Doctor drawing blood from a patient as part of the Tuskegee Syphilis Study. Source: National Archives Atlanta, GA via Wikimedia Commons

Another Burden To Bear

A History of Racial Health Disparities in America

06.05.20

The COVID-19 pandemic has disproportionately impacted communities of color. According to the CDC, 33% of people who’ve been hospitalized due to the virus have been African-American, despite making up only 18% of the population. The ongoing crisis is a reminder of the racial health disparities that have plagued the United States throughout its history. So on this episode of BackStory, Joanne and Brian learn about how different communities have struggled to acquire adequate health care.

NOTE: This episode was recorded before protests took place across the country in response to the killing of George Floyd by a white police officer. The protests, in addition to the death toll of COVID-19, serve as brutal reminders of the systemic inequalities afflicting communities of color.

Suggested Reading:

Murray, Shaw, and Siegel’s Reproductive Rights and Justice Stories (Law Stories Series)

Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South by Kylie Smith

Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital by Martin Summers

health disparities

Open Episode Transcript as PDF

Segments

Bad Blood

For 40 years, the Public Health Service told 600 African-American men in Alabama that they were receiving free healthcare from the federal government. In reality, the PHS, in partnership with the Tuskegee Institute, was researching the natural history of syphilis. The men who had syphilis were never informed of their diagnosis– instead the PHS told them they were being treated for “bad blood,” a colloquial term for syphilis, anemia, and fatigue, as Joanne explains.

Music:
Seamless by Blue Dot Sessions

Tuskegee experiment; health disparities

00:00:00 / 00:00:00

View Transcript

Speaker 1:
Major funding for BackStory is provided by an anonymous donor, the National Endowment for the Humanities and the Joseph and Robert Cornell Memorial Foundation.

Brian Balogh:
From Virginia Humanities, this is BackStory. Welcome to BackStory, the show that explains the history behind today’s headlines. I’m Brian Balogh.

Joanne Freeman:
I’m Joanne Freeman.

Brian Balogh:
If you’re new to the podcast each week, along with our colleagues at Ed Ayers, Nathan Connolly, we explore a different aspect of American history.

Joanne Freeman:
In 1932, 600, African American men in Alabama were told by the Public Health Service that they were receiving free health care from the federal government. In reality, the PHS in partnership with the Tuskegee Institute was conducting a study to examine the natural history of syphilis.

Joanne Freeman:
Nearly 400 of the men in the study had syphilis. The other 200 did not. But the men were not informed of their diagnosis. Instead, the PHS told them they were being treated for quote, bad blood, a casual term used to describe a mix of ailments like syphilis, anemia, and fatigue. The project was originally planned to take about six months. Instead, it lasted for 40 years.

Joanne Freeman:
In 1972, the Associated Press broke the news of the Tuskegee study to the public, it was met with swift backlash. The study ended that year after a panel found the men with syphilis had never received proper treatment for the disease, even after penicillin became the go to treatment drug in the mid 1940s. The panel also found the researchers had never informed the men of the study’s true purpose, and were not given all the information needed to provide informed consent.

Joanne Freeman:
A year later, in 1973, the NAACP filed a class action lawsuit on behalf of the patients and their families. The federal government paid $10 million in a settlement and agreed to provide free medical care to all living patients and their descendants. But the painful memory of the Tuskegee study did not end with monetary and medical compensation. Patients continue to struggle with health problems because their condition went untreated for decades. The study also contributed to a broader distrust of the medical system among patients and their families. In 1997, President Bill Clinton apologized for the government’s wrongdoing.

Bill Clinton:
What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry.

Brian Balogh:
The Tuskegee Study is just one example of the history of racial health disparities in the United States. The COVID-19 pandemic has shown that these disparities are sadly still present today. Communities of color are being hit hard by the virus. According to the CDC, 33% of people who’ve been hospitalized due to COVID-19 have been African American. This is a striking statistic considering African Americans make up only 18% of the population.

Mental Health, Malpractice, and Marginalization

Brian talks with Kylie Smith, author of the forthcoming book Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South, about the perceptions of psychiatrists and doctors toward African-American patients since slavery. We also hear from Martin Summers, author of Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital, about treatment at Saint Elizabeth’s Hospital in Washington D.C.

Music:

Come As You Were by Blue Dot Sessions

Delicious by Blue Dot Sessions

health disparities; mental illness; psychiatry

00:00:00 / 00:00:00

View Transcript

Joanne Freeman:
On today’s episode, we’re going to look at a few examples of racial health gaps throughout American history.

Brian Balogh:
You’ll hear how tuberculosis disproportionately affected Native Americans in the early 20th century, and what the government did to combat it.

Joanne Freeman:
We’ll discuss a court case in the 1970s about a change in reproductive justice for Latino women.

Brian Balogh:
As our current pandemic serves is a brutal reminder of this country’s racial health disparities, it’s important to recognize that a difference in health outcomes doesn’t only pertain to one’s physical well-being. Mental healthcare has long been marred by mistreatment and detrimental diagnoses for patients of color.

Kylie Smith:
The most striking example is really around schizophrenia. At the moment, the data suggests that schizophrenia is diagnosed six times more for black men than it is for whites. That is different to what it used to be in the past, and it also means that depression is under diagnosed in African Americans.

Brian Balogh:
Kylie Smith is an associate professor for nursing in the humanities at Emory University in Atlanta. She’s also the author of the forthcoming book, Jim Crow in the Asylum: Psychiatry and civil rights in the American South. She says mental healthcare in the United States has been plagued by racism for centuries.

Kylie Smith:
I think the most striking example of the way that psychiatrists and physicians were thinking about racial difference, especially during slavery, comes down to one particular doctor who’s quite famous in the history of medicine, infamous really, Samuel Cartwright, who was actually from Virginia, but he wrote in 1851, in the New Orleans Journal of Medicine, a really quite long and detailed article about differences between the African American and the white body and also mind.

Kylie Smith:
He talked about how the African American person was basically designed for slavery because they had a great a bend in the knee. When you read it, you just think this is ridiculous, how could this be possible that anyone would think this way? But he’s really reflecting these broader ways of thinking that are trying to justify slavery, and really to justify the position of the African American as subservient, and not quite human. You really see that in his thinking about the psychology of the psyche, I guess of the African American, where he will talk about them being much more childlike, they do better under protection, they should be kept submissive, because that’s their natural state.

Kylie Smith:
With that, you have this idea that they’re not as well developed psychologically. He invented a few interesting mental illnesses in particular, one condition that he called drapetomania, which was the illness of running away from slavery. You can see in this kind of thinking, this kind of circular logic that makes the behavior of African Americans pathological.

Brian Balogh:
How does that kind of thinking carry into the treatment inside asylums after the Civil War?

Kylie Smith:
There are so many things happening in that post Civil War period around the construction of new asylums. As those asylums begin to get built in more places in the 1860s and 1870s, they would take in African American patients, small numbers to start off with, but it began to increase and they were segregated. At that point in time in American psychiatry, the main prevailing therapeutic approach was what we call moral therapy or moral treatment. It really came out of Europe and the UK, this idea that if you put a patient, a distressed or excited or anxious patient, you would need to take them away from their environment and put them in some kind of idyllic countryside estate.

Kylie Smith:
A lot of these institutions look quite imposing and quite beautiful. But also because they were rural, they also meant that people could be put to work. Moral therapy did rely on this idea that people should be kept busy. That’s fine if you’re a white middle class lady, and the treatment that you’re going to be given is, you could sit in a nice room and do your tapestry, or you could maybe do some gardening. But what we have found that for African American patients, moral therapy translated to work on the farm.

Kylie Smith:
There’s very little difference between how people were worked on a plantation and how they were worked on an asylum farm. That is the main form of treatment that African American men were given and the women were put to work in the laundry and the kitchen, just as how they had been on the plantation.

Brian Balogh:
Did this persist throughout the Jim Crow era, which is to say the whole first half of the 20th century in the south, in the United States?

Kylie Smith:
Yes, it did. It persisted for quite some time. It persisted in at least two places that I’m aware of until the late 1960s. It really was about… Especially in places where a separate facility had been built for African American patients. It could really be out of sight out of mind. People were working on farms and working to the extent that the farm was providing all of the food for the hospital, and not only food for the hospital, but surrounding neighborhoods and was making a profit for the hospital.

Brian Balogh:
Could you describe the line between determining that someone had engaged in criminal behavior and, on the other hand, mental illness, especially as it was applied to African Americans?

Kylie Smith:
That line between mental illness and criminalization I think is really a very fine line historically and current. I think, historically speaking in the emancipation and reconstruction period, I think it was very easy for African American behavior to be considered criminal before it was considered a mental illness. Whereas with a white person, there might be some kind of empathy, or maybe they’re traumatized, but for a black person, the first port of call would be the police.

Kylie Smith:
A lot of that is behavior. I think that comes out of emancipation and reconstruction. People are traumatized, people are trying to find a home, trying to find some kind of work, trying to make sense of their new lives. It was very easy for the systems that were in place to classify African American behavior as criminal.

Martin Summers:
Prior to emancipation, the first half of the 19th century, the psychiatric consensus held that black people were relatively immune to insanity.

Brian Balogh:
Martin Summers who’s also researched the history of black mental healthcare, he’s the author of Madness in the City of Magnificent Intentions: The History of Race and Mental Illness in the Nation’s Capital. He says psychiatrists in the 1800s said African Americans were actually immune to insanity because of physiological and cultural reasons.

Martin Summers:
Physiologically, it was thought that black people did not have advanced enough nervous systems to deteriorate in the first place. Then also, because they were slaves or the overwhelming majority of black people in the United States were slaves, there was this idea that they were protected from the kinds of stimuli that might be exciting causes for insanity such as stress, or too much education, right? Because, again, they essentially had all of their needs taken care of by their masters.

Martin Summers:
After emancipation, when all of a sudden you have an increasing number of African Americans being admitted into asylums, there is an attempt to explain this increase in rates of insanity. Psychiatrists basically point to emancipation itself, freedom itself as driving black people insane because again, they did not have the cognitive capacity, or the emotional ability to actually survive in society as free willed subjects or subjects with free will. That in itself was leading to their mental breakdown.

Brian Balogh:
Both Martin and Kyle Smith know the discrepancy in how psychiatrists treated white and black mental health patients wasn’t isolated to the deep south. Martin has researched the story behind St. Elizabeths Hospital in Washington, DC.

Martin Summers:
St. Elizabeths Hospital was founded in 1855. What makes St. Elizabeths very interesting is it’s one of the few Southern asylums that actually admits both white and black patients from very early on. Really from the day it opened, it admitted black patients, but it did so against this larger backdrop of a psychiatric consensus that pretty much held that African Americans themselves as “primitive peoples” were relatively immune to insanity.

Martin Summers:
Just as you have this hospital opening up and admitting, “colored insane” they’re doing so at a time when most physicians thought that black people were relatively immune. From the very beginning, insane African Americans constituted a problem for the psychiatrists at St. Elizabeths.

Martin Summers:
In some ways racial segregation, there was a therapeutic rationale to racial segregation itself. For white patients, that environment that they needed to be in needed to essentially be racially homogenous, because it was thought that being in an integrated environment might cause them stress. They also should be in an environment with people who were suffering similar diseases as them. But that kind of rationale didn’t apply to black patients. For instance, black patients, there wasn’t an effort to separate a black person who was diagnosed with melancholia from say a black person who was diagnosed with epilepsy. Although, there was very much an effort to separate white melancholics from white epileptics.

Martin Summers:
The idea that an insane person needed to be removed from the environment that was causing them emotional and psychological stress didn’t apply to black patients to the same extent as it applied to white patients.

Brian Balogh:
These conditions often went unchallenged throughout the first half of the 20th century. However, Kylie Smith says that things started to change in states like Alabama during the 1960s. That was when civil rights activists, lawyers and federal agencies started to look more into conditions of mental health facilities, such as Searcy Hospital in Mobile, Alabama.

Kylie Smith:
Health Education and Welfare launched an investigation into that hospital and they sent an inspector down in 1967. She said, “It was like something out of a Kafka play.” Those are her words, that it was really the most horrible thing she’d ever seen, and that Searcy Hospital was being run like a plantation, were her words.

Brian Balogh:
In the late 1960s, civil rights advocates brought a case before district court judge named Frank Johnson challenging Alabama segregation policies in mental health hospitals.

Kylie Smith:
It was obvious to him right away that it was not medically justified. There were a bunch of psychiatrists who were called to testify and they all said there is no medical justification for segregation, that it doesn’t harm black or white patients to be treated together. Interestingly, that there is no difference in the way that black or white mental health should be treated. One psychiatrist even said, “I don’t believe that there is any difference between the black and the white brain, that the difference is that we see are a result of social inequality, not a lack of intelligence.”

Kylie Smith:
It didn’t take Frank Johnson long to decide that segregation in the state psychiatric hospitals was illegal. He ordered that they should be integrated in February of 1969. I believe that that’s the last [inaudible 00:18:34] civil rights desegregation case in Alabama.

Kylie Smith:
A court case like this, the names are known. I was very lucky to find out a lot about one particular patient who had a very brave mother, who made a signed affidavit about the way that her son was treated at Searcy Hospital. She’s talked about how she went to visit him one day, and he was very upset. He took his mother and father into the bathroom and he showed them bruises and welts on his back where he had been dragged into a cupboard and beaten by two white male attendants.

Kylie Smith:
There could be a tendency to say, well, people who worked in psych hospitals, those attendants, they were not great anywhere. But she went on to say that she thought it was racially motivated. She pointed to the fact that both of those attendants who she named were members of the local clan, and that the clan had had a demonstration around Searcy Hospital at the time of the integration attempt.

Kylie Smith:
For me, that’s a really powerful story because it tells me that these hospitals are occurring in the middle of extreme violence, and they’re a part of this broader racial tension, and that they’re not immune to the effects of white supremacy. You think that these places that they’re called asylums, but there’s no asylum there. I think that that’s a really powerful, for me, a reminder of what people had to live with every day, and how much courage it took for her to put her name to an affidavit to the court to protect her son.

Brian Balogh:
You refer to the civil rights movement. I’d like you to address the ways in which mental health diagnoses were used to label and marginalize civil rights activists.

Kylie Smith:
That’s a really interesting question. When we talk about does the formal desegregation movement, does it end segregation in mental health hospitals? Yes, to some extent, because they throw thousands of patients out. They just throw them out on the street, they give them a prescription for Thorazine and say, see you later. Obviously, the numbers drop overall, but there are some other things happening in psychiatry and mental health that I think have continued that segregation and that are exactly as you said, specifically aimed at activism.

Kylie Smith:
In the mid-70s, the American Psychiatric Association changed its diagnostic criteria for schizophrenia. To one cluster of symptoms, it added the word aggressive, which had not been in that cluster of symptoms before. Then almost immediately pharmaceutical companies start advertising medication. There’s a famous ad for one particular medication called Haldol that was advertised to psychiatrists, and it shows a figure who looks like James Brown with a black power fist. It says, “Are your patients aggressive? Are they out of control?”

Brian Balogh:
Wow, this was advertised in magazines?

Kylie Smith:
Yeah, it was advertised in the Archives of General Psychiatry, a medical journal. We have come full circle back to this space where we’re… I don’t think this has ever gone away, this criminalization of black resistance, and not just criminalization, but that it’s pathological. I think that that’s also related to the underlying idea that black culture itself is pathological. We see that debate come up a lot in education, segregation, and the Moynihan Report about is black culture deprived? There’s already this idea that just to be black used to be mad in some way.

Brian Balogh:
Tell me more about where we are today. You certainly established a very long line of historical discrimination in the way diagnosis is used, and for that matter the way treatment is applied. What else explains that horrifying disparity that you talked about?

Kylie Smith:
We have a general problem with mental health infrastructure in the United States, generally. I think that is obvious to everyone. There are not enough services where people live, that there is a too easy overlay with incarceration. I think that those are very complicated historical problems, and they’re not always related purely to race. There’s an overlay with poverty, and there’s an overlay in the way that different states also will approach mental health infrastructure funding and insurance.

Kylie Smith:
It’s layers of complication. Mental Health funding and insurance depends on whether a particular state has expanded Medicare in a particular way. You’ll see states that haven’t expanded Medicare or Medicaid to cover mental illness. That’s where you’ll see an almost direct trans-institutionalization, where either people who are old go to nursing homes, and then people who are on public insurance with mental illness end up in prison. That’s why we now have a situation where prisons are the largest mental health providers in the country.

Brian Balogh:
Kylie Smith is an associate professor for nursing and the humanities at Emory University. She’s the author of the forthcoming book, Jim Crow in the Asylum” Psychiatry and civil rights in the American South. You also heard from Martin Summers, Professor of History and African Diaspora studies at Boston College. He’s the author of Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital.

Fighting Invisible Enemies

Decades of physical and cultural genocide robbed Native Americans of their traditional diets and lifestyle, leaving them susceptible to infectious disease, particularly tuberculosis, which ravaged communities during the late 19th and early 20th centuries. Starting in the 1920s, field nurses sent by the government traveled from reservation to reservation to help reduce the number of deaths from disease. Historian Clifford Trafzer, author of Fighting Invisible Enemies: Health and Medical Transitions among Southern California Indians, tells Brian how western health care workers and Indigenous communities worked together to fight tuberculosis, and developed an appreciation of each others’ medicine ways.

Music:

Afterglow by Podington Bear

Dark Matter by Podington Bear

Peter Gray by Podington Bear

Dole It Out by Podington Bear

Moonlight by Adrian Berenguer

Forecasting by Podington Bear

American Indians; health disparities; medicine; tuberculosis

00:00:00 / 00:00:00

View Transcript

Brian Balogh:
In the early 20th century, Martha Manuel was a little girl growing up in San Manuel Indian Reservation in Southern California. She loved to play around the foothills of the San Bernardino Mountains. But one day something happened that caused Martha to become very ill.

Clifford Trafzer:
While she was playing with her cousin-

Brian Balogh:
This is Clifford Trafzer, professor of history at the University of California, Riverside.

Clifford Trafzer:
A shaman came out of the Aroyal, the wash, and he said to these kids, “You cannot play here. Now you go on, I’ve left something down here and I don’t want you to mess around here.”

Brian Balogh:
Shamans or medicine people were born with or given the gift of spiritual healing. They existed in every Native American group.

Clifford Trafzer:
They have power to find this energy that is out there around all of us, and then pull it in and then use it.

Brian Balogh:
Shamans were considered very powerful, able to affect the physical body with their medicine, for better or for worse.

Clifford Trafzer:
He left the area and the kids went away and played in another area but they got curious and came back to that area.

Brian Balogh:
Pretty soon Martha started getting sick.

Clifford Trafzer:
Her cousin got her home and her grandmother doctored her for a while, but they didn’t know what was wrong with her. She got a high fever. She was sweating. She was moving her head back and forth in delirium.

Brian Balogh:
Martha’s family got her into a hospital where she stayed for several days, but they couldn’t do anything for her. She was put into a horse drawn wagon and taken to Agua Caliente Indian Reservation in Palm Springs to see a high level shaman named Pedro Chino.

Clifford Trafzer:
He laid her down in front of a hot spring that is still there, of course at our Caliente, and he started praying and singing and he was asking for his familiar, his power to come to him so that he could diagnose what was wrong with this girl. As he was singing and praying, then he would smoke a cigarette and blow smoke on her. This is one of the diagnostic ways of shamen to find out where the problem was. Then he used his breath to blow over her body until he found it in her leg.

Clifford Trafzer:
Then he was a sucking doctor, and he probably used a pipe, a clay pipe to put it on the area and then sucked and pulled out a white worm. Then he took it and he threw it into the fire to kill it, and Martha woke up right away.

Brian Balogh:
While researching healthcare on Southern California reservations, Cliff spoke to many Native Americans who told them about the incredible healing powers of the shaman. But in the early 20th century, around the same time Martha got sick, there was a health crisis much bigger than a white worm and shamans were having a hard time fighting back against it.

Clifford Trafzer:
Infectious diseases were spreading among the Indian people of Southern California. Although some of the doctors, Indian doctors could address symptoms, they were not successful in getting rid of the various diseases.

Brian Balogh:
Decades of physical and cultural genocide robbed Native Americans their traditional diets and lifestyle, leaving them susceptible to infectious disease, particularly tuberculosis.

Clifford Trafzer:
By confining Indians to reservations in small areas, and then they could not live as they used to live so their housing was very poor, often living in shacks. In addition, that their food sources had been destroyed by settler communities.

Brian Balogh:
Tuberculosis and other infectious diseases also circulated at Indian boarding schools that would send children home to die and infect their families on reservations. Even though Native Americans were dying of tuberculosis at much higher rates the rest of the population, the government wasn’t doing anything about it. Many officials erroneously believed Native Americans slept outside in the fresh air and had access to healthy food, and that the diseases only infected those in city slums.

Clifford Trafzer:
The various commissioners of Indian affairs kept not believing that this was really happening, even though they received letters from missionaries from teachers from Indian agents saying we really have a problem with TV and it’s growing.

Brian Balogh:
But a turning point came in 1922, when Hubert Work was appointed Secretary of the Interior. He was an army doctor who had served in Europe during World War I.

Clifford Trafzer:
He had worked with nurses, college trained nurses. He had such a positive view of these women that when he became Secretary of Interior, he insisted that something had to be done. He felt that one of the first things that should be done was to put college educated nurses onto reservations to help families in every home.

Brian Balogh:
The field nurses were sent to the reservations around the country, getting to know indigenous communities.

Clifford Trafzer:
They were writing monthly reports talking about who they were seeing and what the problems were and how they were going to address whatever the problem is. It could be eye problems, teeth problems, and it could be tuberculosis, measles, chicken pox, mumps, you name it.

Brian Balogh:
Younger Native Americans who had been to boarding schools knew about infectious diseases, bacteria and viruses. They had already been teaching older community members about these things, and often assisted field nurses with translation.

Clifford Trafzer:
We have a testimony of going into homes and showing them if you could use this room and scrub it down with like Clorox and will totally sanitize this room and then put this young person in here, this older person in here. I know of instances where nurses helped families build small shacks out back of their homes and explain to them you need to isolate this person.

Clifford Trafzer:
They would teach folks how to boil plates and forks and urge them to burn all excess food. Don’t eat after this person eats because you’ll spread the bacteria, it will come in to you.

Brian Balogh:
A key to the nurses success depended on a close relationship between nurses and Native American mothers, grandmothers and aunts. They controlled indigenous households and made decisions regarding the health and care of children and family members.

Clifford Trafzer:
The disease was so horrible, and it was so local that you saw people dying of this horrible disease that consumes your body. That families understood, we don’t want this, we want to follow your instructions, and they did, they worked together.

Brian Balogh:
Field nurses were not pressuring communities to give up their traditional medicine ways. Most Native Americans believed it made sense to accept their help. Tuberculosis was a separate disease and it needed separate solutions.

Clifford Trafzer:
The nurses began tracking who has TB? They name names and then they find out who their contacts are, and they would go to them and they would test them. Just as we’re in a pandemic now, what is being argued by the public health people today is exactly what was argued in the 1920s and ’30s, as well as the 1940s and they did get control of tuberculosis before they had an antibiotic.

Brian Balogh:
In fact, Native American Health improved across the country, thanks to the partnership between the tribal leaders and healthcare workers, but it didn’t last. After President Roosevelt died and Truman became president, Congress turned very conservative. In an attempt to wash their hands of the, “Indian problem”, the government moved to terminate the legal relationship between the United States and Indian tribes. They dissolved the medical branch of the Indian service and made Native American Health responsibility of states and counties. But this move ended up defunding healthcare for many indigenous communities.

Clifford Trafzer:
The problem here in Southern California was that the Public Health Service did not serve the Indian people of the Mission Indian Agency and the Southern California Indian Agency. They just closed the hospital, they fired all the doctors, they fired all the nurses and stopped medical health care for American Indians.

Brian Balogh:
From that point on, Native Americans across the country had to figure out health care for themselves. Many communities created Western healthcare systems on reservations, controlled and funded by the people who live there.

Clifford Trafzer:
They fill up the boards and they decide who they’re going to hire and fire and they decide how they were going to use their money.

Brian Balogh:
But having a completely independent healthcare system means having limited resources. In the era of Coronavirus, this translates into a much higher infection rate. As of this broadcast, the Navajo Nation has the highest infection rate in the country.

Clifford Trafzer:
Many people are frightened because COVID-19 has really taken off on the reservations, and they have not received the federal funding that was allocated two, three weeks ago it was approved, but it hasn’t come to them. All the tribes… We know about the Navajo Nation, but all of the tribes are feeling the effects of COVID-19. It’s catching up onto their reservations now and spreading rapidly.

Brian Balogh:
Some people in reservations have limited access to computers, telephones, or even television or radio. It’s reminiscent of the information gap 100 years ago, when tuberculosis on reservations was at its worst. With information about the virus changing daily, Cliff says that field work is the best way to reduce COVID-19 infections on reservations.

Clifford Trafzer:
We need teams of people, health care workers to go to tribes and tribal homes to explain what is happening and how best to prevent the spread of COVID-19.

Brian Balogh:
Clifford Trafzer is a professor of history at the University of California, Riverside, and the author of Fighting Invisible Enemies: Health and Medical Transitions Amongst Southern California Indians.

The Madrigal Ten

In the summer of 1975, a group of Latina women in California banded together to file a class action lawsuit. They wanted to seek justice for pregnant women who had endured manipulation and coercion from doctors. These women claimed their rights as patients had been ignored because of their race and because they did not speak English. Joanne talks with Maya Manian, visiting professor at Howard University School of Law, about the story behind Madrigal v Quilligan.

Music:

True Blue Sky by Blue Dot Sessions

Denouement by Podington Bear

Latinos; health disparities; legal history; litigation; pregnancy

00:00:00 / 00:00:00

View Transcript

Joanne Freeman:
In the summer of 1975, a group of women in California banded together to file a class action lawsuit. Their mission was to seek justice for pregnant women who had endured manipulation and coercion from doctors. These women claim their rights as patients had been ignored because of their race, and because they did not speak English. Who were these women, they became known as the Madrigal 10.

Maya Manian:
The Madrigal 10 were a group of Mexican American women who alleged that they suffered coerce sterilizations at the Los Angeles County USC Medical Center back in the 1970s.

Joanne Freeman:
This is Maya Manian she’s a visiting professor at Howard University School of Law and has researched the story behind the lawsuit, Madrigal v. Quilligan. As Maya mentioned, the Madrigal 10 alleged that in the early 1970s, doctors at the Medical Center in Los Angeles coercively sterilized them.

Maya Manian:
What the women’s stories exposed was common patterns in the ways Medical Center staff coerced these women into undergoing sterilization procedures. All of the 10 cases involve women whose primary language was Spanish and each of the women underwent a tubal ligation after childbirth by cesarean section. What was happening is that nurses and physicians exploited the fact that the women had limited English language skills and were seeking medical care for childbirth. There were a number of different ways this was happening.

Maya Manian:
First, all of the women were approached for consent to sterilization while in the midst of labor. Some of them testified that they were also heavily medicated at the time, and they were pressured into signing English language consent forms that they could not understand.

Maya Manian:
Second, most of the women had to resist multiple requests by multiple staff to submit to sterilization. From coming in for intake to being wheeled into the OR to have their C-section. Then third, in addition to being repeatedly pressed to sign these English language sterilization consent forms which they couldn’t understand while they’re in the midst of labor pains, many of the women lack accurate information about the need for and consequences of a tubal ligation. They would think that well, if you can get your tubes tied, you could get them untied, that it was reversible. They did not understand the consequences of this surgery.

Joanne Freeman:
But the malicious practices in the medical center didn’t go unnoticed. A doctor named Bernard Rosenfeld suspected he was witnessing sterilization abuse in the maternity ward and decided to blow the whistle.

Maya Manian:
What Dr. Rosenfeld did is he managed to get medical records of what he saw as sterilization abuse of women seeking medical care at the maternity ward. He managed to bring this to the attention of two lawyers in the area. He was reaching out, working after his shift, reaching out to journalists, to civil rights groups, to government officials in the hopes of spurring some legal action.

Maya Manian:
His efforts finally paid off when his concerns came to the attention of Antonia Hernandez and Charles Nabarrete, who were two of the lead attorneys in the Madrigal v. Quilligan case, and they were very young, Mexican American attorneys.

Joanne Freeman:
Well, let’s talk a little bit about some of the details there because it’s an amazing story, and the details are as shocking as anything else about this case. Maybe tell us a little bit about in the 1960s, and in the 1970s, what is it precisely that was going on in that maternity ward? What were these doctors doing or saying to these women?

Maya Manian:
Each of these women provided testimony during this court case. Just to give you a few examples to give you a flavor of why this was coercive and why women of color who were fighting this coined the term sterilization abuse, because it was seen as an abuse of the process of getting informed consent before treatment. For example, one of the women Georgina Hernandez, testified she arrived at the hospital, she was bleeding, she was experiencing labor pains. Staff pressed her to consent to sterilization at the time of admission, but she refused. She said no, but her labor progressed. The doctors felt a ceasarean delivery was necessary, even though she had already refused to submit to sterilization while she was in labor and heading into an emergency C-section.

Maya Manian:
She was asked again about having her tubes tied. Hernandez later recalled, she recalled a woman coming to her right before she’s about to go in for the surgery to deliver her baby and she says, “I don’t remember seeing this woman’s face, I just remember a voice telling me you better sign those papers or your baby could probably die here.”

Maya Manian:
This was the pattern, 10 stories like this, with this very, very similar pattern of being coerced or pressured under these very scary circumstances into consenting to a surgery, that some of them did not understand what the consequences were.

Joanne Freeman:
Obviously, based on what you’re telling us, then this is something like a campaign being carried out against these Latina patients. What is the rationale that these doctors are using that makes them feel that this is a logical thing to do?

Maya Manian:
Well, I should note here that the doctors deny that. The doctors who testified and to this day the doctors deny that there was any such campaign. That there was any such policy to coerce these women into sterilization. Now, there’s contradictory testimony not only from the women themselves, but there was another witness that was called to the stand on behalf of the woman, this woman Karen Banker, who was a medical student at the time, and who said she was a first hand witness to what was happening on the maternity ward.

Maya Manian:
She testified that the rationale was to cut the birth rate of people of color in the county. She testified that she heard that as the rationale, and that she also witnessed what these women were describing. That a doctor would hold a painkiller in front of a mother who was in labor pains and say, “Do you want the painkiller? Sign the papers. You need to sign the papers now.”

Maya Manian:
Now the women and their lawyers said the rationale was this racialized targeting of poor women. This is going back to a long history in California in particular, of targeting the reproduction of Mexican Americans and the Mexican population, particularly because of these racialized notions that Mexican women are hyper-fertile, that Mexican people have large families, and this is a population that we don’t want to grow.

Joanne Freeman:
Then how does this play out in the courtroom once they’re there?

Maya Manian:
There’s two phases to this litigation. In their challenge the Madrigal 10, they filed their lawsuit in June 1975, and they pursued two avenues of relief. One is known as injunctive relief, and the other is damages. Injunctive relief means they wanted a court order changing federal and state policies on informed consent. They want to actually change the rules going forward, so that this doesn’t happen to more women in the future.

Maya Manian:
In particular, they say it’s coercive and unfair to use English language forms that are written at a level that most of your patient population cannot understand. We want to change this to appropriate Spanish language consent forms and we want other safeguards to protect against coerced sterilization.

Maya Manian:
They sought injunctive relief to toughen up federal and state policies on informed consent to sterilization. That was the first phase of the case. The second phase of the case, the legal term is damages, and that is financial compensation for these 10 women’s injuries. That is to recognize we were injured, and we deserve financial compensation for that.

Maya Manian:
In the first phase, seeking injunctive relief that would strengthen sterilization consent policies, the women achieved a victory, they actually won a court order to improve those policies and to change the consent forms. One of those key achievements was adding waiting periods to sterilization, which we still have today. We still have laws where you have waiting periods prior to a sterilization procedure. It is because of this history. It’s not because of a paternalistic notion that people don’t know whether or not they should get sterilization, it’s because of this history of sterilization abuse, to make sure that it’s not being pressured in high pressure circumstance.

Joanne Freeman:
It was given up basically under duress is right.

Maya Manian:
Under duress. That’s what they’re trying to avoid.

Joanne Freeman:
Now, what did the defendants argue against all of these pretty logical arguments? What was the defendants’ case?

Maya Manian:
That was the second phase of the case, which was do we give damages to these 10 women? Do we admit or does the court agree that these 10 women had their reproductive rights violated, had their right to procreate violated? That they were coerced into sterilization? The doctors testified that they had a custom in practice of looking at the sterilization consent form. That they didn’t remember these individual plaintiffs, this is a very, very busy maternity ward. They don’t remember each individual plaintiff. But they said, “We respect consent,” is what the doctor testified. “We do that by looking at these forms.”

Maya Manian:
Ultimately, Judge Curtis credited the physician’s testimony that, generally speaking, we look at these forms, and that’s a custom and practice to rely on these forms to be certain that informed consent was granted. Now, Curtis, actually didn’t dispute the testimony of the women, but just that I don’t see a pattern here of racialized targeting of these women’s reproduction. He was very dismissive to the Madrigal 10’s argument that this was racialized targeting of their reproduction. Instead, he just thought as each one is just an individual case, and unfortunately, there was a breakdown in communication, but I don’t see any reason to say that these women should win damages here.

Maya Manian:
In a nutshell, in an inversion of their intended purpose, Curtis treated these consent forms as a shield against physician liability, rather than as a means to protect patient autonomy. Our modern understandings of informed consent law is that it’s a protection of the patient’s decision making and bodily autonomy. It’s supposed to be a benefit to the patient. Here, it’s just a shield for the physician against viability.

Maya Manian:
Unfortunately, the women did not win compensation for themselves, but they did achieve victory for changing along going forward for women coming after them.

Joanne Freeman:
The judge in that case, essentially dismissed the healing component of this and clung to the forms.

Maya Manian:
Clung to the forms and credited the physician’s testimony over the women’s.

Joanne Freeman:
Did the Madrigal 10 ever receive any kind of an apology from anybody, like the State of California for the events that transpired?

Maya Manian:
No, unfortunately, they did not. Now, I should note that in 2003, California did issue a formal apology for its history of coercive sterilization, although it did not award victims any reparations, but this was not specific to the Madrigal 10. This was even going back to the era of eugenic sterilization. Today, we think of California as very progressive, very reproductive rights friendly. But California actually in 1909, was the third state to adopt laws authorizing the sterilization of the “feeble minded” and feeble minded in quotes, that was the language used in eugenic sterilization laws. California actually accounted for one third of the 60,000 non-consensual sterilizations that were performed throughout the US in the early 20th century in this eugenics era, but there was no specific apology to the Madrigal 10.

Joanne Freeman:
It’s a practice with deep roots. It’s a practice that to some degree still confronts some denial. To what degree is sterilization still a threat for some people today?

Maya Manian:
It is very much still a threat for some people today. It’s not gone away, and there are other ways in which sterilization is still a concern. Although, technology has changed. Now we have what are called LARKs, long acting reversible contraception. Now, LARKs are a wonderful thing. Sterilization is a wonderful thing for people who want it. Reproductive technologies are a double edged sword. They have promise and peril. They help women and pregnant people or could be pregnant people control the reproduction, but they can also be so easily abused.

Maya Manian:
There’s a lot of enthusiasm around LARKs, but reproductive justice advocates also fear that these will be used to target low income populations in the same way that the era of family planning, federal funding for family planning was ushered in the ’60s and ’70s, and that was the double edged sword. Poor women got access to these technologies, but then they also suffered abuse.

Maya Manian:
We see that today. There’s been reporting about large programs where the state will pay for insertion of a long acting removal contraception but not removal, in which case you have effectively been sterilized. We always have to think about the double edged sword of technologies that we have available to help people control their reproduction, but in the wrong hands, they can lead to abuse. That is still a concern today, especially when we think about this in connection with the full spectrum of reproductive health policy.

Maya Manian:
Sterilization is very much linked to our policy on contraception, on abortion, on welfare and even back in the ’70s, reproductive justice advocates, women of color were linking these different issues. This is the early ’70s. There’s Roe v. Wade is happening, there’s talk about, and debates about not only about sterilization abuse but also about abortion. Back in the ’70s, activists, reproductive justice and rights activists noted or argued that cutting back on access to abortion is going to mean increased sterilization abuse. Because how are poor women especially going to control their reproduction? If they can’t afford to pay for contraception, they can’t afford another child, welfare payments are cut back, they can’t access abortion care, because of all the increasing restrictions put on abortion. The only funded alternative left is sterilization. There’s different ways you can think about sterilization being coerced.

Joanne Freeman:
Maya Manian is a visiting professor at Howard University’s School of Law. You can find her research on Madrigal v. Quilligan in the book, Murray, Shaw and Siegel’s, Reproductive Rights and Justice Stories.

Brian Balogh:
That’s going to do it for us today, but you can keep the conversation going on long. Let us know what you thought about the episode or ask us for questions about this. You’ll find us at backstoryradio.org, or send an email to backstory@virginia.edu. We’re also on Facebook and Twitter, @BackStoryRadio. Whatever you do, don’t be a stranger.

Joanne Freeman:
BackStory is produced at Virginia Humanities. Major support is provided by an anonymous donor, the National Endowment for the Humanities, the Joseph and Robert Cornell Memorial Foundation, the Johns Hopkins University and the Arthur Vining Davis foundations. Additional support is provided by the Tomato Fund cultivating fresh ideas in the arts, the humanities and the environment.

Speaker 1:
Brian Balogh is Professor of History at the University of Virginia. Ed Ayers is Professor of the Humanities and President Emeritus of the University of Richmond. Joanne Freeman is Professor of History and American Studies at Yale University. Nathan Connolly is the Herbert Baxter Adams Associate Professor of History at the Johns Hopkins University. BackStory was created by Andrew Windham for Virginia Humanities.