An Investigation into the Racial History and Modern Implications of American Healthcare
By: Solveig Lee
Tags: Race, Health, Healthcare, Raceinamerica, American History

Extended Essay for the International Baccalaureate program investigating the question “what impact has the United States’ healthcare system had on Black Americans’ access to quality healthcare?”

Introduction

The position of Black people in America traces back to the foundation of the United States. Systemic racism has created layers of unacknowledged disadvantages leading to political, social, and economic racial inequalities unaddressed by American politics. Within healthcare, racism and economic inequality combine to further disadvantage Black Americans. Political and historical facets of American healthcare with regards to racial inequality will be investigated through the question: “What impact has the United States’ healthcare system had on Black Americans’ access to quality healthcare?”¹ The answer will chronologically outline the relationship between Black Americans and American healthcare.

To acknowledge both racist practices and inequalities, this essay will investigate the origin of modern inequalities through historic public policy and medical practices, analysis of American healthcare, and statistics of health and poverty. The racial wealth gap and power imbalances within prominent institutions will be considered. Investigation will focus on statistics, modern research, credible news sources, and relevant political action.

Healthcare is viewed as a basic human right, and the acknowledgement of racial and socioeconomic inequality within American healthcare will likely reveal global health inequalities. Healthcare and inequality are found globally. Studying these global topics in tandem will offer insight on global issues and solutions.

1 1619–1865; Slavery

Black Americans have been exploited and oppressed by systematic racism as an outcome of The United States’ development as an autonomous nation during an era of slave labor. This oppression was possible because of a racially imbalanced power structure. Exploitation of slaves was especially prevalent in medicine. In the American colonies, as white Americans profited off of slave labor, so did American medicine. In researching medical schools and Southern slave trade, Todd Savitt argues that slaves were easy targets for ambitious white physicians² as “voiceless” and “medically incompetent” entities controlled by white enslavers.³ This racial power dynamic is seen in the political and scientific development of healthcare rendering Black Americans powerless to the decisions of white politicians and doctors.

The discontinued Western and Southern Medical Recorder documented “reports of surgical experiments to treat injuries, birth defects, and tumors, all pioneered on slaves.”⁴ These gruesome experiments used dangerous, invasive tactics in a time before anesthesia or sterile surgery.⁵ Stephen Kenny’s paper on slaves in American medicine details an experiment performed by medical apprentices on a slave infant. The experiment, an attempt to remove a tumor in the four-week-old’s neck, was painfully botched, causing the girl to suffer for years until her premature death, without repercussions for either apprentice. Her skull became a specimen in the University of Maryland’s medical museum.⁶ This case was one of many showing the normalization and authentication of medical experimentation on slaves, many of which were displayed and studied in prominent institutions.

These practices were commonplace in medical experimentation. Kenny states in his study that “white medical students…expected education and training based on the observation, dissection and experimental treatment of slaves.”⁷ Slaves were trafficked to universities and “Negro hospitals”, which were institutions of “risky medical research” and destinations for diseased slaves.⁸

Slaves became integral to the development of American medicine. Savitt argues that given the volume of experiments done, “we are moving here toward a view of experiments on slaves as something more systematic.” Slaves became integral to the development of American medicine, and the exploitation is seen in the 1989 discovery of thousands of bones in a basement of the Medical College of Georgia, evidence of grave robbing and medical experimentation on slaves. The Medical College of Georgia “and others like it grew in the shadow of slavery.”

Savitt’s most profound revelation was that “under the skin, [doctors] knew on some level that people were the same. So they used [slaves] in medicine. They knew that, but still saw slaves as different from other people.”⁹ This dismissal of slaves’ full humanity provides insight into the system of exploitation from which American healthcare originated. America has never fully acknowledged the repercussions of slavery, and American healthcare continually disenfranchises Black Americans as a result of its foundation. American medicine fails to redeem itself from its exploitative past, benefitting from experiments on Black people, like Henrietta Lacks’ exploited cells and the Tuskegee experiment.

The political ramifications of slavery are evident in the racial power imbalance in the highest offices of government as well as medical institutions. Viewing Black people as subordinate workers aiding the country’s development, white Americans established a racial imbalance that influences modern politics and medicine. Disproportionate poverty has also resulted from roots of economic inequality. The percentage of Black Americans below the poverty line has always been higher than the percentage of Blacks in America. Out of the 34 million Americans in poverty, 24% are Black and 42% are white.¹⁰ Yet the racial makeup of America, according to the 2019 U.S. Census estimates, is 13.4% Black and 76.3% white.¹¹

2 1865–1877; Reconstruction

After slavery was abolished, newly freed slaves had few resources, staying in abandoned buildings in close living quarters. The poverty and congregation of freedmen is a result of the lack of support post-slavery. Healthcare was a privilege and sickness a result of poverty, and therefore many freedmen got smallpox and suffered without treatment. Before the 1900s boom in healthcare development, whenever freedmen went to healthcare facilities or doctors for help “they were turned away” because of their race and poverty.¹²

The smallpox epidemic became a national health crisis, with so many freedmen dying that “in some towns and cities, their bodies [littered] the streets.” To address the crisis, the federal government formed the nation’s first federal healthcare program in 1865, the Freedmen’s Bureau Medical Division.¹³ The podcast 1619 emphasizes the first Black female doctor in America, Rebecca Lee Crumpler, and her experience in this program. Crumpler documents the “completely under-resourced” Freedmen’s hospitals, which lacked medicine, quarantine facilities, beds, and doctors. There were approximately 120 doctors employed by the program for 4 million freedmen.¹⁴ Freedmen’s Bureau Medical Division was created to “prevent diseases that might eventually spread into white communities”, while avoiding Black dependency by limiting assistance. The program opened a few understaffed hospitals to avoid spread, but closed them at any sign of progress. The government’s deliberate failure to provide resources resulted in even more smallpox deaths among freedmen.¹⁵

The government seemingly solved the epidemic through the program, making many believe that despite the help freedmen received, they continued dying, and therefore their deaths must be inevitable. A theory emerged that Blacks were “going extinct” because they couldn’t survive autonomously. Many Americans began to believe that sending help was futile. A congressman argued against freedmen’s hospitals with this theory, saying, “No charitable black scheme can wash out the color of the Negro, can change his inferior nature or save him from his inevitable fate.”¹⁶ The concept of Black people’s inevitable inferiority still circulates today. Louisiana Senator Bill Cassidy inferred that physiological differences cause Black patients to die with more frequency from COVID-19, calling systematic racism “rhetoric.”¹⁷

The first American Healthcare system failed its patients. The American government emphasized political interest and the safety of white Americans over Black healthcare needs. The program was a deliberate facade of equality and a manipulation of the basic human right of healthcare. The government allowed Black Americans to experience the potential development of American society and technology without truly reducing inequality. The policy continued the legacy of inequitable treatment of Black Americans for white gain.

3 1900–1920s; Privatization & Industrialization

A commercialized American healthcare system is formed from a lack of dedication to healthcare by the government and capitalist initiative to profit off of healthcare needs by insurance companies. In response to industrialization and issues of worker health, many European countries began to formulate the beginnings of universal healthcare systems in the early 1900s, the United States had no plans for centralized healthcare. Instead, as Karen Palmer stated at a Physicians for a National Health Program meeting, “the federal government left matters to the states and states left them to private and voluntary programs.”¹⁸ The lack of a federally centralized healthcare system led to the privatisation of American healthcare. Despite President Theodore Roosevelt’s support for universal healthcare, “most of the initiative for [healthcare reform] took place outside of government.” The system was not created by elected officials but private businessmen. Insurance companies saw no long-term monetary benefit in writing insurance policies because they believed Americans would take advantage of coverage, especially sick people who would cost more than they paid.¹⁹ These companies, who the American healthcare system now relied on, “lacked the means to calculate risks accurately and set appropriate premiums”, further skewing access to reasonably priced healthcare and favoring middle and upper-class whites.²⁰

Roosevelt was followed by presidents who postponed national government involvement in social welfare due to the impact of WWI, the desire for normalcy, and fears of communism.²¹ Therefore, although nearly all European nations created national health insurance, “similar proposals in the U.S. were rejected because of lack of interest and resistance from physicians and commercial insurers.”²² These proposals were also rejected by white male politicians elected by white male voters, excluding the interests of women and minorities. During this period of healthcare development, the American Medical Association’s (AMA) membership grew rapidly.²³ The AMA was founded in 1847 to promote scientific and medical progress and was “almost exclusively white.”²⁴ Therefore, Black people lacked representation in both medical organizations and the government.

As this healthcare system was being established, medicine itself was developing into a more prestigious profession. Visiting physicians were replaced with hospitals, and healthcare became more expensive. As Americans spent more money on healthcare, prepaid service plans began to form. An early contract example was an agreement between Dallas school teachers and Baylor University Hospital, in which the teachers received “up to 21 days of inpatient care a year for regular monthly payments of 50 cents.”²⁵ These contracts exemplify the capitalism within American healthcare and necessary focus on monetary gain. While the contracts were a more affordable option, their main purpose was “to assure hospitals a steady income stream during a period of declining revenues” creating a system where hospitals and insurance companies profited off of American sickness.²⁶ Without government regulation or funding, hospitals needed profit to provide care and insurance companies could profit off hospital and consumer needs.

In 1915, the American Association of Labor Legislation (AALL) drafted a healthcare insurance bill proposing coverage for those earning under $1200 a year, “services of nurses, doctors, and hospitals”, and “sick pay, maternity benefits, and a death benefit.” The AMA initially supported this bill, writing “[the AALL’s] plans are so entirely in line with our own that we want to be of every possible assistance.” However, the bill was scrutinized by state medical societies, and before long the AMA sided with others and denied it had ever favored the measure.²⁷ The AMA, a white organization, struck down this significant possibility of a national healthcare system that would have benefited Americans below the poverty line and disproportionately low-income Black Americans.

Throughout the 1920s, healthcare costs continued to rise, and insurance became an issue for American citizens. Worried third-party payers would restrict their ability to set their own fees, doctors created a network of insurance plans called Blue Shield.²⁸ The successful Blue Shield and Blue Cross insurance plans incentivized commercial insurers to create their own programs. Commercial insurers benefited from experience-rating, a method which predicts a person’s future medical costs based on their past experience, offering healthier people lower rates and sicker people higher rates, which created competition for the Blue Cross and incentivized healthier customers to join their insurance program, thus maintaining profit.²⁹

American healthcare combined capitalist interests, monetary necessities, and a lack of government involvement to create a system that prioritized income over health. The manipulation of a basic human necessity was instrumental in the exclusion of Black Americans from American development. Healthcare had the potential to decrease racial wealth and achievement gaps but instead increased racial inequality in America.

4 1930s-50s; Socialized Medicine

During President Franklin Roosevelt’s term, public healthcare was overshadowed by a need for unemployment and old age benefits resulting from the Great Depression. Therefore, FDR excluded the AMA-opposed universal health insurance in his Social Security bill of 1935. In 1939 there was another national healthcare insurance proposal by FDR’s Tactical Committee on Medical Care. Their proposal was included in Senator Wagner’s bill and gave support to federal grants for state implemented healthcare. However, the 1938 elections flipped the House and Senate, blocking nearly all social policy legislation, including the committee’s National Health Act of 1939.³⁰

America’s war on communism after World War II energized the AMA’s anti-national healthcare crusade, calling universal healthcare plans “socialized medicine.” During this crusade, President Truman “proposed a single egalitarian [healthcare system] that included all classes of society.” Yet Congress and the Senate disapproved, calling it “the most socialistic measure this Congress has ever had.” This plan would have provided healthcare coverage for all Americans, most importantly low-income and disadvantaged minorities. Additionally, “the AMA, the American Hospital Association, the American Bar Association, and most of the nation’s press…hated the plan”.³¹ The AMA knew a national health insurance program would hurt their profits and attacked it, taking their fight against universal healthcare to another level through advertisements advocating to “keep politics out of medicine.” The AMA created a fearful narrative that government officials would intervene in private medical decisions, destroying the doctor-patient relationship.³²

The AMA’s campaign against universal healthcare exemplifies the power of political rhetoric and influence by non-political organizations. During the Cold War, American citizens feared change rather than embraced it, and the AMA harnessed this fear in their fight against progressive healthcare legislation.

An advocate for Truman’s plan was Montague Cobb, a Black doctor and medical professor at Howard University. Cobb knew the plan was a step toward equalizing racial health disparities and desegregating American hospitals. However, “Cobb was one of the only doctors to defend Truman’s plan and defy the AMA”³³ and “national health insurance became vanishingly improbable.”³⁴ America was left with the same profit-based healthcare system: “still too expensive for most Americans to afford and as segregated as it has ever been.”³⁵

Additionally, racist medical practices and ideology remained. In 1932, almost sixty years after emancipation, hundreds of poor Black men signed up for a “Free Blood Test”, “Free Treatment”, and, unknowingly, for the Tuskegee syphilis experiment. This “secret” experiment was conducted by the US government’s Public Health Service to “study the progression of the deadly venereal disease — without treatment.”³⁶ The exploitation mirrors experimentation on Black slaves and resulted in the slow and painful deaths of nearly all subjects, including some members of their families.

Reporter Deneen Brown argues the implications were far reaching. “It destroyed the trust many African Americans held for medical institutions — a legacy that persists today.”³⁷ This holds true for many atrocities committed by American medicine on Black Americans. The mistrust in the American healthcare system is founded by modern health outcomes (maternal mortality rates, for example) and historic disregard of Black humanity.

5 1960s-2020; The Illusion of Progress

In 1958 a new bill was introduced, offering to cover hospital costs for the elderly through Social Security. The plan garnered immense public support, and to maintain profit, the AMA introduced an opposing eldercare plan. The government then expanded the bill to cover physician services, creating the Medicare and Medicaid programs. In 1965 the bill was signed into law by President Johnson: a solitary victory for equitable American healthcare.

Government response to the 1960s Civil Rights movement included the 1968 Kerner Commission (following the Los Angeles Watts riots) which proposed recommendations to address “pervasive discrimination in employment, education and housing.” Without action, it failed to bridge the racial gap. The typical Black household income increased 42.8% from 1968 to 2017, but received only 61.6% of the annual income of a typical white household. Poverty rates declined for Blacks; Blacks are 2.5 times more likely to be in poverty as whites in 2017, compared to 3.5 in 1968. The most important indicator of long-term success is home-ownership, yet the percentage of Black homeowners barely changed (41.1% in 1968 and 41.2% in 2017) while white home-ownership increased.³⁸ The Kerner Commission stated “our nation is moving toward two societies, one black, one white — separate and unequal”, yet the marginally embraced recommendations failed to address decades of systemic oppression.³⁹ Political recognition of unequal access to essential resources and achievements gaps was, however, an important starting point.

Despite political acknowledgement of racial inequality, racism remains pervasive in American healthcare. Race is inaccurately represented as a health factor without acknowledgement of outside factors. In an Atlantic article, Hamza Shaban states: “race has become a biologically distinct, scientifically valid category despite the unnatural and social process of its creation.” Proving the arbitrary nature of biological racial categorization, researchers have found “there is more genetic variation among individuals within conventionally defined racial groups than between individuals of different racial groups”, making clear that relying on race as an explanation for health differences is erroneous.⁴⁰

Although race is not a technically sound scientific category, it is a health factor because of systemic racism disproportionately placing minorities in poverty. Lower-income and minority communities suffer more from pollution and stress while lacking healthy food, healthcare, and quality education. However, race as an individual indicator of health is a racist ideology. Race is an invented social construct which concretely affects people’s lives because of centuries of persistent racial discrimination. Lindy Braun, Brown professor of Africana Studies and Medical Science stated, “I am not making an argument never to use race in health research. I think the use of race as a social category is entirely appropriate to study the health effects of a discriminatory social world — but always in combination with gender and measures of class.”⁴¹

Scientists have used racial distinction in medicine since its invention. During the American Civil War Benjamin Gould’s study found that white soldiers had higher lung capacity than “Full Blacks” or “Mulattoes.”⁴² Gould’s study, now disproved, still influences medical outcomes. The spirometer, a tool used to measure lung capacity, is race-corrected in accordance to Gould’s study: “normal values for lung health are reduced for patients that doctors identify as black.” This practice masks potential environmental explanations for lower lung capacity, and relies on the “science” of racial difference for “disability estimates, pre-employment physicals, and clinical diagnoses.”⁴³ The spirometer confirms racial biases and creates inaccuracies in health measurements. This practice insidiously contributes to racism in American healthcare, a modern equivalent of blatantly racist 19th century skull measuring, equating size with “morality and intelligence.”⁴⁴

Other risk calculators also fail to diagnose Black Americans correctly, restricting necessary care. Medical tools measuring kidney, osteoporosis, and obstetric function factor race into the diagnosis and give Black patients scores which make them less likely to receive treatment.⁴⁵ A study by Dr. Nwamaka Eneanya at UPenn emphasizes this phenomenon through creatinine measurements. When identifying kidney function, doctors measure the amount of creatinine in the blood. Lower filtration levels indicate kidney problems, and require referral to a specialist. In Eneanya’s study, a Black patient and a white patient with the same creatinine levels received different results; the white patient’s level was 28, while the Black patient’s “race correction”⁴⁶ raised their level to 33. The white patient was referred, the Black patient was not.⁴⁷

Race-based medical technology can be traced back to many things. Most prominently the belief in biological racial differences and the segregation of hospitals up until the 1960s. Both contributed to a white standard of healthcare, lacking consultation and holistic study in medical fields that might have recognized earlier that race is not reliable for genetic differentiation and differing treatment.⁴⁸ The segregated hospitals and medical associations created two separate health realities for Black and white American patients and doctors, leading to racial disparities in diagnosis and access to treatments.

In America’s medical system today “roughly 6 percent of physicians and surgeons are black”⁴⁹, despite Black Americans suffering disproportionately from many health problems. In annual US health studies, Black respondents had consistently poorer health; in 1991, 9.6% of white and 16.8% of Black respondents reported poor health, and that disparity stays consistent.⁵⁰ Additionally, racial disparity in maternal mortality rates is an essential indicator of inequality (mentioned in section 1). In 2018, researchers found that regarding maternal mortality, “black women fared the worst, dying 2½ times more often than white women.” Researchers “suspect a combination of institutional racism in society and the health care system…increased susceptibility to certain health conditions…[and] access to quality prenatal care.”⁵¹

COVID-19 also disproportionately affects Black Americans. Nancy Kreiger, a social epidemiologist at Harvard writes that COVID-19 is “pulling a thread … revealing patterns that have long been known in public health.”⁵² COVID-19 perfectly, albeit unfortunately, encapsulates long-term inequities in society and healthcare. Poverty disproportionately affects Black Americans. Conditions of poverty, including crowded living spaces, low-paying service jobs, reliance on public transportation, and lack of access to resources lead to clustered outbreaks in poor neighborhoods. In addition, long-term health problems linked to poverty such as lower lung capacity and chronic illnesses amplify negative effects of COVID-19, increasing low-income Black Americans’ mortality rate.

COVID-19 deaths emphasize the racially disproportionate poverty and infection rates. Cities tracking cases by zip code and race find that Black neighborhoods have the highest infection rates. Additionally, CDC data shows Blacks as 2.8x more likely to die after contracting COVID-19.⁵³ In Milwaukee, 70% of deaths were clustered in predominantly Black neighborhoods.⁵⁴

The American healthcare system and disproportionate poverty are large factors in the high Black infection and death count, however, false information regarding Black health pervades all conversations regarding healthcare. Throughout history there have been politicians arguing that Black healthcare is not important because Blacks are predisposed or responsible for their illness (smallpox in the 1870s, COVID-19 in 2020).

The 1968 Kerner Commission acknowledged racial inequities but had no impact without subsequent social change. Social and political progress requires collaboration between federal, state, and local governments and organizations. Regarding COVID-19, the extreme duality of American politics created a partisan view of the virus, amplifying the partisan issue that healthcare has become. Bernie Sanders embodies the “leftist” standpoint, regarding the American healthcare system as “a byzantine network of medical institutions dominated by the profit-making interests of insurance and drug companies.”⁵⁵ The politicization of healthcare polarizes Americans and presents healthcare as a privilege rather than a right.

Conclusion

Unequal access to healthcare and racially disproportionate health problems are due to historical and political problems of racial injustice and inequality. Main factors in today’s healthcare inequality are due to historical precedent, political conflict, and inaction.

Poverty affects health and access to healthcare because of a lack of resources and fair healthcare coverage, which disadvantages the disproportionate number of Black Americans in poverty. American healthcare continues to use discriminatory racialized medical technology and research. American medicine’s foundation in slave experimentation plays a large factor in medical biases and callousness toward Black health problems.

Myriad racial disparities in healthcare were not investigated in this paper. Psychological and philosophical aspects of disenfranchisement of Black healthcare could be analyzed. Medical technologies, political conflict, and individualized experiences were summarized. The sociological effect of American healthcare was analyzed broadly and could be explored further. Overall, investigation led to an understanding of health inequities in America and offered insight on causes for global inequities.

Healthcare inequality must be recognized in order to create an equal resource for all Americans. Successfully combating healthcare inequalities requires action: political action against racially disproportionate poverty, universal healthcare, more Black doctors, research, and training on implicit racial bias in healthcare, removal of race-based healthcare technologies, and much more. Inequitable healthcare is an American problem, and, as COVID-19 exhibits, inequalities will persist unless concrete action is taken.