Louis T Wright, MD, FACS (1891 to 1952), and the Integration of American Medicine Don K Nakayama,
MD, MBA, FACS
Louis T Wright, MD, (1891 to 1952, Fig. 1) was the most prominent African-American surgeon of the first half of the 20th century. Growing up in the Jim Crow South, training in medicine at Harvard, and practicing as the country’s most prominent black surgeon during the Harlem Renaissance, he faced racial animus throughout his life. He advanced racial integration of all hospitals, medical schools, and training programs. He opposed accommodation to segregation, especially all-black hospitals. With a commanding personality and in key positions in both medicine and racial politics, he shaped the integration of US medicine. His legacy came 12 years after his death, when the Civil Rights Act of 1964 outlawed discrimination on the basis of race in all public and federally supported facilities, including hospitals. Despite his impact, Wright is not widely known in medical history. Most of the material in this article draws from recent summaries of his work with the National Association for the Advancement of Colored People (NAACP) by physician-historian P Preston Reynolds1 and a selfpublished biography by Robert C Hayden, not widely circulated but available through an internet vendor.2 Wright became the second African-American Fellow of the American College of Surgeons (ACS)3 and brought other qualified black surgeons into the organization,4 2 important stories reviewed by others and not included in this article. Figure 1. Louis T Wright, MD, 1891 to 1952. (From: the Harvard Medical Library in the Francis A Countway Library of Medicine, Cambridge, MA, with permission.)
Racial inequities in health care W Montague Cobb, of Howard University, studied health care among African Americans in the early 20th century; his grim statistics summarized by Reynolds.1 Experts at the time estimated the need for physicians at 1 for 750 persons. For African Americans, that ratio was 1 for 3,377; in Mississippi, it was 1 for 18,527. Of the 1.5 million hospital beds in the country, only 15,000 e 1% e were open to
black patients. In some areas, only 75 beds were open to 1 million African Americans, far below the national target of 4.5 beds per 1,000 persons. Without access to community hospitals, African-American patients were treated in proprietary hospitals owned by black physicians, themselves barred from practice in established facilities. Of the 112 allblack hospitals in the US, the ACS had accredited only 25. Training opportunities for African-American physicians and surgeons were similarly limited. All 26 medical schools in the South, except Howard Medical College in Washington, DC and Meharry Medical College in Nashville, TN, refused black applicants’ admission. Of the 52 schools in the North, only 82 of the 590 African-American medical students attended schools other than Howard and Meharry. Eighty-five of the 116 positions open to African-American trainees in the country were in only 4 all-black hospitals.1
Disclosure Information: Nothing to disclose. Dr Nakayama received a grant from the Southern Surgical Association, Joseph M Donald Endowment Fund. Presented at the Southern Surgical Association 125th Annual Meeting, Hot Springs, VA, December 2013. Received December 5, 2013; Accepted December 10, 2013. From the Department of Surgery, West Virginia University School of Medicine, Morgantown, WV. Correspondence address: Don K Nakayama, MD, MBA, FACS, 1 Medical Center Dr, PO Box 9238, Health Sciences Center South, Suite 7700, Morgantown, WV 26506-9238. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
869
ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.040
870
Nakayama
Louis T Wright
Jim Crow laws maintained a separate system for black patients and doctors in the South, a “separate but equal” principle that the US Supreme Court held as constitutional in its 1896 Plessy vs Ferguson decision. Segregation was present to nearly the same extent in the North, where medical schools did not select African-American students, training programs chose not to train minority interns and residents, and hospital staffs ignored the applications of black physicians for privileges. How to confront centuries-long racial discrimination is a classic debate that continues today, embodied by 2 titanic figures in US history, Booker T Washington (1856 to 1915) and WEB Du Bois (1868 to 1963). A Frontline television documentary from 1998 (available online) gave a useful introduction.5 Washington preached self-help, individual achievement, and the development of black institutions that eventually would become integrated into mainstream white society. Saying that Washington’s strategy would only perpetuate inequality and white oppression, Du Bois demanded equal rights and access to all institutions through a politically active civil rights agenda. His stance was radically aggressive given the magnitude of racism and the wide gulf that separated black from white society. Washington’s approach appealed to many physicians as more achievable: Accommodation to the reality of being an African American in that era and provision of the best care to their patients within the resources available, embracing a windfall should it come, often from a progressive philanthropist. Wright and others took Du Bois’ stance. They saw the difference in schools and hospitals that were open to Caucasians but closed to them, but supported by taxes everyone paid. Black patients had far inferior facilities that their doctors owned and kept financially afloat. Wright defined integration in health care as a core issue of the civil rights movement. His dedication and leadership led to integration in health care that forever changed American medicine. Growing up in Georgia Wright was born July 23, 1891 in LaGrange, GA, a textile town 60 miles southwest of Atlanta. His mother, Lula Tomkins Wright, was a teacher. Born into slavery, his father, Ceah Ketcham Wright, attended Meharry and became a physician. The elder Wright, who had abandoned his practice for a Methodist ministry, died when young Louis was only 4 years old. The family moved to Atlanta, where the mother returned to teaching at Clark College, a Methodist freedmen’s school in Atlanta.1 There she married William Fletcher Penn (1871 to 1934), who had become, in 1897, Yale University’s first AfricanAmerican medical school graduate.6 He was attending
J Am Coll Surg
the Leonard Medical School for Blacks in Raleigh, NC, when he had the opportunity to perform with a local college quartet on a concert tour. While in New Haven, CT, he happened to meet an influential Yale medical school faculty member who helped him gain admittance there in 1893. He earned high marks and was editor of the medical school class yearbook. Returning to Atlanta, Dr Penn, barred from established hospitals, started a proprietary hospital where he could practice.1 Dr Penn formed a fast relationship with his stepson and took him on house calls, the boy waiting in the car while his father visited a patient. Car ownership among African Americans then was rare, and the Penn vehicle attracted the attention of stone-throwing thugs.1 Racial tension exploded in the Atlanta Riot of 1906. Gangs of white men, estimated in the thousands, swarmed the African-American neighborhoods of South Atlanta. They beat innocent passersby, broke windows of blackowned businesses and homes, and set streetcars and autos on fire. Official estimates were 25 dead in the melee.7 Du Bois, then a sociology professor at Atlanta University, estimated more than 4 times that number died.2 Wright, rushing home to safety from school, passed a man hanging by his neck from a rope tied to a tree, a victim of lynching. On reaching his house, he found his father, rifle in hand, protecting his family and home. Dr Penn gave the boy another firearm and stationed him at the front door with instructions to shoot anyone who entered the front yard. A sympathetic white neighbor, a handyman who kept the Penn automobile in working order, later secreted the family away from the area to safety.2 Wright excelled at all levels at Clark College, where the faculty taught elementary and secondary levels in addition to undergraduates. Staying there for college, he continued to win honors in all academic subjects, was baseball team manager, and acted in school plays. Graduating summa cum laude and valedictorian in 1911, he decided on a career in medicine. With the encouragement of Clark professors and his stepfather, and having utmost confidence, Wright made his way to Cambridge, MA, to interview for admission to Harvard. It was an unheard of step for a prospective AfricanAmerican medical student who had only 2 realistic choices, Meharry or Howard. Having studied medicine in both a ramshackle freedman’s school and in an Ivy League institution, Dr Penn was clear in his advice to travel north. Unfortunately, Wright soon burned through the modest bankroll his father and friends gave him for his trip. To make ends meet in Boston, he found work as a hotel porter.2 At Harvard When Wright entered the office of Harvard director of admissions Channing Frothingham, Jr, the don knew
Vol. 218, No. 4, April 2014
immediately that there was a misunderstanding. Though light-skinned, there was no mistaking Wright’s race. The admissions clerk had mistakenly identified Wright’s undergraduate college as Clark College in Worcester, MA, not the freedmen’s school in Atlanta. When Frothingham demurred that there was an error, Wright insisted that he had entirely legitimate credentials that satisfied the qualifications for admission. The professor agreed to a compromise: An on-the-spot oral examination with Harvard biochemist Otto Folin. His undergraduate degree having been in chemistry, Wright passed. He began his studies the day after Labor Day 1911 (Fig. 2).2 Racism continued at Harvard. On entering his first day of anatomy laboratory, Wright’s fellow students had suspended a cadaver, a black man, from a beam by cranial tongs inserted in his ears so he looked like a lynching victim. When he arrived for his rotation in obstetrics and gynecology, the professor informed him that arrangements had been made for him at a segregated hospital. The
Figure 2. Wright as a Harvard medical student. (From: the Harvard Medical Library in the Francis A Countway Library of Medicine, Cambridge, MA, with permission.)
Nakayama
Louis T Wright
871
attending staff did not believe that white women at the Harvard-affiliated Boston Lying-In Hospital would allow an African-American medical student to examine them and deliver their babies. With conviction, Wright stated that he had paid his tuition and he would take the standard rotation at the main hospital. No one complained. Wright missed the first day of another rotation when he marched in a protest against the DW Griffith film, The Birth of a Nation (1915), opposed by the NAACP because of its glorification of the Ku Klux Klan and stereotypical depiction of slaves. His professor excused his absence, saying that attending the protest was the correct thing to do.2 Wright showed an aptitude for research and worked with such Harvard luminaries as Walter Cannon (1871 to 1945)8 and Folin, his ad hoc examiner. He won the Hayden academic scholarship all 4 years and graduated in 1915, fourth in his class, easily in the group to be honored by election into Alpha Omega Alpha (AOA), the national medical honor society. However, an unknown student blackballed him, and classmates with lower marks won the honor.1 A graduate with his accomplishments would have continued training at one of the Harvard residencies. But Harvard surgeons, including Harvey Cushing, opposed having an African-American trainee. Others gave Wright more exposure to surgery on his clinical rotations, knowing that he would have limited opportunities for adequate graduate training.2 His stepfather urged him to apply for an internship at segregated Freedman’s Hospital in Washington, DC, one of a handful that trained AfricanAmerican doctors. In 1915, he took the entrance examination and 2 weeks later received his appointment.1 Training and start in Atlanta Wright excelled as an intern. He was certain that skin pigmentation could not invalidate the Schick dermal skin reaction for diphtheria immunity. He then he proved that black patients who were immune to diphtheria demonstrated the diagnostic response. The publication was the first clinical investigation to come from Freedman’s Hospital.9 At the end of the internship year he was recognized as best trainee.2 In 1916, he returned to Atlanta to assist his stepfather, who was having financial difficulty.1 He treated Clark College faculty and students and served as football team doctor. Barred from all-white community hospitals, Wright practiced in a converted 2-story frame house with 12 beds and a makeshift operating room, a far cry from the Harvard hospitals where he had been a year earlier. In 1917, a fire razed the modest infirmary despite Wright’s futile efforts with a garden hose.2 Many members of the black medical community, mostly Meharry and Howard graduates who felt the sting of inferiority compared with counterparts who had superior
872
Nakayama
Louis T Wright
educational opportunities, ostracized Dr Penn from Yale and Dr Wright from Harvard, an attitude Wright would see again in Harlem.2 Some African-American patients preferred white physicians, not believing black doctors were as well trained. W Montague Cobb (1906 to 1990) recounts an episode in which one patient rejected Wright’s services. “Don’t you ever come see nobody of mine,” she said, “I don’t believe a n****r can be a doctor.”10 Wright had promised his family that he would stay in Atlanta for 1 year. Oppressed by the racism in the South and unable to ply his profession at the level he desired, he was ready to leave at year’s end. His close friend, Walter F White, had an opportunity to join the national NAACP organization an assistant field director. (He later would become executive secretary of the national organization.) White’s pay, however, would be at a steep cut from his job with Herman E Perry’s prosperous black enterprise, the Standard Life Insurance Company. “You’d be a damned fool to stay here in Atlanta,” Wright told his friend, “Life will mean much, much more to you when you are fighting for a cause than it possibly can if you stay here just to make money. You’ll stagnate and die mentally.”2 Military service With some relief, Wright enlisted in the Medical Reserve Corps of the US Army when World War I began. Qualifying as first lieutenant, he was first billeted at Camp Upton on Long Island. Among his duties was vaccinating the enlistees for smallpox by rubbing a solution that contained attenuated virus into 2 needle skin scratches. The technique seldom led to a “take,” the eruption of small vesicles at the site. He tried intradermal injection, the technique used in Schick tests, and kept track of the results. The difference was remarkable e a 70% take rate compared with 8% e a result Wright subsequently reported in 1918, establishing his credentials as a clinical investigator.11 While on Long Island, he met Corinne Cooke, a Caucasian teacher and USO volunteer, whom he married in 1918, 1 month before leaving for France.1 His unit was close by the front lines when a gas shell released phosgene only a few hundred yards away from his station. He nearly died; the damage to his lungs was a handicap for the rest of his life. When recovered, he worked in the rear, where his commanding officer recognized his surgical talent and leadership. “You’re the best doctor in the division,”2 he said, putting the black lieutenant in charge of surgeons and nurses of both races on wards of the main triage hospital. Promotion, though, eluded him throughout the war in favor of junior Caucasian colleagues. On discharge from active duty, he finally won his captain’s bars. Purple Heart in hand, he disembarked in New York City at war’s end.1
J Am Coll Surg
Harlem’s “medical renaissance” Wright and Corinne settled in Harlem, the emerging center of black life and culture in America. In the 1920s Harlem attracted a cultural elitedartists, writers, and musicians whose works created the “Harlem Renaissance.” African Americans gained political identity and clout through their increasing numbers. Social thought and political action followed, with organizations like the NAACP and the Urban League addressing issues that arose from racism and discrimination.12 Hayden2 noted there was also a Harlem medical renaissance. Black physicians, dentists, and pharmacists organized the North Harlem Medical Society (NHMS), a forum that addressed health problems that affected the community and its residents. Wright soon became its leading figure.2 Wright’s target was the community’s largest health facility, city-owned Harlem Hospital, its patients uniformly black but its medical staff entirely white. Black physicians who applied for privileges were routinely rejected.2 Wright pushed his application up the city bureaucracy without response for months, so he personally contacted hospital superintendent Cosmo O’Neal. Respecting Wright’s military service, Dr O’Neal brought him on staff at its lowest level, an outpatient position without admitting privileges. When Wright arrived for work in 1920, 4 white staff physicians quit in protest and O’Neal found himself reassigned to traffic detail in the ambulance driveway.1 Wright and his allies pressed city and hospital officials. Editorials in black community newspapers urged appointment of black physicians. Seven more AfricanAmerican physicians received appointments, but like Wright, at the lowest rung and without admitting privileges. Headline-grabbing scandals involving graft and patient neglect hit the hospital in 1921, supported 1 year later by an NAACP investigation. Mayor John F Hylan, who had received 75% of Harlem’s vote in his latest election, posed a familiar solution: Conversion of the hospital to an all-black facility. The option was anathema to Wright, who flatly rejected the mayor’s proposal.2 Wright converted Director of Surgery John Fox Connors to his cause. Connors, a Harlem Hospital fixture since 1903, had opposed bringing African Americans onto the hospital professional staff, believing that doing so would be controversial and disruptive. However, he aspired to membership in the elite American Surgical Association, where publications in the surgical literature were a requirement. Wellpublished Wright helped him and they became allies. Wright and his colleagues won full hospital privileges. Racial integration in other hospital programs followed: the nursing school in 1923 and the surgical training program in 1927.2 With growing influence, Wright attracted opposition from both races. White physicians who opposed integration
Vol. 218, No. 4, April 2014
resigned. Black physicians accused Wright of favoring graduates from schools in the North and discriminating against those from Howard and Meharry, a prejudice he had faced before among black physicians in Atlanta. The hospital board intervened in 1930: 23 white and 2 black doctors lost their positions; 12 black doctors won appointments. Connors became board president; Wright, secretary. The next year, 72 African-American physicians were on the staff, all connected to Wright. He also had final approval on house staff appointments. Hayden2 observed that he became like a czar, “Mr Harlem Hospital.” A few years earlier, Wright believed the ColumbiaPresbyterian Medical Center was ready for integration when its plans for a new facility on Harlem’s western border were announced. In 1925 he raised thousands of dollars for the project from the Harlem community. Trouble immediately followed the 1928 opening: A black nursing student was turned away when her race was discovered on her first day and a black patient was refused admission. Wright’s and his colleagues’ applications for admitting privileges were never answered. Dean Sage, hospital president, avoided responding to queries for 3 months until he finally asked that the issue be dropped to avoid controversy that would harm the new hospital.2 In April 1930, representatives from the Julius Rosenwald Fund met with the city hospital commissioner and NHMS physician leaders e excluding Wright e about the possibility of funding an all-black hospital in Harlem. A great supporter of African-American education through individual grants and all-black institutions such as the Tuskegee Institute, the charity also had supported voluntary black hospitals in other cities. Once he got word of the talks, Wright split from the NHMS and with allies of both races, he formed the Manhattan Medical Society (MMS) to support integration. The MMS successfully thwarted both an all-black hospital in Harlem and a segregated Veterans’ Administration (VA) hospital in New York similar to one founded in 1923 in Tuskegee, AL.1 Hard feelings from the conflict, however, plagued Wright for the rest of his career.2 When Connors died in 1935, Wright was in line to succeed him as chief of surgery. The city hospital commissioner, however, made it a rotating assignment among senior surgeons, each serving in turn for 2 years. Soon after Wright’s turn came in 1938, as the first AfricanAmerican chief of a city hospital service, he suffered acute cavitary tuberculosis of his right lung. He spent the next 3 years in hospitalization and treatment. Immediately on his return in 1941, he was unanimously elected director of surgery, a position he held until his death. He considered himself lucky to have survived tuberculosis; half of his college class by then had died of the disease.1
Nakayama
Louis T Wright
873
With the NAACP In 1917, Wright became a charter member of the NAACP’s Atlanta chapter, its first in the South, serving as treasurer. In 1931, Wright joined the board of directors of the national organization. He was named its first African-American chair in 1934, a position he held until his death 18 years later. In an address to delegates at the organization’s 1936 convention, he elevated discrimination in health care to such NAACP causes as making lynching a federal crime (25 occurring in that year alone) and access to higher education in the South. At the next year’s convention, he declared that all-black health institutions “are separate, but not equal.”1 The NAACP helped to stop plans for all-black VA hospitals in Mount Bayou, MS, and Fort Huachuca, AZ.2 Opposition came from an unlikely source: WEB Du Bois, NAACP founding member and editor of its publication, The Crisis. He editorialized in January 1934 that the NAACP should accept voluntary segregation “as a practical necessity” if an opportunity arose to improve the situation for African Americans. He used Harlem Hospital and the Tuskegee VA Hospital as examples of the dilemma NAACP faced: Integration of 1 hospital but continued exclusionist policies at essentially all of the remaining hospitals in the city, and the benefits of providing access to health care at an all-black VA hospital. In Du Bois’ view, both deserved support. In accommodating segregation in health care, Du Bois broke on an NAACP core issue. In the ensuing controversy, he refused to recant his editorial and resigned in July.2 After his 3-year hiatus in treatment for tuberculosis, Wright resumed work as NAACP board chair. In 1944, an NAACP panel of both blacks and whites investigating the state of health care among America’s blacks stated that segregation in medicine created “a medical ghetto,” which hardened substandard care and medical education. Later that year Wright led an unsuccessful effort to deny federal hospital construction funds to segregated hospitals under the Hill Burton Act, then before Congress.1 Last years and legacy Wright’s respiratory condition precluded an active clinical practice, so he turned to full-time clinical research. He published 100 articles and book chapters on infectious disease, trauma, and cancer chemotherapy.13 His health, burdened by aftereffects of toxic gas and tuberculosis, slowly deteriorated. More than 1,100 people, including Eleanor Roosevelt, attended a dinner in his honor in 1952 at the Statler Hotel in New York City, on the occasion of establishment of a library bearing his name at Harlem Hospital. Six months later he died at age 51. The next year, he posthumously received the
874
Nakayama
Louis T Wright
American Cancer Society medal. His wife, Corinne, and 2 daughters, both physicians, survived him.2 Assuming leadership of the NAACP Health Committee, Cobb and the association’s Legal Defense and Education Fund allied with the National Medical Association and the National Urban League to push hospital and medical integration through a series of court challenges. Success followed a decade later with the landmark Simkins vs Cone decision in 1963, which declared the separatebut-equal provision in the 1946 Hill Burton Act unconstitutional, opening hospitals built with federal funds to all patients and prohibiting their staffs from excluding physicians on the basis of race.14 The US government prohibited racial discrimination in all federal programs in the 1964 Civil Rights Act15 and the 1965 Social Security Act, which established Medicare.16 These landmark court and legislative achievements had their beginnings decades earlier, when a young African-American student passed an on-the-spot chemistry examination in Cambridge and proved he belonged in the American medical mainstream. Acknowledgment: The author acknowledges the support of the Joseph M Donald Archival Collection and Endowment Fund of the Southern Surgical Association, and the Harvard Medical Library in the Francis A Countway Library of Medicine. REFERENCES 1. Reynolds PP. Dr Louis T. Wright and the NAACP: Pioneers in Hospital Racial Integration. Am J Pub Health 2000;90:883e892. 2. Hayden RC. “Mr Harlem Hospital.” Dr Louis T. Wright. A Biography. Littleton, MA: Tapestry Press; 2003.
J Am Coll Surg
3. Kernahan PJ. In: Nahrwold DL, Kernahan PJ, eds. A Century of Surgeons and Surgery: The American College of Surgeonsd1913e2012. Chicago: American College of Surgeons; 2012. 4. O’Shea JS. Louis T. Wright and Henry W. Cave: How they paved the way for fellowships for Black surgeons. Bull Am Coll Surg 2005;90:22e29. 5. Frontline. The two nations of Black America. Available at: http://www.pbs.org/wgbh/pages/frontline/shows/race/etc/road. html. Accessed May 18, 2013. 6. Bigelow BC. Contemporary Black Biography, Volume 4. Detroit: Gale Research; 1993:282286. 7. Bauerlein M. Negrophobia. A Race Riot in Atlanta, 1906. San Francisco: Encounter Books; 2001. 8. Wright LT. The effect of alcohol on the rate of discharge from the stomach. Boston Med Surg J 1916;175:627. 9. Wright LT. The Schick test with especial reference to the Negro. J Infect Dis 1917;21:265e268. 10. Cobb WM. Louis Tompkins Wright, 1891-1952. J Natl Med Assoc 1953;45:130e148. 11. Wright LT. Intradermal vaccination against smallpox. J Am Med Assoc 1918;71:654e657. 12. Wintz CD. Introduction. In: Gates HL, Higganbotham EB, eds. Harlem Renaissance Lives: From the African American National Biography. Oxford: Oxford University Press; 2009: viieix. 13. Bibliography of scientific papers of Louis Tompkins Wright. Harlem Hosp Bull 1953;6:89e95. 14. US Commission on Civil Rights. Equal opportunity in hospitals and health facilities. Civil rights policies under the Hill Burton program. Washington, DC: US Government Printing Office; March 1965. 15. Reynolds PP. Hospitals and civil rights 1945 e 1963: The case of Simkins vs. Moses H. Cone Memorial Hospital. Ann Intern Med 1997;126:898e906. 16. Reynolds PP. Professional and hospital discrimination and the US Court of Appeals Fourth Circuit 1956-1967. Am J Pub Health 2004;95:710e720.
MD, MBA, FACS
Louis T Wright, MD, (1891 to 1952, Fig. 1) was the most prominent African-American surgeon of the first half of the 20th century. Growing up in the Jim Crow South, training in medicine at Harvard, and practicing as the country’s most prominent black surgeon during the Harlem Renaissance, he faced racial animus throughout his life. He advanced racial integration of all hospitals, medical schools, and training programs. He opposed accommodation to segregation, especially all-black hospitals. With a commanding personality and in key positions in both medicine and racial politics, he shaped the integration of US medicine. His legacy came 12 years after his death, when the Civil Rights Act of 1964 outlawed discrimination on the basis of race in all public and federally supported facilities, including hospitals. Despite his impact, Wright is not widely known in medical history. Most of the material in this article draws from recent summaries of his work with the National Association for the Advancement of Colored People (NAACP) by physician-historian P Preston Reynolds1 and a selfpublished biography by Robert C Hayden, not widely circulated but available through an internet vendor.2 Wright became the second African-American Fellow of the American College of Surgeons (ACS)3 and brought other qualified black surgeons into the organization,4 2 important stories reviewed by others and not included in this article. Figure 1. Louis T Wright, MD, 1891 to 1952. (From: the Harvard Medical Library in the Francis A Countway Library of Medicine, Cambridge, MA, with permission.)
Racial inequities in health care W Montague Cobb, of Howard University, studied health care among African Americans in the early 20th century; his grim statistics summarized by Reynolds.1 Experts at the time estimated the need for physicians at 1 for 750 persons. For African Americans, that ratio was 1 for 3,377; in Mississippi, it was 1 for 18,527. Of the 1.5 million hospital beds in the country, only 15,000 e 1% e were open to
black patients. In some areas, only 75 beds were open to 1 million African Americans, far below the national target of 4.5 beds per 1,000 persons. Without access to community hospitals, African-American patients were treated in proprietary hospitals owned by black physicians, themselves barred from practice in established facilities. Of the 112 allblack hospitals in the US, the ACS had accredited only 25. Training opportunities for African-American physicians and surgeons were similarly limited. All 26 medical schools in the South, except Howard Medical College in Washington, DC and Meharry Medical College in Nashville, TN, refused black applicants’ admission. Of the 52 schools in the North, only 82 of the 590 African-American medical students attended schools other than Howard and Meharry. Eighty-five of the 116 positions open to African-American trainees in the country were in only 4 all-black hospitals.1
Disclosure Information: Nothing to disclose. Dr Nakayama received a grant from the Southern Surgical Association, Joseph M Donald Endowment Fund. Presented at the Southern Surgical Association 125th Annual Meeting, Hot Springs, VA, December 2013. Received December 5, 2013; Accepted December 10, 2013. From the Department of Surgery, West Virginia University School of Medicine, Morgantown, WV. Correspondence address: Don K Nakayama, MD, MBA, FACS, 1 Medical Center Dr, PO Box 9238, Health Sciences Center South, Suite 7700, Morgantown, WV 26506-9238. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
869
ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.040
870
Nakayama
Louis T Wright
Jim Crow laws maintained a separate system for black patients and doctors in the South, a “separate but equal” principle that the US Supreme Court held as constitutional in its 1896 Plessy vs Ferguson decision. Segregation was present to nearly the same extent in the North, where medical schools did not select African-American students, training programs chose not to train minority interns and residents, and hospital staffs ignored the applications of black physicians for privileges. How to confront centuries-long racial discrimination is a classic debate that continues today, embodied by 2 titanic figures in US history, Booker T Washington (1856 to 1915) and WEB Du Bois (1868 to 1963). A Frontline television documentary from 1998 (available online) gave a useful introduction.5 Washington preached self-help, individual achievement, and the development of black institutions that eventually would become integrated into mainstream white society. Saying that Washington’s strategy would only perpetuate inequality and white oppression, Du Bois demanded equal rights and access to all institutions through a politically active civil rights agenda. His stance was radically aggressive given the magnitude of racism and the wide gulf that separated black from white society. Washington’s approach appealed to many physicians as more achievable: Accommodation to the reality of being an African American in that era and provision of the best care to their patients within the resources available, embracing a windfall should it come, often from a progressive philanthropist. Wright and others took Du Bois’ stance. They saw the difference in schools and hospitals that were open to Caucasians but closed to them, but supported by taxes everyone paid. Black patients had far inferior facilities that their doctors owned and kept financially afloat. Wright defined integration in health care as a core issue of the civil rights movement. His dedication and leadership led to integration in health care that forever changed American medicine. Growing up in Georgia Wright was born July 23, 1891 in LaGrange, GA, a textile town 60 miles southwest of Atlanta. His mother, Lula Tomkins Wright, was a teacher. Born into slavery, his father, Ceah Ketcham Wright, attended Meharry and became a physician. The elder Wright, who had abandoned his practice for a Methodist ministry, died when young Louis was only 4 years old. The family moved to Atlanta, where the mother returned to teaching at Clark College, a Methodist freedmen’s school in Atlanta.1 There she married William Fletcher Penn (1871 to 1934), who had become, in 1897, Yale University’s first AfricanAmerican medical school graduate.6 He was attending
J Am Coll Surg
the Leonard Medical School for Blacks in Raleigh, NC, when he had the opportunity to perform with a local college quartet on a concert tour. While in New Haven, CT, he happened to meet an influential Yale medical school faculty member who helped him gain admittance there in 1893. He earned high marks and was editor of the medical school class yearbook. Returning to Atlanta, Dr Penn, barred from established hospitals, started a proprietary hospital where he could practice.1 Dr Penn formed a fast relationship with his stepson and took him on house calls, the boy waiting in the car while his father visited a patient. Car ownership among African Americans then was rare, and the Penn vehicle attracted the attention of stone-throwing thugs.1 Racial tension exploded in the Atlanta Riot of 1906. Gangs of white men, estimated in the thousands, swarmed the African-American neighborhoods of South Atlanta. They beat innocent passersby, broke windows of blackowned businesses and homes, and set streetcars and autos on fire. Official estimates were 25 dead in the melee.7 Du Bois, then a sociology professor at Atlanta University, estimated more than 4 times that number died.2 Wright, rushing home to safety from school, passed a man hanging by his neck from a rope tied to a tree, a victim of lynching. On reaching his house, he found his father, rifle in hand, protecting his family and home. Dr Penn gave the boy another firearm and stationed him at the front door with instructions to shoot anyone who entered the front yard. A sympathetic white neighbor, a handyman who kept the Penn automobile in working order, later secreted the family away from the area to safety.2 Wright excelled at all levels at Clark College, where the faculty taught elementary and secondary levels in addition to undergraduates. Staying there for college, he continued to win honors in all academic subjects, was baseball team manager, and acted in school plays. Graduating summa cum laude and valedictorian in 1911, he decided on a career in medicine. With the encouragement of Clark professors and his stepfather, and having utmost confidence, Wright made his way to Cambridge, MA, to interview for admission to Harvard. It was an unheard of step for a prospective AfricanAmerican medical student who had only 2 realistic choices, Meharry or Howard. Having studied medicine in both a ramshackle freedman’s school and in an Ivy League institution, Dr Penn was clear in his advice to travel north. Unfortunately, Wright soon burned through the modest bankroll his father and friends gave him for his trip. To make ends meet in Boston, he found work as a hotel porter.2 At Harvard When Wright entered the office of Harvard director of admissions Channing Frothingham, Jr, the don knew
Vol. 218, No. 4, April 2014
immediately that there was a misunderstanding. Though light-skinned, there was no mistaking Wright’s race. The admissions clerk had mistakenly identified Wright’s undergraduate college as Clark College in Worcester, MA, not the freedmen’s school in Atlanta. When Frothingham demurred that there was an error, Wright insisted that he had entirely legitimate credentials that satisfied the qualifications for admission. The professor agreed to a compromise: An on-the-spot oral examination with Harvard biochemist Otto Folin. His undergraduate degree having been in chemistry, Wright passed. He began his studies the day after Labor Day 1911 (Fig. 2).2 Racism continued at Harvard. On entering his first day of anatomy laboratory, Wright’s fellow students had suspended a cadaver, a black man, from a beam by cranial tongs inserted in his ears so he looked like a lynching victim. When he arrived for his rotation in obstetrics and gynecology, the professor informed him that arrangements had been made for him at a segregated hospital. The
Figure 2. Wright as a Harvard medical student. (From: the Harvard Medical Library in the Francis A Countway Library of Medicine, Cambridge, MA, with permission.)
Nakayama
Louis T Wright
871
attending staff did not believe that white women at the Harvard-affiliated Boston Lying-In Hospital would allow an African-American medical student to examine them and deliver their babies. With conviction, Wright stated that he had paid his tuition and he would take the standard rotation at the main hospital. No one complained. Wright missed the first day of another rotation when he marched in a protest against the DW Griffith film, The Birth of a Nation (1915), opposed by the NAACP because of its glorification of the Ku Klux Klan and stereotypical depiction of slaves. His professor excused his absence, saying that attending the protest was the correct thing to do.2 Wright showed an aptitude for research and worked with such Harvard luminaries as Walter Cannon (1871 to 1945)8 and Folin, his ad hoc examiner. He won the Hayden academic scholarship all 4 years and graduated in 1915, fourth in his class, easily in the group to be honored by election into Alpha Omega Alpha (AOA), the national medical honor society. However, an unknown student blackballed him, and classmates with lower marks won the honor.1 A graduate with his accomplishments would have continued training at one of the Harvard residencies. But Harvard surgeons, including Harvey Cushing, opposed having an African-American trainee. Others gave Wright more exposure to surgery on his clinical rotations, knowing that he would have limited opportunities for adequate graduate training.2 His stepfather urged him to apply for an internship at segregated Freedman’s Hospital in Washington, DC, one of a handful that trained AfricanAmerican doctors. In 1915, he took the entrance examination and 2 weeks later received his appointment.1 Training and start in Atlanta Wright excelled as an intern. He was certain that skin pigmentation could not invalidate the Schick dermal skin reaction for diphtheria immunity. He then he proved that black patients who were immune to diphtheria demonstrated the diagnostic response. The publication was the first clinical investigation to come from Freedman’s Hospital.9 At the end of the internship year he was recognized as best trainee.2 In 1916, he returned to Atlanta to assist his stepfather, who was having financial difficulty.1 He treated Clark College faculty and students and served as football team doctor. Barred from all-white community hospitals, Wright practiced in a converted 2-story frame house with 12 beds and a makeshift operating room, a far cry from the Harvard hospitals where he had been a year earlier. In 1917, a fire razed the modest infirmary despite Wright’s futile efforts with a garden hose.2 Many members of the black medical community, mostly Meharry and Howard graduates who felt the sting of inferiority compared with counterparts who had superior
872
Nakayama
Louis T Wright
educational opportunities, ostracized Dr Penn from Yale and Dr Wright from Harvard, an attitude Wright would see again in Harlem.2 Some African-American patients preferred white physicians, not believing black doctors were as well trained. W Montague Cobb (1906 to 1990) recounts an episode in which one patient rejected Wright’s services. “Don’t you ever come see nobody of mine,” she said, “I don’t believe a n****r can be a doctor.”10 Wright had promised his family that he would stay in Atlanta for 1 year. Oppressed by the racism in the South and unable to ply his profession at the level he desired, he was ready to leave at year’s end. His close friend, Walter F White, had an opportunity to join the national NAACP organization an assistant field director. (He later would become executive secretary of the national organization.) White’s pay, however, would be at a steep cut from his job with Herman E Perry’s prosperous black enterprise, the Standard Life Insurance Company. “You’d be a damned fool to stay here in Atlanta,” Wright told his friend, “Life will mean much, much more to you when you are fighting for a cause than it possibly can if you stay here just to make money. You’ll stagnate and die mentally.”2 Military service With some relief, Wright enlisted in the Medical Reserve Corps of the US Army when World War I began. Qualifying as first lieutenant, he was first billeted at Camp Upton on Long Island. Among his duties was vaccinating the enlistees for smallpox by rubbing a solution that contained attenuated virus into 2 needle skin scratches. The technique seldom led to a “take,” the eruption of small vesicles at the site. He tried intradermal injection, the technique used in Schick tests, and kept track of the results. The difference was remarkable e a 70% take rate compared with 8% e a result Wright subsequently reported in 1918, establishing his credentials as a clinical investigator.11 While on Long Island, he met Corinne Cooke, a Caucasian teacher and USO volunteer, whom he married in 1918, 1 month before leaving for France.1 His unit was close by the front lines when a gas shell released phosgene only a few hundred yards away from his station. He nearly died; the damage to his lungs was a handicap for the rest of his life. When recovered, he worked in the rear, where his commanding officer recognized his surgical talent and leadership. “You’re the best doctor in the division,”2 he said, putting the black lieutenant in charge of surgeons and nurses of both races on wards of the main triage hospital. Promotion, though, eluded him throughout the war in favor of junior Caucasian colleagues. On discharge from active duty, he finally won his captain’s bars. Purple Heart in hand, he disembarked in New York City at war’s end.1
J Am Coll Surg
Harlem’s “medical renaissance” Wright and Corinne settled in Harlem, the emerging center of black life and culture in America. In the 1920s Harlem attracted a cultural elitedartists, writers, and musicians whose works created the “Harlem Renaissance.” African Americans gained political identity and clout through their increasing numbers. Social thought and political action followed, with organizations like the NAACP and the Urban League addressing issues that arose from racism and discrimination.12 Hayden2 noted there was also a Harlem medical renaissance. Black physicians, dentists, and pharmacists organized the North Harlem Medical Society (NHMS), a forum that addressed health problems that affected the community and its residents. Wright soon became its leading figure.2 Wright’s target was the community’s largest health facility, city-owned Harlem Hospital, its patients uniformly black but its medical staff entirely white. Black physicians who applied for privileges were routinely rejected.2 Wright pushed his application up the city bureaucracy without response for months, so he personally contacted hospital superintendent Cosmo O’Neal. Respecting Wright’s military service, Dr O’Neal brought him on staff at its lowest level, an outpatient position without admitting privileges. When Wright arrived for work in 1920, 4 white staff physicians quit in protest and O’Neal found himself reassigned to traffic detail in the ambulance driveway.1 Wright and his allies pressed city and hospital officials. Editorials in black community newspapers urged appointment of black physicians. Seven more AfricanAmerican physicians received appointments, but like Wright, at the lowest rung and without admitting privileges. Headline-grabbing scandals involving graft and patient neglect hit the hospital in 1921, supported 1 year later by an NAACP investigation. Mayor John F Hylan, who had received 75% of Harlem’s vote in his latest election, posed a familiar solution: Conversion of the hospital to an all-black facility. The option was anathema to Wright, who flatly rejected the mayor’s proposal.2 Wright converted Director of Surgery John Fox Connors to his cause. Connors, a Harlem Hospital fixture since 1903, had opposed bringing African Americans onto the hospital professional staff, believing that doing so would be controversial and disruptive. However, he aspired to membership in the elite American Surgical Association, where publications in the surgical literature were a requirement. Wellpublished Wright helped him and they became allies. Wright and his colleagues won full hospital privileges. Racial integration in other hospital programs followed: the nursing school in 1923 and the surgical training program in 1927.2 With growing influence, Wright attracted opposition from both races. White physicians who opposed integration
Vol. 218, No. 4, April 2014
resigned. Black physicians accused Wright of favoring graduates from schools in the North and discriminating against those from Howard and Meharry, a prejudice he had faced before among black physicians in Atlanta. The hospital board intervened in 1930: 23 white and 2 black doctors lost their positions; 12 black doctors won appointments. Connors became board president; Wright, secretary. The next year, 72 African-American physicians were on the staff, all connected to Wright. He also had final approval on house staff appointments. Hayden2 observed that he became like a czar, “Mr Harlem Hospital.” A few years earlier, Wright believed the ColumbiaPresbyterian Medical Center was ready for integration when its plans for a new facility on Harlem’s western border were announced. In 1925 he raised thousands of dollars for the project from the Harlem community. Trouble immediately followed the 1928 opening: A black nursing student was turned away when her race was discovered on her first day and a black patient was refused admission. Wright’s and his colleagues’ applications for admitting privileges were never answered. Dean Sage, hospital president, avoided responding to queries for 3 months until he finally asked that the issue be dropped to avoid controversy that would harm the new hospital.2 In April 1930, representatives from the Julius Rosenwald Fund met with the city hospital commissioner and NHMS physician leaders e excluding Wright e about the possibility of funding an all-black hospital in Harlem. A great supporter of African-American education through individual grants and all-black institutions such as the Tuskegee Institute, the charity also had supported voluntary black hospitals in other cities. Once he got word of the talks, Wright split from the NHMS and with allies of both races, he formed the Manhattan Medical Society (MMS) to support integration. The MMS successfully thwarted both an all-black hospital in Harlem and a segregated Veterans’ Administration (VA) hospital in New York similar to one founded in 1923 in Tuskegee, AL.1 Hard feelings from the conflict, however, plagued Wright for the rest of his career.2 When Connors died in 1935, Wright was in line to succeed him as chief of surgery. The city hospital commissioner, however, made it a rotating assignment among senior surgeons, each serving in turn for 2 years. Soon after Wright’s turn came in 1938, as the first AfricanAmerican chief of a city hospital service, he suffered acute cavitary tuberculosis of his right lung. He spent the next 3 years in hospitalization and treatment. Immediately on his return in 1941, he was unanimously elected director of surgery, a position he held until his death. He considered himself lucky to have survived tuberculosis; half of his college class by then had died of the disease.1
Nakayama
Louis T Wright
873
With the NAACP In 1917, Wright became a charter member of the NAACP’s Atlanta chapter, its first in the South, serving as treasurer. In 1931, Wright joined the board of directors of the national organization. He was named its first African-American chair in 1934, a position he held until his death 18 years later. In an address to delegates at the organization’s 1936 convention, he elevated discrimination in health care to such NAACP causes as making lynching a federal crime (25 occurring in that year alone) and access to higher education in the South. At the next year’s convention, he declared that all-black health institutions “are separate, but not equal.”1 The NAACP helped to stop plans for all-black VA hospitals in Mount Bayou, MS, and Fort Huachuca, AZ.2 Opposition came from an unlikely source: WEB Du Bois, NAACP founding member and editor of its publication, The Crisis. He editorialized in January 1934 that the NAACP should accept voluntary segregation “as a practical necessity” if an opportunity arose to improve the situation for African Americans. He used Harlem Hospital and the Tuskegee VA Hospital as examples of the dilemma NAACP faced: Integration of 1 hospital but continued exclusionist policies at essentially all of the remaining hospitals in the city, and the benefits of providing access to health care at an all-black VA hospital. In Du Bois’ view, both deserved support. In accommodating segregation in health care, Du Bois broke on an NAACP core issue. In the ensuing controversy, he refused to recant his editorial and resigned in July.2 After his 3-year hiatus in treatment for tuberculosis, Wright resumed work as NAACP board chair. In 1944, an NAACP panel of both blacks and whites investigating the state of health care among America’s blacks stated that segregation in medicine created “a medical ghetto,” which hardened substandard care and medical education. Later that year Wright led an unsuccessful effort to deny federal hospital construction funds to segregated hospitals under the Hill Burton Act, then before Congress.1 Last years and legacy Wright’s respiratory condition precluded an active clinical practice, so he turned to full-time clinical research. He published 100 articles and book chapters on infectious disease, trauma, and cancer chemotherapy.13 His health, burdened by aftereffects of toxic gas and tuberculosis, slowly deteriorated. More than 1,100 people, including Eleanor Roosevelt, attended a dinner in his honor in 1952 at the Statler Hotel in New York City, on the occasion of establishment of a library bearing his name at Harlem Hospital. Six months later he died at age 51. The next year, he posthumously received the
874
Nakayama
Louis T Wright
American Cancer Society medal. His wife, Corinne, and 2 daughters, both physicians, survived him.2 Assuming leadership of the NAACP Health Committee, Cobb and the association’s Legal Defense and Education Fund allied with the National Medical Association and the National Urban League to push hospital and medical integration through a series of court challenges. Success followed a decade later with the landmark Simkins vs Cone decision in 1963, which declared the separatebut-equal provision in the 1946 Hill Burton Act unconstitutional, opening hospitals built with federal funds to all patients and prohibiting their staffs from excluding physicians on the basis of race.14 The US government prohibited racial discrimination in all federal programs in the 1964 Civil Rights Act15 and the 1965 Social Security Act, which established Medicare.16 These landmark court and legislative achievements had their beginnings decades earlier, when a young African-American student passed an on-the-spot chemistry examination in Cambridge and proved he belonged in the American medical mainstream. Acknowledgment: The author acknowledges the support of the Joseph M Donald Archival Collection and Endowment Fund of the Southern Surgical Association, and the Harvard Medical Library in the Francis A Countway Library of Medicine. REFERENCES 1. Reynolds PP. Dr Louis T. Wright and the NAACP: Pioneers in Hospital Racial Integration. Am J Pub Health 2000;90:883e892. 2. Hayden RC. “Mr Harlem Hospital.” Dr Louis T. Wright. A Biography. Littleton, MA: Tapestry Press; 2003.
J Am Coll Surg
3. Kernahan PJ. In: Nahrwold DL, Kernahan PJ, eds. A Century of Surgeons and Surgery: The American College of Surgeonsd1913e2012. Chicago: American College of Surgeons; 2012. 4. O’Shea JS. Louis T. Wright and Henry W. Cave: How they paved the way for fellowships for Black surgeons. Bull Am Coll Surg 2005;90:22e29. 5. Frontline. The two nations of Black America. Available at: http://www.pbs.org/wgbh/pages/frontline/shows/race/etc/road. html. Accessed May 18, 2013. 6. Bigelow BC. Contemporary Black Biography, Volume 4. Detroit: Gale Research; 1993:282286. 7. Bauerlein M. Negrophobia. A Race Riot in Atlanta, 1906. San Francisco: Encounter Books; 2001. 8. Wright LT. The effect of alcohol on the rate of discharge from the stomach. Boston Med Surg J 1916;175:627. 9. Wright LT. The Schick test with especial reference to the Negro. J Infect Dis 1917;21:265e268. 10. Cobb WM. Louis Tompkins Wright, 1891-1952. J Natl Med Assoc 1953;45:130e148. 11. Wright LT. Intradermal vaccination against smallpox. J Am Med Assoc 1918;71:654e657. 12. Wintz CD. Introduction. In: Gates HL, Higganbotham EB, eds. Harlem Renaissance Lives: From the African American National Biography. Oxford: Oxford University Press; 2009: viieix. 13. Bibliography of scientific papers of Louis Tompkins Wright. Harlem Hosp Bull 1953;6:89e95. 14. US Commission on Civil Rights. Equal opportunity in hospitals and health facilities. Civil rights policies under the Hill Burton program. Washington, DC: US Government Printing Office; March 1965. 15. Reynolds PP. Hospitals and civil rights 1945 e 1963: The case of Simkins vs. Moses H. Cone Memorial Hospital. Ann Intern Med 1997;126:898e906. 16. Reynolds PP. Professional and hospital discrimination and the US Court of Appeals Fourth Circuit 1956-1967. Am J Pub Health 2004;95:710e720.
