African American Physicians and Organized Medicine, 1846-1968: Title and subTitle BreakOrigins of a Racial Divide

By the end of the 19th century, US physicians had formed 2 national associations: the National Medical Association (NMA) and the American Medical Association (AMA). This peculiar duplication reflected a profession segregated by race. The AMA was almost entirely white; the NMA predominantly black—founded in reaction to the exclusion of black physicians by many state and local medical societies and the AMA's refusal to recognize several racially integrated societies. This professional segregation lasted well into the civil rights era.

The complex history of race in the medical profession is rarely acknowledged and often misunderstood. Yet US medicine's legacy of segregation and racism is linked to the current paucity of African American physicians, distrust of professional associations by some physicians, and contemporary racial health disparities. The goal of this article is to encourage a discussion within the profession of medicine about how to heal and unify the profession in the pursuit of providing equitable health care for all.

In 2005, the AMA Institute for Ethics invited a panel of experts to review and analyze the historical roots of the black-white divide in US medicine. The chief source materials that the panel examined were from the archives of the AMA, the NMA, and newspapers, the latter via online databases.^{1 - 3} In addition, we searched MEDLINE using keywords race, segregation, and integration and the Medical Subject Headings term prejudice.

The group has completed a number of reports (Box)⁴ that provide additional details and direct quotations from primary source materials on specific aspects of the history of African American physicians and the medical profession. This article provides a summary of findings. When interpreting this history, the panel avoided hypothesizing about historical actors' motivations, emphasizing instead the results of decisions. Some broader social context is provided, but due to space constraints this article focuses on a few key events and turning points, ending with the major civil rights watershed of the late 1960s (Table).

AMA indicates American Medical Association; NMA, National Medical Association.

^aThese reports and an interactive timeline of events are available at http://www.ama-assn.org/go/AfAmHistory.

Medical societies were the crucibles in which the organized profession of medicine was formed. Within them, physicians met and developed relationships with professional colleagues and provided a forum to present papers and learn the latest techniques and treatments. After 1900, hospital admitting privileges became closely linked to medical society membership, as did relationships with state licensing and regulatory bodies. By the 20th century, exclusion from these societies often meant professional isolation, erosion of professional skills, and limitations on sources of income.^{5 - 7}

Yet in the pre–Civil War United States, the idea of a single, unified, national medical association ran against the tide of strong regional divisions over slavery. In slave states, most African Americans were regarded as property; many white physicians relied on the patronage of slaveholding plantations for a living, and some were slaveholders themselves.⁸ Often, enslaved communities developed their own practitioners and therapies partly as a means of resisting medical abuse and neglect.⁹ Meanwhile, in the North, Rush Medical School (Illinois) awarded a medical degree to an African American, David Jones Peck, in 1847.¹⁰ Seven years later, the Massachusetts Medical Society accepted into membership its first African American, John Van Surly DeGrasse.¹¹

Scientific racism—including theories that blacks were different from whites in ways that justified enslavement—was common in the United States and Europe, with many prominent US physicians at its vanguard.^{6 ,12 - 13} An 1850 AMA committee reported, for example, that “[the] Negro brain is nine cubic inches less than the Teutonic [European].”^{14 (p57)} However, some physicians challenged these theories, including the abolitionist Philadelphian John Bell, chair of the committee that drafted the AMA Code of Medical Ethics, who published a paper presented at the British Royal Society challenging the brain-size theory.^{15 (p301)}

Amid this climate of sectional discord, the AMA was founded in 1847 as a federation of medical societies, colleges, and institutions—the majority being state and local societies—to create a “uniform and elevated standard. . . for the degree of MD”; to provide a common code of medical ethics; and to promote the profession's “interests,” “honour,” “respectability,” “knowledge,” and “usefulness.”^{16 - 17 (xxvi),18 (pp19-34),19 (p17),20 (pp55-56)} The AMA, as a social and scientific fraternity, aimed to represent the entire nation, and each member brought his own prejudices and worldviews.²¹

Some AMA members, and its Code of Medical Ethics,^{20 (pp99-100)} espoused the ideal that scientific qualifications alone (ie, a “regular” medical education) should determine membership in the profession. Nevertheless, many AMA members vehemently opposed associating with black physicians, either professionally or socially.^{6 ,21}

Both before and after the Civil War, the AMA maintained a pattern of North-South balance in locating national meetings and electing presidents.^{4 ,21} The 1869 annual meeting was held in New Orleans with President William Baldwin of Alabama stating, “Eight years ago we were separated by civil war . . . [that] engendered the bitterest feeling in every other national organization . . . [I]t has been left to the [AMA] to teach . . . charity and forgiveness.”^{22 (pp56-60)}

The AMA's plan to maintain professional unity was tested, however, when 3 regularly educated, licensed black physicians—Alexander Thomas Augusta, Charles Burleigh Purvis, and Alpheus W. Tucker—sought recognition as delegates at the AMA's 1870 meeting in Washington, DC.²³ (Service as a delegate was the primary route to AMA membership.)⁴ These 3 physicians were members of Washington, DC’s, new, racially integrated National Medical Society, which had been formed shortly before a congressional investigation found that the Medical Society of the District of Columbia refused to admit these same 3 physicians, “solely on account of color.”^{24 (p2550),25}

At the 1870 meeting, physicians lodged ethics complaints against 3 societies: the National Medical Society, the Medical Society of the District of Columbia, and the Massachusetts Medical Society. The all-white Medical Society of the District of Columbia challenged the seating of all members of the National Medical Society, claiming that it “was formed in contempt of” and had “attempted, through legislative influence, to break down” the Medical Society of the District of Columbia by petitioning Congress to address racial discrimination within the Society.^{23 (pp173-174),24 (p2551)} The National Medical Society, in turn, charged the Medical Society of the District of Columbia with licensing “irregular” practitioners. Lastly, dissident Massachusetts physicians charged their own state society with accepting “irregulars” into membership.^{26 (pp29,53-54)} Irregulars, such as Thomsonians and homeopaths, were held to practice “an exclusive dogma to the rejection of the accumulated experience of the profession”^{20 (pp99-100)}—an important issue for the AMA, since its members competed with irregulars and considered them to be unscientific.^{18 (pp114-115),21 (p174)}

All 3 cases were referred to the AMA's Committee on Ethics. That committee found the charge regarding the Medical Society of the District of Columbia's granting licenses to irregulars was “not of a nature to require the action of the [AMA],” and recommended inclusion of the all-white delegation.^{26 (p54)} The committee also urged recognition of the all-white Massachusetts Medical Society delegation, even though the charge that they accepted irregulars as members was “fully proved” and “plainly in violation of the Code of Ethics.”^{26 (p29)}

With respect to the integrated National Medical Society, however, following protracted deliberation, the committee remained divided, 2 to 3. Two of the AMA's founders led the ensuing debate: AMA vice-president Alfred Stillé, speaking for the committee's minority, recommended recognition of National Medical Society members.^{26 (pp55-56)} AMA past-president Nathan Smith Davis spoke for the committee's majority and urged exclusion.^{26 (pp53-55)} When the issue was put to a roll call vote—in which the 36 delegates from the Medical Society of the District of Columbia, but not the National Medical Society, were allowed to vote—the minority report was tabled (114 to 82), and the majority report was adopted, resulting in the exclusion of National Medical Society members from the AMA.^{26 (pp29,56-58)}

Following the vote, 2 Massachusetts delegates, Horatio R. Storer and John L. Sullivan, explicitly raised the issue of race. Amid “a storm of hisses” countered by “Go on! Go on!”²⁷ Sullivan proposed that the AMA adopt as policy that “no distinction of race or color shall exclude from the Association persons claiming admission and duly accredited thereto.”^{26 (p65)} The convention postponed action on this so that Davis could further clarify the Ethics Committee's reasoning. Davis reiterated that the National Medical Society “used unfair and dishonorable means to procure the destruction” of the Medical Society of the District of Columbia, and added that some members of the National Medical Society were not licensed to practice medicine in Washington, DC (leaving unsaid that many AMA delegates were not licensed and that, in DC, licenses were issued by the all-white Medical Society of the District of Columbia).^{26 (pp65-66)} Sullivan's proposal was then tabled. Storer, who had supported admission of National Medical Society members, then proposed a resolution stating that Davis had “distinctly stated and proved that the consideration of race and color has had nothing whatsoever to do with the decision.” This motion passed.^{26 (pp66-67)}

The AMA thus declined to embrace a policy of nondiscrimination and excluded all members of the integrated National Medical Society. Exclusion was achieved through selective enforcement of membership standards: allowing leniency to 2 all-white delegations that had breached scientific credentialing standards, while stringently applying standards of collegial behavior to an integrated society—and, immediately thereafter, officially absolving itself of the charge of racism. This act of self-absolution is evidence of, if not guilt, at least a recognition that the decision had the effect of racial discrimination—which some physicians found condemnable.²³ Indeed, 1 white commentator, reflecting on the decision, wrote, “I doubt whether, in the last fifty years, a national scientific body has convened anywhere that would have excluded a competent scientist on the ground of color.”^{23 (p178)} The AMA, he noted, had put up “new barriers to entrance”^{23 (p177)} and, in doing so, “unharnessed itself from its code of ethics.”^{23 (p180)}

Until 1874, any medical society, school, or institution could send a delegation to the AMA's national convention. But following another failed attempt to seat an integrated medical society at the 1872 AMA meeting,^{28 (pp54-59)} Davis proposed that delegations be restricted to state and local medical societies and that state societies, not the national convention, should determine which local societies would be officially recognized by the AMA.²⁹ Davis' adopted proposal conceivably had various motivations.³⁰ But because many societies—especially in the South, where most African Americans resided—openly practiced racial exclusion, this structure effectively excluded most African Americans from the AMA.

African American physicians responded to their exclusion from AMA-affiliated medical societies by founding their own medical societies. The biracial Medico-Chirurgical Society of the District of Columbia was founded in 1884^{31 - 32} ; the Lone Star State Medical, Dental, and Pharmaceutical Association of Texas in 1886³³ ; the Old North State Medical Society of North Carolina in 1887³⁴ ; and the North Jersey National Medical Association in 1895.³⁵ None of these societies could send delegations to AMA meetings. In 1895, feeling the need for a national organization to support black physicians, leading African American physicians formed the NMA.^{6 (pp392,400-402),36}

Notably, neither the NMA nor the AMA has ever had any explicit, race-based membership criteria. The NMA described itself as “conceived in no spirit of racial exclusiveness.”³⁷ The AMA similarly “boasted itself as exclusive only of the false in science and character.”^{23 (pp172,176)} Among the NMA's founders was at least 1 African American AMA member: Daniel Hale Williams of Chicago.³⁶ Despite the absence of formal exclusionary policies at the national level, the segregation of organized medicine at the turn of the century was nearly complete—the AMA was almost entirely white, the NMA, mostly black.^{6 - 7}

Abraham Flexner's 1910 report to the Carnegie Foundation for the Advancement of Teaching (the Flexner Report) contributed to a complex period of evolution in medical education.³⁸ However, it also reinforced segregated and unequal medical education for African Americans. The report, initiated at the request of the AMA,^{38 (p170)} recommended closing all but 2 African American medical colleges then in operation—Howard University and Meharry Medical College—despite Flexner's acknowledgment that 2 schools would be unable to train enough black physicians to serve the 9.8 million African Americans living in the United States in 1910.^{39 - 40 (pp180-181)} Moreover, Flexner recommended the coeducation of women and men, but accepted racial segregation in medical schools, noting, in addition, that black physicians should be trained differently; namely, to “humbly” serve “their people” as “sanitarians.”^{40 (pp178-181)}

By the 1930s, race discrimination—enforced by Jim Crow laws—had permeated all areas of US life, including medicine.^{41 - 42} Faced with hospitals that rejected African American patients or relegated them to separate, substandard facilities, African American physicians led a movement to build black hospitals.⁴³

Prior to World War II, however, the NMA and the plight of the physicians and patients it served were rarely mentioned in AMA records. One of the first documented NMA-AMA interactions concerned the AMA's American Medical Directory, which listed all US physicians. Since its first edition in 1906, the Directory had listed African American physicians as “colored.” This designation reportedly harmed African American physicians, in part by making it harder, or impossible, to obtain liability insurance and bank loans.⁴⁴ Despite protests from the NMA, the AMA Board of Trustees in 1931 did not “feel disposed to make any change in its . . . policy of designating colored physicians.”⁴⁵ In 1939, however, as negative publicity rose around persistent NMA objections, the board dropped the designation from subsequent editions of the Directory.^{46 - 47}

Although the AMA had a few (≈0.3%) northern black members by 1938,⁴⁸ racial exclusion within AMA-affiliated societies, particularly in the South, precluded most African American physicians from joining the AMA.³² In 1939, responding to discussions with NMA leaders and a supporting resolution from the AMA's all-white New York delegation, the AMA board appointed a subcommittee to consider “certain problems . . . inimical to the welfare of colored physicians and the people whose medical welfare they have at heart.”^{49 (pp74,86)} According to the board report, the first of these “problems” was “[t]he erroneous impression created by publicity bearing on the question of membership in the [AMA].”^{49 (p86)} The report admonished discriminatory practices, asserting that “membership in the various component county societies should not be denied to any person solely on the basis of race, color or creed.”^{49 (p86)} However, the report—adopted by the AMA House of Delegates—also asserted that “every component county medical society has the right of self government in local matters and membership.”^{49 (p86)} Thus, in principle, the AMA had a policy recommending nondiscrimination; in practice, however, each constituent society of the AMA could still discriminate at its discretion.

According to Woodward, “American [World War II] propaganda stressed above all else the abhorrence of . . . Hitler's brand of racism and its utter incompatibility with the democratic faith.”^{41 (p131)} Many Americans, however, came to see similarities between “Hitler's brand of racism” and white supremacist ideologies in the United States.^{41 (pp130-134),50} Partly because of this moral crisis, “[b]lacks and an increasing sector of liberal white America came out of the war with a fresh determination to uproot racist ideologies and institutions at home.”⁴²

These changing social attitudes were reflected in the medical profession. In the late 1940s and 1950s, several northern and southern constituent societies of the AMA opened their doors to African Americans for the first time. And both black and white physicians fought to integrate racially exclusive medical specialty boards.^{32 (pp132-136)} In 1950, Peter Marshall Murray of New York became the first African American to serve in the AMA House of Delegates.^{32 (p163)} Murray noted that African American physicians were “admitted to membership in some county societies” in every southern state but Mississippi and Louisiana by 1955.^{32 (p134)}

Nevertheless, between 1944 and 1965, more than a dozen attempts to expand black physicians' professional inclusion were rebuffed by the AMA house.⁴ In 1952, for example, the Old North State Medical Society appealed for admission to the AMA as a constituent association. Although endorsed by the AMA's North Carolina delegation, the AMA house voted to deny the request.^{51 (pp11-12)} The AMA-affiliated Rhode Island Medical Society proposed excluding discriminatory societies from the AMA in 1963, but the idea was rejected for reasons that had remained unchanged for decades: “progress” was already being made and membership matters were controlled by constituent societies.^{52 (pp178-179)}

These rationales were fiercely disputed, however. In 1952, Martha Mendell, a member of the Physicians Forum, an activist medical organization in New York,⁵³ noted,

The continued exclusion of Negro physicians by southern medical societies is not just a national, but an international disgrace. The claim of the AMA that it is powerless to correct this practice because of the ‘autonomy’ of its component societies is an evasion of its responsibility. Surely, if the southern medical societies decided to admit chiropractors to membership the AMA would quickly find the means of re-defining this autonomy.^{53 (p305)}

Physicians played an important role in the Civil Rights Movement,^{7 ,53 - 54} but largely outside the AMA. Physicians assumed prominent roles in the National Association for the Advancement of Colored People and other advocacy groups and in lawsuits that sought to end hospital segregation.^{7 ,32 ,55} Both black and white physicians participated in civil rights marches and picket lines, rendering medical aid and bearing witness to the sometimes fatal violence perpetrated by segregationists.^{7 ,32 (pp159-190)}

National Medical Association leaders were critical players in these efforts.³² As early as the 1950s, William Montague Cobb, editor of the Journal of the National Medical Association, included a column entitled the “Integration Battlefront” that addressed civil rights struggles in the medical sphere. In 1957, Cobb organized the first Imhotep National Conference on Hospital Integration.^{7 (pp268-269),32 (pp143-144)}

The AMA, in contrast, was widely seen as uninterested in, or even obstructing, the civil rights agenda. For example, although the AMA sent representatives to the first Imhotep conference, Cobb noted that the AMA refused to “participate officially and actively” in subsequent meetings.^{7 (pp268-269),32 (pp143-144)} In 1961, the AMA elected not to defend 8 NMA physicians who had been arrested for asking to be served at a Fulton County Medical Society luncheon in the whites-only section of Atlanta's Biltmore Hotel cafeteria.^{7 (pp264-265),32 (p162)} In 1965, future Medical Committee for Human Rights National Chairman Paul Lowinger recorded his experiences caring for those injured by violent segregationists on the Selma to Montgomery march. JAMA reportedly accepted his letter for publication on April 29, 1965, but 3 weeks later informed him it would not be published due to its “controversial” nature.^{32 (p171)} And NMA leaders asked repeatedly for the AMA to support efforts to amend the Hill-Burton Act's “separate but equal” provision—which allowed for the construction of segregated hospital facilities with federal funds—but the AMA remained silent.⁴ Instead, the AMA focused on combating federal encroachment into health care, which it termed “socialized medicine.”⁵⁶ In 1964, NMA President Clement explained: “The [AMA’s] opposition to federal control over hospital[s] is much better known and established than its interest in removing discrimination based on race from admission and staffing policies.”⁵⁷

In 1963, AMA and NMA representatives, hoping to develop a common agenda, met periodically as a “liaison committee” at the AMA's Chicago headquarters.^{58 (p38)} In August 1963, they convened to discuss the Hill-Burton Act, Medicare, and other issues. American Medical Association President-elect Welch reported that the AMA might support repealing Hill-Burton's “separate but equal” clause after another liaison committee meeting planned for December 19, 1963.^{32 (p175)} But by this time, Cobb, now the NMA president, openly expressed frustration:

For seven years we have invited them to sit down with us and solve the problem [of hospital integration]. The high professional and economic levels of these bodies and the altruistic religious principles according to which they are supposed to operate seem to have meant nothing. By their refusal to confer they force action by crisis. And now events have passed beyond them. The initiative offered is no longer theirs to accept.^{32 (p174)}

Cobb was proven correct when the Civil Rights Act of 1964 was passed. The NMA championed the act.^{32 (p172)} The AMA records contain no significant mention of it.

Although the AMA remained silent during debates over the Civil Rights Act, it was not silent during its implementation. Department of Health, Education, and Welfare regulations would have required physicians receiving federal funds to sign statements of compliance, formally forswearing racially discriminatory practices.⁵⁹ The AMA strenuously objected to this—its house labeled such oaths “degrading,” because physicians already had a code of ethics forbidding discrimination.^{60 (pp111,157-158)} The AMA took credit when the Department of Health, Education, and Welfare dropped the requirement in 1966 “because of objections,”⁶¹ thereby rendering physicians' services uniquely unaccountable to civil rights legislation.⁵⁴

Tensions between the AMA and NMA increased as the organizations took opposing positions on other important legislation. Since 1939, the NMA had backed national health insurance⁶² and, in 1962, its House of Delegates endorsed Medicare.⁶³ The AMA opposed both proposals as “socialized medicine” and instead of Medicare backed the 1960 Kerr-Mills law, which provided federal matching grants to support state-administered health care programs for the elderly.^{64 - 66} The AMA's opposition to Medicare reflected the sentiment of the majority of physicians in 1965,⁶⁷ and NMA leaders recognized that it was “a dissenter from the dominant organization of American medicine.”^{32 (p173)} However, the NMA argued that Kerr-Mills was “disappointing” and that Medicare “offered the greatest opportunity and probability that the health needs of the aged would be fully met.”⁶⁸

On June 12, 1963, the Medical Committee for Human Rights—a biracial, national organization comprising primarily liberal, white physicians—and other prominent white and black organizations sent an “Appeal to the AMA” to “speak out” against segregation, the Hill-Burton Act's “separate but equal” clause, and “the racial exclusion policies of State and County medical societies.”^{32 (p162)} This was followed by a series of public protests and pickets, including those at the AMA meetings in 1963, 1965, 1966, and 1968.^{32 (pp163-164,194-195),69} AMA Board Chairman Hopkins responded in 1963 that the picketing served only “to obscure the achievements in medical science being reported at the meeting.”^{32 (p163)}

Following passage of the Civil Rights Act in 1964 and Medicare in 1965, segregation within hospitals became illegal.^{54 ,56 ,70} Yet several resolutions to strengthen the AMA's nondiscrimination policies were again rejected before the AMA house voted to amend its constitution and bylaws in 1968, giving the Judicial Council (now the Council on Ethical and Judicial Affairs) the authority to expel constituent societies for racial discrimination in membership policies.^{71 (pp137,207)} The Council on Ethical and Judicial Affairs' authority to investigate and sanction discriminatory societies was never exercised.

In the United States, organized medicine emerged from a society deeply divided over slavery, but largely accepting of systemic racial inequities and theories espousing black inferiority. Emblematic of existing societal values and practices within the profession, medical schools, residency programs, hospital staffs, and professional societies largely excluded African Americans. For more than 100 years, many medical associations, including the AMA, actively reinforced or passively accepted this exclusion. Still, throughout this history, vocal groups of physicians—black and white, and within and outside these associations—challenged segregation and racism.

It is tempting to simplify this story into one of heroes, villains, or victims. Heroes would include the numerous physicians who challenged discrimination in organized medicine. But Nathan Davis, a hero of most AMA narratives, would be cast as a villain, along with those who defeated attempts to eliminate segregation in the profession. Among the victims would be the generations of African American physicians excluded from the mainstream of American medicine and the patients whose needs went unmet because of this exclusion.

History rarely offers simple morality tales, however. Despite being victims, many African American physicians and institutions performed heroically.^{6 - 7 ,31 - 32 ,43} Among the white heroes, a physician who berated the AMA for excluding blacks in 1870 also advocated against black suffrage, illustrating the deeply entrenched racism of the times.²³ Abraham Flexner ultimately became a strong advocate for Howard and Meharry medical schools.³⁹ Davis and other AMA leaders, though often racist, also sought to build a national association in a divided nation. Ironically, they pursued professional unity by countenancing racial exclusion. For almost a century after Reconstruction, US society chose the same false national unity, tolerating and even facilitating white American prejudice and racism against African Americans.

With the civil rights era, US medicine, like the nation, entered a period of profound change. Most recently, AMA support for this independent exploration of its history is, itself, a part of an ongoing professional evolution. Yet despite much progress, this legacy continues to adversely affect African Americans. African Americans in 2006 represented 12.3% of the US population,⁷² but just 2.2% of physicians and medical students.⁷³ This is less than the proportion in 1910 (2.5%), when the Flexner Report was released.^{7 (p584)} The care of African Americans remains largely segregated, which contributes powerfully to racial disparities in care.^{74 - 76} And, not surprisingly given this history, African Americans remain underrepresented in the AMA.⁷³

As leaders of the medical profession come together and move into the future, they should do so with a clear recognition of the effects of the past but also an awareness that the story of African Americans and organized medicine is still being written.