A Historical Perspective on Disparities as Context for Our Work Ahead

Abstract

BAYLOR HEALTH CARE System's laudable accomplishments in promoting care equity and Dr. Joseph Betancourt's analysis in this same issue illustrate how far we have come toward reducing disparities in care-and how far we still must go. For hospitals and health systems, historical context is important here, as the roots of disparities in the US healthcare system run deep and merit consideration as we push forward to improve how we serve society's most vulnerable people.HISTORICAL BACKDROP TO CURRENT EQUITY EFFORTSThat Baylor, a system situated in the once rigidly segregated South, has emerged as a leader in reducing care disparities is particularly noteworthy when we consider the long and troubled history of healthcare for minorities and other vulnerable populations in the United States.As with most aspects of life, medical care in the United States, and especially in the American South, was segregated by race prior to the civil rights era. Across much of the South, and even in northern cities with significant populations of African Americans, a separate system of hospitals served black patients and provided training and practice opportunities for black physicians. African Americans in the South largely received care at only hospitals, and even those requiring emergency care often were turned away by white institutions (Zheng and Zhou 2008).That hospitals for black patients existed at all owes in part to the reaction of African American physicians to the terrible consequences that the lack of hospital care had on sick and injured blacks. Black physicians spearheaded efforts to establish these facilities after the Civil War and through the first half of the twentieth century-from about 40 in 1900 to about 370 by the early 1960s (Zheng and Zhou 2008). But in terms of health outcomes, progress was slow-especially in the South, where hospital care for African Americans was scarce. In Mississippi, for example, black lay midwives delivered more than 80 percent of African American babies well into the 1940s, and overall, the health status of blacks changed little between the slavery era and the start of the Great Depression (Smith 2005).Ultimately, the 1964 Civil Rights Act and the application of its antidiscrimination safeguards to Medicare ended sanctioned separation of races in hospitals. As important were the urban health departments and public hospitals, especially in the North, that stepped in to fill the void of care for blacks and other minorities well before civil rights reforms took hold. The New York City Health Department, for example, worked with the Urban League in 1916 to reduce high infant mortality rates among blacks, lowering deaths from diarrheal and respiratory diseases from 71 and 80, respectively, of every 1,000 black infants to 48 and 50 in one year (Beardsley 1990). Prominent public institutions that in the latter half of the 1900s coalesced into the nation's healthcare safety net trace their beginnings as historically black hospitals-the Civil War-era Freedmen's Hospital in Washington, D.C., which later became Howard University Medical School's teaching hospital, among the first.That legacy of providing access to society's most vulnerable reverberates strongly today among those essential hospitals and health systems committed to keeping their doors open to the uninsured, the underinsured, and other disadvantaged patients. Against the historical backdrop of this nation's profound care inequities, the efforts today of Baylor and other systems like it are all the more remarkable and deserving of recognition.But clearly, we need to do much more, as Betancourt shows us. All hospitals-not just those that historically have championed the cause of the vulnerable-must recognize the urgent need to ensure that all patients receive the highest quality of care possible. More to the point, they need to follow Baylor's lead and emulate the work of the many other essential hospitals that make understanding and meeting the particular needs of minorities a priority. …