Confronting the Past to Right a Wrong

The tragic death of George Floyd in 2020 sparked a new era of increased public awareness among white people of racial injustice in America and the pernicious effects that racism has on various aspects of society.  Many organizations, public and private, took the opportunity to re-examine how their values and practices may be perpetuating these harms.  Some delved extensively into their legacies and did not like what they saw.  The Milbank Memorial Fund, publisher of The Milbank Quarterly, was among this latter group.  Despite its 117-year history of funding advances in public health and striving to improve health policy making in the United States, the Fund’s scrutiny of its past revealed a harsh truth–that it had played a role in the United States Public Health Service (USPHS) Syphilis Study at Tuskegee and Macon County, Alabama.  For Milbank staff and Board members, this was a disturbing revelation that begged answers to disquieting questions.  How and why did this happen?  What was the decision-making process that led to the Fund’s participation?  What must the Fund do to rectify the harm caused by its involvement in the study?

In April of this year, Milbank Memorial Fund President Christopher Koller publicly acknowledged the Fund’s role in the study, which was racist in conception and design and caused considerable harm to the study subjects and their families, all of whom were poor African Americans who had been deceived by USPHS researchers.  In “Harms and Healing,”¹ which appears in this issue, Mr. Koller disclosed the fact that the Fund had paid for services associated with the burials of men who died in the course of the study between 1935 and 1972.  The funds included burial stipends used as an incentive to obtain family consent to allow for autopsies of the men.  Although the Fund’s involvement in the study always had been a matter of public record, the details had remained obscure over the five decades since the study ended.  Moreover, the Fund had never openly acknowledged its role nor apologized for it, despite opportunities to do so.

This painful revelation came to light just as the staff was beginning organizational development work on diversity, equity, and inclusion following Mr. Floyd’s murder and the rise of the Black Lives Matter movement.  Staff considered the syphilis study an egregious wrong inflicted upon innocent, unsuspecting persons under the guise of “good science” and important medical research.  To right this wrong, staff believed that the Fund would first need to publicly confront its past, however distressing that might be.  Only by doing so could the task of repairing the harm begin.  In Mr. Koller’s words, “Only when the harm is acknowledged is healing even a possibility.”

The Fund’s Board of Directors concurred.  It chose to confront this sad period in the Fund’s history, and also took immediate and concrete steps to make restitution for the role that the Fund had played in the study.

Over the past year, we have been on a journey of discovery that we hope will lead to restorative justice.  First, our organizational work on diversity, equity, and inclusion led to the drafting of our Racial Equity Statement of Purpose,² which commits us to document, understand, and learn from our past.  This statement of obligations and actions guides us as we seek to transform our organizational culture and increase the diversity of our staff, Board of Directors, state policy networks, authors, reviewers, and editorial advisors.  I reported on some of this work in my December 2021 Editor’s Note.  At the Quarterly, we have incorporated diversity and equity explicitly into the journal’s core values and made health equity a fourth area of editorial focus.  We also have increased (and continue to increase) the racial, ethnic, geographic, and disciplinary diversity of our Editorial Advisory Board, opinion writers, and manuscript reviewers.  We continuously strive to reach and encourage a more diverse set of scholars to submit their research to the Quarterly.  The Racial Equity Statement of Purpose amplifies these ongoing efforts.

In order to understand better the Fund’s specific role in the Tuskegee study, we commissioned noted historian, Susan Reverby of Wellesley College, to explore how and why the Fund chose to participate in the study, and why it remained silent about its involvement for so many years.  Professor Reverby had full access to the Fund’s archival records during her research.  Her unabridged report is available on the Fund’s website.³  At my invitation, Professor Reverby also produced a summary of the report’s key findings, which we are pleased to present in this issue of the Quarterly.  “The Milbank Memorial Fund and the US Public Health Service Study of Untreated Syphilis in Tuskegee: A Short Historical Reassessment” is a sobering account of the factors and events behind the Fund’s involvement in the study.  Most striking are the interlocking relationships between USPHS officials and Fund officers and advisors that likely contributed to the Fund’s initial decision to participate in the study and to its subsequent decisions to remain involved over time.  The author identifies several lessons that should aid the Fund in reexamining its governance structure and decision-making processes to avoid future episodes of this kind.  Her analysis also highlights how the action steps taken by the Fund may serve as a blueprint for other organizations to follow.

Other articles of interest in this issue of the Quarterly include:

• Julie M. Donohue on the enduring importance of Stephen Soumerai and coauthors’ classic 1993 article, “A Critical Analysis of Studies of State Drug Reimbursement Policies: Research in Need of Discipline,” whose conceptual and analytic frameworks remain as relevant today as they were almost 30 years ago.
• Andrew Anderson and Derek M. Griffith on measuring the trustworthiness of health care organizations and systems, using a conceptual model that explains the constructs of trust and trustworthiness in the context of health care through the application of existing theories of human behavior.
• Jessica Greene on how patients’ experiences build their trust in clinicians and health care organizations.
• Seth Berkowitz on addressing income-related health inequity through four different policy approaches—social services, social enfranchisement, social insurance, and social assistance.
• Sahil Sandhu and colleagues on how public financing approaches have progressed in the United States and England to support social prescribing.
• Margarita Alegría and colleagues on how ethnic minority context alters the risk for developing mental health disorders and psychological distress for Latinx young adults.
• Breena Taira and colleagues on evaluating interventions to meet the requirements of California Senate Bill 1152 in the emergency departments of a public hospital system.
• Shana Kushner Gadarian and colleagues on the effects of an online COVID vaccine messaging and endorsement campaign aimed at increasing vaccine awareness among minoritized populations.
• Shiyin Jiao and colleagues on estimating the impact of Medicaid expansion and federal funding cuts on the staffing and patient capacity of Federally Qualified Health Centers.
• Anne-Marie Boxall on what the State Innovation Model experiment tells us about the capacity of states to implement complex health reforms.
• Huseyin Naci and colleagues on the coverage of new drugs in Medicare Part D.
• Daniel R. Arnold and colleagues on whether state bans of Most‐Favored‐Nation contract clauses restrain hospital price growth.

In closing, we invite readers to explore the Quarterly’s website for timely opinion pieces on important policy issues (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/).  Recent contributions include:

• Sara Rosenbaum on overcoming the impact of the Trump administration’s public charge rule;
• Gail Wilensky on getting health care workers back to work and other workforce shortage challenges;
• Dalton Conley on controversies surrounding CRISPR germline editing; and
• David Rosner on the US Supreme Court’s crush of OSHA at the expense of workers’ health and safety.

References 

1. Koller CF. Harms and Healing. Milbank Q. 2022.
2. Milbank Memorial Fund. Racial Equity Statement of Purpose. https://www.milbank.org/about/racial-equity-statement-of-purpose/. Accessed May 4, 2022.
3. Reverby SM. “An Opportunity of this Kind:” The Milbank Memorial Fund and the U.S. Public Health Service Study of Untreated Syphilis in Tuskegee, A Report to the Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2022/04/Reverby_report_4.24.pdf . Accessed May 4, 2022.

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