By Esther Choo, Associate Professor of Emergency Medicine, Oregon Health & Science University
This spring, New York City removed a statue of James Marion Sims, the controversial “father of modern gynecology,” from Central Park. The decision was celebrated by those familiar with his legacy, including many physicians.
Sims’ innovations had unquestionable value. He introduced an early version of the vaginal speculum and new methods of performing gynecological exams. He is particularly known for developing a procedure for repairing vesicovaginal fistulas, a childbirth-related condition that creates erosion of tissue between the bladder and the vagina and leads to uncontrolled leakage of urine through the vagina. This procedure is still used today.
In removing Sims’ statue but preserving it in another location, city officials stated that New York “wants to remember darker moments in history, if not elevate them.” Indeed, the field of medicine has long struggled to benefit from gains in knowledge without being complicit in the “darker moments” — the acts of racism and cruelty — that achieved them.
The field of medicine has long struggled to benefit from gains in knowledge without being complicit in the “darker moments” — the acts of racism and cruelty — that achieved them.
In the case of Sims, his results may have been revolutionary but his means were grim. He used black slaves to test various surgical approaches to repair the fistulas. These operations occurred without their apparent consent (permission was obtained from their masters) and with no anesthetic; the slave women have been described as screaming and crying, while a team of physicians stood nearby observing and learning. One woman was operated on by Sims over a dozen times.
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Some historical views have been forgiving of Sims, stating he adhered to surgical standards of the day, worked within the context of deeply racist and sexist times, that the women he operated on suffered deeply from the underlying condition and ultimately benefited from his surgeries. Even with all of this in mind, it is hard to take a generous view of his gruesome, dehumanizing experiments. In studying neonatal tetanus, he tested a theory that the condition arose from movement of the neonatal skull during protracted births on female slaves, using an awl to pry the skull bones of infants into alignment. These experiments were fatal to the infants.
Further, Sims refused to take responsibility for his black slave study subjects: Poor outcomes were due to “the sloth and ignorance of their mothers and the black midwives who attended them.” It seems their lives were despised, not valued; a means to find a solution that he could then apply to white women. (White women, apparently, received his cure with the additional benefit of surgical anesthesia).
Sims refused to take responsibility for his black slave study subjects: Poor outcomes were due to “the sloth and ignorance of their mothers and the black midwives who attended them.”
Sadly, Sims was not the only doctor to use racial minorities like test rats. In 1951, a black woman named Henrietta Lacks was diagnosed with cervical cancer and her unusually rapidly proliferating malignant cells, ideal for biomedical research, were taken, used and disseminated around the world without her permission or knowledge. These “HeLa” cells, incidentally, were used to test the first vaccine for polio, a disease that itself has a racist history: the fight against polio won widespread public support while conceived of as a “white” illness, and for many years black victims of the disease were ignored and systematically excluded from treatment options.
The infamous Tuskegee experiments observed black men for symptoms of syphilis (but did not treat them), continuing long after a simple, inexpensive cure became available. The subjects were also not told what exactly the researchers were studying. Although I learned about Tuskegee as part of the background for modern research ethics, the experiment edged uncomfortably into my personal timeline: It did not end until 1972, one month after I was born, making it, in my mind, not just a footnote in medical history, but a real and present darkness.
We humans are as quick to embrace and decry distant examples of injustice and cruelty as we are to ignore ongoing, immediate instances of it.
We humans are as quick to embrace and decry distant examples of injustice and cruelty as we are to ignore ongoing, immediate instances of it. There are persistent racial and ethnic disparities in the provision of gynecologic and obstetric treatments. Black women in the U.S. live in the wealthiest nation in the world and yet experience a bafflingly high maternal death rate. Such health disparities are likely compounded by exclusion of racial and ethnic minorities and women from clinical research, even as more research is needed to correct their poor health outcomes. The typical paradoxes created by differentials of power and wealth, in other words, are well represented in both medical care and research today.
Racism in medicine is not always hidden as structural or implicit biases. At a recent national meeting of the American College of Obstetrics and Gynecology (ACOG), a presentation suggested that a key element in fighting maternal mortality — which, again, disproportionately affects black women — is to prevent women from getting pregnant in the first place.
The statement, at best, was an unfortunate conflation of issues related to personal choice and family planning with issues surrounding desired, high-risk pregnancy. At worst, it reinforced old themes of constant, casual devaluation of black women’s lives. Understandably, it created an uproar: Dr. Margarette Shegog, a family medicine physician, responded that the comment was “appalling” and “fundamentally disregards systemic racism.”
Dr. Willie Parker, chair of Physicians for Reproductive Health and a board-certified OB-GYN, further clarified the issue on Twitter, stating, “Maternal mortality, like rape, is a societal barometer, not a metric of personal decisions. Women with desired pregnancies become maternal deaths too… Advocacy for planned pregnancy isn’t interchangeable with the resolution of health disparities. Both are necessary to mitigate maternal risk for all women, especially women of color and poor women.”
Our past is not an immunization against the present. Physicians may aspire to adhere to the highest modern standards of ethical and beneficent behavior, but must also be mindful of the fact that in a generation or two, today’s standards may look as obviously cruel as Sims’ audience of peers observing a procedure through the screams of his patient-subjects looks to us now. Sims’ New York statue may be displaced, but it continues to cast a long shadow. How to step out of that shadow and make positive health outcomes equitable is the public health challenge of our time.
Dr. Esther Choo is an emergency physician and researcher who studies health disparities, substance use disorders and gender bias. An associate professor in the Center for Policy Research in Emergency Medicine at Oregon Health & Science University, sheis also co-founder of Equity Quotient, which measures metrics of gender equity in healthcare organizations. She tweets at @choo_ek.
Dr. Esther Choo is an emergency physician and researcher who studies health disparities, substance use disorders, and gender bias. She obtained her M.D. from Yale University, did her clinical training at Yale-New Haven Hospital and Boston Medical Center, and completed a health services research fellowship at Oregon Health & Sciences University. She has published over 65 research manuscripts on substance use disorders, health disparities, gender bias, and emergency care.
She serves on the executive board of FeminEM.org and Women Physicians For Humanity, and started the #DoctorsSpeakOut project capturing the opinions of physicians about the Senate health care bill. She also created the #thatsbias hashtag to advance discussions of gender bias in medicine, and #codehate to raise awareness about racism in the healthcare setting.