We'll Fight It Out Here: A History of the Ongoing Struggle for Health Equity: How a coalition of Black health professions schools made health equity a national issue by David Chanoff and Louis W. Sullivan

We'll Fight It Out Here: A History of the Ongoing Struggle for Health Equity by David Chanoff and Louis W. Sullivan, MD is an extraordinary story of women and men who worked to improve the health and human condition of Black and other underserved or unserved populations. They established and sustained academic health professions institutions and provided health care, including health services and health education, to targeted populations. The Association of Minority Health Professions Schools has served all segments of society dating back to the 1800. The book chronicles instances where member schools engaged in human subjects research and educated a diverse population including racial/ethnic minority, sex/gender minoritized, low-income, rural, and urban students. They sustained a social agenda that extended across the globe. Minority health professions schools have historically targeted and educated African American students and students from other parts of the African Diaspora and the African continent. As a result, their impact extends beyond the U.S. Because of their common missions and the need to build a sustained collation, in 1976, the Association of Minority Health Professions Schools (AMHPS) was founded for the modern era.

The Association of Minority Health Professions Schools' work dates to the middle 1800s. Historically, minority health professions schools provided formal education and training in medicine, dentistry, veterinary medicine, pharmacy, nursing, biomedical science, and various allied health programs. Due to limited resources, perceived need and demand, the schools modified or closed some of their education and training offerings. As they do to the present day, graduates participated in human subjects research; were among the pillars in educating health care professionals of minority health professions schools; engaged in direct patient care in the public and private sectors; assumed federal, state, and local government positions; and provided leadership in a plethora of public health areas. As global health communities strive for health equity, these Black health professions schools banded together to form the Association of Minority Health Professions Schools (AMHPS) to "fight" for health equity before the term health equity was popularized by health professionals, educators, and public health officials. The hallmark of AMHPS's major achievements begins with its founding in 1976, continues with the 2010 elevation of the National Center for Minority Health and Health Disparities to an Institute within the National Institutes of Health in the U.S. Department of Health and Human Services. The AMHPS member schools continue to press the United States towards a framework of equity in both health and health care.

Chanoff and Sullivan's book chronicles the AMHPS story in 11 chapters, starting with an unnamed, enslaved Black man owned by a White doctor. The Black man assisted the doctor in his medical practice in Windsor, Connecticut. After "working" with the White physician for many years, the enslaved man was granted his freedom, adopted the name Prius Manumit, and established his own medical practice. According Chanofff and Sullivan, Manumit was the first African American physician accepted by White society. Better-known African American physicians include James Derham (Durham), who was born in 1762, in Philadelphia, and practiced medicine there, and Martin Robinson Delany and James McCune Smith who were in medical school, but who were forced to withdraw due to racist objections from their Harvard classmates. Harriet Kezia Hunt, an African American woman, also was forced to withdraw from Harvard because of racism and patriarchy. Interestingly, in 1869, Robert Tanner Freeman, an African American man, graduated in the first class of the Harvard School of Dental Medicine. After their forced withdrawal from Harvard, Delany and Smith completed medical school abroad, returning to the U.S. to practice medicine. Both became involved in civil rights and other efforts to improve the well-being of African Americans.

Chapter 1 details Delany's and Smith's separate roles and philosophical positions concerning African Americans' emigration and expatriation. The chapter reviews the challenges that Black physicians had in joining the American Medical Association and discusses the need for and founding of the National Medical Association, the major Black physicians' organization, which exists to this day.

Chapter 2 reviews the appalling post-Civil War morbidity and mortality among African Americans. In five Southern states the death rate among White children under the age of five, was 88.4 per thousand. For Black children it was 151.60. Black male life expectancy was thirty-five years. In Georgia, there was one Black physician for every 21,470 Black people. During this period, many White physicians refused to treat Black people.

Howard Medical School, established in 1868, and the Medical Department of Central Tennessee College, which opened in 1876 and later became Meharry Medical College, were the first medical schools in the South for African Americans. Unlike Howard, Meharry was founded specifically to educate Black medical students. Howard and Meharry also established dental, nursing, and pharmacy schools. Later in the 20th Century, Xavier University, Hampton University, Florida A & M University and Texas Southern University started pharmacy schools. In 1945, Tuskegee Institute (now Tuskegee University) founded its College of Veterinary Medicine. Chapter 2 reviews the challenges and accomplishments of Black physicians during this period.

Chapter 3 discusses the founding of the National Medical Association in 1895, the leadership roles of Black physicians, and how medical science expanded its understanding of disease. U.S. medical schools were not comparable to European medical schools, particularly Germany, because of their failure to integrate medical science into medical education. The etiology of disease was a mystery and that heavily influenced how health care was practiced. The underlying belief held by many health scientists was that disease was caused by imbalances in four constituent elements of human physiology and temperature. In the late 19th century, the discovery of bacteria, germ theory, and the evolving understanding of cell biology transformed medical education. By 1877, several medical schools in the U.S. were exploring introducing laboratory science into the medical curriculum. In 1884, Johns Hopkins University expanded its traditional two to three-year medical school curriculum to four years. As a result, other U.S, medical schools made major shifts in the teaching and learning processes, which resulted in exploding costs. At that time, there were 148 U.S. medical schools, including 14 Black medical schools. Chapter 3 discusses how Abraham Flexner visited 155 medical schools in the U.S. and Canada, evaluated their curriculum and, due to major deficiencies, recommended that many of the schools close. Howard College of Medicine and Meharry Medical College were the two Black medical schools that remained open. Both Howard and Meharry had dental schools.

Chapter 4 reviews the founding of AMHPS and Morehouse School of Medicine (which started as a department of Morehouse College, an all-male historically Black undergraduate college [HBCU] in 1975), and the need to increase the number of Black physicians. Although Howard and Meharry had continued to focus on increasing the number of Black physicians, the need was far greater than could be met by these two schools. The predominately White medical schools were unwilling or unable to admit and graduate significant numbers of Black students, although such students were both willing and able to meet the growing medical care needs of the Black population.

To address this problem, the President of Morehouse College invited Louis Sullivan MD, a Morehouse College alumnus, along with several others, to Atlanta to discuss the possibility of starting a new medical school. Dr. Sullivan became the top candidate to serve as founding Dean of what became Morehouse School of Medicine. This chapter details how, as founding Dean of the evolving medical school, Louis Sullivan proposed to the presidents of Howard and Meharry that they work together to assure funding and other opportunities to support the three schools. Meharry had already worked with Xavier University and the College of Veterinary Medicine at Tuskegee University to obtain federal construction loans. In the fall of 1977, Sullivan hosted the first meeting of the group that was to become the revived AMHPS. The association expanded to include Charles R. Drew University of Medicine and Science and several schools of pharmacy and pharmacal sciences. The AMHPS members worked with the U.S. Congressional Black Caucus, other units in the federal government, and federal officials in the legislative and executive branches to advance the shared missions of AMHPS.

The background work that AMHPS conducted that contributed to the 1985 Report of Secretary's Task Force on Black and Minority Health, commonly known as the Heckler Report, is discussed in Chapter 5. For the first time this Report documented that morbidity and mortality were patterned by race and/ethnicity. The Heckler Report included data and recommendations to support health initiatives for Native American/Alaska Native, Asian/Pacific Islanders, and Hispanic groups, as well as for the Black population. However, there were much more data for the Black and White populations than for the other groups. A series of meetings with federal officials and others by AMHPS members promoted funding and other support for their institutions. One initiative was to work closely with the U.S. Congressional Black Caucus Health Brain Trust chaired by the Honorable Louis Stokes, U.S. Congressman from Ohio. As it does to this day, the Health Brain Trust met yearly, during the Annual Congressional Black Caucus Legislative Weekend, to discuss health and health care needs in the Black community. Legislative action often occurs resulting from the Health Brain Trust sessions.

Chapter 6 describes landmark legislation initiated and/or promoted by AMHPS. The chapter does an excellent job outlining AMHPS's support for minority health activities across the U.S. The Heckler Report documented continuing racial and ethnic health disparities, particularly in the Black population. The Heckler Report was an indictment of the federal government, by the federal government. At the time it was published (1985) none of the Department of Health and Human Services operating divisions had any focus on the health of Black people or any other racial or ethnic minority group. As a result of the Heckler Report, a Deputy Assistant Secretary of Minority Health was appointed. Simultaneously, AMHPS was able to acquire funds through the Department of Education, which went directly to the schools. Morehouse School of Medicine moved from a two-year medical school to a four-year school, becoming the first Black medical school established in more than one hundred years. As AMHPS continued to expand its legislative activities, other HBCUs sought ways to be included in the funding opportunities. The AMHPS leadership was able to work with the presidents of other HBCUs to avoid conflicts, so that as other HBCUs became eligible for funding, Morehouse School of Medicine would not lose its funding. The chapter describes several other legislative initiatives that supported different AMHPS member institutions.

Chapter 7 discusses the learning curve for AMHPS members as they negotiated working in the political landscape to serve the best interests of all the member schools. During the Reagan Administration, Congress was often divided, with Democrats controlling the House and Republicans controlling the Senate. Issues, such as civil rights, voting rights, the Martin Luther King Jr. assassination, and school integration stimulated national discussions of equality for all people in the U.S. These issues were consistent with AMHPS's social agenda. The AMHPS member schools were in seven states, which formed the basis for a national strategy to inform and educate Congress and the public about the health of Black people and other people of color. The states were located in areas that made it possible for AMHPS to document the national role their schools played in educating underrepresented minority health professions students. The AMHPS graduates disproportionately served in communities of color providing much needed health care in the states where they were located.

To promote the Morehouse School of Medicine, Louis Sullivan invited President Ronald Reagan to speak at the July 1982 opening of the first building constructed independently of Morehouse College. However, Reagan's support for the Bob Jones University ban on interracial dating put Sullivan at odds with the Black community. Fortunately, Reagan declined the invitation and Sullivan then invited Vice President George H.W. Bush, who accepted. Over time, Sullivan and Bush developed an excellent relationship, which predated two notable events. George H.W. Bush was elected President and Sullivan asked Barbara Bush to join the Morehouse School of Medicine, Board of Trustees. Mrs. Bush accepted the invitation, and Louis Sullivan was asked by President Bush to join the President's Cabinet, as U.S. Secretary of the Department of Health and Human Services (DHHS). Dr. Sullivan was the first African American physician to serve as Secretary of DHHS. His position greatly enhanced his ability to improve the health of all who lived in the U.S. The AMHPS mission also benefited from Sullivan's appointment. However, both Sullivan and the AMHPS had to be intentional about avoiding any real or perceived conflict of interest among DHHS, Morehouse School of Medicine, and AMHPS.

Chapter 8 focuses on the role of the newly established Office of Minority Health (located in DHHS), Secretary Sullivan's ability to assure the health of the nation, and any appearance by Sullivan of conflict of interest between his previous positions as President of the Morehouse School of Medicine and President of AMHPS and his new role as Secretary of the U.S. Department of Health and Human Services. Secretary Sullivan moved quickly to align DHHS with the national need to diversify its leadership to better reflect the profile of the nation. He appointed Bernadine Healy, MD, a non-Hispanic White woman, to head NIH. Bill Toby, an African American man, was selected to head the Health Care Financing Administration. Antonia Novello, MD a Puerto Rican woman physician, was selected as U.S. Surgeon General. Other appointments occurred throughout DHHS, and in the operating divisions at Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Health Resources Services Administration (HRSA), and beyond. Offices of minority health were established in many state health departments. The State of Ohio established the first Office of Minority Health in a state health department. Congressman Louis Stokes represented the east side of Cleveland, Ohio in the U.S. Congress. Stokes and Sullivan had a longstanding, deeply positive relationship, which helped defuse Republican and Democratic conflicts related to major health policy, particularly related to the health of minority populations. Stokes and AMHPS leadership worked closely together to improve the financial viability of the AMHPS schools.

The Disadvantaged Minority Health Improvement Act was enacted during this period to strengthen the pipeline of underrepresented minority students interested in pursuing health careers. The act also addressed the issue of underrepresented faculty by creating a minority educational-loan repayment program that forgave educational loans for faculty at Meharry, Tuskegee, and Xavier. The chapter details how AMHPS worked during Sullivan's time as Secretary and beyond to advance minority health, particularly at NIH. The chapter describes the establishment of the NIH Office of Minority Health and the challenges that John Ruffin, PhD faced as its new director, and why the mission of his office often conflicted with the core values of NIH. The offices of minority health in other DHHS operating divisions faced similar challenges to those experienced by NIH's Office of Minority Health. However, the size, budget, and visibility of NIH made Ruffin's job more difficult than the same job in other operating divisions and minority health offices, and the barriers to success more daunting. For nearly 40 years the Democrats controlled the House of Representatives. However, in the 1994 midterm election, Democrats lost the House and Newt Gingrich, Congressman from Georgia, and the Republican Contract with America, changed the previous bipartisan support that AMHPS enjoyed. Once again, AMHPS had to devise new strategies to advance its mission.

Chapter 9 recounts the earlier years of Georgia Congressman Newt Gingrich and Secretary Louis Sullivan working collaboratively to promote the Morehouse School of Medicine during Sullivan's presidency of the school. However, within a short time, Gingrich and a group of Republican House members posed a financial threat to Morehouse School of Medicine and to the other AMHPS schools. The Republican Contract with America changed the relationships between Democratic and Republican House members, which had an adverse impact on funding and other benefits that AMHPS schools experienced. Previously, Democrat Louis Stokes and Republican Jerry Lewis met regularly to discuss AMHPS and other minority health concerns. While they did not always agree, they had open lines of communication. With the new Republican-controlled House, such relationships ended. While there was chaos in the House, Stokes had allies in the Senate. Senator Arlen Specter, the Pennsylvania Republican, was familiar with AMHPS and previously sponsored minority health legislation. He was aware of some of the challenges that John Ruffin as the new Director of the Office of Minority Health was experiencing at NIH. Sullivan, with Senate support from Specter and House support from Stokes, was able to elevate the NIH Office of Minority Health to a Center, with the authority to establish endowments to qualifying institutions. The chapter describes the political process that led to the Office becoming a Center, despite opposition from within NIH leadership. The challenge within the Republican House and Senate was how to pass the Minority Health and Health Disparity Research and Education Act with support from both Democrats and Republicans. Since 1976, AMHPS had accomplished much. However, most of the original AMHPS leadership had retired, and the AMHPS agenda with new leadership was unclear.

Chapter 10 describes how AMHPS operated with new leadership and a new president, George W. Bush. As noted, a major accomplishment during this time was elevating the Office of Minority Health to a Center with a budget of $80 million to operate the first year. The new Center not only had a budget, but it had the new authority to award grants, which included granting research endowments to qualifying institutions. The Center also established a loan repayment program and a center of excellence program. Several of the AMHPS schools received centers of excellence designations, which allowed Ruffin to fund research on minority morbidity and mortality, research that was not being done sufficiently in other institutes.

Beyond human subjects research, racial and ethnic disparities in health and health care were well documented. The 2003 book published by the Institute of Medicine of the National Academies of Medicine titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare documented widespread inequities in providing health care to Black people. Another report, Missing in Action: Minorities in the Health Professions, explored areas where the lack of Black and other health professionals of color adversely affected the health of underserved populations.

Racial/ethnic health care disparities and the lack of underrepresented racial/ethnic health care professionals demonstrate where changes are needed to eliminate those disparities. However, there is reluctance by the federal, state, and local policymakers and the scientific community to implement policies and fund programs to make the appropriate changes. Thus, AMHPS leadership must continue to provide, support, and promote policies and programs in a manner that aligns with its original mission.

Chapter 11 highlights a mission shared among the AMHPS schools. That mission was and continues to be a social mission. The chapter details specific dates and times when AMHPS members and/or their staffs performed essential leadership tasks that advanced the mission of the association, often at the expense of their individual school. The chapter recounts specific strategies and engagements that resulted in federal legislation and policies that influenced NIH research direction, expanded HRSA health professions education programs, broadened CDC community engagement partnerships, and redirected FDA drug clinical trials. Minority representation increased on many DHHS operating division advisory committees, request-for-applications (RFA) review panels, search committees, and other venues where policy and funding decisions were made. Many of the initiatives inspired by AMHPS leadership changed the political landscape regarding national health policy related to health and health care for Black and other underserved populations.

The presidency of AMHPS rotated based on professional discipline. A physician, veterinarian, pharmacist, dentist, and a lawyer served as presidents of the Association. Presidents and deans of the different schools rotated as AMHPS president. This was done to ensure that the perspectives of the various health professions were considered in organizational and policy decision-making. Rotating the presidency enhanced the likelihood that the priorities of the different health care disciplines would be considered. For example, medical care allows a broad range of procedures performed by nurses under direct or indirect supervision of a physician. With dental care, expanded use of auxiliaries under indirect supervision of a dentist is far more limited, and it is governed by dental licensing boards, state by state.

While the AMHPS schools focused on health and health care, the overall vision was much broader. As suggested by the subtitle of the book under review, AMHPS made health equity a national issue. The mission of AMHPS rendered any short-term goal of one of the schools secondary to the collective interest of the association. The AMHPS schools, while not all HBCUs, are all grounded in improving the human condition for those in greatest need. Many of the early AMHPS leaders began their undergraduate education at an HBCU. They were taught and/or inspired by faculty and staff at one of those institutions. It was not uncommon for an HBCU student to reflect on the advice given to them by an admired teacher or administrator. For example, many of the men who attended Morehouse College, during the tenure of President Benjamin E. Mays quoted advice that President Mays provided. Many of the previous AMHPS leaders attended professional and graduate schools at a predominately White institution. Unless they attended Howard or Meharry, they might have been the only Black student in their class, and for some, in the institution. Many of the early AMHPS leaders had direct experiences of overt personal and institutional racism as they pursued doctoral studies. They overcame those challenges by collective support, often outside of their educational and/or work environments.

Creating AMHPS, as an organization, was necessary to move equity forward in systems that deny opportunity to Black and other people of color. Promoting health equity is a challenge in systems yet to eliminate racial/ethnic, sex/gender, age, and socioeconomic disparities as well as implicit and explicit bias. Sustaining health equity demands the tenacity that AMHPS has demonstrated since its inception nearly 50 years ago. I believe that title of the book, We'll Fight It Out Here, is the mantra that charactered AMHPS in the past, characterizes AMHPS in the present, and will characterize AMHPS in the future and, the future is NOW!