The Burdens of Race and History on Black People’s Health 400 Years After Jamestown

The matter of race is a common thread throughout the historical tapestry of American society. Discourse on race tends to focus on the lived experience of Black people, because of the “peculiar institution” of slavery in America. Medical historian Todd Savitt documents examples of racism in medicine to illustrate his observation that “some white Southerners claimed and many others believed that blacks were medically different from whites and so in need of special treatment.”^1(p53) The special treatment, in this context, provided the facade of medical authority supporting the prevailing wisdom that people of African descent derived from a species other than human and as such could be justifiably used as “chattel,” as slaves. Now, 400 years after the first slaves were brought to America, the vestiges of the belief that Black people are “less than” human remain solidly entrenched in today’s society.

The contemporary fear and mistrust Black people have toward medicine, and the beginnings of their legitimate discontent, derives from the fact that “white medical educators and researchers relied greatly on the availability of African American patients … for dissection, surgery, and bedside demonstrations.”^1(p77) This is one origin of negative racial attitudes within the health professions. Unfortunately, far too many of these attitudes, dating from the time of slavery and Jim Crow, exist as contemporary vestiges of the past hiding in our health care delivery system, exposed from time to time by landmark studies like the US Department of Health and Human Service’s Report of the Secretary’s Task Force on Black and Minority Health (also known as the Heckler Report)² and the Institute of Medicine’s (now the National Academy of Medicine) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.³

The freedom from slavery that was guaranteed in 1863, a major leap forward for the nation, did not grant equal treatment to Black people. One of the most evident manifestations of the persistent discrimination and racism that still exist today is in our health—specifically, health disparities. Although a substantial body of evidence has established that racial and ethnic minorities in the United States have lower life expectancies and suffer more from numerous health conditions than their White counterparts,³ the health of Black people has not always been documented. A 1977 report by Lee and Lee noted that “the standard histories and the best known accounts of the black condition [during slavery] provide little more than anecdotal information on black health and black mortality.”^4(p170)

Although health disparities between Blacks and Whites in the United States have existed since the very first settlers arrived, there was no systematic documentation of excess death among Black and other minority groups compared with the White population until the 1985 publication of the Heckler Report.² In 2002, the Institute of Medicine’s report Unequal Treatment further delineated a significant body of research documenting the existence of disparities in the actual delivery of health care services.³ According to the report, minorities were less likely to be given appropriate cardiac medications or to undergo bypass surgery, and were less likely to receive kidney dialysis or transplants, compared with their White counterparts. In 2004, a systematic review focused specifically on cardiac care concluded that

after examining the most rigorous studies investigating racial/ethnic differences in angiography, angioplasty, coronary artery bypass graft (CABG) surgery, and thrombolytic therapy … African Americans were statistically less likely than whites to undergo CABG surgery in 21 of the 23 most rigorous studies that calculated odds ratios to compare CABG use. Although there is a convincing body of evidence that race continues to matter in the health system, a nationally representative survey of physicians revealed that the majority of physicians do not view a patient’s race/ethnicity as a factor in obtaining care.^5(p503)

Another review of health care indicators concluded that although there has been improvement in selected health care disparities, overall progress has been slow.⁶ This review assessed health care trends along a number of quality indicators, but it noted that the sheer magnitude of publications precluded a systematic review. This is both encouraging and disheartening. It is encouraging that disparities in health and health care are gaining the national attention that is a necessary step to finally achieving equity. It is disheartening that despite the body of work massive enough to preclude a systematic review, disparities still have not been eliminated.

The United States has made progress in extending the length and quality of life for everyone, but even with that progress there is clear evidence that certain racial and ethnic groups—Black, Latino, American Indian, Asian and Pacific Islander—suffer a disproportionate burden of premature illness and preventable death compared with Whites.^6,7 As racial and ethnic populations continue to grow toward becoming the numerical majority, their health and well-being will become the health baseline status for the nation.

Race and racism continue to be the color line that, as first described by W. E. B. Dubois, defines the great challenge of our democracy; as he stated, “[T]he problem of the Twentieth Century is the problem of the color line. … the relation of the darker to the lighter races of men in Asia and Africa, in America and the islands of the sea.

In the 21st century, that color line runs through population health. It is sometimes easier to gloss over race and racism than to face them head-on and acknowledge how pervasive they are in today’s society. We must focus on educating and inspiring the general public to demand ethical health treatment as a major element in the elimination of social inequality. If we are to succeed in the quest to eliminate racial and ethnic health disparities to achieve health equity, we must bring to the foreground a history that, because of the magnitude of its shame, has been too often ignored in discourse about the pervasive influence of racism in the fields of medicine and public health.