November 2014 JMSMA

November

VOL. LV

2014

No. 11

Calling All Mississippi Physician-Photographers Enter the JMSMA 2015 cover photo contest Load your camera or grab your digital. Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physician/ photographer.

Size: Vertical format 5 x 7” or 8 x 10” Deadline Extended to January 5th, 2015 Deadline: November 29, 2014 Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

SAVE THE DATE FOR

CME in the Sand M A Y 22-26, 2015 Sandestin Golf and Beach Resort Destin, Florida ALL physicians are invited to attend this fun, family – oriented event, hosted by the MSMA Young Physicians Section

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 and the Editors The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director

NOVEMBER 2014

VOLUME 55

NUMBER 11

Scientific Articles Medical Student Education in the Department of Surgery at the University of Mississippi Medical Center in the 21st Century

352

Curtis G. Tribble, MD and Marc E. Mitchell, MD

Just Off the Press- Oseltamivir for Influenza in Adults and Children

356

Katie Langley, PharmD and Richard L. Ogletree, PharmD

Special Articles Race and Health Care in Mississippi during the Civil Rights Years

358

John Dittmer, PhD

The Meeting

370

Richard D. deShazo, MD, Robert Smith, MD, and Leigh Baldwin Skipworth, BA

President’s Page Mississippi Mental Health System – In Crisis

365

Claude D. Brunson, MD; MSMA President 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 39158-2548.

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.

Copyright© 2014 Mississippi State Medical Association.

Related Organizations American Medical Association

377

Departments From the Editor: An Apology Long Overdue 350 Physician’s Bookshelf: John Marshall Stone 378 Poetry in Medicine: “Night Call” 380

About The Cover: Autumn Colors on the Natchez Trace Parkway- Martin M. Pomphrey, Jr., MD, who serves on the MSMA Committee on Publications, captured this colorful fall foliage image off the Natchez Trace Parkway. The reddish leaves and berries on some of the branches appear to be consistent with dogwood trees (Cornus genus) in autumn.

He writes, “My wife Sue and I were on a fall overnight trip to French Camp (exit: MS Hwy 413 - milepost 180) when I photographed this image.” Further up the Trace is a picnic area at mile marker 275 known as Dogwood Valley where the Natchez Trace passes through a small valley with an unusual stand of large dogwood trees. Here a sunken portion of the Old Trace runs through the small wooded area.

Historic and medicinal records note, the bark of Cornus species is rich in tannin and has been used as a substitute for quinine to treat malaria. During the Civil War, Confederate soldiers would make a tea from the bark to treat pain and fevers, and use dogwood leaves in a poultice to cover wounds.

Dr. Pomphrey is a retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. r November

VOL. LV

Official Publication of the MSMA Since 1959

2014

No. 11

November 2014 JOURNAL MSMA 349

From the Editor: An Apology Long Overdue

H

istory was made in many ways when Dr. Claude Brunson was inaugurated president at MSMA’s annual session in August. Within his inaugural address, Brunson discussed extensively the topic of medicine and race and issued an official apology on behalf of the MSMA for any past actions and inactions which may have fostered racial inequity. He celebrated the progress made by our Association to increase diversity of both membership and leadership and to confront the difficult history of medicine and race in such forums as your Journal. He also recognized the work of MSMA’s Ad Hoc Committee on Diversity and ongoing efforts to develop an official statement on diversity.

[Brunson, CD. Inaugural address of the 147th president Claude D. Brunson, MD. J Miss Med Assoc. 2014;55:298-302].

That sad night in 1968 when Martin Luther King was shot and killed in Memphis, Robert F. Kennedy offered what I consider the most perceptive and enduring reflection of how we as Americans must live in this diverse society to preserve liberty for all. While reading from his favorite poem

by the Greek poet Aeschylus, Kennedy commented: “But we have to make an effort in the United States. We have to make an effort to understand, to get beyond, or go beyond these rather difficult times…What we need in the United States is not division; what we need in the United States is not Lucius M. Lampton, MD hatred; what we need in the United States is not violence and lawlessness, but is love, and wisdom, and compassion toward one another, and a feeling of justice toward those who still suffer within our country, whether they be white or whether they be black.”

The recent unrest in Ferguson, Missouri reminds us that the issue of race remains with us. We still must ask: what kind of community and nation are we? Let us create a world dedicated to love and to justice between fellow human beings, and work, as Kennedy so eloquently said, “to tame the savageness of man and make gentle the life of this world.”

Contact me at lukelampton@cableone.net.

—Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Sharon Douglas, MD

Professor of Medicine and Associate Dean for VA William Lineaweaver, MD 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 Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, 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 Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Chris E. Wiggins, MD Medical Director Orthopaedic Surgeon Medical Assurance Company of Mississippi, Ridgeland Bienville Orthopaedic Specialists, Pascagoula Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

350 JOURNAL MSMA November 2014

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Managing the Risks November 2014 JOURNAL MSMA 351

• Scientific Articles • Medical Student Education in the Department of Surgery at the University of Mississippi Medical Center in the 21st Century Curtis G. Tribble, MD; Marc E. Mitchell, MD

A

bstract

The approach of the Department of Surgery at the University of Mississippi to the education of medical students is considerably different from that of earlier eras. An overview of the current strategies for medical student education adopted by the Department in recent years and the philosophies behind them is presented.

Key Words:

Career choice, Education, Mentors, Students, Surgery

Introduction In recent years, the Department of Surgery at the University of Mississippi Medical Center (UMMC) has undertaken an effort to optimize the education of medical students in the discipline of Surgery. While part of the focus of this optimization has been to stimulate interest in careers in Surgery, we recognize that less than 10% of all medical students in the United States will choose a career in Surgery.1 It is our view that the primary goal of every medical school should be to train good, well-rounded, general doctors, recognizing that all medical school graduates will go on to further training in a discipline of their choice, ranging from family medicine to the broad array of interventional disciplines. Since almost everyone will need an operation at some point in their lives, all physicians will need to know the basics of the discipline of surgery. It has been said that ‘the eye does not see what the mind is not prepared to know.’2

Author Affiliations: Former Vice Chair for Education of the Department of Surgery at the University of Mississippi. He is now Professor of surgery at the Heart &Vascular Center at the University of Virginia Health System. (Dr. Tribble). Professor of Surgery and formerly James D. Hardy Chair of Surgery at the University of Mississippi Medical Center (Dr. Mitchell).

Corresponding Author: Marc E. Mitchell, MD, Department of Surgery, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 (memitchell@umcmed.edu.)

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The Philosophy of the Educational Program in Surgery There are, of course, some areas of medical care in which patients are managed primarily by surgeons or teams that have significant involvement from surgeons or other interventionalists.

These areas include trauma, vascular disease, congenital and cosmetic defects, implantation of prosthetic devices, endocrine disorders, and transplantation. Still, most patients who need to make their way to an appropriate surgeon will do so through referral from their primary physicians. Therefore, virtually every physician will have to diagnose surgical conditions, refer patients appropriately, help prepare patients for their operations, and help manage them postoperatively. Thus, the overall educational goal of the Department of Surgery is to insure that every UMMC graduate understands the principles of participating in these important areas of patient care.

There are many basic principles of good medical care that are traditionally learned on surgical rotations. These include sterile technique, anesthesia and the care of the unconscious patient, pain management, and perioperative care, including critical care. In addition, students learn many basic technical skills while on surgical rotations, such as the basic techniques of wound care.3 Furthermore, many students will find themselves participating in mission work or military medicine at some point in their careers, both of which have very significant emphasis on various levels of surgical care. In addition, it is important for all medical students to learn about the balancing of the risks and benefits of surgical interventions. Another area of importance in the development of well-rounded physicians is the analysis of care that has not gone well, a process that is formalized in the weekly Morbidity and Mortality conferences that are ubiquitous in Departments of Surgery.4 At UMMC, we believe that not only do students learn best by being involved in the care of patients, but we also are confident that even those early in their educational trajectories can contribute in a meaningful way to the care of the patients. An example of this contribution is illustrated by one of our former

mentors who started every operation by saying, “Everyone in this room will have a different view of what we will be doing. If you see something that those of us doing this operation might be missing, speak up.” Of course, students can contribute in many other ways, including answering questions for the patients and families, providing additional attention to their needs in other ways, and even by asking pertinent questions of their mentors.

Developing a Comprehensive Educational Plan With these principles in mind, we sought to develop a comprehensive plan that spanned all years of medical school to increase the exposure to and education in the various facets of the surgical disciplines. This plan has been developed to provide opportunities from the time a student becomes interested in a career in medicine until their graduation. We wanted not only to convey basic medical knowledge and skills but also to create an environment and a culture that would optimize learning and performance.5, 6 Premed Students For those who have not yet begun their formal medical education, we have developed observerships, in which students can spend as little as a day in the hospital. There is a program organized in conjunction with the Office of Multicultural Affairs that finds preceptors with whom interested students can spend up to 30 hours. Some of the students in this program choose to spend their time with a surgeon. The Office of Student Affairs also coordinates an annual program which allows college students to spend a Saturday on the UMMC campus. The Surgery Interest Group (SIG) officers help present information about careers in Surgery to these students.

Students in the First Two Years of Medical School In the first two years of medical school, all students have an opportunity to participate in the SIG.7 The SIG officers, with guidance from a faculty advisor, organize a series of presentations by an array of surgeons, both faculty and residents, to introduce various aspects of their lives and careers to the students. The SIG also coordinates a suturing workshop in the fall in which Department of Surgery faculty and residents help the first and second year students learn basic suturing techniques utilizing their cadavers. This program has been enthusiastically supported by the Department of Anatomy in conjunction with the Department of Surgery and is quite popular with the students.8 The SIG also helps organize an introduction to the Operating Room with a nurse instructor, which allows all who have completed the course to participate at any time thereafter in the Operating Room. The Department offers three day observerships for the first and second year students who sign up to spend time on a surgical service of their choice.

These observerships are scheduled in ways that minimize their time away from the students’ regular courses and studies.

The Department of Surgery’s Surgical Scholars program accepts up to 15 students for an intense summer program during the summer between the first and second years of medical school. Stipends for students participating in this program have been made possible by a generous endowment created in the Department by the grateful family of a patient cared for here at UMMC. Students apply for these positions, participate in a formal interview process with the surgical faculty and are assigned to areas of interest for an immersion experience for the summer. Many of these students participate actively in scholarly activities, some of which have resulted in presentations at medical meetings and have been published in the medical literature.

In addition to the Surgical Scholars program, students between the first two years may choose to participate in a summer observership program organized by the Office of Student Affairs. In this program, students can choose three experiences, each two weeks in length, which can include rotations on surgical services. The Department of Surgery takes in an additional 12 students through this program. As is the case with the Surgical Scholars program, there is a small stipend given to the students who participate.

The School of Medicine also has a more formal research program called the Medical Student Research Program (MSRP), which requires interested students to find qualified research mentors, create proposals that are judged for quality and feasibility, and agree to establish a relationship with this mentor for the remainder of their time in medical school.

Generally, one or two students at a time choose to spend this time in a Department of Surgery sponsored research program.

Students in the Third Year of Medical School During the third year of medical school, the Office of Academic Affairs organizes a Career Development Series.

This program is conducted approximately one day a month during the lunch hour and each clinical department in the School of Medicine is allowed one day to interact with the participating students. One faculty member in the Department of Surgery, in collaboration with several surgical residents, organizes a short presentation which is followed by a question and answer period in which the students are able to ask detailed questions about career opportunities, training paradigms, and the lifestyles of those participating.

The more formal third year student clerkship in Surgery consists of a two-month-long experience on the surgical services. One of these months is spent at UMMC or the Veterans Hospital on a traditional general surgical service such as surgical oncology, general surgery, or acute care surgery or trauma. The second month is spent on one of the specialty services in the Department, including Vascular Surgery, Plastic Surgery, Cardiothoracic Surgery, Pediatric Surgery, Urology, or Transplant Surgery.

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All third year medical students have, in addition to the required basic clerkships, three electives of two weeks duration that are spread out during the academic year. The students can use these periods to gain exposure to areas of medicine that would not have been as accessible in a prior era when the third year experiences were more prescripted. Many students choose to spend one of these blocks on a surgical service in which they have an interest but have not been able to experience.

Students in the Fourth Year of Medical School All UMMC medical students are required to spend another month on a surgical service during their fourth year.

Those interested in a career in Surgery generally choose to do a month on one of the primary services in the Department, often choosing rotations that they did not experience in the third year. A recently developed option for fourth year students is to spend time in a variety of surgical clinics. This option has proven popular for those planning careers in non-surgical fields, as these students can choose to participate in surgical clinics relevant to their evolving career goals. For instance, a student who is considering training in Pulmonary Medicine might opt to spend a portion of this rotation in a General Thoracic Surgery clinic, or a student contemplating a career in Cardiology might choose to spend a portion of this rotation in the Vascular Surgery Clinic. Fourth year students also have the opportunity to participate, with several members of the Department of Surgery or with others from the University, in medical mission work in Africa. These opportunities are obviously very different from the usual student experiences of medical school and frequently result in ‘battlefield promotions.’

The faculty of the Department of Surgery take an active role in mentoring and helping students plan their fourth year rotations and residency application strategies. We meet with students individually and as a group to address the common questions and concerns of these students. Many in the department spend significant amounts of time helping the students applying for surgical residency positions optimize their applications strategies throughout the fourth year of medical school.

Specifically designed for fourth year students matched into a surgical residency, the Department of Surgery is collaborating with national surgical educators in the development of a ‘Surgery Boot Camp’ which will teach these future surgical residents more advanced surgical skills. This course will help these future residents learn more technical and clinical skills such as laparoscopic techniques, chest tube and line insertion, managing critical care patients or patients with urgent surgical conditions, and how to function as a surgical intern.9 Philosophy and Plan for the Education of Medical Students at UMMC In summary, the educational experiences in Surgery for the students of the UMMC have evolved over the years with

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an emphasis on both inspiration and education while ensuring a well-rounded education for all of our graduates as well as providing an opportunity for all to discern whether a career in a surgical discipline might be appropriate choice.

References 1. Tribble CG, Newburg DS. Attracting medical students to careers in surgery. Current Surgery. 2002; 59:327-329.

2.

Tribble CG, Merrill WH. The way we talk is the way we teach. J Thorac Cardiovasc Surg. 2014; 147:1155-1159.

3.

Edlich RF, Rodeheaver GT , Tribble CG, et al. Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years. J Emerg Med. 2010; 38:40-50.

4.

Newburg DS, Tribble CG. Remember and Forgive: The incorporation of principles of sports psychology into a curriculum of surgical education. J Performance Ed. 1995; 1:25-28.

5.

Towler MA, Adibin MR, Tribble CG. Edlich’s Academical Village. J Emerg Med. 1993; 11:353-357.

6.

Newburg DS, Tribble CG. Mental Strategies in Surgery. J of Excellence.

1999; 1:1-18.

7. Tribble CG, Kern JA, Smith M, DuBose JD. The Establishment of a Surgical Interest Society for Medical Students. Am J Surg. 2002; 183:618-21.

8. Raymond DP, Iwanik MF, Sawyer RG, Tribble CG. New medical students: Knot interested? Focus on Surg Educ. 2001; 18:29-30.

9.

Sawyer RG, Tribble CG, Newburg DS, Pruett TL, Minasi JS. Intern call schedules and their relationship to sleep, operating room participation, stress, and satisfaction. Surgery. 1999; 126:337-342.

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November 2014 JOURNAL MSMA 355

• Just Off the Press: Info You Want to Know • Oseltamivir for Influenza in Adults and Children Katie Langley, PharmD; Richard L. Ogletree, PharmD Article: Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014 Apr 10; 348:g2545.1 Background: Oseltamivir (Tamiflu) is approved by the Food and Drug Administration for both the treatment and prevention of influenza virus types A and B. Oseltamivir is currently on the list of World Health Organization essential drugs.1 A previous Cochrane Review found oseltamivir to be effective for both prophylaxis and treatment of influenza.2 A later update to this review stated that neuramidase inhibitors, such as oseltamivir and zanamivir (Relenza), have low effectiveness and therefore should not be used for seasonal influenza control.3 The review was again updated a few years later at which time the authors found that oseltamivir was effective in both treatment and prophylaxis of symptomatic influenza. However, the authors cited reporting bias due to their inability to review unpublished trial data.4 Due to the risk of reporting bias, there is reason to reevaluate the previously stated benefits of oseltamivir.1 Objective: The purpose of this systematic review was to review all clinical study reports identified from published and unpublished randomized controlled trials and relevant regulatory data to describe the potential benefits and harms of oseltamivir.

Design: Systematic review with meta-analysis Methods: Data sources included clinical study reports, trial registries, electronic databases, regulatory archives, and correspondence with manufacturers. Target studies included both published and unpublished randomized placebo controlled trials testing the effects of oseltamivir for treatment, prophylaxis, and post-exposure prophylaxis of influenza. Trials containing patients with either HIV or malignancy were excluded from this review.

Results*: 23 trials (9,623 participants) were included.

In the treatment of adults, oseltamivir • Relieved symptoms earlier by 16.7 hours (8.4-25.1, P<0.001) • Did not affect the rates of hospital admission between groups (RR 0.92, 0.57-1.50) • Did not affect the rate on sinusitis, bronchitis, and otitis media • Reduced investigator unverified pneumonia (RR 0.55, 0.22-1.49); (NNTB 100, 67-451) • Increased the risk of nausea (RR 1.57, 1.14-2.51); (NNTH 28, 14-112) and vomiting (RR 2.43, 1.75-3.38); (NNTH 22, 14-42)

In the treatment of children, oseltamivir

• Relieved symptoms in otherwise healthy children earlier (mean difference 29 hours, CI 12-47 hours, p=0.001); effect not significant in children with asthma • No significant effect on hospital admissions in prophylaxis trials • No effect on the rate of sinusitis, bronchitis, and otitis media, however, with wider CIs • No significant effect on pneumonia (RR 1.06, 0.62-1.83) In prophylaxis trials, oseltamivir • Reduced symptomatic influenza by 55% (RR 0.45, 0.30-0.67); (NNTB 33, 26-55)

• Increased risk of headaches (RR 1.18, 1.23-2.35); (NNTH 32, 18-1150) and nausea (RR 1.96, 1.20-3.20); (NNTH 25, 11-116)

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Conclusion: The authors concluded that there is reason to question the stockpiling of oseltamivir, its inclusion on the WHO list of essential drugs, and its use in clinical practice as an anti-influenza drug. There was a benefit of reduced symptomatic influenza seen in prophylaxis trials.

Reviewer’s Comments: Third party payers use these types of reviews in order to make decisions for coverage status of medications. We may see a decrease in the number of third party payers that cover oseltamivir. Oseltamivir may still have a place Figure 16: Oseltamivir versus placebo for prophylaxis. Symptomatic influenza in adult prophylaxis as prophylactic therapy forofpatients at high risk for severe complications due to influenza such as the extremely young and the individuals. elderly. However, the routine use as a treatment for influenza might be of limited benefit.

Footnotes: *NNTB – number needed to benefit; NNTH – number needed to harm; RR – relative risk; RD – risk difference Figure 1. Forrest plot for oseltamivir versus placebo for adult prophylaxis of symptomatic influenza

Figure 15: Pneumonia in all oseltamivir included trials by method of data capture of diagnostic confirmation Figure 2. Pneumonia in all oseltamivir included trials by method of data capture of diagnostic confirmation

Figures 1 and 2 reproduced from: Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014 Apr 10; 348:g2545. Used with permission.

References:

1. Jefferson T, Jones MA, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014 Apr 10; 348:g2545.

2. Jefferson T, Demicheli V, Deeks J, Rivetti D. Neuramidase inhibitors for preventing and treating influenza in healthy adults. Cochrane Database Syst Rev. 2000; Issue 2. Art. No.: CD001265. DOI: 10.1002/14651858.CD001265.

CJ. Neuraminidase inhibitors for preventing and treating influenza in healthy adults. Cochrane Database of Syst Rev. 2006, Issue 3. Art. No.: CD001265.

DOI: 10.1002/14651858.CD001265.pub2.

4. Jefferson T, Jones MA, Doshi P, Del Mar CB, Dooley L, Foxlee R. Neuraminidase inhibitors for preventing and treating influenza in healthy adults. Cochrane Database of Syst Rev. 2010, Issue 2. Art. No.: CD001265.

DOI: 10.1002/14651858.CD001265.pub3.

3. Jefferson T, Jones MA, Doshi P, Del Mar CB, Dooley L, Hama R, Heneghan

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• Special Article • Race and Health Care in Mississippi during the Civil Rights Years John Dittmer, PhD; Professor Emeritus, DePauw University (University of Mississippi Medical Center, June 20, 2014)

I

ntroduction

Dr. John Dittmer was the keynote speaker at the First Marston Symposium on Race and Health titled, “Can Physicians Heal Themselves?” Dr. Dittmer is professor emeritus of history at DePauw University and is acknowledged as the most knowledgeable expert on the civil rights era in Mississippi. His two books on the topic, Local People and The Good Doctors give rich detail not only of what happened but also of the personalities and purposes of those involved and their motivations. These award-winning books are now part of the civil rights history curriculum at many major universities.

Dr. Dittmer served as dean of Tougaloo College earlier in his career, and he continues to return to Mississippi for scholarly work, teaching, and speaking.

—Richard D. deShazo, MD

Associate Editor ummer 1964

S

Fifty years ago the White Knights of the Ku Klux Klan burned Mount Zion Methodist church to the ground. Members of that congregation, located in Neshoba County, Mississippi, had given civil rights workers permission to use the church for a school that summer. The following day two young activists from the Congress of Racial Equality, Michael Schwerner, white, and James Chaney, black, drove over from Meridian to investigate. With them was Andrew Goodman, a white college student from New York who had volunteered to spend his summer vacation working for the Movement in Mississippi. Returning from Mount Zion early in the afternoon, the three activists were arrested by Neshoba County deputy sheriff Cecil Price and taken to the county jail in Philadelphia. They were never heard from again.

In the summer of 2014, hundreds of senior citizens, most in their late 60s and 70s, arrived in Jackson. They stayed in the city’s finest hotels and were treated with the utmost respect by city officials and by the Jackson police. A half century ago they had come to Mississippi as volunteers in what would later be called “Freedom Summer,” invited by civil

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rights leaders to work on voter registration campaigns, staff community centers, and teach in the new Freedom Schools.

Non-threatening stuff, one would think. But for many white Mississippians, the influx of hundreds of “outside agitators” constituted an invasion that had to be repelled.

During its 1964 spring session, the state legislature had passed a series of laws banning picketing and leafleting, while doubling the number of state police. Here in Jackson, Mayor Allen Thompson beefed up his force, bought 200 shotguns and ordered 50 more, converted two city trucks into troop carriers, and purchased a combat vehicle—“Thompson’s Tank”—that carried ten officers and two drivers, with shotguns protruding from gun ports.

Rumors spread like wildfire. Some whites were convinced that black men sporting white bandages around their necks had been designated to rape white women. Sales of guns, ammunition, and Klan memberships boomed.

In McComb, upstanding citizens formed HELP, INC., a self defense group organized in a white middle class neighborhood. Members set up an alarm system to warn of an imminent attack by the civil rights workers. HELP guidelines warned citizens to “keep inside during darkness or during periods of threats. Know where your children are at all times…Do not stand by and let your neighbor be assaulted.”

They were expecting this, from a bunch of college kids who had just taken their final exams?

Mississippi Threatened Why did white people in Mississippi feel so threatened?

The short answer is that since the end of World War II, black veterans like Medgar Evers, Amzie Moore, and Aaron Henry had been demanding an end to racial segregation and all that it implied. When in 1954 the Brown decision declared segregated schools unconstitutional, opponents of race mixing formed an organization called the Citizens’ Council to make sure integration did not occur in the Magnolia State.

1960 brought the sit-ins to much of the upper South, and the following year Freedom Riders came to Mississippi to

desegregate bus and train terminals. Many of them did time in Parchman penitentiary, and when they came out, they joined the Movement. A new organization, the Student Nonviolent Coordinating Committee (SNCC), was born. SNCC activists made Mississippi their major center of operations, opening projects first in McComb and then on up into the Delta.

In the spring of 1963 Martin Luther King was leading protests in Birmingham, Alabama. Young black activists from Tougaloo College started a Birmingham of their own, boycotting downtown merchants, demanding an end to segregation, jobs, courtesy titles for blacks, and formation of an interracial committee. Mayor Allen Thompson said no dice, the protests escalated, and Medgar Evers was gunned down in his carport by a Citizens’ Council member named Byron de la Beckwith. Meanwhile, President John F. Kennedy and his brother, Attorney General Robert, had adopted pretty much of a hands-off policy, unwilling to enforce the U.S. Constitution here unless they were forced to, as when James Meredith desegregated the University of Mississippi.

After the death of Medgar Evers, movement activists working in the state decided that if they did not do something dramatic to attract federal attention and involvement, the Citizens’ Council and a newly revived Ku Klux Klan would wipe them out. The Council of Federated Organizations (COFO), the umbrella agency that included all the major civil rights groups operating in the state, decided to hold a mock election in the fall of 1963 to prove to the nation that blacks here would vote if they could. During that campaign in which Aaron Henry ran for governor and the Reverend Ed King for lieutenant governor, about a hundred white students from Yale and Stanford came down to help get out the vote. Their presence was duly noted.

Throughout the winter and spring of 1964 Klan night riders roamed the state. On a single night in May the Klan burned crosses in 64 counties. Black homes, businesses, and churches were bombed and burned. White Mississippi officials and police did nothing to deter the violence (in some cases the police WERE the Klan) and President Lyndon Johnson appeared to be following the same hands-off policy as had his martyred predecessor John Kennedy. With the Klan running wild, how could COFO persuade local people to come to a meeting, much less go down to the courthouse and in full view of the public, try to register to vote? Why not do something really dramatic, like inviting not a hundred but a thousand white college students to spend their summer vacation in Mississippi? (It was assumed, correctly, that most of the volunteers would be white.) Their presence would certainly bring visibility and publicity, and with that perhaps a degree of protection, forcing the federal government to take action. That argument carried the day, and in the spring of 1964 the word went out on northern college campuses that students should consider spending their summer working with civil rights activists in Mississippi.

A Black Mississippi Doctor When Dr. Robert Smith of Jackson first learned that a thousand activists would be descending on Mississippi, he lamented, “My God, what can we do? How are we going to manage?” The ninth of twelve children, Bob Smith grew up on a cattle farm in Terry, Mississippi. He attended Tougaloo College, graduated from Howard Medical School, and in 1962 began practicing medicine in Jackson. He got involved in the black freedom struggle and treated civil rights workers for free.

Smith knew that the influx of hundreds of new workers was bound to increase the level of violence across the state. The volunteers would also need medical attention for problems resulting from stress as well as for the normal ailments afflicting people moving into a new and strange environment. He also assumed that with few exceptions white Mississippi physicians would have nothing to do with these outside agitators who, after all, were out to destroy the southern way of life. That left their health care in the hands of the small number of black doctors—less than fifty of them— practicing in the state. Even some of them would not treat civil rights workers, and certainly not white ones, for fear of retribution from whites in their communities. Only a handful of physicians, including Smith, James Anderson, and A. B. Britton in Jackson, Aaron Shirley in Vicksburg, Matthew Page in Starkville, Cyril Walwyn in Yazoo City, and Gilbert Mason on the Gulf Coast, had publicly identified with the movement and would treat civil rights activists for free. Clearly, help from the outside was needed.

Dr. Smith contacted local movement leaders who also saw the need for medical assistance. They got in touch with Tom Levin, a New York psychoanalyst who had been active in the movement, and asked him to assemble a team of “Northern physicians and those involved in the auxiliary health professions” to come to the state in teams during the summer to provide basic health care for the civil rights workers. Levin called a dozen of his associates in the New York area, and that group formed an organization, the Medical Committee for Human Rights (MCHR) that recruited more than 100 health care professionals - doctors, nurses, psychologists, and social workers- to spend part of their summer vacations in Mississippi.

The Medical Volunteers Although these medical volunteers were not a monolithic group, the typical MCHR charter member was a physician, Jewish, male, in his thirties or early forties, the child of Eastern European or Russian immigrants. They were the first generation of Jewish students not subjected to rigid medical school quotas. All were liberal in their politics. Some were in private practice; others taught in medical schools or were working in the field of public health. Only a handful of the doctors who went South in the summer of 1964 were black.

The physicians who made the journey to Mississippi knew they were going into dangerous territory—the

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“disappearance” of Chaney, Schwerner, and Goodman lay heavy on their minds. And they were in for some surprises.

These northern doctors, who had grown accustomed to the respect and deference accorded members of their profession, found themselves the object of hostility and hatred in the South. Although they were older than the typical volunteers and wore coats and ties, they were still Yankees aligned with Martin Luther King and his dangerous ideas.

Whatever hope there was for a dialogue between the medical volunteers and local white physicians vanished when two prominent health care professionals, Harvard psychologist Robert Coles and MIT’s Joseph Brenner, wrote a letter to all the white doctors in Mississippi imploring them to overcome their prejudices and provide treatment for civil rights workers.

They reminded their Mississippi colleagues that they were bound by the Hippocratic oath, helpfully quoting the relevant passages for their southern brethren. Only some two hundred words long, the “Brenner–Coles letter” sent shock waves through the Mississippi medical community. Whatever its intent, the letter was so obviously patronizing that it alienated even those physicians who might have been cooperative.

MCHR warned its volunteers that “nothing should be said to impugn the integrity of Mississippi physicians.” But the damage already had been done.

The medical volunteers had hoped to practice medicine during their week in Mississippi, but Archie Gray, the head of the state Department of Health and a vehement segregationist, made it clear that they would not get licenses. Administering first aid was not prohibited, however, and that summer some doctors stretched the definition to fit the occasion.

The MCHR in Mississippi When the medical volunteers arrived in Jackson, they were met by Dr. Smith and representatives of COFO for orientation. From there they were driven to movement projects throughout the state where they performed a variety of functions. They did examine civil rights workers and apply “first aid” where necessary. They discovered that a good number of the veteran activists were suffering from what Robert Coles called “battle fatigue,” now recognized as Post Traumatic Stress Disorder. Providing psychiatric care and “rest and recreation” opportunities for burned out Movement workers became an important function for MCHR. During Freedom Summer the doctors spoke at community meetings talking about basic medical issues to local people, many of whom had never been to a physician. They tried to reach out to the local white medical establishment, attempting unsuccessfully to persuade their Mississippi counterparts to end the rigid segregation and discrimination that was so devastating to the health of black Mississippians.

One of the most important functions of the MCHR doctors was “Medical Presence,” a service they provided over the next decade wherever needed across the country.

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Medical Presence meant that whenever there was a civil rights demonstration, an MCHR person would be there, easily identifiable by their “professional dress,” black bag, and Red Cross emblem on their sleeve. If a demonstrator were beaten by members of a mob or the police, a doctor would be there to give assistance. Even more important than this was the simple fact that when a physician was present the level of violence seemed to decline: members of a mob seemed to think twice when an obvious authority figure was there. (This was also true when the doctors went into jail to examine arrested civil rights workers. After such a visit, the imprisoned activists were less likely to be beaten by their jailors, who knew the physicians would testify to the condition of the inmates.)

There were some problems, however. First of all, most of the medical volunteers knew little about the South, and some were quite naïve. Dr. Sidney Greenberg told the following story on himself. After arriving at the Jackson airport, he was driven into town by a civil rights worker.

Noticing a familiar flag flying atop a building, the good doctor asked his driver, “Is this the British consulate?” Greenberg recalled that the driver started laughing so hard that he almost drove off the road and promised his passenger that he would see to it that he got a real Confederate flag as a memento of his trip to the Magnolia State.

Not all the volunteers had the sense of humor and adventure as did Greenberg. Several physicians brought with them an attitude of superiority, based on their training and status. Sally Belfrage, a white volunteer who wrote a wonderful book called Freedom Summer, was stationed in Greenwood and had this recollection of the MCHR presence in her project: “The first few doctors who came to help us lurked around the library using up some of their endless good will by sprinkling the books with Borax, which was supposed to be lethal to cockroaches but only made the bindings soapy; assigning a variety of vitamin, iron, and salt pills to staff stomachs; directing `Now we will wash our hands’ to those seen petting the resident kittens, Freedom and Now; and asking me to make posters reading PLEASE FLUSH THE TOILET. I tried to explain that those who didn’t flush the toilet couldn’t read, being for the most part under seven, but that didn’t make any headway either.”

Unlike most of their colleagues, a few volunteer doctors refused requests that they use their rented cars to transport people to meetings or assist in the normal tasks that people shared in the freedom houses or community centers. Other physicians refused to examine local blacks with serious untreated health problems, either because such work was not on their assigned list of responsibilities or because they feared retribution from Archie Gray.

Still, overall the work of the Medical Committee in Mississippi was a success and received high marks from the COFO staff and the young volunteers. The physicians did provide some medical support, but more important was

simply the fact that they were there, an adult professional presence that contributed a small sense of security to a besieged group of civil rights activists. It’s not surprising, then, that after the summer the participating health care people decided to make the Medical Committee for Human Rights a permanent organization with a headquarters and paid staff in New York and chapters in major cities across the country.

Its membership rolls included health care activists Benjamin Spock, Paul Cornely, and Paul Dudley White, who had been President Dwight Eisenhower’s personal physician.

The MCHR Beyond Freedom Summer Although now a national organization, MCHR’s primary concern remained the South. But that role was changing.

Although the Committee had come to Mississippi to provide health care for Freedom Summer volunteers, once they arrived these health care professionals quickly became aware of the shocking conditions facing the vast majority of the state’s black citizens, a situation exacerbated by a health system grounded in racial segregation.

For a snapshot of what it was like to be black and poor in Mississippi, listen to an excerpt of a report by a panel of distinguished physicians who toured the Delta in the late 1960s: “In child after child we saw thin arms, sunken eyes, lethargic behavior and swollen bellies…homes where children were lucky to eat one meal a day. Children were fed communally—that is, by neighbors, who give them scraps of food. We do not want to quibble over words [the report concluded] but ‘malnutrition’ is not quite what we found.

They are suffering from hunger and disease and directly or indirectly they are dying from them—which is exactly what ‘starvation’ means.”

Quite simply, tens of thousands of African Americans were in worse shape in the mid-1960s than they had been a century earlier as slaves. Why? The mechanization of the cotton plantations meant that there were no more jobs. And when the new food stamp program went into effect, everyone had to pay something for the stamps, and many poor people had no money at all. There was no Medicaid in the state, and Medicare was just starting to kick in.

In addition to their poverty, blacks had to contend with racism in the delivery of health care. Hospitals either excluded blacks or subjected them to horrifying conditions in segregated wards. For example, for many years Baptist was the only private hospital in Jackson to admit black patients.

But all of them were in one room, with fewer than 40 beds to serve the city’s black population of more than 50,000.

Dr. Aaron Shirley—one of the heroes of this story—recalls that “Within that one room everything took place…surgery, delivery, pediatrics, whatever. I saw a kid about nine years old being treated. And in the bed next to him was an old guy with tubes running out of everything with cancer. Mothers were confined in this exposed ward with their new babies.”

Until the late 1960s, in many southern hospitals black doctors were denied privileges, even when black patients were admitted. Just why they were barred is an example of Catch 22: to obtain hospital privileges, doctors had to belong to the local medical association, which did not permit black physicians to join. In 1963, health care activists, including Bob Smith as the sole southern physician, picketed the convention of the American Medical Association, the parent organization of the local medical societies, at its annual convention in Atlantic City, demanding that the AMA take action against its southern societies. The AMA responded that while it was opposed to racial discrimination, local associations had the right to choose their own members. Not until 1968 did the AMA threaten to expel local associations that denied blacks membership, and not until 2008 did the AMA apologize for its racist policies.

MCHR leaders were getting a crash course in southern medicine, Jim Crow style, and decided to open a southern field office in Jackson. They appointed a young black psychiatrist named Alvin Poussaint as director, and he was ably assisted by a staff of nurses, including Phyllis Cunningham and Josephine Disparti, white women from the North who came to Mississippi during Freedom Summer and stayed to become part of MCHR’s operation. Poussaint and his staff continued to provide medical care for civil rights workers, but now they saw as their major task doing something about a health care “nonsystem” that all but shut blacks out.

The MCHR and Hospital Desegregation One of their most important projects was to gather information about discriminatory practices in Southern hospitals. The Civil Rights Act of 1964 had provided health care activists with a powerful weapon to sue against segregated hospitals. The club they wielded was Title VI of the law, which denied federal funds to individuals and organizations practicing racial segregation. Medicare was scheduled to go into effect on July 1, 1966, and hospitals that still practiced segregation, or did not admit blacks at all, could be denied participation in the Medicare program.

Poussaint designed a 23-question form for MCHR workers and local activists to use in their investigations, and they began to collect data. In some hospitals, such as Kings Daughters in Yazoo City, the evidence was indisputable.

Although built with federal funds, Kings Daughters had never admitted a black patient. More typical was the general pattern of segregation, discrimination, and humiliation found at Scott County Hospital in Morton.

That county was nearly 50% black, yet blacks had only three rooms and five beds. The rooms for white patients had air conditioners, but there were none in the rooms for blacks.

One bathroom served all black patients; every room on the white floor had a private bathroom. The “Negro rooms” had no bed lights, mirror lights, or night lights. Any black person

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seeking emergency care had to wait until all whites had received attention, including those who came in later. Fathers could not see their newborn babies because they were on the “white” floor.

Although Medicare was to go into effect in just a few months, few southern hospitals had begun to integrate their facilities. Hospital administrators did not believe the federal government was serious, and indeed Washington had been dragging its feet. But under pressure from MCHR and other rights organizations the President himself took action.

“The Federal Government is not going to retreat from its responsibility,” said Lyndon Johnson. The answer to the problem of discrimination is simple, he said: “It is for every citizen to obey the law.”

The Department of Health, Education, and Welfare (HEW) assigned 750 people to investigate conditions in southern hospitals. One of the investigators, Dr. Paul Plotz, had been working at the National Institutes of Health before being drafted for this crusade. His experiences in the field were interesting and typical of those of other investigators.

In one community, the day before his visit, hospital staff had taken down all the Jim Crow signs and discharged all the black patients. At a large Catholic hospital in Nashville, the administrator, a nun, was assuring Plotz that the hospital did not discriminate at all when her phone rang. It was the Admissions Office, asking where to put a new patient. “We have a white bed on 5 West,” she replied, and then sheepishly looked up at Plotz.

On another hospital tour, after he had pointed out that the white ward had air conditioning while the black ward did not, his host cryptically replied, “They don’t like cold air.” And in one case a hospital official had dressed a black janitor in pajamas and put him in a bed on an all-white floor.

With this kind of intense scrutiny from HEW, most hospitals were cleared for federal funding by the time the Medicare program began in July of 1966. Some, like Baptist in Jackson, refused to desegregate for a few years but by the early 1970s something of a revolution had taken place in southern hospitals. They needed every federal dollar they could get, and when faced with a hard line coming out of Washington, defiance was not an option. Racial problems remained, of course, but the hospital became the most integrated facility in town, and it remains so today. MCHR doctors and nurses and local black health care practitioners played a key role in this transformation.

Geiger persuaded a wealthy benefactor to fund a small health clinic in the Holmes County hamlet of Mileston, which provided free diagnostic and acute care. The Mileston operation was a success, but it was a drop in the bucket.

Geiger realized that it was not replicable, that it would be impractical to “go out and find philanthropists for every new clinic.” In December of 1964 a memorable meeting took place in Greenville. Attending were local black doctors, including Dr. Robert Smith, representatives of the Delta Ministry, which was underwriting much of the MCHR budget in Mississippi, Count Gibson, chair of the Department of Public Health at Tufts University and one of the few southern white physicians in MCHR, and Geiger.

Jack Geiger’s life story is fascinating. Son of a New York doctor, he ran away from home at age 16 and lived for a year with black actor Canada Lee in Harlem. During World War II Geiger enlisted in the merchant marine, serving on the USS Booker T. Washington, the only ship with a black captain.

After the war he attended the University of Chicago, where he helped launch a two-year campaign to end discriminatory practices at the university hospital and to persuade the medical school to admit black applicants. For a time after his graduation he was science editor for the International News Service. Next he enrolled at Case Western Reserve Medical School, and in 1961 he was a founder of Physicians for Social Responsibility, a group dedicated to the elimination of nuclear weapons. Three years later he was in the first wave of MCHR Mississippi volunteers.

It was late in the evening of that December meeting in Greenville that Geiger recalled the health care experiment he had observed first hand in apartheid South Africa, of all places, where a decade earlier he had studied under two young physicians, Sidney and Emily Kark. The Karks had developed a concept called community-oriented primary care and applied it in two existing clinics serving blacks living in an urban public housing project and on a rural tribal reserve. Everyone in these defined areas was considered to be a patient. Staff members collected information about health problems and developed a comprehensive plan of attack, including health services, nutrition programs, preventive medicine, and even environmental interventions. Once he made this connection, Geiger had an epiphany of sorts. “A good northern medical school ought to come down to the Delta and run a comprehensive teaching center, properly funded and the whole works—health, community organization, and social change.”

Roots of the Federally Qualified Health Center (FQHC) Program But the major health care problem facing several hundred thousand black Mississippians, as previously noted, was that they were too poor to obtain medical assistance of any kind. MCHR activists knew they had to do something about this problem. Freedom Summer volunteer Dr. Jack

The First Rural Community Health Center in Mound Bayou Geiger’s dream became a reality. With the invaluable assistance of local black physician Bob Smith and Count Gibson, who saw to it that Geiger received a tenured position at Tufts, Geiger persuaded the new federal poverty agency, the

See Dittmer, continued on page 367....

362 JOURNAL MSMA November 2014

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• MSMA President’s Page • Mississippi Mental Health System – In Crisis

I

mentioned in my inaugural address the issue of Mississippi’s Mental Health System, a system that is now in crisis. This crisis is a result of two core issues: 1) the system is not able to provide readily accessible, quality, comprehensive and cost effective mental health services to Mississippians; and, 2) the United States Department of Justice (DOJ) has taken legal action against the State for failing to comply with various federal statutes and Supreme Court rulings that address public mental health systems.

The DOJ began its investigation of the public mental health system in May 2011 and focused the investigation on Mississippi’s compliance with Claude D. Brunson, MD federal statutes and rulings, specifically the Americans with Disabilities Act 2014-15 MSMA President (ADA) and the Olmstead decision of the United States Supreme Court. The ADA and Olmstead decision require states to care for persons with disabilities and mental illness in the least restrictive setting appropriate to meet their needs. The DOJ issued a findings letter in December 2011 asserting that Mississippi had not fully complied with the requirements of the ADA or the Olmstead decision; DOJ demanded the State take remedial measures to avoid litigation. The State of Mississippi is currently engaged in negotiations with the DOJ to reach a settlement agreement.

Interestingly, this action by the DOJ was not an unforetold event. It was preceded by a report issued in 2010 by the Mississippi Joint Committee on Performance Evaluation and Expenditure (PEER) titled Planning for the Delivery of Mental Health Services in Mississippi. The report criticized the Board of Mental Health for not focusing on strategic planning, for allowing community based programs to fall behind and for not planning the reallocation of resources to meet emerging needs. In response to that report, the Joint Legislative Study Committee on Mental Health was formed; hearings were held; but, not much has changed.

For the moment, the DOJ has agreed to forgo litigation related to services for children with mental health conditions until March 21, 2015, and it has also agreed to forgo litigation related to adults with mental illness and individuals with intellectual and developmental disabilities until July 1, 2015.

Sadly, it has not taken a PEER Committee report or a DOJ lawsuit to tell Mississippi physicians and families that our mental health system is broken. Mississippi’s physicians have for years pleaded for relief for their patients and those patient’s families who desperately need a responsive and effective system to address mental health needs. The Mississippi Psychiatric Association (MPA) has made gallant efforts to get a better system in place.

Specifically, 2008 MPA President Dr. Bo Holliman made a presentation that laid out the concepts behind an improved mental health system to a legislative task force on mental health that same year. He expounded on these concepts during the 2010 legislative session when he made a comprehensive and visionary presentation to the leadership of the committees of oversight for mental health and outlined in plain terms the problems and probable solutions to the dysfunctional system. In fact, the DOJ letter of initial findings to the Governor referred to Dr. Holliman’s testimony as a point of reference for problems and solutions.

In Dr. Holliman’s testimony, he presented a set of recommendations to the legislature which remain appropriate but have not been acted upon. The gists of those recommendations follow: • Put physicians back in full charge of medical necessity determinations and certifying medical necessity.

• Programs for the seriously mentally ill should have priority, including group homes, licensed personal care homes, and housing.

• Update the qualifications required for the DMH executive director in accordance with national standards and best practices for the position with a reporting structure to the BMH; and medical directors should be appointed for the CMHCs.

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• Require that other administrators be physicians and/or persons trained in healthcare administration.

• Reconstituting the Board of Mental Health as was done with the Board of Health; requiring the majority of members and the Chair to be a physician trained and experienced in the delivery of quality mental health services.

I have recently spoken with major stakeholders addressing the ills of our mental health system including officials in the DOJ, our state legislative and executive leadership, the attorney general’s office, the Department of Mental Health, our Psychiatric Association leadership and Mississippi physicians.

I have reviewed in detail the problems in our mental health delivery system, both structural and organizational. What I have found during this factfinding tour has been disheartening. But as I met with stakeholders, I was encouraged and hopeful. There was not a single person who did not agree that we had work to do and a responsibility to fix our broken system. We owe nothing less to those Mississippians who need and deserve a well-functioning mental health system.

Data suggest that one in four fellow citizens will be touched by a mental health issue at some point in time on an annual basis. This can range from a mild case of depression or similar outpatient diagnosis to major treatment disorders requiring inpatient services.

We must stand up for improved, accessible, and quality care for our fellow citizens in need.

I am not naive about the task that lies before us to reengineer this broken system. I have been warned of the almost impossibility to make changes in such a large, bureaucratic and politicized system. But, I also recognize our responsibility as physicians to care for patients.

These patients are no exception.

And, while this task may be challenging, it is not impossible.

We must now roll up our sleeves and get to work. We have successfully taken on huge challenges in our past, such as tort reform and redesign of the State Board of Health. It is time now to add Mental Health to that list of successes — not for us, but for our patients and fellow citizens.r

Governor Phil Bryant recently praised Mississippi’s monumental tort reform law, highlighting new statistics that prove Mississippi is the best state for physicians to practice medicine. Pictured with the Governor is MSMA President Claude Brunson, MD, right.

MSMA represented at announcement of state’s first Clinton Foundation health initiative- Claude Brunson, MD, right, president of MSMA, is pictured with Gillian Sealy, center, national director of the Clinton Health Matters Initiative, and Natchez Mayor Butch Brown, left.

366 JOURNAL MSMA November 2014

Dittmer, continued from page 362....

Office of Economic Opportunity, to fund two comprehensive health centers sponsored by Tufts, one in the Boston public housing project of Columbia Point and the other in Mound Bayou, Mississippi. Located in the Delta county of Bolivar, Mound Bayou is a historically black town made famous by the patronage of Booker T. Washington early in the 20th century.

Bolivar was the third poorest county in the nation with an unemployment rate of over 50 percent. Cotton had been king, but now sharecroppers had been replaced by machines.

Without jobs, blacks had little access to health care. In such an environment where one had to choose between food, rent, and medicine, good health was almost impossible.

Recognizing that basic medical services alone would not address the underlying causes of poverty, Geiger envisioned the health center as a primary agent of social change affecting all aspects of the lives of the population it served. Its mission was “to implement social, economic and human rights in concrete ways by providing health care but also by addressing the social determinants of health through employment, environmental interventions, housing repair and development, a massive self-help nutrition program, community organization for economic and political empowerment, and the provision of educational opportunity.”

“Health care alone is not the point,” Geiger observed.

“That would be like putting a Band-Aid on and sending our patients back home to the same conditions that made them sick in the first place.”

Taking their cue from the civil rights movement, the Tufts team saw community organization as key to success.

The associate director of the center was John Hatch, a black social worker from Boston with southern roots. Hatch and a team of volunteers made house calls, then met with small groups, and finally held large community meetings that led to the formation of health associations. This was a grass-roots program where the patients took pride in their center and had a direct stake in its operation and success.

The Tufts Delta Health Center opened its doors in 1967.

As noted, in the Mississippi Delta a patient’s needs went far beyond the diagnosis and treatment of illness. As one resident put it, “I’ve been sick sometime, always broke, sometimes hungry, and never lived in a decent house. I do believe one begets the other.” At the health center Geiger began writing prescriptions for food. When some government bureaucrat objected to this unorthodox procedure, the physician responded, “The last time we looked in the book, the specific therapy for malnutrition was food.”

Providing food for hungry patients was a stopgap measure, and Hatch came up with the idea of a cooperative farm, where local people could use their agricultural skills to grow vegetables instead of cotton. Within a short time a thousand families were farming 600 acres of rich delta soil, growing hundreds of tons of vegetables annually.

The farm coop was but one example of what made the Delta Health Center program unique, both for its time and for ours. Where the traditional health clinic dispensed pills and shots, at Mound Bayou the staff attacked the root causes of poor health and deprivation.

Sanitation expert Andy James headed an environmental team that dug protected wells and built sanitary privies, put screens on windows, and fumigated houses to control, if not eliminate, the rats and mosquitoes and other disease carriers.

Helen Barnes, an obstetrician-gynecologist, directed family planning and nurse midwifery programs, including early child care, which led to a dramatic decrease in infant mortality from 60 per thousand live births in 1960 to fewer than ten by 1972.

The center also sponsored nutritional and social programs for senior citizens living in isolated areas, and it initiated a bus transportation system to bring people from rural communities to the clinic for treatment.

Perhaps the most enduring—and inspirational—aspect of the health center was its educational program. At night the doctors, nurses, and social workers taught GED high school equivalent courses. Local people got training for jobs as secretaries, medical assistants, librarians, technicians, and sanitarians. Staff members used their northern contacts to place Bolivar County blacks at leading universities and professional schools. By 1975 the health center education program had produced 7 physicians, 5 Ph.Ds in clinical sciences, two environmental engineers, 6 social workers, numerous nurses, and the first ten black registered sanitarians in Mississippi history, this in a county with some of the worst public schools in the country.

Shortly after the first center opened in Columbia Point, young Senator Ted Kennedy paid a visit and was so impressed that he pushed through an appropriation of $51 million dollars to start up new health centers.

Both Bob Smith and Aaron Shirley served as physicians during the first year of the operation of the Tufts-Mound Bayou Health Center and brought back what they learned to Central Mississippi. Shirley and James Anderson opened the Jackson-Hinds Comprehensive Health Center in 1970, and it quickly eclipsed Mound Bayou to become the largest health center in the state, as well as a “national showplace,” with federal officials and health care planners making the pilgrimage to Jackson to observe and learn.

In 1993, Shirley put in motion plans to convert a large, bankrupt shopping mall in the middle of Jackson into a “state of the art ambulatory health care facility providing quality health care for the urban poor,” working in partnership with the University of Mississippi Medical Center. The Jackson Medical Mall opened in 1995 and covers 53 acres, all under one roof. Those of you here today are familiar with the scope of its operation and reach into the neighboring community.

This community health care endeavor has attracted widespread interest, with health care administrators studying the feasibility

November 2014 JOURNAL MSMA 367

of replicating his model nationwide.

Bob Smith established the Mississippi Family Health Center in 1970, which has been a training ground for more than 200 African American medical students and other health care professionals. Smith was instrumental in developing cooperative relationships between Tougaloo and the medical schools at Brown and Tufts and served as an adjunct professor at both institutions. After winning the right to practice at local hospitals in the mid-1960s, Smith became a charter staff member of Hinds General Hospital when it opened in 1967.

Elected chief of Family Medicine in 1974, he then became the first African American to serve as chief of staff at Hinds. His operation in Jackson, now called Central Mississippi Health services, became a federally funded comprehensive health center in 2002, expanding to three sites including one at his alma mater, Tougaloo College.

There are now some 22 health center organizations in Mississippi operating more than 140 delivery sites and serving almost 300,000 patients. Nationally, there are now some 1100 centers operating at upwards of 5,000 sites, providing primary care for nearly 20 million Americans. Unfortunately, cutbacks beginning in the Nixon administration negatively affected the health center movement. The program was transferred to the Department of Health, Education and Welfare and funding cut back for Medicare and Medicaid programs. Health centers felt the pinch and were forced to eliminate most of the outreach program pioneered at Mound Bayou.

Still, in this age of political polarization in Washington, the community health center movement has received bipartisan support. President George W. Bush provided additional funds for health centers. Here at home last June, Republican Senator Roger Wicker gave a speech in Mound Bayou in which he noted, “Community health centers have become an integral part of Mississippi’s rural communities…I will continue to champion efforts to strengthen the ability of community health centers to provide quality health care.”

Most of you here today are much more aware of the current state of health care in Mississippi today, and this symposium is examining the problems facing providers and patients in poverty-stricken areas of the state. Still, there is reason for hope, and for potential solutions we may need to go back to the future. This August in Mound Bayou the H. Jack Geiger Building will be dedicated, marking an expansion of the Delta Health Center. Geiger will speak and in attendance will be others who made the community health center movement possible. The Center’s director, John Fairman, has pledged to restore the Delta Health Center to its original purpose and mission when it served as a model for the rest of the country.

A Retrospect on the MCRH As for the Medical Committee for Human Rights which was, in retrospect, one of the most important institutions to emerge from Freedom Summer, it underwent several

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transformations in the late 1960s and 1970s. Medical Committee physicians were in the vanguard of the health center movement nationally, and they also believed that the centers should be the foundation of health care for all Americans, not just the poor. Many of these early activists, now in their 70s and 80s, remain active today in the ongoing debates about the future of health care in America. So, although it went into decline during the Nixon years and did not survive Ronald Reagan’s presidency, MCHR lives on in the continuing social activism of its members. Their banner, “Health Care is a Human Right,” has been dusted off to become the rallying cry of the new health care movement.

No doubt Martin Luther King put it best. Addressing the annual convention of the Medical Committee for Human Rights nearly 50 years ago, King said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Bibliography 1.

Dittmer, J. Local People. University of Illinois Press, Urbana and Chicago, 1994.

2.

Dittmer, John. The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care. New York: Bloomsbury, 2010. Print.

3. McMillen. Dark Journey. Black Mississippians in the Age of Jim Crow.

1989. Univ Illinois Press, Urbana.

4.

Ward TJ. Jr. Black Physicians in the Jim Crow South 2003. Univ of Ark Press, Fayetteville.

5.

Belfrage S. Freedom Summer 1965 Univ Press of Virginia.

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• Special Article • The Meeting Richard D. deShazo, MD, Robert Smith, MD, and Leigh Baldwin Skipworth, BA [This article, “The Meeting,” includes the text of a presentation by Dr. Richard deShazo, written in collaboration with Robert Smith, MD and Leigh Baldwin Skipworth, BA, for the First Marston Symposium on Race and Health held June 20, 2014, on the campus of the University of Mississippi Medical Center in Jackson. The title of that symposium was “Can Mississippi Physicians Heal Themselves?” The symposium was one of the many events in Mississippi commemorating the 50th anniversary of Freedom Summer, 1964. Over 180 black and white physicians accepted UMMC’s state-wide invitation to attend this event co-sponsored by The Mississippi Humanities Council and the William Winter Institute for Racial Reconciliation at the University of Mississippi. Discussions among physicians following the presentations were led by Winter Institute facilitators and suggested both a need for and interest in racial reconciliation among Mississippi health professionals. Dr. deShazo’s article suggests the principles of restorative justice pioneered by Bishop Desmond Tutu in South Africa could be helpful moving forward. Another presentation from the symposium by John Dittmer, PhD appears in this issue of the JMSMA on on page 358.] — Lucius M. “Luke” Lampton, MD, Editor

S

ummary

A group of black physicians whose request to attend educational programs at the University of Mississippi Medical Center had been rebuffed by the school’s second dean played a central role in helping UMMC survive a federal investigation for non-compliance with the Civil Rights Act of 1964. Unknown to Dean Robert Marston, these physicians had been active in civil rights activities at both state and national levels and were in dialogue with federal civil rights agencies and with the NAACP who filed the complaint against UMMC. Marston called on them as part of a marathon of preparation for the inspection, and they assisted him in achieving an improbable outcome, a finding of compliance. In the process, Marston developed a positive relationship and ongoing dialogue with these black physicians and realized their value to Mississippi.

In turn, they elected him to membership in the Mississippi Medical and Surgical Society.

Introduction

The book “Pressure From All Sides” by Maurine Twiss, longtime University of Mississippi Medical Center (UMMC) Director of Public Information, and Dr. Robert Currier, UMMC’s first Chair of Neurology, along with the numerous historical documents Twiss left in UMMC’s Rowland Library Archives are a treasure trove for medical historians1 (Figure 1).

Author Information: Departments of Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi (Dr. deShazo and Ms. Skipworth) Central Mississippi Health Services, Jackson, Mississippi (Dr. Smith).

Corresponding Author: Richard deShazo, MD; James D. Hardy Clinical Sciences Building, 2500 North State Street - L605, Jackson, Mississippi 39216 (rdeshazo@umc.edu).

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Figure 1. Maurine Twiss, the first Director of the Office of Public Information at the University of Mississippi Medical Center (UMMC) during Marston’s tenure. She kept extensive typed notes of activities related to civil rights.

These have been previously reviewed and more recently catalogued by Janis Quinn for the Rowland Medical Library at UMMC. The brief description in the book and the significance of a remarkable meeting on April 13, 1965, between Dr. Robert Marston, the second Dean of the UMMC School of Medicine, and five Mississippi black physicians have long been overlooked.

We have reported parts of this story elsewhere, but additional details that form the historical context are now available with the discovery of the Twiss documents. These have now been catalogued by Janis Quinn in the Rowland Medical Library Archives at UMMC.

Twiss wrote, “On April 13, 1965, Marston met with those (black) physicians and told them he had not previously had access to a group such as theirs. When we set up the meeting with the black physicians, we inadvertently lucked into access to NAACP leaders cognizant of the NAACP on three levels local, state, and national. Even though he hadn’t known them or about them, they knew everything that was going on at The University Medical Center.”1 Who was Dr. Robert Q. Marston and what was the significance of the meeting?

Robert Q. Marston, MD

Dr. Robert Marston arrived in Jackson as the second dean and hospital director of the six year old University of Mississippi Medical Center in 1961 (Figure 2). It was a time of social turmoil in the United States, and Mississippi soon became the epicenter of it.

The same year, 1961, waves of Freedom Riders began arriving in Mississippi, and racial violence became an everyday event. Dr. James Anderson had just started general practice in Jackson, provided care for injured riders in his office, and sent the seriously injured to the University emergency room (Figure 4).

Figure 4. James Anderson, MD was the practice partner of Aaron Shirley, MD. He was active in civil rights in McComb, MS, and the Jackson area. Anderson was a co-founder of the Jackson-Hinds Comprehensive Health Center (FQHC).

4

Figure 2. The University of Mississippi Medical Center circa 1955

2

Marston was a southern gentleman in every respect. A native of rural Virginia, graduate of The Virginia Military Institute and The Medical College of Virginia, he was both a Rhodes and a Markle Scholar and was on track to become a national academic leader (Figure 3). Ole Miss Chancellor John D. Williams found him as an assistant dean at Medical College of Virginia and offered him the opportunity for a major professional leap he could not turn down.

Figure 3. Robert Q. Marston, MD, Dean of the School of Medicine and Director of the University of Mississippi Medical Center (UMMC) in 1961

Shortly after his arrival, Marston received a request from The Mississippi Medical and Surgical Association, an affiliate of The National Medical Association, to allow black Mississippi physicians to attend teaching conferences at the medical center since they had difficulty getting CME elsewhere in the state. Chancellor Williams had told Marston that he was not recruited to effect social change so he turned the request down and had no substantive interactions with black physicians until 1964.1 More about that later.

Jim Crow in Medicine in Mississippi

Marston found that Jim Crow had not exempted medicine in Mississippi and was firmly established there long before 1961. For instance, J.A. Miller, MD, a black graduate of Williams College and The University of Michigan Medical School, was tarred, feathered, jailed, and run out of Vicksburg in 1918 after 18 years of practice. He appeared too prosperous and fell out of favor with the local white establishment.4 Blacks qualified for admission to medical school in Mississippi were offered state-sponsored scholarships as enticements to attend traditionally black medical schools out of state to prevent integration at Ole Miss. Black Mississippi medical school graduates who had received state scholarships were not allowed to enter residencies in Mississippi but were required to return to Mississippi after residency for a 5-year payback anyway.

When Dr. Aaron Shirley started his scholarship payback as the only black physician remaining in Vicksburg in 1960, the local affiliate of the state medical association denied his request for membership (Figure 5). State medical association membership was required for hospital privileges and access to continuing education. He got neither. So, he and his wife became civil

November 2014 JOURNAL MSMA 371

rights advocates there. His outpatient medical practice grew even as he was constantly threatened by the Ku Klux Klan.

Figure 5. Aaron Shirley, MD practiced in Vicksburg, MS, and Jackson, MS. Dr. Blair Batson chose him to be the first black resident (pediatrics) at UMMC. He has received the McArthur Fellowship Award and served as a member of the Institutes of Medicine. † Died on November 26, 2014.

5

The few black physicians who did receive hospital privileges in the state, physicians like A.B. Britton, Jr, MD, of Jackson, known as a brilliant practitioner, had to admit their patients to substandard, “annex” hospital units like the Green Annex at the Baptist Hospital (Figure 6).

Figure 7. Clinton Battle, MD made house calls daily in the African American section of Indianola, MS, prior to being forced by the Citizen’s Council to leave the state.

UMMC and the Civil Rights Conflict

The University of Mississippi Medical Center was already caught up in the civil rights conflict by the time Marston arrived (4). In 1956, the Sovereignty Commission accused the UMMC of fostering “creeping integration” that triggered an investigation by the legislature. Black and white children were reported as watching television together in a hospital playroom (Figure 8). Marston told the legislature he could not figure out how to keep children from playing with each other and asked for suggestions on how to stop that. They had none.

Figure 6. AB Britton, MD was a mentor to black physicians in Central Mississippi and member of the Mississippi Advisory Committee to the US Civil Rights Commission.

6

Racial turmoil in Mississippi accelerated after the Brown vs. Board of Education school desegregation decision in 1954.

In 1955 Governor JP Coleman created the State Sovereignty Commission to gather intelligence and effect espionage against those supporting civil rights activities. Supported by state dollars, the Sovereignty Commission financed the White Citizens Council; the Citizens Council and later the Mississippi White Knights of the Ku Klux Klan did the dirty work.

Like other Mississippi black physicians, Dr. Clinton Battle had become a leader in his local NAACP Chapter and that put a target on his back. He left his Mississippi practice in Indianola in 1959 after The Citizens Council there forced planters to stop paying him for the care of field workers because of his NAACP leadership (Figure 7).

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Figure 8. 1956 United Press International press release concerning the investigation of UMMC for allowing black and white children to play together in a hospital playroom The same year, some affiliates of the Mississippi State Medical Association offered black physicians “S” or scientific memberships to attend CME at their meetings. However, “S” members had to leave before the social hour, dinner, and business meeting attended by regular members. Regular members did not want to eat with them. Dr. Gilbert Mason, NAACP President in Biloxi and leader of efforts to desegregate beaches with the “Gulf Coast Beach Wade-ins,” was an “S” member (Figure

9). He bit his lip and attended the affiliate meetings, even after his office was firebombed by the KKK.

Figure 9. Gilbert Mason, MD (leading a line of demonstrators to the left of the policeman in the figure) was the President of the Biloxi chapter of the NAACP and led efforts to gain access for blacks to the public beaches on the Gulf Coast.

In 1962, Marston called medical students to a meeting at the medical center to dissuade their plans to go to Oxford during the integration of Ole Miss by James Meredith.1 In 1963 Maurine Twiss called in the early morning hours to inform Marston that Medgar Evers, Mississippi NAACP Field Director and protégé of H.R.M. Howard, MD, Chief Surgeon at the Taborian Hospital in Mound Bayou, had died in the medical center emergency room after being shot in the back in his driveway (Figure 10). His physician, Dr. A.B. Britton, Jr., sat in the colored waiting room at the medical center during the extended attempt to save Evers. Evers’s death prompted The National Medical Association to try again to address their grievances with the American Medical Association (AMA), including denial of membership to black physicians.

Figure 10. Medger Evers, the Mississippi Field Director for the NAACP

in a civil rights planning meeting on the night Evers was murdered (Figure 11). He joined other physicians a week later in an organization he helped start, the Medical Committee for Civil Rights, in an attempt to speak to the AMA House of Delegates at their annual meeting in Atlantic City. The AMA refused to let Medical Committee members speak so the Medical Committee made national news by picketing outside the convention center. It was Smith who later called the Medical Committee to Mississippi to provide health care for the students and other civil rights workers who came to Mississippi during Freedom Summer of 1964. These events were the subject of the book, Figure 11. Robert Smith, MD was co-founder of the Medical Committee for Human Rights and the Federally Qualified Health Center Movement.

11

The Good Doctors.5 In 1964, after visiting the members of the Mount Zion Methodist Church, one black and two white civil rights workers were murdered by the Ku Klux Klan near Philadelphia, Mississippi (Figure 12). The church had been burned by the KKK after agreeing to serve as a Freedom School for Freedom Summer activities. Six weeks later, the FBI brought their bodies to the medical center for autopsy. The autopsies were performed Figure 12.

Federal Bureau of Investigation, June 1964 “missing poster” showing the 3 civil rights workers whose bodies were later found in Neshoba County, Mississippi in August 1964

Dr. Robert Smith of Jackson, an NMA member, private practitioner, student health physician at Tougaloo College, and later a clinical faculty member at UMMC, had been with Evers

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by a pathologist in private practice in the presence of two medical center pathologists and the autopsy report was provided to the FBI. One day later, a forensic pathologist from New York viewed the body of Meridian native James Chaney at the medical center.1 He reported to the press that the Mississippi pathologists had attempted to cover up the fact that he was severely beaten before being shot. This charge was followed by articles in Ramparts Magazine and the Yale Journal of Biology and Medicine which said events in Mississippi around the autopsies were “reminiscent of events in Nazi Germany.”

Marston sprang into action to rebut the charges, but there was little he could do to offset the bad national publicity for the medical center. J. Edgar Hoover refused Marston’s request to lift the FBI embargo on the autopsy findings which later proved that the New York pathologist’s charges were false (Figure 13).

Figure 14. Lyndon Johnson Signing Civil Rights Act of 1964

Figure 13. J. Edgar Hoover’s July 1965 negative response to a request from Dr. Marston for release of the Featherston autopsy reports on 3 civil rights workers

UMMC Following the Civil Rights Act of 1964

The events surrounding Freedom Summer of 1964 were the tipping points that led to the passage of The Civil Rights Act of 1964 and The Voting Rights Act of 19656 (Figure 14). As a result, Marston was required to sign a civil rights compliance document in 1964 attesting that there was no employee racial discrimination at UMMC or lose federal funds. The UMMC Comptroller provided a report showing that would be over 2 million dollars, a crippling loss for noncompliance (Figure 15).

Marston consulted the director of the State Sovereignty Commission and found that the legislature was unlikely to make up any loss of federal funds incurred. He successfully obtained approval from the Sovereignty Commission to sign the compliance document after the Commission labeled it “an example of voluntary compliance without the option to fully desegregate.”

Immediately thereafter and late at night, Marston and Twiss secretly removed “colored” and “white” signs around the university hospital.6 Subsequently, the wall between the black and white dining areas disappeared overnight.

Things soon got more complicated. In March of 1965, Marston learned that the NAACP Education and Legal Fund had filed a federal complaint against UMMC and other southern

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Figure 15. 1963-1964 UMMC budget (Twiss Files, UMMC) hospitals for failure to comply with Title VI of The Civil Rights Act of 1964. Title VI required desegregation of all medical facilities receiving federal dollars (Figure 16).

Dr. Marston used Washington contacts from his days as a researcher at the National Institutes of Health to learn that the federal plan would immediately sequester federal funds to UMMC until federal inspections took place and compliance was documented. While trying to learn the specifics, he hired the first black UMMC faculty member on March 11, 1965, despite the objections of the Institutes of Higher Learning (IHL) Board.

Because of the potentially disabling financial risks to the medical center, Marston rolled the dice and requested that UMMC be the first hospital charged to receive a federal civil rights inspection, a daring move since the hospital was totally

segregated.1 To his surprise, the Department of Health and Human Services accepted his request and informed him that the UMMC inspection would take place two days later, April 16, 1965. A marathon of activities followed.

eral inspections.

On April 16, 1965, two federal inspectors arrived on time.1 In their presence, Marston read a speech written by Twiss and Associate Dean Gronwal at a faculty meeting. He declared that integration was the law and they had to abide by it (Figure 17). Issues of social justice were never discussed.

The inspectors left that afternoon and word came down that the medical center had been cleared, but federal money stopped flowing anyway.

Figure 16. 1965 Associated Press release on NAACP legal action against UMMC and other hospitals in the South (Twiss Files, UMMC)

The Meeting

As a Washington contact recommended, Marston convened a black “Community Physician Advisory Group” and immediately met with Drs. A.B. Britton, Jr., William Miller, Robert Smith, and James Anderson from Jackson and Cyril Walwyn from Yazoo City. He had no relationship with them.

Moreover, Dr. Robert Smith was the physician whose request, on behalf of the Mississippi Medical and Surgical Association, Marston had turned down years earlier for access of black physicians to teaching conferences.2 The black physicians, however, had a close relationship with each other. They had been meeting regularly for years to coordinate civil rights activities locally and nationally and to coordinate their interactions with the federal government.

Marston was unaware of their leadership in the NAACP and NMA, Britton’s presidential appointment with the US Civil Rights Commission, or the offer Smith received to be an assistant secretary in the Equal Opportunity Division of the US Department of Health and Human Services (HHS).

Twiss’s notes record Marston’s surprise in an April 13, 1965, meeting where he found the black physicians friendly, articulate, well-dressed professionals who were more aware of the details of the NAACP complaint against UMMC and the federal investigation of it than he was. The group gave him useful suggestions, mentioned the locations of some “colored” signs Marston and Twiss had missed, and suggested that the “colored” line in the cafeteria be closed.3 Marston’s hospital administrator was resistant to desegregation of the hospital for fear the white patients would leave. Marston gave him a written directive to integrate the hospital wards immediately. The hospital administrator eventually did so but in the process pioneered what came to be known as the “Medicare Shuffle” where patients were moved around to simulate non-existent integration just prior to fed-

Figure 17. Marston 1965 Speech to Faculty with hand written note by Maurine Twiss (Twiss Files, UMMC)

On June 7, 1965, another federal inspector appeared unannounced and wanted to know why there were still “colored” and “white” lines in the cafeteria. This time Marston took the advice of his Advisory Committee and the “colored” line was closed. Late in June, the money began to flow again, but it was clear that more inspections were to follow.

As they sat side by side on a flight back to Jackson one evening, Marston commented to Robert Smith that the continuous civil rights problems at the medical center had become “risky to the career of a Rhodes Scholar” and he was “looking at other opportunities.”3 Indeed, many were impressed with Marston’s handling of the “situation at the medical school in Mississippi,” and in 1966 he was recruited to a position as Associate Director of the NIH where he soon became Director.

Marston then served as President of the University of Florida from 1974 until his retirement after which he continued highly active in emeritus status until his death.

What Shall We Make of All of This?

Maurine Twiss noted of the Advisory Committee, “It seemed to me that no matter how profound their belief in the civil rights movement, how determined they were to remove inequities, they did not want to damage the state’s medical center.1 That prevailing attitude got the medical center through some dangerous times.” “The counsel of these few black physicians was of inestimable lasting value to the institution.”

Despite the treatment this physician group had received

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from the medical community and the academic medical center in Mississippi, they saw UMMC as an important resource to address the extraordinary health disparities among Mississippians regardless of their color.

Familiarity Bred Respect

Marston came to understand how much common ground he had with his black colleagues and developed personal relationships with them that later led to his quiet induction into the Mississippi Medical and Surgical Society.6 He also came to understand the extraordinary influence of Mississippi black physicians in the planning and execution of Great Society Health Programs including Headstart and the Federally Qualified Health Center Program in which Robert Smith, James Anderson, and Aaron Shirley were leaders.6 For Marston, familiarity, rather than breeding contempt, brought admiration, appreciation, and respect of the black physician leaders who risked their lives and livelihoods in attempts to improve health in Mississippi.

Marston walked a tightrope between a segregationist state government and a federal government under pressure from civil rights advocates and the federal courts. Although he arrived as a white southern physician with all the preconceptions about blacks of the day, he broke through prejudice, tradition, and the violence of the era and came to see black physicians as worthy colleagues. But like many of us, he learned the hard way.

Respect Bred Reconciliation

In 2008, leaders of the American Medical Association apologized in person and in writing to the National Medical Association for behaviors that adversely affected the lives of black physicians and black patients during the Jim Crow Era and subsequently7 (Figure 18). An open apology such as that is one component of a process called “restorative justice.” The process focuses on the needs of both the victims and the offenders who have either actively or passively been involved in a wrong doing. The principles of restorative justice developed out of South Africa’s Truth and Reconciliation Commission (TRC) championed by Bishop Desmond Tutu of the Anglican Church with the process to end apartheid. A second component is the open acknowledgment of the wrongs committed as we have done here. Application of the principles of restorative justice has been found useful in promoting reconciliation and positive behavior changes for many forms of injustice.8 Until recently, the Mississippi State Medical Association had not publicly acknowledged physician complicity in past injustices to our black colleagues and the negative effects they have had on health in the state.9, 10, 11 As one Mississippi physician [deShazo], I am sorry for the abuses of the past.

If we are to address Mississippi’s last place in health, it will take Mississippians, of all colors, working together to make this happen. There is still pain from the past among health professionals, pain that separates us. It is time for racial

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Figure 18. 2008 article from the Journal of the American Medical Association (JAMA) summarizing efforts at racial reconciliation between the AMA and the predominately black National Medical Association. The efforts included an apology to black physicians for the AMA’s long history of racial discrimination against black physicians.

reconciliation among health professionals in Mississippi. It will be a shame if physicians should fail to lead in that effort.

Let’s talk about it.12

References 1.

Twiss MC, Currier RD. Pressure from All Sides. The University of Mississippi Medical Center in the 60’s. The University of Mississippi Medical Center, Jackson. 2004:85-148 2. Twiss MC. Archives of documents by Maurine Twiss. Archives, Rowland Medical Library, University of Mississippi Medical Center.

3. deShazo RD, Smith R, Skipworth LB. A white dean and black physicians at the epicenter of the civil rights movement, Am J Med. 2014;127(6):469478.

4. deShazo RD, Smith R, Skipworth LB. Black physicians and the struggle for civil rights. Lessons from The Mississippi Experience. Part 1 Am J Med. 2014 In Press.

5. Dittmer, John. The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care. New York: Bloomsbury, 2010.

6. deShazo RD, Smith R, Skipworth LB. Black physicians and the struggle for civil rights. Lessons from The Mississippi Experience. Part 2 Am J Med. 2014 In Press.

7. Davis RM. Achieving racial harmony for the benefit of patients and communities. JAMA 2008;300(3):323-325.

8. Latimer J, Dowden C, Muise D. The effectiveness of restorative justice practices: a meta-analysis (http://www.sagepub.com/vaughnstudy/articles /corredctions/Latimer.pdf) 9. deShazo RD, Lampton L. The educational struggles of African American physicians in Mississippi: finding a path toward reconciliation. J Miss State Med Assoc. 2013;54(7):189-198.

10. Lampton LM. Opening the doors of the great republic: sex, race and organized medicine in Mississippi. J Miss State Med Assoc. 2013;54(7): 205-213.

11. Brunson, CD. Inaugural address of the 147th president Claude D. Brunson, MD. J Miss Med Assoc. 2014;55(9):298-302.

12. Quinn J. Promises Kept. The University of Mississippi Medical Center, Jackson. 2005:96.

• AMA • MSMA Delegation Supports New AMA Principles for MOC In response to Resolution 12 from the 2014 House of Delegates meeting, your AMA Delegation voted to update the AMA’s policy on maintenance of certification (MOC) at the recent 2014 AMA Interim Meeting in Dallas. The adopted policy outlines principles that emphasize the need for an evidence-based process that is evaluated regularly to ensure physician needs are being met and activities are relevant to clinical practice. The MOC principles now include: • MOC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.

• The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.

• MOC should be used as a tool for continuous improvement.

• The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.

• Actively practicing physicians should be well-represented on specialty boards developing MOC. • MOC activities and measurement should be relevant to clinical practice.

• The MOC process should not be cost-prohibitive or present barriers to patient care.

• Specialty boards, which develop MOC standards, may approve curriculum, but should be independent from entities designing and delivering that curriculum, and should have no financial interest in the process.

Please note the last new principle about specialty boards being independent from entities designing the curriculum was referred. The policy encourages specialty boards to investigate alternative approaches to MOC and directs the AMA to report annually on the MOC process.

Your AMA Delegation believes this new policy meets the intent of the MSMA House of Delegates to ensure full transparency, reduce the burden of duplicate education requirements, limit financial gains by specialty boards, and otherwise diminish onerous MOC requirements. r

AMA Adopts New Policy to Encourage Access and Equity in Telemedicine Payments At the 2014 Interim Meeting of the AMA, new policy was adopted directing the AMA to lobby Congress to require CMS to pay for telemedicine services for patients who have problems accessing physician specialties that are in short supply in areas that are not federally determined “shortage” areas. Physicians from across the country showed overwhelming support for this new policy, highlighting the need for more specialty services to be provided to underserved areas through new, innovative telemedicine avenues. The original proposal for policy included directing the AMA to establish policy to request that CMS no longer utilize geographic adjustment payments for telemedicine. This portion of the policy was removed after physicians from across the country stood in opposition to adoption based on the emphasis that there are rationales for these geographic adjustments and that telemedicine services should be subject to the same Medicare payment processes as any other medical service.

MSMA physicians have worked closely with Congressman Harper as well as Senators Wicker and Cochran on federal legislation aimed at improving telemedicine reimbursements through CMS. MSMA physicians will continue working with the Mississippi Congressional Delegation and the AMA in passing meaningful telemedicine legislation. r

AMA Backs Interstate Compact to Streamline Medical Licensure During the 2014 AMA Interim meeting, the House of Delegates adopted policy to support the Federation of State Medical Board’s Interstate Compact for Medical Licensure and to work with stakeholders to ensure adoption by the states of the Interstate Compact for Medical Licensure and creation of the Interstate Medical Licensure Compact Commission. Delegates strongly supported the adoption of this policy after ensuring that participating state medical licensing boards would unambiguously retain their existing authority to license and discipline physicians. Delegates also confirmed that the Compact would not regulate changes to states’ existing medical practice acts. These concerns align with existing AMA policy in opposition to national licensure.

Supporters of this policy claim that the Federation’s Compact will expedite interstate licensing, resulting in a positive impact on patient’s access to care through in-person or telemedicine services. The Mississippi Board of Medical Licensure has not yet taken a position on the Compact, though AMA President Elect Steven J. Stack, MD encourages more states to join with the ten state medical boards that have already adopted it. One complication of the Federation’s Compact is that effective implementation requires each participating state to pass uniform legislation, giving the same authority and restrictions to that state’s delegates for the Commission. r

November 2014 JOURNAL MSMA 377

• Physician’s Bookshelf • JOHN MARSHALL STONE A historical narrative by Ben Earl Kitchens, MD Thornwood Book Publishers P. O. Box 273 Iuka, Mississippi 38852

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his month our featured volume is a masterful biography written by MSMA’s own Dr. Ben Kitchens of Iuka. I learned of this recent release when I ran into Dr. Kitchens at a medical conference this summer and asked “Have you written any new books lately?” Ben told me of his most recent project, a book on the life and times of John Stone of Tishomingo County.

The volume tells us a fresh story of a fascinating man and the Northeast Mississippi landscape that formed him. John Stone tirelessly and selflessly served Mississippi throughout his entire life beginning with the cataclysmic days of the Civil War. As Captain Stone, he led the Iuka Rifles of Company K of the 2nd Mississippi Regiment with Lee’s army of northern Virginia into the opening conflict of the war, the Battle of Bull Run (First Manassas). For his valor he later achieved the rank of Colonel (beating out Ripley’s own Colonel W. C. Falkner for the leadership role) and later participating in the important battles of Antietam, Gettysburg, and the Wilderness. Stone was in the thick of the war from start to finish. He was finally taken prisoner in April 1865 and was in a Union POW camp in Ohio. He was released from imprisonment on Johnson’s Island on July 25, 1865. He returned home as a hero to find the land he loved destroyed by four years of war and suffering from defeat, despair, and dire poverty. Stone was a natural leader, a tireless worker, and an appealing “people person” who immediately began to forge Northeast Mississippi from the ashes of war’s devastation.

The book chronicles his rise from local hero and town leader on to service in the highest office of our state during perhaps the most difficult period of our history, the so-called “Reconstruction.” Dr. Kitchens writes…

“John M. Stone was a quite distinguished son of the South, one of Mississippi’s truest and most steadfast…As Mississippi’s ‘businessman governor’, he preferred not to make any decisions, based on his position as governor that would enrich him politically unless it was also fair and in the best interest of Mississippi and her citizenry. Governor Stone maintained this strict discipline throughout his life. He incurred no scandals during his two years as railroad commissioner, six years as senator, and almost 12 years as governor…. His steadfastness in refusing to grant unwise pardons, make appointments, or modify his inherent beliefs for political gains seems incredulous in comparison to today’s political operatives.”

Before the publication of Dr. Kitchens’s book very little had been written about Governor Stone and this troubled time in Mississippi’s history. This extensive and very readable volume was a massive undertaking and quite a labor of love for a busy rural physician. When you read Dr. Kitchens’s words you can feel the passion he has for writing the history of Northeast Mississippi, a region which has been for the most part ignored in publications about our state’s past, and his deep affection for telling the Governor Stone’s life story.

378 JOURNAL MSMA November 2014

My interest was piqued for reading this book because of my admiration for its author and fellow family physician, Dr. Ben Earl Kitchens. Lest we forget, Ben should be hailed as one of our modern day medical heroes. He is a Past President of the Mississippi Academy of Family Physicians (1981-82) and should go down in medical history for making one of the most significant contributions to the battle for Malpractice Reform in our state when he single handedly ran the daily MISSISSIPPI MALPRACTICE TORT BLOG about ten years ago. This daily internet posting composed during what had to be hundreds of insomniac nights rallied Mississippi physicians together and informed them of the ongoing crisis. The culmination of his efforts to impassion the normally complacent doctors to action led to critical changes in these laws as they affect medical practice.

Of this time, the shy and retiring Ben says, “As far as the tort fight, you can describe it as you experienced it. To me, it was rather intense and at the time, with the inroads the powerful trial lawyers had made, I felt that I was fighting for the lifeblood of medical practice. That’s why I put so much time and effort into it… The younger docs will have to be vigilant, however, and maintain strong bonds with those we have promised to serve, or adverse actions and Ben Earl Kitchens, MD power grabs will re-emerge in a short number of years. …I was very appreciative of the resolution passed by the House of Delegates of the Mississippi State Medical Association recognizing my contribution and the service award presented by the Mississippi Academy of Family Physicians….I remain thankful for the legislative protection that we now have in Mississippi that allows us to practice our profession without the unwarranted threats of so many lawsuits, that has reduced the constant threat that produced so much defensiveness and excessive ordering of so many unnecessary tests for our patients, that has made malpractice premiums manageable, and which has allowed us to warmly embrace our lawyer friends again.”

Dr. Kitchens has written another fascinating book, his sixth and perhaps best volume to date. For anyone who wants to learn more about Mississippi history during the Civil War and Reconstruction, I would heartily recommend this biography of Governor John Stone. I would go so far as to recommend that a copy of this book should be in the hands of every statewide elected official. The Honorable Governor J. M Stone is to be emulated as a model life for any political official and public servant.

On your Christmas list for yourself as well as all your politically minded friends, you may purchase Dr. Kitchens’s book online at www.shop.tishomingohistory.com, by telephone at 662-423-3500, or by check or money-order payable to TCHGS, P. O. Box 273, Iuka, MS. 38852. The price is $29.95 (+ 6.00 S/H) and 100% of the proceeds support the Old Tishomingo County Courthouse Museum. Order: http://www.tishomingohistory.com/stone_order_form.pdf Bravo, Ben! Keep the writing coming.

—Dwalia South, MD; Ripley Chair, MSMA Committee on Publications

Journal of the Mississippi State Medic Journal of the Mississippi State Medical Association

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The University of Mississippi Medical Center Digestive Diseases Division in Jackson, Miss is seeking a BC/BE Gastroenterologist. Faculty candidates should submit a CV via fax to 601-984-4548. EOE, M/F/D/V.

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UMMC Family Medicine physicians are sought for Attn: Andy Cote employment with Division Hancock Medical Center in Digestive Diseases Manager Bay St. Louis and Diamondhead, MS. Please 2500 North State St send CV to: Gigi Askew, Medical Staff Jackson, MS 39216-4505 Services, Hancock Medical Center, 149 Drinkwater Blvd., Louis, MS Fax 39520 601-984-5534 OfficeBay St. 601-984-4548 acote@umc.edu

November 2014 JOURNAL MSMA 379

Dear Mr. Cote:

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• Poetry and Medicine • [This month, we print another poem by the gifted poet Robert Ray “Bob” McGee, MD, a Clarksdale internist. McGee writes under the pseudonym of Thomas Browne, MD. He recently published a lovely and brilliant volume of poetry entitled “Case Reports and Other Epiphanies,” printed by the Old Man’s Press of Clarksdale. He’s an accomplished and talented poet, to be sure, publishing poems as early as 1980 in such publications as the “Annals of Internal Medicine” and “The Pharos.” A selection of his writing was also included in Dr. Trey Emerson’s “Avocation of Compassion,” published in 1989. To obtain a copy of his poetry collection, go to lulu.com or write to Dr. McGee directly at 303 Cypress Avenue, Clarksdale, MS 38614. This poem offers up a reflection on a night house call. Those who still make them in this age of GPS navigation can relate to the lone porch light gleaming and awaiting in a “long dark row of porches.” Also, how perfect are the lines, “I go in, where death waits, / To dispute the issue / As God lets me.” Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

Night Call I get up sleepy in the night Slowly dress in the half-light, I start my car and turn out Into the lonely, silent, moon-drenched street, No one else abroad for me to meet.

Here is the house I know it by the porch light gleaming The only one in a long dark row of porches.

I go in, where death waits, To dispute the issue

As God lets me.

—Thomas Browne, MD Clarksdale

380 JOURNAL MSMA November 2014

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PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

Every year, MSMA staffs the Capitol Medical Unit during the legislative session with a full time nurse and a volunteer physician each day. The Doctor of the Day program runs from January through March and allows MSMA members to participate in the legislative process by being front and center at the state capitol. Doctors of the Day are only asked to provide minimal health care services to legislators and capitol staff. Doctors of the Day volunteer for half days on Monday and Friday while Tuesday, Wednesday, and Thursday are full day commitments. As Doctor of the Day, you will be introduced in the House and Senate chambers by your local legislators and thanked for your service. This is a perfect opportunity to not only “give back,” but have valuable personal time with your legislator and voice support for pro-medicine policies.

To participate in MSMA’s Doctor of the Day program, please use the interactive calendar found on MSMAonline.com. please contact Blake Bell at BBell@MSMAonline.com.