How the Rise and Fall of Shaw’s Medical School Helps Explain Modern Racial Disparities

Six years ago, Nicole Carr was in the thick of covering the COVID-19 pandemic as an investigative TV journalist in Atlanta. Outside of work, she was four months postpartum and juggling virtual schooling for her two other children. 

“It’s a scary time. It’s an uncertain time,” Carr remembers.

After the 11 p.m. broadcast one night, Carr was exhausted but restless. She wondered, “How the heck did they get through this 100 years ago?” Then it clicked: She knew her great-grandfather had attended medical school during the 1918 flu pandemic. Perhaps his story, which Carr knew little about, could give her a new perspective on the current historic moment.

“I decided to go looking for him in some archives that night,” she said.

She wasn’t looking to write a book. But the history she uncovered became the backdrop of The Price of Exclusion: The Pursuit of Healthcare in a Segregated Nation, released Tuesday. The book chronicles pioneering Black doctors, like her great-grandfather, Dr. Lawrence St. Clair Ferguson, as well as exclusionary policies that led to the demise of most Black medical schools in the U.S. in the 20th century—the effects of which, Carr posits, are still seen today in disparate health outcomes for Black patients and a shortage of Black doctors.

“I started drawing some parallels between the political unrest, race relations, health care, pandemic—they were dealing with all the stuff we’re dealing with right now, in 2020,” Carr said. “That turned into the proposal.”

Carr’s home state of North Carolina plays a key role in the book. The first chapter focuses on Shaw University, the historically Black university in Raleigh that, in 1880, established the country’s first four-year medical school—a longer-than-usual curriculum for the time that Carr writes was set “because of a groundless doubt concerning the Negro’s ability to practice medicine.” In its nearly 40 years of existence, Leonard Medical School produced more than 430 graduates, many of whom went on to achieve success in medicine, business, and public service in North Carolina and elsewhere.

Carr, a graduate of Winston-Salem State University, writes in the book that she visited Raleigh “to touch the spaces that I hope will explain the divide that remains today between civil rights, community health, and Black life.” The Assembly spoke with her about that journey and what she learned while reporting the book.

This Q&A has been edited for length and clarity.

I did not know Shaw was home to the country’s first four-year medical school. Did you know that prior to writing this book, and why was it an important place to start the story? 

I have an uncle in Raleigh, his name is Ted Johnson, and he’s a Shaw graduate. I told him what I was finding out about my dad’s side of the family through my research, and he says, “You know, Shaw had a medical school.” I said, “I did not.” Combined with the family research, I realized there was a story to be told that would help us understand the time we were in.

I thought it was important for the book to start with the first chapter, “The Medical Education of the Negro Sets the Standard,” to reset our thinking around what education means in a democracy, because right now we’re watching access be cut short to the very same profession. It’s through different methods, but I wanted people to understand that, like so much of our forgotten history, America cannot reach its ideals and its promise of a democracy for all without the inclusion of the formerly enslaved who built the country. We often find so many firsts in Black history—not just for Black people, but for the country, because our full citizenship is what allows America to realize its promise.

Given the anti-everything movement that we’re facing now—the anti-DEI [diversity, equity, and inclusion] and anti-CRT [critical race theory] movement—it was important to pull the language from the archives that showed us that the thinking behind making Shaw a four-year medical school was: If you are going to begin to put the Negro in a white coat, he should go to school longer and prove himself as intellectual and capable as the white man. They were expanding education standards to challenge a group of people based on an idea of merit and intellect, and some of that language is now being used to justify a lot of policies that relate to education, race, admissions, you name it.

That’s how we get to Shaw. And I am trying to understand, as a North Carolina native, why I did not know this.

As you point out in the book, the graduates of Leonard went on to be very successful. Readers in Raleigh will probably recognize the name of Manassa T. Pope, North Carolina’s first licensed Black doctor, whose home is an historic landmark downtown. Other alumni operated hospitals or ran for office. What do you think their success says about the quality of education students received at Shaw?

I think their success represented the promise that education has for us when we can access it. Education is not about us being able to spit out facts on a testing sheet. Being able to further your education allows you to envision yourself differently, and I think it’s really important to understand how Black people in America envisioned themselves in the immediate aftermath of enslavement. People were ready to go to college after emancipation; I teach at an institution, Morehouse College, founded in the two years after enslavement.

Education also opens the door to political power, and I think that’s what we see demonstrated here. You go, and you’re trained to do one thing, but you understand that the thing you do is a part of a larger ecosystem, and that’s what these doctors realize. You don’t get to just be the doctor, you become a part of a socioeconomic engine that makes the community run. Their success is indicative of what happens when the front door to the schoolhouse is open for everyone. This is why redistricting for school districts is a political fight. This is why voucher systems go to state lawmakers, because we’re really figuring out how we determine who gets what and how much of it they get.

As far as the quality of education at Shaw, they had some of the best professors. They didn’t have Black instructors in the beginning. These are white men, mostly from the North, who are in community with philanthropists and believe in funding a lot of religious organizations. They believe that education for the American Negro is the right thing to do, to offer. But they also go in these backrooms, and they try to determine how far to go with this. While their intentions are good, they’re also saying, “The measure of whether they’re good enough is if they can do what the white man can do.” Take from that what you will.

I also wrote about other physicians outside of North Carolina [and who were trained at other schools], like one who owned a printing press for the Atlanta Daily World, and people who were opening insurance companies and banks. And Dr. Hubert Eaton of Wilmington is a part of practically every desegregation case in New Hanover County. He fights for access his entire career, while he’s practicing medicine. Really, the book could have been written through the lens of attorneys, through some journalists. It’s really a story about what happens when you level the playing field for folks who want to play a part in this society.

You write that Dr. Eaton successfully lobbied the state of North Carolina to pay for his medical education expenses in Michigan in the 1940s, which was another piece of history I didn’t know. 

The way that we often recount the Eaton story is that the state of North Carolina was so kind as to pay for his education. You cannot tell the story without noting that because Leonard Medical School had been closed down, he had no option under Jim Crow laws to get an equal and equivalent education in his home state. There was no separate but equal available because there was no medical school anymore. 

He sued over that, and Black people were doing this all over. The legal argument is that because you cannot offer this where I live, I cannot have a reasonable chance to get an education that I want here, then you owe me the opportunity somewhere else. And that’s how he becomes the only Black person in the graduating class at the University of Michigan the year that he graduates. It’s not that North Carolina was so kind. That’s how we ought to always recount this story. 

The book details changes to medical education in the early 1900s, beginning with new “goalposts” set by the American Medical Association that mandated medical schools have an endowment of $600,000, facilities with “top-grade” equipment, and a four-year curriculum—standards that were virtually impossible for most Black medical schools to meet. What were the impacts of these changes?

If you want a school to have a $600,000 endowment to get points in your criteria, I don’t know a Black school in the decades post-emancipation that would have that kind of endowment. They hadn’t been around. How do you compare that to the Harvards and Yales of the world? Endowments were built through land deals, through enslaved labor. So how were the formerly enslaved, as soon as they’re free, supposed to build institutions that had endowments that were built off the backs of the enslaved? The math is not mathing. It’s impossible.

They also looked at the quality of facilities. If you go back to the founding documents in the medical school at Shaw, you see how the university’s founder, Henry Tupper, was begging the Baptists to donate and help build the school. Is it a state-of-the-art building for the time? No. Is it working? Absolutely. That’s like your neighborhood school. Is your old neighborhood school that was built in the ’80s a pretty school? Maybe not. Do you have enough taxpayer dollars to build a new school in the next 10 years? No. Are the teachers in there still good? Yeah. What if they threatened to close our schools today because you can’t get enough money to get a new building? The criteria is pretty ridiculous when you think about the challenges that were before them.

Only two Black medical schools survived the evaluations. Meharry Medical College [in Tennessee] had a little bit more money from the philanthropists than Shaw did, and they were growing at a different rate. Howard University [in Washington] had congressional appropriations. 

But Leonard, at the time, was producing more black physicians in the Southeast than Meharry was. So when it closed [during the 1918 flu pandemic], you fast-forward to a Dr. Eaton era, where he has to go to Michigan. 

You write that the man tasked with evaluating medical schools based on the new standards, Abraham Flexner, “had questionable credentials for the role.” He’d never attended medical school and had written a book “on the shortcomings of American universities.” That sounds similar to some of the attacks we’ve seen on higher education in recent years. Do you think that’s a valid comparison?

Absolutely. And I’m going to say something that will make people uncomfortable: That is a function of white supremacy. That is allowing people to envision a world not based on credentials or experience, but what people should do to shape the world they want. It’s not shaped by facts, and it’s not shaped by common sense. 

Flexner didn’t have a medical education. He didn’t have a health care background. He barely made it through one of his own graduate programs, but he had a connection to the president of Vanderbilt University, and he had a connection to someone in the Carnegie Foundation. He was connected. That was it. There’s nothing in Flexner’s background that says he should have been evaluating every medical school in North America.

People today have a vision for what education should be, and it’s not a vision that includes everyone. It doesn’t take cultural responsiveness into account; it punishes you for that. And that’s what Flexner does, and he’s enacted generational damage by closing these places when we are legally segregated in every facet of life. He determined that Black people will not be going to medical school in numbers. That’s why just about 5% of doctors in the country today are Black. 

There are four Black medical schools in America: Howard and Meharry, which outlasted Flexner, Morehouse School of Medicine in Atlanta, and the Charles R. Drew University of Medicine and Science in California. Yet the challenges that are being made today are that schools like Yale and the University of California, Los Angeles, are admitting students based on faulty criteria.

Toward the end of the book, you mention legislation—including a bill introduced in Congress by N.C. Rep. Greg Murphy—that has threatened to cut funding for medical schools if they teach or promote DEI. You also note that Black medical student enrollment plunged after the Supreme Court’s decision three years ago. All of that comes as the country is facing a shortage of doctors. What’s your outlook on the state of medical education given these challenges?

I don’t think we have an opportunity to repair the damage that is being done right now. We won’t have the opportunity to repair that for decades to come. The repeal of affirmative action begins this challenge to admissions, and you don’t get a chance to catch up, because every time you make a dent in it, we’re moving the goalpost on who deserves access to education. 

The other reason I think what’s happening right now is so dangerous is because, on July 1, the Big Beautiful Bill is going into effect, and that’s going to cap students’ loan limit and their ability to borrow money for their education. You take the racial wealth gap into consideration, then you add that on the generational damage, the broken pipeline as it is, I don’t know where we go.