Juneteenth and the legacy of healthcare inequity

June 19th marks an important date in the history of African Americans.  Even though the Emancipation Proclamation was signed in 1863, it wasn’t until June 19, 1865 that all slaves were given freedom.

The founding fathers wrote in the Declaration of Independence “All men are created equal and are endowed by their Creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness. . . “  At the time these words were written, the men constructing our constitution were not counting the people who were forced to come to the New World in chains to live a life of servitude.  By the date the constitution was signed, slavery in the colonies was already a decades-old practice.

History holds many examples of servitude.  From the ancient Greek and Roman societies to the early settlers in America.  People were usually enslaved based on social class, debt or the conquest of war. But prior to the slave trade that brought millions of Africans to the New World, slavery was never based on race.

Over four hundred years have passed since the first Africans arrived in America, but in many ways they still do not enjoy the life, liberty or pursuit of happiness that the Declaration of Independence guaranteed. One of the many problems they still experience is a lack of access to adequate healthcare.  African Americans make up just over 13% of the population of the United States, yet health challenges have disproportionately affected this population.[1]  They are much more likely to die from cancer, heart disease and many other chronic illnesses than any other racial or ethnic groups.

The health disparities of today have deep roots in the past.

From the time they were abducted from their villages and marched to the coast, the future slaves were not given any medical treatment. The journey was long and hard.  Death rates during the trek from the interior of the African continent to the West Africa Coast were as high as 50%.[2]  The journey from Africa aboard ships to the Americas was even more treacherous with exposure to new diseases, lack of sanitation, overcrowding and poor nutrition.  On board there were no physicians assigned to treat the slaves.  A number of slaves were tossed overboard at the first signs of illness, so the ship owners would be compensated by insurance companies.  Up to 50% of the live “cargo” never finished the journey.

The pattern of poor health outcomes continued in the New World where slaves were overworked, lived in poor housing and were exposed to all types of weather.  A lack of proper nutrition added to the problem.  Nothing they were provided or encountered was suitable for supporting basic human needs.  White doctors would only tend to slaves if forced to.

It might be difficult to imagine that the words “all men are created equal” would not apply to the Africans brought over in the slave trade. Slavery itself was the antithesis of freedom. The founding fathers recognized the moral dilemma.  The idea of race was used to solve the problem.  If Africans were not the same as white people, if they were in fact something less than “men,” then they could be denied the right to freedom.  The roots of racial inferiority are here, in the very early years of the country.  Predominantly white doctors wrote off black people as less than human.

The 18th century saw the founding of almshouses, asylums and poorhouses.  These were the first hospitals for the new republic’s “unworthy” poor.   The recipients of such charity were overwhelmingly black.  Charity brought with it vulnerability, and black people became easy targets for all manner of exploitation.

The changes in medical training during the same time frame required actual patients, so medical students would have experimental subjects.  Tragically, the almshouses provided a ready supply of people who could be used for such purposes.  The dramatic contrast between the affluent lifestyle and economic opportunity of white doctors and the desperate status of their black patients only served to deepen accepted notions of racial inferiority. But it also became the basis for a heightened lack of trust between African Americans and the medical profession.  The poorhouses evolved into hospitals where ethics were disregarded and exchanged for exploitation and indifference.

The United States prospered under President Andrew Jackson (7th President of the United States), who owned over 300 slaves during a span of 77 years.  Prosperity didn’t extend to the black people toiling in the fields. The deficits in healthcare for slaves continued. Under the continual threat of slave rebellions, the frequency of illness gave way to traumatic injuries from owners relentlessly oppressing and punishing their slaves.  Once the Atlantic slave trade was outlawed by England, “domestic slave production” led to more obstetrical complications, maternal and infant death as slaves were forced to bear children under deplorable conditions.

The medical profession went to great lengths to justify slavery through science.  America’s top medical school, the University of Pennsylvania School of Medicine, used pseudoscience and anthropology to document the inferiority of blacks and Native Americans.  For example, Samuel A. Cartwright, a physician of note, presented a report that described a malady unique to slaves, “drapetomania.”[3]  Translated from latin it means runaway madness and was used to explain why slaves would try to escape.  The report also falsely stated that blacks had smaller brains and blood vessels.  Unfortunately, this is one of the many medical myths that continues to haunt the African American population today.

During the Civil War, far more black soldiers died than white, even in the Union army.  The hospitals treating soldiers were segregated into white units and black units, but the black units never had enough medical staff.  When the same illnesses and injuries were sustained by whites and blacks, the whites would recover and the black soldiers often died or were disabled for life.

As a result of the Civil War, the country found itself in the midst of the largest refugee crisis of the 19th century.  Many former slaves were left without a home.  Neglected by the Union soldiers and without health care, many of the former slaves perished from diseases like smallpox and cholera.  Others simply died of starvation.  While the history books celebrate the emancipation of slaves, the true aftermath became the largest biological crisis of the 19th century when up to 4 million former slaves suffered from illness or died.[4] Black Americans were under the threat of extinction.

Lincoln’s new hope

To address the problems, President Lincoln established the Freedmen’s Bureau in 1865 which facilitated the opening of universities, hospitals, soup kitchens and clinics in the south.  The hope was that by providing food, shelter, clothing, medical services and access to education to the newly freed slaves they would be able to transition from slavery to freedom. Push back from the Southern states that viewed the act as a waste of federal money caused President Johnson to veto the bureau’s renewal in 1866 and by 1872 the bureau was dismantled.

Although more blacks were now becoming doctors, the overall health system became segregated as a consequence of racist black codes and Jim Crow laws. Hospitals and clinics for black people were often understaffed without adequate resources.  When a hospital did allow black patients, it was in a completely separate wing and the two areas did not permit intermingling.  If a black patient was able to access healthcare, they would find the care to be less than that received by a white person with the same illness.  These poor health outcomes are still a part of what shapes America today.

Ironically, at the same time medical care was so deeply segregated, black doctors began to earn the respect of their ­white counterparts.  Quietly and behind the scene, black doctors were able to achieve the desegregation of Cook County and Harlem Hospital medical staff. The black medical staff was no longer relegated to the “black only” wing of the hospital and could benefit from the expertise of the white medical staff – and vice versa.

Regrettably, any strides that were made toward health equity in the aftermath of the Civil War were lost during the Great Depression (1929-1933) when more than 20% of the total United States population was unemployed. Even white collar professionals were faced with income reductions of up to 40%.  The health status of all Americans plummeted. The African American population was once again faced with disease and death that threatened their extinction in the U.S.

Black soldiers returning from World War II expected more.  They had fought for the country that had been less than welcoming.   Instead, they were locked out of the mainstream medical system as health insurance came into the picture.  Only about 4% of the population could afford health insurance, the rest were left to pay medical expenses directly or relied on charity.  Black Americans avoided the hospitals altogether. Generations of poverty and a health system dominated by white doctors all but guaranteed that the health deficit would continue.  Most of the top health organizations, including the prestigious American Medical Association (AMA), ignored the mounting societal pressure at the beginning of the Civil Rights movement to desegregate hospitals and medical staff.

And yet the Civil Rights Era also provided hope of a new beginning for African Americans.  Medicare/Medicaid legislation was signed, marking the first time that black people would have access to quality healthcare. However, instead of equity, the black population was assigned to the inferior level of a dual health system — one level of care for the white people who could afford insurance and out of pocket expenses, another level of care for black people who were on Medicaid or had no insurance at all.  The improvements held for a decade then went downhill.  The health deficit that originated with slavery returned.

The Affordable Care Act

It would be thirty-five years until significant strides were made in healthcare.  In 2010 the Affordable Care Act (ACA) was signed into law with the goal of making sure every American had access to quality, affordable healthcare.  While the ACA did help African Americans obtain insurance, they are still more likely to be uninsured than their white counterparts.  The problem lies in the cost of insurance and health services.  Because blacks earn less than whites, the average cost of health care premiums is almost 20% of their total income.[5]  And, while most African Americans have health insurance of some kind, they suffer from illness and infirmity at higher rates than any other racial or ethnic group.  This means they will spend more on healthcare overall, further depleting any disposable income.

The ACA did improve health outcomes for many African Americans because, with insurance, they are more likely to see a healthcare provider and receive earlier diagnosis and treatments.  But compared to their white counterparts, there is still a large difference in quality of care and outcomes.  The health of an individual depends on more than just having health insurance.  Access to medical professionals, health clinics and the services to diagnose and treat illness is dependent upon location and transportation.  Even when access is available, the quality of healthcare is often inferior, and the number of professionals who accept patients on Medicaid is low.  Typically there just aren’t enough physicians to treat everyone.

Clearly health reform is needed to address the ongoing issue of racial inferiority when it comes to the health of Black Americans.  While progress has been made in recent decades, there are far too many blacks who are struggling with basic needs including a living wage and access to quality healthcare.  The long-standing effects of racism touch all African Americans, but there is also a sense in which it touches all Americans regardless of their race. The reality, made most evident by our experience with the coronavirus pandemic, is that realizing our potential as a nation, both to be healthy and prosperous, depends fundamentally on fulfilling our commitment to equality – not least with regard to healthcare access. If any of us cannot freely access the care we need to enjoy good health, then all of us suffer loss.

The list of those losses includes the contributions and achievements of millions of Americans equally gifted by God, the enrichment they can bring to all our lives and a generosity and kindness of spirit that recognizes we truly are equal and that we need be the uncompromised beacon of freedom we aspire to be.

[1] Taylor, J. (2019, December 19). The Century Foundation. https://tcf.org/content/report/racism-inequality-health-care-african-americans/.

[2] Boyd, M. W., & Clayton, L. A. (1992). An American Health Dilemma: A history of blacks in the health system. Journal of the National Medical Association, 84(2), 189–200.

[3] McClain, M. (2019, April 30). A brief history of the enduring phony science that perpetuates white supremacy. The Washington Post. https://www.washingtonpost.com/local/a-brief-history-of-the-enduring-phony-science-that-perpetuates-white-supremacy/2019/04/29/20e6aef0-5aeb-11e9-a00e-050dc7b82693_story.html.

[4] Harris, P. (2012, June 16). How the end of slavery led to starvation and death for millions of black Americans. The Guardian. https://www.theguardian.com/world/2012/jun/16/slavery-starvation-civil-war.

[5] Taylor, J. (2019, December 19). Racism, Inequality, and Health Care for African Americans. The Century Foundation. https://tcf.org/content/report/racism-inequality-health-care-african-americans/.