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A horrifying catalog of the centuries-long medical exploitation of African-Americans

Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present
By Harriet A. Washington
Doubleday, 501 pp., illustrated, $27.95

I vividly remember how I was taught to perform a rectal examination as a second-year medical student in the early 1970s. Our instructor, a respected surgeon, described the technique to a group of eight of us, then took us to a surgical ward to perform the examination for the first time. He found a middle-aged black man, whom he then ordered to submit to examinations from all eight of us. I shall never forget the terror, dismay, and resignation in that man's eyes as he quietly submitted to our probing fingers.

As Harriet Washington demonstrates in "Medical Apartheid," this episode was hardly unusual. In her important new book, Washington, a journalist and ethicist, provides a comprehensive account of the exploitation of black Americans in medical education and research. She proceeds chronologically, discussing such subjects as the use of black bodies in anatomical dissection, the medical care of slaves, the surgical experiments on slaves by physician J. Marion Sims, eugenics, scientific racism, and government-sponsored radiation experiments after World War II using unwitting African-Americans as guinea pigs. The notorious Tuskegee Syphilis Study , in which about 600 black men with syphilis were left untreated by the US Public Health Service in an effort to study the natural history of the disease, is seen to be not an aberration but merely the most famous episode in a centuries-long pattern of unethical research behavior with blacks.

Washington demonstrates a changing pattern to the experimental exploitation of blacks. In the 19th and early 20th centuries, when racism in the United States was at its most intense, numerous episodes of flagrant maltreatment occurred. After World War II, as racism began to ebb, the worst of these abuses ended. However, African-Americans continued to be overrepresented in clinical trials relative to their percentage of the general population. This largely reflected the fact that academic medical centers drew most of their "clinical material" from their immediate geographic surroundings -- areas that were often heavily black in demographic composition.

In very recent times, Africa has become a new medical laboratory for Western pharmaceutical companies, and Washington ends the book with a number of disturbing examples in which impoverished Africans have been exploited as experimental subjects in ways that echo the use of slaves in antebellum America. In this, parallels can be seen with other recent instances of public health imperialism. For example, as historian Allan Brandt discussed in his 2006 Garrison Lecture to the American Association for the History of Medicine , US tobacco companies have been aggressively marketing and selling their products in Third World countries to offset declines in domestic sales. Such episodes of public health imperialism warrant much further investigation.

Most of the episodes Washington relates are well known among medical historians. Herbert Morais , Linda Clayton , Michael Byrd , James H. Jones, Susan Reverby , Todd Savitt , and others have written splendidly on the various topics discussed in the book, and Washington acknowledges her heavy reliance on these authors. The achievement of the present study lies not in its original research but in how it weaves these well-known events together into a single, powerful narrative -- one that clearly demonstrates that the experimental exploitation of African-Americans was not an occasional aberration but part of a long tradition. The book thus helps explain the deep suspicions of the medical establishment widely found among African-Americans today, as well as the existence of significant contemporary health disparities between blacks and whites.

Washington is to be commended for the balanced tone she uses to discuss such an explosive subject. She writes with justifiable outrage and tells many spell binding tales, but the book is not an anti-medicine polemic. Indeed, she recognizes that the participation of African-Americans in clinical studies is essential, and one of her purposes in writing is to help put these atrocities in the past and to encourage African-Americans to participate in medical research in the future.

Regrettably, the narrative is marred by some jarring factual errors. For instance, the author states that the noted eugenicist Charles Davenport "wrote the National Origins Act of 1924." Davenport played no such role. Similarly, she writes that before the Civil War, "medical students were . . . expected to undergo specialized training during several years, not months, on the clinical floors of hospitals." This statement describes conditions in 20th-century medical education, not the ante bellum era. Fortunately such errors do not undermine the accuracy of the underlying analysis.

What is missing from the book? Largely, the recognition that the ethical problems in medical research pertain not to race alone but to the power relations of scientific medicine. For centuries the urban poor have been exploited as "teaching material" in the great hospitals of every Western country. In America since the later 19th century, similar stories could be told about immigrants, Catholics, Jews, and others who habituated the charity wards of US teaching hospitals. Even medical students, ever fearful of professional repercussions should they offend their professors, have often been forced into being research subjects. Medical research has always tended to take advantage of the powerless and voiceless, whoever they might be. "Medical Apartheid" would have benefited had this larger perspective been brought to the discussion.

Intrinsic to medical research is a moral dilemma: balancing the interests of the individual patient with those of the population, and the rights of the present generation with those of the future. How a society resolves these tensions reveals much about its attitudes, culture, and values. For those seeking to understand these important matters, Washington's fine book is an excellent place to start.

Kenneth M. Ludmerer, MD, is professor of medicine and professor of history at Washington University, in St. Louis, Mo., and the author of "Time to Heal" and "Learning to Heal."

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