Lecture Thirteen: The Flexner Report and African American Physicians

Two pages of the Flexner Report condemned African American medial providers, hospitals, and patients to decades of struggle.  Relying on the AMA's medical-racial script, and playing into the atmosphere of Progressive eugenics, Flexner's chapter devoted to the African American medical situation flowed from what united white orthodox providers and fed the corporate impetus that would finance the new health care system.  Essentially, Flexner sought to close all but two African American medical schools, condemn graduates from those schools to being sanitation workers who would assure that African Americans don't spread disease to whites, and deflect corporate funding elsewhere.  The results were disastrous.

Transcript

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You'll see that the readings this week are really short. Um, one is just a chapter from the Flexner Report, chapter 19. It's two pages long. Probably one of the more impactful two pages that have ever come out of a report in terms of its effect on the African American medical community. And another one is also a very one-page uh article from a woman, uh, African-American woman who graduated soon after the Flexner Report, and she just very briefly says what she went through. So this chapter is kind of amazing because all these years the AMA has concealed its medical racial script. It used it to consolidate white doctors, it used it to assure that no African American doctors uh became members, it assured it to uh push research that focused on racial difference um and to push public health measures that focused on uh isolating uh people of color. And this was uh not just African Americans, but uh Chinese, Japanese, Mexicans, uh Jews, Native Americans, um many, many books uh written about uh these type of activities that some of which were already occurring in the late 1800s. So why'd the AMA do this? Well, of course, the AMA didn't write the report. It is curious that this chapter found its way in the report uh expressing what the AMA had covertly been uh adhering to for all these many decades. But to Abraham Flexner, um, it was crucial to carve out a niche for African American doctors, and that niche was not going to be in mainstream Orthodox medicine, as this chapter clearly states. First of all, all but two African-American medical schools were told to shut down immediately and would no longer be able to graduate licensed doctors. One of them hung on for a few years, but essentially they did shut down. Howard and Mahirney, the two oldest African-American schools, Howard being still financed by the federal government, Mahirney still having a fairly decent uh philanthropic group that kept it alive, uh, were allowed to exist, but not necessarily as regular Orthodox medical schools as described in the report. By placing these two schools outside the orbit of what a proper school was going to become after this report was published. Remember, research institutions, full-time faculty, a formulaic curriculum, um, all overseen by uh the AMA and its uh Committee of Education. These schools weren't going to be any of those things. So by insisting on the closure of all but two African-American schools and placing these two schools outside the orbit of the AMA corporate alliance, the report assured that African-American doctors would remain isolated. Their alterity was codified by a report that essentially was a manifestation of the medical racial script, stating that, quote, the upbuilding of Howard and Maherney will profit the nation much more than the inadequate maintenance of a larger number of schools, unquote. Flexner calls on these two schools to focus on not training African-American doctors in the German sense, these research doctors who follow a scripted protocol, but rather African-American hygiene workers. That's what he's looking at. And their main job is to care for African Americans and to keep disease, black diseases away from white people. He called for corporate philanthropies, the very ones that were only paying for these research institutions to help these schools survive because he felt it was important. Quote, if at the same time these men can be imbued with a missionary spirit so that they will look upon the diploma as a commission to serve their people humbly and devotedly, they may play an important part in the sanitation and civilization of the whole nation, quote. That's what he wanted the corporate institutions to support. And he wrote, quote, the practice of the Negro doctor will be limited to his own race, which in its turn will be cared for better by good Negro physicians than by poor white ones. He then stated that, quote, not only does the Negro himself suffer from hookworm and tuberculosis, he communicates to his white neighbors. The Negro, therefore, must be educated not only for his sake, but for ours, i.e., white people, because he has the tremendous importance that belongs to a potential source of infection and contagion. A well-taught Negro sanitarium will be immensely useful. An essentially untrained Negro wearing an MD degree is dangerous. That says it all. This is what the AMA has been pushing for, and this became effectuated by the report and ultimately by law. So essentially, this chapter created a dual medical system, one that established expansive research-based institutions, fed and beholden to the AMA and foundational funding, and then a tiny bastion of African American medical education that sat on a very precarious island. This became the crux of the report's mixed messaging to African-American schools and foundations that funded them. Would graduates from these two schools gain an MD, be eligible for licensure, have an opportunity to be part of mainstream medicine, or were they destined to be something different? And would corporate foundations, whose goal was to promote a medical research behumoth in American medical schools, help fund the two remaining schools like Flexner was asking them to do, knowing that they would not generate a profit for them. None of this was well delineated in the report. If the Flexner Report in total was a disciplinary tool that we can see through the Foucault lens, disciplinary tool that essentially created a unified medical class at if they followed the rules and did exactly what they were told. We know it was disciplinary that way, but it certainly was even more disciplinary for the African-American doctors who by this time had begun to flourish. You can see this as a very overt expression of racial capitalism, whereby the AMA united Orthodox white male doctors under one rubric that received new funding and prestige, higher salaries, and all the blessings of corporate money, while relegating African-American providers to a walled-off alterity that stood in opposition to the unity of white Orthodox medicine. I mean, this is a biopolitical disciplinary tool seeking to expunge the very dangerous healers and African-American bodies from the mainstream that the AMA have been calling for forever, however quietly. And similarly, to prevent African-Americans from spreading their contagion and their biology to whites. Remember, this was also a eugenic text. And the idea that we needed to wall off these other races was because of eugenic science that stipulated that the only way for the white race to triumph was to keep the genes from other races away from whites. Keep the races separate. Flexner actually tried to get corporate funding. He set up a program through the Rosenwald Foundation, Julius Rosenwald was a founder of Sears. And he uh along with Fechner, Flexner created a program to help uh train uh African-American medical school graduates through a fellowship that would help them learn laboratory science. But of course, this is not exactly what Flexner wanted. And in the end, because a lot of these uh people that they recruited, these African-American students, still had to work, still were more interested in clinical work than laboratory work, uh Rosenwald withdrew his money, um, citing the fact he wanted to fund quite quote, men who are willing to devote themselves to research work, who are fitted to take positions in the leading laboratories of the country, which is not what Flexner or any other people on the committee desired. Flexner responded that, quote, it was in our minds that these graduates would go among their own people where their problems must be solved, namely in the South. This discordance between what the corporate funders wanted and what Flexner was looking to led to a crisis in funding for these schools. And a crisis as to what graduating from these schools even meant. Flexner would actually spend much of his life assuring that these two schools survived. Um, but the AMA and corporate allies, they had no such allegiance. They put Mihiri on probation multiple times and threatened to shut it down. Um, the focus in the AMA clearly was on white male doctors, and it was not going to spend any time uh worrying about the fate of African-American schools, despite the fact that Flexner wanted this little niche. After Flexner, about 10 African-Americans graduated from standard medical schools a year, and about 90 from these two African-American schools. They were all given medical licenses with a stipulation that they would only practice in African-American communities and African-American hospitals or no hospital, because in many communities, especially in the South, no African-American was allowed to practice in any hospital. Um, and they had to follow the rules of whatever local medical society existed. Local medical society, by the way, that they were not allowed to join because they were still blocked from joining those or the AMA. Um, for the next hundred years, the number of African-American doctors did not increase. And the ratio of African-American doctors to the African-American population um just grew larger and larger, and there was a true lack of uh African-American professional class until um uh the 1960s started to change that with medical civil rights. Between 1903 and 1934, philanthropic foundations donated over $150 million to primarily white medical schools. You know, we're seeing $10 million do this one, $10 million do this one. Um, Rockefeller Foundation archives show that while declaring that, quote, the provision of adequate facilities for the proper training of Negro physicians is urgent, unquote. The general education board of the foundation donated only $125,000 to Mahiri and $250,000 to Howard, far, far lower than other schools. In those same years, Yale received half a million, Chicago one and a half million, Johns Hopkins, two million. Um and and those numbers didn't just go away. Uh they were getting numbers like that every year for quite a while, while the foundations were basically turning their backs on the African-American schools. Flexner even attacked the AMA several years later, calling it, quote, the advertising center in medical education, which for years tried to make the world think that Chicago was the medical center of the country, unquote, misusing corporate funds for its own benefit. Yes, that was the purpose of the very report that Flexner wrote, to put the AMA in the driver's seat, and their driver's seat was not going to play the game that Flexner wanted with African-American schools. When the AMA started trying to censor both these schools, um, not only did Flexner fight back, but the man who actually led the uh attempt in the Carnegie Foundation to create this report, who is Henry Purchett, he fought back too. Um and he said, you can't be grading these schools, they they don't belong in the same grading system as white schools that are making all this money through corporate foundations. As one historian wrote, quote, Pritchett came to understand that private profit, not the public interest, was the main goal of the American Medical Association. Pritchett believed that if left to own its own devices, the AMA would destroy all medical education for African Americans. Pritchett, who worked for the Carnegie Foundation, appealed to Andrew Carnegie for help, saying that these schools are gonna die. Uh but you know, Carnegie was a, like Rockefeller, a big eugenicist, and he wrote back in a letter I found that said, quote, if we start helping medical colleges for colored people, we cannot discontinue, unquote, stating that the African-American medical schools would become dependent on whites, just like African Americans were dependent on whites, and this was very dangerous through a eugenic lens. Um Flexner believed that the two African-American medical schools, quote, were caught in a power squeeze between, on the one hand, two large foundations that put white medical education needs above black, and on the other hand, a powerful medical organization, the AMA, that refused to recognize the special needs of African-American medical schools and African-American physicians. And this binary language should not have shocked anyone. I mean, this this two-page chapter was the medical racial script that had been put together in the colonial times in a nutshell. The two prongs of that script. One, that African Americans were biologically different, they were a unique species and were prone to diseases that they could infest into the white population. And number two, African-American providers were essentially dangerous and unqualified and should not be allowed to practice medicine. See, even when people graduated, when students graduated from these schools, one of the criteria that this report created was that you had to do a one-year internship. Now, mind you, this was invented by Osler. Osler believed that doctors should um graduate and then go into a hospital and get intensive training and then lifelong learning. Remember, Osler was a believer in lifelong learning. Medical school is just the beginning, and medical school is all about seeing a lot of patients and then learning about their diseases, not the other way around, as the Flexner model was, which was learning about a lot of diseases and then seeing a couple patients. Absolutely the opposite of what Osler wanted. Um, but you know, again, this was in many ways um the one thing that Osler contributed was that you do a one-year internship. The problem is it had to be done at an AMA-approved hospital, and all of them were white. They were white hospitals. And as the short article in their states, a lot of African-Americans were simply not allowed to do the internship. Without the internship, you couldn't be licensed. And and there were um workarounds that were created so that most of the people who graduated, these hundred uh medical students, did eventually find their way to get licensed. But just for an example, um, even as more hospitals started to accept small numbers of African Americans, let's jump ahead to 1927. At that point in the entire country, only 14 hospitals offered spots to African-American medical graduates. And at that time, of the approximately 100 African-American graduates that year, 70% were able to find some type of internship, which was certainly higher than what happened immediately after the report when Isabella Vanderbol's article was written. So, what did the African American medical class do? I mean, they they had been thriving, they had their own national organization, they had state organizations, they they were actually doing quite well at this point. Um they started working with some other corporate foundations and they tried to build up an infrastructure that would allow them to continue to practice medicine. For instance, uh several leaders, especially in the National Medical Association, worked with several um funding sources, uh, the Rosewal, the same Sears Foundation, and also the Duke Endowment, facilitated the construction of African-American hospitals. And black wings added to white hospitals, where African-American doctors can continue to take care of African-American patients and also get trained in their internship year. Tuskegee Hospital, which is well known for the Tuskegee syphilis experiment, which we'll discuss in the last chapter, last lecture, um, is one such hospital that was created from this funding. Uh, again, not Rockefeller and Carnegie. There are other sources. And uh Rosenwald gave uh uh the NAACP two and a half million dollars in the 1920s to build this hospital. Initially, this hospital fell under white leadership, but many in the ANMA pushed back, and ultimately the hospital was run and staffed by African-American professionals, although still beholden to the dictates of its white sponsors, who constantly asked for reports and constantly fired presidents and other leaders if they didn't like them. W.E.B. Du Bois, who um was not a fan of these segregated institutions, wrote in 1923, quote, the only decent method would have been to have placed this institution in the law-abiding north where it belongs. And even now, despite the fact that these millions of dollars of brick and equipment have been stuck in the morass of the Black Belt, the best way out of the mess would be to tear the hospital down and rebuild it within the confines of civilization, unquote. But it's unlikely that even in the North, doctors could surmount the medical racial script that was now imprinted on the medical landscape and reading through a lot of records. There were constant fights, for instance, in New York, about the ability of African-American doctors to work in hospitals that had been previously taking care of African-American patients and allowing African-American doctors. It was almost like this was a step backwards. It's interesting, too, that the National Medical Association, the NMA, had a very mixed reaction to the report and its aftermath. I mean, on the one hand, it gained incredible importance among the African-American community. Every African-American doctor was going to benefit from joining the National Medical Association and having a community that basically had been stripped away. But on the other hand, you really didn't see much criticism coming out of the NMA about all this stuff that was now going on as a ramification of the report's racial language. Um, because really the NMA was a classic orthodox medical institution. And rather than wanting to fight the report and all it it advocated, NMA leaders wanted to be part of this. They wanted to be part of the German medical system, they wanted to have research facilities. You know, they they wanted to get rid of quack doctors, which they considered not them. In fact, right around the time of the report, the NMA created its own um survey of African-American schools and deemed most of them to be deficient, you know, because in many ways mirroring the AMA survey. And one of the leaders of this, uh uh, Dr. H. F. Gamble, who is the NMA's educational director, wrote letters to these schools and said, Look, you guys got to fix yourselves up. It it really remember, the NMA was all about Booker T. Washington method of self-improvement. Um, you have to exist segregated from the white community and be better than them to survive. That's kind of what the message we see. And I read through all these NMA um uh journals for these years, and this was the message. The the one thing that several of the most established NMA thinkers and writers said is do not blame this on racism. It has nothing to do with racism, it's about our own deficiencies. The NMA did appeal to the press and said, look, in one editorial they wrote that the NMA remained in sync with the AMA's mission of reforming healthcare, hoping to, quote, present a unified picture of and give voice to a class of doctors who saw themselves as new Negroes, unquote, equally devoted to progressive science and reform as their white colleagues. And and again, this this was an Attempt to join rather than oppose. John Kenney, one of the most prominent NMA members and one of its founders, quote, applauded Flexter's mandates of modern facilities and laboratories for the school. Another editorial said, quote, the Carnegie Foundation report on medical education continues a source of much comment, both favorable and adverse. But the only words adverse that they talked about were that they needed to have more African-American doctors. Quote, the American Medical Association is a great society, has done great good to the profession and is publishing a great journal. The reorganization perfected some years ago was a gigantic undertaking to energize and focalize the scattered powers of the profession. As a lover of the profession and in an interested but unbiased speculation, the journal, the NMA, would like to see the warfare cease between white and black doctors. In other words, we applaud what the AMA is doing. We're with you guys, but the AMA never responded and never would. Not until 2008, when they offered an official apology that garnered a lot of attention, did they actually apologize for anything they did? And thus rather than attack the AMA, a lot of the articles and editorials in the NMA Journal were there to show that the African-American middle class was not what the Flexner Reports, chapter 19, described it as. That these were doctors at the same caliber as the best white doctors. And that's what they wanted to show. In the 1911 journal editorial, which was the year that this report came out, wrote, quote, Any man who judges the Negro of today by the black mammies, piccadillys, and lazy lads of the past will learn his to his humiliation that he is woefully ignorant. The Negro of today demands a man's place among men. He's willing to serve, but will not be subservient. So the NMA kind of took this reality and went with it. And what would they do? They wrote articles uh trying to become part of this new program, extolling the virtues of African-American doctors who clearly deserved it. Um, but then but also had a pivot and realized okay, if we are not going to be part of mainstream medicine, we have to help create an alternative medical world, even more so than during the error of Jim Jim Crow, and that was fairly easy to do. Again, John Kenney wrote a year after the Flexner report. I do not say let us have more medical schools. The existing medical schools meet our necessary demands. They're doing great work. Let us strengthen them until they are second to none. But I do say let us have more hospitals and nurse training schools, more well-trained physicians and nurses, which was a theme throughout the journal. Probably the most prolific and I think eloquent writer in the journal of the National Medical Association, C.W. Roman, in a piece called Self-Adjustment, wrote, quote, The conclusion is plain then. If we are ever going to get in harmony with our race, our country, our climate, and our environment generally, we must adjust ourselves. For the externals are like the tide of the Pontiac Sea that keeps its due course ever flowing and ebbing, unquote. His message is clear. Don't push back, but rather work within the boundaries set up by this new reality. Without a doubt, there is now a caste system in American medicine. The top were white male physicians, the bottom were black physicians, and the middle were the various other scattered races and women who had a bigger place at the table than African-Americans, but also did not have a table of their own, unlike the African Americans. It's interesting, that's the primary difference. African Americans had already established a pretty viable healthcare infrastructure during the era of Jim Crow, and they were able to use that as well as some corporate funding and the mixed messaging of chapter 19 to create a new system. But as we'll see in our concluding chapter, without power, which the African-American medical class completely lacked now, without power you could be, you could not be there when you need to to defend the African-American community. And you may even be forced to take actions that ultimately harm the African American community, which is exactly what happened. And um unfortunately that did not change until the 1960s. So we'll conclude by talking about uh very briefly the legacy of Flexner, both in terms of the healthcare system we have today, and just also I want to talk about how it affected some aspects of African American care, um, because that is so important. And um we will get to that next.