How America Has Racialized Medicine During Epidemics

Just a month ago, there was chatter about how African Americans have a unique racial immunity to the novel coronavirus. Now that data is emerging that African Americans are actually contracting Covid-19 at alarming rates, the new chatter is just the opposite: that African Americans instead have a unique racial vulnerability to it. While there are many potential good explanations for this disparity, including racism in the health care system, much of the focus has been instead on black people’s behaviors as the cause. In a recent press conference, U.S. Surgeon General Jerome Adams, an African American, addressed the disparity in black deaths by scolding black people to “step up” their social distancing game while chiding them about avoiding alcohol, tobacco, and drugs.

There is unfortunately a long, sordid history in the medical world of holding black people responsible for poor health outcomes, despite the racial discrimination they have encountered in doctor’s offices and hospitals. Connecticut College gender and women’s studies professor Mab Segrest explores this history in her new book, “Administrations of Lunacy: Racism and the Haunting of American Psychiatry at the Milledgeville Asylum.”

The asylum in the title is the Georgia State Lunatic, Idiot, and Epileptic Asylum in Milledgeville, Georgia, (today called the Central State Hospital) which opened in 1841 and became the largest mental health institution in the world in the 1960s before shuttering in 2010 (though one remaining building from its mammoth 2,000-acre plot still takes some patients from jails and prisons).

Segrest explores how the hospital’s chief superintendent in the 1880s, Theophilus O. Powell, began developing medical theories that became foundational for U.S. disease outbreak response policies. His ideas also became the underpinning for theories on innate racial vulnerability — that black people are culturally, intellectually, and genetically inferior — as a way of explaining racially disparate health outcomes. When the black patient population began escalating in the Milledgeville Asylum in the late 19th century, Powell said emancipation was driving African Americans insane, because they no longer had access to what was then considered “the hygienic effects of slavery.”

Because doctors were focusing on this emancipation theory, they failed to recognize and respond to the other growing epidemics of tuberculosis and pellagra in the asylum — disease outbreaks for which Powell had no effective answer. His idea that sicknesses were based on innate racialized hygiene and heredity would eventually ignite some of the most dangerous medical ideas in the world — ideas that would claim the lives of millions of African Americans, Jews, and other people of color in the U.S. and abroad.

CityLab spoke with Segrest about her book and how the work of Powell at the Milledgeville Asylum is connected to how medical and government leaders have responded to the Covid-19 pandemic today. The interview below has been edited for length and clarity.  

What are some of the most obvious patterns you see today that ring similar to what happened in the Milledgeville Asylum in the late 19th century?

The pattern that I see emerging today goes back to the oldest antebellum ideas of blaming black people. Before the Civil War they said that slavery was good for the slaves, that the white master was looking out for them. Then after the Civil War, the line became to blame what white people were doing — like lynching and stealing the vote and impoverishing people — on emancipation.

In 1895, all of the [mental health institution] superintendents from the South got together for one of their annual meetings, and the question they asked at was, “Is emancipation prejudicial for the Negro?” A remarkable question for the psychiatrists to be asking, and they all answered yes, because slavery was so “hygienic.” Anything that happened to black people after emancipation was their fault because they should have stayed slaves basically. So this pattern of blaming the victim then is very deeply set.  

What did these doctors miss, in terms of cures and treatment, by focusing on race and behaviors?

I found when I looked at the records of the Georgia asylum that Superintendent Powell, as he wrote about degenerate populations, immoral people, and unfit people, he was at the same time presiding over multiple epidemics within his own institution that he wasn’t paying attention to. Because he really didn’t care about the germ theory of disease, although that had been around since 1882 when Robert Koch in Germany discovered the tubercle bacillus. And you might think that a superintendent who was alarmed at the rising rates of tuberculosis in his insane asylum for both black and white people, but particularly for black people, might want to be up on the latest research, but he wasn’t. He was more concerned with these very simplistic ideas like heredity and would claim that 90% of the folks in the asylum were there because of their bad families or hygiene.

By the turn of the century, half the cases of TB were being contracted within the asylum itself. So this man at one point could blame vulnerable people for being immoral and degenerate and in danger of infecting the rest of the world and the rest of the country. And at the same time, the thing he was really responsible for, which was the health of the people under his care, he completely neglected. So there was an epidemic of tuberculosis and also an epidemic of pellagra, which blossomed all over the South in the early 20th century.

Covid-19 is exacerbated by environmental injustice, pollution, and food insecurity. What parallels do you see there?

Tuberculosis was airborne, not hereditary. Pellagra turned out to be nutritional, which meant that the asylum was starving its people. A wonderful doctor from the U.S. Public Health Service, one of the public health heroes in my book, was asked to come to the asylum by the administrators because they had people starting to die in huge numbers from pellagra, which was a dreadful wasting disease. Goldberger had a sense that the disease might be nutritional. The people at the asylum said, “Oh no, no, no, no, we all eat the same thing.” Well, he just was very empirical. He just followed them through the cafeteria line and he saw who got what [food]. He saw the doctors, the superintendents, the nurses and the white people — I mean he just saw the hierarchies of food distribution.

So he thought to himself, “Who doesn’t get pellagra? The well-to-do.” So, he said, “Well, I’m going to take two wards and I’m going to feed them the diet of the well-to-do.” He took a black woman’s ward and a white woman’s ward, and he fed them the diet of the well-to-do for six months. None of them got sick. He proved that if you feed people well, you can prevent the disease.

What becomes the ultimate consequence of how race became essentialized in diagnoses and treatments, in terms of public health policy today?

Superintendent Powell becomes very influential in the medical world. He became the president of the precursor to the American Psychiatric Association [the American Medico-Psychological Association] in 1897. He’s really elevated in his profession. And he’s forwarding these ideas of degeneracy and slavery’s hygienic effects, which start to roll over into the eugenics movement, which starts in Europe, but lands in 1903 in the United States.

Some of the eugenics leaders go to the Carnegie Foundation and get money to set up the Eugenics Records Office at Cold Spring Harbor in New York to start promoting eugenics in the United States. Because if you said that the problem is population — if the problem is tubercle bacillus then you don’t put people in overcrowded conditions. If the problem is the coronavirus, then you do social distancing, you wash your hands and you look like hell to get a vaccine for it. But if the problem is degenerate populations then you have to eliminate those degenerate populations.

So we started sterilization, and sterilization after the 1930s and 1940s was really rampant in these state institutions set up for mental illness and the so-called feeble-minded. And Hitler is paying attention in the 1920s and 1930s so they started sterilizing people. Then in 1939 they went beyond sterilization to elimination of people and started the Aktion T4 program, which was the first Nazi extermination program aimed at disabled people. They just cleared out the hospitals and mental hospitals and figured out a gas chamber for them. That was the beginning of Nazi extermination. These ideas have really deep roots and extreme consequences.  

So you see a through line from how Superintendent Powell handled disease outbreaks to how the White House is handling the Covid-19 pandemic now?

Well, today we have doctors, medical people, nurses who are trying to give us the best information about how to keep everybody safe when we have no remedy for it and no immunity. The best we can come up with is social distancing, washing our hands — these practices that are flattening the curve, as we’ve been taught by Dr. [Anthony] Fauci. Well Dr. Fauci is now having his life threatened for contradicting Trump. And Trump is busy blaming people and deflecting.

It’s a kind of willful ignorance, which was the same thing that Dr. Powell had. He didn’t study the tubercle bacillus, he didn’t need to know that because he knew you could just blame people for it. We’ve had this information from China from January on. The president has been warned of it from January on. He’s denied it, he’s deflected it. And now the United States has the highest rates of infection of any in the world, which was so tragically unnecessary. (Editor’s note: The U.S. has the highest number of confirmed deaths in the world as of April 13, although not the highest rate deaths per capita. Rates of confirmed infection are also being tracked, but remain imprecise due to testing limitations.) And now we’re seeing some of the actual racial demographics come out that black people are disproportionately being affected. And that is just the oldest story in this country.

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