CONCLUDING POSTSCRIPT:
IMPLICATIONS FOR THE UNITED STATES

The South African Truth and Reconciliation Commission's investigation of the health sector under apartheid has laid bare the long record of pervasive and institutionalized racism, segregation, limitation or outright denial of access to medical care, gross violations of human rights and willful abandonment of the ethical commitments of medicine. No industrialized nation in the last half century has so deliberately initiated and so long sustained a system with such massive effects on the health and life expectancy of its own population. But the scale, intensity and rigidity of the apartheid system should not obscure the fact that health sector racism and its attendant human rights violations are not unique to South Africa. Few nations are immune. To examine many aspects of the South African record is, for example, to find striking parallels to the health sector record in the United States—and not merely in the distant past. In many ways, the South African and American experiences illuminate each other, and such comparisons carry implications for both societies. It seems appropriate, therefore, for the American participants in this joint venture with the Truth and Reconciliation Commission to offer a brief review of their own national experience of human rights in health care, and to consider it in the light of South Africa's current efforts at transformation.

Most such reviews begin with a reference to the federally sponsored Tuskegee Syphilis Study, in which for 40 years some 399 black men in Alabama were deliberately and secretly denied effective treatment in order to "document the natural history of the disease." (The natural history of syphilis infection had already been thoroughly established; the underlying—and false—racist premise was that blacks were biologically different, and so the natural history might be altered). In the twenty-five years since its public disclosure, as medical historian Vanessa Gamble notes, the Tuskegee study "has moved from being a singular historical event to a powerful metaphor. It has come to symbolize racism in medicine, misconduct in human research, the arrogance of physicians, and government abuse of black people."¹

As Gamble and many other historians of medicine have shown, however, Tuskegee merely extended a legacy of race-based human rights violations in medicine that began more than two centuries earlier with the use of slaves for often brutal medical and surgical experimentation. (One physician described "research" in which he performed a total of thirty surgical procedures on a slave woman—without anesthesia).² Antebellum medical journals, especially but not only in the southern United States, published numerous pseudoscientific articles containing the usual derogatory stereotypes of blacks as biologically different, intellectually inferior, and emotionally labile; these implicitly justified slavery as a necessary and essentially benign institution.³ Not even death afforded an end to abuse. The bodies of many blacks (often stolen from graves) were shipped to medical schools for use in anatomy demonstrations and dissections.⁴

The Civil War and the Emancipation Proclamation ended the total dehumanization of blacks in the South, but the political freedom of the brief Reconstruction period was rapidly replaced by disenfranchisement in the South and by pervasive de jure and de facto racial segregation—including the health sector—in both North and South. In health care as in education, housing, urban and rural infrastructures and other areas, facilities and resources were separate and unequal; in the southern states, Jim Crow laws and vigilante terrorism by organizations such as the Ku Klux Klan maintained a social order strikingly similar to that of apartheid. Slavery was succeeded by the sharecropper system, a form of economic peonage; in the north, people of color were excluded from most skilled occupations.

Most hospitals in the United States either refused admission to blacks or admitted them only to segregated and inferior wards, often in the basement. No blacks were admitted to medical schools in the South, and only a handful in the North. Nor was the racism of the last half of the nineteenth century directed only at people of African descent; in a striking precursor of South Africa's forcible relocations and the creation of artificial homelands, the Native American population was decimated and confined to reservations. In the West, harsh restrictions on immigration and systematic discrimination were directed against Chinese and other Asians.

There was, nevertheless, some progress in the health sector. Several medical schools were established to train black physicians. A small network of separate black hospitals developed, although it was not until 1891 that the first black-controlled institution, Provident Hospital in Chicago, opened. Since many state medical societies refused membership to black physicians—thus effectively denying them hospital staff privileges as well as membership in the American Medical Association—minority physicians formed the interracial (but overwhelmingly black) National Medical Association, formed for some of the same purposes that were to inspire South Africa's NAMDA decades later.

Well into the twentieth century, discrimination and segregation by race remained characteristic of the health sector. The American eugenics movement in the 1920s and 1930s produced a new burst of pseudoscientific racism, and engendered eugenics laws enabling forced sterilization—carried out primarily though not exclusively against blacks—that remained on the books of some states well into the 1970s. After World War II, a massive government-funded program to build hospitals, the Hill-Burton legislation, permitted (though did not require) the construction of separate white and black facilities.

As late as the early 1950s, one survey found that while 83 percent of general hospitals in the North offered patient care on an integrated basis, only 6 percent of Southern hospitals admitted African-Americans without restriction; of the remaining 94 percent, 33 percent did not admit any African-American patients, 50 percent had segregated wards, and the remainder had modifications of segregated patterns. In the South, only 6 percent of hospitals offered internships and residencies, and only 25 percent provided medical staff privileges, to African-American physicians, usually restricting their work to the segregated wards for black patients. In these institutions, racial segregation required separate blood banks, linens, bathrooms, cafeterias and waiting rooms. The situation was little better in the North, where only 10 percent of surveyed hospitals accepted African-Americans as interns and residents, and only 20 percent offered staff privileges.⁵

Forces for change in the health sector were gathering, however; interracial organizations such as the Association of Interns and Medical Students (AIMS) and Physicians Forum supported efforts by the National Association for the Advancement of Colored People (NAACP), the National Medical Association, the National Urban League, and the Congress of Racial Equality (CORE) to end segregation and discrimination in hospitals. But it was not until the great direct-action civil rights movement began in the 1960s, with nonviolent sit-ins, freedom rides, marches, boycotts and mass protests under the leadership of the Student Non-Violent Coordinating Committee (SNCC) and the Southern Christian Leadership Conference headed by Martin Luther King, Jr., that massive change occurred. One result was congressional passage of the Civil Rights Act of 1964, which established a national priority against discrimination in the use of federal funds and provided for enforcement by withholding funds or "by any other means authorized by law." An intensive campaign involving the government's judicial, legislative and executive branches, using the threat of cutting off Medicare certification and all other federal funds to noncompliant hospitals and clinics, that was supported by the American Hospital Association and other professional organizations, effectively ended most formal racial segregation and discrimination in health sector facilities, although powerful differences in access to care, because of economic and geographic disparities, continued.

The civil rights movement (and the passage of the Voting Rights Act in 1965, which tempered but did not totally end the South's strategy of "massive resistance" to integration) focused national attention on the problems of hunger and poverty, disproportionately affecting (but not limited to) people of color. The resulting governmental "War on Poverty" implicitly recognized that the health status of America's minority populations, characterized by huge differences in infant mortality rates, burdens of acute and chronic disease, and life expectancy, could not be altered by health care change alone but required the reduction of inequity in incomes, education and economic opportunity and protection against dangerous social, biological and physical environments. Over the next thirty years, despite assaults by conservative forces on these measures and on "affirmative action" programs, the African-American middle class quadrupled in size; at the same time, the increasing urban segregation of poor people of color limited health progress. One study in the 1990s demonstrated that life expectancy for adult males in central Harlem was lower than in Bangladesh. While infant mortality rates for both blacks and whites steadily improved, the gap between them remained as great as ever. And although African-Americans comprise approximately eleven percent of the U.S. population, their number includes only three percent of the nation's physicians.

Racism aside, and despite the worldwide attention to the crimes of Nazi doctors and the publication of the Nuremberg Code in 1948, major attention to problems of medical ethics, accountability in research and treatment, and human rights in the health sector did not surface until the mid-1960s. Even then abuses like the Tuskegee study and the testing of contraceptive and other drugs primarily on third-world populations did not end immediately. Today they are secure aspects of medical and other professional education, and there are careful and institutionalized mechanisms for the oversight of research; nevertheless, racial and gender disparities in the allocation of resources for diagnosis and treatment continue to occur.

South Africans will recognize in this account the many parallels to their own experience, as well as some crucial differences. Change in the U.S. followed a slow curve over more than two centuries; change in South Africa has been far more abrupt. In the United States, there was an existing egalitarian and democratic social contract—the Constitution, including the Bill of Rights—and the struggle was, and is, to apply it fully to an oppressed minority. In South Africa, a majority was brutally repressed by a small minority wielding the social contract called apartheid. But some implications seem clear. Real change in South Africa's health sector will require intensive and continuous effort by every branch of government, spurred by an informed and demanding population. Human rights protection and professional accountability require secure and institutionalized mechanisms, and cannot be left to the health professionals alone, even with systematic improvements in their training in medical ethics. Racism is persistent and deeply entrenched, but not insuperable. Major improvements in health status do require health system reform, but more importantly they flow from improvements in housing, nutrition, education and the environment. And these, in turn, require not only the assumption of political power by the majority but also significant redistribution of income and economic opportunity.

One other aspect of the parallels between the American and South African struggles must be mentioned. As Robert Kinloch Massie argues in the recently published book, Loosing the Bonds: The United States and South Africa in the Apartheid Years, the South African struggle for liberty and justice was a direct continuation of the long American struggle for civil rights. There is another—and darker—side of that parallel: the same conservatives who opposed civil rights in the U.S. were apologists for apartheid and defenders of the South African government's oppressive actions. And that effort included the American Medical Association.

The record of conservative American leaders and their publications has recently been reviewed in detail by Jacob Heilbrunn in a liberal journal, The American Prospect. He notes:

During the first stage, in the 1960s, conservatives depicted blacks as racially inferior to whites and praised the homelands policy of South Africa. In the second stage, in the 1970s, conservatives painted apartheid as a necessary evil; the Soviet threat required the United States to support South Africa. In the final stage, in the 1980s, the right decried the move toward divestment and sanctions, argued that capitalism would save the country, and portrayed Nelson Mandela and the African National Congress as pawns of the Kremlin. ⁶

In the 1960s, for example, the conservative National Review argued that, "the whites are entitled, we believe, to pre-eminence in South Africa." Its editor, William F. Buckley, after traveling through South Africa for several weeks, wrote, "there has never been any reason to doubt Verwoerd's own sincerity. He means to help the blacks." In 1965, the conservative leader Russell Kirk echoed South African propaganda that blacks were not fit to govern themselves, that black enfranchisement "would bring anarchy and the collapse of civilization," and "Bantu political domination would be domination by witch doctors." And in the 1980s, during the height of the Reagan administration's support of the apartheid regime, in a policy called "constructive engagement," its architect, Chester Crocker, Undersecretary of State for African Affairs, told a South African reporter that, "all Reagan knows about southern Africa is that he's on the side of the whites." During this period, the American Medical Association consistently supported the South African Medical Association, fought for its inclusion in the World Medical Association and against its international isolation, and in 1989, sent a delegation to South Africa to hold a press conference and declare that there was no evidence of discrimination. Ironically, this group was in South Africa at the same time that a human rights mission of the American Association for the Advancement of Science was gathering evidence for a review of the devastating effects of apartheid on health. Much has changed since then in the U.S. and, most obviously, in South Africa, but a final parallel continues: in both societies, there is much more yet to be done. The work of the Truth and Reconciliation Commission, and the participation of the American Association for the Advancement of Science, Physicians for Human Rights, the Committee for Health in South Africa, the American Psychiatric Association, and the American Nurses Association, are steps in that ongoing process.

NOTES

¹ Gamble, VN. "Under the Shadow of Tuskegee: African Americans and Health Care." American Journal of Public Health 1997; 87:1773-1778.

² Sims, JM. The Story of My Life. New York: Appleton. 1889; 236-237.

³ Savitt. TL. "The Use of Blacks for Medical Experimentation and Demonstration in the Old South." Journal of Southern History, 1982; 48:331-348.

⁴ Humphrey, DC. "Dissection and Discrimination: The Social Origins of Cadavers in America, 1760-1915." Bulletin of the New York Academy of Medicine, 1973; 49:819-827.

⁵ Reynolds, PP. "The Federal Government's Use of Title VI and Medicare to Racially Integrate Hospitals in the United States, 1963 Through 1967." Am J Public Health, 1997;87:1850-1858.

⁶ Heilbrunn, J. "Apologists Without Remorse: American Conservatives on South Africa." American Prospect 1998; 36:23-29.