Medical Apartheid

Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present is Harriet A. Washington's landmark, National Book Critics Circle Award-winning exposé of centuries of medical exploitation of African Americans. Published by Doubleday in 2007 after years of archival research into medical journals, institutional records, and firsthand interviews, the book documents with devastating precision how Black bodies were systematically used as raw material for American medical progress — and how the structures of scientific racism created the persistent health disparities that endure today.

A Tradition of Exploitation

From the earliest days of colonial America, enslaved and free Black people were subjects of medical experimentation without consent. Washington begins in the 18th century, when medical schools across the United States faced a shortage of cadavers for anatomical dissection. Laws in several states allowed unclaimed bodies of the poor and imprisoned to be used for anatomical study, but the majority of bodies supplied to anatomy departments — including the infamous 1989 discovery of thousands of bones beneath the Medical College of Georgia, approximately 75% of them African American — were taken from Black burial grounds. The 1788 Doctors' Riot in New York City was a direct response to the practice of digging up bodies from the African Burial Ground (now the African Burial Ground National Monument), where an estimated 15,000 African Americans were interred.

J. Marion Sims and American Gynecology

One of the book's most devastating chapters examines James Marion Sims (1813-1883), the South Carolina physician widely celebrated as the "father of modern gynecology." Washington documents how Sims acquired four enslaved women — Lucy, Anarcha, Betsey, and others — and subjected them to repeated, agonizing rectal and vaginal surgeries to develop a cure for vesicovaginal fistula, a devastating complication of childbirth. Sims operated on these women without anesthesia over as many as thirty procedures each. He claimed the procedures were "not painful enough to justify the trouble and risk of attending the administration," a justification that collapses under scrutiny: Sims administered ether when he began offering the same repair procedures to white women in Montgomery a few years later. Washington also details Sims's experiments on Black infants, including one in which he used shoemaker's tools to open a Black baby's skull based on the racist theory that Black infants' skulls grew faster than white infants', killing the child.

Scientific Racism and Its Institutions

Part 1 of the book excavates the entire edifice of "scientific racism" — the pseudoscientific belief in Black biological inferiority — that was mainstream in American medicine through the mid-20th century. Washington traces how craniometry, phrenology, and early eugenics were used to justify slavery, Jim Crow subordination, and experimental inequity. She documents how Harvard professor Louis Agassiz and other influential academics used phrenological measurements to argue that Black Americans were biologically inferior, and how these ideas were embedded in medical curricula, public health policy, and clinical practice.

The Tuskegee Syphilis Study as Symptom, Not Cause

Perhaps the book's most important analytical contribution is its treatment of the 40-year Tuskegee Syphilis Study (1932-1972). Rather than treating Tuskegee as an isolated horror, Washington argues it was the logical product of a system that had already conditioned white physicians to view Black bodies as disposable research material. Through new interviews with the advisory panel members who investigated the study, Washington reveals that panel chair Dr. Broadus Butler actively suppressed language describing intentional racism in the study's final report and convinced the panel to destroy tapes of their investigative interviews.

Part 2: The Twentieth Century and Vulnerable Subjects

In Part 2, Washington shifts to 20th-century experiments on disproportionately targeted vulnerable populations. She covers Holmesburg Prison dermatology experiments, in which Philadelphia prison inmates were exposed to radioactive compounds, mustard gas, and mind-altering drugs for pay. Under the direction of Dr. Albert Kligman, over 500 compounds were tested at Holmesburg between 1951 and 1974, and prison records show Black inmates were more frequently assigned to the most dangerous experimental groups.

Reproductive Rights and the Mississippi Appendectomy

Washington's chapter on reproductive injustice is one of the most deeply researched in the book. She examines how Margaret Sanger's Negro Project, which opened birth-control clinics in Black neighborhoods beginning in the 1930s, operated in a context of eugenic anxiety about Black population growth. Contraceptive research itself relied on poor and Black women as unwitting test subjects — the birth control pill, Norplant, and Depo-Provera were all initially tested on women in Puerto Rico, Africa, and Mexico before White American women were exposed to significant risks.

The most notorious practice she documents is forced sterilization. From the early 1900s through the 1970s, an estimated 70,000-100,000 Americans were forcibly sterilized under state eugenic laws. Black women were disproportionately targeted. Fannie Lou Hamer, the civil rights activist, received a "Mississippi appendectomy" — a hysterectomy performed without consent during surgery for an unrelated condition. So common was this practice among Black women in Mississippi that it was simply called the "Mississippi Appendectomy."

Sickle Cell Disease as a Racial Construct

One of Washington's most analytically original chapters examines sickle cell disease. Though the trait is most common in people of African descent because it confers malaria resistance, Washington shows how U.S. policymakers and employers treated it as a uniquely "Black" condition. In the 1970s, the federal government pushed mandatory genetic screening programs. Because existing tests could not distinguish between carriers (who were healthy) and those with active disease, thousands of healthy Black Americans were labeled as disabled: airline pilots were grounded, military cadets were expelled, and workers were fired. Washington frames this as yet another way that medical science reproduced racial stereotypes and inflicted economic harm.

AIDS, Foster Children, and Compound Vulnerability

Washington documents the HIV/AIDS drug trials conducted at New York City institutions on children primarily from the foster care system between 1988 and 2005. Many of the minors were placed in these trials without legally authorized consent. Family members described pressure from welfare officials and physicians to continue participation, raising serious questions about whether poor Black children in state custody were treated as convenient, low-barrier research subjects.

Government Biological Warfare: MKNAOMI

The most alarming chapter in Part 3 details MKNAOMI, a CIA and military program that tested biological weapons on unknowing American civilians. In Florida, Georgia, and the Virgin Islands — communities with majority-Black populations — the U.S. government released swarms of mosquitoes carrying yellow fever and other pathogens to observe whether insects could effectively transmit disease in population centers. Washington contrasts this with a 1969 cancellation of a zinc cadmium sulfide spray test, which was called off out of concern for bald eagles in the affected area. The implication — that Black Americans were less worth protecting than eagles — is unspoken but devastating.

The Henrietta Lacks Case and Its Aftermath

Washington places the story of Henrietta Lacks — whose cancer cells (HeLa) were harvested without knowledge or consent in 1951 at Johns Hopkins — within the broader continuum of medical exploitation. HeLa cells became the foundation of countless biomedical advances, generating billions in research value while the Lacks family received nothing and learned of the cells only decades later. Washington shows how the Lacks case and Tuskegee together shaped a cultural memory of medical abuse that still produces measurable health outcomes: communities with this history are less likely to enroll in clinical trials, undermining efforts to understand disease and develop treatments in those same populations.

Recommendations for Reform

In her epilogue, Washington does not stop at documentation. She proposes concrete reforms: restoring the independence and representativeness of institutional review boards (IRBs), banning exceptions to informed consent in federally funded research, requiring bioethics education for federally funded researchers, and extending the same research accountability standards abroad that apply domestically. She emphasizes that Black communities must be included in clinical research not just as subjects but as genuine partners in research design.

The Genuine Threat to Research Participation

Critics such as Glenn Theorsell have noted that Washington invokes Tuskegee skeptically, at times implying connections between contemporary events and the study that are exceptions rather than rules. Washington acknowledges this risk but insists that the appropriate response is not to ignore the history but to reform the system that created it. She is explicit that Black Americans should participate in clinical research — but only under conditions of full transparency, genuine informed consent, and representative oversight.

Harriet Washington as Researcher

Harriet A. Washington holds a master's degree in bioethics from Harvard Medical School, has been a fellow at the Harvard School of Public Health, and is a senior research scholar at the National Center for Bioethics at Tuskegee University. Her academic credentials in bioethics, combined with years of journalistic research into medical archives, gave the book its distinctive authority: it is simultaneously a work of investigative journalism, academic history, and moral philosophy. She has since published follow-up works including Infectious Madness (2016) and Deadly Monopolies (2011).

Conclusion

Medical Apartheid is not an easy book. It documents cruelty, humiliation, suffering, and death inflicted on the bodies of people who — by the logic of the society that inflicted it — were considered less than fully human. What makes it more than a catalog of horrors is Washington's analytical rigor: she connects each documented episode to a structural system — scientific racism, institutional power, and economic exploitation — that made them inevitable rather than incidental. The book directly contributed to the American Medical Association's formal apology to Black physicians in 2008 and to growing reform efforts in ethics governance. It remains essential reading for anyone who wants to understand not just the past of American medicine but the unresolved injustices that shape its present.

Part 1: A Troubling Tradition — Medical Experimentation from Slavery to Jim Crow

The first section of Medical Apartheid traces medical experimentation on African Americans from the colonial period through the post-Civil War era. Washington opens with the grim economics of the 19th-century American medical school: as the number of medical colleges expanded rapidly in the decades before the Civil War, demand for human cadavers for anatomical dissection far exceeded legal supply. Several states passed "anatomy acts" that allowed medical schools to appropriate the remains of the poor, the imprisoned, and the unclaimed — but even these provisions were inadequate. The overwhelming majority of bodies obtained through "resurrectionist" grave robbery were African American, reflecting both the vulnerability of Black communities and the racial contempt that treated Black cemeteries as convenient supply depots.

The 1788 Doctors' Riots in New York City erupted when it became known that Columbia College medical students were systematically robbing the African Burial Ground — a site that would eventually become the African Burial Ground National Monument — for anatomical subjects. A mob of 5,000 citizens stormed the college, and the resulting violence made clear the depth of popular resistance to the desecration of Black bodies. Yet the practice continued largely unabated in other cities.

Washington couples this history with the story of J. Marion Sims, the South Carolina physician who performed gynecological surgery on enslaved women without anesthesia. Sims's repeated operations on four identified enslaved women — Lucy, Anarcha, Betsey, and a fourth whose name Washington reconstructs — were not clinical emergencies. They were experiments in the development of repair techniques for vesicovaginal fistula, a condition in which prolonged, obstructed labor creates a tear between the bladder and vagina. Between 1845 and 1849, Sims performed as many as thirty separate procedures on Anarcha alone. He later claimed anesthesia was unnecessary because Black people did not experience pain as intensely as whites — a fabrication contradicted by his own decision to use anesthesia for white patients in Montgomery some years later. The chapter on Sims is one of the most carefully documented in the book; Washington reconstructs the enslaved women's experiences from Sims's own published papers and finds contradictions between his stated aims and the actual conduct of his experiments.

Scientific Racism as Institutional Orthodoxy

Washington follows the institutional legitimation of racial pseudoscience through the late 19th and early 20th centuries. From Louis Agassiz at Harvard to the eugenicists at Cold Spring Harbor Laboratory, American scientists developed elaborate systems of craniometry (skull measurement) and anthropometry to prove Black biological inferiority. These were not fringe theories confined to racist pamphlets; they appeared in mainstream medical journals, shaped admissions and hiring in medicine, and informed public health policy well into the 1960s. Washington demonstrates that this pseudoscientific tradition created the intellectual scaffolding that made racialized medical experimentation appear to participants not merely acceptable but necessary: if Black people were genuinely biologically inferior, experimentation on them was not only not unethical but potentially beneficial for understanding supposedly degenerate biology.

Part 2: The Usual Subjects — Twentieth-Century Experiments on the Vulnerable

The second third of the book documents 20th-century experimentation on disproportionately Black populations. Washington opens with the Holmesburg Prison dermatology trials in Philadelphia, where from 1951 through 1974 Dr. Albert Kligman exposed over 500 prison inmates — many of them Black — to hundreds of pharmaceutical compounds, including radioactive isotopes, chemical warfare agents, high doses of psychoactive drugs, and industrial chemicals. Records from the prison hospital show that Black inmates were assigned more frequently to the highest-risk experimental groups. When the trials became public, Kligman fame shifted from acclaimed researcher to a figure associated with ethical dereliction; Washington shows how the same research (he went on to develop Retin-A) was partly financed by pharmaceutical companies and the U.S. military, and how the state of Pennsylvania enabled the exploitation by maintaining a captive population of prisoners who had little ability to decline.

This section also covers syphilis experiments conducted on Black sharecroppers in the American South during the same period, experiments conducted on Black children to study what Washington calls the "violent gene" hypothesis (linking racial criminality to genetics through prison studies of youth), and human radiation experiments conducted in partnership between the military and the Atomic Energy Commission — in several of which Black patients in hospitals were irradiated without their knowledge when they presented for other conditions.

Reproductive Rights, Sterilization, and the "Mississippi Appendectomy"

The reproductive rights chapter is one of the book's most thoroughly referenced sections. Washington traces the development of the birth control pill through trials conducted primarily on women in Puerto Rico, where monitoring was lax and serious side effects were underreported. She notes that when the pill was released for broader use, mortality from blood clots was dangerously understated. Long-acting contraceptives — Norplant and Depo-Provera — were tested on poor and minority women in the United States and abroad before their full safety profiles were established, and the pattern persisted the post-approval phase: Black and Hispanic women continued to be the primary test population, absorbing the unknown risks of large-scale pharmaceutical use.

Washington then turns to compulsory sterilization — the eugenic practice of rendering people permanently infertile as a condition of their receiving public services or as a criminal punishment. From the 1907 Indiana sterilization law through the 1970s, an estimated 70,000 to 100,000 Americans were forcibly sterilized. The practice was disproportionately directed at African American, Puerto Rican, and Native American women. Fannie Lou Hamer, the Mississippi civil rights activist, was given a hysterectomy without her knowledge or consent during unrelated surgery in 1961 — a procedure so routine among Black women in Mississippi that it became known as the "Mississippi Appendectomy." Washington describes how this practice was not primarily the work of rogue practitioners but was endorsed by state laws, carried out in county hospitals with official sanction, and often had to be consented to by a judge or medical superintendent who applied a standard of "unfitness" that was essentially racial.

Part 3: Race, Technology, and Medicine

The final section turns to late 20th and early 21st-century issues, arguing that though the overt violence of slavery-era experimentation has receded, its structural effects persist. Washington examines sickle cell disease — a genetic condition prevalent in populations from regions where malaria is endemic, affecting people of African, Mediterranean, and Middle Eastern descent — and shows how U.S. policy aggressively racialized it. The 1972 Sickle Cell Control Act funded mass screening programs, but the screening technology of the era could not distinguish between people who were healthy carriers of the sickle cell trait and those with active disease. The result: healthy Black Americans were denied jobs, including airline pilots grounded by the FAA and cadets expelled from the Air Force Academy, based on a screening result that was medically meaningless.

Washington also covers the intersection of AIDS and ethics. Between the mid-1980s and 2005, New York City's foster care system placed HIV-positive children in clinical trials of experimental AIDS drugs at major hospitals. Many of the children — predominantly Black and Hispanic — were enrolled in trials without genuine informed consent from their guardians. Washington interviewed family members who described pressure from social workers and physicians to keep children enrolled. Her analysis is careful: she does not claim the children were targeted specifically because of race, but she demonstrates that the systemic disregard for children in state custody, combined with the racial composition of the foster care population, created a predictable outcome: mass enrollment without accountability.

MKNAOMI and Government Biological Warfare

The most chilling chapter in Part 3 details the MKNAOMI program — a CIA and military effort to develop biological weapons. Washington documents how, from the 1950s to the 1970s, the U.S. government conducted tests that released swarms of mosquitoes (including malaria-carrying species) into predominantly Black and low-income communities in Florida, Georgia, and the U.S. Virgin Islands. The aim was to assess whether insect vectors could effectively spread infectious disease in American population centers. Washington contrasts the commitment to these human experiments with the 1969 Pentagon decision to cancel a scheduled zinc cadmium sulfide spray test over several states because of concerns for the bald eagle population. The implicit parallel is devastating: Black civilians were less strategically protected than eagles.

The Henrietta Lacks Case as Ongoing Exploitation

Washington situates the Henrietta Lacks story at Johns Hopkins Hospital in 1951 within the broader arc of the book. Lacks, a Black tobacco farmer and mother of five, presented at Johns Hopkins with cervical cancer. During her treatment, cells from her tumor were harvested without her knowledge or consent, cultured, and distributed worldwide. The HeLa cell line became the single most important biological tool in medical research, instrumental in the development of the polio vaccine, cancer drugs, gene mapping, and more — generating an estimated billions of dollars in research value. The Lacks family received nothing and did not learn until decades later that their mother's cells were still alive in laboratories across the world. Washington shows how the Lacks case mirrors Tuskegee: massive public health benefit extracted from Black bodies without consent, compensation, or acknowledgment.

Cultural Memory and Trust

Washington's central argument, developed across all three sections, is that attempts to explain Black Americans' documented mistrust of the medical system as an "overreaction to Tuskegee" are fundamentally wrong-headed. Tuskegee is the most famous incident, but it is the apex of a pyramid of abuse, not its base. From colonial grave robbing through 20th-century forced sterilization and HIV trials, the structure of exploitation remained consistent: Black bodies were treated as objects rather than subjects, and Black lives were assigned less value than white ones within the moral economy of American medicine. This history is not ancient history — its consequences are measurable. Communities with this legacy are less likely to participate in clinical trials, making it harder to study diseases that disproportionately affect them and harder to develop treatments tailored to their biological realities.

Washington's Reform Agenda

The book concludes with five specific reform recommendations. First, institutional review boards (IRBs) must be structurally independent from the institutions they oversee and must include genuine community representation. Second, the FDA's "exception from informed consent" provision for emergency research must be eliminated — it has been used to enroll Black children in AIDS drug trials without parental notification. Third, federally funded researchers must receive mandatory bioethics education before receiving grants. Fourth, the same ethical standard must apply to American researchers abroad as to those at home. Fifth, and most communally oriented, Washington argues that marginalized populations must be involved in designing research before it begins, not merely selected as the subjects for experiments conceived elsewhere. The book refuses the position that its revelations disqualify Black Americans from research participation; instead, Washington insists that the appropriate response to exploitation is reform, not avoidance.

Reading Guide

Sufficiency: Medical Apartheid is complete in itself — every chapter is necessary, and no single section is optional. It is a single encompassing argument supported by hundreds of individual documented cases.

Recommended path: Read sequentially. The book builds its argument from colonial history through contemporary bioethics, and each section retroactively illuminates the previous ones. Part 1 establishes the historical pattern; Part 2 demonstrates its 20th-century persistence; Part 3 shows its present-day consequences.

Chapters to prioritize: The chapters on J. Marion Sims, Tuskegee, reproductive rights, and MKNAOMI are the most historically significant and most thoroughly documented. If pressed for time, those four sections contain the book's hardest evidence and sharpest analysis.

Chapters to read carefully: The chapter on sickle cell disease — often underappreciated in reviews — is Washington's most original analytical contribution. It demonstrates how racial pseudoscience can persist even after the pseudoscientific language itself is abandoned.

Overall difficulty: The book requires attention but not specialized medical knowledge. Washington explains all technical terms clearly. Its emotional weight demands pauses; many readers will require intervals between chapters.

Why It Won the National Book Critics Circle Award

Medical Apartheid won the 2007 National Book Critics Circle Award for Nonfiction, along with the 2007 PEN Oakland Award, the 2007 American Library Association Black Caucus Nonfiction Award, and the Gustavus Myers Outstanding Book Award. The National Book Critics Circle praised Washington for unearthing a "hidden underbelly of scientific research" and making it accessible to a general readership without sacrificing historical or scientific precision. The book was also selected by Publishers Weekly as one of the best books of 2007. These awards reflect the book's dual achievement: it is a landmark work of historical recovery and an urgent contribution to contemporary bioethical debate. Washington did not simply tell a historically significant story — she permanently altered the conversation about the relationship between race, research, and medicine in America.

Biography as Archival Recovery

Where Mukherjee used the metaphor of a "biography" to structure a narrative about an abstract disease, Washington uses a structural approach that is simultaneously biographical and epidemiological: each chapter recovers the life and body of a specific patient, experimenter, or institution, then situates that case within a broader statistical pattern. This is not mere narrative technique. It is an epistemological argument. Washington insists that the only way to understand the scale of what happened is to experience it both as a series of personal tragedies and as a systematic institutional practice. J. Marion Sims becomes not just "a controversial physician" but a specific man who made specific choices; the enslaved women he operated on become people with names — Lucy, Anarcha, Betsey — rather than anonymous footnotes.

Strengths

The book's greatest strength is the sheer density of archival evidence Washington brings to every claim. She draws not on secondary accounts but on medical journal articles, government reports, court records, and her own primary interviews with survivors, family members, and investigators. Her chapter on the Tuskegee Syphilis Study adds material that had never been made public: interview transcripts from the 1972 advisory panel that investigated the study, including revelations that panel chair Broadus Butler suppressed language about racism and ordered the destruction of panel interview tapes. This is not a history book built on salvage journalism — it is a history built on original documentary work.

The analytical clarity is another strength. Washington consistently resists the temptation to present medical experimentation as a conspiracy of individual villains. James Marion Sims, the doctors at Holmesburg Prison, the Tuskegee researchers, the pharmaceutical researchers who screened contraceptives on Puerto Rican women — these were not rogue actors. They were physicians operating within an institutional and intellectual framework that treated Black bodies as inherently valuable for research while inherently unworthy of the protections applied to white patients. Framing exploitation as systemic rather than personal is what gives the book its ongoing relevance to contemporary medicine.

The scope is also formidable. Washington covers over 250 years of history, from colonial-era grave robbing through 21st-century AIDS drug trials, and does so without scattering. She moves between antebellum surgical experiments, 1970s contraceptive research, 1950s biological warfare, and 2000s foster-care trials with a steady narrative logic, always returning to the central mechanism: racial hierarchy as a license for medical exploitation.

Weaknesses and Critics

The book's most consistent criticism, advanced most prominently by bioethicist Ezkeiel Emanuel in The New York Times (January 24, 2007), is that Washington conflates practices that do not rise to the threshold of genuine experimentation with the documented atrocities at the core of the book. Emanuel specifically took issue with her treatment of sickle cell screening programs, arguing that mass public health screening is a legitimate medical intervention even when carried out imperfectly, and that grouping it with unethical human experimentation muddles the moral category Washington is trying to establish. Washington responded to this criticism in a letter to The New York Times (March 18, 2007), noting that Emanuel's own research on the ethics of clinical trials includes positions that were contested by subjects in the studies she documents, and objecting to Emanuel's framing that her work casts all medical research with Black subjects as inherently suspect.

Some medical historians have also taken issue with Washington's treatment of the Tuskegee study, arguing that by emphasizing the structural pattern of which Tuskegee was a part, she risks diluting the study's particular moral horror. The Tuskegee study — in which 400 Black men with syphilis were deliberately left untreated for 40 years so researchers could observe the disease's natural progression — is among the worst sins in American research history, and some critics believe the book's insistence on placing it in a continuum obscures its singularity.

Washington might have included more on the work of Black physicians who, within a racist system, actively worked to protect Black patients — physicians like Dr. Daniel Hale Williams, who founded Provident Hospital in Chicago as a training institution for Black doctors and nurses in 1891 precisely because Black patients were systematically excluded from teaching hospitals. The absence of this story does not undermine the book's argument, but it would have addressed the reasonable question of whether Black physicians were able to mediate the relationship between Black patients and the research establishment.

Comparison with Killing the Black Body

Dorothy Roberts's Killing the Black Body (1997) offers a parallel but distinct argument about racialized medical exploitation, with a tighter focus on the regulation of Black women's reproduction. Where Washington's scope is encyclopedic — slavery to the present, surgery to genetics to pharmaceuticals — Roberts concentrates on reproduction as a single site of racial control. Killing the Black Body is the more explicitly feminist and legal analysis, while Medical Apartheid is the more comprehensive historical recovery. Both books are essential, and both share a concern with informed consent and bodily autonomy, but Roberts's book has been more influential in legal scholarship while Washington's has been more influential in bioethics and medical education.

Impact on Public Understanding

The book's most measurable impact was on the American Medical Association. In 2008 — the year after publication — the AMA issued a formal apology to the nation's Black physicians for its history of racial exclusion, a gesture that Washington's historian colleagues directly attributed to the public pressure generated by Medical Apartheid. The book was also cited in the decision to remove the J. Marion Sims statue from Central Park in 2018, and has been used in medical school curricula at Harvard, Johns Hopkins, and Columbia to teach research ethics and health equity.

The book's central contribution to public understanding may be its refutation of the Tuskegee-as-origin myth. By demonstrating that Tuskegee was an endpoint rather than a beginning — the logical, predictable outcome of centuries of treating Black bodies as research material — Washington changed the terms of the debate about Black distrust of medicine. She replaced the psychological question "Why don't Black people trust doctors?" with the historical question "Why should they, given what was done?" The new framing does not guarantee resolution, but it does demand a more honest answer.