Revisiting Nurse Rivers
Creators: name: Kearns, Lisa
Publisher: name: Voices in Bioethics
Year: 2013

description: The Tuskegee syphilis study’s most enduring figure is also one of its most intriguing. Nurse Eunice Rivers was instrumental to the study for both procuring its members and then keeping them involved in it. Straddling as she did the professional medical world and the world of the study’s subjects, she was the ideal link between the disparate spheres.1 Over the years, historians who have studied Rivers have found her to be a complex character: a black woman who betrayed her race even as she sought to improve the black subjects’ well-being; a nurse who betrayed her profession by dooming those she was charged with caring for. Through modern eyes, she becomes more victim than betrayer: a victim of her gender, powerless to speak up in a man’s world, or a victim of race herself, powerless in a world controlled by whites.2 Susan Smith, in “Neither Victim Nor Villain,” analyzes the Tuskegee study from the perspective of Rivers as a black professional, in the historical context of her gender and race.3 Another, equally compelling way to look at Rivers is also within a historical context, again as a medical professional, but this time as one attempting to practice that profession during an economically devastated and racially repressive period of American history. The poverty and unemployment prevalent in the rural South of the 1920s and 1930s is the background against which Rivers ought to be evaluated. And although social conditions don’t provide excuses for her involvement in the infamous study, they do offer a context in which to try to make sense of her participation. • The economic boom before the crash of 1929 didn’t skip the South, but its effects there were much different than in other parts of the country. By 1920, for the first time in United States history, most Americans lived in cities, and by 1940 an additional 6 million farmers had left the fields for urban areas, among them cotton growers from the South.4 For rural America, then, the boom before the bust meant a population drain, and in the decade following World War I the South was the most rural region in the country.5 As wartime demand for agricultural products (chiefly cotton) gave way after Armistice Day to material surpluses and overfarmed land, farmers migrated in droves to urban centers. Left behind were those who either could not or would not follow suit. Yet, David Kennedy notes, “the urbanization of early twentieth-century America can be exaggerated. More than one in five working Americans still toiled on the land in the 1920s.” At the same time, “a stubborn agricultural depression, the product of war and technological change, badly exacerbated the problems of the countryside.” In 1930 four-fifths of all blacks remained in the South.6 President Herbert Hoover decided to address the social problems of the time by gathering the brightest minds in the country (a month before the market crash of October 29, 1929) and asking them to amass nationwide data and analysis that would be, according to Hoover, “the basis for the formulation of large national policies looking to the next phase in the nation’s development.”7 The report was delivered in 1933: the exhaustive Recent Social Trends, which provided data on everything from the nation’s mineral resources to the impact of new technology on work and home life. Writes Kennedy, “From its turgid prose and endless tables emerged a vivid portrait of a people in the throes of sweeping social, economic, and political change, even before they were engulfed by the still more wrenching changes of the Depression era.”8 That turgid prose also revealed a stark conclusion: If residents of the rural South were suffering during that era, black residents were suffering significantly worse. Earlier immigration restrictions (via literacy tests, for example) culminated in a 1921 quota law, followed by an even more stringent one in 1924 and then another in 1929.9 The resulting reduced immigrant workforce created employment opportunities for blacks in towns and cities, furthering emptying rural farms of tenant farmers and sharecroppers; a devastating boll weevil infestation in Southeast cotton fields spurred even more relocation as crops failed.10 Those who stayed in the countryside lived in deplorable conditions. By as late as 1940, homes for both black and white tenant farmers were valued at around $250. Few houses had running water; fewer still had flush toilets.11 Black farmers also faced a credit system that was particularly unfavorable to them. The usurious interest rates they were charged (15 percent to 35 percent) drastically ate into already meager profits. “This crop mortgage system is weak to begin with and its abuses make it even more burdensome,” Recent Social Trends reported. “With these handicaps the returns from farming are small… After this small product has been divided between tenant, the landlord and the furnisher of credit, the shares are inadequate to support a good standard of living.”12 It was in this bleak social and economic landscape that Rivers found herself when she was starting her career. And if she hadn’t noticed it from the confines of the nursing program at the Tuskegee Institute, she witnessed it firsthand after her 1922 graduation in her first job, with the Movable School. Tuskegee Institute founder Booker T. Washington wanted to teach agricultural techniques to black farmers in the last decade of the 19th century. That idea led to the establishment of an agricultural extension department at Tuskegee and ultimately the Movable School,13 so named because it brought a learning center to people (first by a mule-drawn wagon and later via truck). The original “Farmers’ College on Wheels” initially educated farmers on new technology and methods to help improve crop and livestock yields. In 1918, federal funding allowed the hiring of home economics instructors, who taught women canning, cooking, and cleaning,14 and later public health professionals came on board to teach basic hygiene and sanitation skills.15 In 1923, Rivers joined the school as a public health nurse. In addition to basic hygiene, she taught women and midwives safe birthing methods, childcare, and how to tend to the sick, and provided men information on “social hygiene,” euphemism for sexually transmitted diseases.16 The Movable School ventured to the farthest rural corners of Alabama, including Macon County, the pool from which prospective subjects for the Tuskegee study would be drawn. For Rivers, the Movable School was more than just an opportunity to advance the Tuskegee Institute’s philosophy of service to the indigent; it was a job at a time when jobs were scarce, and it was a good one at that. Landing it was an achievement in itself. Black nurses had fewer employment opportunities than white nurses did, and Southern black nurses lucky enough to find work were paid lower salaries for performing the same duties as their white counterparts. In Alabama, for example, white nurses were paid $110 a month by the board of health, while black nurses received $65.17 The openly racist attitudes of even those in the profession compounded the economic inequalities. Darlene Clark Hine writes of Margaret Bruesche, a white nursing teacher in Fairfield, Alabama, who felt that “the negro woman has no place as a graduate nurse.” They weren’t smart or well educated, “they are not conscientious and their sense of responsibility is very weak.” (At least Bruesche was ostensibly assessing professional skills. A white nursing superintendent at Atlanta’s Grady Hospital at the time felt black nurses hadn’t “any morals… They are such liars…and will cut up each other’s clothes for spite.”)18 Rivers remained with the Movable School for nine years, until the Depression forced financial cutbacks that led to the elimination of her position, leaving her to choose between unemployment and a night nursing supervisor position at the John A. Andrew Memorial Hospital at the Tuskegee Institute. She chose the latter. She hated working the night shift, and less than a year later, as she was preparing to migrate north herself, she heard about a job with the United States Public Health Service, working on a study of the effects of untreated syphilis on black men.19 It was an assistant’s position, paying a then-attractive $1,800 a year.20 Rivers’s years with the Movable School in and around Macon County, and her concurrent work for the Bureau of Vital Statistics for the Alabama Health Department compiling birth and death records in the same area, were on-the-job preparation for the Tuskegee position. Her experience and performance were impressive enough that Dr. Eugene Dibble, medical director of the Tuskegee Institute and head of the Andrew Hospital, recommended Rivers, who had been one of the institute’s star nursing school pupils, for the opening. She was hired for the study in 1932 to monitor the participation of its black subjects.21 With 21st-century eyes it might be difficult to see how a black woman would be willing to participate in something called “The Tuskegee Study of Untreated Syphilis in the Negro Male.” But in light of the prevailing economic conditions in the rural South early in the previous century, it is not so hard to discern reasons why. Syphilis was rampant and posed a serious health threat, and treatments available then were harsh. (“I saw so many reactions with these medications,” Rivers said in an interview.22) The natural progression of the disease was to be studied in hopes of determining better treatments.23 By taking the job with the U.S. Public Health Service, Rivers would be working to help the people she knew to be in desperate need of medical attention. Also, in the beginning decades of the 1900s, it was presumed that the course of the disease progressed differently through blacks than it did through whites—the Tuskegee study would complement the Oslo study of untreated syphilis in whites.24 “This is the way I saw it: that they were studying the Negro just like they were studying the white man, see, making a comparison,” Rivers said later.25 Yet given the scarcity of good jobs for black women, in the rural South in particular, a perhaps more compelling reason for Rivers to join the study is simply that it offered employment—and a chance to get off the odious night shift. (“I was so glad to go off night duty that I would have done anything,” Rivers said.26) That the position was one in the career for which Rivers had trained was a bonus. Nursing positions were not easy to come by, and the Depression was forcing state public health departments to cut funds.27 The unemployment rate for the country was approaching 25 percent.28 Rivers was an ideal candidate for the job. She had been an exemplary student at Tuskegee. She’d done administrative work for the Bureau of Vital Statistics, and nursing school had trained her to examine patients. The Movable School had taught her public outreach and the interpersonal skills of a public health nurse; her personality and tact were remarkable.29 In fact, Dr. Dibble cited her effectiveness as a public health worker when he suggested her for the Tuskegee position.30 The relationships she established with the people in Macon County from her Movable School days would be the key to her success in the Tuskegee job. Other syphilis studies were being conducted at the time, and a lack of patient compliance with treatment protocols was an ongoing, pervasive challenge. A Birmingham, Alabama, doctor who had worked with public health syphilis programs noted that failing to keep up with treatment until cure was an issue for both blacks and whites, and that developing a way to keep patients compliant would be essential to any program’s success.31 As it turned out, Rivers excelled at making sure that patients enrolled in the study stuck with it. The study was originally designed to last six to eight months, but of course it went on far longer, and by the time the decision was made to leave the termination date open-ended, Rivers was a firmly entrenched Tuskegee team member. After all, notes Susan Smith, “Rivers considered her participation in the study merely a continuation of her previous public health work.”32 Over the course of the study she had become more than just an assistant; she was, if not in title, the de facto chief liaison between the doctors and the subjects. Dr. Raymond Vonderlehr, director of the Public Health Service’s venereal disease division and the head of the study from its inception till 1943, acknowledged Rivers’s skills in ensuring the ongoing compliance of the subjects.33 • If Rivers’s complicity in withholding treatment in the original study can be understood within the economic and employment contexts of the time, can it also explain why a caring, dedicated nurse would continue to risk the lives of her patients—patients she had known and followed for 15 years—after an accepted treatment for syphilis became available, in the mid-1940s? Yes, but this time Rivers needn’t be regarded as someone lucky enough to have a job but rather as a dedicated Tuskegee team member. If she was an entrenched member of the Tuskegee team when the decision was made to continue the study indefinitely, by the time penicillin was widely available she would have been a full-fledged “company woman.” Others in the study came and went over the years, but Rivers steadfastly remained. (She was replaced by Elizabeth Kennebrew in 1965 but continued to help Public Health Service physicians when they were in town, and remained in contact with the men.34) Rivers was a loyal employee who identified more with the researchers—the company—than she did with the subjects. Born and raised in rural Georgia,35 she may have come from the subjects’ world, but even at the beginning of the study she didn’t live in it anymore. Ten years out of nursing school, she was working steadily, both for Tuskegee and in her midwife-training capacity.36 She was a working professional. Smith refers to “Rivers and other black professionals,” and suggests that this professionalism may have “blinded them to the high price paid by poor, rural black men in the study.”37 To the scientific assistant part of Rivers, the poor, rural black men were subjects; to the nurse part of her they were patients. But more important, they were her job. She was working for an organization whose purpose was to gather data on untreated syphilis in black men; thus, it would have been more surprising if treatment had been provided. As some journalists realized at the time, given the study’s design, withholding penicillin was a foregone conclusion. Penicillin was withheld because all treatment was withheld.38 Darlene Clark Hine suggests that “[years] of conditioning and living in the South made it virtually impossible for Rivers to have rebelled against a white, male government doctor, the ultimate authority figure in her world.”39 Looking at Rivers as a loyal employee accounts for her subservience to the white government-official doctors in charge in a different way: They were her bosses, and as a good employee she did what the bosses told her to do. Telling moments from two interviews with Rivers suggest she strongly identified with the Tuskegee study team. She rarely spoke of her role in the scandal,40 and so publicly expressed few regrets. However, in a 1977 conversation with Helen Dibble and Daniel Williams, she allowed one: that the results of the study’s labor may have been lost. “[T]his was the thing that was so disturbing to me was that somehow all of the records of this study and the health department have been destroyed,” she told them.41 Another moment came in an interview with James Jones several years after a $10 million class-action lawsuit against the U.S. government was settled with the living participants of the study, in 1974.42 Jones and Rivers were driving through Macon County when Rivers saw a former study participant in a field and went out to say hello. When the man asked her why she had stopped coming by to see him, she told him, “You don’t get the money and Nurse Rivers too.”43 • Considering Rivers in the specific socioeconomic context in which she lived is one more way to make sense of her ongoing participation in what is now known as a deadly racist medical experiment perpetrated against Rivers’s own friends and patients. By first seeing her as fortunate to have secured a position with the study and then as a loyal team member later on, she escapes the harsher accusations of race traitor and coward; more important, it is consistent with her remaining in history the dedicated, caring nurse she professed to be. “Really and truly,” said Nurse Rivers, “when we were working with those people…that was the joy of my life.”44 Today she might simply be called a cog in the machine, but half a century ago she was someone lucky to be working in her chosen profession when nearly a quarter of the country was not working at all, someone who did not have the luxury of resigning in protest. 1. James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment—A Tragedy of Race and Medicine (New York: The Free Press, 1981), p. 6. 2. Susan M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: The University of North Carolina Press, 2009), p. 168. 3. Susan L. Smith, “Neither Victim Nor Villain: Eunice Rivers and Public Health Work,” Tuskegee’s Truths, ed. Susan M. Reverby (Chapel Hill: The University of North Carolina Press), p. 349. 4. David M. Kennedy, Freedom from Fear: Part I: The American People in the Great Depression (New York: Oxford University Press, 1999), p. 16. 5. Ibid., p. 18. 6. Ibid., p. 16–17. 7. Ibid., p. 11–12. 8. Ibid., p. 12. 9. Recent Social Trends in the United States: Report of the President’s Research Committee on Social Trends (New York: McGraw-Hill Book Company, Inc., 1933), p. 557. 10. Ibid., p. 566. 11. Wayne Flynt, “Poverty in Alabama” (Encyclopedia of Alabama, http:encyclopediaoflabama.org, November 2007). 12. Recent Social Trends, p. 570. 13. Felix James, “The Tuskegee Institute Movable School, 1906–1923,” Agricultural History, July 1971: Vol.45, No. 3, p. 202. 14. Ibid., p. 206. 15. Ibid., p. 208. 16. Reverby, Examining Tuskegee, p. 170. 17. Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession 1890–1950 (Bloomington: Indiana University Press, 1989), p. 92. 18. Ibid., p. 101. 19. Reverby, Examining Tuskegee, p. 170. 20. Jones, Bad Blood, p. 102. 21. Ibid., p. 6. 22. Laurie interview; Eunice Rivers, Stanley H. Schuman, Lloyd Simpson, and Sidney Olansky, “The Twenty Years of Follow-up Experience in a Long-Range Medical Study, Public Health Reports 68 (1953): 394, cited in Jones, Bad Blood, p. 163. 23. “The U.S. Public Health Service Syphilis Study at Tuskegee” (Centers for Disease Control and Prevention, www.cdc.gov/tuskegee). 24. Smith, “Neither Victim Nor Villain,” p. 354. 25. Laurie interview, p. 167. 26. Ibid., p. 111. 27. Ibid. 28. Robert VanGiezen, Albert E. Schwenk, “Compensation from Before World War I Through the Great Depression,” Compensation and Working Conditions, Fall 2001 (Bureau of Labor Statistics, www.bls.gov/opub/cwc/cm20030124ar03p1.htm, posted Jan. 30, 2003). 29. Clark Hine, Black Women in White, p. 155. 30. Jones, Bad Blood, p. 111. 31. Ibid., p. 46. 32. Smith, “Neither Victim Nor Villain,” p. 358. 33. Jones, Bad Blood, p. 116. 34. Reverby, Examining Tuskegee, p. 172. 35. Ibid., p. 169. 36. Ibid., p. 172. 37. Smith, “Neither Victim Nor Villain,” p. 360. 38. Jones, Bad Blood, p. 9. 39. Clark Hine, Black Women in White, p. 156. 40. Reverby, Examining Tuskegee, p. 168. 41. Helen Dibble, Daniel Williams, “An Interview with Nurse Rivers,” Tuskegee’s Truths, ed. Reverby, p. 327. 42. “The U.S. Public Health Service Syphilis Study at Tuskegee: The Tuskegee Timeline” (Centers for Disease Control and Prevention, www.cdc.gov/tuskegee). 43. James H. Jones to Susan M. Reverby, Personal Communication, July 7, 2004, cited in Reverby, Examining Tuskegee, p. 183. 44. Jones, Bad Blood, p. 161.
description: Voices in Bioethics, Archives (2013)