July 2013 Journal MSMA by Journal MSMA

July

VOL. LIV

2013

No. 7

APR_MSC-MS_FullPg_Final(PressReady).pdf

4/1/13

4:48 PM

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W W W. H P PA R T N E R S . C O M

Biloxi

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. Subscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. Advertising rates: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

S SI

PPI S T

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VOLUME 54

NUMBER 7

Scientific Articles

Adult Non-Cardiac ECMO for the Treatment of ARDS – The Mississippi Experience Lonnie Frei, MD

I L A SSOC

Official Publication of the MSMA Since 1959

185

Special Articles

The Educational Struggles of African-American Physicians in Mississippi: 189 Finding A Path Toward Reconciliation Richard D. deShazo, MD Associate Editor and Lucius M. Lampton, MD, Editor Opening the Doors of the Great Republic: Sex, Race, and Organized Medicine in Mississippi Lucius M. Lampton, MD, Editor

Related Organizations

Mississippi State Department of Health

205

188

Editorials

“Bottomline-Itis”: Race for the Cure…Please! D. Stanley Hartness, MD, Associate Editor

203

Maples’ Musings (or Musings of a Madman) We Need More Doctors. Really? Michael D. Maples, MD

205

President’s Page

The Power of Saying Thank You Steven L. Demetropoulos, MD, MSMA President

201

Departments

From the Editor: Inviting the Uninvited Images in Mississippi Medicine Una Voce: Disease State Asclepiad: Paul Harold Moore, MD

182 214 216 220

About The Cover: “MSMA Photomontage”- Retired radiologist William Frederic “Bill” Pontius, MD, of Ocean Springs created this collage of images to form the acronym for our Mississippi State Medical Association (MSMA). Photos were taken of various signage found on Mississippi Gulf Coast sites and then assembled in this aesthetic design by Dr. Pontius. Identification for locations of photographs spelling MSMA left to right, top, and then bottom: M- Biloxi National Cemetery located on the grounds of the Department of Veterans Affairs Medical Center and adjacent to the Keesler Field Air Force Base, S - Biloxi’s Sanger Theater, M- Gulfport Memorial Hospital established in 1946, and A- the Grand Biloxi Casino, Hotel, and Spa. MSMA’s Annual Session inspired compositing this photomatage. The 145th Annual Session of the House of Delegates will be held August 16-17 at the University of Mississippi Medical Center’s Norman C. Nelson Student Union in Jackson. Turn the page for details. For more on Dr. Pontius, see “Asclepiad” in the July 2012 JMSMA. Mollie, his wife, is a president-elect of the MSMA Alliance. r July

VOL. LIV

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JULY 2013

2013

No. 7

JULY 2013 JOURNAL MSMA 181

From the Editor: Inviting the Uninvited

ack in 1898, MSMA President Carroll Kendrick encouraged our association’s physicians to become “committees of one” to recruit new and diversified membership. His long ago charge is inherent in our Hippocratic Oath. In sentences after we swear by Apollo, we promise to look upon physicians and their offspring “in the same footing as my own brothers.” Hippocrates saw medicine as an “art” and its practitioners as “disciples.” In this capacity, we have responsibilities to our professional peers, and among those responsibilities is to encourage interest and involvement by our brothers and sisters in our association, Mississippi medicine’s best hope for physicians. Our association in the past failed to live up to its professional ideals by excluding African-Americans as full members until the mid-1960s. Such was wrong. Unfortunately, the sins and mistakes of our predecessors can’t be undone. In his little dictionary of Creole proverbs, Gombo Zhebes (1885), the New Orleans writer Lafcadio Hearn quoted the following expression: “Zaffere qui fine passé narien; lante qui pour vini qui li!” Loosely translated: “What’s past is nothing; it’s what’s to come that’s the rub!” This old Creole idiom sums it up well. We can’t fix the past; what matters most is how we live the future, and as

Sir William Osler said, “Word of action is stronger than word of speech.” How to do it? My friend, H. Todd Coulter, MD of Ocean Springs, who served as MSMA’s first African-American vice speaker, once termed the solution, individual recruitment of individual members, the “sacrament of invitation.” Todd described this sacred activity as reaching out to our physician brothers and sisters, one on one, and “inviting the uninvited.” Most members become first involved at the local component society level and often times as a result of a personal invitation from another doctor. So we see what we have to do: become committees of one performing the sacrament of invitation. Let us right the past wrongs of our association by making our MSMA today and in the future diverse, open, tolerant, and inviting. Let us treat our peers as brothers and sisters, and let us keep the MSMA table open to all physicians, whatever their race, sex, religion or political philosophy. This diverse open table will be accomplished by the resolve of individual members to extend the sacrament of invitation one on one to our peers and only by inviting the uninvited. Contact me at lukelampton@cableone. net. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg

Owen B. Evans, MD Professor Emeritus, Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Sharon Douglas, MD Emergency Medicine Physician, Gulfport Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A William Lineaweaver, MD, FACS Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

182 JOURNAL MSMA JULY 2013

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Assistant Professor of Medicine, Division of Hematology-Oncology, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

STEP UP TO THE MIC for

Medicine

145TH ANNUAL SESSION

August 16 - 17 UMC NormAN C. NelsoN studeNt uNioN

Agenda Friday, August 16 10:45 a.m.

MSMA Alliance Past Presidentâ&#x20AC;&#x2122;s Luncheon (invitation only)

11:30 a.m.

Board of Trustees Lunch Meeting

1:00 p.m.

House of Delegates, Addresses of MSMA President, AMA President, and Alliance President

2:00 p.m.

Reference Committee Hearings

2:00 p.m.

MSMA Alliance Pre-Convention Board of Directors Meeting

7:00 p.m.

MSMA Alliance Scholarship Fund Silent Auction Inauguration of 146th MSMA President James A. Rish, MD Hilton Hotel

Saturday, August 17 8:30 a.m.

MSMA Alliance House of Delegates & Officer Installation

9:00 a.m.

MSMA Excellence in Medicine Awards

9:45 a.m.

Candidate Speeches

10:30 a.m.

Caucus Meetings

11:30 a.m.

Voting & Lunch, Board of Trustees Meeting

12:00 p.m.

MSMA Alliance Awards Luncheon

1:00 p.m.

House of Delegates

3:30 p.m.

Board of Trustees Meeting

6:30 p.m.

UMMC Alumni Dinner

JULY 2013 JOURNAL MSMA 183

Medical Assurance Company of Mississippi Serving Generations of Mississippi Physicians When Paul H. Moore, III, MD, began his practice of medicine in 2013, he had many decisions to make. But for the decision of medical liability insurance, he only had to look to his father and grandfather and follow in their footsteps. The Moore family of physicians is one of several multi-generational families that Medical Assurance Company of Mississippi has protected through the years by providing their professional liability insurance. For over 35 years, Mississippi physicians have looked to MACM for their professional liability needs. Today, MACM is an integral part of Mississippi’s healthcare community through its dedication to risk management and claims services for our insureds. A dedicated staff and physician involvement at every level guarantee that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows MACM to be the carrier of choice in Mississippi for generations of Mississippi physicians.

Left to Right: Paul H. Moore, III, MD Urogynecology, Jackson P. H. (Hal) Moore, Jr., MD Radiology, Pascagoula Paul H. Moore, Sr., MD Radiology, Pascagoula

For more information on MACM’s professional liability coverage:

1.800.325.4172 • www.macm.net

184 JOURNAL MSMA JULY 2013

• Scientific Article • Adult Non-Cardiac ECMO for the Treatment of ARDS – The Mississippi Experience

Lonnie W. Frei, MD bstract

The University of Mississippi Medical Center (UMMC) has become a center for ECMO (Extracorporeal Membrane Oxygenation), providing this service to patients requiring this life-saving modality. UMMC is the only ECMO center in the state. Prior to the cases presented, ECMO use at UMMC has been limited to neonates and the pediatric patient population as well as by the cardiothoracic service for patients with cardiac failure or inability to wean from bypass. The use of ECMO for non-cardiac support in the adult population has been limited in the past, but recent reports in the literature and experience elsewhere has proven the viability of the technology. This is a retrospective report of the first three adult non-cardiac cases employing ECMO for ARDS (Adult Respiratory Distress Syndrome) in Mississippi. We achieved 100% survival in a disease process which reportedly carries a mortality ranging from 20-50%. A brief review of ECMO and its use in this population is also presented.

Keywords: ECMO, ARDS Case 1

The patient is a 34-year-old male who sustained a gunshot wound to the abdomen which required surgical treatment for multiple small bowel injuries. He initially had a relatively benign post-operative course which required multiple returns to the operating room for debridement and delayed closure of his abdomen. He required ventilator support for only the first

few days of his hospitalization and was easily managed with supplemental oxygen only. On day 6 of his admission he returned to the operating room for closure of his wound at which time he had massive aspiration during intubation. His surgery case was canceled, and he was returned to the SICU. He was unable to be ventilated by any means of support. His x-ray showed diffuse infiltrates consistent with aspiration. (Fig. 1) His blood gas (ABG) prior to the institution of ECMO was 7.14/76/40, showing a pO2/FiO2 ratio of 40, consistent with ARDS and profound respiratory failure. This was obtained on 100% FiO2 and high PEEP (positive end expiratory pressure). It was decided to place the patient on ECMO support. During the placement of the cannula for ECMO, the patient experienced a V-tachy cardiac arrest due to hypoxia and underwent CPR while ECMO support was being instituted. On start-up of the ECMO, the patient’s oxygenation immediately improved to a pO2=360. He came out of cardiac arrest and was then maintained on ECMO for 6 days. On day 6 of his treatment, his ABG was 7.48/34/452. His chest x-ray showed improvement in the diffuse infiltrates, and he was weaned to standard ventilator therapy. An ABG on 50% was 7.56/24/124. The patient was eventually weaned to extubation and discharged home without any supplemental oxygen requirement. Fig 1. Patient 1- Aspiration pneumonitis. ABG: 7.14/76/40

Author Information: Dr. Frei earned his M.D. at the University of Wisconsin-Madison. He completed residency training in general surgery at Upstate Medical Center in Syracuse, N.Y., and a surgical critical care fellowship at the University of Miami-Jackson Memorial Medical Center in Miami, FL. Before joining the Medical Center faculty, he was a faculty member in the Departments of Surgery at Frankford/Torresdale Hospital in Philadelphia, PA; St. Louis University Health Sciences Center; St. John’s Mercy Medical Center, St. Louis; Jackson-Madison County General Hospital in Tennessee; Beth Israel North Hospital, Manhattan, NY; and State University of New York, Stony Brook. Corresponding Author: Lonnie W. Frei, MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505 (lfrei@umc.edu).

JULY 2013 JOURNAL MSMA 185

Case 2

The patient is a 52-year-old male who was the victim of a motor vehicle crash in which he sustained multiple injuries, including multiple rib fractures, spinal fractures, bilateral lower extremity factures, and retroperitoneal hematomas. He required multiple blood transfusions and went to the OR on multiple occasions for repair of his orthopedic and spinal injuries. His respiratory status continued to deteriorate and became unresponsive to standard ventilator support. By day 8 of his hospitalization he had an x-ray picture consistent with ARDS, and his ABG on maximal ventilator support with 100% FiO2 and high levels of PEEP was 7.37/46/49. (Fig. 2). This is a pO2/FiO2 ratio of 49, consistent with ARDS and profound respiratory failure. ECMO was instituted and the initial ABG was 7.26/57/463. He remained on ECMO for 8 days and was weaned to standard support; his post-ECMO ABG was 7.38/45/135. Although this showed a pulmonary function ratio in excess of 200, there were still signs of an acute lung injury (ALI). Over the succeeding days he was weaned to 40% FiO2 and extubated. He was eventually discharged to acute inpatient rehab to continue his recuperation. Fig 2. Patient 2- CT scan of ARDS lung. ABG: 7.37/46/49

Case 3

The patient is a 22-year-old male who fell from a tree while hunting. He sustained bilateral open factures of his tibias and pulmonary contusions. He was not found immediately after his fall and was in traumatic shock upon admission. He received multiple blood transfusions, required intubation, and was placed on standard ventilator support. His respiratory status deteriorated, and he required increasing levels of oxygen and PEEP. On the day that ECMO was instituted, his oxygen

186 JOURNAL MSMA JULY 2013

levels progressively worsened, going from pO2 =58 to pO2 =50 immediately prior to ECMO. Once on ECMO his pO2 rose to 518 (ABG 7.44/54/518). His course on ECMO was complicated by bouts of sepsis. Although always adequately oxygenated, the pO2 levels fluctuated more than the preceding cases. After 8 days of treatment with clearing chest x-ray, ECMO was weaned and the patient was able to be maintained on standard ventilation. Within 6 more days the patient was extubated to a nasal cannula. He was eventually discharged home with no supplemental oxygen requirement. Discussion ECMO is a modality which has been available for many years, but its use in adults with acute respiratory failure or ARDS has been limited. The traditional use of ECMO has been in infants and newborns with congenital diaphragmatic hernias, cardiac malformations, meconium aspiration syndrome, and severe pulmonary hypertension. In adults it has been used primarily to support patients with cardiopulmonary failure. The most comprehensive guidelines for the use of ECMO have been published by the Extracorporeal Life Support Organization (ELSO). 1 Early attempts to use EMCO in adults were not successful.2,3 More recently there was a randomized trial of ECMO use in adults performed in England, known as the CESAR study.4 This study found improved survival in patients with ARDS treated with ECMO. The study required transfer to specialized ECMO centers and incurred costs twice that of standard ventilation. The study has many points that can be disputed regarding its validity, especially the survival statistics when compared to the control group (both arms showed survival higher than expected when looking at historical data), but it nonetheless opened the door on ECMO in adults with ARDS. Shortly after the publication of the CESAR study, there was further experience with treating ARDS with ECMO during the H1N1 flu epidemic in Australia, New Zealand, and then globally as it improved survival for patients. Mortality rates of 21% for ECMO patients compared favorably with historical data for ARDS mortality which range to 40% or greater. 5 A recent review of ECMO for ARDS in adults appeared in the New England Journal of Medicine in 2011.6 The review lists the indications and contraindications for the use of ECMO in severe cases of ARDS. Some of these are extensions of the criteria used in the CESAR study, especially uncompensated hypercapnia. This is an excellent review article for gaining further insight into the modality. The requirement for full anticoagulation is a major contraindication in ECMO trauma/surgical patients. Most of the patients with ARDS treated with ECMO have had viral or bacterial pneumonitis. Our patients all had ARDS due to non-infectious etiologies (massive aspiration; TRALI [transfusion associated acute lung injury]; shock/sepsis/long bone fractures) all known to be causes of ARDS. They demon-

strate the efficacy of ECMO, in etiologies of ARDS other than infectious. Our survival rate of 100% for profound ARDS (all patients had a pO2/FiO2 ratio of 50 or less) is higher than the reported mortalities found in the literature. All of our patients were treated with V-V (veno-venous) ECMO since all demonstrated excellent cardiac function. Our patients were started by day 8 of their disease, consistent with current recommendations for use of ECMO. The duration of EMCO in our patients ranged from 6-8 days. The costs associated with ECMO were high, but the 100% survival rate moderates those costs by providing survivors who can return to the workforce and be productive. The standard lung support used during ECMO was done using ventilator settings consistent with the settings advocated by the ARDSNet studies, or even lower. This is suggestive that ventilator management using “lung protective measures” such as low levels of PEEP, low tidal volumes, and minimized pressure settings does in fact, allow for lung rest and healing.7, 8 Further experience with ECMO in severe or profound ARDS is warranted. The use of ECMO does support the use of treatments which allow lung rest. ECMO in adults with ARDS can be provided at specialized centers. The University of Mississippi Medical Center is one of those centers for the state registered and recognized by ELSO. We are available for referral from around the state.

References 1.

Extracorporeal Life Support Organization. Patient specific guidelines. April 2009:15-19 (http://elso.med.umich.edu).

Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study. JAMA 1979;242:2193-6.

Morris AH, Wallace CJ, Menlove RI, et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994;149:295-305.

Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet 2009;374:1351-63.

The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Membrane Oxygenation for 2009 influenza A (H1N1) Acute Respiratory Distress Syndrome. JAMA 2009;302(17):1888-95.

Brodie D, Bacchatta M. Extracorporeal Membrane Oxygenation for ARDS in adults. N Engl J Med 2011;365:1905-14.

The Acute Respiratory Distress Syndrome Network, Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. N Engl J Med 2000;242:1301-8.

Putensen C, Theuerkauf N, Zinserling J, et al. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med 2009;151:566-76.

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JULY 2013 JOURNAL MSMA 187

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188 JOURNAL MSMA JULY 2013

• Special Article • The Educational Struggles of African-American Physicians in Mississippi: Finding A Path Toward Reconciliation Richard D. deShazo, MD, JMSMA Associate Editor, and Lucius Lampton, MD, JMSMA Editor

“Let men of good will and understanding change the old order, for this is a new day.”—Medgar Evers, 1961. “It is true that we have come a long way since the days of Jim Crow segregation. But the plain fact is that race still matters.” —Sherrilyn A. Ifill, President, NAACP Legal Defense and Education Fund, June 14, 2013.

Introduction Minority physicians choose primary care and rural practice sites more so than others.1 Those specialties and practice sites are desperately wanting in rural America. Here in Mississippi, and across the United States, a significantly smaller percentage of minorities choose medicine as a career compared to their total percentage of the population. There is renewed interest in understanding how and why shortages of minority physicians exist and what can be done to increase the numbers of minorities in the medical profession. In the process of studying this issue, new information was discovered on the history of the medical education of black physicians. Uncovered in this research were data on a relatively unknown, state-sponsored regional plan to divert black applicants from attending all-white health professional schools in the Southern states, including Mississippi, which persisted until the 1970’s.

A Crooked Path Made Straight A Recent Publication from Mississippi That information was reported in the article, “Crooked Path Made Straight: The Rise and Fall of the Southern Governors’ Plan to Educate Black Physicians,” published in the July 2013 issue of The American Journal of Medicine (AJM). This article explores the response of Southern Governors to the problem of medical education for their black citizens after the Second World War.2 The article Corresponding Author: Richard deShazo, MD, Department of Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216 [rdeshazo@umc.edu].

delineates a carefully considered plan to shuttle AfricanAmerican medical school candidates to historically black medical colleges by joining in a Compact to purchase the struggling Meharry Medical College, founded in 1876 in Nashville, Tennessee as the first medical school in the South expressly for blacks. Rather than admit blacks to their own professional schools, the Southern states joined together to create a “geographic district for the establishment, acquisition, operation, and maintenance of regional schools.”3 This plan was placed in the hands of a board of control, the Southern Regional Education Board (SREB). Proposed Ownership of Meharry Medical Conference by the Southern Governors’ Conference The SREB’s original plan involved the purchase of Meharry, then in precarious financial condition, and the utilization of regional funding to maintain a “separate” medical, dental, and nursing school for Southern blacks. Such an arrangement hoped to satisfy federal laws then addressing racial segregation in higher education. Pressure from Meharry alumni thwarted the transfer of the institution to the SREB, and the Compact was amended in 1948 to permit member states, including Mississippi, to contract with Meharry through the SREB for the medical education of its black citizens. The new system maintained Meharry’s autonomy and solved its financial crisis. Historian James Summerville writes, “For the next decade, the college led all other participating Southern schools in the number of contract students it enrolled. Most of them would have been denied admission to the segregated state medical schools or prohibited by expense from pursuing education for a career in health.”3

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Downstream Effects of Scholarships for Black Physicians Despite the benefit of a full medical scholarship, the AJM article asks if the SREB played a role in slowing the growth of the number of black physicians in the United States. It concluded, “It is clear that the Southern states continued to use the SREB system to procure slots in outof-state, traditionally black educational institutions well into the 1970s, when black medical students began to be admitted to state medical schools. This was despite the 1950 US Supreme Court decision in Sweatt v Painter, a ruling that should have been the death knell of separate but equal in professional education. It is reasonable to conclude that arrangements made between the Southern states, the SREB, and the participating medical schools not only slowed the integration of state medical schools in the South but also contributed to the ongoing shortage of black physicians in the US. Funding for medical education through the SREB functioned as a quid pro quo to encourage black applicants to medical school not to pursue admission to their state medical schools in the South. On the other hand, the SREB arrangement did provide opportunity and financial support to attend medical school for black students from states where later federal intervention was subsequently required to ensure their access. Now that open admission policies are in place in all states, SREB scholarships facilitate medical education for students who otherwise might not be able to afford the tuition costs associated with a medical education.”2 The writers assert, “Thus, this crooked road has been made straight. Nevertheless, how the curse of racial discrimination in the US has contributed to health disparities in our country, and the efforts to which Southern leaders were willing to go to preserve it, must be taught and remembered.”2

The SREB: Preserving the Old Social Order of the Jim Crow South Black Veterans Return after World War II Here is what we have learned. After World War II, increasing numbers of black veterans began to apply to segregated state universities under the provisions of the GI Bill.4,5 In response, Southern states increased their efforts to prevent integration of their educational institutions, including all white state professional schools. This effort was more out of determination to preserve the social order established after Reconstruction than out of concern for competition from black physicians.6 One of these strategies was to provide scholarships to traditionally black institutions for potential African-American applicants to all white state professional schools. At the 1945 meeting of the Southern Governors’ Conference, subsequently known as the Southern Governor’s Association, the governors of Alabama and Florida proposed a centralized, region-wide scholarship program to facilitate

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out-of-state medical training for African-American professional students.7 In 1948, the Governor’s Compact established the Board of Control for Southern Regional Education, which subsequently became known as the Southern Regional Education Board (SREB), the instrument to accomplish that goal. The Compact was quickly ratified by the legislatures of 15 Southern and border states, including Mississippi.8,9 The SREB began operation in 1949. That year, 149 African-American students on Southern Regional Education Board scholarships, matriculated at Meharry Medical College in Nashville and Howard University in Washington, D.C. in medicine and related fields. Two hundred eleven white students attended all-white state institutions on Southern Regional Education Board scholarships, primarily in health professions schools not existing in their own states.9 This gave the appearance of compliance to court action on the “separate but equal” doctrine that had made segregation in education possible since 1896.10,11

Felix J. Underwood: A State Health Officer and a Doctor Shortage in the Heart of the Segregated South An Enlightened MSMA President and Health Officer The story of black physicians in Mississippi both parallels and strays from the experiences of black physicians in other states who signed the 1948 compact. Despite the dominance of a segregated social structure, Mississippi was somewhat different than most other states that signed the compact in reaching out to its few black physicians, largely due to the medical and public health leadership of one man, the enlightened physician Felix J. Underwood, MD (18821959), who served as president of the Mississippi State Medical Association (MSMA) from 1919-1920. As state health officer from 1924-1958, Underwood was tireless in his efforts to improve the medical condition of Mississippi’s blacks. In 1937, in the pages of the Mississippi Doctor, he encouraged MSMA physicians to take “vigorous measures” to improve the health of their black patients. Ahead of his time, he understood the social determinants of health, stating, “One of the best preventive medicines (is) decent housing (and) better pay. T.B. and all kinds of diseases have always been highest among Negroes. Why? Not because the Negro has some constitutional defect. But because of crowding and malnutrition.”12 Underwood was equally progressive with black medical education. He had initiated postgraduate courses for physicians in the state as early as 1931 with the financial support of the Federal Children’s Bureau and soon talked the MSMA into supporting education for practicing physicians, then termed “extension type of teaching.” Underwood had the Commonwealth Fund of New York and Tulane University

School of Medicine assist the Mississippi Board of Health in perpetuating these “extension courses.” The program expanded in 1935 “for the purpose of bringing newer methods of diagnosis and treatment to the medical profession and thus lowering maternal and infant death rates.”13 The first set of 10 lectures on obstetrics was conducted only for white physicians. Underwood then created a similar set of lectures conducted by obstetrician and pediatrician Walter Henry Maddux, MD, Senior Consultant for the Federal Children’s Bureau in Washington, DC, for “colored practicing physicians.” Underwood later reported, “Doctor Maddux lectured in nine Mississippi centers beginning August 15, 1936. Colored physicians, as well as many pharmacists and dentists, participated in the program. The percentage of attendance for colored physicians was 94%. Following the completion of the medical education program for colored physicians, the Mississippi Medical and Surgical Association (MMSA) [an organization founded for and by black physicians] unanimously requested additional lectures and clinics on other medical subjects.” Thus, despite the segregation in Mississippi at both the local and state level, Underwood and his Board of Health, by statute consisting only of MSMA members, recognized the contributions of the state’s black physicians, and worked with the MMSA to provide postgraduate education in the midst of the Depression. Also noteworthy was the enthusiastic response of black medical professionals to these rare opportunities for quality post-graduate education.13 The Commonwealth Fund As early as 1931, Underwood’s connections with the Commonwealth Fund led to Mississippi’s use of medical scholarships to increase the physician workforce. These initial scholarships were for only white students to attend the segregated Tulane University School of Medicine only and were based on scholastic record, financial need, personality, health, and character. In applying for and accepting a Commonwealth Fund scholarship, the student agreed to practice medicine in a rural area in the state for at least three years. These early scholarships provided $1,000 annually for the four years of medical school. After 10 years of operation and 44 scholarships, the Commonwealth Fund withdrew its support of Mississippi’s scholarship program for undergraduate medical students in January 1941. However, this decade long program laid the groundwork Underwood was seeking for the education of physicians for rural practice, and he initiated a similar program utilizing state funds 5 years later. After he pronounced a physician shortage in the state in 1941, Underwood published an article in the December 1945 Mississippi Doctor titled, The Mississippi Doctor Shortage and What to Do About It. The MSMA’s Committee on Education, on which he served,

supported his efforts. In a report on the physician shortage in the October 1945 Mississippi Doctor, Underwood wrote, “The State Board of Health has prepared this bulletin of facts on the doctor shortage in the belief that, if the people know the facts, they will realize the danger and take the necessary steps to solve the urgent medical needs.”14 The 1946 -1948 Mississippi Legislature After the Second World War, Underwood perceived the gross inadequacies of the state health system, including its poor facilities and low workforce, and pushed for action in the state legislature. In 1938 the state had 1446 physicians, 1392 white and 54 black. By 1946, the number had dropped to 1213, with 1163 white and 50 black.15 Faced with declining numbers of both white and black physicians, he aggressively led Mississippi’s leadership to embrace the National Hospital Survey Program and the National Hospital Construction Program, with the first contract for building a Hill-Burton Act hospital in Mississippi in Booneville. He convinced the 1946 Legislature not only to pass legislation which would eventually create a 4-year medical school, but also to become the first state to inaugurate a medical scholarship program for doctors, one that included African Americans. He convinced the 1948 Legislature to inaugurate a nurse scholarship program and a statewide program for nursing education, also open to blacks. The physician scholarships were placed under the direction of a Medical Education Board, which provided loans to “deserving young future physicians” in an amount not to exceed $5,000 over four years or over $1,250 in any one school year. Under the terms of the contract, the young physician promised to return to a rural community or area of 5,000 or less population and practice a minimum of two years. After each year of practice, one-fifth of the individual’s student loan was wiped out, and if a physician practiced for five years there, the entire loan was erased. 16 Mississippi Hospital Commission Report A publication of the Mississippi Hospital Commission reported the program’s evolving success: “As of August 30, 1948, such scholarships had been granted 144 medical students. Three had completed their medical training and had started practicing.”17 By June 30, 1951, the medical education program had awarded 332 scholarships, with 200 medical students in 24 medical schools. The recipients represented 79 counties and 178 towns, revealing significant geographic diversity.18 The State Medical Education Board was still in operation in the 1960s, apparently still in charge of the Mississippi medical scholarships.19 By 1961, both black and white physician numbers were increasing. Total physicians were 1675, 62 blacks (59 males, 3 females), and 1613 whites (1566 males, 47 female). This represented

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Mississippi Black Physician Southern Regional Educational Board Scholarship Recipients. (left to right) James Anderson, MD; Aaron Shirley, MD; Robert Smith, MD; and Helen Barnes, MD. significant increases for each race since the startup of the scholarship program in 1946 with 12 black (24% increase) and 450 white (39% increase) recipients.19 Despite these increases, it is clear that black physician numbers remained terribly low. They represented less than 4% of the total, and no appreciable change in the total percentage was attained over the 15-year period.

A 4-Year Medical School for Mississippi Mississippi Behind the Curve Mississippi was also different from many other states in that it lacked most undergraduate and graduate health professional training programs or schools until 1955, when the University of Mississippi School of Medicine was established as a 4-year, racially segregated medical school. MSMA had advocated enlargement of the 2-year medical school at Oxford to four years in October 1945, two years at Oxford and two clinical years at “a larger city.” Dr. J. C. McGhee wrote, “How long will we quibble about this important question while our boys go elsewhere to study and too often to locate?” McGhee, as well as most of the state physician leadership, understood the dangers of educating physicians in other states, which often captured them. As Dr. H. R. Shands concluded in the MSMA Medical Education Committee Report, “During the past 20 years, over 3,000 Mississippi boys have finished medicine in more than a dozen medical schools in other states. Less than 40% came back to practice in Mississippi.”20 Mississippi Doctor Editor-inChief W. H. Anderson had written similar sentiments a year before: “The population of our state is largely rural and the income per family is small, so when our boys are taught out of the state in terms of large expensive hospitals and equipment, interns, nurses, orderlies, and charts, they know not how to practice in the country and small town; neither do they have the inclination. They have been enamored of the

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bright lights; they have caught the vision of fancy specialist fees, short office hours in the forenoon, golfing by afternoon, and partying at night. Back home the road looks hard, and it is. The inducement to return is small.”21 Views of the Medical Establishment The efforts to build a 4-year school did not necessarily extend to the state’s black citizens. Mississippi Doctor Editor Lawrence Long shared the opinion of the state’s white physicians toward educating its black citizens in July 1945 by noting that there was already a plan to send black candidates to school in Tennessee, a reference to the coming SREB arrangement with Meharry. Long endorsed the plan and suggested, “A few good Negro doctors would be fine.”22 It was clear that there was no intention to integrate a new 4-year medical school by the medical status quo in the state. In Mississippi, it is difficult to argue that these SREB scholarships were supported solely to encourage blacks to leave the state, even if such was the result in many cases, for up until 1955, every white medical student in the state also had to leave the state to complete their medical school training. It seems the SREB scholarships were simply the way to keep the schools segregated and maintain the social order, with little thought as to impacting black physician numbers, which were considered negligible in the overall workforce by the medical community anyway.22

Black Physicians: Sent Away to Train, Return to Challenges Four Extraordinary Mississippians Representative of black physicians of this period are the careers of four extraordinary Mississippians who attended Howard and Meharry medical colleges on Southern Regional Education Board scholarships. The experiences of three of them (Drs. Smith, Anderson, and Shirley) formed

the basis for the book, The Good Doctors, which addresses the struggle around healthcare for Mississippi black citizens during the Civil Rights era.23 Scholarships were awarded to Aaron Shirley and James Anderson to attend Meharry Medical School, and to Robert Smith and Helen Barnes to attend Howard Medical School. These scholarships were administered through the Mississippi State Board of the Institutions of Higher Learning, then called the College Board, located in Jackson, the state capital. The scholarships required that recipients return to Mississippi to practice medicine for Figure 2. (left to right) Walter Lear, MD, Robert Smith, MD, and J.S. a minimum of five years in rural areas. “Mike” Holloman, MD, picket the AMA meeting in Atlantic City, N.J. in 1963. When these physicians completed medical school, they found they were unable to obtain internships An Appeal by a Mississippi Physician to the AMA or other graduate medical education in their home state as Dr. Robert Smith, who returned to Mississippi after his the University of Mississippi Medical Center (UMMC), the medical training on scholarship at Howard, traveled from state’s only academic health center, did not accept black apJackson to Atlantic City, New Jersey in 1963, shortly after plicants. So, they began post-graduate training elsewhere. the murder of his friend, Medgar Evers. He unsuccessfully To be fair, all white physicians had to do the same, as there lobbied the AMA on behalf of black physicians for their were no accredited residency training programs until 1955. membership in the AMA, an event that made national news. How Many Came Back to Practice in Mississippi? (Figure 2) Drs. Smith, Anderson, and Shirley also provided healthcare to white and black civil rights workers in MissisAn unknown number of young black physicians resippi during Freedom Summer in 1964 at great personal risk. turned to Mississippi to honor their practice agreements after Subsequently, these three physicians played important roles post-graduate education, only to be welcomed with a new in the start-up of the national network of Federally Qualiarray of challenges in their segregated professional environfied Health Centers (FQHC). That initiative developed from ments. Some black physicians were allowed hospital staff the community health clinic movement initiated in Missisprivileges, usually in segregated wards. Dr. Robert Smith sippi during the civil rights era by the members of the Medirecalls that he and Dr. Albert Britton (the close friend and cal Committee for Human Rights in which these physicians physician of Medgar Evers) were given medical staff priviwere active.25 We have reviewed the history of FQHCs as an leges at present-day Baptist Hospital in Jackson by the early important component of the Affordable Healthcare Act and 1960s, although their practice was limited to a segregated the expansion of Medicaid.26 annex of the hospital. Others, like Dr. Aaron Shirley, learned upon their return to Vicksburg in the early 1960s that some hospitals required membership in the (local) component society of the state medical association to receive admitting and attending privileges from hospital credentials committees. However, since black physicians were racially excluded as members of the association, they were left unable to obtain hospital admitting privileges, which prevented them from caring for their patients who required hospitalization. Their choices were to make arrangements with a white physician to admit their patients to a segregated ward at a white hospital, if available, or not admit patients at all. As a result, many black physicians saw their practices limited. This process was institutionalized by an 1948 American Medical Association (AMA) resolution officially proclaiming that “the county medical society is the sole judge of whom it shall elect to membership.”24

An Aspiring Gynecologist in Greenwood A fourth Mississippi native and Southern Regional Education Board scholarship recipient, Dr. Helen Barnes, who later became a board certified obstetrician/gynecologist, had returned to Mississippi in 1960 to complete her scholarship payback in Greenwood, Mississippi, prior to completing her OB/GYN residency. She was given “scientific (S)” membership in the local medical society. Dr. Barnes was later recruited to work at the first rural FQHC in the United States which had opened at Mound Bayou, Mississippi. She eventually served as the first black medical faculty member of the University of Mississippi Medical School for many years. More about Dr. Barnes later. 27

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Black Hospitals in Mississippi The Knights and Daughters of Tabor, a black fraternal organization, had previously established The Taborian Hospital in Mound Bayou in 1942 to provide hospital privileges for black physicians.26 [From 1947 to 1974, Meharry sent residents, interns, and medical students to train at Taborian.] Other black fraternal organizations established successful hospitals in Mississippi to address this problem including the Afro-American Sons and Daughters whose hospital had operated in Yazoo City, Mississippi since 1928. These hospitals always struggled financially. With the arrival of the Hill-Burton Hospital Act and later Medicare, these hospitals would lose their ability to survive due to a multitude of factors, including increased regulatory burdens, intensified competition from larger regional hospitals, and the departure of black physicians associated with them. 28 The Black Physician Diaspora We could locate no records to determine either the number of black students who left Mississippi during this era to attend medical school at Meharry or Howard Medical College under state sponsorship or the number who established permanent medical practices in Mississippi. However, 18 Meharry Medical College graduates who were representative of the larger Southern black physician diaspora wrote Meharry to protest the terms of the 1948 Southern Regional Education Board Compact.29 This was at a time when the ratio of black physicians to black patients was 1:17,000 in Mississippi.

The “S” Members at State Medical The Medicare legislation signed into law by President Lyndon B. Johnson in 1965 prohibited discrimination against black professionals in participating hospitals. Although Medicare removed one obstacle for the practice of medicine in Mississippi for black physicians, others persisted. In Mississippi black physicians remained persona non grata in the state medical association (MSMA) until they were admitted to some regional components, not as regular members, but as “scientific members” with the “S” designation after their name. That designation meant that they could attend continuing medical education and scientific events but not social or business meetings and could not serve in any office or on any committee.14 The first “S” member was Oswald G. Smith, MD of Clarksdale in 1956.30 Helen Barnes, MD mentioned above, was the first black female member of MSMA, was admitted as an “S” member in 1960 from Greenwood.31 She was aware of the AMA’s resolution of 1948 and refused to join the AMA early in her career. So strong was her desire not to join the AMA, she later left MSMA after becoming a full member when unification occurred. It was not until 1967 that the “S” designation was removed from the listing

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of members. (See Dr. Lampton’s article “Opening the Doors of the Great Republic” on page 205 in this issue for more.) The negative impact of sending black physicians away for their training is telling in the story of Dr. Oswald G. Smith. Returning to Mississippi after service in World War II, he practiced for an extended period in the Delta. Despite his prominence and success there, he returned north by 1960 for further training. He was never to return to his home state, attracted by greener pastures less dominated by the issue of race. (See Images in Mississippi Medicine in this issue.)

Recruitment of Minority Students and Graduate Physicians to the University of Mississippi Medical Center Resistance to Integration by Elected Officials Despite Supreme Court Rulings in 1948 and 1950 mandating open admissions for African-Americans to state institutions, admissions of blacks to Southern medical schools did not occur until much later.32,33 Attempts by progressive leadership for institutional change at the Medical Center met little favor with its major funding source, the state legislature, or its governor, Ross Barnett, who appointed himself Registrar of the University of Mississippi in an attempt to block the admission of black students.34 The Southern states continued to use the Southern Regional Education Board system to procure slots for medical students in out-of-state, traditionally black educational institutions. The UMMC, like other southern health science centers, was under intense scrutiny by the US Department of Health, Education, and Welfare for compliance to federal anti-discrimination policies at the time. The Medical Center came close to losing federal funds in 1965 until it successfully passed a federal inspection and site visit.34 Robert Q. Marston, MD The Dean of the Medical School and Director of the Medical Center in the mid 1960s was Dr. Robert Q. Marston, an extraordinary leader who led the difficult institutional changes required to accommodate the obligations of the Civil Rights Act of 1964. He would maintain in 1965 that work to integrate the Medical Center began long before 1964, stating that “originally, the entire complex was designed in anticipation that it would be an integrated institution.”35 This suggests that such pragmatic leaders as Dr. David Pankratz, Dr. Arthur Guyton, Dr. Tom Brooks, Dr. Robert Snavely, and others may have planned for the eventual integration of the institution prior to 1955, as they engaged in architectural design of the new campus with William Lampton Gill. In an address delivered to the Medical Center Assembly on April 16, 1965, Dean Marston, MD, said, “The policy of the University Medical Center has been, and is now, and will con-

tinue to be, the elimination of discrimination on the basis of race as spelled out by Congressional policy and executive implementation according to the letter and the spirit of the Civil Rights Law.”35 However, Marston met resistance at his every move. Dr. Jack Geiger, who led the establishment of the community health center model in both Mississippi and the United States, remembers hearing accounts of early federal inspections of the Medical Center, to be sure Title VI (which forbade segregated public facilities) of the Civil Rights Act of 1964, was being enacted.37 Marston is remembered telling a pediatrician auditor that he was committed to full integration of the facility, but he was facing significant obstacles and pleaded for patience from the auditors. As a show of his good faith, Marston led the visiting group to the first integrated ward at the facility, the ICU, which contained 4 patients, 2 white, 2 black, all 4 in a coma state.37 Despite Marston’s sincere efforts, the active recruitment of minority students and faculty at the UMMC languished until 1970, when the United States Department of Health, Education, and Welfare forced the issue with a compliance plan.36 A Black Medical Student in 1966 Although a black medical student was admitted to the UMMC School of Medicine in 1966, it was not until 1972 that the first black medical student graduated.36 In 1966, the UMMC accepted its first black resident, Dr. Aaron Shirley, a Southern Regional Education Board scholar mentioned previously. By then, he had completed his 5 year scholarship pay back in Vicksburg and was planning to go to Oklahoma for residency in pediatrics with no intention to return. Dr. Blair E. Batson, the progressive Chairman of the Department of Pediatrics at UMMC, offered him an earlier residency startup than the University of Oklahoma, and he stayed.36 All four of the Mississippi Southern Regional Education Board scholars mentioned have made their careers in Mississippi and remained active in community affairs at many levels. By 2004, the UMMC had 29 black medical students, 10 black dental students, 49 black nursing students, 78 black students in the School of Allied Professions, 62 in the Graduate School, and 33 in hospital sponsored residency programs.36 Today, the medical center’s now willing struggle to increase minority student matriculation is challenging. This reflects not only past history of racial discrimination in the state but the fact that outstanding Mississippi African-American premed students are actively recruited by the most competitive medical schools in the US. For instance, Brown University in Rhode Island, a historically Baptist institution, has provided medical education to black students through a relationship with Tougaloo College in Jackson since Reconstruction and continues to do so.

The AMA Apology and Medicine’s Role in the Legacy of Jim Crow Medicine: Organized Medicine’s Efforts to End Racial Disparities A Shortage of Black Physicians Many conclude that arrangements made between the Southern states, the Southern Regional Education Board, and the participating medical schools not only slowed the integration of state medical schools in the South but also contributed to the shortage of black physicians by delaying integration of state professional schools. However, it appears that these efforts not only exported those African-Americans who then had to seek post-graduate education out of the state, but also exposed them to less segregated medical communities that offered better professional opportunities. Perhaps even more than the out of state education, these Mississippi exiles returned home to find demeaning professional circumstances. The oppressive segregated world these black physicians faced in many ways explains the still small number of African-American physicians, significantly fewer in numbers than their percentage of the general population, as well as the smaller number who have chosen to permanently practice in Mississippi and the South. The AMA’s 2008 Acknowledgement Organized medicine has been slow to acknowledge its involvement in the perpetuation and tolerance of segregation of both physicians and patients. The AMA published an acknowledgement and apology for its complicity in these discriminatory acts in 2008 after receiving an internal report on the organization’s role in discriminatory practices.38 In the same issue of the JAMA, the AMA admitted these practices had a profoundly negative effect on the health of African Americans.39 Even before that apology, the AMA, along with other national medical associations, proactively approached the persisting impact of Jim Crow medicine through multiple overtures. After the 2000 launch by the U.S. Department of Health and Human Services (HHS) of Healthy People 2010, the issue of racial disparities achieved additional traction at the AMA. In December 2000, AMA President Randolph Smoak and U. S. Surgeon General David Satcher signed a Memorandum of Understanding between the AMA and HHS to address racial disparities. Subsequently, in 2002, the AMA House of Delegates (HOD) approved a resolution to make the elimination of racial and ethnic disparities in health care a priority issue. The resolution catalyzed the creation of the Commission to End Health Care Disparities in October 2003, with AMA and the National Medical Association (NMA) cochairs of the Commission.40 Other AMA efforts to address racial and ethnic disparities were the creation of the AMA Minority Affairs Section, which provides a national forum on advocacy on minority health issues, as well as the professional concerns on minor-

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ity physicians and medical students, and the creation of the AMA Minority Scholars Awards. These are $10,000 merit scholarships given annually by the AMA Foundation to up to twelve minority medical students.40 Noteworthy during this time was the leadership of Dr. J. Edward Hill of Tupelo, Mississippi, a past MSMA president who served on the AMA Board of Trustees from 1996 to 2007 (except for 2003-4) and served as Chair of the Board from 2002-3 as well as President-Elect and President from 2004-6. Although Hill’s period of service ended before the official apology, he served in a leadership role in most of the initial recent efforts on racial reconciliation which were addressed during his period on the Board.41 The 2013 AMA Medical Education Report In June 2013, the AMA Council on Medical Education released a report to its House of Delegates in Chicago entitled “Implementation of Accreditation Standards Related to Medical School Diversity.”42 The report summarized the status of implementation of the Liaison Committee on Medical Education (LCME) diversity standards, provided data on trends in medical student, resident, and faculty diversity and described current strategies to enhance medical school diversity. With encouragement from the AMA in July 2009, the LCME, instituted diversity standards IS-16 (institutional diversity) and MS-8 (pipeline programs) which require medical schools to address how they deal with these issues.43 This report noted that at least 13 medical schools across the country were cited for failures to meet these diversity standards. The outreach and pipeline programs currently ongoing at the University of Mississippi School of Medicine have been recognized as models for other states in the recruitment of a diverse student body. A recent LCME accreditation review ranked UMMC’s efforts at institutional diversity as among the best in the United States. Doctors Back to School The AMA has also promoted the decade old program, “Doctors Back to School” (DBTS). The program focuses on the need for more minority physicians and encourages children from under-represented minority groups to consider medicine as a career option.40,44 It sends physicians and medical students into the community to introduce school children, especially those from underrepresented racial and ethnic groups, to physician role models. DBTS was originally launched in March 2002 by the AMA Minority Affairs Section, and as of 2007, the AMA is partnering with the Commission to End Healthcare Disparities to increase the number of physicians and schools taking part in the program. Specialty organizations have joined in. Last year, the American Academy of Family Physicians, through its Commission on Science and Public Health has created an AAFP PowerPoint

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version of DBTS for family physicians to utilize. Mississippi native Marshala Lee, MD, recently spoke to high school students in Greenwood, Mississippi utilizing the AAFP PowerPoint, a program also piloted with Tulane Medical Students during their Family Medicine training in Magnolia, Mississippi. Lee commented, “The students I met in Greenwood were smart. These were in advanced science classes, anatomy, biology, chemistry, and physics. But they also face obstacles. Roughly 90% of students in this school in the Mississippi Delta are black teens from socioeconomically disadvantaged backgrounds. The majority of them qualify for the free lunch program. The community’s teen pregnancy rate is high, detouring many bright kids from college and a better future. They need encouragement and inspiration. Physicians can provide both.” In addition to the AAFP PowerPoint, Lee added slides on Drs. Jocelyn Elders, Ben Carson, and Mae Jamison, all pioneering black physicians. 44

Conclusion: Inviting the Uninvited Our Eight Percent Our country’s legacy of racial discrimination has significantly contributed to low numbers of minorities, especially African-Americans, choosing medicine as a career. Just over 9% of all physicians in the United States are African-American, Hispanic, American Indian, Native Hawaiian, or Alaskan Native, while almost 30% of the patient population are from these racial groups. This problem is acute and pronounced in Mississippi. Licensure data reveals that there are over 500 active black physicians out of about 5917 total practicing physicians in the state. 45 More than 37% of Mississippi’s citizens are black, however, only 8% of the physicians are black. Mississippi Needs More Physicians In the years to come, the rural South will need to recruit and retain large numbers of primary care physicians from inside and outside of the Southern states to meet the tidal wave of obesity-related chronic illness that looms in our immediate future.26 Since so much of what we discovered has connections with our state and underpins our present health workforce issues, increasing the numbers of black physicians in Mississippi as well as improving their practice environment are essential in providing the citizens of Mississippi with access to quality care. While putting this information together, we also learned that our black colleagues, old and young, painfully remember the past treatment of black physicians in Mississippi, and the wounds remain unhealed. It is obvious more must be done to eliminate the vestiges of Jim Crow medicine which persist in our profession in Mississippi.

What Can We Do? So, what can we as MSMA members do to aid the healing? First, we can continue to support UMMC’s efforts to improve diversity. Mississippi’s efforts, at least at UMMC, are national models for improving diversity of students and faculty, and such efforts and programs must continue in an aggressive manner. One of the more creative approaches is the Mississippi Rural Physician Scholarship Program (MRPSP), established at UMMC with MSMA leadership in 2007. This innovative program, with goals similar to the Commonwealth Fund Scholarship efforts seventy years earlier, not only will increase access to care for the state’s minority population but also includes significant percentages of minority students among its scholars due to intense recruitment. Each legislative session since 2007, MSMA has lobbied for additional program funding, and this year our MSMA was able to have the cap removed on the program to permit even more students to receive scholarship funding and return to rural communities. We need to continue our Association’s strong support of MRPSP and UMMC’s multiple other efforts to improve diversity of our healthcare workforce. Second, our Association should explore promoting diversity in our profession beginning at the youngest levels. MSMA physicians should embrace and promote among its doctors programs such as the AMA’s Doctors Back to School Program and the AAFP PowerPoint version, which have already been utilized in Mississippi successfully. Finally, our Association should follow the AMA’s example and create a Minority Affairs Section within our House of Delegates to focus on minority health and minority physician issues. A Color Blind House of Delegates Acknowledgement of both the wrongs of our past, as well as the significant changes for the better that have occurred are needed to help assure that qualified health professionals, regardless of their race, know they are welcome here in Mississippi and in our MSMA. This must occur both at the House of Delegates level and on the “one-on-one” level, where individual members reach out and invite those not participating or not invited in the past to participate fully in our association. We encourage MSMA to follow the examples of the AMA and UMMC in active efforts to make our Association not only color blind, but keenly aware of the social determinants which impact the quality of the health of Mississippi’s people. We hope this issue of JMSMA is a big step in that direction.

Acknowledgements

Leigh Baldwin Skipworth, BA and Karen Evers, BS provided invaluable assistance in the production and research of this manuscript. The authors would also like to

thank the physicians who granted interviews. This article was written as a part of Mississippi’s commemoration of the 50th anniversary of the death of Medgar Wiley Evers.

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deShazo RD, Riley W, Guinn K, Winter W. Crooked path made straight: The rise and fall of the southern governors’ plan for the education of black physicians. Am J Med. 2013;126(7):572-7.

Summerville, James. Educating Black Doctors: A History of Meharry Medical College. University of Alabama Press: University, 1983;97-99.

Onkst, David H. “First a Negro… Incidentally a Veteran”: Black World War Two Veterans and the G.I. Bill of Rights in the Deep South, 1944-1948. J Social History 1998;31 (3):517-543.

Herbold H. Never a level playing field: Blacks and the GI Bill. J Blacks Higher Ed. 1994; 6:104-108.

Silver JW. Mississippi: the Closed Society. Harcourt, Brace, and World New York, New York, 1963.

Sugg Jr RS, Jones GH. The Southern Regional Education Board’s Ten Years of Regional Cooperation in Higher Education. Baton Rouge, LA: LSU Press; 1960. (Multiple pages from this book address this issue.)

The Southern Regional Education Compact. Feb 8, 1949. http://www. statutes.legis.state.tx.us/Docs/ED/htm/ED.160.htm. Accessed July 25, 2012.

Gant FG. The Southern Regional Educational Programs. Pub Adm Rev. 1952;17:106-111.

10. Plessy v Ferguson 163 U.S. 537 (1896). 11. Missouri ex. rel. Gaines v Canada 305 US 337(1938). 12. Lampton, Lucius. Mississippi’s medical giant: Felix Joel Underwood, the man who saved a million lives. J Miss Med Assoc. 1999;40(9)322.

13. Underwood, Felix, and R. N. Whitfield. Public Health and Medical Licensure in the State of Mississippi, 1938-1947, Vol. 2. Mississippi State Board of Health, Jackson, 1947. 189-191.

14. Ibid., 189-192;218-219. 15. Ibid., 284. 16. Galloway, D. V. The Hospital Program in Mississippi. Mississippi Commission on Hospital Care, 1948, 1-9.

17. Ibid., 8. 18. Underwood, F. J. Thirty-Seventh Biennial Report of the State Board of Health of the State of Mississippi. 1949-1951. Jackson, 1951, 14.

19. Gray, Archie L. Forty-third Biennial Report of the State Board of Health of the State of Mississippi. 1961-1963. Jackson, 1963, 21,31.

20. Shands, H. R. and Felix Underwood. “State Committee Favors Four-Year Medical School.” Miss Doctor. October, 1945, 450-455.

21. Anderson, W. H. Editorial. Miss Doctor. September 1944, 103. 22. Long, Lawrence. “To Have or Not to Have.” Miss Doctor. July 1945, 377. 23. Dittmer J. The Good Doctors. The Medical Committee for Human Rights and the Struggle for Social Justice in Healthcare. Bloomsburg Press, New York, New York: 2009,8-17, 20.

24. Baker RB, Washington HA, Olakanmi O, et al. African-American

physicians and organized medicine, 1846-1968. Origins of a racial divide. JAMA. 2008;300(3):306-313; (Additional information was obtained in an interview by Luke Lampton of Aaron Shirley, February 6, 2013, and a telephone interview by Luke Lampton of Robert Smith, April 13, 2013 and multiple discussions of Richard deShazo with Drs. Shirley, Smith, and Barnes.)

25. Dittmer J. New Encyclopedia of Southern Culture. Vol. 22: Medicine and Science. University NC Press, Chapel Hill: 2012,226-8.

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26. deShazo RD. Who will care for the newly insured under health reform? J Miss Med Assoc. 2011;52:263-9. Black Physicians in the Jim Crow South. University of Arkansas Press 2003, 71.

27. Lampton, Lucius. “Asclepiad: Helen B. Barnes, MD.” J Miss Med Assoc.

2012(10):352. (Additional information was obtained from interviews by Luke Lampton of Helen Barnes on September 9, 2012 and December 8, 2012.)

28. Beito, David. Black Fraternal Hospitals in the Mississippi Delta, 19421967. J Southern History. Feb. 1999;65(1):109-140.

29. Copy of undated telegram to the Meharry Administration, Minutes of the Executive Committee, Board of Trustees. Meharry Medical Archives.

30. Transactions of the Mississippi State Medical Association, 51st Annual

Session of the House of Delegates. Reports on Constitution and By-Laws. 1954: 23.

31. Officers and Councils of the Mississippi State Medical Association. Directory of the Mississippi State Medical Association 1961:95.

32. Sipuel v Board of Regents of University of Oklahoma 332 US 631 (1948). 33. Sweatt v. Painter, 339 U.S. 629 (1950). 34. Twiss MC, Currier, RD. Pressure from All Sides. The University of

Mississippi Medical Center in the 60’s. The University of Mississippi Medical Center, 2006.

35. Marston, Robert. Medical Center Policy on Civil Rights Implementation. Typescript. April 16, 1965.

36. Quinn J. Promises Kept. The University of Mississippi Medical Center. University Press of Mississippi; 2005:92;

37. Lampton, Luke. Interview with Luke Lampton of Dr. Jack Geiger, MD, April 4, 2013.

communities: Contrition, 2008;300(3):323-5.

reconciliation

and

collaboration.

JAMA.

39. Baker RB, Washington HA, Olakanmi O, et al. African-American Physicians and organized medicine, 1846-1968: Origins of a racial divide. JAMA. 2008;300(3):306-313.

40. American Medical Association. “Five-year Summary, The Commission to

End Health Care Disparities: Unifying efforts to achieve quality care for all Americans.” 2009; http://www.ama-assn.org/resources/doc/public-health/ cehcd-five-year-summary.pdf. (This publication provides both a history of work on health care disparities by the AMA; Besides Healthy People 2010, the report of the Institute of Medicine “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”) National Academies Press, 2003. Accessed June 10, 2013.

41. Lampton, Luke. Interview with J. Edward Hill, June 15, 2013. 42. Report of the Council on Medical Education, Report 3: Implementation of

Accreditation Standards Related to Medical School Diversity. AMA House of Delegates Handbook, June 2013.

43. Liaison Committee on Medical Education (LCME) Standards on Diversity.

http://health.usf.edu/NR/rdonlyres/92D05DFC-AABB-4C3C-82E7-9321E2 B6A44C/33724/LCMEStandardsonDiversity1.pdf. Accessed June 10, 2013.

44. Lee, Marshala. “Going ‘Back to School’ Helps Inform, Inspire Teens.”

(Editorial) AAFP News Now. April 17, 2013; http://www.aafp.org/newsnow/opinion/20130417docbackschooledl.html; http://www.ama-assn.org/ ama/pub/about-ama/our-people/member-groups-sections/minority-affairssection/doctors-back-school.page. Accessed June 10, 2013.

45. Mississippi State Board of Medical Licensure, Annual Report 2012,9. 46. deShazo RD. Joseph and Jefferson Davis, The community health centers: Mississippi and 11 billion dollars. J Miss Med Assoc. 2011;52(5):155-58.

38. Davis RM. Achieving racial harmony for the benefit of patients and

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• President’s Page • The Power of Saying Thank You

s my tenure as your president draws to a close, I am reminded of all the people that I need to thank who have helped me this past year. It also reminds me of the importance of saying “thank-you” in general and how we don’t do that enough. It is a quality that has been recognized in all the leadership books throughout the last decades. It is the best motivator of people but we all too often forget about it. Just telling someone that you appreciate the job that they do on your behalf and recognizing their effort means so much to that person’s self-esteem. This Steven L. Demetropoulos, MD goes beyond just the people with whom you work. It can be the clerk that 2012-13 MSMA President gives you good service in the grocery store or the mechanic that is changing your oil at the quick lube or the waiter that serves you in a restaurant. Some of the most obvious thank-yous that are oftentimes neglected are those to your family: thanking your spouse for support and encouragement, thanking your children for working hard in school and making good grades, or when they do well on the sports field. This especially holds true with the people that you work with. If you will pick out a particular trait or quality, be specific about it, and compliment that person on that ability, it will create so much positive self-esteem for that person. It encourages them to keep up the good work and to do their job with excellence. It is a much better motivator than criticism. I reread one of the old classic leadership books, How to Win Friends and Influence People by Dale Carnegie, and I realized that I wasn’t saying thank-you enough to people that I work with. So I started making a point to say thank-you to three people every day and to compliment them on a specific quality or talent that they have. It actually made me embarrassed that I wasn’t doing that much more often because it created so much positive self-esteem for those people and they were so appreciative that I took the time to recognize them. As I exit my role as your president, I have some thank-yous to say. First, I would like to thank my partners for trading shifts and covering for me during the many events of this past year. I could not have done this without your support. I also want to thank all the component society presidents and all the members that attended the different component society functions at which I spoke across the state. You made me feel so much at home. You were very gracious and hospitable. It was so neat to see so many different parts of the state and make new friends from those areas. I would like to say thank you to the staff at State Medical Association, to Blake Bell and Anna Morris who worked tirelessly on all the legislative agenda this year and to Neely Carlton, our legal counsel, who oversaw the legislative agenda and was able to empower Anna and Blake to do the job while addressing many other special projects like drug diversion and the pharmaceutical board. I would like to thank Virginia Jackson who organized my trips, lodging, meetings, and basically kept the schedule for me. I would like to thank Phyllis Williams who has worked very closely with all the Medicaid issues that I have tried to take on this past year and who has brought a tremendous amount of knowledge and expertise to that area. I also want to thank Karen Evers who worked on all of my Journal MSMA projects and kept me on track with my articles as well as my recipes. Finally, Charmain Kanosky, who attended almost all the component society meetings with me, has been a great source of advice, and has worked tirelessly on behalf of the organization. She has created a culture at the State Medical Association with the staff that is focused on making our board, president and association as successful as we can be. That’s the end of my thank-yous but I don’t want it to stop here. I would like you to try this new skill. Pick out two or three people each day to give a very heartfelt thank you for what they do on your behalf, for their excellent service, and for the enthusiasm that they have for their job. Be an encourager instead of a criticizer and see all the positive influence that you will have on someone’s life. Thank you.

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ust what the doctor ordered GRILLED LAMB CHOPS

saved one of my favorites as my last recipe and that is grilled lamb chops. Many people have never eaten lamb or they don’t think of it as a possible entrée. I would suggest that you buy the rack of lamb at Sam’s or at your grocery store if it is domestic lamb. I like to cut the lamb chops so that they are two lamb chops thick with the single bone so the lamb chop is actually about a half inch thick. My son likes to think of them as “little lamb lollypops” because you leave the bone in. I normally marinate them for about two hours in lemon juice and olive oil with some garlic on them. I use a hot fire with the grill. Sprinkle them with salt and pepper, a little bit of rosemary, oregano, and I add some more garlic on top. Grill the chops for about a minute and a half on each side. You want to serve them medium rare. That is just about enough time to have good grill marks on one side; flip them over and you will have good grill marks on the other side. Pull them off the grill, sprinkle them with a little olive oil, and then squeeze a lemon over them. They are ready to eat. These really go great with a delicious summer salad of tomatoes,feta cheese, and cucumbers. For a side dish try a little pasta with some Pecorino Romano cheese on it or some grilled zucchini and yellow squash. If you have never tried lamb, this is the premium way to try it. We love to serve these on special occasions like birthdays or New Year’s Eve. Bon Appetit! Steve Demetropoulos, MD

When your medical office is short-staffed, you get frustrated. When you get frustrated, you dread going to work and you start playing hooky.

Component societies meet with a beat... Address local concerns

When you start playing hooky, the bills pile up. When the bills pile up, Mama ain’t happy. When Mama ain’t happy, ain’t nobody happy.

KEEP MAMA HAPPY. When your office is short-staffed, use the MSMA Online Job Bank! Learn more: www.MSMAonlinejobs.com 202 JOURNAL MSMA JULY 2013

Develop grassroots support for issues Improve the health of their communities.

Visit the SOCIETIES page at MSMAonline.com for local medical societies’ listings. Email officer updates and upcoming meetings / events to Virginia Jackson (VJackson@MSMAonline.com) or call 601-853-6733, ext. 307. • Coast Counties Medical Society - 6:00 pm, Aug. 8 and Nov. 14 The Great Southern Club, Hancock Bank Building, Gulfport • Prairie Medical Society - 6:30 pm, Sept. 10, Old Waverly, West Point

• Editorials • “Bottomline-Itis”: Race for the Cure…Please!

f there were a vaccine for prevention, I would’ve already taken it, but apparently, like so many in our profession, I thought I was immune. I chose to ignore the warning signs until the problem was already full-blown. By that time, it was too late, and I ended up a statistic. Upon retiring after a forty-plus year career in Family Medicine in my hometown, Beth and I relocated to Jackson to be near our daughters and their families (read “grandchildren”). I was approached by one of the large metropolitan health D. Stanley Hartness, MD groups and soon found myself invited to the dance at one of their outpatient clinics. Associate Editor My dance card stayed full for three years, working three days each week and one Saturday per month, until about six months ago when my schedule was drastically slashed to one day a week. I was forced to vacate my office and “room” with one of my partners across the hall, and my nurse was reassigned. I naively failed to realize that the clock at the ball was rapidly approaching midnight. I’ll admit that I had begun to feel somewhat discomfited: • When I heard the phrase, “You guys have got to turn those exam rooms”, • When an in-house drug dispensary was established (“They’re flying off the shelves in our other clinics”), • When physicians are addressed by their first names with no regard to their age or years in practice, • When I discovered “Admin” has in place an EHR surveillance that makes the NSA look like child’s play! Three months later I was advised that my position (“not you personally”) was being eliminated as of June 30, strictly a “business decision”. With almost daily newspaper articles and television reports of primary care physician shortages particularly in Mississippi in the face of burgeoning insurance rolls, this turn of events left me scratching my head…but with no recourse. Generated by the powers-that-be, letters sent out to patients gave the impression that I was simply folding my tent and disappearing into the night rather than being tossed out on my ear, actually creating more questions than they answered. Thank goodness I had committed to serve as camp doctor at Strong River Camp and Farm the last week of June, making my transition back to the real world less traumatic. When my daughters were campers some thirty years ago, I received my five-year Strong River pendant, and now I’ve recycled myself for another five years with grandchildren. It was refreshing not to obsess about “the bottom line” and to concentrate instead on helping each child live out the camp’s simple philosophy for campers to get: 1. Really hungry and experience the satiety of delicious, nutritious home-cooked meals featuring vegetables and fruits grown on the farm across the highway and picked on the day they are enjoyed! 2. Filthy dirty and experience the refreshing exhilaration of a good hot shower. 3. Dog-tired and experience the rejuvenation of a good night’s sleep. Trust me. I’m really not into astrology. But, I recently happened to glance at my horoscope (Taurus) which read, “You’re much better off precisely because things didn’t work out as planned.” Hopefully that’s no bull!

—Stanley Hartness, MD, Jackson

JULY 2013 JOURNAL MSMA 203

• Guest Editorial •

Maples’ Musings (or Musings of a Madman) We Need More Doctors. Really? Michael D. Maples, MD, Medical Director Medical Assurance Company of Mississippi

hear and read this pleading as if it is an undeniable truth and I am puzzled. I am puzzled by the evidence that abounds in my world and I am particularly skeptical knowing the main drivers of medical care.

In economic circles there is a dictum: “If the Federal Government were in charge of the Sahara Desert, there would soon be a shortage of sand.” It may not be a reality we are dealing with; it may be a perception. At my current age and station in life, I have grown weary of people telling me what is obviously false as if it were the truth. I will proceed with my case. If we truly need more doctors to take care of sick people, why are there so many doctors treating cosmetic problems? Are there not enough sick people? We have family physicians, obstetricians, and all manner of physicians who are waging a war against wrinkles and unsightly spider veins. We have healthy, highly trained, experienced physicians working 30 hours a week. We have physicians writing narcotic prescriptions and getting paid in cash. We have physicians promising to make old people young and to give them “young” levels of sex hormones. Really? We need more doctors? The demographics indicate a lot more old people in the population and therefore a lot more wrinkles and a lot less testosterone. We obviously need more doctors to take care of this aging population. But what of the sick people in the ICU? Doctors now want nurse practitioners to perform even the more technically challenging procedures on critically ill patients. It seems counter intuitive. I guess we need more doctors. Back to my problem with the “truth.” The Parthians were purported to have valued three things: the ability to ride well, to shoot the arrow straight, and to speak the truth. It seems that society values what is rare. I believe the truth must have been rare in the age of Parthians and perhaps today. When somebody glibly tells me something, I would like to know the supporting facts and whether they have a personal or professional interest in the conclusion. I do not have the space to delve into all of the various interests desiring more physicians, but you better think about it before you sign on. It seems that we may need more doctors that will take care of sick people, wrinkled people, and hypogonadotrophic people. If a significant portion of our doctors are going to “cure” wrinkles and unsightly spider veins and pass out narcotics and give testosterone to old men, then I suppose the bureaucrats and insurance companies and hospitals are correct, we do need more doctors. One should not conclude that I do not appreciate smooth skin, youthfulness, or money. These are all important things to some patients and doctors. But if the goal is to have a healthy productive population and a good return on the health care dollar, then just having more doctors may not be the answer. r

204 JOURNAL MSMA JULY 2013

• Special-Article • Opening the Doors of the Great Republic: Sex, Race, and Organized Medicine in Mississippi Lucius M. “Luke”Lampton, MD, Editor

ntroduction

A “great republic” is what the father of modern medicine, Sir William Osler (1849-1919), called our profession, describing it as a meritocracy based on egalitarian principles, a product of the Greek intellect and its emphasis on rational science. Making reference to the ancient god of medicine and healing, Osler asserted further: “Distinctions of race, nationality, colour, and creed are unknown within the portals of the temple of Aesculapius.”2 Despite this noble tradition, he acknowledged in 1902 that the profession, made up of humans prone to delusions and frailty, often fell short of its ideals and was riddled with “a bigoted, intolerant spirit” he called “chauvinism,” from which physicians must emancipate themselves.3 Here in Mississippi, our profession’s journey to free itself of the shackles of race and sex discrimination has been long and difficult. Closing doors rather than opening them was the original focus of our profession’s energies in the state, often for the right reasons, to exclude quacks and charlatans who claimed to be physicians. (There also was an extensive effort to exclude homeopaths and osteopaths for decades, but that is a story for another day.) What follows is a brief exploration, far from complete, of the role sex and race played over the last 157 years in organized medicine in Mississippi.

Board of Medical Censors (1819)

Neither race nor sex was noted in any of the early documents of our profession in the state. The first state law regarding the practice of medicine was passed on the heels of statehood in 1819, “An act to regulate the admission of physicians and surgeons to the practice of medicine and surgery in the state of Mississippi.” This progressive and well-drafted legislative act, approved on February 12, 1819, established the Board of Medical Censors, which would grant licenses to practice medicine. The act made no mention of sex or race, although female or black applicants were probably not even suspicioned to be on the horizon by the drafters of the legislation. Approval would be based on “satisfactory evidence of

qualifications being produced” including “the test of examination before the board.”4 This was the standard mode eventually utilized by other states and even countries to ensure competency of their physicians. Mississippi physicians today still have to pass the three-step United States Medical Licensing Exam and provide evidence of their qualifications and training to our state licensure board in order to be licensed.

First By-Laws (1856)

The first by-laws of our association (written in 1856) also made no mention of race or sex in membership rules. Article 2 stated, “Any regular physician of good standing who shall have graduated at any respectable medical institution, and all physicians who have received the honorary degree of M.D. from a medical school of such character, and who recognize and are governed by the principles and standard authorities of the profession, and conform to its code, as put forth by the American Medical Association, shall be eligible to membership, and none others, save by a unanimous vote of the Association present.” That said, the original preamble referred to the profession as “medical men,” which again underscores the antebellum assumption that the term physician implied the male sex.5

Medical Licensure (1882)

Perhaps the most important document of our profession in the state is the law which established our current medical licensure system, the 1882 “Act to Regulate the Practice of Medicine in the State of Mississippi.” Drafted by MSMA leadership of the period and approved on March 3, 1882, the act was the first great political accomplishment of our association. Despite its creation in the Reconstruction period, there is no reference to sex or race in the document. At the time, there were black physicians practicing in the state and female physicians were growing in number nationally. This act did require an “examination in writing” to be conducted by the State Board of Health. Also included was strong language against “peripatetic quacks and traveling charlatans.”

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Licensure as a physician would depend on professional training, in both medical schools and hospitals, with references to character. This law would allow many to “grandfather” in with lesser training and also allow those who had not graduated from medical school but did pass the exam a route to practice. However, the act was well-crafted and opened the doors to qualified physicians of any sex or race to practice medicine in the state of Mississippi.6

Women and our MSMA Our association was progressive and even ahead of its peers in integrating women, at least white women, into our ranks and even leadership. More than fifty years after the first female in the United States received a medical degree (Elizabeth Blackwell, 1849), our MSMA admitted into its ranks its first female member and the state’s first licensed female physician in 1901, May Farinholt Jones, MD (1866-1940). A native of Virginia and a graduate of the Woman’s Medical College of Baltimore in 1897, Jones became the first woman to take and pass the state medical board examination. She specialized in student health medicine, becoming the physician for the all-female Mississippi State College for Women (now MUW) in Columbus and later physician for the State Teachers College (now USM) at Hattiesburg in 1912. In 1919, she went to the Mississippi State Sanatorium for Tuberculosis, where she finished out her career in 1929. This brilliant pioneer was not only admitted, but was embraced by our association, being asked to address members at annual session as well as to take on state association leadership roles. She delivered excellent scientific lectures, beginning soon after her admission and throughout her career, on subjects from typhoid fever to influenza. The lectures were lively and keenly intellectual. No doubt she had a gifted mind and went on to be an excellent physician. MSMA leaders recognized this brilliance. Our own MSMA became one of the first state associations in the country to place a female member in a high office when in 1903 she was elected as second Vice President of the association, the third highest office in the association. Strangely, after assuming this high office, she held no other major office, although she regularly attended and frequently addressed the annual sessions with medical talks.7 Women, whose membership numbers remained relatively low for decades, would remain involved in leadership roles in our association, largely at the component society level, until the 1990s, when female leadership became almost common as numbers swelled. Dr. Candace Keller served as the first female MSMA president in 2000-1, soon followed by Drs. Dwalia South and Helen Turner. Other significant female leaders included Dr. Mary Gayle Armstrong, who served as first female chair of the AMA delegation, and Dr. Freda M. Bush, who not only served on the AMA delegation but also as president of the Mississippi Board of Medical Licensure.

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Race and Medicine No AMA Membership Race, however, in this Deep South state, would be more difficult to overcome for our association. In that grim and difficult period immediately following the Civil War, the first black physicians appeared in Mississippi, with the first observed at Vicksburg in 1865.8 Entry into the profession was slow for blacks, and by 1890, only 34 black physicians and surgeons practiced in the state, and none appears to have been a member of MSMA. Racial exclusion of blacks was not a Mississippi phenomenon, but rather a national one. At this time, the American Medical Association (AMA) denied admission to blacks. In 1895, the National Medical Association was established largely by Southern African-American physicians at a time when “separate but equal” segregation and Jim Crow laws and customs dominated the country.9 This was both at state and national levels, with various black professionals from teachers to physicians forming separate professional societies. In the wake of the landmark Supreme Court case Plessy v. Ferguson (1896), which originated in nearby Louisiana, racial segregation would be legally sanctioned by the federal courts, asserting the flawed concept of

The Clarion-Ledger announced the organization of the Mississippi Medical and Surgical Association on May 17, 1901. The MSMA would welcome and praise its creation.

Dr. Sidney Dillon Redmond (1871- 1948) — also known as S. D. Redmond of Jackson, was a physician, lawyer, and delegate to the Republican National Convention from Mississippi.

Dr. Sidney D. Redmond was one of the founders and the first president of the Mississippi Medical and Surgical Association. He received a license to practice medicine in Mississippi in 1897. Here is a copy of his temporary license. (Courtesy L. Lampton)

“separate but equal” as legitimate public policy, making segregation the law of the national landscape until repudiated in the Brown v. Board of Education decision of 1954.

Medico-Chirurgical Association of Mississippi

At about the time the MSMA was bringing Mississippi’s first licensed female physician into the organization as a member, fifteen of the state’s black physicians, who were not allowed in the then-segregated MSMA, formed the MedicoChirurgical Association of Mississippi. (“Chirurgical” is an archaic, traditional term for “surgical.”) On the last page of the May 17, 1901, Daily Clarion-Ledger, an article was entitled, “The Negro Doctors: First Meeting Held and State Organization Formed.” It stated, “The colored doctors of Mississippi are holding their first annual convention in this city. The chief organizer of the association of negro physicians was Dr. S. D. Redmond, of this city, who conceived the idea of holding an annual gathering of the recognized practitioners for the discussion of topics of importance to the profession. There is a very good attendance at the convention, nearly every negro doctor in the State being present, and quite a number of able and creditable papers were read at today’s session. Tonight the visiting doctors will be entertained by the local members of the profession.” A few days later, the same newspaper printed a follow up article, stating, “The Medico-Chirurgical Association of Mississippi has just concluded its first session in this city and made a very creditable showing. The association was one of the most intelligent bodies of colored men that ever assembled in this city. The discussions were entered into with much enthusiasm and were very interesting from a professional view, reflecting great credit upon the participants. The following officers were elected: Dr. S. D. Redmond of Jackson, president; Dr. A. M. Dumas, of Natchez, vice president; Dr. L. T. Miller of Yazoo City, second vice president; Dr. E. W. Moore, of Columbus, recording secretary; Dr. J. M. May, Westside, corresponding secretary; Dr. S. A. Miller, Canton, treasurer. The next meeting will be held in Vicksburg.”10 What were white doctors thinking when this separate racial organization was established? The MSMA’s official publication, the monthly Mississippi Medical Record, made positive mention of the Medico-Chirurgical Association’s founding. In its July 1901 issue, Editor H. H. Haralson wrote, “Fifteen negro physicians organized the Medico-Chirurgical Association of Mississippi, at Jackson, Miss., on May 17. In the past 30 years, six medical schools for negroes have been established, and a total of 941 graduated students has been the result. The organization of a medical society is a step higher and must deserve all the credit given it.”11

Dr. Sidney D. Redmond and Dr. L.T. Miller

These articles indicate several things. One, that the

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organization was established in May 1901, not 1900, as has been sometimes asserted. Two, that its lead instigator (who would become its first president) was the brilliant Dr. Sidney Dillon Redmond (1871-1948), a physician and lawyer in Jackson. Redmond had begun the practice of medicine several years before and married Ida Revels, a daughter of U. S. Senator Hiram Revels, the first black senator in the country. Redmond would become chairman of the state Republican Party for a long period and at his death was reputed to be the wealthiest black man in the state.12 Also, noteworthy is another of the leaders in the society’s establishment, Dr. L. T. Miller of Yazoo City, easily the most prominent AfricanAmerican physician of his era. In the 1920s Miller and businessman Tom J. Huddleston built the first black owned and operated hospital in the state, the Afro-American Sons and Daughters Hospital in Yazoo City.13 Within Mississippi’s closed racial society, professional oases, such as this society, were created by black physicians. Eventually the association would become the “Mississippi Medical and Surgical Association,” which remains a vital professional association focused on the needs of the black physician and the black community. It is of significance that the voice of the MSMA of 1901 welcomed this peer in organized medicine positively, despite the gross racism of the period. Yes, separate but equal ruled the land, and the official MSMA publication at least acknowledged that its black peers were performing a vital service for medicine in the state.

Separate but not Really Equal

Wrote Neil McMillen in Dark Journey, “Black physicians, dentists, and pharmacists, functioning as they did almost entirely within a separate black world, generally encountered less white hostility than their counterparts in law. If some white professionals accepted their responsibilities to serve the sick without regard to race or remuneration, others clearly preferred to practice only among their own people and were more than willing to share their impoverished black patients with Negro colleagues. Yet until after 1890 there were few black health professionals in Mississippi… By 1930 there were seventy-one black doctors in the state, more than twice as many as in 1890.”14 By 1953, Mississippi had 1497 physicians, of which 53 were black (almost twenty less black physicians over two decades). Also, of the 1497 physicians in 1953, 1091 were members in good standing of the MSMA, with 1089 being members in good standing also of the AMA.15

MSMA Membership

The surviving constitutions and bylaws of the MSMA do not appear to have mentioned “race” until 1954. In the 1893 version, membership status was granted to those who were graduates of medical schools, residents of Mississippi, and licentiates to practice medicine in the state, who were of

208 JOURNAL MSMA JULY 2013

good moral and professional reputation. Although black physicians satisfied these descriptions, racial exclusion appears to have been easily accomplished by the process of selection, which also required every member to be proposed in writing by three members of the association and referred to the officers of the association for “final action.”16 In an attempt to lessen the centralized powers of selection, the House of Delegates reorganized the association in 1903 based on AMA recommendations to place more power in the state societies at the component/local society level. Passed in 1902, laying on the table until 1903, as a constitutional change, the new constitution increased opportunities for membership, at least for white members, stating, “The members of this association shall be the members of component county medical societies.”17 This reorganization proved helpful to expanding the grassroots membership of the organization, placing power in hands of the regular members and out of the hands of the entrenched power structure of leaders heading the association. At times this would be both positive and negative for increasing diversity. However, local component societies maintained the “status quo” of Mississippi. Racial segregation in medicine would be maintained, despite this constitutional change, for the next 51 years.

AMA Membership and Local Politics

The AMA had long been accepting blacks as members, but only if they were members of their local affiliates. Placing power in these local affiliates to determine membership dates to the end of the nineteenth century when the AMA began this movement to stimulate membership at the local level, ironically to increase diversity of membership and break up power oligarchs controlling the state associations. However, such a system had a tragic outcome for blacks in the South, largely eliminating their involvement at the national level. In the 1940s, one black Tennessee physician joined the AMA during a several year period of work in Indiana, but when he returned to Tennessee he lost his AMA membership because he was racially excluded from joining the Tennessee Medical Association and his local society. In the AMA’s construct, he was not a member in good standing of the local AMA affiliate, thus not eligible for membership in the national organization.18 The push to challenge this injustice for most of the nation’s black physicians began in 1947 when the National Medical Association appealed to the AMA for the inclusion of all licensed black physicians into the AMA, even if they were not allowed in their local affiliates. Later Mississippian Robert Smith, who was mentioned in an earlier article in the JMSMA, would continue this push. This led to efforts by the AMA House of Delegates to end medical segregation. In 1948, New York’s society introduced a resolution asking the AMA to amend its constitution to prohibit any affiliate from excluding a qualified physician on account of race. Although

this resolution was defeated, national pressure on state affiliates to change their racist policies had begun. By 1950, state affiliates in Oklahoma, Maryland, Delaware, Missouri, and even Florida, had dropped their racial policies for membership, although at local society levels, racial segregation con-

The Sphinx, the official organ of Alpha Phi Alpha Fraternity, recognized the significance of Oswald G. Smith’s entry into the MSMA. This historic African American fraternity publication glowingly noted Smith’s achievement in a 1956 article entitled “Medical History Made in the Delta.”

tinued in many communities for years to come. In 1950 and again in 1952 the AMA House of Delegates passed resolutions encouraging affiliate societies to review any racial policies of exclusion.19

Scientific Membership in the South

The pressure from the AMA and from within their own state associations led several of the Southern medical associations to create limited “scientific” memberships. These “scientific” memberships included black physicians in the lectures and educational programs of associations, but excluded them from voting and social events. Despite this demeaning status, this membership did allow black members to be in official “good standing” with their local societies even in the Deep South, thus allowing black membership in the AMA. (Although one Mississippi “scientific” member recalled in his memoir that such membership did not allow AMA membership.) This would be our own MSMA’s approach in 1954. Nationally, this special category designation, this limited membership based on race, was not unique to Mississippi, and various states approached integration in similar ways. North Carolina, like Mississippi, utilized a “scientific” membership for black members until the 1960s, while Louisiana would entertain no status for blacks within its state association until the mid-1960s. Perhaps the most progressive on racial inclusion was our neighbor Alabama, whose physicians voted to end racial exclusion at its county societies in 1953.20 Mississippi’s first step away from Jim Crow medicine would occur at the 1954 MSMA annual session, when Dr. H. C. Ricks presented to the House of Delegates the recommendations of the Committee on Constitution and By-Laws to create a subsection in the constitution creating “Scientific Membership.” The by-laws change stated: “Negro physicians meeting the professional qualifications set forth in Chapter 1, Section 1, may be elected to scientific membership by component societies. The rights and privileges of scientific membership shall be limited to participation in the scientific work of the association and such members shall not vote or hold office. Scientific members shall pay no dues to component societies or the State Association. In addition, to these provisions, the privileges of scientific membership shall be subject to rulings of the Council.”21 Although passed in 1954, like all by-laws changes, this alteration would not take effect immediately, lying over a year, being approved again in 1955 without ceremony, then taking effect at the beginning of 1956. Over the next few years, the word “Negro” would also be deleted from the description of Scientific Membership, removing any direct reference to race in the constitution and by-laws.22 Bizarrely, the “scientific” status, despite the inherent stigma, was for that time a creative approach by the “progressive” members of the association to admit African-Americans within Mississippi’s brutal, closed racial society, which was violently resistant to

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any integration of any type whatsoever. Even this archaic and demeaning approach to inclusion was met with resistance by many of the more conservative and racist members of the association. This was, of course, a very different Mississippi and at a very different and difficult time. Within days of the approval of this by-law change, which occurred May 13, 1954, Brown v. Board of Education would be handed down (May 17) by the U.S. Supreme Court, which overturned the long held national policy of separate but equal. The state itself shifted further into a reactionary mode with state government battling any and all civil rights initiatives and any and all integration efforts. Emmett Till would be murdered the next year, and in 1956, the state Legislature would create the Sovereignty Commission to battle all integration overtures within the state. The “closed society” of Mississippi, inflamed and radicalized, had begun battling what many perceived as its second civil war. What is amazing is that in this racially charged climate, in what many considered the most racist and segregated state in the union, any effort to include African-American physicians in the membership would be successful. But it was, and there is no doubt that the creation of this shameful category of membership would be a positive “next step” on the long road to end Jim Crow medicine. This action began the racial integration of our association.

Oswald Garrison Smith, MD, the First Scientific Member

The first African-American to be admitted/elected into the MSMA, although in this limited “scientific” status, was Oswald Garrison Smith (1915-2002) of Clarksdale. (See this month’s “Images in Mississippi Medicine” on page 214.) He was born September, 4, 1915 in Vicksburg, the son of Mr. and Mrs. Perry Monroe Smith. He attended the public schools of Mound Bayou and attended Bolivar County Training School there. His parents later moved to Shelby. He attended Tennessee State College for 3 years and later graduated with an MD from Meharry Medical College on May 28, 1940. He passed the Tennessee State Medical Board on June 15, 1940, and interned a year at Homer G. Phillips Hospital in St. Louis (a respected training black hospital), then passed W. Virginia State Boards in 1942.23 He served in the 45th Engineer Regiment as an officer in the medical corps, serving in the Burma jungle at Tagap, the 335th Station Hospital in the China/Burma/India theatre of war, a large hospital constituted of black physicians and nurses.24 The Sphinx, the official organ of Alpha Phi Alpha Fraternity, recognized the national significance of Smith’s entry into the MSMA. In this historic African-American fraternity publication, Smith’s achievement was glowingly reported in an article entitled “Medical History Made in the Delta.” The article reads: “Brilliant young Brother (Dr.) Oswald G. Smith of Clarksdale, Miss., became the first Negro to be admitted to membership in the local chapter of the American Medical

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Association. Recognition given Dr. Smith came as the result of his distinctive achievement in the field of medicine and public service ‘beyond the call of his professional duty.’” (This public service “beyond the call” of duty was not explained further, but apparently Smith achieved a local hero status due to his medical work prior to his admission.) The article further commented that the local Delta chapter of the fraternity held a public program honoring Dr. Smith for this achievement. It noted, “The city-wide tribute was carried out at Metropolitan Baptist Church, Clarksdale, and a capacity audience was present.” At this large public ceremony, attorneys from Memphis came to speak on Smith’s accomplishment, and local officials even presented him with a plaque to “climax the program.”25 Smith’s sharp academic intellect is more than evident in his surviving medical writings. During his period in Clarksdale, he published an article, “Oral Anemia Therapy with Roetinic,” in the Journal of the National Medical Association. Smith even contributed an article to the official publication of our association, The Mississippi Doctor, in March 1959, entitled “Clinical evaluation of antivert in symptoms associated with Meniere’s syndrome.” Four years after his historic selection, Smith left Mississippi to continue his postgraduate training at the Bronx VA Hospital in Bronx, NY, finishing in June 1961. (At the time, he would not have been accepted for post-graduate training at the University Medical Center in Jackson due to its own state enforced segregation policies.) He would never return to practice in the state, although for years he retained his “scientific” status in the organization. He moved eventually to Rockville Centre, NY, engaged in the practice of anesthesiology. He died on October 15, 2002 at the age of 87 years, with his last place of residence being South Orange, Essex County, New Jersey. 26

Other Scientific Members Several prominent black physicians would soon join Dr. Smith as scientific members. By 1958, these physicians included: Philip Moise George of Mound Bayou, Milas S. Love of Gulfport, and Gilbert R. Mason of Biloxi. By 1961, Helen Barnes of Greenwood and Matthew J. Page of Greenville, and by 1965 James B. Yeldell, Jr. of Greenville. Sadly, the association’s segregated status up until the mid-1960s is plainly obvious just by looking at the official MSMA directories. “Colored” doctors are listed in a separate category from the rest of the membership, whether they were scientific members or not.27

Gilbert Mason, MD - Second Scientific Member The second “scientific”African-American member of our MSMA appears to have been Dr. Gilbert Mason (1928-2006) of Biloxi. Dr. Mason was a native of Jackson who graduated from Howard University Medical School in 1954. He began

Dr. Gilbert Mason of Biloxi was one of the most prominent AfricanAmerican physicians in Mississippi. He actively sought MSMA membership, first as a “scientific” member in the 1950s and later as a full member in the 1960s. his practice of family medicine in Biloxi in 1955, becoming a MSMA scientific member soon afterwards, he remembered. He soon was recognized as one of the state’s leading crusaders for racial equality, organizing in 1959 the Mississippi Gulf Coast “beach wade-ins,” the state’s first civil disobedience in the Civil Rights era. When he arrived in Mississippi in 1955, he resented racial exclusion from the MSMA and jumped at the chance to integrate it, even in a limited status. Mason overlooked the humiliation of the second class membership and joined as an “S” member. “My attitude was get your foot in the door. Go, see, be seen, and find out what’s going on. So every time the Mississippi State Medical Association or the Coast Counties Medical Society met, I showed up if I possibly could. As the only black physician in attendance, I was in many a lonely place,” he remembered in his memoir. 28 Mason took comfort in his evolving friendships with white physicians and remembered in 1959 when four white members of the Coast Counties Medical Society (Dr. Frank Gruich, Dr. Charles Floyd, Dr. A. K. Martinolich, and Dr. D. L. Clippinger) formally protested his exclusion from a scientific gathering because the speaker was a gubernatorial candidate who requested no blacks be in the audience. The four whites joined Dr. Mason in demanding his right as a scientific member to be at this part of the meeting. The executive committee did not budge and even threatened to go after Mason’s medical license if he did not leave. He recalled: “At this point, my four white colleagues arose almost as one body in righteous indignation and said, ‘If you put Dr. Mason out, we go, too.’…So we left, all five of us, one black and four courageous whites, in Mississippi in 1959. Those gentlemen, those champions of human rights and justice, those four white physicians recognized me, a black man, as a fellow physician. In the face of humiliation and ridicule from their own colleagues, they came out with me.”29

Helen Barnes, MD, Scientific Member The first African-American woman to be a scientific member and a full member was Dr. Helen Barnes of Jackson. (For more on Dr. Barnes, see J Miss State Med Assn. 2012;53(10):352) When she arrived in the hot summer of 1960 to a segregated Greenwood, Mississippi, the first person she went to see was past MSMA President Dr. Howard A. Nelson, a surgeon who was also a progressive leader of our association. Nelson slipped her without fanfare into the Delta Medical Society as a scientific member. She recalls his apology at her exclusion from the social functions, telling her this was “the best he could do for now” in segregated Mississippi in 1960, and he added, “Things will change.” Although she remembers clearly the brutal racism of the period, she also recalls the genuine camaraderie with white physician peers and friends who would “carpool” with her driving to various Delta medical meetings.30

Howard Nelson, MD, MSMA President Howard Nelson appears to have been among the leaders of the MSMA in the 1950s and 1960s who encouraged racial inclusion at the state level. He would serve not only as president but on the board of trustees, as speaker, and even as AMA delegate. In all of these roles he, more than any other white member in our association, appears to have been sensitive to this issue and fought, however silently behind the scenes, for the end of racial exclusion. As leader of Mississippi’s two man AMA delegation in 1968, Nelson stood up before the annual meeting of the AMA House of Delegates and publicly supported a Massachusetts Medical Society resolution to expel from the AMA “any constituent society” that excluded physicians on racial or religious grounds, an important endorsement which stunned the audience at the time and

Dr. Howard Nelson of Greenwood served as MSMA president, speaker, AMA delegate, and on the board of trustees. He also long served his component society as its secretary. He was among the more progressive MSMA leadership and attempted to include blacks in the membership begining in 1954.

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helped overturn a reference committee’s recommendation to take no action.31 In the Delta, where Nelson practiced, and in other pockets of black physician concentration, such as Jackson and the Gulf Coast, white physicians knew first-hand the quality of their black peers. In these communities, black physicians provided essential medical services not only for their underserved patients but also for their overburdened and overworked white peers.

Aaron Shirley, MD No visionary component society secretary like Howard Nelson embraced Dr. Aaron Shirley upon his arrival in Vicksburg in 1960. Not only was Shirley not invited to join the local medical society due to his race (“I was colored in those days,” he remembers) but such exclusion dramatically impacted his practice of medicine. Why? “The Vicksburg hospitals had in their bylaws that one had to be a member of State Medical to receive admitting privileges,” he recalls. He aptly describes this, “a method to restrict hospital privileges based on race,” without directly stating such. Such treatment he considered “insulting” and beneath professionalism, and due to such past insults, he has never joined this association. In 1980, as the battle to redesign the State Board of Health and the Board of Medical Licensure heated up, Dr. Shirley criticized Governor William Winter’s proposal to maintain MSMA’s power to nominate physicians to serve on the Board of Licensure. When asked before a legislative committee why he wasn’t a member of state medical, Dr. Shirley commented then, “I’ve chosen not to join…There are philosophical differences. The philosophy of the Mississippi Medical and Surgical Association is we owe it to our patients to take stands on issues. We take positions on issues that affect poor people. The Mississippi State Medical Association does not take those kinds of positions.” Three decades later, he still feels the same way, he told me recently. 32

Robert Smith, MD Another prominent and courageous medical civil rights pioneer was Dr. Robert Smith of Jackson. Dr. Smith played a critical role in the establishment of the Medical Committee for Human Rights, which included more than 100 health professionals who worked in Mississippi to battle for public health and social justice. With Smith’s leadership, the group contributed significantly to ending segregation in Southern hospitals and even picketed the AMA annual meetings to protest the persisting segregation policies of the Southern AMA affiliates. I plan a future article in the JMSMA focused on details of Dr. Smith’s important work.33

The End of Scientific Membership Scientific Membership would last only a decade. Pressure on white Mississippi physicians and hospitals to end Jim Crow medicine continued. With the ruling on the landmark

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federal case Simkins v. Cone (1963), the passage of Civil Rights Act of 1964, and the coming of Medicare, medical segregation’s days were numbered. Things were changing for the better in Mississippi. At the 1965 MSMA annual session, the Board of Trustees proposed the elimination of the Scientific Membership, effectively eliminating any “separate” status for black members. Speaking to the House of Delegates in 1965, Dr. John B. Howell, Jr. stated: “The Board of Trustees believes it appropriate to discontinue the degree of membership in our association designated ‘Scientific Membership.’ There are sufficient active and exempt categories of membership to accommodate all applicants who may be elected by the several component medical societies.” After recommending this deletion from the by-laws, the board further recommended “that this proposal be referred to each component medical society for consideration and discussion during the 1965-6 association year and presented to this House of Delegates for final action at the 98th Annual Session in 1966.” And without objection, this report of the Board of Trustees was received, to lie on the table for one year as constitutionally required, since it was a by-laws change. It would be approved in final status in 1966, apparently taking effect immediately.

Full Membership for Black Physicians Dr. Gilbert Mason, who had been the most prominent scientific member, remembered his election in the spring of 1966 as a full voting member of his local society and the MSMA, along with Dr. Milas Love, also a highly regarded black physician and scientific member on the Coast. Remembering his sense of accomplishment, Mason recalled: “After eleven years of persistence, the walls came tumbling down. I was finally free to benefit from full association with other professionals on an equal basis.” Mason and Love appear to be the first blacks to receive full voting membership in the MSMA. In 1972, Mason would become the first black delegate ever elected by a component society to represent it at the MSMA House of Delegates annual meeting.34 Since 1966, the role and prominence of black physicians have dramatically increased. Although no African-American has been elected MSMA president, Dr. Claude Brunson currently serves in the most powerful office of the association, that of Chairman of the Board of Trustees. Over the years, blacks have also been elected to various offices, committees, and councils, including as members of Board of Trustees, as vice speaker, as AMA delegates, and as members of the Board of Medical Licensure.

The AMA Apology of 2008 In July 2008, the AMA officially apologized for its “history of racial inequality toward African-American physicians” and pledged to continue “its current efforts to increase the ranks of minority physicians and their participation in the AMA.” The late Dr. Ron Davis, then AMA Immediate Past

President, wrote in a commentary published in the July 16, 2008, JAMA: “The AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine.” The apology was among several initiatives the AMA pursued to reduce racial disparities in medicine and to recruit more blacks to become doctors and to join the AMA.35 In the wake of the AMA apology, in the fall of 2008, the board of the Mississippi Academy of Family Physicians (MAFP) followed the AMA’s actions by officially expressing “regret over times in the past that any member of this Academy may have fostered racial inequity, whether it was by engaging in actions that promoted racial inequity or by inaction in not supporting racial equity” and “committed itself to promote equity in this state, racial or otherwise, striving to lead the nation in improving our citizens’ emotional, social and spiritual health as is mandated in our mission statement.” The MAFP further took the step to honor its first African-American member, Dr. Gilbert R. Mason, Sr., with a posthumous “Humanitarian Award,” which was presented to Mason’s physician son at an Academy dinner in the fall of 2012.36

The Laws of the State of Mississippi, 1882. Jackson: J. L. Power; 1882: 33-39.

History of the Mississippi State Medical Association. Third Edition. Jackson: MSMA; 1982: 146; Transactions of the Mississippi State Medical Association. 1901-1923. (The biographical notes of May F. Jones from the collection of Luke Lampton were also consulted here.).

Wharton VL. The Negro in Mississippi 1865-1890. New York: Harper and Row; 1965: 129.

History of NMA. www.nmanet.org, accessed Feb. 2, 2013.

We Had Heroes

22. Constitution and by-laws of the Mississippi State Medical Association. Chapter

10. Daily Clarion-Ledger. (Jackson, Mississippi), May 17 1901; May 20, 1901. 11. Haralson, HH, ed. Mississippi Medical Record.1901:5(7):244. 12. Sewell GA. Mississippi Black History Makers. Jackson: University Press of Mississippi; 1977: 105-118.

13. Ibid. 121. 14. McMillen N. Dark Journey: Black Mississippians in the Age of Jim Crow. Urbana: University of Illinois Press;1989: 170

15. Transactions of the MSMA House of Delegates, 1953. Jackson: MSMA; 1953: 22.

16. Transactions of the MSMA, 1901. Oxford: Globe Printing; 1901: 239-240. 17. Transactions of the MSMA, 1903. Oxford: Globe Printing; 1903: 20, 236. 18. Ward T. Black Physicians in the Jim Crow South. Fayetteville: The University of Arkansas Press; 2003:202.

19. Ibid. 203-211. 20. Ibid. 211; Mason G. Beaches, Blood, and Ballots: A Black Doctor’s Civil Rights Struggle. Jackson: University Press of Mississippi; 2000:41.

21. Transactions of the Mississippi State Medical Association 51st Annual Session of the House of Delegates. Reports on Constitution and By-Laws. 1954:23.

What is clear these many years later is that there were courageous black heroes and white heroes in Mississippi’s battle to end Jim Crow medicine. Names in our association like Oswald Smith, Gilbert Mason, Robert Smith, Milas Love, Helen Barnes, Matthew Page, Philip George, James Yeldell, Frank Gruich, Charles Floyd, Andrew Martinolich, David Clippinger, and Howard Nelson, along with many others, should be remembered with appreciation. These men and women battled successfully to make our MSMA live up to its professional ideals and principles. They not only changed Mississippi medicine forever but in doing so also contributed significantly to the end of racial apartheid in our state.

2, Section 4. J Miss State Med Assoc. 1965:6(7):273.

23. “Oswald G. Smith.” Student file, Meharry Medical College Library Archives Department.

24. Mandas G. History of All Black 335th Station Hospital. www.335th stationhospital. org, Accessed Feb. 2, 2013.

25. Beatty, Jr. WB. Brothers of Alpha Phi Alpha Fraternity. Medical history made in the Delta. The Sphinx. Official Organ of Alpha Phi Alpha Fraternity, Inc. 1956;42(3):19. http://issuu.com/apa1906network/docs/195604203? Accessed January 10, 2013.

26. Smith OG. Oral Anemia Therapy with Roetinic. Journal of the National Medical

Association. 1957:49(2): 87–90; (Other supporting publications include Smith OG. Clinical evaluation of antivert in symptoms associated with Meniere’s syndrome. Mississippi Doctor. 1959: 36(10):222-4; West Virginia Board of Medicine records, www.wvbom.wv.gov. Accessed Feb. 3, 2013; Social Security Death Index, www.mocavo.com. Accessed Dec. 10, 2012.).

27. MSMA Directories of Mississippi Physicians. 1956-65. 28. Mason, G. Beaches, Blood, and Ballots: A Black Doctor’s Civil Rights Struggle.

Acknowledgements

For their extraordinary assistance with the research and writing of this article, the author would like to thank Karen A. Evers, JMSMA Managing Editor, and Christyne M. Douglas, Archivist, Meharry Medical College Library Archives, Nashville, TN.

References 1.

Bean WB. Sir William Osler Aphorisms. New York: Henry Schuman, Inc.; 1950:107.

Silverman M, Murray J, Bryan C. The Quotable Osler. Philadelphia: American College of Physicians; 2003: 69.

McGovern JP, Roland CB.The Collected Essays of Sir William Osler. Vol. 1. Birmingham: The Classics of Medicine Library; 1985:179.

Underwood F, Whitfield RN. Public Health and Medical Licensure in the State of Mississippi, 1798-1937. Jackson: Tucker Printing House; 1938:135-6.

Lampton L. The Original Report of the Proceedings of the December 1856 Medical Convention. J Miss State Med Assoc. 2006; 47(6):180-1.

Jackson: University Press of Mississippi; 2000: 40.

29. Ibid., 40-41. 30. Lampton, L. Interviews with Helen Barnes. September 9, 2012 and December 8, 2012.

31. Dittmer J. The Good Doctors. New York: Bloomsbury Press; 2009: 207-8. 32. The Clarion-Ledger. April 1, 1980; Lampton, L. Telephone interview with Aaron Shirley. Feb. 6, 2013.

33. Dittmer J. The Good Doctors. New York: Bloomsbury Press; 2009, 13; Thomas

JG, Wilson CR. eds. The New Encyclopedia of Southern Culture, Volume 22, Science and Medicine. Chapel Hill: University of NC Press; 226-228.

34. J Miss State Med Assoc. 1967:8(7):478; Mason G. 40-41. 35. O’Reilly, KB. AMA apologizes for past inequality against black doctors.

American Medical News. July 28, 2008; accessed www.amednews.com. Feb 2, 2013. (This apology came in response to an AMA-appointed expert panel’s report on race and organized medicine: “African-American Physicians and Organized Medicine, 1846-1968: Origins of a Racial Divide,” also published in JAMA.)

36. Board Minutes, MAFP, Fall 2008 meeting; (Another supporting reference is

MAFP Press Release. Mississippi Academy of Family Physicians Honor Dr. Gilbert R. Mason, Sr. with Award. Nov. 13, 2012.)

JULY 2013 JOURNAL MSMA 213

• Images in Mississippi Medicine • Oswald Garrison Smith, MD (1915-2002), the first African-American member of MSMA

swald Garrison Smith was born September 4, 1915, in Vicksburg, the son of Mr. and Mrs. Perry Monroe Smith. He attended the public schools of Mound Bayou and Bolivar County Training School. He then studied at Tennessee State College and later graduated with an MD from Meharry Medical College in Nashville in 1940 (when this photo was taken). After an internship at Homer G. Phillips Hospital in St. Louis, he served as an officer in the medical corps in the China/Burma/India theatre of war. After the war, he began the practice of medicine in Clarksdale. In 1956, Smith was elected as the first African American member of the MSMA. Smith appears to have been widely respected for his medical skills, and by March 1959, became the first African- American to contribute an article to the MSMA journal, then called “The Mississippi Doctor.” He left Mississippi to continue his postgraduate training in New York. He moved eventually to Rockville Centre, New York, and engaged in the practice of anesthesiology. He died on October 15, 2002, at the age of 87 years. (For more on Dr. Smith and the integration of this association, see related articles in this issue by Drs. deShazo and Lampton.) This photo is courtesy the Meharry Medical College Archives Department, with special thanks to Christyne M. Douglas, archivist. If you have any other information on Dr. Smith, please contact Dr. Lampton. Also, if you have a photograph or image related to Mississippi medicine which would be of interest to your fellow physicians, please send as a high resolution jpg file to Dr. Lampton at lukelampton@cableone.net or contact the Journal MSMA. —Lucius Lampton, MD, Editor

214 JOURNAL MSMA JULY 2013

Advocacy, Leadership, Quality and Professional Identity

AnnuAl Scientific ASSembly October 31 – November 2, 2013

SAndeStin Golf And beAch ReSoRt, deStin, fl bAytowne confeRence centeR

Assembly Highlights and Events

How to Register Online: sma.org/assembly Telephone: 800.423.4992, ext. 620 Mail or Fax -Download Form: sma.org/assembly

Meets C Requirem ME e Risk Ma nts for nagemen t and Med ical Erro rs

Education!

Alliance Activities!

w Infectious Diseases w Cardiovascular Diseases w Psychiatry/Mental Health w Neurology w Hot Topics in Medicine w Abstract Presentations w Poster Presentations w New Drugs Update w ICD-10 Update w e-Communication: Potential and Pitfalls w Health Reform Update w Prevention of Medical Errors

w Raffle w General Sessions w State and County Project Exhibits

Collegiality and Networking! w Beach Party Welcome Reception w Hospitality Area w SMA/SMAA Presidents’ Installation Luncheon

Halloween Family Fun! w Trick or Treat in Sandestin’s Village Streets w DJ Music – Events Plaza Stage w Spooky Fireworks

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230

JULY 2013 JOURNAL MSMA 215

• Una Voce •

Disease State? “A disease is farther down the road to being cured when it breaks forth from concealment and manifests its power… You need not wonder that diseases are beyond counting: Count the cooks!” —SENECA the Younger [4? B.C. –A.D. 65] Moral Epistles to Lucilius, LVI

ny wizened physician with enough Betz cells remaining in the cranium to formulate a thought must surely ponder the upheavals daily foisted upon our professional lives. The sociologically driven shifts in 21st Century medicine are nothing short of seismic. Much of the change has been positively awesome in scope; think of advances such as my med school classmate Dr. Hannah Gay’s recent breakthrough discoveries in the curative treatment of HIV disease. When Hannah and I graduated from med school in 1980, AIDS was not an illness we had ever seen or even heard of in our training at UMC. This ‘new disease’, HIV/AIDS, was not identified until 1981. I first recall hearing about the ‘coming pandemic’ while in residency training. It was widely interpreted then to be a disease of gay men, and likened to a Biblical scourge of retribution for the practice of sodomy and homosexuality in general. Just a few years before the discovery of AIDS, the DSM-II nomenclature of ‘Homosexuality’- 302.0 had been struck from our reference texts as a disease entity. Beginning in 1973, the American Psychiatric Association no longer deemed homosexuality as a pathological deviation of sexual development, rather simply a variant of human sexual behavior. Diagnosis 302.0- ‘Sexual Orientation Disturbance’ became the new diagnostic label for the psychiatric disorder which would henceforth be reserved only for individuals whose sexual interests were ‘directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or who wish to try to change their sexual orientation.’ (i.e., if you’re happy and you know it, clap your hands! However, if you are an un-gay gay person, well then you are one sick puppy, you need a psychiatrist, a diagnostic code, and some insurance to pay for your curative treatment.) In the interest of time, follow my train of thought here, and fast forward to 2013. Work continues on that dreaded DSM-V manual and now we must contemplate that our own AMA as of their meeting this June has now formally declared our nationwide plague called obesity a DISEASE. By naming obesity as a disease, the intent of our AMA was to improve the quality and length of life for all Americans. As a bonus, we’ll get some good codification, and fatness will become a bona fide illness that physicians can treat with bariatric medicine regimens, surgery, counseling and psychotherapy in order to get fairly reimbursed for our time and trouble. Once again, it seems that money drives every medical decision made these days…from every exam-room patient encounter, every prescription written, and every specialist referral, thence all the way to Capitol Hill. You can know with absolute certainty that the insurance companies did not want this to happen. For them it is nothing short of a calamity. While greater than 1/3 of Americans are technically obese, well more than fifty percent of Mississippians fall into this category. This means more than half of the residents of the Magnolia state are DISEASE ridden…including me and perhaps even you, dear reader. This means that I have been ‘diseased’ since I was a toddler at my mother’s breast and did not even know it. My poor misguided parents, having survived teen marriage and rearing their first two children during the height of the Great Depression, suffered from the ‘delusion’ that a chubby baby was a healthy baby. They knew firsthand from their Appalachian childhood what true nutritional diseases were. They had known family members stricken with pellagra, scurvy, and rickets…diseases modern day physicians know only from historical texts. The medical pendulum has certainly swung, hasn’t it?

Dwalia S. South, MD Ripley

216 JOURNAL MSMA JULY 2013

The great conundrum regarding obesity as a disease state is this: our country does not have a functioning mechanism in place to help the uninsured working person to get even critical coronary disease treated without driving him into bankruptcy court. How then can it possibly hope to pay for the “treatment” of the more than 75 million suffering with the dreaded curse called obesity? The short answer is that we cannot. One way to look at this issue is that a large percentage of overweight people aren’t sick…well, not yet at least. Obesity as a disease process is all about the degree of one’s fatness, its limitations on one’s health, and the co-morbidities with other chronic illness. Obesity is a complex psychological, physiological, and sociological problem with genetic propensities and environmental factors playing major roles as well. It is characterized by the compulsive consumption of food and the inability to restrain from eating despite the conscious desire to do so. These symptoms strikingly parallel the definitions of drug dependence, and substance abuse and has led some to suggest that obesity is a ‘food addiction’ disorder. (The current DSM-IV manual recognizes eating disorders such as anorexia and bulimia as mental disorders with severe impairments and adverse outcomes, but not obesity in general as being pathological.) Simply being fat is not a disease; gluttony is an all-too common variant of normal human behavior. Being morbidly obese and the exhibition of compulsive eating behaviors do however comprise ill health and the disease spectrum. It strikes me that a person who is overweight bears a similarity to the homosexual population we alluded to earlier. No one consciously makes the choice to be viewed as an abnormal, repulsive person, to suffer discrimination and hostility on a daily basis, and to be devalued as a detriment to society. If a person suffers emotional anguish and ill health due to their obesity, can we then diagnose them as having a codifiable disease called ‘Adjustment Disorder of Adipose Storage?’ I can see the “Fat Pride” flag flying now…hundreds of criss-crossed golden French fries, outlined with red ketchup borders, set against a lovely chocolate background with a whipped cream fringe. Salute! You have endured all my rambling about disease states and we have yet to explore the precise definition.

dis-ease: 1. any departure from health; an illness 2. a particular destructive process in an organism 3. an evil or destructive tendency or state of affairs

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When I was discussing the topic of this column with a very valued long-time MSMA physician friend, our thoughts turned to other dysfunctional organisms we must deal with. She and I decided that American Medicine in general and our Association in particular were by definition suffering from a disease state…because we seem to have, slowly and insidiously, strayed from our original noble reason for being. We say in the MSMA Mission Statement that our organization exists “to serve as an advocate for its members, their patients, and the public health; that our association exists to promote ethical, educational, and clinical standards for the medical profession and the enactment of just medical laws”…and that we unite together as physicians “to act on matters affecting health and the practice of Medicine.” Our association is certainly far from the personification of evil, but some of us simplistic old fogeys feel that MSMA, at times, is no longer focused on being the altruistic, collegial, educational, public-spirited force for the good of all the physicians who serve Mississippi. We see it displayed at times as a medical oligarchy of chauvinism with a distorted obsession for power and expressing the irrational belief in the inferiority of physicians who do not hold similar partisan political views. Some of us have succumbed to the pernicious virus that causes us no longer to recognize the soul of our original calling: healing, scientific study and advancement, devotion and service to our patients, and loving-kindness to our fellow physicians. Yes, obesity is definitely a chronic disease state. As with so many other illnesses, there is no simple cure, no magic bullet. The patient himself has the major influence on his prognosis. Most certainly, obesity is a treatable disease if the patient is aware of the potential consequences AND has the personal motivation to fix it. The disease state of our MSMA fortunately is not a terminal condition, but requires the application of cautious and methodical treatment. The health of our medical society is restorable if our members are aware of the consequences and have the personal fortitude and courage to fix them. Attending and participating in MSMA Annual Session is the first step toward affecting a cure, fellow doctors. I sincerely hope to see you there. —Dwalia South, MD; MSMA Past President MSHOSPASSN_Layout 1 7/24/12 8:24 AM Page 1 (Opinions expressed in this editorial are

solely those of the author who bears complete responsibility for its content.)

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YOU ARE A STAR.

is vital to the MSMA. It is the arm of the association that, through philanthropy, gives our physicians the ability to positively impact and improve the health of Mississippians. The number of ways in which we can make an impact through the Foundation is innumerable, and it is important to see physicians leading these efforts. That is why I’m asking that all of Mississippi’s physicians and friends of medicine will join me in supporting the MSMA Foundation.

CHAIR, MSMA BOARD OF TRUSTEES

Stacey Ferreri

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JULY 2013 JOURNAL MSMA 219

• Asclepiad •

aul Harold Moore, MD- Born at home in rural Winston County, Mississippi, in 1927, Paul H. Moore, the youngest of ten children, has resided in Pascagoula, Mississippi, since 1963 when he joined his brother-in-law in the practice of radiology at Singing River Hospital. In 1972, he founded Singing River Radiology Group and served as its president until 1996. For 36 years until his retirement in 1999, he tirelessly served patient and partner; employee and colleague; profession and community. After graduating from Louisville High School in 1944, he spent 18 months in the US Army, after which he attended East Central Junior College, Auburn University, Mississippi College, and the University of Southern Mississippi. In 1949, he married the former Jean Mauldin of Waynesboro. Having returned to Louisville High School to teach science and coach football, basketball, and baseball, he received a masters degree in education from the University of Mississippi in 1951. In 1954, he returned to Ole Miss to complete post-graduate study required to qualify for medical school, which he began in 1955 as part of the first class to begin training in the new University of Mississippi School of Medicine in Jackson. He received his MD in 1959 and completed his medical training with a rotating internship at Chatham Memorial Hospital in Savannah, Georgia, and a radiology residency at the University of Florida in Gainesville, Florida. In addition to his duties with Singing River Radiology Group, Dr. Moore has been active in numerous professional organizations including the AMA, the MSMA (past-president), the American College of Radiology (Fellow & Counselor), the Mississippi Radiological Society (past-president), and the Southern Radiological Society (past-president). He is a Diplomate of the American Board of Radiology. In 1964, he was instrumental in establishing the x-ray technology program still offered through Mississippi Gulf Coast Community College. In 2001, Dr. Moore was awarded a Special Presidential Award by the Radiological Society of North America for extraordinary contributions to the field of radiology which included his enormous contribution to the establishment of the National Institute of Biomedical Imaging and Bioengineering (NIBIB) at the National Institute of Health. Dr. Moore’s dedication and service to the University of Mississippi are extensive and include tenures as president of numerous alumni groups, such as the UM General Alumni Association (past-president), the UM Medical Alumni Chapter (past-president), and the UM Foundation, as well as chairman of the Alumni Hall of Fame Committee. Dr. Moore has also served as a member of the university’s Athletic Committee, the Loyalty Foundation Board of Governors, on the School of Medicine’s Dean’s Selection and Dean’s Advisory Committees and on the Advisory Committee appointed by the Mississippi Board of Higher Learning to assist in selection of the Chancellor of the university. In 1996, Dr. Moore was named to the University of Mississippi Alumni Hall of Fame. In 1997, Dr. Moore was appointed by US Senate Majority Leader, Trent Lott, to serve on the National Gambling Impact Study Commission. Locally, Dr. Moore serves (emeritus) on the Board of Directors for Merchants & Marine Bank. He is past-president of the Rotary Club, Jackson County Cancer Society, the local US Navy League, and has been active with the Jackson County Area Chamber of Commerce as well as the United Way of Jackson County. Since 1963, Dr. Moore’s involvement with the First Presbyterian Church of Pascagoula has been active and varied. He has served as deacon, elder, trustee, has taught Sunday School, and chaired many committees, including two capital building campaigns. Dr. Moore’s beloved wife of 62 years, Jean, died in 2011. He subsequently married long-time family friend, Marye Vaughn Boland. They enjoy traveling, yard work, and following local, state, and national politics. Dr. Moore particularly treasures his family: Hal (current president of Singing River Radiology Group) and Melanie, Bill (Director of Singing River Hospital Inpatient Physician Services) and Kay, and six grandchildren (Paul III and Mary Kempton, John and Aleisha, Cole and Devin, Emily and Tyler, Michael and Adelaide, and Mollie) and six great grandchildren (Ravyn, Stratton, Alice, Gage, Henry, Collin). Dr. Hal Moore notes he, his dad, and son Paul III may be the first three-generation family to attend all four years at UMMC. r

220 JOURNAL MSMA JULY 2013

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