Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
Increasingly, diversity, equity, and inclusion (DEI) efforts in medicine are under attack. Critics claim that such efforts are divisive, ineffective, and ultimately harmful to patients. They assert that medical students and physicians should focus exclusively on “hard science” like anatomy and biochemistry and leave “soft science” like sociology and urban planning to social workers and policymakers.
But such an approach minimizes or ignores the tremendous influence that social, economic, and cultural factors have in determining how people access and receive medical care, including the vital interactions that occur between doctor and patient. These elements are shaped by the past and cause persistent inequities that undermine health among groups that have historically been marginalized.
One of the many ways that DEI efforts contribute to medical education is by teaching future physicians about how past shortcomings in medicine impact our present patient care.
The case of Maltheus Avery, a young Black man denied medical care at Duke Hospital in 1950, offers a powerful example. On December 1 of that year, Avery, a World War II veteran who’d fought in the South Pacific, was involved in a head-on collision on a rural North Carolina road between Greensboro and Durham. He was initially taken to Alamance General Hospital, the nearest community hospital. Because he had sustained a head injury, doctors there felt he needed a higher level of care, so he was transferred to Duke, then a young institution that had already established a regional — and budding national — reputation as an elite facility.
But Duke Hospital, no matter its national ambitions, was located in the South during the Jim Crow era. In keeping with the times, Duke Hospital was segregated, treating Black patients on separate wards. This arrangement was clearly unequal, as the proportion of beds allotted for Black patients was about half their representation in the counties the hospital served. And on the night Maltheus Avery arrived at Duke’s emergency room, those beds for Black people were full.
Avery was turned away. He was then transferred to the local Black hospital in Durham, which lacked the resources of Duke; he died minutes after his arrival there. It’s unknown whether Avery could have survived his injuries, but what’s clear is that, from a strictly medical standpoint, Duke likely offered his best hope, a hope that was denied because of his race.
Avery’s story immediately sparked outrage in Black newspapers of the day, which invoked Christian theology to assert that Black lives mattered too. These efforts inspired one early civil rights organization to create a pamphlet describing a dozen contemporary circumstances in which Black people received negligently inferior care in segregated hospitals — or were denied care altogether. In one of the most tragic examples, a Black woman with pregnancy complications was turned away from her local hospital because of her race and sent home, where her pregnancy soon ended in stillbirth.
As much as doctors — both then and now — have regarded medicine as a primarily scientific enterprise, these stories serve as gut-wrenching reminders that social and political realities can dramatically influence medical care.
One of the many ways that DEI efforts contribute to medical education is by teaching future physicians about how past shortcomings in medicine impact our present.
As America went through the tumultuous Civil Rights Movement of the 1960s and Duke became an integrated institution, the Avery story faded from public attention — even at Duke. I never heard a single mention of Maltheus Avery during my time as a medical student there. Not once. Nor did I hear anything else about the history of mistreatment Black patients suffered.
Instead, when the subject of race came up in classes, it followed a predictable script: Disease A was more common among Black people, Disease B had a worse course among Black people, and Disease C was both more common and more lethal in Black people. But why? Instructors did not mention social drivers of health, such as residential segregation or disparities in health insurance coverage. Instead, they implied that genetic differences and/or lifestyle choices were at work. Put more simply, being Black was bad for your health, and little or none of that was the fault of the medical profession or the larger society.
What would it have been like, instead, to learn the Avery story and discuss that we were just a generation removed from Black people being systematically denied medical care because of their race? And to be taught that this medical racism occurred simultaneously with similar discrimination in education and housing? These were the life experiences of many of the Black patients we saw in our clinics and hospitals, but when we encountered their skepticism about our medical recommendations, we labeled their hesitance or resistance as noncompliance rather than as an adaptation to an adverse history that, for us as physicians to address, might require more resourcefulness on our part.
During my second year of medical school, a 50-year-old Black man was admitted to our clinical service with an infection worsened by his poorly controlled diabetes. He needed to start insulin but flatly refused, telling us how his mother got sicker after taking it. After a few days of stalemate between doctors and this patient, I sat down with him to try to understand his thinking. He told me that within a year of starting insulin, his mother went on dialysis, and that her health steadily deteriorated. We discussed his fears as well as his beliefs that insulin was a second-class treatment that doctors gave to Black patients, while everyone else received better options. It was only after hearing out his worldview, and my repeated assurances that I would take insulin in his position, that he reconsidered.
From this encounter and others, I was beginning to discover how my personal background could be especially helpful to some of the Black patients I treated.
My parents had grown up poor during the segregation era, and I had several extended family members who had experienced ill health and dismaying interactions with the health care system. Several uncles struggled with alcohol-related problems. One endured prolonged homelessness. My maternal grandmother died during my first year of medical school, of heart failure and stroke complications, both diseases related to poorly controlled hypertension. None of these relatives was able to establish the sort of relationship with a doctor that might have helped them turn a positive corner with their health. The more I saw the similarities between my family history and many of the Black patients who came to us, the more I envisioned a role for myself as their advocate both in the clinic and beyond.
Maltheus Avery’s story offers other lessons. While his fate was undoubtedly tragic, the trajectory of his two younger brothers provides inspirational narratives that remind us of how Black history is inextricably part of American history.
Waddell Avery had a decorated career in the Army, where he served as a combat medic in Korea and Vietnam, dedicated to providing injured soldiers with the care his brother had been denied. In later years, he worked for the Department of Health and Human Services and helped establish Federally Qualified Health Centers, which disproportionately serve poorer historically marginalized communities.
Parnell Avery also served in the military, then completed medical school and surgery training at Meharry Medical College in Nashville, Tennessee, a leading historically Black institution for aspiring doctors. He settled in Texas, where he became a general surgeon, often caring for patients unable to pay for treatment, and an advocate for health equity. Waddell and Parnell Avery were able to turn personal tragedy into a commitment to improve health conditions for Black people. Surely we owe it to them — and others who made similarly valuable contributions — to learn about their struggles and build upon their life’s work.
[We must] turn the lens on ourselves and continually be prepared to ask how we might be currently contributing to systems that harm patients.
Despite increased equity in medical care since Maltheus Avery’s time, Black people continue to suffer considerably worse outcomes than most other Americans across a wide variety of health measurements that traverse the entire lifespan: Infant mortality. Violent deaths in young adulthood. Maternal mortality. Heart disease, stroke, and a variety of cancers. Overall life expectancy. There are multiple causes for those persistent problems, and it will take doctors and other health care workers, following the legacy of the Avery brothers, to address them.
Even in the face of contemporary challenges, though, 1950 can seem like long ago, a time before the vast majority of Americans alive today were born. Much has improved for Black Americans since then in such areas as legal protections and economic opportunities. From that vantage point, we can safely look back through our modern lens and acknowledge that the conditions of segregated hospital wards that denied care to Maltheus Avery and others were a moral failure. We have evolved, and this comparison between the past and present might provide us with some comfort.
Turning the page on the past, however, is much easier for the medical system itself than for those who were harmed by it.
At the time of Maltheus Avery’s death, his wife was nine months pregnant, and she gave birth to a daughter the week after his death. That child is 73 years old today, and she could show up in one of our clinics or emergency departments, bearing the legacy of what happened to her father. So could many others whose families have been hurt by the system of separate and unequal medical care that defined much of the 20th century. The truth we must face is that our minds tell us that this history is much further in the past than it actually is. Put more eloquently by the famed novelist William Faulkner, “The past is never dead. It’s not even past.”
Today, many medical schools have incorporated instruction about health disparities and social drivers of health into their curricula. But a political backlash is prompting some to revise these lessons or eliminate them altogether, for fear of running afoul of state laws barring discussions about these topics. In doing so, we risk forgetting the real harms done to Maltheus Avery and other Black Americans, and how those stories impact Black communities today. We also lose out on learning about the amazing resilience of people like Avery’s younger brothers, and the way in which their lives — and the lives of many others of that era — can inspire those seeking to address health inequities in our own time.
But perhaps the greatest harm in ignoring the past is the way it might close our minds to our present-day shortcomings. The doctors of Maltheus Avery’s era were presumably motivated by the same desire to improve human health as we are today, yet they participated in a system that unduly harmed a sizable segment of the population. That reality should urge us to turn the lens on ourselves and to continually be prepared to ask how we might be currently contributing to systems that harm patients.
To that end, we must enhance, rather than erase, efforts to better understand how the history of racial discrimination in America has impacted medicine, so that we can better grapple with the barriers that remain in place today.
