Using Reparations to Repair Black Health

 Vernellia R. Randall

Vernellia R. Randall, Eliminating the Slave Health Deficit: Using Reparation to Repair Black Health, Poverty & Race Vol. 11, No. 6 , pages 3-8, 14 . (November/December 2002)

As an African American and as a nurse-practitioner,
I can clearly assert that:
"Being Black in America is dangerous to our health!"

The current health disparities is directly traceable to slavery is a fact that is not well understood. African American still suffer from the generational effect 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, both black, white and others, 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 by past wrongs. This is a much more expansive view than merely calculating the economic harm and writing a check. Under this view, reparations becomes a process that restores hope and dignity and rebuilds the community. "[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, 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 lifes - 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 was health hazards and high death rates during every phase: ¹during the interior trek, ²the middle passage, ³the breaking in period and ⁴the 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-facet long term financial commitment and effort.

The current status of black health is based on long-term system neglect build 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 presences in the new world 64.2% of that time was as chattel slavery and another 26.1% of that time was spent in de jure or "jim crow" segregation. That is, only 9.6% of the total time in the United States has persons of African descent had full legal status as citizens. From a health perspective, 64.2% of the time was spent in 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 a continuous burden.

That deficit will only be removed 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

(1) Eliminate the disparities in morbidity and mortality,

(2) Assure Access to Health Care

(3) Assure Quality Health Care and

(4) Eliminate Racial Discrimination in Health Care and Health Research.

Eliminate the disparities in morbidity and mortality. Eliminating the disparities in morbidity and mortality will require, among other things, (1) a focus on education and prevention through targeted services; (2) the provision of a liveable wage for all persons and families, and (3) the elimination of environmental hazards in African American communities.

Targeted Services. The health disparities among African American has been well established and up until recently eliminating health disparities has not been a goal. For instance, the United States health population goals in Healthy People 2000 focused on reducing the disparities and not eliminating it. 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 ¹diabetes, ²cardiovascular disease, ³maternal and infant mortality, ⁴ HIV/AIDS, ⁵cancer, ⁶oral health, ⁷mental health, ⁸drug, alcohol and tobacco addiction, ⁹asthma and ¹⁰violence (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 servic778es would focus on educational and preventive services. For instances, outlawing the sale of alcohol within 10 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. The key is that for an effective approach to eliminating health disparities, there must be a full range of public health services and actions.

Provide a Liveable 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 at all minimize the need to focus on systemic influences such as poverty and racism. Poverty effects housing choice, job choice, food and education. Since African Americans are disproportionately poor, the elimination of poverty becomes essential to improving the health status of African Americans.

Poverty is not the only problem, also a problem is 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 child care. Poverty and the problems of the working poor could be eliminated by assuring everyone in the United States a "liveable wage" and not merely a minimum wage.

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. The San Francisco Department of Public Health reported livable wages diminish mortality rates, decrease unnecessary hospitalization of the poor, eliminate 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 could be in the form of assuring a livable wage.

Eliminate Environmental Hazards in African American Communities. But a livable wage is not enough also needed is the elimination of racism. Racism in American society effects socio-economic status, education, health care, employment, . . everything. One place that is particularly important for health is the location of environmental hazards and toxic dumps in Black communities, the workplace hazards and the hazards in the home. Studies have documented that hazardous waste landfills are disproportionately placed in African American communities while poor communities are not disparately burdened. In fact, studies have concluded that race more than poverty, land values, or home ownership is a predictor as to 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 fifteen million of the United States’s twenty-six million African Americans (57%) 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. . African-American men have a 27% greater chance than white men of facing safety hazards and a 60% greater chance of facing health hazards in the workplace. In fact, even when you control 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 of five significantly exceed the levels found in white children of the same age living in the same cities. This disparity persisted across income levels. Thus, for families with incomes less than $6000, 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 levels of lead.

Given the above, reparations could be used to remove toxic dumps and landfills from African American communities or completely relocate the communities to safe environment; to make workplace safer and to eliminate lead paint from housing. Such actions will have a significant effect in removing the health deficit

Assure Access to Quality Health Care.

Eliminating the 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 competent health care workforce in black communities, (4) assuring the cultural competence of the health care workforce, and (5) increasing the 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 of universal health care is a scheme of employer-financed insurance and government programs that still leaves 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 and African-Americans, they do not reach all of the uninsured poor. In fact, one-fourth (25%) of African-Americans have no source of health coverage. Even more disturbing is that the number of uninsured African-Americans is increasing. For instance, while the proportion of uninsured non-elderly European-Americans increased only 3 percent from 1977 to 1987 (from 12% to 15%), the proportion of uninsured non-elderly African- Americans increased 7% (from 18% to 25%) during the same period.

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% more than the European-American unemployment rate. However, even where employed, the African-American is more likely to be in a lower paying job which does 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 with lower income, race is an independent factor affecting whether an individual will be insured. 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 than higher income European-Americans. Thus, reparations could be used to expand insurance coverage so that all African Americans have either employer-based or government-based insurance.

Locate health facilities in black community. 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 either closing, relocating or becoming private. In a study done between 1937-1977, researchers showed that 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 service and for the system to provide services at that point is likely to be greater than at an earlier state. Therefore, not only does the loss of services significantly increase health care costs to African-Americans, but also, it increases health care costs to the society in general.

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 to provide uncompensated care under the Hill-Burton Act. 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 predominately 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 either merged, converted or consolidated. By 1991, only 12 hospitals continued to "struggle daily just to keep their doors open". As a result of closures, relocations, and privatization, many African-Americans are left with limited, and difficult access to hospitals.

Thus, reparations would provide for 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 an important aspect of 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 cost, increased mortality and increased costs to society.

Given the increased morbidity and mortality among African-Americans logically one would expect more health care providers in their communities not fewer, and more African-Americans in health care fields. Scrutiny of the physicians heading in the Yellow Pages of any major city, clearly indicates that many physicians do not physically locate their offices in the African-American community.

Despite being 12% of the population, African-Americans are seriously under-represented in every health care professions. For instance, Only 3% of the physicians, 2.5% of the dentists and only 3.6% of the pharmacists are African-Americans. This lack of representation is particularly significant for African-American communities which rely on African-American professionals for care. 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 or African American, 2/613 had 70% African-American or African American patient loads, and 1/613 had 90% African-American or African American patient loads. 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 (i.e., 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.

The shortage of African-American professionals further affects health care availability by limiting African-American input into the health care system. While the control of health care distribution is ultimately in the hands of the individual physician, that control is influenced and limited by law, hospital practices and policies, and the medical organization of the physician's practice. 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, the policy makers' ignorance results in their overlooking African-Americans' health concerns.

Clearly, a significant issue for eliminating the 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. For instance, an African-American did not receive a degree in an American medical school until 1847. While some white schools (nine) admitted African-Americans prior to the Civil War, most schools did not.. In fact, even in 1971, 21 medical schools out of 85 still had no African-American students.. Even with the admission of African-Americans to predominantly white schools, the African-American medical schools, Howard University and Meharry Medical School, still train 75 percent of African-American physicians.

Thus, reparations could be used to increase the availability of providers in the community. This could be done by providing scholarships for blacks to enter health care professions, by providing grants to university and colleges to increase their graduation rate of persons who will work in urban area, 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 to 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 is a representation of 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 (middle- class, middle-aged, European American) the more likely the person will not have 'meaningful access' to quality health care. Merely providing financial coverage for health care does nothing to assure that African Americans will have access to care that is culturally competent.

One barrier to culturally competent care is the physicians' own negative perceptions about African Americans. Because they have differing needs and problems in accessing care, physicians may 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 assure by requiring: (1) health professional schools to train providers from a diverse background; (2) all physicians to have a rotation during their internship and externship the focus on providing culturally competent care; (3) providers to take continuing educational units in cultural competency; (4) health care facilities and managed care organizations to complete and submit on regular basis a cultural competency assessment to a regulatory agency (5) 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 women and minorities, and to research by women and African American scientists (21.5 percent and .37 percent, 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 Reparations would assure that health care research and development would be focused on the health issues of African Americans. 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.

"It might be that civil rights laws often go unenforced; it might be that current inequities spring from past prejudice and long standing economic differences that are not entirely reachable by law; or it might be that the law sometimes fails to reflect, and consequently fails to correct, the barriers faced by people of color."

-- Derrick Bell

Federal laws related to eliminating racial discrimination in health care delivery is 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. First, although required by regulation to produce data, the Office of Civil Right's ("OCR") Title VI enforcement effort has produced little consistent data for evaluating Title VI compliance. Second, there has been "little uniformity in how different states handle Title VI requirements, little guidance, little analysis of the information collected by this process, no research and development. Third, Title VI lacks specific definitions of prohibited discrimination and acceptable remedial action. Fourth, OCR has relied on individual complaints as a means of enforcement which is particularly troubling where most discrimination and even 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 particular difficulty addressing issues of "unthinking discrimination", 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, individuals will 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 they have been injured by the provider. Third, the health care system, through managed care, has actually built in incentives which 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, the laws do not address the current barriers faced by African American; 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:

There is substantial evidence that discrimination in health care delivery, financing and research continues to exist. Such evidence suggests that Federal laws designed to address inequality in health care have not been adequately enforced by federal agencies. . . [Such failure has] . . . resulted in a failure to remove the historical barriers to access to quality health care for women and minorities, which, in turn has perpetuated these barriers.

Thus, as a part of reparations, an Health Care Anti-Discrimination Act should be enacted which among other things, (1) authorize and fund testers and (2) recognize disparate impact, (3) assure fines and regulatory enforcement (4) require a health scorecard for health agency, provider or facility, and (5) require data collection and reporting.

Authorize and fund the use of medical testers. To discourage health care discrimination, an 'aggrieved person' should 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 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 five racial and ethnic categories is not collected systematically. Further, racial and ethnic classifications are often limited on surveys and other data collection instruments, and minorities often are mis-classified on vital statistics records and other surveys and censuses. It is important to collect the most complete data on African Americans, and 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 provider 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. The existing data collection does not allow for regularly collecting race data on provider and institutional behavior. Reparations would require facility and provider data collection and public reporting.

Conclusion

In it is 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 is 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.

Alan D. Freeman, Legitimizing Racial Discrimination Through Anti-discrimination Law: A Critical Review of Supreme Court Doctrine, 62 Minn. L. Rev. 1049 (1978).

Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Editors, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy (2002)

David Barton Smith, Addressing Racial Inequities In Health Care: Civil Rights Monitoring And Report Cards, 23 J. Health Pol. Pol'y & L. 75 (1998)

Karen Scott Collins, Allyson Hall, and Charlotte Neuhaus, U.S. Minority Health: A Chartbook (1998)

Marianne Engelman Lado ,Unfinished Agenda: the Need for Civil Rights Litigation to Address Race Discrimination and Inequalities in Health Care Delivery, 1. 6 Tex. F. on C.L. & C.R. 1 (Summer 2001)

Pamela Short et al., Health Insurance of Minorities in the United States 1(2) J. HEALTH CARE FOR POOR & UNDERSERVED 9-24 (1990).

Robert D. Bullard, The Legacy of American Apartheid and Environmental Racism, 9 ST. JOHN'S J. LEGAL COMMENT. 445, 445-48 (1994).

Sidney D. Watson, HEALTH CARE IN THE INNER CITY: ASKING THE RIGHT QUESTION, 71 N.C. L. Rev. 1647 North Carolina Law Review (June, 1993)

U.S. Commission on Civil Rights: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality, Volume II, The Role of Federal Civil Rights Enforcement 438 pp. No. 902-00063-1. (Sept., 1999)

U.S. Commission on Civil Rights, The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality, Volume I, The Role of Governmental and Private Health Care Programs and Initiatives. 287 pp. No. 902-00062-2. (Sept., 1999)

U.S. Dept. Of Health & Human Services, Health Status of Minorities and Low Income Groups: Third Edition 5-8 (1991)

Vernellia R. Randall, Racist Health Care: Reforming an Unjust Health Care System to Meet The Needs of African-Americans, 3 Health Matrix 127 (Spring, 1993)

Vernellia R. Randall, Slavery, Segregation and Racism: Trusting the Health Care System Ain't Always Easy! An African American Perspective on Bioethics , 15 St. Louis U. Pub. L. Rev. 191(1996)

W. Michael Byrd and Linda A. Clayton, "An American Health Dilemma: A Medical History of African Americans and the Problem of Race, 1900 to Present" (2002)

W. Michael Byrd and Linda A. Clayton, "An American Health Dilemma: A Medical History of African Americans and the Problem of Race, Beginnings to 1900" (2000)

Woodrow Jones, Jr. & Mitchell F. Rice eds, HEALTH CARE ISSUES IN BLACK AMERICA: POLICIES, PROBLEMS AND PROSPECTS (1987)