An American Health Dilemma: Race, Medicine, and Health Care in the United States 1900-2000 (review)

An American Health Dilemma is as fascinating an anachronism as its subject matter. It is a "real" book, a growing rarity in health policy where books are edited collections of articles or reports designed for other purposes. It is also unwavering in its insistence about the role our racial history has played in health and health policy in the United States, a subject that most authors at best give only a passing sentence or two. Finally, it is an extraordinarily ambitious and almost encyclopedic venture. Historians prefer the comfort of well-crafted vignettes of a particular place and time, and policy analysts seek the comfort of a more circumscribed theme surrounding the life of a particular policy initiative. W. Michael Byrd and Linda A. Clayton take it all on, the whole "American Health Dilemma." That dilemma is the immense gulf between the rhetoric of equality of opportunity in the American creed and the reality of the legacy of racism as it continues to affect medical science, medical practice, the organization of care, and disparities in health. An American Health Dilemma: Race, Medicine, and Health Care in the United States 1900-2000 is the second of two volumes. The first volume, An American Health Dilemma: A Medical History of the Problems of African Americans and the Problems of Race, Beginnings to 1900, was published in 2000. It takes a similar encyclopedic approach to this less well-chronicled record of previous centuries.

Part 1 of volume 2 traces the development of modern medicine in the early part of the twentieth century and the evolution of the health system. The more familiar history of the emergence of scientific medicine—the evolution of the hospital and early attempts at health care reform—is interlaced with discussions of eugenics and the resulting practice of involuntary sterilizations, the persistence of racial disparities in death rates throughout this period, and the evolution of a racially segregated system of care.

Part 2 of this volume traces developments from 1945, through the civil rights era, to the present. The book presents the more familiar battles over national health insurance, the passage of the Medicare and Medicaid programs, and the eventual failure of the Clinton health care reform package. These are interlaced with a description of the continued persistence of disparities in health and the National Medical Association's alliance with the NAACP Legal Defense Fund and other civil rights groups in integrating medical schools, pushing the passage of Medicare, and integrating hospitals. Perhaps the most instructive component, however, is the extensive discussion of the historical background of low-income persons and blacks in particular in medical experimentation without their consent. It puts the Tuskegee syphilis project in context, rather than as a peculiar aberration. The disparities discussed range from the purchase of slaves by the "father of gynecology" in order to operate on them experimentally without anesthesia (described in the first volume) to the seemingly pervasive and more contemporary instances of involuntary and coerced use of blacks in medical experimentation.

The third and final part of the book attempts to distill the lessons of this racial history for the future of medicine and health care reform. Byrd and Clayton conclude that the United States faces the likelihood of a permanent health and health care underclass and may be unable to shed the legacy of the troubling past described in the book.

The two volumes of this work, more than 1,000 pages of text and 150 pages of selected bibliography and bibliographical notes on sources, are overwhelming. Pulling so many sources together is an exhausting task, and the authors should be commended for their diligence. A tyrannical editor, however, would have greatly strengthened this effort. This could have...