Juneteenth Reflections:

“Where We Were”
The History of Healthcare in Black America

By Valarie Franklin AIA, NOMA; Senior Associate Moody Nolan Nashville

Tough times call for tough conversations. As the nation and the world stare in the face of tragedy in epic proportions, the COVID19 pandemic and racial injustices are bringing long held disparities to an even clearer light. Paramount among these disparities is the elusiveness of Equity in the black community. Simply and boldly stated, there is a dark history in America of all people not being treated equally or equitably. This 3-part series will take look at how this ill foundation has impacted equity in the infrastructure of the healthcare system in the black community by exploring the history of “where we were,” the present and challenging state of “where we are,” and the hopeful state of “where we hope to be.” In order to change the narrative, we must be responsive to it. As design professionals our core mandate inspires us to be responsive to project needs, our client’s goals, and our communities’ injustices through thoughtful innovation leavened with empathy. There must be a deep commitment to these goals even when it calls for us to have tough conversations. This series will start with a look at America’s history which the set a foundation of healthcare neglect, abuse, and inequity in black America.

A History of “In-Equity” in Healthcare:
At the root of it all is the aftermath of 246 years of slavery and the subsequent 103 years of Black Codes, the Convict Lease System designed for blacks as the “new slavery”, and Jim Crow Segregation. Being only 56 years into the current state of Civil Rights it is important to note that this is essentially the undoing of nearly 350 years of lawful injustice against black people in America by its government. 

1619 to 1865
The disregard of healthcare for blacks started on the slave ships where they were regarded as cargo instead of human beings. Over the legal slavery years as many as 4 million souls were beaten or starved to death crossing the Middle Passage, and all included in that number of deaths suffered from Healthcare Neglect. Healthcare Neglect is the major thread of slavery and beyond neglect; black bodies were abused mistreated and commodified; therefore, the challenges of healthcare for blacks during the years of legalized slavery were many. Poor nutrition, being excessively worked, improperly clothed, unsanitary and inadequate living conditions made slaves susceptible to diseases for which they did not receive care. Mortality rate of slaves was twice as high as slaveowners and half of slave infants died during their first year of life, again the mortality rate of the infant of slaves was twice as high as their slave owners. During the times of slavery, blacks were treated as property to be bought and sold.  The rights of humanity were not extended to them and slave owners had no problem dismantling entire families, taking parents away from their children or children away from their parents, for a good sale. Slaves endured harsh treatment and were only kept healthy enough so that they could work to serve their masters.

1846-1928
The Convict Lease System incarcerated mainly black males on erroneous and unjust charges in order to have them leased out as servants.  This system was designed specifically for blacks as the “new slavery” and became even more prevalent after slavery was abolished through the Emancipation Proclamation in 1863. Within this system, there were separate prisons for blacks in which they were treated inhumanly and denied healthcare. The black contract servants were often “worked to death” as their predecessors were during the times of legal slavery. These convicts were often sent to work on plantations, mines, and railways. The Convict Lease System is considered one of the harshest and most exploitative labor systems outside of slavery in America’s history due to corruption, lack of accountability, and racially motivated injustices. Orphaned and “criminal” children were also leased out under this system.

1865-1866
Black Codes were laws governing the conduct of blacks in southern states and were reflective of the white obsession with controlling former slaves by limiting their freedoms after slavery was abolished. Even though slavery was abolished, blacks were resented so law makers, especially in the south, enacted laws that would continue to keep blacks under subjection. Black codes reinforced contract slavery and made it illegal for blacks to have any occupation other than farmer or servant. There were no black doctors and it was often illegal for a white doctor to provide healthcare to blacks in certain jurisdictions. The sick quarters called “Bed Stocks” on plantations also doubled as punishment cells.

1877-1964
In 1877, Jim Crow Laws enforced racial segregation in Southern states. These laws in effect canonized economic, educational, housing, social, and healthcare disadvantages for black people. There were no facilities including hospitals that would serve blacks where whites were present, so they continued still largely without healthcare; however, in the North a few years prior to the abolishment of slavery, hospitals began to arise specifically to provide much needed healthcare to slaves. The first “black” hospital was Freedman’s Hospital located in Washington DC on the campus of Howard University. This hospital, built in 1862, still exists today as Howard University Hospital and is among one of the three remaining traditionally Black hospitals. Freedman’s Hospital was the only Federally funded health care facility for blacks in the nation.

As blacks gained admittance to segregated hospitals, funding and treatment aimed to be “separate but equal” was far from equal to that of their white counterparts. Hundreds of years of racial injustice had perpetuated biased inferiority and stereotype theories.  It was widely accepted and taught that black people were “less than” human.  This led to scientific abuse and unethical experimentation with black people as test subjects.

In 1932, the United States Public Health Service conducted a 40-year unethical clinical trial on a total of 600 impoverished black male sharecroppers in Macon County, Alabama.  The Tuskegee Study of Untreated Syphilis in the African American Male started as a collaboration with the historically black college, Tuskegee Institute (now Tuskegee University). The university and the test subjects were told that they would receive free healthcare if they participated in a clinical study. 399 of the 600 had initially tested positive for latent syphilis. They were never informed of their diagnosis and were given placebos to treat what the doctors told them was a benign condition called “bad blood.”  Hundreds died from this experiment including wives and children of the infected patients.  As Tuskegee University alumni, I remember reading the book “Bad Blood” by journalist John Carreyrou.  This book was required reading at the university and I remember having discussions with my classmates about the devastating impact on the physical and economic health of the town that the study inflicted for generations and generations after. This U.S. Government sanctioned unethical experiment and other such atrocities (prior and after) significantly damaged the trust of the black community toward public health efforts and continues to contribute to the reluctance of many poor black people in seeking routine preventive care.

In an attempt to restore trust in the black community, the National Medical Association (NMA), the largest and oldest national organization representing African American physicians and their patients in the United States from 1900-1960, made a concerted effort to increase the number of black doctors especially in the segregated South. They bolstered support for historically black medical colleges, which were formed mostly in the South due to denied admittance of blacks to medical schools as a product of segregation. The first such school was Meharry Medical College in Nashville Tennessee founded in 1876. Meharry has produced more than 7,000 alumni currently practicing in the U.S.  In addition to providing quality professional health care education, exemplary patient care, and compassionate community outreach, the college produces the Journal of Health Care for the Poor and Undeserved, a national public health journal.

1964-2020
In 1964 the Civil Rights Movement led by Dr. Martin Luther King Jr. resulted in the approval of the Civil Rights Act which demanded an end to legalized segregation. At times de-segregation had to be invoked forcibly by the Federal Government upon local municipalities especially in the South. Schools and Hospitals were required to admit blacks, but by this time long held beliefs were difficult to dispel because laws don’t necessarily change the hearts of man. The fallout of years of healthcare neglect in the black community continues to run its course in America while its people wrestle with generations of biased concepts put upon blacks. To medical professionals, the lack of healthcare equity in the black community is presenting detrimental effects on their black patients.  Many journals have been written on the topic which are backed up by scientific evidence.  According to the American Journal of Public Health, 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. In a 2001 publication titled “Race, Medicine, and Health Care in the United States: A Historical Survey,” The Journal of the National Medical Associates addressed racism per Van den Berghe (emeritus scholar, anthropologist and sociologist). He highlighted direct correlations to racism and health outcomes, and he defined racism as “any set of beliefs that organic, genetically transmitted differences (whether real or imagined) between human groups are intrinsically associated with the presence or the absence of certain socially relevant abilities or characteristics, hence such differences are a legitimate basis of invidious distinctions between group socially defined as races.” Van den Berghe went on to explain that Americans are dealing with two types of racism which have historically had impacts on the healthcare outcome of blacks.

Paternalistic Racism: Old-Fashioned post abolishment racism. Blacks viewed as immature, irresponsible, improvident, fun-loving, child-adults-inferior, but lovable as long as they did not deviate from clearly defined roles. In this form of racism, the object was seen as a pet to be taken care of to a certain degree; however, resistance or rebellion by the object triggered extreme disproportionate brutality. Although these slave owners felt that they were the most humane among slave owners, the brutality of such punishments always resulted in negative health outcomes for the slaves as they were not part of the healthcare system and were left to nurse their own wounds.

Competitive Racism: Post slavery racism.  With the abolishment of slavery, the poor and working-class whites who were in the majority and assumed control, would no longer accept the slaveowner’s paternalistic image of blacks as good children or pets. To them blacks were seen as uppity, insolent, aggressive, thuggish, dishonest competitors for scarce resources. In this form of racism, the object was viewed as an enemy to be annihilated. This type of racism resulted in unwarranted killings of blacks and legalized segregation by the United States government. The idea was “you have yours and I will have mine, but mine will always be better than yours because I have power over you.” This type of racism brings us to where we are today in 2020, racism based on “power.” The blinders have been pulled back as COVID-19 patients in “government redlined” disadvantaged areas are disproportionately negatively affected by the virus due to generations of healthcare neglect based on racism in America.

In all honesty, I began writing this series to address the COVID-19 pandemic before the horrific and brutal murders of Ahmaud Arbery, Breonna Taylor, and George Floyd were brought to light and ignited a global “Black Lives Matter” movement. There were days that I just cried and could not continue to write this article as it exacerbated my emotions by the shear knowledge I encountered from my research and the all too real experiences that I have encountered throughout my lifetime. What brought the tears to my eyes was the calcification of the horrors in what I was writing directly resulting into these recent killings. The facts is that what I was writing made it starkly clear to me that Black Lives have not mattered throughout much of America’s history. In reflection on this day, Juneteenth 2020, and as we approach the birthday of our nation’s independence, “Black Lives Matter” is a declaration that must finally be affirmed in our country and throughout the world. It is not an exclusionary statement to other races because it has been “by design” that blacks are denied basic human services, empathy, opportunity, and equity in the systems afforded by the United States Declaration of Independence that allow a persons to thrive and create a positive trajectory for future generations through “the inalienable right of a person to LIFE, LIBERTY, and the pursuit of HAPPINESS”.

Please stay tuned to this series. Part II will cover the present and challenging state of “Where we are.” It will cover the health implications of redlining (the systematic denial of various services by federal government agencies, local governments as well as the private sector, to residents of specific neighborhoods or communities, either directly or through the selective raising of prices), food equity, gentrification, healthcare access, and COVID-19 the prevalence of comorbidities in the black community.

READ MORE

READ PART 2 IN THIS SERIES: HEALTHCARE IN BLACK AMERICA - WHERE WE ARE

READ PART 3 IN THIS SERIES: HEALTHCARE IN BLACK AMERICA - WHERE WE HOPE TO BE