Part of what made Avery’s death so tragic was that it happened at Duke University, founded by Methodists and widely regarded in that era as a forward-thinking institution. In this episode we look at how Duke’s leaders responded to criticism from all over the country—and ask the hard question: Does the fact that in 1950 segregated hospital care was the law of the land in southern states let Duke off the hook?
Guests include Warren Kinghorn, a professor in both Duke Divinity School and the Department of Psychiatry, and Don Taylor, a professor in the Sanford School of Public Policy.
UNHEALED: A Story of Race, Memory, and a Teaching Hospital
Episode 5: Invisible Racism
Transcript
Dr. Damon Tweedy: One morning in January, 1951, Hollis Edens, then the president of Duke, walked into his office and found a most remarkable letter on his desk.
Voice-over, James E. Bryant: We, the students of the Agricultural and Technical College of North Carolina, would like to register our protest against the treatment of the late Maltheus Avery.
Dr. Jeff Baker: The writer of the letter was the president of the student council. He was outraged after having read news reports about the death of a fellow student who had been denied admission at Duke Hospital following an auto accident because “there was no available bed in the Negro ward.” And he posed this question:
Voice-over, James E. Bryan: We are in no position to pass judgment on the efficiency of the medical staff at Duke Hospital, but in the light of this incident, we are forced to wonder if this staff has ever heard of the Hippocratic Oath and the teaching of the Nazarene. We urge that you take the necessary steps to make it impossible for such an incident of this nature to occur in the future.
Dr. Damon Tweedy: You've got to admire the courage of this group of Black students for calling out what they saw and going straight to the top of the power structure of Duke University. Remember this was North Carolina in 1951, when black people were, by law, second-class citizens.
Dr. Jeff Baker: I would love to have met these guys. And by the way, for good measure, they send a copy to the governor as well. And their question goes to the heart of this week's episode of UNHEALED, where we've been wrestling with the meaning of the very same incident those students we're talking about. I'm Jeff Baker and I direct Duke School of Medicine's Ethics Center.
Dr. Damon Tweedy: And I'm Damon Tweedy. I'm a psychiatrist at Duke and author of the book, Black Man in a White Coat. And today we're going to take a look at how Duke responded to Maltheus Avery’s death. It turns out that President Edens got a lot of letters about it from all over the country.
Dr. Jeff Baker: A lot of letters and many of those letters ask the same question: what is Duke going to do so this never happens again?
Dr. Damon Tweedy: And …?
Dr. Jeff Baker: And as we all know, President Edens rapidly called a press conference, issued a public apology, and called for an immediate end to segregated hospital wards throughout the south.
Dr. Damon Tweedy: (sigh) … if only that were really true.
Dr. Jeff Baker: Well, I wish that was what had happened. No, he didn't do anything of the sort. But, he did do something. What he did do was to write back to all those letter writers, and his responses actually give us a window into how Duke's leadership justified what was actually its failure to take action.
Dr. Damon Tweedy: Sure, but in the end, doesn't it just boil down to the sad but obvious truth that racial segregation was the norm in 1950 and that Duke Hospital was part of that system?
Dr. Jeff Baker: Well at the most basic level, yes. And I think we ought to be clear, in case it needs to be said, in trying to understand Duke's perspective here, we are not excusing Duke's behavior just because racism was a basic fact of American healthcare in 1950.
Dr. Damon Tweedy: Yeah, I'm with you on that. Cause there were many people even back then who called out medical racism for the moral wrong that it was.
Dr. Jeff Baker: That's absolutely right. But if all we do is just to condemn Duke's response, we risk missing something pretty important. Because this isn't just a story about racism, it's about the kind of racism that respectful white folks engaged in. It wasn't about waving the Confederate flag or wearing a white hood, but about participating in a racist system and not challenging it. It's about how racism is embedded in the institutions and cultural assumptions that surround us, what's often called structural racism.
Dr. Damon Tweedy: Let's get back to the meat of the story. Let's talk about President Edens’s reply to the student letter.
Dr. Jeff Baker: Alright. Well, Edens had already read of course about Avery in the newspapers and he had in fact received a very irate letter from the local Veterans Education office.
Dr. Damon Tweedy: Yes, because as we discussed in an earlier episode, Maltheus Avery was an army veteran who had served in World War II.
Dr. Jeff Baker: That's right. So in response, Edens did what all good administrators do. He asked for a report. And we actually still have the text of that report, which is written by the superintendent of Duke Hospital, F. Ross Porter. In a nutshell, Porter’s report focused on the medical facts of the case. It didn't even mention race. Here's what Porter wrote:
Voice-over, Superintendent Porter: As you know, he was brought here from another hospital on the slim possibility that some brain operation offered him any improvement, although he appeared to be in a hopeless condition. The patient was carefully examined by our brain surgeons upon his arrival here and their conclusion was that no brain operation offered him any improvement.
Dr. Jeff Baker: The report concluded that since Duke didn't have any beds, Avery was better off at another hospital and so he was transferred out.
Voice-over, Superintendent Porter: The problem of insufficient hospital facilities to meet all the needs is a problem with which we struggle every day.
Dr. Damon Tweedy: The report completely avoided any mention of race.
Dr. Jeff Baker: That's right.
Dr. Damon Tweedy: And no mention of the fact that there were beds available on the white ward.
Dr. Jeff Baker: No mention at all.
Dr. Damon Tweedy: I'm really struck by how the report framed the central question in strictly medical terms—whether surgery could have saved Avery or not. First, we’ll never know the answer to that question. And second, that wasn't the main concern for Maltheus's mother. The point was that Duke Hospital had beds, yet it turned away a man who needed care simply because he was Black. So instead of spending his final hours in a hospital bed with nurses and family at his side, he was shuttled away to another hospital where he essentially died on arrival.
Dr. Jeff Baker: So let's get back to that letter from the student council president at NC A&T. Edens wrote back, included a lengthy excerpt from the report, and made clear that, while he regretted the incident, Avery simply wasn't a candidate for surgery.
Dr. Damon Tweedy: That probably didn't go over well with the students at A&T.
Dr. Jeff Baker: No, it didn't go over well. The school's newspaper editor reprinted both letters word for word, and he responded with his own editorial and he didn't mince words.
Voice-over, James E. Bryant: Avery is a Negro, or at least he was until his untimely death recently. His being a Negro denied him use of the full facilities of the Duke University Hospital.
Dr. Jeff Baker: And pointing out that taxes from both Blacks and whites help support hospitals, he added:
Voice-over, James E. Bryant: Why must Negroes be herded off into a separate ward? Are they not entitled to the goods and services that their monies pay for? Where is this democracy that we speak to high heaven of?
Dr. Damon Tweedy: Those are some strong words. He was really calling out the system for its sheer hypocrisy.
Dr. Jeff Baker: And this would be the first of many letters about Avery that President Edens was going to get over the next few months. And as best as we can tell, he wrote pretty much all of them back. And with each letter he included a copy, once again, of the superintendent's report. And by and large, he stuck to its conclusion. Avery had to be transferred away because he wasn't a candidate for surgery, not because of his race.
Dr. Damon Tweedy: Jeff, I know you spent a lot of time pouring through those letters in the archives. Give us some of the highlights.
Dr. Jeff Baker: So honestly, some of the most affecting letters came back from African-Americans who had been hospitalized at Duke Hospital and shared their own experience. Like this woman from South Carolina who wrote a letter describing what she called several not two pleasant features within the hospital, such as the fact that the Black ward where she stayed had only one bathroom for both men and women. And…
Voice-over, Letter from patient, August 5, 1951: Just as disturbing to me and perhaps a far more dangerous portent is the fact that, almost without exception, Negro patients are addressed by their first names while white patients are given their appropriate titles.
Dr. Damon Tweedy: I guess I'm not really surprised by that. That was often the way Black and white people interacted in the south in those days. My parents would tell me lots of stories like that. But it's also a good example of how those attitudes didn't stop at the door of a hospital. You have to wonder how it might've led to other ways of Black people being treated differently then That's what she seemed to imply at least.
Dr. Jeff Baker: Yeah, her letter honestly didn't surprise me either, I'm sorry to say. But one thing that did surprise me going through all these letters was that a lot of them came from Methodists who talked about Duke's vision in religious terms.
Dr. Damon Tweedy: It's hard to imagine that happening today, but that was a different time. Remember the student letter that called out Duke for not following the teachings of the Nazarene? And don't forget that cartoon called "No Room at the Inn."
Dr. Jeff Baker: Yeah, you're right. You actually see this kind of language in a lot of these letters. But what's striking to me in the letters to Edens is how many refer to Duke's reputation as a Christian institution. Like here's an example from a Sunday school teacher writing for the town of Bad Acts, Michigan.
Voice-over, Thelma Allen, April 11, 1951: We in my small town are shocked over the incident. It was even discussed in the Methodist Sunday school today. Duke University and the University Hospital have much to answer to, and I should think one in your capacity would rather stand up for a cause than watch for the paycheck each month. I hope you will take a voice in this and answer the wrath that is sweeping the land.
Dr. Damon Tweedy: Wow. The wrath that is sweeping the land?
Dr. Jeff Baker: Yeah, I love this letter and she was just getting started.
Voice-over, Thelma Allen, April 11, 1951: Your hands are no doubt tied by biased non-Christian anti-colored factions on your board. But it will be fine to see someone in the south have guts enough to answer this atrocity to the colored people who were born here.
Dr. Damon Tweedy: She has definitely given him the business, as some of us would say, but we should probably explain what she's talking about.
Dr. Jeff Baker: President Edens himself had to report to a board of trustees, and the head of that board was actually a politician and senator of North Carolina named Willis Smith. Smith was a notorious and nationally-famous segregationist and that didn't help Duke's reputation outside the South.
Dr. Damon Tweedy: So I'm just trying to envision this white Sunday school teacher from Michigan calling out Duke as non-Christian and anti-colored.
Dr. Jeff Baker: It's an amazing letter. As I went through the letters, I like to call this the bad-ass letter from Bad Ax, Michigan.
Dr. Damon Tweedy: Nice. But it's pretty hard to imagine someone today criticizing Duke for not following its Methodist mission. I bet most people here nowadays don't even know that Duke was founded by Methodists.
Dr. Jeff Baker: I'm quite sure you're right about that. But the reason I think it's important is because it shows that Duke Hospital didn't just fall short of our own expectations as we look back from the year 2024. It fell short of its own mission, the mission set up by Duke's founders.
Dr. Damon Tweedy: You mean the Duke family, right?
Dr. Jeff Baker: That's right. Washington Duke, James B. Duke. They were industrialists like Andrew Carnegie and John Rockefeller, but they were also philanthropists and they were Methodists.
Dr. Damon Tweedy: I spoke about this very topic with Dr. Warren Kinghorn after he'd heard one of our talks on Matthew Avery. So Warren's a psychiatrist I trained with many years ago who now has a joint appointment at Duke's Divinity School. He also had noticed and commented to me on how many of the letter writers had mentioned Duke's failure to fulfill its own Christian mission.
Dr. Jeff Baker: And this matters because Duke Hospital was really founded with two missions. One was the one we all know and love: to train doctors and nurses and provide cutting-edge medical care. The other, though, was the traditional mission of simply providing care for the sick, regardless of whether or not they could be cured. And this, Warren said, helps us understand why it felt so wrong to Avery's family that Duke Hospital had turned him away regardless of whether or not he could have been saved. And he asked a question that I honestly hadn't thought of. What are hospitals for?
Dr. Warren Kinghorn: Are they just high-tech places for technology to be dispensed? Are they just places for cure or are they places where we can have a basic and fundamental expectation of care, and care in the sense of welcome and being treated with dignity and being cared for even if cure is not possible? This is where I think the historical roots of the hospital being not primarily technological centers of cure, but being places of hospitality and openness to the one who's in need, is critical. And so, before the obligation of cure is the expectation of care and of hospitality. And if hospitals are not places of hospitality, then what are they?
Dr. Jeff Baker: So as strange as it feels to us, more of the letter writers appeal to religious principles than to secular justice.
Dr. Damon Tweedy: With one big exception—the guy we met in our last episode, who probably wrote more letters to President Edens than any other person.
Dr. Jeff Baker: Our old friend Jim Dombrowski.
Dr. Damon Tweedy: That's him. The one who ran that early civil rights organization, the Southern Conference Education Fund.
Dr. Jeff Baker: That's right. So remember how we, after learning about Avery's death, Dombrowski sent all those surveys to hospitals across the south asking how many white beds and how many Black beds they each had, and what was their policy when a Black person needed emergency admission, but the only free beds were on the white wards. Remember all that?
Dr. Damon Tweedy: I do.
Dr. Jeff Baker: Well, Dombrowski sent one of those surveys to Duke, and once again, Edens just sent them back a copy of the report. No answers to the questions. Dombrowski kept on writing back wanting that information, and Edens kept sending the same response, over and over.
Dr. Damon Tweedy: Well, he was nothing if not persistent. And when I looked over one of his letters, I did notice that Dombrowski tried to appeal to Edens’s sense of right and wrong.
Voice-over, James Dombrowski: I'm certain that this matter of segregation in hospitals is as distasteful to you as it is to me.
Dr. Jeff Baker: And following that letter, finally Edens did start to crumble, at least a bit, and he finally conceded that there was in fact more to the story than simply the number of beds at Duke Hospital.
Voice-over, President Hollis Edens: Your letters raise a series of unrelated questions. They are addressed to a complicated problem of tangled social relations.
Dr. Damon Tweedy: “Tangled social relations.” I think that's the closest Edens would ever come to naming segregation in racism.
Dr. Jeff Baker: Yeah, that's the closest I ever found. I have to say, though, that I was curious what Edens would've said had he actually answered Dombrowski’s survey. How many Black beds were there at Duke compared to white? Were there enough? And what made it so unthinkable to admit an African-American to the white ward in a true emergency? Luckily I didn't have to look far for the answers. One of our colleagues at Duke was working on these very questions.
Professor Don Taylor: My name's Don Taylor. I'm a professor in the Sanford School of Public Policy.
Dr. Jeff Baker: Turns out Professor Taylor and a team of collaborators did a really deep dive into the history of Duke. Among a lot of other interesting facts, they found this.
Professor Don Taylor: The proportion of beds that Duke had, let's say in the first 20 or so years, was probably about half of what would have been required if the goal had been for the beds to match the black population in Durham. So Duke began with explicit wards and beds available for what were called Negro patients then, and probably had about half as many as would have been needed to care for the local population.
Dr. Jeff Baker: So if you're a numbers person, Taylor's team has got those. They found that in 1950, the year we're talking about, Duke had 451 beds for whites and 73 for Blacks.
Dr. Damon Tweedy: So that means that Black people, who were about one third of the population that Duke served, had only one sixth of the beds set aside for them.
Dr. Jeff Baker: Yeah, and the irony is that Duke Hospital had been founded specifically to provide care for both Blacks and whites.
Professor Don Taylor: When James Buchanan Duke died and his will was read and probated, the first thing it did was create the Duke Endowment.
Dr. Jeff Baker: The Duke Endowment is interesting. It was actually a lot more than just a philanthropy. One historian called it a kind of regional development plan dedicated to improving the health of both whites and Blacks across the Carolinas. In fact, it was the only southern-based philanthropy promoting healthcare for Blacks as well as whites. The trouble was that Duke Hospital opened in 1930, at the low point of the Great Depression.
Professor Don Taylor: It was a terrible time to start a hospital. It was a terrible time to start a medical school from a financial perspective. So money was front and center for the first 20 to 25 years.
Dr. Damon Tweedy: I have to say though, it's hard for me to believe that that's the only reason there weren't enough beds for Black people given what we know about the South in those days.
Dr. Jeff Baker: Yeah, I know, absolutely. And I actually think Professor Taylor would agree with you. I think what he's trying to say is that this was about racism and money. And even though Duke Hospital did survive the depression, it was still struggling financially. It had to figure out a way to generate income if it was going to survive and flourish. And they did that by seeking out private patients who could pay for their own care.
Dr. Damon Tweedy: And in those times, many of those who couldn't pay were Black.
Dr. Jeff Baker: That's right and the consequence was that a lot of Black emergencies had to be transferred.
Professor Don Taylor: The backup plan was to transfer them to Lincoln Hospital. And that's what happened in the Avery case, but I think it was more of a general way of functioning.
Dr. Jeff Baker: So there was always what I'd call a dotted-line relationship between Duke and Lincoln. Lincoln and Duke were both supported by the Duke Endowment. And sometimes Duke doctors came over to Lincoln to work together.
Dr. Damon Tweedy: The problem of course was that while Lincoln Hospital had great doctors and nurses, it didn't have nearly the resources that Duke did.
Dr. Jeff Baker: That's right. So the hospital often had to make do with what it had. For example, bed pans were sterilized in a bathtub filled with solution because the hospital couldn't afford a real bed-pan sterilizer. And in the nursery babies were sometimes stacked in double decker bassinets.
Dr. Damon Tweedy: You would not have seen that at Duke. So it's no wonder that Maltheus Avery's family was furious that he was sent from Duke Hospital to Lincoln with his life hanging in the balance.
Dr. Jeff Baker: That's right. And in fact the director of Lincoln Hospital in the sixties, Dr. Charles Watts, later said this about the Avery incident.
Voice-over, Dr. Charles Watts: Avery was typical of a lot of patients sent on to Lincoln under the guise of no beds. Many were sent here who should not have been. Proper medical care would have dictated that you do not move a patient to a smaller, less well-equipped hospital, except that they were Black.
Dr. Jeff Baker: And even more striking are the words of Dr. Eugene Stead, the physician-in-chief at Duke in 1950. Stead said this in a 1983 interview about Avery, and I'll warn you, these are pretty strong words.
Voice-over, Dr. Eugene Stead): If there was no Black bed available and if there were beds in the white service, he was sent somewhere else. Nobody sweated over it. It was just the era of segregated restaurants and toilets. It happened every day and some were bound to die.
Dr. Damon Tweedy: That is a stunning quote.
Dr. Jeff Baker: It's stunning, and it comes from Dr. Stead, who actually was a doctor who tried to change the system. But he was a blunt-spoken person and he was just describing how things were. I think he's trying to say that everyone at this time just kind of assumed this was the natural order of things.
Dr. Damon Tweedy: And the truth is that it was the way things were in the 1950s, sad as that is. And Dr. Stead was probably right. Most of the doctors at Duke and the nurses probably just took segregation for granted.
Dr. Jeff Baker: I think that's probably right. Racism was baked into the system and many, maybe even most people, didn't even really stop to think about it, let alone question it or challenge it. But what does that mean for us now? How does that history bear on Duke Health today? Here's Don Taylor again.
Professor Don Taylor: The point of history is not to say, oh look, Duke did a bad thing—that means Duke is bad. It's more, I think, for us to think about what about our own lives should we be looking more closely at. Just looking at this history, it's very easy to say, oh Duke should not have been segregated as long as they were. Maybe they should have taken a stand in, I don't know, 1955 or something. That's very easy for us to say now. I think we would be better off focusing the eye on what are we doing today where we're still not living into these things that we are criticizing people for, you know, 50, 60, 70 years ago.
Dr. Damon Tweedy: That's exactly the question I want everyone to think about. What will people be saying about us 50 years from now?
Dr. Jeff Baker: That's right. And I can't help but compare the racism that's baked into the system, what's called structural racism, to the water in a fishbowl where we're the fish. And you know we doctors are really bad at seeing the water we're swimming in because we're just too busy to really look.
Dr. Damon Tweedy: Or maybe we've convinced ourselves that we're colorblind, whatever that means.
Dr. Jeff Baker: Yeah, looking back, I think I was guilty of that when I was a medical student here at Duke in the 1980s. I never really thought that much about the fact that in some clinics, the patients were mainly white, and others there were mostly Black.
Dr. Damon Tweedy: I certainly saw that same pattern when I trained in the 1990s and 2000s. But none of the faculty that I worked with seemed to notice. Or if they did they certainly didn't talk about it around me.
Dr. Jeff Baker: So the old line between Black and white had given way to a new line between private and public patients, between those who could pay and those who couldn't, and that often played out on racial lines.
Dr. Damon Tweedy: And that's where we're headed with our next episode. We're going to fill in the gaps between when Maltheus Avery was turned away from Duke in 1950 and the reality today.
Dr. Jeff Baker: We're going to talk about what changed and what didn't change after the hopes raised by the Civil Rights Movement.
Dr. Damon Tweedy: It's a lot to cover in one episode, but it's important, so I hope you'll stay with us for that. I'm Damon Tweedy.
Dr. Jeff Baker: And I'm Jeff Baker. Thanks for listening.
UNHEALED was produced by the Trent Center for Bioethics, Humanities & History of Medicine at Duke School of Medicine. Our producer is Beverley Abel. Keith Weston is mix engineer. Our project manager is Nikki Vangsnes. Marjorie Miller provided project assistance. Music by Blue Dot Sessions and Pond Five. Funding has been provided by the Josiah Charles Trent Memorial Foundation, Mary Duke Biddle Foundation, and Duke Institutional History Project. Our website is unhealed.duke.edu.