16 August 2019
Dear Interested Readers,
Race and Healthcare
The New York Times Magazine has launched a program this month that it is calling “The 1619 Project.” This year is the 400th anniversary of slavery in America. The piece that you will find if you follow the link begins:
The Fourth of July in 1776 is regarded by most Americans as the country’s birthday. But what if we were to tell you that the country’s true birth date, the moment that its defining contradictions first came into the world, was in late August 1619?
That was when a ship arrived at Point Comfort in the British colony of Virginia, bearing a cargo of 20 to 30 enslaved Africans. Their arrival inaugurated a barbaric system of chattel slavery that would last for the next 250 years and form the basis for almost every aspect of American life. The 1619 Project is a major initiative from The New York Times memorializing that event on its 400th anniversary. The goal of the project is to deepen understanding of American history (and the American present) by proposing a new point of origin for our national story. In the days and weeks to come, we will publish essays demonstrating that nearly everything that has made America exceptional grew out of slavery.
Race, or the associated issues of white supremacy, or white advantage, has been the biggest, and yet most avoided or ignored issue in our national story. As Jill Lepore points out in her magnificent 2018 review of American history, These Truths: A History of the United States, we have had issues with race, and there has been controversy over how we treat people who are not white since Columbus encountered the indigenous people of the Caribbean. Lepore points out with staggering documentation that the founding fathers knew that slavery was wrong, and that the travesties that are present in our founding documents are evidence that in the complex political math of what many of them knew to be right, and the compromises necessary to get a deal and to protect established economic interests, what was right was subtracted to get to an answer that was expedient. She documents that our founding fathers were just as aware of the injustices and cruelties of slavery, as well as the suppression of the rights of women as we are, and chose to ignore the voices calling for real equality for all, regardless of race or gender. Lapore has written a biography of Benjamin Franklin’s sister and documents her pleadings with him to free his own slaves. Abigail Adams implored her husband John to defend the rights of women. The only logical conclusion is that the lofty words “We hold these truths to be self evident…” has been a work in progress for a long time, and during that long time, and until this day, there has been a taint on the “greatness” of our country. Knowing what is right has not been our problem. Doing what is right has always been our challenge, and for long stretches of time good intentions have persisted side by side with the suffering associated with our delay in making those words ring true. As Jennifer Szalai, a reviewer of the book, writes.
One part of this story is how the founders — and generations of politicians thereafter — contorted themselves and their reasoning to maintain a concept of equality that excluded women and people of color. Recounting how such jarring discrepancies would play out in the founders’ actual lives, Lepore is matter-of-fact. James Madison almost sold a slave to buy a book of enlightenment philosophy. Despite George Washington’s ambivalence as a slaveholder, the people he claimed as his property were still subject to a crude and brutal utility: His dentures were constructed out of a combination of ivory and nine teeth yanked from their mouths.
As any regular reader of these notes can attest I have been reading a lot about race and economic inequality over the last few years in my attempt to better understand the social determinants of health. You could go to http://strategyhealthcare.com/ and type “social determinants of health” into the search function and come up with a long list of postings that are filed with quotes from my readings. One of the most profound statements I have read, and that I do not think that I have included in a previous post, is Malcolm Gladwell’s confession in his best selling book Blink of his own bias against black Americans as revealed in a test that he has taken many times and never passed, that is designed to detect racial bias. What makes that remarkable is that he, like Barack Obama and Frederick Douglas, is biracial.
Following the advice of Gladwell, and admitting to the same struggle to expunge the imprinting that is noted in the above link, I have struggled all my life with the issues of race presented by my environment and heritage. I am a son of the South, as well as an American with ancestral roots that go back to the 1620s. I have recently learned from 23 and Me that my ancestors, most of whom were from the British Isles and Western Europe, some of whom were slave holders, must have intermingled their DNA with those that they owned because about 1% of my own DNA is from West Africa, and the list of the thousand or so “relatives” that 23 and Me has produced reveals my genetic relationship to dozens of African Americans.
I was taught that the Civil War was fought to defend “states rights” which was obviously a thin disguise for the attempted preservation of the right to continue slavery. Apartheid existed in every community that I lived in, and to some degree still persists in southern cities like Atlanta, Birmingham, and Houston all of which have had African American mayors and simultaneously have had “white flight” to the suburbs and to private schools where a de facto form of segregation can persist. My childhood was spent in the waning hours of the Jim Crow South, and I can personally attest that like the stench in a room where smokers have been for a long time, you can still smell the odor even though the Civil Rights Act of 1964 and The Voters Rights Act of 1965 technically established equality and confirmed “These Truths…” What I did not expect to find when I came North was the persistence of those same abhorrent passions in Boston where the racial divides and hostilities were thinly veiled, but nevertheless present.
There were no African American students in my public school classes in the South, and I graduated from high school nine years after Brown v. The Board of Education of Topeka. There were very few African American students in the schools my children attended in Newton and Wellesley, Massachusetts between 1970 and 2003, and many of the black students who were enrolled in their schools rode buses for hours every day from Roxbury, which could be legitimately considered a ghetto. Almost every American city has de facto segregation of the races that has been maintained as the legacy of the time before the Civil Rights act was passed by the local administration of the federal programs that were designed to enable the emergence of racially diverse neighborhoods. Until recently, I have been as ignorant as most Americans of the economically devastating effects suffered by African Americans long after Jim Crow was dead through programs like “redlining” and other tricks of maintaining segregation by local governments granted to them through federal laws that were to be managed by local officials.
We have developed the ability to pass a law designed to move us toward “These truths,” or to create equal opportunities, and then undermine the objectives of the law through complex administrative processes managed to perpetuate the disadvantages of people of color. Do you know the stories of how many Black Americans were excluded from Social Security or GI Bill benefits? Is it any wonder that in an era when we are still experiencing violence from white supremicists and other hate groups the question of “reparations” is becoming a central issue in the process of selecting the next president?
One of the first articles in the “1619 series” was written by Jeneen Interlandi, and has the provocative title, “Why Doesn’t The United States Have Universal Health Care? The Answer Has Everything To Do With Race.” I felt that I needed to describe some of our shared history, and my own experience with race in America, before reviewing this challenging article. She begins her discussion of the black experience with healthcare by taking us back to the period immediately after the Civil War. There is a companion piece in the 1619 program that has an equally provocative title, “Myths About Physical Racial Differences Were Used To Justify Slavery–And Are Still Believed By Doctors Today,” written by Linda Villarosa that goes back even further in the shabby history of race and medicine in America.
Interlandi points out that in the late 1860s smallpox moved through the freed population of former slaves quite differently than it moved through the white population. “Healthcare disparities” were not a named understanding in the 1860 but they certainly existed:
In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.
Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”
Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.
White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.
If you think that the disgusting comments of that 19th century congressman represents behavior that we have moved beyond, let me remind you of the recent comments of Congressman Steve King of Iowa in relationship to rape and incest.
One of the most delightful discoveries for me in the article by Ms. Interlandi was her presentation of Dr. Rebecca Lee Crumpler, the first African American female physician. She graduated from the New England Female Medical College in 1864. The medical college that admitted her was later merged into Boston University Medical School. Interlandi writes:
At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”
The hope of a better life for Black Americans was put on long term hold after reconstruction:
In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent…
In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities…
Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get.
She describes the evolution of a black medical community after the AMA barred black doctors. Most black doctors were graduates of the two Black medical schools, Howard and Meharry. She reports that since the 50s the black National Medical Association has advocated for a nationalized health plan because healthcare is a basic human right. The AMA was always in opposition to any program of public assistance to those who needed healthcare implying, as we still hear, that such programs were socialist and un American.
The Kaiser Foundation has created a small slide deck that demonstrates the persistent disparities that many black Americans endure even after passage of the ACA. There is no question that there is a significant correlation between the states of the old South and the states that have blocked the Medicare expansion. It is no surprise that the lawsuit that currently threatens the ACA originated in Texas. The Kaiser charts show that the ACA has reduced disparities, but they persist and represent a continuing state of denial of care for their most vulnerable, and predominately black population. It is had to prove in a way that we will all accept, but also hard for most of us to deny, the possibility that our continuing failure to treat black Americans with the healthcare equity they deserve arises from our well documented legacy of racism and the history of our systematic marginalization of Black Americans.
Interlandi ends her article by stating the only logical conclusion that can flow from the evidence she has presented.
One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.
How long will we tolerate the inconsistency between our foundational documents and the realities that we must admit have persisted for much too long a time? That was the question behind the famous “I Have a Dream Speech” that the Reverend Dr. Martin Luther King, Jr. made on a hot August day in Washington 56 years ago when he declared:
…one hundred years later, the Negro still is not free. One hundred years later, the life of the Negro is still sadly crippled by the manacles of segregation and the chains of discrimination. One hundred years later, the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later, the Negro is still languished in the corners of American society and finds himself in exile in his own land. So we have come here today to dramatize a shameful condition.
You may say that things are better, that we have made great progress toward his dream, but any review of the data leads us to conclude that the progress we have made, painfully slow progress, does not constitute the fulfillment of his dream. You might also remember that Dr. King said,
“Of all the forms of inequality, injustice in health is the most shocking and inhuman.”
To steal sentiment from a song of the civil rights era, the answer to Dr. King’s question is still blowing in the wind, and 56 years later it is remains more a dream than a reality, but we must continue to repeat the story of the dream until it becomes a reality that we all accept. The Triple Aim is also a dream that has no real chance of realization until we address our inability to live up to our own rhetoric about “These truths…” Until we secure the dreams of equality and color blind opportunity, our “truths” are only an unrealized possibility, and our opportunity for true greatness eludes us.
Perhaps some day the check for the debt we owe African Americans will be delivered and cashed. Until then things remain much the same as they were when Dr. King introduce his dream. Equity in healthcare has been an elusive dream for a very long time, disparities will continue to exist, and what should have been a reality a long time ago will remain just a dream.
I have a dream that one day this nation will rise up and live out the true meaning of its creed: “We hold these truths to be self-evident; that all men are created equal.”
Savoring Summer As It Slips Away
I look forward to summer more than I anticipate any other season. I enjoy spring, but it has so many false starts that it becomes a one day at a time phenomena that is punctuated by returns of winter that can frustrate me until early June. Fall is beautiful, but the color is quite variable from year to year, and then by the third week in October everything is brown, and most of it is down. I say that I love the four seasons including winter, but there is a little white lie in that declaration. I love winter, but I also fear it. Things happen. My walks can become opportunities for physical disaster. Last winter I had a few surprise falls on icy and snow covered roads despite using ski poles and micro spikes on my shoes. Fortunately, I still bounce, and all my layers of sweaters and jackets must provide some protection from trauma. I am now a devoted practitioner of Pilates as I seek to maintain balance and flexibility, and as much as possible avoid “going to ground,” as I move into my later seventies, and perhaps with luck into my nineties.
My love of summer is not based in the reality that there is less violent weather or less possibility for trauma, I think that it is more related to all the flowers and all the fauna I see, and the sense that nature is just a little bit more accessible or less hidden from view. Summer can still have its disappointments, like the reality that there were no baby loons on our lake this year. But, there are so many other offerings that ameliorate that loss like the family of common mergansers that I see literally running across the water. The mother is pictured in today’s header. It’s been fun to watch the little ones become more and more independent of the mother. Another avian surprise that occurred this week has been the sudden appearance of cormorants! I have had a home in the Upper Valley since 1995, and have spent a lot of time on its lakes, and this is the first time I have seen a cormorant here.
Just this week, we had high winds and driving rain that lasted only about a half hour as a front went through. Then the sky cleared in a flash revealing a brilliantly lighted full double rainbow! There were other events of note this week. We were visited by a pack of at least eight loons for a few days. They must have been juveniles that were out visiting around and looking for fun.
Perhaps my appreciation for summer at the lake was enhanced this week because we had visitors. My father’s widow and my sister-in-law flew up from North Carolina for a long overdue visit. Neither of them had ever been north of New York City. They marveled at the vibrant green ferns that are everywhere in many varieties that I take for granted. We spent a lot of time on the water putting around in my old boat while fishing with worms. (I am not usually a bait or spin casting fisherman.) We caught a lot of fish, mostly “pumpkin seeds” or “blue gills,” if you prefer, and I saw things through their eyes that I usually overlook. Perhaps the most surprising sighting was “old man” turtle. I had seen him before several years ago in exactly the same place, just past the end of my dock in about four feet of water. His head is about the size of two softballs. His shell is larger than the lid on a large rubbish barrel, and his gnarly legs and toes end in claws that look like they could belong to a bear. He may be as old as I am, or older.
Today’s letter comes to you from the redwoods of coastal California. We are here to visit our two grandsons, ages five and almost two. They live a few miles outside of Santa Cruz in Felton, California where there are many trails to explore, and there are magnificent beaches sporting talented surfers just a short ride ride away. We are here to visit them in their new home, and share the experience of the five year old’s first few days of kindergarten at the local public school. The trip also seems like a very good way to savor a little more summer and see how the world looks from the left coast. Whatever you are doing, and wherever you are, I hope that you will enjoy the best weekend of your summer. The Labor Day weekend and the traditional start of fall are coming up fast.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
