society for Historians of the Early American Republic, Rochester, NY: 2010. Starr P. The social transformation of American medicine. New York, NY: Basic Books, 1982. Brown WW. The black man, his antecedents, his genius, and his achievements. New York, NY: Thomas Hamilton, 1863. Delany MR. The condition, elevation, emigration, and destiny of the colored people of the United States. 1852. Reprint, New York: Arno Press, 1968. Blight DW. In Search of Learning, Liberty, and Self Definition: James McCune Smith and the Ordeal of the Antebellum Black Intellectual. Afro-Americans in New York Life and History. 1985;9:7–25. Still J. Early recollections and life of Dr. James Still. Philadelphia, PA: JB Lippincott, 1877. Porter DB. David Ruggles, an apostle of human rights. J Negro History. 1943;28(1):23– 50. http://dx.doi.org/10.2307/2714783 Rollin FA. Life and public service of Martin R. Delany: Subassistant Commissioner, Bureau Relief of Refugees, Freedmen, and of Abandoned Lands, and Late Major 104th U.S. Colored Troops. 1868. Reprint, Boston, MA: Lee and Shepard, 1883. Buzby JH. John Stewart Rock: teacher, healer, counselor. Salem, NJ: Salem County Historical Society, 2002. Cobb WM. James McCune Smith. J Natl Med Assoc. 1952;44(2):160. James McCune Smith to Gerrit Smith, May 12, 1848 in Satuffer, J. The Works of James McCune Smith: Black Intellectual and Abolitionist. Oxford: Oxford University Press, 2006. Harley EH. The forgotten history of defunct black medical schools in the 19th and 20th centuries and the impact of the Flexner Report. J Natl Med Assoc. 2006 Sep;98(9): 1425–29. Anderson JD. The Education of Blacks in the South, 1860–1935. Chapel Hill, NC: University of North Carolina Press, 1989. Gambell VC. Making a place for ourselves: the black hospital movement, 1920–

Powers, Oriol, and Jain

22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.

81

1945. Oxford: Oxford University Press, 1995. http://dx.doi.org/10.1093/acprof:oso /9780195078893.001.0001 Byrd WM, Clayton LA. An American health dilemma. New York, NY: Routledge, 2000. Sullivan LW. “Managing the unmanageable” the U.S. Department of Health and Human Services, 1989-1993. Trans Am Clin Climatol Assoc. 2002;113:78–88. Savitt T. Abraham Flexner and the Black medical schools. 1992. J Natl Med Assoc. 2006 Sep;98(9):1415–24. Link EP. The civil rights activities of three great negro physicians (1840–1940). J Negro History. 1967;52:169–84. http://dx.doi.org/10.2307/2716112 Savitt TL. Race and medicine in nineteenth- and early-twentieth-century America. Kent, Ohio: Kent State University Press, 2007. Byrd WM, Clayton LA. An American health dilemma. New York, NY: Routledge, 2000. Hine DC. Black professionals and race consciousness: origins of the Civil Rights Movement, 1890-1950. J Am History. 2003;89(4):1279–94. http://dx.doi.org/10.2307 /3092543 Baker RB, Washington HA, Olakanmi O, et al. African American physicians and organized medicine, 1846-1968: origins of a racial divide. J Am Med Assoc. 2008;300:306– 13. http://dx.doi.org/10.1001/jama.300.3.306 Lear WJ. William Montague Cobb. Am J Public Health. 2002;92(2):193. http://dx.doi .org/10.2105/AJPH.92.2.193 Dittmer J. The good doctors: the medical committee for human rights and the struggle for social justice in health care. London: Bloomsbury Press, 2010. Sullivan LW. “Managing the unmanageable” the U.S. Department of Health and Human Services, 1989-1993. Trans Am Clin Climatol Assoc. 2002;113:78–88. The Sullivan Commission on Diversity in the Healthcare Workforce. Missing persons: minorities in the health professions. Washington, DC: The Sullivan Commission, 2004. Satcher D. The Initiative to Eliminate Racial and Ethnic Health Disparities is moving forward. Public Health Rep. 1999 May–Jun;114(3):283–7. http://dx.doi.org/10.1093 /phr/114.3.283 Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press, 2002. Iglehart JK. Diversity dynamics—challenges to a representative U.S. medical workforce. New Eng J Med. 2014 Oct;371(16):1471–4. Dugger RA, El-Sayed AM, Dogra A, et al. The color of debt: racial disparities in anticipated medical student debt in the United States. PLoS One. 2013 Sep 3;8(9):e74693.