Black and Blue. John Hoberman
people is also accepted because it can serve the emotional interests of both whites and blacks. Even racist whites have found opportunities for feeling magnanimous about their concern for black health. The white Christian masters of antebellum slave plantations, for example, saw themselves as medically conscientious guardians of their black wards, even if their primary motive was to maximize the efficiency of the labor force. The mistaken idea that these slaves had enjoyed excellent health under the supervision of their white overseers became a staple of post-emancipation racial mythology.
The severe health problems that afflicted the liberated and impoverished black population following emancipation were now interpreted as one more pernicious effect of the freedom that had created social conditions in which the allegedly filthy hygienic habits and disease-spreading sexual licentiousness of black people could flourish. Black health problems became a major source of racist resentment. As the Journal of the American Medical Association commented in 1909: “In former times they lived a healthy out-door life, and, if for no other reason, in the commercial interests of their owners they were well fed, clothed and lodged. In the last half-century, however, they have left their open-air life and gravitated into the cities, without any one to overlook their physical well-being. Their happy-go-lucky disposition has led them to ignore all principles of sanitation—even if they had an opportunity of becoming acquainted with them….”7 The medical misery of black people was rationalized as a natural consequence of the “disposition” that had brought about a state of degradation for which whites bore no responsibility. The only responsibility incumbent upon white health authorities was to do everything possible to make sure that unhealthy blacks did not infect the white population.
A half century after this JAMA commentary, Dr. Robert A. Hingson of the Case Western Reserve University School of Medicine in Cleveland told the readers of the nation's only black-edited medical journal that the very survival of African Americans had been made possible by “the humanitarian and scientific ministrations of a compassionate nation,” in which the (white) medical profession had played a principal role. This anesthesiologist's report on black and white mortality during obstetrics and surgery suggests that he was more compassionate than most of his peers toward the plight of the black patients who were dying under anesthesia in much greater numbers than their white counterparts. He even quotes Franklin D. Roosevelt on the unmet needs of the nation's poor. At the same time, he appears to have been oblivious to the entrenched medical racism of his own profession, which he believed bore no responsibility for the medical problems of his black patients. “We shall leave it to the sociologist to determine the damage the scars of history have left upon the black man,” he writes. Separating the medical profession from the damage done to black people in this way expresses a tenacious and self-protective institutional instinct that still prevails over the self-critical approaches to the racial health disparities that have emerged since Hingson pointed to the “racial melancholia” that “all physicians, and especially all psychiatrists” recognized as a syndrome affecting the black population in the 1950s.8 The persistence of this self-defensive posture among white physicians is evident both in the medical literature and from other sources that describe dysfunctional relationships between white doctors and black patients.
The desperate conditions created by urban poverty have ensured a constant flow of disordered or self-destructive black patients to emergency rooms staffed by white and foreign-born physicians who draw their own conclusions about racial character: “I did a year of training in general medicine at a university-affiliated, inner-city hospital,” says one doctor, “and it was the worst year of my life. The place was a snake pit.” Constant exposure to the self-destructive behaviors indulged in by what appear to be disproportionate numbers of an ethnic group can have a devastating effect on how doctors feel about such people: “The patients were there either because they abused drugs, or had an illness like diabetes that they wouldn't take care of, or were alcoholic, or had gotten beaten on the head while they were robbing a store. Almost all of them had self-inflicted illness. It's very hard to get real sympathetic with people who make themselves sick.”9 These scenarios, in which disorderly, recalcitrant, and criminal individuals demoralize the physicians who attempt to help them, can reinforce in doctors' minds some deeply rooted ideas about intractable social pathologies from which some blacks seem unable to escape.
Negative images of black patients among white physicians have not been limited to the most deranged or irresponsible black patients who show up in the nation's emergency rooms. American medicine's traditional strategies for minimizing white responsibility for black health problems have always included a more general denigration of the intelligence and emotional stability of blacks who seek medical care. During the first half of the twentieth century, white doctors' impatience with “the Negro patient” became a familiar theme in the medical literature. “He is an unwieldy, unwilling, unsatisfactory patient,” JAMA reported in 1899.10 The principal “obstacles to negro practice,” according to a 1908 JAMA extract from the Mississippi Medical Monthly, were “a delight in fooling the doctor if possible; an utter inability to understand and follow directions; the interposition of outsiders, who dissuade from obedience to instructions; the undying fondness for filling his belly; his morbid dread of water; his poverty and filth, and fondness for night prowling and sexual excesses.”11 Over the next half century a medical folklore made up of many such assessments of “the Negro patient” appeared in the medical literature. These accounts presented blacks as particularly exasperating examples of what came be known as “noncompliant” patients who lack the intelligence or the self-discipline to follow doctors' orders.
The other and ostensibly different type of “Negro patient” who provoked medical commentary during the era of Jim Crow was the docile simpleton who displayed a striking medical naïveté or a slavish version of compliance that evoked the submissive Sambo stereotype. White doctors commented on his “optimism” or stoicism or “the absence of worry” in such people. “Complications are accepted as being foreordained and unavoidable. The majority of them bear pain, impairment of function, and the destruction of tissue with little complaint or apprehension,” two urologists write in 1935.12 “His idea of the medical world,” a syphilis expert wrote in 1910, “is that there is a remedy for every disease and that all that the doctor does is to select the right medicine.”13 Dr. R. A. Vonderlehr, a participant in the Tuskegee scandal, commented in 1936: “The average negro is a most congenial person and he has a tendency to agree with almost everything that one wishes him to agree with.”14
A sometimes fatal consequence of this disconnect between doctor and patient has been a tendency among blacks to neglect symptoms and delay visits to the doctor. “The average negro,” an Arkansas doctor wrote in 1926, “does not call for medical aid until he thinks himself seriously ill. He first tries all kinds of charms, herbs and teas, thereby cheating himself of his best opportunity of recovery.” This doctor also notes “much confusion in medical terms. They have no such words as stools, urine, etc., in their vocabulary.”15 A cardiologist comments in 1927 on how differently blacks and whites describe chest pain: “That which the white man speaks of in a striking, graphic manner, the negro refers to as 'misery in the stomach' or 'misery in the chest.'”16 Speaking a medical language of their own, such black patients appear to have received little sympathy from the white physicians who could not understand them. Today such problems persist but are wrapped in a depersonalizing jargon that speaks of “the complex interaction between physician and patient” or “problems in communicating with their physicians.” This terminology can make physicians and patients equally disoriented participants in a process that may seem beyond remedy or the responsibility of either party.
Comments about the black patient's tendency to ignore symptoms and delay treatment have appeared in the medical literature for the last century. But the tone in which such behaviors are described in today's medical journals has changed from one of impatience and contempt to a more politically correct humane understanding of circumstances and motives. Sarcasm and exasperation have been replaced by the somber (and often stultifying) idiom of public health professionals and their recognition of sociological factors bearing on black health problems that offer an alternative to simply blaming the victims.
In summary, the American medical establishment has never mobilized on behalf