Black and Blue. John Hoberman
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This account of how the racial presentation of a patient occurs in clinical medicine corresponds perfectly to a description that appeared in the Annals of Internal Medicine in 1996. The problem with giving patients racial identities in this manner is that “a physician's assumptions about a patient's race that result in the elimination of possible diseases or the narrowing of focus to one disease in the differential diagnosis may have serious negative consequences.” This author points to the case of a European boy (coded “white”) who presented with abdominal pain and anemia and whose surgery was abruptly canceled when his previously undiagnosed sickle-cell anemia came to light. A second case, concerning a young man coded “black,” ended in his death after he was treated for a sickle-cell crisis his doctors inferred on the basis of his presumed “race” and the patient's remark that he had once been told he had “sickle cell.”144 “What surgeon has not been embarrassed,” a white physician asked in 1960, “by operating for acute appendicitis, only to find a normal appendix because he failed to remember sickle cell disease in the differential diagnosis.”145 The fact that this physician, Dr. John Scudder, registers embarrassment rather than alarm reflects the casual approach to diagnosing black patients we have already seen in a number of cases from previous decades. A year earlier, a paper on blood transfusions by Dr. Scudder had produced a front-page story in The New York Times titled “Blood Expert Says Transfusion Between Races May Be Perilous.” “This may sound wrong sociologically,” he commented, “but it is scientifically correct.”146 In May 1960 the African American-edited Journal of the National Medical Association noted that, following the news coverage of Dr. Scudder's paper, “several states have enacted laws or implemented old measures stipulating that Negro blood be separated.”147 What had alarmed Scudder was the immune response of “a white war veteran” to a blood transfusion from a “Negro donor” whose blood did not contain an atypical antibody matching that of the white patient. Scudder proceeded to recommend, on the basis of the differing racial distributions of blood groups and antibodies, the racial segregation of blood to avoid dangerous incompatibilities.
Case studies of medical folklore and how these ideas are transmitted from one generation to the next are never analyzed in the mainstream medical literature. An interesting example of this sort of analysis appeared several decades ago in the black-edited Journal of the National Medical Association, at a time when the civil rights movement was encouraging black self-assertion in every social venue, including medicine. In his article on “Racial Contrasts in Obstetrics and Gynecology,” the white obstetrician William F. Mengert announced that his purpose was “to examine objectively each racial contrast in obstetrics and gynecology and place it in one of two categories: folklore or real difference. When this is done it becomes obvious that many racial contrasts depend upon social factors such as custom, social and financial station, rather than race.” Over the previous century, as we will see later on in this book, many medical authors had made little or no effort to distinguish between the folkloric beliefs that circulated among doctors and real scientific information.
The white physician who confesses in print to having mistakenly believed in “Negro” traits or disorders has been an absolutely exceptional contributor to the medical literature. White physicians commented occasionally during the Jim Crow era on their colleagues' inaccurate ideas about racial differences, even as pseudoscientific racial interpretations of the human organism and its diseases continued to predominate over this sort of caution. Some physicians understood, for example, that the stereotype of the venereal disease-ridden Negro was likely to produce some medical misjudgments. “In approaching the subject of syphilis in the negro,” a Charleston, South Carolina, doctor writes in 1915, “there is especial need to guard ourselves against preconceived notions. It is the prevailing opinion that practically every negro who has reached middle life is syphilitic, an opinion which finds support in the exceedingly lax moral standards of the race. This opinion may be true, but I have not been able to find any definite and exact data upon which it is based.”148 “I am…prepared to admit, in the light of recent investigations,” another Charleston doctor wrote two years later, “that in all probability some [eye] affections which were attributed to syphilis may have been tuberculosis…. It behooves us to jack up, as it were, our diagnostic machinery to meet the times.”149
The medical men of this period were willing to concede that physicians were vulnerable to some other mistaken ideas about black patients in addition to the constant harping on the perils of the syphilitic Negro. It is not true, a professor at the Atlanta Medical College asserts in 1915, that the Negro race “is not afflicted with adenoids in the nasopharynx,” even if local variations in the disorder have created this impression.150 In 1925, a JAMA editorial on “Rectal Pathology in the Negro” warned against making “sweeping generalizations” about Negro tissues on the premise that the black man is an evolutionary (“atavistic”) throwback.151 It is now clear, a New Orleans doctor wrote in 1932, “that in spite of a rather widely held opinion to the contrary, the negro race is quite as susceptible to this terrible disease [cancer] as is any other race and people.”152 (Newsweek told its readers in 1963 that “Negroes are far less prone to cancer than whites.”153) A Columbia University psychologist who in 1939 compared blacks to apes cautiously noted that the medical literature “has carried with it many superstitions in regard to predisposition of the colored race for certain types of mental disturbances or a relative infrequency for others.”154 If doctors think infectious mononucleosis is relatively rare among “the colored,” two physicians from Richmond, Virginia wrote in 1944, it is probably because they have not bothered to examine the blood smears of their black patients.155 A counterpart to the Southern physician, the British colonial physician, could make his own mistakes. A doctor who had assumed that “reticulocytes were larger in Africans than in Europeans” confessed his “misapprehension” in 1952.156
These confessions of error in the medical literature show that the pseudoscientific consequences of racially motivated medical thinking— “preconceived notions,” “sweeping generalizations,” and “superstitions” among them—were making themselves apparent to the more open-minded sort of medical man even during the era of Jim Crow segregation. The other major theme that runs through these observations about diagnosing blacks is the careless and mistaken assumption that these people enjoyed various degrees of immunity to a variety of disorders: adenoids, cancer, mononucleosis, and many more. In addition, these doctors sometimes concede that such careless and mistaken diagnoses were the direct result of medical negligence on the part of white practitioners who did not take the trouble to examine their black patients with sufficient care. As one physician noted in 1920, in the case of suspected exophthalmic goiter, blacks “are often less minutely examined than white patients.”157 If the Negro infant death rate for congenital malformations is half that of white infants, another doctor surmises in 1932, “This difference is probably due, in part, to less careful observation of Negroes.”158 A 1946 JAMA commentary on “Maternal Care and the Negro” concluded that “errors in judgment and technic as well as neglect on the part of the physician were 50 per cent more frequent in the care of colored mothers.”159 The impact such observations might have had on the doctors who made them would surely have been buffered by the profound racial paternalism that characterized the medical profession at this time. In the words of the commentator on obstetrical neglect: “The educational and intellectual deficiencies of the Negro favor poor obstetric results.” It is for this reason that these comments should be read as confessions of error rather than as a recognition of ethical deficiencies.
Apart from this climate of prejudice, there is another way to understand why physicians might avoid careful examination of black patients in some cases. In some Southern towns, black patients could wait from four to six hours just to be seen, and some were not asked to remove their clothes for physical examinations.160 There is no one way to explain physician behavior of this kind; some practitioners must have made a conscious decision to give black people short shrift, while others may have been reacting to phobias rooted in apprehensions about racial differences, whether these were cultural or biological. The psychoanalyst and anthropologist George Devereux has offered some explanations of such behaviors based on what he observed while instructing