Decisions about medical training and licensing in the 19th and early 20th century are still having an impact today.
A paucity of Black physicians is shortening the lives of African Americans—and politicians are starting to take note. Senators Roger Marshall (R-Kans.) and Bernie Sanders (I-Vt.) have proposed the Bipartisan Primary Care and Health Workforce Act to address the broader shortage of primary care physicians. The bill allocates funding to medical schools for increasing the number of primary care physicians and requires 20% of its funding to go to Minority Serving Institutions, including historically Black medical schools. This provision aims to increase the number of Black primary care physicians.
[time-brightcove not-tgx=”true”]It’s an important first step toward addressing the longstanding and disproportionate lack of Black physicians. The origins of this shortage lie in three aspects of professionalization and “reform” of medicine that took place from the mid-19th through the early 20th centuries. These changes made it harder for Black physicians to become licensed and discouraged them from even trying. Understanding this history can provide a useful guide as lawmakers work to try to address this shortage and reduce the racial heath disparities that are so damaging to Black Americans.
At the time of the American Medical Association’s founding in 1847, most people viewed medicine as more of a trade than a profession. The white male physicians who founded the AMA hoped a professional organization raising and enforcing standards would also raise the prestige—and consequently, the pay—for doctors. Seeing the presence of Black doctors as a threat to these goals, the AMA’s leaders quickly moved to prevent them from becoming members of their new organization.
This push epitomized the racism and bigotry animating the AMA in this period. During its antebellum years, six of 14 AMA presidents came from slaveholding or border states, and half of the group’s meetings were in the South. The message was unmistakable: the AMA saw enslavement as an acceptable status for Black Americans.
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The AMA worked assiduously to keep Black physicians out. The organization required membership in a local medical society to join, and virtually all local societies barred Black members. A rare exception was Washington, D.C.’s National Medical Society. At its 1870 annual meeting, however, the AMA got around this potential loophole by refusing to seat either Black or white representatives from the National Medical Society explicitly because it was an interracial organization. (In 2008, the AMA formally apologized for its contributions to racial inequality in medicine; the organization now recognizes racism as a “serious threat to public health” and has taken steps to support equity in medicine.)
Without AMA membership, Black physicians had fewer professional opportunities, which made pursuing medicine less desirable since it would be harder to make a living.
As the AMA gained stature and influence over medical education and training, its commitment to racial exclusion made it even tougher for Black physicians to practice medicine and increased hurdles for Black Americans who might’ve dreamed about becoming doctors.
Between 1870 and 1910, the white physicians who controlled the AMA began demanding that states adopt licensing laws that required physicians to pass an exam and meet educational requirements to legally practice medicine. These laws generally required doctors to complete medical school, as well as a subsequent internship.
Additionally, in cooperation with the Carnegie Corporation, the AMA’s Council on Medical Education, which formed in 1904, hired educator Abraham Flexner to study the standards of medical schools in the U.S. and Canada. In 1910, Flexner published his report with devastating consequences for the numbers of Black doctors. He recommended shuttering five of the seven historically Black medical schools that trained the vast majority of Black physicians. As far as Flexner was concerned, “The negro needs good schools, rather than many schools.”
Even keeping two Black medical schools open was a grudging concession on Flexner’s part. Black doctors would only care for their own race, but they were still necessary—for the benefit of white America. “The negro must be educated not only for his sake, but ours,” the report declared. Black Americans could “communicate” maladies like “hookworm and tuberculosis,” and “self-protection” dictated wanting good care for them. The implication was clear: Black doctors were necessary primarily to keep contagious diseases away from white populations.
Flexner hoped for the “speedy demise” of the schools that had failed to meet his standards. And when it came to Black medical schools, his wish was granted. Within two years of the Flexner Report, three Black medical schools closed, and by 1924, only two such schools remained.
The lack of Black medical schools dramatically reduced the pool of Black doctors. Even worse, in the same period, post-medical school internships became a standard requirement for earning a medical license. This new requirement made it even more difficult for Black people to become doctors. At the time, finding an internship was a byproduct of personal connections between medical school faculty and hospital staff members—and Black doctors were far less likely to have these relationships. Interns also lived in the hospital, which almost always restricted the opportunities for Black physicians to the few Black hospitals that would hire them. The long odds of securing an internship discouraged Black Americans from even trying to become doctors.
Internship requirements were especially burdensome for Black women physicians. Isabella Vandervall, a 1915 graduate of the New York Medical College, wrote about her four failed attempts to secure an internship in the Medical Woman’s Journal, “For many years the colored woman physician has practiced and prospered, but now, in this twentieth century, this era when women in general are forging ahead …a huge stumbling block, one which seems almost insurmountable, has suddenly been placed in the path of the colored woman physician.”
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The results of these barriers to entry were seismic. Over the half century after the Flexner Report, only two more HBCU medical schools would open. The lack of schools and the burdensome internship requirements dramatically reduced the production of Black physicians—one estimate concluded that the closures prompted by the Flexner Report dropped the number of Black doctors by between 10,000 and 30,000 over the ensuing century. The lack of Black doctors, in turn, beget even fewer Black doctors because it meant the absence of role models and institutional knowledge to inspire and help young Black Americans who might’ve been interested in medicine.
The lack of Black doctors promotes medical mistrust and results in poorer health outcomes. Conversely, when Black patients see Black doctors, their health outcomes improve. For example, there is a longstanding racial disparity in incidents of cardiovascular deaths. Yet, such episodes declined by 19% among Black men when they received treatment from Black physicians. Similarly, Black infants are three times more likely to die than white infants. When they see Black doctors, however, this “mortality penalty” is halved.
This history exposes how practices that appear benign or beneficial to both practitioners and patients—such as implementing increased requirements for experience—can reduce the pool of doctors critically needed to provide care for underserved Black communities. This lesson can guide policymakers as they move to try to reduce the shortage of Black doctors and ameliorate the health consequences that have plagued Black communities for too long.
Margaret Vigil-Fowler is an award-winning historian of race, gender, and medicine. She is an expert on the history of Black physicians and recently completed a National Academy of Education and Spencer Foundation Postdoctoral Fellowship.
Made by History takes readers beyond the headlines with articles written and edited by professional historians. Learn more about Made by History at TIME here.
