This year, Dr. L. Natalie Carroll continues a long and illustrious tradition as she assumes the mantle of the presidency of the National Medical Association (NMA), the nation's largest professional association of African American physicians. Dr. Carroll's tradition of excellence and service began in earnest with her 1974 graduation from Meharry Medical School in Nashville. The broad scope of her training included surgery and obstetrics/gynecology, and her research has garnered prestigious recognition such as the International Scholarship Award. Dr. Carroll's deep concern with the health of African American families has been reflected in her tireless health advocacy. Her many medical leadership positions include chair of Obstetrics and Gynecology at St. Elizabeth's Hospital in Houston, Texas; the presidency of the Lone Star State Medical Association; and many important positions with the NMA. Her community leadership includes the Texas Department of Health Advisory Board Commission on Birth Defects and Genetic Abnormalities, Depelchin Children's Center board of directors, as well as many other organizations.

Aetna's 21st African American History Calendar has a 21st-century focus: the campaign to end the disparities that separate African Americans from the bounty of the American health care system. Here, we also celebrate what we have learned from yesterday and can put into practice today to give African Americans a healthier tomorrow. Each month, you will read about a critical health issue and about an African American medical leader who has worked to eliminate the causes of racial health disparities. But first, here is a brief overview of the long struggle to bring equality to African American health care.

The United States has achieved great social, legal and economic progress, and African Americans have served as catalysts of this social change. Now, a dramatic cultural transformation is sorely needed to revolutionize the health status of African Americans by eliminating racial health disparities.

The term "health disparities" refers to the wide gap in the measures of good health status exhibited between white Americans and African Americans. What are some of the causes of health disparities? Many factors are at play, including lack of access to health care, poor socioeconomic status, bias within the health care system and ofttimes differential treatment from medical professionals. Many of the present-day disparities result from centuries of discrimination against African Americans in which health care was not available or the quality was inferior.

Within the last century, medical advances have added three full decades to American life expectancy, increasing it from 47 to 77 years. But the average African American will never see his 70th birthday, and his or her years will be sicker ones. Black infants are twice as likely to die before their first birthdays. African Americans also have a much higher incidence of and death rates from heart disease, stroke, diabetes, asthma and all major cancers. Infectious disease affects African Americans disproportionately. For example, most HIV/AIDS cases affect people of color, and hepatitis C rates are up to 500 percent higher in African American men. Morbidity from violence and mental illness occurs at a higher rate in African Americans, as well. Most cripplers and killers of African Americans are preventable; curable when detected early and treatable when diagnosed such as heart disease, respiratory illness, stroke, cancer and diabetes.

"Of all the forms of inequality, injustice in health is the most shocking and the most inhumane."
     Reverend Dr. Martin Luther King Jr.
     Second National Convention of the Medical
     Committee for Human Rights, 1966

Dr. King's powerful statement tells us that health care equality is an essential component of the civil rights struggle. It also tells us that the gap between black and white health status has been with us for a long time.

Neglect and Exploitation
The deplorable state of African American health reflects a long history of medical abuse and neglect that began when Africans were brought to this country in bondage. Historical works such as Todd Savitt's Medicine and Slavery, and An American Health Dilemma by Linda Clayton and Michael Bryd capture the gruesome details of how African Americans' unhealthful, disease-ridden environment; nutrient-poor diet; ceaseless hard labor; harsh punishment; crowded conditions; inadequate shelter and scant clothing encouraged disease and high death rates. Contributing further to this atrocity was the substandard, often exploitative, medical care that used African Americans far more often than whites for medical display; often-painful, involuntary experimentation and autopsy; as documented in works such as Bones in the Basement by Robert Blakely and Judith Harrington. Centuries of this cruel propensity led to many abuses such as the 1932-1972 U.S. Public Health Service study that actively withheld treatment from hundreds of poor African American sharecroppers in Alabama, popularly known as the Tuskegee Syphilis Study.

According to experts such as the late Harvard public health advocate Dr. Alonzo Yerby, the roots of two-tiered medical care derive from the Old World tradition of "poor law" medicine. Free care was provided in public institutions, but it was limited in scope and often administered by trainees. As slavery ended, American almshouses provided such care -- in deplorable conditions. Later, the hospital movement arose, but conditions and care were so substandard and exploitative medical experimentation so rampant that no one who could afford private care visited the hospitals.

The Struggle of African American Physicians
Although few schools of medicine admitted blacks, African Americans began to earn medical and nursing degrees even before the end of slavery. But African American doctors were barred from residencies and hospital appointments. As a result, they were unable to care for their ill patients in the hospitals. They also were not allowed to join the major medical societies such as the American Medical Association (AMA). To address the interests of African American physicians and their patients, the National Medical Association (NMA) was founded in 1895.

Between 1868 and 1930, more than 245 black medical and nursing schools produced the vast majority of the African American nurses and doctors. But the health care gap was constantly reinforced by separate and unequal medical care in the racially segregated South and in the medically segregated North. Worse, black hospitals were dealt a death knell in 1909 when Abraham Flexner published his report, Medical Education in the United States and Canada. It condemned African American hospitals and training sites as substandard, and every one was forced to close, except for Howard and Meharry. This sad state of affairs was not improved when the Hospital Survey and Construction Act -- the "Hill-Burton" Act -- codified medical racism into law in 1946 by sanctioning the construction of "separate but equal" medical facilities for African Americans.

Medical Civil Rights: The First Wave
By 1962, medical scientists began to gather methodical statistical data, which, for the first time, revealed in stark numbers the shocking racial disparities in health care. Progress had been frustratingly erratic, as one important health measure, infant mortality, illustrates. In 1940, the infant mortality rate of African Americans was 70 percent greater than that of whites; two decades later, in 1962 it had worsened significantly, to 90 percent greater than that of whites. Parallel higher rates of death and disease were quantified among African Americans everywhere.

The efforts of the NMA, NAACP, political activists and numerous social justice organizations paid off in 1964 with the passage of the Civil Rights Act, which, for the first time, guaranteed that federally funded facilities must be available to all without regard to race. It was followed by the 1964 Social Security Act and the 1965 Medicare Act that provided health insurance for the aged. But the new laws did not change medical policies, and the Civil Rights Act promised to become an empty victory unless health care providers embraced the same aggressive activism as had political activists.

Front-line Physicians
African American physicians rose to the occasion, providing not only political leadership and support, but medical services during the Civil Rights movement. One of the most active was Harvard psychiatrist Dr. Alvin Poussaint, a leader of the multiracial Medical Committee for Human Rights, who organized medical support for the March 1966 march on Jackson, Mississippi.

When the smoke cleared, African American physicians and the NAACP had achieved the reversal of policies and laws that supported centuries of black disproportionate disease and death rates. The Hill-Burton Act was rescinded, and the AMA finally urged all its chapters to admit African Americans.

Civil Rights: The Second Wave
"The elimination of health disparities is the civil rights issue of the 21st century."
     The Hon. Donna Christian-Christensen, M.D., Chairwoman
     Congressional Black Caucus' Health Braintrust

Health disparities eradication proved stubborn, as noted in the 1979 surgeon general's Healthy People Report on Health Promotion and Disease Prevention. In February 1998, after two decades of similar reports, U.S. Surgeon General David Satcher, under the aegis of President Bill Clinton, decided upon a bold, radical approach to addressing health disparities. He issued the President's Initiative to Eliminate Racial and Ethnic Disparities in Health. This announcement was marked by a bold promise to not reduce, but to totally eliminate the health disparities between white and African Americans by the year 2010. Critics worried, "Can it be done?" but Dr. Satcher has observed, "We have heard from many people who have told us that our goal of eliminating disparities by 2010 is overly ambitious. We have responded by saying that in the 21st century, neither history nor humanity can settle for less."

The strategy proposed bringing African American health care up to par in six key areas of health by the year 2010. These are: infant mortality, diabetes, cardiovascular disease, cancer screening and management, HIV/AIDS infection rates, and childhood and adult immunizations. These include specific diseases such as diabetes and cancer, but there are other important "background" health issues that the U.S. Department of Health and Human Services calls leading health indicators: mental health, injury and violence, environmental quality, immunizations, and access to health care. The combination of physical activity, overweight, tobacco use, substance abuse and responsible sexual behavior also are key. Every African American must make the appropriate lifestyle choices if medical experts are to successfully close the health care gap.

A Vision Realized
The surgeon general's enthusiasm is warranted: Of the 95 objectives that specifically address the health status and needs of African Americans in 2000, 70 percent already have shown progress. This success is partly due to the fact that the movement to close the racial health care gap is not taking place in a vacuum, but rather is coupled with the "Healthy People" goals set for the entire nation in the surgeon general's periodic Report on Health Promotion and Disease Prevention.

Closing the health care gap no longer should be a lonely battle for scattered physicians and advocates. This new civil rights struggle now tops the national health care agenda. A healthy nation equally among all people is a victory and benefit for America.