1.12: Critical Issues in African American Health

Kevin G. McQueeney

University of New Orleans

INTRODUCTION

A deep connection between the field of medicine and the overall treatment and perception of African American extends back to the founding of this country. Proponents used pseudo-scientific ideas about the "natural" inferiority of Blacks to justify racism and slavery. In turn, these same forces led to a health inequality—with poor care from the medical field and higher rates of serious health issues—that persist in the present. African Americans have also faced lasting barriers in gaining employment and professional recognition in the healthcare field.

From the origins and continuation of health inequality to the fight to gain access to professional medical treatment, African American health and healthcare in U.S. history are interrelated issues. African American physicians, dentists, and nurses along with Black medical schools and hospitals have done pioneering work. While traditionally receiving less attention than issues like voting, housing, and education, the African American fight for healthcare is an important component of the Black freedom struggle, and a key aspect for understanding the current state of Black Americans.

BLACK HEALTH IN EARLY U.S. HISTORY

African American health is inextricably linked to slavery. Physician and scholar Rodney G. Hood argues that health disparity can be traced back to the period of slavery and the origins of racism, an effect he calls the "slave health deficit." The enslavement of millions of African Americans had severe and lasting health impacts, both during the period of slavery and after.¹ The initial period of enslavement may have been the most lethal. Historians estimate that as many as 50% of Africans died before leaving the continent, during capture, the forced march to slave holding areas, or waiting in pens.² Somewhere between 15-20% died during the Middle Passage across the Atlantic from the fifteenth through the nineteenth century.³ The mortality rate varied by place of origin, conditions in captivity and on the ship, and the point of destination. As many as 675,000 died during capture, captivity, or transportation to this country.⁴ Of the 450,000 Africans who made it to the U.S., an additional 4.3% died in the period between arrival and sale, and as many as 25% perished during the "acclimation period" of their first eighteen months as they adjusted to new locations, climates, and diseases.⁵

Enslaved individuals suffered from significant health problems. The Black infant and childhood mortality rate was double the rate for Whites. Over half of all Black children were born severely underweight due to the poor treatment and lack of nutrition for pregnant slaves; many women miscarried or gave birth to stillborn babies. On average, Black mothers could nurse for only four months, compared to eight months for White babies. Early weaning, horrid living conditions, and lack of nutrition led to more than 50% of Black infants dying before the age of one.⁶

Poor health continued into adulthood. A low-quality supply of food resulted in "protein hunger" and deficiencies in thiamine, niacin, calcium, Vitamin D, and magnesium.⁷ The cramped and poorly constructed slave cabins, contaminated water sources, and harsh working conditions exacerbated malnutrition, leading to higher susceptibility to disease and developmental problems. Many enslaved people suffered from rickets, bowed legs, dysentery, respiratory ailments, cholera, typhoid, worms, skin problems, dementia, blindness, seizures, and swollen abdomens.⁸ The lack of recordkeeping at many plantations makes it difficult to know exact numbers, but scholars estimate the average life expectancy for an enslaved individual came to only 21-22 years, compared to 40-43 years for White during the antebellum period.⁹ Mortality rates varied by location and by the type of plantation: enslaved people died at higher rates on sugar and rice plantations than on cotton-growing plantations.¹⁰

The field of medicine both justified the poor treatment of African Americans and contributed to their health problems. Building on the writings of White intellectuals going back to at least the Greeks, leading American scientists and physicians categorized African Americans as biologically inferior and less intelligent, or even subhuman. By the early 1800s, proponents of slavery used this pseudo-scientific argument to justify slavery. Defenders of slavery further argued that Africans were more genetically predisposed to work in the fields than Whites. Thomas Jefferson advocated this position in his influential Notes on the State of Virginia (1805). While he concluded that enslaved Africans were "inferior to the Whites in the endowments both of body and mind," he argued that they possessed some qualities that made them genetically designed to labor, notably that they "seem to require less sleep" and were "more tolerant of heat." Physicians perpetuated the belief that Africans also had resistance or immunity to diseases like yellow fever.

Because of these views, African Americans did not receive proper healthcare. Slave-owners primarily cared about profit; this, not benevolence, served as their main motivation to seek medical care for enslaved individuals. Owners wanted slaves to recover quickly to return them to labor. On plantations, few slave-owners employed physicians. Instead, the master, his wife, an overseer, or even designated slaves provided care prescribed in home health guides.¹¹ Owners also focused on using medical knowledge to increase the birth rate among the enslaved population. Buyers placed great emphasis on the perceived fertility of females, in the hopes that these women would give birth to children that would be considered the slave owner's property.¹² Slave-owners usually called for a physician only as a last resort, and racist attitudes affected the care offered by White physicians. White doctors experimented on enslaved individuals in pursuit of medical advances due to their beliefs that Blacks were inferior and had higher tolerances of pain. These doctors sought no consent from the enslaved but instead from the slave owner. Physicians applied this gained knowledge to benefit the White community.¹³

The inequality in access to healthcare and the poor treatment by physicians in this period marked the beginning of a healthcare system based on racial discrimination. The view of African Americans as inferior and "less worthy" meant that few received proper medical care for curable afflictions. In some ways, free Blacks faced worse healthcare, with little access due to high rates of poverty and physicians who refused to treat Black patients. A two-tiered healthcare system—with greater access and treatment for Whites—persisted for much of American history. Due to this neglect, enslaved individuals provided care for themselves. They used folk medicine they had learned in Africa before slavery—including Cesarean birthing and inoculation for smallpox—or from other enslaved members, passed down orally. Black women predominantly served in this role and functioned as midwives for fellow slaves and even White women. For many African Americans, medical treatment included plant-based and herbal remedies as well as spiritual elements like prayers, charms, songs, and conjuring, vestiges of African healing traditions. Even when White physicians were available, many preferred to use folk healers who offered more holistic and personalized care. Some herbal remedies worked, and even those that did not presented less potentially negative side effects than popular official remedies like bleeding or mercury. Although many Whites opposed Black medical practitioners—for example, South Carolina and Virginia passed laws in the mid-eighteenth century to prohibit the practice—some Southern plantation owners relied on Blacks to provide medical care.¹⁴

African Americans also used medical knowledge as a form of resistance. Some enslaved individuals feigned illness to purposely slow down work, get needed rest, or spend time with family. Unfortunately, slave owners often suspected slaves of making up illnesses even when truly sick, forcing the sick to work and punishing those they thought to be making up an ailment.¹⁵ In response to slave-owners’ treatment of female slaves as "breeders" producing more enslaved individuals to work in the fields, some enslaved women used early forms of birth control or even abortion to prevent this and regain some form of control over their bodies.¹⁶

BLACK PHYSICIANS IN THE ANTEBELLUM PERIOD

Some African Americans, both slave and free, learned medicine under an apprenticeship. For example, James Durham was born in Philadelphia in 1762. Serving as a physician's assistant to a series of owners, Durham bought his freedom in 1783. Durham established his own practice in New Orleans, treating White and Black patients. In 1788, Durham briefly returned to Philadelphia, where he befriended Dr. Benjamin Rush, a leading physician, Founding Father, and opponent of slavery. In speeches and letters in support of abolition, Rush held up Durham as an example of the intelligence and capability of Blacks. Durham moved back to New Orleans in 1789, where he continued to practice medicine until at least 1802. However, Spanish rules permitted him to treat only throat ailments after 1801 due to his lack of a formal medical degree. Durham is believed to be the first Black physician in the United States.¹⁷

Some free Blacks went to medical school in Europe or at a small number of Northern colleges. Born in New York City in 1813, James McCune Smith became the first African American to earn a formal medical degree. The son of a woman who bought her freedom, Smith attended the city's school for free Blacks. Denied admission to American colleges, Smith finished the University of Glasgow in 1837. After an internship in Paris, he returned to New York City, set up his own practice, and became a leading African American intellectual and abolitionist. Smith helped found the National Council of the Colored People with Frederick Douglass and wrote the introduction to Douglass's My Bondage and My Freedom. Smith also became the first African American published in a medical journal, and refuted ideas of racial differences.¹⁸

A handful of others attended medical college in the United States. Born in Baltimore in 1815, Samuel Ford McGill moved with his family to Liberia in 1826. He returned to the United States to attend medical school at Dartmouth College and graduated in 1839. McGill practiced in Liberia and trained other physicians in the country.¹⁹ David J. Peck became the first African American to receive a medical degree from an American medical school—Chicago's Rush Medical College in 1847; he was also the first to practice in the United States—initially in Philadelphia, and then Pittsburgh, before moving to Nicaragua in 1852. Like Durham, abolitionists held up Peck as an example of the equal intellect of African Americans.²⁰ After first working as a nurse for eight years, Rebecca Lee Crumpler became the first African American woman to complete a doctorate in medicine in 1864. Crumpler worked in Richmond, Virginia— providing care for recently freed individuals through the Freedmen's Bureau—and ran a practice in Boston, Massachusetts.²¹

Few African Americans had formal opportunities to receive medical training. Only a handful of medical colleges admitted Black students, and those who did graduate faced obstacles in practicing. Few physicians referred patients to Peck's practice or recognized him as a doctor, for example, leading him to close after only two years. Most White patients refused to utilize a Black doctor. Despite these barriers, Black physicians served as intellectual and civic leaders in the Black community and played prominent roles in the abolition movements.

THE CIVIL WAR

African Americans played a significant role in the Civil War, including in healthcare. With many White physicians serving in the Confederate Army, plantation owners increasingly relied on enslaved folk medical practitioners for care. The South also used enslaved African Americans to treat wounded Confederate soldiers.²² Hundreds of thousands of African Americans fled during the war, leading to a major health crisis. The U.S. Army created refugee camps as it traveled. Housing was quickly constructed and of poor quality, as were food sources and sanitation. Thousands died of disease—smallpox, in particular—and hunger. Despite the harsh conditions, over 400,000 Black refugees lived in refugee camps in Corinth, Mississippi; Memphis, Tennessee; New Bern, North Carolina; and elsewhere. They provided invaluable services for the army as soldiers, teamsters, nurses, and seamstresses, and created new lives in freedom.²³

In Washington, D.C., the Union Army built the "Contraband Hospital" as part of a refugee camp on the outskirts of the city. Like other camps, overcrowding, poor living conditions (most lived in tents even during the winter), and limited food and water (only one well supplied the entire camp) caused many to become sick. The hospital provided care for camp inhabitants. At first, the hospital's staff was primarily White, but in May 1863, Alexander T. August—an African American—became the surgeon-in-charge. After August's appointment, Black doctors increasingly staffed the hospital, working with Black nurses mostly drawn from the camp's residents. The government closed the camp in December 1863, but continued the hospital, moving it several times, before eventually becoming the Freedmen's Hospital with a permanent home on Howard University's campus in 1868. In all its various locations, Black nurses and doctors trained at the hospital, and then went to work at other hospitals or their own practices.²⁴

The Freedmen's Bureau set up hospitals like the one in D.C. in other states, with a peak of 45 in 1867. These hospitals provided care for tens of thousands, many of whom had never before received professional medical treatment. However, these institutions suffered from a lack of funding, low salaries that made hiring difficult, and poor building conditions. When the Freedmen's Bureau ended in 1872, only the Freedmen's Hospital in D.C. remained open.²⁵

Black Health and Healthcare After the Civil War

Poor health continued to afflict African Americans in the war's aftermath. At least one million suffered or died from diseases like smallpox.²⁶ Due to high rates of poverty, many could not afford proper medical care, and those who could, experienced discrimination from predominantly White physicians. This poor treatment, plus the history and continued experimentation on Black bodies by White doctors, resulted in a lasting distrust of the medical field. As a result, many Black Americans still relied on Black folk practitioners and midwives.²⁷ Health problems had other significant effects that affected future generations. On top of other issues like racial discrimination, health problems made it difficult to acquire land and wealth, and prevented mobility. Even after the war, many African Americans remained stuck in the South; over 90% of African Americans still lived in the South at the end of the nineteenth century.²⁸

After the Civil War, African Americans made some gains in the medical field. The son of former slaves, Robert Tanner Freeman became the first African American to graduate with a doctorate in dental surgery. Freeman apprenticed under a White dentist, and after an initial rejection from Harvard, which refused to admit Black students, he and another student—George Franklin Grant—were admitted to Harvard Dental School in 1867. Freeman graduated in 1869 and set up a practice in his home city of Washington, D.C.²⁹ Freeman's classmate, Grant, became Harvard's first Black faculty member. Grant was a pioneer in the care of patients with congenital cleft palates, patenting a device that allowed patients to speak better.³⁰ Ida Gray Nelson Rollins became the first female African American doctor of dentistry, graduating from the Ohio College of Dentistry in 1890 and practicing in Cincinnati and Chicago.³¹

However, most medical schools still refused to admit Black students. As a result, several Black medical colleges originated, starting with Howard University's medical department in 1868. Most of these schools were affiliated with missionary organizations like the American Missionary Association, received little funding, and employed few staff.³² By the 1890s, over nine hundred Black physicians held medical degrees and practiced in the United States, serving a population of 7.5 million African Americans.³³ Graduates of these programs still faced major obstacles in gaining professional experiences and acceptance. Founded in 1847, the American Medical Association was the most prestigious organization in the medical profession. Local chapters determined membership, and almost all refused to admit Black physicians. This resulted in the denial of post-graduate lectures and trainings. In response, a Black equivalent of the AMA—the National Medical Association—formed in 1895. Similarly, in 1908 the National Association of Colored Nurses started. Additionally, most White hospitals refused to hire Black doctors. Almost all required AMA membership for employment, effectively barring African Americans. In the late nineteenth century, many Southern states formally segregated public hospitals, and private hospitals voluntarily followed suit. Hospitals refused to hire Black physicians and treated Black patients only in separate wings or different buildings.

Facing discrimination from White hospitals as both patients and physicians, African Americans began their own hospitals. In 1891, a group of Black physicians founded the Provident Hospital and Training School Association in Chicago, the first Black-operated hospital in the nation. Provident also held several other distinctions: it had the first interracial staff, offered the first training space for Black nurses, and was the site of one of the earliest open-heart surgeries in 1893. Black hospitals throughout the country—primarily in the North—followed; by 1919, one hundred and eighteen Black hospitals existed. During that same period, the number of Black nurses grew significantly as well, greatly aiding the proliferation of Black hospitals. Spelman College opened the first Black nursing school in 1881.³⁴

Numerous problems hampered Black hospitals though. Due to high Black poverty rates, hospitals collected little money in patient fees, and Black hospitals usually did not receive funding from state or local governments. The lack of government aid forced these institutions to rely on donations and fundraising campaigns and to endure continuous money shortages. Financial problems made expansion extremely difficult, limiting the number of patients who could be served and preventing improvements in medical equipment and building facilities. This latter condition led to constant issues with licensing inspections. Black hospitals also faced staffing problems. Very few White medical schools admitted African Americans, and only seven Black medical colleges existed by 1910. Like hospitals, these schools faced funding problems. In 1904, the American Medical Association created the Council on Medical Education (CME) to study and standardize medical education. The CME asked the Carnegie Foundation to fund a study, led by Abraham Flexner, of all medical colleges in the United States. Of the seven Black medical schools in existence at the time of the Flexner Report (1910), the five colleges named in the report as "inadequate" all closed in the following thirteen years. Only Howard University and Meharry College maintained their medical schools, and another Black medical college did not open until the Charles Drew Medical School in Los Angeles started in 1966. During that fifty-six-year period, the number of Black physicians, which had increased steadily in the prior fifty-year period, declined.³⁵

The dearth of Black physicians made staffing hospitals difficult, especially in the South. Oppressed by segregation, many Black doctors left the South as part of the Great Migration. Some African American leaders also openly criticized Black hospitals, arguing that their existence helped to support segregation; proponents of segregation could point to Black hospitals as justification for not integrating public hospitals. Defenders of Black hospitals highlighted the great need for the institutions and the biracial staffs as examples of cross-racial cooperation; hospitals like Provident and Flint Goodridge in New Orleans had White patients in the 1890s and early 1900s, although this largely ceased as segregation increased and the color line hardened.³⁶

Even though many faced great professional discrimination, Black doctors served as leading medical pioneers in the first half of the twentieth century. In 1897, Dr. Solomon Carter Fuller graduated from the Boston University School of Medicine and became the nation's first Black psychiatrist. He worked at the Westborough State Hospital in Boston and served as a faculty member at his alma mater. After working with Dr. Alois Alzheimer at the Royal Psychiatric Hospital in Munich, in 1912 Fuller published the first major study of Alzheimer's disease in the U.S.³⁷ Others too made major contributions: Dr. Louis T. Wright developed the intradermal injection for smallpox vaccination in 1917; Dr. William August Hinton created the Hinton Test for the diagnosis of syphilis in 1936 and published the first medical textbook authored by an African American in 1938; and Dr. Charles Drew developed new techniques for the storage and transportation of blood and plasma during World War II.³⁸

The Black medical profession made significant advances in the first half of the twentieth century. The National Medical Association created the National Hospital Association in 1923 as part of its efforts to increase professionalization and standards and to prevent Black hospitals from closing. The NMA improved training, held conferences, wrote recommendations on hospital administration, and published articles on Black medical advances in their journal.

PUBLIC HEALTH

African American leaders played prominent roles in highlighting these issues and pushed forward efforts to address Black public health problems. In 1906, W.E.B. DuBois published The Health and Physique of the Negro American to counter the claims of White supremacists like Frederick Hoffman that the higher African American mortality rate was evidence of their natural inferiority. Hoffman—who worked at the Prudential Life Insurance Company—wrote Race Traits and Tendencies of the American Negro in 1896, in which he stipulated that African Americans were healthier during enslavement and would soon die out as a race. In his rebuttal, DuBois argued that the high death rate caused by diseases like tuberculosis resulted from African Americans' higher rates of poverty, not from racial inferiority. "All the evidence," DuBois noted, "goes to show that it is not a racial disease but a social disease." He used as evidence demographic data collected by the United States Census Bureau. DuBois further advocated that increasing the number of Black hospitals, physicians, and healthcare workers, and improved sanitation, education, insurance, and economic opportunities would lower the mortality rate. Finally, DuBois called for the creation of local health care leagues to take the lead in combating Black public health issues.⁴⁰

Head of the Tuskegee Institute in Alabama and perhaps the most influential Black American at the time, Booker T. Washington also addressed public health. Washington's Tuskegee Institute held a week-long event each year at the school and in the surrounding community that focused on sanitation and public health. Washington urged residents to thoroughly clean and whitewash their homes and to make improvements to promote better health. The school also sponsored public health talks. Starting in 1912, the Tuskegee Institute hosted a clinic during the health week, with physicians from throughout the country offering free medical treatment.⁴¹ Speaking in 1914, Washington argued that 45% of Black deaths were "preventable" and African American serious illnesses cost the economy 100 million dollars annually. Washington called for a National Negro Health Week in 1915. An oversight committee at the Tuskegee Institute made recommendations each year on what local committees should do and called for churches, schools, fraternal organizations, and other community groups to participate. The week focused on home sanitation; education about tuberculosis and sexually transmitted infections, especially syphilis; school health programs; free clinics; and neighborhood cleanups. The U.S. Public Health Service— which later controversially conducted the exploitative, forty-year syphilis study on Black men in Tuskegee, detailed later in this essay—became a co-sponsor in the 1920s. The weekly event turned into year-round activities and educational material known as the National Negro Health Movement, a program that existed until 1951.⁴²

Recognizing that many African Americans could not afford medical treatment, some Black hospitals offered low-cost or free clinics for the indigent, and began providing their own insurance program for the working-class. Flint Goodridge Hospital in New Orleans was among the earliest, starting in 1936. For $3.65 dollars a year, patients were eligible for up to 21 days of hospitalization; they could also add their spouse for a total of $6.00 per couple, or all the children for a total of $8.50 per family. By 1938, over three thousand people enrolled. The American Medical Association endorsed the plan, and identified it as the cheapest in the nation, and Life Magazine hailed it as "heartening" inspiration during the Great Depression and Jim Crow.⁴³

While free clinics, insurance programs, and public health initiatives led to improvements, African Americans still suffered higher rates of disease and death. The Great Depression further exacerbated these health problems, disproportionately affecting African Americans. It led to an increase in the Black poverty rate and a related decline in the number and financial stability of Black hospitals. The National Medical Association argued that a "Black medical ghetto" existed in the U.S., with African American residents not receiving enough medical care and an insufficient number of Black hospitals to serve the large population.⁴⁴ Some African American leaders sought federal health funding. They argued that even those that upheld Jim Crow should support this effort as improved Black health would be good for the nation's economy. While pushing for federal aid, Black advocates often had to accept segregation rather than fight for integration in order to make some gains.

In 1943, the American Hospital Association (AHA) recommended that the federal government pass legislation to aid building of more hospitals. After lobbying by the AHA and a speech by President Truman calling for improved healthcare, Congress passed the Hospital Survey and Construction Act (known as the Hill Burton Act) in 1946. The legislation made available federal funding for the expansion of existing hospitals and the construction of new ones, with the goal that each state would reach a quota of 4.5 beds available per 1,000 residents. Although a federal law, each state determined the allocation of funding. Furthermore, while the bill forbade racial discrimination, it permitted spending to support segregated facilities, as part of the "separate but equal" doctrine, until the Supreme Court struck down that provision in 1963.⁴⁵

Most of the Hill Burton funding went to the South, as it was the region with the country's greatest need. Although White hospitals received most of the support, some aid facilitated the building of new Black hospitals or improvements on existing ones. Other federally funded programs helped cities and states create new health departments and maternal and child clinics. While these federal programs provided much-needed aid, critics argued that like Black hospitals, segregated health programs continued to uphold Jim Crow and health inequality.⁴⁶

MEDICAL EXPLOITATION

Despite gains due to legislation, many African Americans remained distrustful of the government's involvement in healthcare. In the early twentieth century, the government funded forced sterilization programs in 32 states for tens of thousands of women, primarily people of color. Originating in the late nineteenth century, the eugenics movement spread in the U.S. starting in the 1900s. Eugenics was based on the concept that selective breeding should be encouraged, with government involvement, to improve society. Supported by funding from leading organizations like the Carnegie and Rockefeller foundations, scientists from top universities carried out pseudo-scientific research that demonstrated supposed negative genetic traits of certain groups that should not be allowed to reproduce: the mentally ill or disabled, those deemed sexually deviant, criminals, immigrants, the indigent, and minorities. Some doctors actively engaged in eugenicide, killing patients or willfully neglecting them— often newborns—until they died.⁴⁷

Forced sterilization became the most mainstream manifestation of eugenics, with states adopting forced sterilization laws in the first decade of the twentieth century. Although masked as progressive reform (to produce the most superior citizens and to reduce government spending on providing for the "unworthy") and supported by public health advocates, scientists, physicians, and politicians, forced sterilization was a product of racism and xenophobia. In many ways, proponents promoted forced sterilization similar to the ways they advocated residential segregation (i.e., African Americans should be kept out of White neighborhoods to prevent the spread of disease) or anti-miscegenation (i.e., interracial marriage and children would produce "inferior," mixed race children, damaging to White purity). The Nazis partially modeled their own policies of sterilization and eugenicide in the 1930s and 1940s on American practices.⁴⁸

Eighteen Southern states adopted sterilization laws and often used them to target African American women. In 1964, Mississippi Freedom Democratic Party leader Fannie Lou Hamer spoke of her own experience. In 1961, Hamer underwent surgery in Mississippi for a uterine tumor. During surgery, and without her consent, the operating physician performed an unnecessary hysterectomy. Hamer highlighted the commonality of the procedure, which she dubbed a "Mississippi appendectomy," and estimated that physicians at the hospital, without consent and with no medical need, sterilized approximately 60% of Black female patients.⁴⁹

HEALTHCARE AND CIVIL RIGHTS  

Starting in the 1940s, the Black National Medical Association began to support the efforts of the NAACP and others to push for the integration of hospitals. Black civic leaders first targeted the Veterans Administration hospitals in 1945, finally succeeding in integration of these federally funded hospitals in 1953. Like others areas of civil rights, the push for medical equality proved extremely difficult.⁵⁰

Most hospital nationwide remained segregated through the 1960s; one 1956 study found segregation in 83% of hospitals in the North and 94% of hospitals in the South. While the Civil Rights Movement most prominently focused on the desegregation of schools and voting rights, activists also fought for health equality. Community health workers established their clinic in places like Mississippi where none existed for African Americans. Medical students pushed schools to serve nearby Black residents. Lawyers sued hospitals that violated the discrimination provision of the Hill Burton Act. Black physicians played prominent roles in the NAACP and other civil rights groups. For example, T.R.M. Howard, a surgeon and president of the National Medical Association, founded the Regional Council of Negro Leadership in 1951, a Mississippi-based civil rights organization, and rose to national fame for his involvement in the case of Emmett Till, murdered in 1955. Physicians John Holloman Jr. and Walter Lee started the Medical Committee for Civil Rights in 1963. The group picketed the annual American Medical Association convention that year in protest over the organization's continued acceptance of discrimination by local chapters (it would not formally bar racial exclusion until 1968); marched in the 1963 March on Washington; and provided care during the Mississippi Freedom Summer.⁵¹

After years of advocacy and litigation, President Lyndon Johnson signed the Civil Rights Act of 1964. Title VI of the bill mandated ineligibility for receiving any federal funds for any institution that discriminated against minorities. Congress followed up Title VI with the passage of the Social Security Amendments of 1965, which included Medicare—primarily health insurance for those 65 and older—Medicaid—insurance for those with low incomes.

Compliance by hospitals proved difficult as many resisted desegregation. Especially in the South, many hospitals either continued to employ only White doctors or hired a token number of Black physicians to avoid lawsuits. The NAACP made numerous complaints against hospitals for continuing to use segregated wards, water fountains, benches, and even telephones. The Department of Health, Education, and Welfare found in the 1970s that hospitals containing 58% of the nation's beds ignored the statute, and the department launched a large-scale campaign, supplemented by numerous lawsuits by civil rights groups, to force hospitals to integrate and end discrimination. However, although federal laws mandated that hospitals that violated the discrimination statutes should be denied federal funding, few hospitals received any significant punishment for offenses. Lawsuits against hospitals for discrimination against Black patients and in hiring Black physicians continued through the 1980s with little substantial changes.⁵²

Apartheid healthcare persisted. Many hospitals admitted little or no Black patients, and few admitted Medicare and Medicaid patients. Poor Black patients primarily remained at underfunded city or Black hospitals. Although Medicare and Medicaid allowed more indigent patients to receive hospital care, the cost of treatment typically exceeded the compensation for treatment, leaving those hospitals financially struggling and affecting their quality of care.

CONTINUED INEQUALITY

While the immediate years after integration saw some health gains for African Americans, particularly for those who previously had no access at all, improvements largely stagnated after 1975. Starting in the 1980s, Black morality began to increase again, and African American life expectancy declined. With White flight to the suburbs, Black residents were increasingly concentrated in urban cores with underfunded and lower-quality healthcare.⁵³

In the face of continued health disparity, African American groups again provided their own medical services. Leonidas H. Berry founded an organization named the "Flying Black Medics." Sponsored by the Methodist Episcopal Church and local community groups, the group began flights in 1970 from Chicago to Cairo, Illinois, providing free medical care and supplies to poor African Americans.⁵⁴ In the late 1960s, the Black Panther Party became involved in healthcare. The national organization required all chapters to provide health clinics due to continued health discrimination and inequality. The Panthers also launched a sickle cell anemia awareness campaign, providing education and free screening for the disease, which the organization felt was understudied and underfunded as it disproportionately affected African Americans.⁵⁵

The Black Panther Party's health program further reflected the distrust of medical institutions. As detailed earlier, physicians used enslaved African Americans for medical experiments. Hospitals and prisons continued this practice after slavery ended, and medical colleges stole African American cadavers for student training. Perhaps the most famous example of medical exploitation was the Tuskegee Experiment, started by the U.S. Public Health Service in 1932. The program recruited 600 Black men—399 with syphilis, and 201 not infected—for a study on the effects of the disease. Administrators promised free medical treatment for participants. However, physicians did not inform the men of the purpose of the study and did not treat the individuals who had syphilis, even after penicillin was discovered as a cure in 1947. In 1972, the Associated Press reported on the story, leading to a public outcry and investigations. Recent research has demonstrated that the history of medical exploitation, particularly the Tuskegee Experiment, has led African Americans to be more distrustful of doctors and less likely to use healthcare services, contributing to the higher mortality rare.⁵⁶

In the 1980s, the increase in the Black mortality rate also corresponded with the decreased funding for hospitals that predominantly served the African American community. State aid declined dramatically, particularly with the economic recession. The number of Black hospitals rapidly plummeted as a result. From 1961 to 1988, fortynine Black hospitals closed, including Chicago's Provident Hospital, the first Blackoperated hospital in the country.⁵⁷

CONCLUSION

Health inequality persists in America. The Center for Disease Control and Prevention found that African Americans have a significantly shorter life expectancy (75.1 years) than Whites (78.7). African Americans suffer from higher rates of illness and health problems; the CDC estimates that 13.6% of African Americans are in poor health compared to 9.5% of Whites. The overall mortality rate has dropped for all races in the past two decades, driven by declining deaths from cancer, heart attacks, and strokes.

However, African Americans still have a mortality rate 16% higher than Whites (down from 33% in 1999), and are more likely to die at every age. The discrepancy is particularly notable in infant mortality—a rate of 10.93 per 1,000 for Blacks and 4.89 per 1,000 for Whites—and in maternal deaths with a rate of 43.5 Black deaths per 100,000 live births compared to 12.7 White deaths per 100,000 live births.⁵⁸

Health inequality reflects multiple factors: higher rates of unemployment, obesity, and poverty; and lower rates of home ownership, education, and wealth. African Americans also continue to have less access to welfare: 11.2% under the age of 65 do not have healthcare, compared to 7.5 of Whites. Researchers have also demonstrated that racial discrimination, including from the healthcare system itself, also negatively impacts health.⁵⁹ Inequality continues in the medical profession, too. While making up 12% of the overall population, less than 6% of physicians and surgeons are Black.⁶⁰

The roots of health inequality date back to the beginning of this country. Treated as racially inferior, neglected or excluded by White healthcare systems and as the victims of systematic and institutionalized racism and segregation, African Americans have suffered higher rates of disease and mortality than White Americans throughout this country's history. African Americans have fought for increased access; provided care for themselves in various forms, from enslaved midwives to Black hospitals; and made important contributions to the medical field. However, the historical vestiges of a two-tiered healthcare system remain as deeply entrenched as other aspects of structural racism.

Discussion Questions

1. What is the "slave health deficit" and how has it persisted?

2. What barriers have historically prevented African Americans from becoming physicians?

3. How have African Americans provided healthcare for themselves?

4. What changes could be made to the healthcare system to increase African American access?

Writing Prompt

Studies have found that African Americans are much less likely to trust physicians, hospitals, and the healthcare system. As a result, they are also less likely to seek treatment, contributing to higher mortality rates. Many attribute this distrust to historical episodes of medical exploitation like the Tuskegee Experiment. Others highlight the history of racism and discrimination by healthcare providers. Taking a historical perspective, what do you believe has contributed to this mistrust? What can be done to address this issue and improve trust in healthcare?

¹ Rodney G. Hood, "The 'Slave Health Deficit': The Case for Reparations to Bring Health Parity to African Americans," Journal of the National Medical Association, 93:1 (January 2001), 1-5.

² William M. Byrd and Linda A. Clayton, "An American Heath Dilemma: A History of Blacks in the Health System," Journal of the National Medical Association, 84 (1992), 189-200.

³ Byrd and Clayton, "An American Health Dilemma."

⁴ Henry Louis Gates, Jr., "How Many Slaves Landed in the U.S.," The Root, January 6, 2014.

⁵ Herbert S. Klein, Stanley L. Engerman, Robin Haines, and Ralph Shlomowitz, "Transoceanic Mortality: The Slave Trade in Comparative Perspective," William & Mary Quarterly, 58:1 (January 2001), 93-118, 13; Herbert S. Klein, The Atlantic Slave Trade (Cambridge: Cambridge University Press, 1999), 178.

⁶ Steven Mintz, "Childhood and Transatlantic Slavery," in Children and Youth in History, Item #57, http://chnm.gmu.edu/cyh/items/show/57, accessed January 1, 2018.

⁷ Herbert C. Covey, African American Slave Medicine: Herbal and Non-Herbal Treatments (Lanham, MD: Lexington Books, 2007).

⁸ Robert William Fogel, Without Consent or Contract: The Rise and Fall of American Slavery (NY: W.W. Norton, 1989), 137.

⁹ "What was Life Like Under Slavery," Digital History, 2016, http://www.digitalhistory.uh.edu/disp_textbook.cfm?smtID=2&psid=3040, accessed July 11, 2019.

¹⁰ Covey, African American Slave Medicine, 8.

¹¹ Covey, African American Slave Medicine, 36.

¹² William Byrd and Linda A. Clayton, "Race, Medicine, and Healthcare in the United States: A Historical Survey," Journal of the Medical Association, 93:3 (March 2001), 11s34s.

¹³ Ibid.

¹⁴ Covey, African American Slave Medicine, 43.

¹⁵ Covey, African American Slave Medicine, 38.

¹⁶ Stephanie M. H. Camp, Closer to Freedom: Enslaved Women and Everyday Resistance in the Plantation South (Chapel Hill: University of North Carolina Press, 2004).

¹⁷ Charles E. Wynes, "Dr. James Durham, Mysterious Eighteenth-Century Black Physician: Man or Myth," The Pennsylvania Magazine of History and Biography, 103:3 (July 1979), 325-333.

¹⁸ Thomas M. Morgan, "The Education and Medical Practice of Dr. James McCune Smith (1813-1865), First Black American to Hold a Medical Degree," Journal of the National Medical Association, 95:7 (July 2003), 603-614.

¹⁹ James L. Sims, George L. Seymour; and Benjamin J.K. Anderson, African-American Exploration in West Africa: Four Nineteenth-Century Diaries (Bloomington: Indiana University Press, 2003), 370.

²⁰ Michael J. Harris, "David Jones Peck, MD: A Dream Denied," Journal of the National Medical Association, 88:9 (1996), 600-604.

²¹ National Library of Medicine, "Dr. Rebecca Lee Crumpler Biography," National Institute of Health, 2013, https://cfmedicine.nlm.nih.gov/physicians/biography_73.html, last accessed July 11, 2019.

²² Covey, African American Slave Medicine, 46.

²³ Jim Downs, Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction (Oxford: Oxford University Press, 2012), 95.

²⁴ Jill L. Newmark, "Contraband Hospital, 1862-1863: Health Care for the First Freedpeople," BlackPast.org, 2017, http://www.Blackpast.org/perspectives/contrabandhospital-1862-1863-heath-care-first-freedpeople, last accessed July 11, 2019.

²⁵ Vanessa Northington Gamble, Making a Place for Ourselves: The Black Hospital Movement, 1920-1945 (Oxford: Oxford University Press, 1995), 6.

²⁶ Downs, Sick from Freedom.

²⁷ Byrd and Clayton, "Race, Medicine, and Healthcare in the United States," 319.

²⁸ T.D. Logan, "Health, Human Capital, and African American Migration Before 1910," Explorations in Economic History, 46:2 (2009), 169–185.

²⁹ Winston Benjamin, "Robert Tanner Freeman," BlackPast.org, 2017, http://www.Blackpast.org/aah/freeman-robert-tanner-1846-1873, last accessed July 11, 2019.

³⁰ Chris Ott, "George Franklin Grant," BlackPast.org, 2017, http://www.Blackpast.org/aah/grant-george-franklin-1847-1910, last accessed July 11, 2019.

³¹ Phylisha W. Agbor, "Ida Gray Nelson Rollins," BlackPast.org, 2017, http://www.Blackpast.org/aah/rollins-ida-gray-nelson-1867-1953, last accessed July 11, 2019.

³² Todd L. Savitt, "Abraham Flexner and the Black Medical Schools," in B. Baransky and N. Gevitz, eds., Beyond Flexner: Medical Education in the 20th Century (NY: Greenwood Press, 1992), 5-218.

³³ Herbert G. Ruffin, "Daniel Hale Williams," BlackPast.org, 2017, http://www.Blackpast.org/aah/williams-daniel-hale-1856-1931, last accessed July 11, 2019.

³⁴ Gamble, Making a Place for Ourselves, 3.

³⁵ Savitt, "Abraham Flexner and the Black Medical School," 1420.

³⁶ Gamble, Making a Place for Ourselves, 17.

³⁷ Camelie Heung, "Solomon Carter Fuller," BlackPast.org, 2017, http://www.Blackpast.org/aah/fuller-solomon-carter-1872-1953, last accessed July 11, 2019.

³⁸ "Black History Month: A Medical Perspective: Chronology of Achievements," Duke University Medical Center Library & Archives, 2016, http://guides.mclibrary.duke.edu/Blackhistorymonth/chronology, last accessed July 11, 2019.

³⁹ Gamble, Making a Place for Ourselves, 183.

⁴⁰ Robert A. Wortham, "W.E.B. DuBois and Demography: Early Explorations," Sociation Today, 7:1 (Spring 2009), http://www.ncsociology.org/sociationtoday/v71/phila.htm, last accessed July 11, 2019.

⁴¹ "National Negro Health Week," Journal of the National Negro Health Association, 39:2 (March 1947), 78-79.

⁴² Sandra Crouse Quinn and Stephen B. Thomas, "The National Negro Health Week, 1915 to 1951: A Descriptive Account," Minority Health Today, 2:3 (March/April 2001), 44-49.

⁴³ Claire Perry and George Sessions Perry, "Penny a Day Hospital," The Saturday Evening Post September 2, 1939.

⁴⁴ Gamble, Making a Place for Ourselves, 183.

⁴⁵ Carla J. Smith, "The Hill-Burton Act: A Basis for the Prevention of Urban Hospital Relocation," Indiana Law School, 55:4 (Summer 1980), 695-715.

⁴⁶ Karen Kruse Thomas, Deluxe Jim Crow: Civil Rights and American Health Policy, 1935-1954 (Athens: University of Georgia Press, 2011).

⁴⁷ Lisa Ko, "Unwanted Sterilization and Eugenics Programs in the United States," Independent Lens, January 29, 2016.

⁴⁸ Edwin Black, "The Horrifying American Roots of Nazi Eugenics," History News Network, September 2003, https://historynewnetwork.org/article/1796, last accessed July 11, 2019. 

⁴⁹ "Fannie Lou Hamer," WGBH Educational Foundation, 2018, http://www.pbs.org/wgbh/americanexperience/features/freedomsummer-hamer/, last accessed July 11, 2019.

⁵⁰ Gamble, Making a Place for Ourselves, 183.

⁵¹ Beatrix Hoffman, "The Medical Civil Rights Movement and Access to Healthcare" (Bethesda, MD: U.S. National Library of Medicine, 2014).

⁵² P. Preston Reynolds, "Professional and Hospital Discrimination and the US Court of Appeals Fourth Circuit 1956–1967," American Journal of Public Health, 94:5 (May 2004), 710-720.

⁵³ Byrd and Clayton, "Race, Medicine, and Healthcare in the United States," 319.

⁵⁴ Hoffman, "The Medical Civil Rights Movement."

⁵⁵ Alondra Nelson, Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination (Minneapolis: University of Minnesota Press, 2011).

⁵⁶ Harriet A. Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (Norwell, MA: Anchor, 2008).

⁵⁷ Mitchell F. Rice and Woodrow Jones, Public Policy and the Black Hospital: From Slavery to Segregation to Integration (Westport, CT: Greenwood Publishing Group, 1994), 101.

⁵⁸ “Black Health, United States, 2016: With Chartbook on Long-term Trends in Health" (Hyattsville, MD: National Center for Health Statistics, 2017).

⁵⁹ Ibid.

⁶⁰ Joseph P. Williams, "Why America Needs More Black Doctors," U.S. News & World Report, August 31, 2018.