The Most Inhuman Inequality

“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. I see no alternative to direct action and creative nonviolence to raise the conscience of the nation.”

These words were spoken by Dr. Martin Luther King, Jr., on March 25, 1966, during a press conference in Chicago connected with the annual meeting of the Medical Committee on Human Rights (MCHR). It’s often forgotten today, but the fight for equal access to quality healthcare was a core principle of the civil rights movement. In his remarks to the packed room that day—an audience of not just press but also a racially diverse group of doctors and other healthcare workers—Dr. King called out the American Medical Association as well as hospitals across the country for violating Black people’s fundamental human right to healthcare by denying them access to quality care. He announced that he and other civil rights leaders would be taking “direct action” against hospitals in Chicago, where segregation still existed in practice if not in law, while a representative of the MCHR laid out a plan to bring federal lawsuits against hospitals in the South that were discriminating against Black patients.

Medicare and Medicaid both arose out of the civil rights movement—the effort to establish both of these programs was led by the NAACP and the National Medical Association, the professional association for Black physicians (the American Medical Association was, at that time, segregated). And the community health center program, which today serves 25 million patients nationwide, can trace its beginnings back to a small health clinic in rural Mississippi established by Dr. Jack Geiger, one of the founders of the MCHR.

Yet Dr. King’s remarks in March of 1966 hardly made the news. In fact, so few news outlets reported on the press conference or the MCHR meeting that, for many years, people questioned whether Dr. King had really made his often-quoted statement on injustice in health—because no one could find any record of him saying it.

Despite the remarkable achievements of Dr. King and other civil rights leaders in advancing health equity, stark disparities in health and healthcare persist today between Black and white Americans. So does the silence about both the scope and the causes of these disparities.

It’s only very recently, thanks to progressive news outlets like ProPublica and NPR, that more people outside of the field of population health have begun to hear just how fatally unequal our health care system is still, as well as how the stresses of being Black in America can literally shorten a person’s life. Yet, the story that might have finally brought this issue to the attention of the greater American public and into mainstream media is tennis superstar Serena William’s account to Vogue magazine of what happened to her when she suffered a pulmonary embolism after giving birth. Williams had had an embolism in the past so she recognized the symptoms when they hit her. She told a nurse, who thought Williams’ pain medicine was making her confused. When she continued to insist, they did a different test than the one she was saying she knew she needed based on her medical history. Finally, they did the correct test and she was properly treated. She was lucky to survive.

Shalon Irving, a health researcher for the Centers for Disease Control, was not so lucky.  Irving died of complications related to high blood pressure three weeks after giving birth to her daughter. Her story came to light through the Lost Mothers project, a joint investigative effort by ProPublica and NPR into the causes of the United States’ high maternal mortality rate. In the wake of the Williams profile in Vogue, publications like the New York Times and Fortune have picked up on the Pro Publica/NPR effort, using Williams’ experience to spotlight the Lost Mothers findings.

Essentially, the narrative has focused on the perceived inferiority of Blacks—bad genes plus bad choices equal bad health.

Continued discrimination in the healthcare system is one reason for the high death rate among Black new mothers. The stress of being Black in the United States is another. (I wrote about both these factors in December, in the post, Pregnant While Black.) “Weathering”—the effect of chronic stress on physical health—contributes significantly to poor health outcomes among both Black men and Black women.

For many years, the accepted theory among healthcare providers and researchers alike was that Blacks had poorer health outcomes than whites due to a combination of genetic predisposition and unhealthy lifestyle. Essentially, the narrative has focused on the perceived inferiority of Blacks—bad genes plus bad choices equal bad health. The term weathering was coined in the early 1970s by Arline Geronimus, then a graduate student, who asserted that the constant stress Black people experienced in their day-to-day lives made them more vulnerable to chronic conditions like hypertension and diabetes. On a recent episode of the NPR podcast Code Switch, now-Dr. Geronimus told host Gene Demby that belief in the narrative of Black genetic predisposition and negative behavior patterns was so strong that it took decades for her theories on weathering—which were backed up by multiple research studies—to even begin to gain credibility.

In the meantime, Blacks in America have continued to develop and die from preventable and manageable conditions at much higher rates and much younger ages than whites. Over 40% of Black adults have high blood pressure as compared to 28% of whites, and over 13% of Blacks have diabetes compared to slightly more than 7% of whites. A report released by the CDC last year included findings that Blacks between the ages of 18 and 49 were twice as likely as whites in the same age group to die of heart disease, stroke and diabetes. In addition, Black women are two to three times more likely than white women to suffer fatal complications of pregnancy. The difference in infant mortality is similar, with 11.7 deaths per every 1000 births to Black women and 4.8 deaths per 1000 births to white women.

The leaders of the civil rights movement understood that there could be no equality among people unless everyone had the same opportunities to attain the highest level of health. As we are beginning to understand (or, perhaps, rediscover), access to healthcare alone will not improve the health outcomes of Black Americans.

Though he was focused on the way healthcare was delivered in this country, Dr. King used the phrase “injustice in health,” not “injustice in healthcare.” Ensuring equal access to high quality care is important and necessary. So is combatting inherent bias in our healthcare system. But unless and until we recognize that the inequities that pervade our society and our institutions are deadly to people’s health, our country will continue to be home to that most shocking, most inhuman of inequalities.

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