Creating a segregated medical profession: African American physicians and organized medicine, 1846-1910.

An independent panel of experts, convened by the American Medical Association (AMA) Institute for Ethics, analyzed the roots of the racial divide within American medical organizations. In this, the first of a 2-part report, we describe 2 watershed moments that helped institutionalize the racial divide. The first occurred in the 1870s, when 2 medical societies from Washington, DC, sent rival delegations to the AMA's national meetings: an all-white delegation from a medical society that the US courts and Congress had formally censured for discriminating against black physicians; and an integrated delegation from a medical society led by physicians from Howard University. Through parliamentary maneuvers and variable enforcement of credentialing standards, the integrated delegation was twice excluded from the AMA's meetings, while the all-white society's delegations were admitted. AMA leaders then voted to devolve the power to select delegates to state societies, thereby accepting segregation in constituent societies and forcing African American physicians to create their own, separate organizations. A second watershed involved AMA-promoted educational reforms, including the 1910 Flexner report. Straightforwardly applied, the report's population-based criterion for determining the need for phySicians would have recommended increased training of African American physicians to serve the approximately 9 million African Americans in the segregated south. Instead, the report recommended closing all but 2 African American medical schools, helping to cement in place an African American educational system that was separate, unequal, and destined to be insufficient to the needs of African Americans nationwide.

Segregation, civil rights, and health disparities: the legacy of African American physicians and organized medicine, 1910-1968.

Between 1910 and 1968, the National Medical Association (NMA) repeatedly clashed with the American Medical Association (AMA) over the latter organization's racial bars to membership and other health policy issues. The NMA, founded in 1895 as a nonexclusionary medical society to provide a voice for disenfranchised black physicians and patients, struggled in its early years, during which AMA leadership took scant notice of it. But skirmishes ensued over such actions as stigmatizing racial labels in the AMA's American Medical Directory, which, beginning in 1906, listed all U.S. physicians but designated African Americans with the notation col. The NMA also repeatedly asked the AMA to take action against overt racial bars on blacks' membership in its constituent state and county societies. During the civil rights era, African American physicians received no AMA support in seeking legal remedies to hospital segregation. And the NMA and AMA found themselves opposed on other policy issues, including Medicaid and Medicare. These differences eventually catalyzed a series of direct confrontations. The 1965 AMA meeting in New York City, for example, was protested by about 200 NMA-led picketers. The NMA's quest for racial equality in medicine was supported by some other medical organizations, such as the Medical Committee for Human Rights. In 1966, the AMA House voted to amend the AMA Constitution and Bylaws, giving its Judicial Council (now the Council on Ethical and Judicial Affairs) the authority to investigate allegations of discrimination. This paved the way for a subsequent era of increasing cooperation and understanding.

Racial and ethnic differences in response to medicines: towards individualized pharmaceutical treatment.

It is now well documented that substantial disparities exist in the quality and quantity of medical care received by minority Americans, especially those of African, Asian and Hispanic heritage. In addition, the special needs and responses to pharmaceutical treatment of these groups have been undervalued or ignored. This article reviews the genetic factors that underlie varying responses to medicines observed among different ethnic and racial groups. Pharmacogenetic research in the past few decades has uncovered significant differences among racial and ethnic groups in the metabolism, clinical effectiveness, and side-effect profiles of many clinically important drugs. These differences must be taken into account in the design of cost management policies such as formulary implementation, therapeutic substitution and step-care protocols. These programs should be broad and flexible enough to enable rational choices and individualized treatment for all patients, regardless of race or ethnic origin.

Community outreach: a call for community action.

For a variety of reasons, end-stage renal disease disproportionately affects minority populations. Factors such as socioeconomic status, cultural differences, and genetic variations, are all involved. In addition, there are often real and perceived barriers for these patient groups in fully accessing the healthcare system. Thus, there is a real need for the development of specific outreach programs that target these high-risk communities. In developing such programs, it is important to realize that there is not a homogeneous 'ethnic community', but rather, like any large demographic grouping, a diverse population. These differing communities will all have different requirements and needs and, thus, outreach programs need to be wide-ranging and adapted for individual, local communities, to ensure that all target audiences are reached. The core aims for these outreach programs must be raising disease awareness and education among minority patients. To achieve this goal, a wide range of organizations need to be actively involved, including national and--importantly--local, community-based patient organizations, and hospital management corporations, as well as local radio and television companies to advertise the outreach initiatives. However, any outreach campaign will need to be combined with policy changes and further research into kidney disease among minority groups if real improvements in outcomes are to be achieved.