As the United States celebrates its 250th anniversary this year, the festivities around the country are commemorating a nation founded on promises of freedom and equality. But journalist and professor Nicole Carr says the country cannot understand the persistent racial inequities in American health care without confronting whom its institutions excluded—and what was lost because of it.

“We all pay the price,” Carr said in an interview about her new book, “The Price of Exclusion: The Untold Story of Black Medical Pioneers and the Roots of Our Health Care Crisis.” “Hate and racism are diseases,” Carr said.

The book traces the history of Black medical professionals who treated patients, established hospitals, advanced medical knowledge, and built institutions despite segregation and systematic attacks on their education and legitimacy. Carr’s findings and America’s 250th birthday converge as racial disparities in the physician workforce are a glaring holdover from last-century efforts to keep Black Americans out of medical school or, if licensed, to only treat Black Americans.

According to physician workforce data from the Association of American Medical Colleges (AAMC), Black Americans account for approximately 12 percent of the U.S. population but only five percent of active physicians. In comparison, Asian physicians make up nearly 20 percent of the workforce and white physicians represent more than half.

Those numbers tell a story beyond racially driven percentages. Studies show that when patients and doctors share the same race, or racial concordance, patients’ health outcomes improve.        

Credit: Amazon.com

The effect of racial concordance is especially notable among Black Americans. According to a 2020 survey by KFF and Andscape (formerly The Undefeated), one in five Black Americans say they experienced being mistreated because of their race in healthcare settings, with non-Black doctors not making eye contact, ignoring their concerns, or not engaging them in shared decisions about disease management.

Also, research has also found that Black newborns may have better survival outcomes when cared for by Black physicians and that Black patients often report stronger communication and trust when treated by doctors who share their racial background.

The positive impact of racial concordance and the low representation of Black doctors in the health care workforce are behind efforts to increase the 22 percent of Black Americans who report sharing race or ethnicity with their doctor.

Dr. Dina Strachan launched the “Find a Black Doctor” website in 2005 to help Black people connect with Black doctors. But the Conservative, rightwing group “Do No Harm” is suing the directory, saying the site racially discriminates against non-Black doctors.

Poor health outcomes among Black Americans are tied to racism or discrimination in health care, according to research conducted by The Commonwealth Fund. And KFF research shows that persistent health disparities among Black Americans are a result of past policies and events, including the elimination of Black medical schools.

And Carr argues that such disparities cannot be separated from decisions made more than a century ago.

Several Black medical schools closed because of the 1910 Flexner Report, which reshaped medical education and reinforced a system in which Black doctors were expected to occupy subordinate roles. Researchers estimate that five shuttered Black medical schools could have produced between approximately 28,000 and 35,000 additional Black physicians by 2019.

Exclusion from organizations such as the American Medical Association also meant Black physicians had limited influence over the policies, research and educational standards that shaped American medicine.

“Their voices were not lifted in what becomes the standard,” Carr said.

The consequences extend beyond who wears the white coat. Carr documents how racist assumptions entered medical journals, textbooks and clinical instruction—including portrayals of Black women as promiscuous, irrational and prone to exaggerating pain during childbirth.

“This is how race medicine is baked into the curricula,” she said. “You can’t separate the current condition from our past existence.”

And those beliefs continue to shadow patient care. In 2024, Black women died from maternal causes at a rate of 44.8 deaths per 100,000 live births—more than three times the rate for White women.

Yet Carr cautions against treating physician diversity as the only solution. Health is shaped long before someone reaches an examination room—by housing, education, food access, environmental conditions and the economic policies governing daily life.

“If you want to decrease inequities in health care, start outside of the hospital,” Carr said. “The hospital’s the last stop.”

That means addressing children’s school-lunch debt, contaminated drinking water, environmental racism and the chronic stress of navigating institutions that were not designed to protect everyone equally.

“If we’re addressing health care,” she said, “we’re addressing humanity outside of the hospital,” Carr said.

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