Introduction

As the globalization of trade, technology, investment, and migration create a more diverse U.S. population, we are increasingly becoming aware of disparities in economics, health care, and human rights. Our nation was founded on the concept that “all men are created equal,”¹ and equal treatment and equal access are the goals toward which we strive. Nowhere else in medicine is the commitment to equality as obvious as it is in our emergency departments (EDs), where the sole criteria for moving to the front of the line is severity of illness. Other specialties now restrict the days and hours during which they are available to patients and tell their patients at hospital discharge to go the ED if they have any problems or concerns. Fewer private physicians are welcoming indigent patients into their practices. Changes in the economy have resulted in a significant increase in the percentage of uninsured.² Only the ED provides medical care 24 hours a day, 365 days a year for every patient with any chief complaint. As advocates for our patients, emergency physicians (EPs) are at the forefront of the promotion of diversity and elimination of disparities in health care not just at home but throughout the world as well.

An awareness of the history of disparities in access to quality health care (Table 1), the benefits of clinical research (Table 2), and medical education and emergency medicine (EM) practice (Box 1) will create a contextual framework within which the reader can appreciate all that has been accomplished, as well as the tasks that remain, as we work toward the ideals of diversity and cultural competency.

Table 1 History of Health Care Disparities

Table 2 History of Disparities in Research

History of Health Care Disparities in the United States

The word disparity, simply defined, implies the lack of parity or the “state of being dissimilar or unequal.”²⁴ America, historically referred to as “the melting pot,” is a nation whose culture is based on dissimilarity but, ostensibly, on equality. The “melting pot” concept implies that disparities melt away as the nation comes to embody a mixture of qualities from the cultures of all people who live in the United States,²⁵ thus giving rise to the equality envisioned by the framers of our Constitution. However, no republic in recorded history has ever been able to embody the equality on which it is theoretically based, and the United States is no exception. The words of the Bill of Rights, “all men are created equal,” were rather promptly contradicted by our Constitution’s Three-Fifths Compromise and Enumeration Clause.²⁶ Parity in representation was not granted to African Americans until the 15th Amendment was passed in 1870, and women were denied suffrage until passage of the 19th Amendment in 1920. Our policies continue to reflect the wish to achieve equality within the realities of our imperfect history.

Disparity in access to care is as old as America itself. Typically, plantation slaves lived in quarters where contaminated drinking water led to frequent outbreaks of cholera, typhoid, and hepatitis and facilitated the transmission of intestinal parasites. Food scraps and human excrement in stagnant water bred the mosquitoes that transmitted malaria and yellow fever.³ Slave owners usually performed the services of leaching and blistering and administered home medications, with a physician being sent for only as a last resort. Slaves came to distrust the care rendered by owners and overseers and developed their own system of care involving herb root doctors and midwives.⁴ It was not until 1852 that hospital care became available to slaves, when the Jackson Street Hospital was founded in Augusta, Georgia, by a white physician, Dr. Henry Fraser Campbell of the University of Georgia School of Medicine. In 1862, Freedmen’s Hospital in Washington, DC, became the only government-funded hospital for Negroes.⁷ Hospitals remained segregated until Executive Order 9981, which mandated the integration of Veterans Administration hospitals, was signed by President Truman in 1948,⁸ and the administration of President Johnson forced integration in 1965 by denying federal Medicaid and Medicare dollars to segregated hospitals.¹⁰

Access to care for members of American Indian tribes was even more restricted. The Bureau of Indian Affairs, established in 1824 by then Secretary of War John C. Calhoun, provided limited health care to the original Americans who had been segregated to reservations. The scope of care was improved when the Indian Health Service was commissioned in 1955,⁹ and access to all hospital care was afforded under the 1965 Medicare and Medicaid legislation.

As recently as 1990, a metaanalysis of 485 articles confirmed that migrant health care was confined almost exclusively to charity migrant clinics, with virtually nothing being known about the health status of the workers.¹¹ Today, lack of access to care plagues America’s rural areas, where 20% of our citizens are served by only 9% of our physicians. Economic recession and loss of employment have resulted in a decreased number of insured patients to support a rural medical practice.¹⁶

History of Disparity in Research

With the advent of antibiotics, vaccines, and other drugs to treat human ailments, the findings of basic science became applicable to the medical care of human patients, and with this came the advent of clinical research. The scientific method was applied to medicine as physician-scientists sought to understand the processes of disease and the best ways to treat them. Clinical research proceeded without regulation, and despite the fact that most scientists conducted their work with the good of their patients as the highest goal, several experiments overtly violated human decency and human rights. The most barbaric of all human experimentation was that conducted in the Nazi death camps during World War II (see Table 2). These experiments were, in fact, so unthinkable that physicians and the public saw this as an aberration and did not believe that doctors could ever violate human rights in any other circumstances. However, in 1963, Saul Krugman of the New York University School of Medicine infected severely mentally retarded children at the state-supported Willowbrook School with live hepatitis B virus, both orally and by injection, to test the effect of gamma globulin on progression of the disease (see Table 2). Dr. Krugman had obtained written consent by mail from the mothers of his subjects, but the consent was woefully inadequate in explaining that the children would be deliberately infected with virus. When the Tuskegee experiments were brought to national attention by Jean Heller of the Associated Press in 1972,²⁷ there was a public outcry against experimentation conducted by the U.S. Public Health Service with tax dollars that violated the rights of U.S. citizens. Both Dr. Krugman and Dr. Taliaferro Clark (the principal investigator on the Tuskegee experiment) justified their actions by stating that these were merely “studies in nature” following the natural course of a human disease.²⁸

History of Disparity in Medical Education

Box 1 chronicles the remarkable history of the education of women physicians and physicians of color in a nation that for more than a century made no formal provision for the education of nonwhites and then chose to relegate them to segregated schools with inferior textbooks and equipment. Not only were African Americans pioneers in the advancement of their own education, but their contribution to advancement in many fields of medicine is also significant. Several suggested readings and links are listed at the end of this chapter for readers who wish to learn more.

Despite the progress that has been made, barriers and biases continue to impede the progress of those underrepresented in medicine (URM) and women who choose to enter the field of medicine. An important study in the Journal of the National Medical Association reported that women believed that the specialties they were encouraged to pursue were affected by their gender and that they were often mistaken for nonphysicians. URM students noted that a lack of same-race role models had a negative impact on their medical school experience, and they overwhelmingly reported feeling the need to be “twice as good” to be treated as equal to white students.²⁹

Diversity and Cultural Competency