Health

By: Diane Epstein

Source:

 Black Women in America, Second Edition

Health

“Of all the forms of inequality, injustice in health is the most shocking and most inhuman,” said Dr. Martin Luther King Jr. in Chicago on 25 March 1966. For black women, this form of injustice has ranged from the horrors of the Middle Passage to disproportionately high rates of heart disease and breast cancer death.

The Middle Passage

The story of the systematic destruction of the physical and mental health of the African American population began in the seventeenth century with the advent of the slave trade. The first merchant ships came to Africa for gold, but later the gold became human bodies. The opening of the American colonies, with their vast natural resources and endless rich farmlands, created a great demand for labor—cheap labor, slave labor. The slave trade thrived and continued to grow well into the nineteenth century.

African men, women, and children were captured and taken from their homes. They were chained together and loaded like livestock into the cargo holds of European merchant ships. In some cases, one naked body was stacked on top of another. Deprived of adequate food, light, and other necessities, their health often failed. Africans survived the journey, when they survived, on almost nothing. Human waste was everywhere, and they were forced to live in it. They were exposed for the first time to European diseases: tuberculosis, diphtheria, and small pox, among others. Africans had no immunity to these diseases, and the death toll was enormous. Less than half of those on the slave ships survived, and many arrived at their destination barely alive. The slave trade fostered one of the factors that helps explain the disparity in mortality rates between black and white Americans even into the twenty-first century—the unbridled use of black people as commodities.

Volumes could be written about the irreparable damage, both physical and mental, caused by the violent transplantation of a people to another culture. The transplant was followed by a “seasoning” period, usually in the Caribbean, that involved all means of physical deprivation and cruelty. Once Africans reached the United States, those who were healthy were put up for auction. The auctions were a dehumanizing examination, by the white community, of the naked bodies of these African people. This process extracted a huge psychological and physical toll on the slaves, as women were separated from their husbands, children, and friends. Once a black woman was sold, she became the complete and indisputable property of her white owner.

During the colonial period in the North, some enslaved people worked on farms, in shops, or in homes, many times in much the same conditions as would indentured servants. On the plantations of the antebellum South, however, the situation was quite different and especially destructive to the health of black women.

Plantation Life

Only the hardiest survived the Middle Passage and the seasoning process. Once purchased by a plantation, Africans lived under the harshest conditions. The adjustment to new, colder climates was difficult. Infection and respiratory diseases were common. Overcrowded slave quarters, lack of sanitation, contaminated drinking water, and poor nutrition combined to create ideal conditions for the spread of disease. The average diet provided calories but only limited nutrition. Nutritional diseases, such as rickets and scurvy, were not uncommon, and without adequate vitamins most slaves had a poor resistance to all diseases.

Compared to whites, Africans suffered a much higher death rate from accidents and infectious diseases. The list of diseases that were prevalent, often in epidemic proportions, includes tuberculosis, pneumonia, rheumatic fever, yellow fever, typhoid fever, cholera, and smallpox. Of course, many other illnesses claimed lives. For instance, many Africans contracted hookworm from walking barefoot over fields covered with compost containing human feces. Others developed tapeworm by eating tainted meat.

Since most slave women worked more than did men, they were at greater risk for health problems brought on by exhaustion and general physical debility. After pointing out that women usually worked side by side with men, doing the same work and the same amount of work in the fields, the historian Brenda Stevenson writes, “some males did perform more physically strenuous work, but women generally worked more—spinning, weaving, nursing, and cooking once their field work was over, to say nothing of the child care and domestic work they did in the quarters.” Men were also given, as a matter of routine, more and better food. Women were often compelled by their owners to share their smaller portions with their small children.

In addition, enslaved women were seldom relieved of their duties while pregnant. According to Richard Steckel, “women continued to work almost until delivery, at least during seasonal peaks in the demand for labor.” This and other health factors on the plantation commonly resulted in miscarriages and stillbirths. Many more black women died in childbirth than did women in the white landowner population. Infant and childhood mortality rates were high. Most black children did not reach their fifth birthday.

Obviously, this was more than a race problem; it was socioeconomic as well. Poor white women were victims of some of the same health conditions and disease patterns. However, they were not subject to the level of violence inflicted on black slaves as a matter of course. Again, Stevenson indicates that, “slave masters and overseers made no distinction in the ways they punished male and female field slaves. It was a brutal, disfiguring, health-threatening attack.” Black women were also subject to terrible sexual violence, from sexual humiliation during beatings to rape.

An appalling example of the violence inflicted on black women occurred in the health field itself. The antebellum years were a time of medical progress, particularly in the area of surgery. Dr. Marion Sims is referred to in med-ical books as the “Father of Gynecology.” It is seldom mentioned that he developed his surgical procedures on enslaved women who had not been anesthetized, on the assumption that black women did not feel pain in the same way or to the same degree that white women did. He is said to have operated on one woman nearly twenty times.

Black women and white women also had considerably different access to healthcare. Enslaved people had little treatment except that provided by their own healers, who used traditional African medicine. This often proved futile against previously unknown conditions and ailments. In essence, for the vast majority of African Americans, life remained a combination of harsh treatment, overcrowding, exposure to cold, ongoing diseases, and early death. Healthcare did not include hospitals, physicians, or any other health professionals. There were no “pesthouses” for those with contagious illnesses. Some slaves were fortunate enough to have owners who would pay for this substandard care.

Health in the Jim Crow South

After the Civil War, formerly enslaved people were released from bondage with nothing—no resources and few skills. Although some free health clinics were established for blacks, the dearth of black physicians made the care they offered questionable. Toward the end of the antebellum years, a meager amount of progress had been made in medical education for blacks. The first black physician, Dr. James Smith, graduated from medical school in 1837. Educated in Europe, Smith returned to the United States to find the possibility of a medical practice virtually nonexistent.

In 1860, historically black Howard University opened its Medical Department. In the forty-five years that followed, a dozen black medical schools attempted to create programs similar to the one offered at Howard. According to Michael Byrd, black physicians increased in number from 909 in 1890 to 3,409 in 1910, mainly from the increase in black schools, translating into an approximate doctor-patient ratio for blacks of 1:3000; the white doctor-patient ratio was 1:770, a significant difference. Such numbers translated into suffering, neglect, and deaths for the black population.

Byrd states, “this tiny handful of professional individuals in no way substituted for, nor represented, the huge number of black healers, providing ‘hands-on care’ for the black communities.” This level of care existed well into the Reconstruction era. A dozen black medical schools were opened following the Civil War, and the two existing black universities opened medical departments. In the end, however, white society's restrictions and limitations forced ten of the schools to close. The little progress made was almost entirely halted by the development of the American Medical Association. This professional organization was highly political and self-serving, furthering segregation for many years through restrictions and covenants to exclude blacks. In 1910, Abraham Flexner published a report on American and Canadian medical schools, sponsored by the Carnegie Foundation and under the supervision of the American Medical Association. It was highly critical of medical schools in general and black medical schools in particular. In pursuit of a higher level of professionalism in medicine, the AMA began to insist on stricter admission requirements and more sophisticated laboratory facilities in schools. To refuse the AMA's recommendations was to lose grants and other funding and be forced to close. In no more than a decade, most of the black medical schools and training facilities were gone. Howard and Meharry Medical College, in Nashville, Tennessee, were the only medical schools approved for funding by Flexner and the AMA, and they were the only ones left.

Throughout the Jim Crow period, a substandard system of medical care continued to exist for African Americans. Dispensaries and clinics for blacks were also scarce, usually funded by black women's organizations, churches, and other groups within the black community. At the time of the Civil War and the Reconstruction era, the mortality rate per 10,000 was 95 for whites and 146 for blacks. As late as the 1920s, life expectancy for blacks at birth was 45.3 years. By the time they were ten years old, life expectancy for African American males and females fell to 39 years, significantly lower than for whites.

Inadequate or scarce healthcare for African Americans was considered “normal” in the order of things. The basic infrastructure of racially segregated and class-exclusive healthcare delivery was still in place through the first half of the twentieth century. Life span, mortality rates, and incidence of disease remained grossly unequal for African Americans. There were, too, a number of health concerns related to medical abuses that can only be called egregious. These, unfortunately, continued well into the second half of the twentieth century.

In her biography of Fannie Lou Hamer, Chana Kai Lee reports that Hamer was involuntarily sterilized when she underwent surgery for a small stomach cyst. Lee points out that this was not an uncommon occurrence for black women in the South. Indeed, as a result of “eugenics” laws passed in a number of states, as many as twenty-five thousand involuntary sterilizations were performed on black women. During the 1950s, some state legislatures proposed bills that would have forced sterilization on any woman who was receiving welfare payments and had a second child.

Life and Health in the North

The Jim Crow South was not the only place black women and their families suffered from the effects of poverty and discrimination on their health. The Great Migration of the early twentieth century brought tens of thousands of southern blacks into the northern urban centers. African Americans in these cities experienced a degree of overcrowding and unhygienic conditions that, if anything, surpassed that of the rural South, nor did they escape the violence that had always haunted their lives.

A new health hazard entered the lives of black women: the northern ghetto. In 1890, 95 percent of all African Americans lived in the South, mostly in rural areas. By the 1960s, 90 percent lived in the North, almost all in urban areas. Many of them had jobs that paid more than they could have imagined in the South, but life also cost more. Complicating matters was that most black women could not get jobs in the factories of the North. They found themselves cleaning white women's houses, a job that was all-too familiar to them. Because housing was segregated, black families lived crowded together in separate neighborhoods. Conditions that were brutal for most of the working poor were even worse for African Americans.

These neighborhoods became known as ghettos, and if African Americans had left the South in part to escape violence, they soon found that they had been unsuccessful. During one summer in 1919, there were twenty-two race riots in the cities of America. The violence, along with overcrowding, unsanitary conditions, and poverty, meant that blacks again faced astronomical rates of maternal death, infant mortality, and infectious diseases.

The first real improvements in the health status of black women did not occur until the Civil Rights movement of the late 1950s and the 1960s, and especially with the passage of the Civil Rights Act of 1964. This act outlawed segregation in places of “public accommodation” such as theaters, restaurants, and hotels. It banned discriminatory practices in employment and housing, and ended segregation in public places, including schools. Unfortunately, places of “public accommodation” did not include hospitals and medical offices, but significant advances were made because of the “federal financial assistance” provision. From that point on, receipt of funds from the federal government required any hospital, clinic, or other medical service provider to eliminate racial discrimination. Unfortunately, under pressure from the South, legislators went to great lengths to limit the definition of “federal financial assistance” in order to preserve the right to discriminate in private medical practices. Nonetheless, the enlargement of medical services to the African American public was hugely significant.

The passage of Medicare and Medicaid was yet another positive step in health services for the black and elderly. There was finally a formal admission that “separate was not equal.” But real access to improved medical care was slow and hard won. For one thing, there were not enough doctors and back-up health professionals to make up for the deficit caused by years of neglect. And laws alone did not ensure equality.

A second and equally important driving force in healthcare progress was the Women's Movement that gained momentum in the 1960s. The movement placed a great deal of emphasis on the need for research into and education about those diseases that affected women most, such as breast, cervical, and ovarian cancer, and on reforms in reproductive issues.

Forced sterilization was also finally addressed. Ruth Sidel, in Women and Children Last, states, “In the early 1970s reports began to surface of forced sterilization of women on welfare and women receiving care in publicly funded hospitals. Suits were filed and regulations passed.” However, according to Helen Rodriguez-Trias, whom Sidel cites, these regulations, “were largely ineffective and unknown or ignored.” The number of sterilizations of nonwhite, low-income women rose in the 1970s, and an organization, the Committee to End Sterilization Abuse (CESA), was formed. Eventually, the department of Health, Education, and Welfare (HEW) developed guidelines to put a stop to this appalling practice.

The Twenty-First Century Condition

At the beginning of the twenty-first century, there were still serious problems for black women in every area of medicine and health. With regard to cancer, African American women, like other groups, were more vulnerable to some forms of cancer than others. Black women continued to have a particularly high incidence of cervical, ovarian, and lung cancer. The risk of death for African American women with breast cancer was 67 percent higher than for Caucasian women, even though black women had a lower incidence of the disease. However, in the early years of the twenty-first century, that trend may be changing. As of 2003, black women were no longer less likely than were white women to have mammograms.

The Cancer Institute has stated that black women make up the lowest level of the socioeconomic strata, with all the health consequences related to that dubious distinction. Among these women, smoking, obesity, poor nutrition, lack of exercise, and lack of knowledge about disease were common. Many women in this category also lacked the money or insurance to obtain adequate medical help. This segment of society was most likely to wait before seeking medical help and least likely to follow through on medical instructions. Obviously, the Medicaid pro-gram was not sufficient to overcome the health deficits of poverty.

Black maternal deaths remained 3.4 times higher than white maternal deaths, and the infant mortality rate was 2.5 times higher for blacks than for whites. However, according to the annual “Vital Statistics” article in Pediatrics magazine in 2002, “From 1990 to 2002, the use of timely prenatal care increased by 6 percent (to 88.7 percent) for non-Hispanic white women, by 24 percent (to 75.2 percent) for black women, and by 28 percent (to 76.8 percent) for Hispanic women, thus narrowing racial disparities.” The disparity in life expectancies narrowed, too. The life expectancy for a black woman in the early twenty-first century was 75.5, as compared to 80.2 for white women.

A four-year study conducted by Ashish K. Jha revealed that black women were twice as likely as were white women to suffer from heart disease, but were less likely to be given standard drugs for prevention and treatment. Black women were nine times more likely to contract HIV than were white women and a third more likely to have diabetes.

An examination of these statistics should remind us that disparities in the healthcare received by black women is part of a class issue as well as a race issue. Since a considerably larger percentage of African Americans lived near or below the poverty level, numbers on the whole are skewed. Numbers for disease and death rates comparing only middle-class black women with middle-class whites would probably be much closer. But it is also important to remember that poverty is a health risk too many black women continue to face.

Growing up a black woman was not without its advantages, however. Young black women were much less likely to suffer from an eating disorder. In a study of more than one thousand black women aged nineteen to twenty-four, there were no cases of anorexia detected, and the rate of bulimia was one-sixth that of white women of the same age. Also, black women were increasingly more likely to report domestic abuse to their doctors than were white women. They were also more likely to resist.

One of the most significant health problems African American women have faced over the centuries is violence, as we have seen, and that continues to be true. A 2004 report by the Violence Policy Center revealed that more than 3 of every 100,000 black women were murdered in 2001, compared with 1 of every 100,000 white women. Domestic violence was the leading cause of death for African American women in the fifteen- to thirty-four- year-old age range. Of these deaths, 53 percent were inflicted with guns.

It is not only the violence inflicted upon themselves that affects black women. They must deal every day with the danger faced by their children and the men they love, from gang violence to police brutality. The atmosphere of violence contributes to such conditions as hypertension, obesity, substance abuse, and other stress-related illnesses. It simply is not healthy to live in a violent world. Addressing that concern is probably the highest priority in healthcare for black women from all walks of life.

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