"Eliminating the Slave Health Deficit: Using Reparations to Repair Black Health,"by Vernillia Randall November/December 2002 issue of Poverty & Race
As an African American and as a nurse-practitioner, I can clearly assert that: ¡§Being Black in America is dangerous to our health!¡¨
That current health disparities are directly traceable to slavery is a fact that is not well understood. African-Americans still suffer from the generational effects of a slave health deficit. And reparations could repair that deficit.
But before we can engage in a discussion around the ¡§slave health deficit,¡¨ I need to lay out a clear definition of reparations. To many --ƒnBlack, White and other -- reparations is viewed as a paycheck, some undetermined amount of money for some long-ago harm. In my view, that is an incomplete and destructive view of reparations. Rather, reparations should be viewed as an obligation to make the repairs necessary to correct current harms done as a result past wrongs. This is a much more expansive view than merely calculating the economic harm and writing a check. Under this view, reparations become a process that restores hope and dignity and rebuilds the community. Writing about the relationship of Japanese-American redress and to African-American claims, Eric Yamamoto concludes, "[R]eparations for African Americans, conceived as repair, can help mend this larger tear in the social fabric for the benefit of both Blacks and mainstream America." This view allows for both responsibility and action by all parties. It allows for healing to begin by allowing the souls of Blacks and Whites to be cleansed. Thus, when I speak about reparations, I am talking about taking up the burden to repair the harm „G that is, to eliminate the ¡§Black health deficit.¡¨
African-Americans lag behind on nearly every health indicator, including life expectancy, death rates, infant mortality, low birth weight rates and disease rates. African-Americans are sicker than European-Americans. We have shorter lives -- we are quite literally dying from being Black! This Black health deficit is directly traceable to the slave health deficit.
The enslavement of Africans was abnormally hazardous, and there were health hazards and high death rates during every phase: during the interior trek, the middle passage, the breaking-in period and the enslavement. The slave health deficit that was established during slavery was not relieved during the Reconstruction period (1865-1870), Jim Crow era (1870-1965), the Affirmative Action era (1965-1980) or the Racial entrenchment era (1980 to present). Thus, repairing the health of African-Americans will require a multi-faceted, long-term financial commitment and effort.
The current status of black health is based on long-term systematic neglect built on a ¡§Slave Health Deficit.¡¨ Another way to think about the kind of commitment needed is to consider that of the total time that persons of African descent have had a presence in the New World, 64% of that time was as chattel slavery and another 26% of that time was spent in de jure or ¡§Jim Crow¡¨ segregation. For less than 10% of the total time in the United States have persons of African descent had full legal status as citizens. From a health perspective, 64% of the time was spent establishing and maintaining a health deficit, and at no point has that deficit been removed. Thus, the burden of a slave health deficit has been continuous.
Elements of a Program
The slave health deficit will be removed only if the United States makes a significant and sustained commitment - undertaking whatever actions necessary. Specifically, to eliminate the slave health deficit, the government will need to:
Eliminate the disparities in morbidity and mortality.
This will require, among other things: (1) a focus on education and prevention through targeted services; (2) provision of a livable wage for all persons and families; and (3) elimination of environmental hazards in African-American communities.
Targeted Services. Until recently, eliminating health disparities has not been a goal. For instance, the goals promulgated by the U.S. Department of Health and Human Services in "Healthy People 2000" focused on reducing disparities, not eliminating them. It was not until "Healthy People 2010" that eliminating health disparities became a goal, and the same health goals for Whites were set for African Americans. Targeting health care services to African-Americans would focus resources on the specific health problems confronting them. States could take steps to target services toward African-Americans. In particular, a focused and sustained effort must be undertaken to eliminate health disparities in diabetes, cardiovascular disease, maternal and infant mortality, HIV/AIDS, cancer, oral health, mental health, drug, alcohol and tobacco addiction, asthma and violence (including domestic violence).
An essential public health approach will need to be taken which includes primary, secondary and tertiary care. Primary care involves services that prevent any harm by changing behavior of individuals and others. Primary services would focus on educational and preventive services. For instance, outlawing the sale of alcohol within ten miles of neighborhoods or schools would be a primary service, since it would impact the actual use of alcohol. Secondary services are services designed to intervene early and minimize the harm done. For instance, early prenatal care can be used to assist women who are pregnant to stop drinking early in their pregnancy, thus reducing the harm done to the unborn child. Tertiary services involve steps after harm has been done and can involve steps that invoke punitive policy or legislative action. For instance, tertiary services would involve alcohol treatment programs, and if the pregnant woman was reluctant to use the services it could involve civil commitment. For an effective approach to eliminating health disparities, there must be a full range of public health services and actions.
Provide a Livable Wage or Income. Health status is caused by complex interaction of many factors, including individual behavior. However, recognizing the importance of individual behavior in health status does not minimize the need to focus on systemic influences such as poverty and racism. Poverty affects housing choice, job choice, food and education. Since African-Americans are disproportionately poor, the elimination of poverty becomes essential to improving their health status.
Poverty is also a problem for the ¡§working poor,¡¨ also disproportionately African-American. The working poor are people whose full-time, year-round earnings are so meager that, despite their best efforts, they can't afford decent housing, diets, health care or childcare. Assuring everyone in the United States a "livable wage," not merely a minimum wage, could eliminate poverty and the problems of the working poor.
A ¡§livable wage¡¨ provides enough income to pay for the basic necessities of daily living: shelter, food, clothing, health care, child-care and transportation. Without a livable wage income, people suffer not only a lack of dignity, but also a variety of social and health problems. In a 2000 study, the San Francisco Department of Public Health reported livable wages diminished mortality rates, decreased unnecessary hospitalization of the poor, eliminated some costs associated with caring for the homeless and saved lives.
Thus, livable wages become a cornerstone to eliminating the slave health deficit, and reparations should be in the form of assuring a livable wage.
Eliminate Environmental Hazards in African-American Communities. One particularly important consideration for health is the location of environmental hazards and toxic dumps in Black communities, workplace hazards and hazards in the home. Studies have documented that hazardous waste landfills are disproportionately placed in African-American communities. Such studies have concluded that race -- more than poverty, land values or home ownership -- is a predictor of the location of hazardous facilities. Race is independent of class in the distribution of air pollution, contaminated fish consumption, location of municipal landfills and incinerators, abandoned toxic waste dumps, cleanup of Superfund sites, lead poisoning in children, and asthma. In 1987, more than 15 million (57%) of the United States' 26 million African-Americans resided in communities with one or more uncontrolled toxic-waste sites. African-Americans faced with a polluting industry moving into their backyard often have the least mobility because of limited financial resources and discrimination in employment and housing.
In addition, African-Americans are disproportionately represented in jobs with the highest environmental hazards, such as fast food and pesticide-intensive farm labor, rubber-making, coke production, battery manufacturing, lead plating and smelting, and industrial laundering. In the workplace, African-American men have a 27% greater chance than White men of facing safety hazards and a 60% greater chance of facing health hazards. Even controlling for the level of job training and education, African-Americans find themselves in substantially more dangerous occupations than whites.
Finally, for African-American children, lead poisoning in the home is a significant health issue. The blood lead levels in urban African-American children under the age five significantly exceed the levels found in White children of the same age living in the same city. This disparity persists across income levels. Thus, for families with incomes less than $6,000, 68% of Black children, compared to 36% of White children, had unsafe blood levels. In families earning more than $15,000, 38% of Black children and 12% of White children had excess lead levels.
Given the above, reparations should be used to remove toxic dumps and landfills from African-American communities or completely relocate such communities to a safe environment; to make workplaces safer and to eliminate lead paint from housing.
Assure Access to Quality Health Care.
Eliminating morbidity and mortality disparities will require access to quality care. Assuring access to quality care will require: (1) assuring universal health care; (2) locating adequate health care facilities within the Black community; (3) assuring a competent health care workforce in Black communities; (4) assuring the cultural competence of the health care workforce; and (5) increasing knowledge about health and health of Black persons and translating it into effective clinical practice
Provide universal health care. The United States and South Africa are the only major industrialized nations without a universal health insurance system that guarantees access to health care for all of their citizens. What the United States has instead is a scheme of employer-financed insurance and government programs that still leave more than 41 million Americans without the financial resources to pay for health care. The lack of health insurance is a particular issue for African-Americans, who are less likely to have employer-financed insurance. While public programs, such as Medicaid and Medicare, are important sources of health care coverage for many low-income African-Americans, they do not reach anywhere near all of the uninsured poor. In fact, one-fourth of African-Americans have no source of health coverage. Even more disturbing is that the number of uninsured African-Americans is increasing. While from 1977 to 1987 the proportion of uninsured non-elderly European-Americans increased from 12% to 15%, the proportion of uninsured non-elderly African-Americans increased from 18% to 25%.
Since private health insurance coverage is linked to employment, racial barriers to employment are one explanation for the significant difference in insurance coverage. For example, in 1990 the African-American unemployment rate was 240% higher than the European-American unemployment rate. However, even where employed, African-Americans are more likely to be in lower-paying jobs that do not provide employer-based health insurance. Another factor affecting insurance coverage is the higher percentage of African-American families with only one adult. Families with two working adults are more likely to have at least one adult with employer-based insurance.
While the absence of health insurance is much more likely among those with lower incomes, race is an independent factor. In fact, the racial difference in proportion of uninsured is most marked at higher incomes. For example, poor/low-income African-Americans are uninsured at about the same rate as poor/low-income European- Americans; however, middle/high-income African-Americans are almost twice as likely to be uninsured as higher-income European-Americans.
Reparations should be used to expand insurance coverage so that all African-Americans have either employer-based or government-based insurance.
Locate health facilities in Black communities. Racial barriers to health care access are based in large part on the unavailability of services in a community. Hospitals that serve the African-American community are closing, relocating or becoming private. In 1982, Alan Sager reported to the United States House of representatives that during the 1937-1977 period the likelihood of a hospital's closing was directly related to the percentage of African-Americans in the population. Throughout the 1980s, many hospitals relocated from heavily African-American communities to predominantly European-American suburban communities.
This loss of services to the community resulted in reduced access to care for African-Americans. Geographic availability and proximity are important determinants to seeking health care services early. If African-Americans fail to seek early health care, they are more likely to be sicker when they do enter the system; and the cost for the patient to receive services and for the system to provide services at that point is likely to be greater. Thus, not only does the loss of services significantly increase health care costs to African-Americans, it also increases health care costs to the society.
Another devastating trend that affects the access of African-Americans to health care is the privatization of public hospitals. Quite a few hospitals (public and non-profit) have elected to restructure as private, for-profit corporations. As public hospitals, many were obligated under the Hill-Burton Act to provide uncompensated care. As private hospitals, these institutions are most likely to discontinue providing general health services to the indigent populations and essential primary health care services to serve African-American communities.
The problem of limited resources is not new and has plagued the African-American community since slavery. Historically, African-American communities attempted to address the problem by establishing African-American hospitals. At one point, more than 200 hospitals were located in predominantly Black communities. African-Americans relied on these institutions to heal and save their lives. Now these institutions are almost non-existent. By the 1960s, only 90 African-American hospitals remained. Between 1961 and 1988, 57 African- American hospitals closed and 14 others merged, converted or consolidated. By 1991, only 12 hospitals continued to struggle daily just to keep their doors open. As a result of these closures, relocations and privatization, many African-Americans are left with limited services and difficult access to hospitals.
Reparations should provide hospitals, clinics, alcohol and drug detox centers, dental health clinics and mental health clinics in the African-American community.
Assure a competent health care workforce in Black communities. Another important aspect of access to care is the availability of health care providers who serve the African-American communities. Providers include physicians, nurses, pharmacists, dentists, as well as the many other health care professionals who serve a community. It should go without saying that proximity increases utilization. African-American physicians have been important in filling the availability gap. Very few White physicians have offices in the African-American community. Without physicians and providers in their communities, African-Americans are likely to delay seeking health care. That delay can result in more severe illness, increased health care costs, increased mortality and increased costs to society.
Despite being 12% of the population, African-Americans are seriously underrepresented in every health care profession. Only 3% of physicians, 2.5% of dentists and 3.6% of pharmacists are African-American. In fact, 75% of African-American physicians practice in or near African-American communities, 90% had patient loads that were at least 50% African-American. Of European American physicians only one in every 163 (.61%) had a 90% African-American patient load. Thus, this shortage of Black health care providers results in sicker individuals and an increase in overall health care costs. If African-Americans are sicker, they need more physicians, not fewer. Yet we see the same limited availability of providers, as of hospitals, to serve African-American communities. In addition, even programs such as Medicaid do not necessarily expand access, since many primary care providers either do not accept Medicaid patients or limit the number of such patients they will accept. It is only natural to look to the African-American physicians to fill this gap.
With so few African-American health care professionals, the control of the health care system lies almost exclusively in European-American hands. The result is an inadequate, if not ineffective, voice on African-American health care issues. This lack of African-American voice leads to increased ignorance on the part of European-Americans regarding issues pertaining to African-American health. When health care issues are defined, policymakers' ignorance results in their overlooking African-Americans' health concerns.
Clearly, a significant issue for eliminating health disparities is increasing the availability of providers in African-American communities. This lack of African-American representation in health care is traceable to slavery, racism and segregation. An African-American did not receive a degree in an American medical school until 1847. While a few White medical schools admitted African-Americans prior to the Civil War, most did not. Even in 1971, 21 medical schools out of 85 still had no African-American students. The American Association of Medical Colleges reported that between 1950 and 1998, out of the 125 U.S. medical schools, 12 graduated 30% of all minority physicians. And for Black physicians, Medical schools at Howard, Meharry and the University of Illinois graduated the most.
Reparations should be used to increase the availability of providers in the Black community. This should be done by providing scholarships for Blacks to enter health care professions; by providing grants to universities and colleges to increase the graduation rate of persons who will work in urban areas; by increasing the capacity of historically Black colleges to train and graduate students; by increasing health care reimbursement for services provided to inner-city residents; and by providing economic incentives to doctors and other health care professionals to locate in African-American communities.
Assure cultural competence of the health care workforce. A person does not have meaningful access to health care if that person is not provided health care within the context of his or her cultural background. Merely providing a person with a piece of paper (insurance) or a provider does not mean that the person will receive health care that assists in improving the person's health status. For centuries, Americans indulged in the fantasy that all persons (Native Americans, immigrants and slaves) blended into one great "melting pot" to become Americans. While it is true that there are unique American cultural similarities that cut across all groups, this country has always had a diverse population of races, ethnic groups, subcultures and religions.
Unfortunately, the medical care system represents one subculture: the middle-class, middle-aged European-American. For instance, the system focuses on individual autonomy rather than family involvement. It assumes a basic trust in the health care system, instead of distrust. It relies on a western, European-American concept of communications. It is built on a Western European concept of wellness, illness and health care. Consequently, the more a patient differs from the cultural prototype, the more likely the person will not have meaningful access to quality health care.
One barrier to culturally competent care is physicians' own negative perceptions about African-Americans. Because they have differing needs and problems in accessing care, physicians tend to see African-Americans as less compliant and more difficult to care for. The problem, however, is not African-Americans, but the health care system's inability to provide effective care to diverse populations. If increased compliance and improved health status are the goals, then the health care system must be flexible enough to match a community's cultural, ethnic, lifestyle and socioeconomic needs.
Through reparations, culturally competent care can be assured by requiring: (1) health professional schools to train providers from a diverse background; (2) that all physicians have a rotation during their internship and externship focusing on providing culturally competent care; (3) that providers take continuing education units in cultural competency; (4) that health care facilities and managed care organizations complete and submit to a regulatory agency on a regular basis a cultural competency assessments; (5) that health care be provided in accordance with realities of the needs of the various ¡§classes¡¨ of the Black community.
Increase knowledge about health of Black persons and translate it into effective clinical practice. Despite volumes of literature suggesting the importance of race, ethnicity and culture in health, health care and treatment, there is relatively little information available on the racial, ethnic and biological differences that affect the manifestations of certain illnesses and their treatments. Billions of dollars are spent each year on health research ($35.7 billion in 1995). However, a strikingly minute percentage of those funds are allocated to research on issues of particular importance to minorities and women, and to research by African-American and women scientists (21.5% and 37%, respectively). In response to years of exclusion of minorities and women, several statutory requirements have been enacted to ensure that research protocols include a diverse population. The health condition of African-Americans will continue to suffer until they are included in all types of health research. The information from that research has to be translated into clinical practice without becoming just another stereotype.
Reparations should be used to assure that health care research and development is focused on the health issues of African-Americans.
Eliminate Racial Discrimination in Health Care and Health Research
Federal laws related to eliminating racial discrimination in health care delivery are limited to Title VI of the Civil Rights Act. Racial inequality in health care persists in the United States despite laws against racial discrimination, in significant part because of the inadequacy of Title VI. Although required by regulation to produce data, the Office of Civil Rights (OCR) Title VI enforcement effort has produced little consistent data for evaluating Title VI compliance. Moreover, there has been little uniformity in how different states handle Title VI requirements, little guidance, little analysis of the information collected by this process, and no research and development. Title VI also lacks specific definitions of prohibited discrimination and acceptable remedial action. Finally, OCR has relied on individual complaints as a means of enforcement, particularly troubling when most discrimination and harm is hidden from the individual.
Even if the provisions of Title VI were improved and data collected, the legal system within which Title VI operates would still be inadequate for the particular difficulties presented by the health care system. That is, the legal system has had difficulty addressing issues of ¡§unthinking discrimination¡¨ „G that is, discrimination that results from acting on biases and stereotypes. While legal standards for discrimination have not always centered on intent, they do so now. Thus, to prove a disparate treatment claim, an individual must show that the defendant intentionally discriminated. Such a standard means that few of the discriminatory acts that occur in the health care system can be successfully litigated, since most occur from ¡§unthinking¡¨ or ¡§unconscious¡¨ biases. As long as the law requires a conscious discriminatory purpose for disparate treatment liability, individual discrimination claims cannot address the issue of unconscious prejudice.
Furthermore, the health care system presents several additional problems. First, as with the situation when racial minorities use housing and lending institutions [see Squires article, page X], individuals may be totally unaware that the provider or institution has discriminated against them. Second, because of the very specialized knowledge required in medical care, individuals may be totally unaware that the provider has injured them. Third, the health care system, through managed care, has actually built in incentives that encourage ¡§unconscious¡¨ discrimination. Because of these issues, an appropriate legal structure is essential to eliminating institutional/cultural racism.
In an effective public health policy, appropriate state and federal laws must be available to eliminate discriminatory practices in health care. Thus, the crux of the problem, given managed care, the historical disparity in health care, and ¡§unthinking" discrimination, current laws do not address the barriers faced by African-Americans; and the executive branch, the legislatures and the courts are singularly reluctant to hold health care institutions and providers responsible for institutional racism. As the United States Commission on Civil Rights found in a 1999 report:
Authorize and fund the use of medical testers. To discourage health care discrimination, an aggrieved person should be redefined to include not only the individual who has been injured, but also one who believes that he or she will be injured, as well as individuals engaged as testers and organizations engaged in testing. In testing, persons pretending to be patients, who share common traits or symptoms except for their race, are sent to health care facilities or providers in order to prove that patients of a particular race receive different treatment. This is important because much of health care discrimination goes undetected and unreported.
Require data collection and reporting. Current data collection efforts fail to capture the diversity of racial and ethnic communities in the United States. Disaggregated information on subgroups within the Census Bureau's five racial and ethnic categories is not collected systematically. Further, racial and ethnic classifications are often limited in surveys and other data collection instruments, and minorities often are misclassified on vital statistics records and other surveys and censuses. It is important to collect the most complete data on African-Americans and other sub-populations, to fully understand the health status of all individuals, as well as to recognize the barriers they face in obtaining quality health care. The lack of data on providers and institutions makes it difficult to conduct research studies and comparative analyses. Furthermore, the lack of a uniform data collection method makes obtaining an accurate and specific description of race discrimination in health care difficult. Existing data collection procedures do not allow for regularly collecting race data on provider and institutional behavior.
As a part of reparations, a Health Care Anti-Discrimination Act should be enacted which among other things: (1) authorizes and funds testers; (2) recognizes disparate impact; (3) assures fines and regulatory enforcement; (4) requires a health scorecard for each health agency, provider or facility; and (5) requires data collection and reporting.
In its broader, most expansive sense, reparations restores hope and dignity because it provides current descendants a way out of their seemingly dead-end lives caused by the lingering effects of slavery, racism and segregation. Reparations ultimately are about social justice, since it is about undoing the harm that has been done to one group in society. Reparations is not a one-way action; it requires the African-American community to undertake action and to rebuild itself. Reparations will rebuild community and cleanse the soul of the nation. Most importantly, reparations could restore the health of people of African descent in America.
Vernellia R. Randall (firstname.lastname@example.org) is Professor of Law at the University if Dayton Law School and has a website on race and racism at http://academic.udayton.edu/race/.
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