DC GENERAL HOSPITAL DOCTORS' DAY ADDRESS David M. French, MD New York, New York
In this address, I am going to begin with a very brief review of the historical origins of city hospitals. Then, I shall switch to the history of city hospitals in the United States, indicating their close association with the evolution of medical care and medical teaching in this country.' Ultimately, I shall tell you the story of DC General's unique contribution to medical care delivery in Washington, DC, and how Howard University played a catalytic role in initiating the changes leading to that contribution. In the process, you will learn more about the roles of two professors and one resident from the Howard University College of Medicine and Freedmen's Hospital who were deeply involved.
THE CITY HOSPITAL: AT THE FOREFRONT OF PROGRESS In preparation for this address, I decided to search the literature for the history of city hospitals. The oldest city hospital in the United States was the old Philadelphia General Hospital, which was founded in 1731 (unfortunately it closed in 1977). Following closely were Bellevue Hospital in New York and Charity Hospital in New Orleans (both founded in 1736), Baltimore (1776), Washington, DC (1806), Cleveland (1837), Boston (1864),2 Cook County (1866), Seattle (1877), and Los Angeles (1878). Massachusetts General Hospital (1821) was originally on that list but with the founding of Boston City Hospital it was moved up a peg. It is important to recognize the alms house origins of the city hospitals.3 Our alms house tradition has its origins in medieval England and is traceable to Henry Address delivered at the District of Columbia General Hospital, Washington, DC, on March 29, 1991. Requests for reprints should be addressed to Dr David M. French, Medical Director, Helen Keller Intl Inc, 15 W 16th St, New York, NY 10011. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
VIII and his battles with the Catholic Church. In his elimination of the Catholic Church from England, he eliminated, in the process, all the public institutions that had been supported by the Church, including its various alms houses, asylums, and other societal support institutions. England, at the local level, was, consequently, inundated with the aged, the chronically ill and permanently disabled, homeless women before and during childbirth, foundlings and orphans, the insane, the feebleminded, and alcoholics along with those with the usual medical and surgical illnesses who were poor or destitute (ie, without family support). The concept of the "unworthy" patient took hold and these were viewed as "inmates" of the new institutional structure-alms houses. Dr David Rothman, director of the Center for the Study of Society and Medicine at the Columbia University College of Physicians and Surgeons, has noted, "The essential function of the alms house, until the 1830s, was to serve as the great catch-all: it housed those who were unattached to family or other social support and who had no call on private charity. The worthy poor were connected to family, friends, or church. The unworthy poor were unconnected." According to Rothman, there was a feeling in the early 19th century that the development of separate institutional environments would better solve many existing problems through institutional discipline and habits of order. Prisons, orphan asylums, insane asylums, and others were set up, draining off from the alms houses all but the medical and quasimedical populations. The other great factor dictating change during this period (in the last half of the 19th century) was the increased growth of medical and scientific knowledge and the recognition by physicians that they had a captive patient population affording a large number of 283
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cases for study in the newly arising city hospitals. The history of modem medicine and its advances is replete with the names of the great in American medicine who had a considerable base within the city hospitals. " The most stigmatized of institutions became the teaching grounds of the most prestigious of physicians."4 It would seem that we have another noteworthy example of city hospitals being in the forefront of American medicine in that the integrated and accelerated development of black health professionals largely started in the city hospitals, leading to the wider acceptance and integration of blacks throughout the medical world.5 The city hospital has afforded the proving ground that ultimately allowed the breakthrough of the barrier that had been created by Dr Abraham Flexner in his report of 1909. I first came to the Gallinger Hospital6 (before it became DC General) as a second-year surgical resident on July 1, 1950. I had come from the Freedmen's Hospital Surgical Residency Training Program as the first black resident ever at Gallinger Hospital. Dr Charles R. Drew chose me to be a pioneer at the frontier of integration of the severely segregated medical care system that existed in Washington, DC, at that time. Black practitioners of that day were not allowed in any of the hospitals of the District of Columbia except for the Freedmen's Hospital, a vestige of one of the three old Freedmen's Bureaus set up after the Civil War. To my knowledge, this was the only one of the three that had a sizeable health facility for use by the newly freed men, and, its facilities being in proximity to Howard University, (which had been established along with its medical school in 1869) became the teaching hospital for the College of Medicine of Howard University. This island of medical care and medical education existed quite isolated from the other medical care and medical education facilities of the District of Columbia. Dr Drew was one of the new breed of well-trained black medical academicians who had risen through the efforts of the first black dean of the medical school, Dr Numa P.G. Adams, with funding from the General Education Board and the Rosenwald Foundation. They became, ultimately, the new chiefs of services and departments and replaced what had previously been, to a large extent, white practitioners and educators. Although Dr Drew did not owe his own education and training to the special efforts underway with funding from the above sources (he had managed this miraculously on his own merit, quite separately), he had a profound conviction that black physicians could compete if given the opportunity, and his life and career were dedicated to 284
proving that point. I became a small part of Dr Drew's dream by pioneering as a Georgetown surgical resident at DC General Hospital. Dr Robert Coffey, chief of surgery at Georgetown, and Dr Drew had become friendly, and Dr Drew challenged him late in 1949 to take one of his surgical residents for a year at Gallinger Hospital. In February or March of 1950, Dr Drew casually informed me one afternoon at the basement lunch counter at Freedmen's Hospital that he had settled on my being that first resident at Gallinger Hospital. I was flabbergasted. In the early hours of Saturday, April 1, 1950, Dr Drew was tragically killed in an automobile accident in rural North Carolina. Those of you who did not have the opportunity to know Dr Drew personally cannot imagine what a profound impact his death had on us at Howard University and Freedmen's Hospital. I firmly resolved to live my life as a physician in a way that would have made him proud and, most of all, to carry out my responsibilities as a pioneer at Gallinger Hospital such that others would be allowed to follow my example. This was the case, and along with trainees from the Howard University Department of Pediatrics under the leadership of Dr Roland Scott, chief of pediatrics at Freedmen's Hospital, Howard University established a toe-hold at Gallinger Hospital for postgraduate training opportunities for black physicians, the first in Washington, DC, outside Freedmen's Hospital. My next contact with the since renamed DC General Hospital came in 1960. I had finished my surgical training at Freedmen's Hospital along with Dr Jesse Barber (now president of the staff at DC General Hospital), had done a short stint in Detroit in the private practice of surgery, had returned to Howard University to teach in the surgery department, and had been to Children's Memorial Hospital in Chicago to train in pediatric surgery with emphasis on cardiovascular surgery. Interest in cardiovascular surgery had come my way as a result of working with the late Dr Charles Hufnagel, then newly appointed to the department of surgery at Georgetown. He had come from Children's Hospital in Boston where he was doing experimental cardiovascular surgery, trying to develop an artificial heart valve. I was at Gallinger when Dr Hufnagel arrived, and I became fascinated by his work. Cardiovascular surgery was just getting its foothold, and I had the marvelous opportunity to be exposed to it as an aspect of thoracic surgery under Dr Edgar Davis, chief of thoracic surgery at Georgetown. In the process, I got to scrub on the early cardiovascular surgery cases at Gallinger Hospital, including the first installation of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
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the new Hufnagel valve for aortic valvular disease. On returning from my subspecialty training at Children's Memorial Hospital in Chicago, I had the opportunity to set up the Pediatric Surgery programs at both Freedmen's and DC General Hospitals. But before that was possible, a most important thing had to occur, namely, the establishment of a Howard University Teaching Program at DC General Hospital. After my return to Howard University to teach early in 1957, at the invitation of Dr Clarence Greene (then professor of neurosurgery and head of the department of surgery), I became closely associated with the dean of the medical school, Dr Robert S. Jason. Negotiations were just evolving that would lead to the full integration of Howard University's medical teaching programs into DC General Hospital. Dr Jason asked me to join him in his discussions with the deans' offices at Georgetown and George Washington University Medical Schools on the redivision of teaching services at DC General Hospital so as to create a third and new Howard University Program. I felt quite privileged to have been selected for this role by Dean Jason, who felt that my previous role as the first Howard University physician to be on the resident staff at the old Gallinger Hospital would be helpful. Ultimately, after having had responsibility for the redesignation of services, I became coordinator (assistant dean) for the five Howard University teaching services at DC General Hospital. The ferment of change favoring the integration of the US health-care system had accelerated in Washington, DC, during this time. Considerable credit for this process must be given to the unceasing activities of the late Dr William Montague Cobb. Dr Cobb, like Dr Drew, had been born and raised in meager circumstances in Washington, DC, and both had the unusual opportunity to attend Amherst College. It is singular that both would return to their hometown to play unique roles in the evolution of medical teaching and training at Howard University and, in the ultimate, integration of health-care services in the District of Columbia. Both Dr Cobb and Dr Drew had been born just prior to the Flexner Report of 1909 titled Medical Education in the United States and Canada, and both graduated from medical school just 20 years after that. Although Dr Drew had not attended Howard University's medical school, as had Dr Cobb, he was, nevertheless, committed to its growth and development. The Flexner Report was the most significant single thing to affect medical education in the United States in this century What is not generally recognized is that the Flexner Report could have maintained and firmly entrenched an JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
underclass of second-class black physicians had its effects been allowed to run their course unopposed. At the turn of the century, segregation had become firmly entrenched in the United States. Although there are black medical graduates from the so-called white schools dating back to the 1850s, most black medical graduates were being produced by several proprietary schools and smaller academic programs. After the Civil War, a considerable amount of effort was directed toward the education of blacks, and several institutions were producing black physicians. These included the College of Medicine at Howard University (1869) and Meharry Medical College, a part of Walden University (1876). Chapter XIV of the Flexner Report came close to establishing a permanent underclass of black physicians.
THE FLEXNER REPORT The Johns Hopkins University, a newcomer to the field of higher education, had available unusual resources for bringing from Europe or sending to Europe future teachers of a brand new highly competitive medical school, so competitive, in fact, that it soon was giving Harvard Medical School a run for its money in the advancement of the clinical and basic sciences in the United States. One of the Hopkins' stars was Dr Abraham Flexner, a bacteriologist. The Carnegie Foundation undertook the task of looking into the status of education above the secondary school level in North America, and in 1909, Dr Flexner prepared a report entitled Medical Education in the United States and Canada, which strongly influenced the setting of standards for medical colleges and led to the closing of all Negro medical training institutions then in existence except Howard and Meharry. Howard University's College of Medicine had been established in 1869 and always was a part of the parent university. Meharry Medical College Colored was established in 1876 and was originally the medical department of Walden University. At that time, there were eight medical schools devoted to the education and training of Negro physicians. It is of value to read the introduction to the Flexner report and, especially, to read chapter XIV, entitled "The Medical Education of the Negro."7 In so doing, one can gain an understanding of the status of blacks in that day and the low esteem in which they were held. I am sure that Flexner was caught up in the feelings of his time, which may explain the disparaging tone in which the training, indeed the conceptualization of a Negro physician, was described. The following quotes reveal this. 285
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The practice of the negro doctor will be limited to his own race, which in turn will be cared for better by good negro physicians than by poor white ones. The negro must be educated not only for his sake, but for ours.
He has his rights and due and value as an individual; but he has, besides, the tremendous importance that belongs to a potential source of infection and contagion. A well taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an MD badge is dangerous.
The negro needs good schools rather than many schools, to which the promising of the race can be sent to receive a substantial education in which hygiene rather than surgery, for example, is strongly accentuated. If at the same time these men can be imbued with the missionary spirit so that they will look upon the diploma as a commission to serve their people humbly and devotedly, they may play an important role in the sanitation and civilization of the whole nation.
Today, the Flexner Report is viewed as the greatest milestone in the annals of medical education in America, and, in many ways, it was. The other side of the Flexner report, as it dealt with provision of medical education for blacks, is seldom noted. Because of the fame of the Flexner Report and the willingness of medical educators to revere its many aspects, there was, I am certain, a perpetuation of the negative and derogatory conceptualization of the black man as of such inferior status as to not be considered seriously for medical education and training beyond that conceived as providable by Howard and Meharry and the handful of segregated hospitals that existed prior to the civil rights movement. It is patently obvious that Dr Abraham Flexner had every intention to maintain a strict pattern of racial segregation and an inferior status for the black physician in the process.
THE AGE OF ENLIGHTENMENT: EDUCATION AND TRAINING OF BLACK PHYSICIANS Dr Cobb and Dr Drew were both born in relatively meager circumstances approximately 4 years before the Flexner Report of 1909, in Washington, DC, the segregated capital of the United States. Both achieved a creditable academic record; both were accepted at Amherst where Dr Drew excelled exceptionally in athletics; and both were greatly stimulated by their 286
academic experience and ultimately accepted to medical schools, Drew at McGill and Cobb at Howard. From here, their courses diverged before coming together again teaching at Howard University's medical school. In the meantime, each miraculously achieved admittance to postgraduate training programs. Dr Numa P.G. Adams, the first black dean at the College of Medicine of Howard University, had succeeded in gaining the attention of philanthropic organizations with the objective of clearly establishing Howard as a "class A" medical school (according to Flexner's own classification) and, in the process, creating a highly educated and trained black faculty to carry on and sustain it in the future. Young promising black physicians were identified, and if postgraduate training was needed, the necessary clout and finances were provided to gain their acceptance to programs previously closed to blacks. Dr Cobb, as a part of that program, went to Western Reserve University and earned a PhD in anatomy. Dr Drew was able to proceed under his own steam and, amazingly (due to the illness of another prospective resident), succeeded in getting surgical training at Columbia University. It was through that connection that he later performed the research, along with Dr Scudder, leading to the development of lyophilized blood plasma. Dr Cobb returned to teach in the anatomy department at Howard, which he continued to do for 48 years, serving for 22 of those years as chairman of the department. Dr Drew came to Howard to teach in the surgery department where he ultimately became head of the department, a post that at the time was occupied by a faculty member from Columbia University. Each of these men was deeply dedicated to the education of black physicians, but, in addition, each had his own ultimate goal. Dr Drew envisaged the training of black surgeons who would be chiefs of surgery throughout the land. Dr Cobb was interested in changing the practice of medicine to the extent that black physicians would achieve full parity with their white counterparts. Thus, I became a willing pawn in the plan of each man when I came to DC General Hospital as the first black resident. Dr Cobb was a forceful writer and public speaker. He sought to develop every forum possible to further desegregate US medical education and hospital systems. During his lifetime, he published more than 660 articles and five books. Dr Cobb served leadership roles of various types over the years in the Medico-Surgical Society of the District of Columbia, the National Medical Association, and other organizations as well. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
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His writings in their organs were scientific, covering a wide range of medical topics (physical anthropology, public health, comparative human anatomy, dental morphology, medical history, and medical education), and also sounded the clarion call in the fight against medical segregation. He edited The Journal of the National Medical Association for 28 years. Over the years, Dr Cobb became more and more involved with the National Association for the Advancement of Colored People (NAACP) serving it in many ways including the role of national president. Two pamphlets that Dr Cobb wrote for the NAACP in 1947 and 1948 succeeded in gaining national attention. These pamphlets were "Medical Care and the Plight of the Negro," in which he described the "negro medical ghetto," and, "Progress and Portents for the Negro in Medicine," which traced, in historical perspective, the sorry story of the closure of black medical schools, the restrictive posture further limiting the training of blacks to Howard and Meharry, and the impossibility of achieving black parity in medicine as a consequence. Dr Cobb organized a series of seven Imhotep National Conferences on hospital integration, starting in 1957*; the first was held in a local black church in Washington. All this, along with the civil rights movement, was a part of what led to the Civil Rights Act of 1964. Dr Cobb called the signing of this legislation by President Johnson the eighth Imhotep conference. It was a great stroke of history and opportunity that allowed me also to participate in the first and the eighth Imhotep Conferences, the civil rights movement itself, and, yes, the integration of DC General Hospital.
MOVING BEYOND THE ALMS HOUSE As I look out over the audience, I recognize some of you who were young residents during those early days when I served at DC General Hospital. Dr Barber and others have related some of the achievements of you and your associates of which we can all be proud. Especially, I am proud of the achievements of the pediatrics department under the able leadership of Dr Stanley Sinkford in the lowering of neonatal mortality at DC General, a singular achievement in this time of crack addiction. Dr Sinkford is one who was here with me in those early days of the establishment of the Howard University teaching services. My hat goes off to him for continuing to fight the good fight. *lmhotep ("He who cometh in peace") is the name of an ancient Egyptian physician, the first in recorded history, who lived 100 years. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
Now, what could I envision in the future of DC General? What do I see that can be done with the magnificent human potential existing here today? My thoughts go back to what I read about the history of Massachusetts General Hospital and its beginnings as the alms house hospital for Boston in 1821. It is common knowledge what has become of Massachusetts General and its role in academic medicine and the creation and application of new knowledge at the cutting edge of medical care. DC General Hospital could become a proving ground for the delivery of premium health care, delivered to the private as well as the indigent patient. I believe that we have reached that point where it is neither efficient nor effective to continue to deliver health care in a mode that differentiates between the "worthy" and the "unworthy" poor. With the advent of Titles XVIII and XIX, there is funding for many who would have been previously considered the "unworthy" poor. Perhaps many have now indeed become "worthy," in the process? Would it not be desirable to add that increment of funding necessary to assure first-class institutional care to the expanded "worthy" poor category? Could this not be done in a way such that the expenditures of Title XVIII and XIX funds would become much more cost effective? Would this not, at the same time, improve the care for all who qualify? Would the improvement of care, made possible thereby, make DC General Hospital desirable for private patients as well? Would it be possible, through such increased incremental funding by the District of Columbia or the federal government in the upgrading of DC General Hospital, to make this possible, that it might pay oft in the process, by making the burden of the "unworthy" poor less burdensome because part of the cost would be offset by the improved funding possibilities for Title XVIII, Title XIX, and private insurance coverage? To my way of thinking, it is through the public/private care split that the city hospitals might lead the way again, this time in the arena for improved and more cost effective health care. The new mayoral administration in Washington, DC, might be interested in taking the leadership for the development of such a model because of its unique relationship to federal funding sources and
responsibilities. The second arena is that of clinical research. I have always thought that DC General has not been developed by the local medical education institutions to the degree that it could be for purposes of clinical research. In this case, I look again at the model of Boston City Hospital, which has long been a major medical research base for 287
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Harvard and Boston Universities. An expansion of such a base at DC General Hospital and its recognition as a center of excellence in medical research along with the kind of upgrading of medical care that would be supported by the District of Columbia and federal governments, as suggested above, would greatly enhance achievement of the public/private split proposed above. Lastly, an expanded role of responsibility for DC General Hospital in the provision of primary health care in the various health-care centers throughout the community would enhance the hospital's image while, at the same time, assure a high standard of health care in a quite different way from the traditional outpatient department model. It would be reasonable to expect that if this involvement in primary health care were widespread enough, it would have a beneficial effect on medical care costs (by lowering hospitalization rates) for the District government, thereby offsetting some of the proposed increased investment in DC General Hospital itself as suggested earlier.
CLOSING COMMENTS I have thoroughly enjoyed having the opportunity to return to DC General Hospital to share with you some
of the history that I was privileged to witness and be a part of. I am indeed pleased to know that what I was involved in years ago, leading to the racial integration of this institution, has paid off in so many ways. Literature Cited 1. Vogel MJ. Machine politics and medical care: the city hospital at the turn of the century. In: The Therapeutic Revolution: Essays in the Social History of American Medicine. Philadelphia, Pa:University of Pennsylvania Press;1979:159175. 2. Viets HR. The resident house staff at the opening of Boston City Hospital in 1864. Journal of History of Medicine. April 1959:170-190 3. Kerson TS. Alms house to municipal hospital: the Baltimore experience. Bull Hist Med. 1981;55:203-220. 4. Friedman E. Public hospitals: doing what everyone wants done but few others wish to do. JAMA. 1987;257:14371439, 1443-1444. 5. Beardsley EH. Good-bye to Jim Crow: the desegregation of southern hospitals, 1945-1970. Bull Hist Med. 1 986;60:367-386. 6. Sackinger DL. A Brief History of District of Columbia General Hospital. Washington, DC:District of Columbia Department of Public Health;1951. 7. International Library of Negro Life and History. The History of the Negro in Medicine. New York, NY:Publishers Company Inc;1967:224-228.
TO SAY ThANK YOIL To those of you who give your time or your gifts for day care for the young, health care for the elderly, mental health programs for all Americans, we say thank you. _ We are your neighbors, your friends, members of the community who benefit from your generosity. Thank you for giving. Thank you for caring. Thank you for becoming united. UnitedWag
THANKS TO YOU IT WORKS FOR ALL OF US.
4
1965 UNITED WRY
THE ADVERTISING COUNCIL C
In this address, I am going to begin with a very brief review of the historical origins of city hospitals. Then, I shall switch to the history of city hospitals in the United States, indicating their close association with the evolution of medical care and medical teaching in this country.' Ultimately, I shall tell you the story of DC General's unique contribution to medical care delivery in Washington, DC, and how Howard University played a catalytic role in initiating the changes leading to that contribution. In the process, you will learn more about the roles of two professors and one resident from the Howard University College of Medicine and Freedmen's Hospital who were deeply involved.
THE CITY HOSPITAL: AT THE FOREFRONT OF PROGRESS In preparation for this address, I decided to search the literature for the history of city hospitals. The oldest city hospital in the United States was the old Philadelphia General Hospital, which was founded in 1731 (unfortunately it closed in 1977). Following closely were Bellevue Hospital in New York and Charity Hospital in New Orleans (both founded in 1736), Baltimore (1776), Washington, DC (1806), Cleveland (1837), Boston (1864),2 Cook County (1866), Seattle (1877), and Los Angeles (1878). Massachusetts General Hospital (1821) was originally on that list but with the founding of Boston City Hospital it was moved up a peg. It is important to recognize the alms house origins of the city hospitals.3 Our alms house tradition has its origins in medieval England and is traceable to Henry Address delivered at the District of Columbia General Hospital, Washington, DC, on March 29, 1991. Requests for reprints should be addressed to Dr David M. French, Medical Director, Helen Keller Intl Inc, 15 W 16th St, New York, NY 10011. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
VIII and his battles with the Catholic Church. In his elimination of the Catholic Church from England, he eliminated, in the process, all the public institutions that had been supported by the Church, including its various alms houses, asylums, and other societal support institutions. England, at the local level, was, consequently, inundated with the aged, the chronically ill and permanently disabled, homeless women before and during childbirth, foundlings and orphans, the insane, the feebleminded, and alcoholics along with those with the usual medical and surgical illnesses who were poor or destitute (ie, without family support). The concept of the "unworthy" patient took hold and these were viewed as "inmates" of the new institutional structure-alms houses. Dr David Rothman, director of the Center for the Study of Society and Medicine at the Columbia University College of Physicians and Surgeons, has noted, "The essential function of the alms house, until the 1830s, was to serve as the great catch-all: it housed those who were unattached to family or other social support and who had no call on private charity. The worthy poor were connected to family, friends, or church. The unworthy poor were unconnected." According to Rothman, there was a feeling in the early 19th century that the development of separate institutional environments would better solve many existing problems through institutional discipline and habits of order. Prisons, orphan asylums, insane asylums, and others were set up, draining off from the alms houses all but the medical and quasimedical populations. The other great factor dictating change during this period (in the last half of the 19th century) was the increased growth of medical and scientific knowledge and the recognition by physicians that they had a captive patient population affording a large number of 283
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cases for study in the newly arising city hospitals. The history of modem medicine and its advances is replete with the names of the great in American medicine who had a considerable base within the city hospitals. " The most stigmatized of institutions became the teaching grounds of the most prestigious of physicians."4 It would seem that we have another noteworthy example of city hospitals being in the forefront of American medicine in that the integrated and accelerated development of black health professionals largely started in the city hospitals, leading to the wider acceptance and integration of blacks throughout the medical world.5 The city hospital has afforded the proving ground that ultimately allowed the breakthrough of the barrier that had been created by Dr Abraham Flexner in his report of 1909. I first came to the Gallinger Hospital6 (before it became DC General) as a second-year surgical resident on July 1, 1950. I had come from the Freedmen's Hospital Surgical Residency Training Program as the first black resident ever at Gallinger Hospital. Dr Charles R. Drew chose me to be a pioneer at the frontier of integration of the severely segregated medical care system that existed in Washington, DC, at that time. Black practitioners of that day were not allowed in any of the hospitals of the District of Columbia except for the Freedmen's Hospital, a vestige of one of the three old Freedmen's Bureaus set up after the Civil War. To my knowledge, this was the only one of the three that had a sizeable health facility for use by the newly freed men, and, its facilities being in proximity to Howard University, (which had been established along with its medical school in 1869) became the teaching hospital for the College of Medicine of Howard University. This island of medical care and medical education existed quite isolated from the other medical care and medical education facilities of the District of Columbia. Dr Drew was one of the new breed of well-trained black medical academicians who had risen through the efforts of the first black dean of the medical school, Dr Numa P.G. Adams, with funding from the General Education Board and the Rosenwald Foundation. They became, ultimately, the new chiefs of services and departments and replaced what had previously been, to a large extent, white practitioners and educators. Although Dr Drew did not owe his own education and training to the special efforts underway with funding from the above sources (he had managed this miraculously on his own merit, quite separately), he had a profound conviction that black physicians could compete if given the opportunity, and his life and career were dedicated to 284
proving that point. I became a small part of Dr Drew's dream by pioneering as a Georgetown surgical resident at DC General Hospital. Dr Robert Coffey, chief of surgery at Georgetown, and Dr Drew had become friendly, and Dr Drew challenged him late in 1949 to take one of his surgical residents for a year at Gallinger Hospital. In February or March of 1950, Dr Drew casually informed me one afternoon at the basement lunch counter at Freedmen's Hospital that he had settled on my being that first resident at Gallinger Hospital. I was flabbergasted. In the early hours of Saturday, April 1, 1950, Dr Drew was tragically killed in an automobile accident in rural North Carolina. Those of you who did not have the opportunity to know Dr Drew personally cannot imagine what a profound impact his death had on us at Howard University and Freedmen's Hospital. I firmly resolved to live my life as a physician in a way that would have made him proud and, most of all, to carry out my responsibilities as a pioneer at Gallinger Hospital such that others would be allowed to follow my example. This was the case, and along with trainees from the Howard University Department of Pediatrics under the leadership of Dr Roland Scott, chief of pediatrics at Freedmen's Hospital, Howard University established a toe-hold at Gallinger Hospital for postgraduate training opportunities for black physicians, the first in Washington, DC, outside Freedmen's Hospital. My next contact with the since renamed DC General Hospital came in 1960. I had finished my surgical training at Freedmen's Hospital along with Dr Jesse Barber (now president of the staff at DC General Hospital), had done a short stint in Detroit in the private practice of surgery, had returned to Howard University to teach in the surgery department, and had been to Children's Memorial Hospital in Chicago to train in pediatric surgery with emphasis on cardiovascular surgery. Interest in cardiovascular surgery had come my way as a result of working with the late Dr Charles Hufnagel, then newly appointed to the department of surgery at Georgetown. He had come from Children's Hospital in Boston where he was doing experimental cardiovascular surgery, trying to develop an artificial heart valve. I was at Gallinger when Dr Hufnagel arrived, and I became fascinated by his work. Cardiovascular surgery was just getting its foothold, and I had the marvelous opportunity to be exposed to it as an aspect of thoracic surgery under Dr Edgar Davis, chief of thoracic surgery at Georgetown. In the process, I got to scrub on the early cardiovascular surgery cases at Gallinger Hospital, including the first installation of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
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the new Hufnagel valve for aortic valvular disease. On returning from my subspecialty training at Children's Memorial Hospital in Chicago, I had the opportunity to set up the Pediatric Surgery programs at both Freedmen's and DC General Hospitals. But before that was possible, a most important thing had to occur, namely, the establishment of a Howard University Teaching Program at DC General Hospital. After my return to Howard University to teach early in 1957, at the invitation of Dr Clarence Greene (then professor of neurosurgery and head of the department of surgery), I became closely associated with the dean of the medical school, Dr Robert S. Jason. Negotiations were just evolving that would lead to the full integration of Howard University's medical teaching programs into DC General Hospital. Dr Jason asked me to join him in his discussions with the deans' offices at Georgetown and George Washington University Medical Schools on the redivision of teaching services at DC General Hospital so as to create a third and new Howard University Program. I felt quite privileged to have been selected for this role by Dean Jason, who felt that my previous role as the first Howard University physician to be on the resident staff at the old Gallinger Hospital would be helpful. Ultimately, after having had responsibility for the redesignation of services, I became coordinator (assistant dean) for the five Howard University teaching services at DC General Hospital. The ferment of change favoring the integration of the US health-care system had accelerated in Washington, DC, during this time. Considerable credit for this process must be given to the unceasing activities of the late Dr William Montague Cobb. Dr Cobb, like Dr Drew, had been born and raised in meager circumstances in Washington, DC, and both had the unusual opportunity to attend Amherst College. It is singular that both would return to their hometown to play unique roles in the evolution of medical teaching and training at Howard University and, in the ultimate, integration of health-care services in the District of Columbia. Both Dr Cobb and Dr Drew had been born just prior to the Flexner Report of 1909 titled Medical Education in the United States and Canada, and both graduated from medical school just 20 years after that. Although Dr Drew had not attended Howard University's medical school, as had Dr Cobb, he was, nevertheless, committed to its growth and development. The Flexner Report was the most significant single thing to affect medical education in the United States in this century What is not generally recognized is that the Flexner Report could have maintained and firmly entrenched an JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
underclass of second-class black physicians had its effects been allowed to run their course unopposed. At the turn of the century, segregation had become firmly entrenched in the United States. Although there are black medical graduates from the so-called white schools dating back to the 1850s, most black medical graduates were being produced by several proprietary schools and smaller academic programs. After the Civil War, a considerable amount of effort was directed toward the education of blacks, and several institutions were producing black physicians. These included the College of Medicine at Howard University (1869) and Meharry Medical College, a part of Walden University (1876). Chapter XIV of the Flexner Report came close to establishing a permanent underclass of black physicians.
THE FLEXNER REPORT The Johns Hopkins University, a newcomer to the field of higher education, had available unusual resources for bringing from Europe or sending to Europe future teachers of a brand new highly competitive medical school, so competitive, in fact, that it soon was giving Harvard Medical School a run for its money in the advancement of the clinical and basic sciences in the United States. One of the Hopkins' stars was Dr Abraham Flexner, a bacteriologist. The Carnegie Foundation undertook the task of looking into the status of education above the secondary school level in North America, and in 1909, Dr Flexner prepared a report entitled Medical Education in the United States and Canada, which strongly influenced the setting of standards for medical colleges and led to the closing of all Negro medical training institutions then in existence except Howard and Meharry. Howard University's College of Medicine had been established in 1869 and always was a part of the parent university. Meharry Medical College Colored was established in 1876 and was originally the medical department of Walden University. At that time, there were eight medical schools devoted to the education and training of Negro physicians. It is of value to read the introduction to the Flexner report and, especially, to read chapter XIV, entitled "The Medical Education of the Negro."7 In so doing, one can gain an understanding of the status of blacks in that day and the low esteem in which they were held. I am sure that Flexner was caught up in the feelings of his time, which may explain the disparaging tone in which the training, indeed the conceptualization of a Negro physician, was described. The following quotes reveal this. 285
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The practice of the negro doctor will be limited to his own race, which in turn will be cared for better by good negro physicians than by poor white ones. The negro must be educated not only for his sake, but for ours.
He has his rights and due and value as an individual; but he has, besides, the tremendous importance that belongs to a potential source of infection and contagion. A well taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an MD badge is dangerous.
The negro needs good schools rather than many schools, to which the promising of the race can be sent to receive a substantial education in which hygiene rather than surgery, for example, is strongly accentuated. If at the same time these men can be imbued with the missionary spirit so that they will look upon the diploma as a commission to serve their people humbly and devotedly, they may play an important role in the sanitation and civilization of the whole nation.
Today, the Flexner Report is viewed as the greatest milestone in the annals of medical education in America, and, in many ways, it was. The other side of the Flexner report, as it dealt with provision of medical education for blacks, is seldom noted. Because of the fame of the Flexner Report and the willingness of medical educators to revere its many aspects, there was, I am certain, a perpetuation of the negative and derogatory conceptualization of the black man as of such inferior status as to not be considered seriously for medical education and training beyond that conceived as providable by Howard and Meharry and the handful of segregated hospitals that existed prior to the civil rights movement. It is patently obvious that Dr Abraham Flexner had every intention to maintain a strict pattern of racial segregation and an inferior status for the black physician in the process.
THE AGE OF ENLIGHTENMENT: EDUCATION AND TRAINING OF BLACK PHYSICIANS Dr Cobb and Dr Drew were both born in relatively meager circumstances approximately 4 years before the Flexner Report of 1909, in Washington, DC, the segregated capital of the United States. Both achieved a creditable academic record; both were accepted at Amherst where Dr Drew excelled exceptionally in athletics; and both were greatly stimulated by their 286
academic experience and ultimately accepted to medical schools, Drew at McGill and Cobb at Howard. From here, their courses diverged before coming together again teaching at Howard University's medical school. In the meantime, each miraculously achieved admittance to postgraduate training programs. Dr Numa P.G. Adams, the first black dean at the College of Medicine of Howard University, had succeeded in gaining the attention of philanthropic organizations with the objective of clearly establishing Howard as a "class A" medical school (according to Flexner's own classification) and, in the process, creating a highly educated and trained black faculty to carry on and sustain it in the future. Young promising black physicians were identified, and if postgraduate training was needed, the necessary clout and finances were provided to gain their acceptance to programs previously closed to blacks. Dr Cobb, as a part of that program, went to Western Reserve University and earned a PhD in anatomy. Dr Drew was able to proceed under his own steam and, amazingly (due to the illness of another prospective resident), succeeded in getting surgical training at Columbia University. It was through that connection that he later performed the research, along with Dr Scudder, leading to the development of lyophilized blood plasma. Dr Cobb returned to teach in the anatomy department at Howard, which he continued to do for 48 years, serving for 22 of those years as chairman of the department. Dr Drew came to Howard to teach in the surgery department where he ultimately became head of the department, a post that at the time was occupied by a faculty member from Columbia University. Each of these men was deeply dedicated to the education of black physicians, but, in addition, each had his own ultimate goal. Dr Drew envisaged the training of black surgeons who would be chiefs of surgery throughout the land. Dr Cobb was interested in changing the practice of medicine to the extent that black physicians would achieve full parity with their white counterparts. Thus, I became a willing pawn in the plan of each man when I came to DC General Hospital as the first black resident. Dr Cobb was a forceful writer and public speaker. He sought to develop every forum possible to further desegregate US medical education and hospital systems. During his lifetime, he published more than 660 articles and five books. Dr Cobb served leadership roles of various types over the years in the Medico-Surgical Society of the District of Columbia, the National Medical Association, and other organizations as well. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
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His writings in their organs were scientific, covering a wide range of medical topics (physical anthropology, public health, comparative human anatomy, dental morphology, medical history, and medical education), and also sounded the clarion call in the fight against medical segregation. He edited The Journal of the National Medical Association for 28 years. Over the years, Dr Cobb became more and more involved with the National Association for the Advancement of Colored People (NAACP) serving it in many ways including the role of national president. Two pamphlets that Dr Cobb wrote for the NAACP in 1947 and 1948 succeeded in gaining national attention. These pamphlets were "Medical Care and the Plight of the Negro," in which he described the "negro medical ghetto," and, "Progress and Portents for the Negro in Medicine," which traced, in historical perspective, the sorry story of the closure of black medical schools, the restrictive posture further limiting the training of blacks to Howard and Meharry, and the impossibility of achieving black parity in medicine as a consequence. Dr Cobb organized a series of seven Imhotep National Conferences on hospital integration, starting in 1957*; the first was held in a local black church in Washington. All this, along with the civil rights movement, was a part of what led to the Civil Rights Act of 1964. Dr Cobb called the signing of this legislation by President Johnson the eighth Imhotep conference. It was a great stroke of history and opportunity that allowed me also to participate in the first and the eighth Imhotep Conferences, the civil rights movement itself, and, yes, the integration of DC General Hospital.
MOVING BEYOND THE ALMS HOUSE As I look out over the audience, I recognize some of you who were young residents during those early days when I served at DC General Hospital. Dr Barber and others have related some of the achievements of you and your associates of which we can all be proud. Especially, I am proud of the achievements of the pediatrics department under the able leadership of Dr Stanley Sinkford in the lowering of neonatal mortality at DC General, a singular achievement in this time of crack addiction. Dr Sinkford is one who was here with me in those early days of the establishment of the Howard University teaching services. My hat goes off to him for continuing to fight the good fight. *lmhotep ("He who cometh in peace") is the name of an ancient Egyptian physician, the first in recorded history, who lived 100 years. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
Now, what could I envision in the future of DC General? What do I see that can be done with the magnificent human potential existing here today? My thoughts go back to what I read about the history of Massachusetts General Hospital and its beginnings as the alms house hospital for Boston in 1821. It is common knowledge what has become of Massachusetts General and its role in academic medicine and the creation and application of new knowledge at the cutting edge of medical care. DC General Hospital could become a proving ground for the delivery of premium health care, delivered to the private as well as the indigent patient. I believe that we have reached that point where it is neither efficient nor effective to continue to deliver health care in a mode that differentiates between the "worthy" and the "unworthy" poor. With the advent of Titles XVIII and XIX, there is funding for many who would have been previously considered the "unworthy" poor. Perhaps many have now indeed become "worthy," in the process? Would it not be desirable to add that increment of funding necessary to assure first-class institutional care to the expanded "worthy" poor category? Could this not be done in a way such that the expenditures of Title XVIII and XIX funds would become much more cost effective? Would this not, at the same time, improve the care for all who qualify? Would the improvement of care, made possible thereby, make DC General Hospital desirable for private patients as well? Would it be possible, through such increased incremental funding by the District of Columbia or the federal government in the upgrading of DC General Hospital, to make this possible, that it might pay oft in the process, by making the burden of the "unworthy" poor less burdensome because part of the cost would be offset by the improved funding possibilities for Title XVIII, Title XIX, and private insurance coverage? To my way of thinking, it is through the public/private care split that the city hospitals might lead the way again, this time in the arena for improved and more cost effective health care. The new mayoral administration in Washington, DC, might be interested in taking the leadership for the development of such a model because of its unique relationship to federal funding sources and
responsibilities. The second arena is that of clinical research. I have always thought that DC General has not been developed by the local medical education institutions to the degree that it could be for purposes of clinical research. In this case, I look again at the model of Boston City Hospital, which has long been a major medical research base for 287
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Harvard and Boston Universities. An expansion of such a base at DC General Hospital and its recognition as a center of excellence in medical research along with the kind of upgrading of medical care that would be supported by the District of Columbia and federal governments, as suggested above, would greatly enhance achievement of the public/private split proposed above. Lastly, an expanded role of responsibility for DC General Hospital in the provision of primary health care in the various health-care centers throughout the community would enhance the hospital's image while, at the same time, assure a high standard of health care in a quite different way from the traditional outpatient department model. It would be reasonable to expect that if this involvement in primary health care were widespread enough, it would have a beneficial effect on medical care costs (by lowering hospitalization rates) for the District government, thereby offsetting some of the proposed increased investment in DC General Hospital itself as suggested earlier.
CLOSING COMMENTS I have thoroughly enjoyed having the opportunity to return to DC General Hospital to share with you some
of the history that I was privileged to witness and be a part of. I am indeed pleased to know that what I was involved in years ago, leading to the racial integration of this institution, has paid off in so many ways. Literature Cited 1. Vogel MJ. Machine politics and medical care: the city hospital at the turn of the century. In: The Therapeutic Revolution: Essays in the Social History of American Medicine. Philadelphia, Pa:University of Pennsylvania Press;1979:159175. 2. Viets HR. The resident house staff at the opening of Boston City Hospital in 1864. Journal of History of Medicine. April 1959:170-190 3. Kerson TS. Alms house to municipal hospital: the Baltimore experience. Bull Hist Med. 1981;55:203-220. 4. Friedman E. Public hospitals: doing what everyone wants done but few others wish to do. JAMA. 1987;257:14371439, 1443-1444. 5. Beardsley EH. Good-bye to Jim Crow: the desegregation of southern hospitals, 1945-1970. Bull Hist Med. 1 986;60:367-386. 6. Sackinger DL. A Brief History of District of Columbia General Hospital. Washington, DC:District of Columbia Department of Public Health;1951. 7. International Library of Negro Life and History. The History of the Negro in Medicine. New York, NY:Publishers Company Inc;1967:224-228.
TO SAY ThANK YOIL To those of you who give your time or your gifts for day care for the young, health care for the elderly, mental health programs for all Americans, we say thank you. _ We are your neighbors, your friends, members of the community who benefit from your generosity. Thank you for giving. Thank you for caring. Thank you for becoming united. UnitedWag
THANKS TO YOU IT WORKS FOR ALL OF US.
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1965 UNITED WRY
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