Medical Associations

Professional organizations of physicians—whose goals are to promote the science and art of medicine and to improve the public health—serve as major components of the health-care infrastructure in the United States. Medical associations have as their mission the establishment and maintenance of a scientifically rigorous, occupationally specific, professional educational training and standards; defining medical ethical codes of practice and behavior; and establishing internal mechanisms for evaluating, disciplining, and sanctioning physicians on technical and ethical grounds. This professional authority is grounded in a culture-based belief in science and medicine and the general acceptance of medical progress as a perceived public good. In the United States the influence of the medical association grew tremendously after the nineteenth century. Organized medicine gained the authority to write most of the nation's public-health and medical-licensing laws; to control its medical-education system; to guide its local, regional, and national health policy; and to influence public attitudes about health.

The country's health system is burdened with a history of racial and medical-social problems. Examples include an increasing health-system apartheid based on race and class and the unequal state of the nation's medical associations. The American Medical Association (AMA) is the better-known medical professional association. It is influential, wealthy, and largely white and represents the country's traditional health interests. Since its founding in 1847, it has become the anchor and focal point of American organized medicine. African-American physicians and patients, and other medically poor and disadvantaged groups, are represented by the lesser-known, largely minority National Medical Association (NMA), which was founded in 1895. These two medical associations' policies, ideologies, and perspectives are startlingly different.

The Western medical profession originated from Egyptian, Sub-Saharan African, and Mesopotamian roots. Early unsuccessful attempts to establish medicine as a profession were based on an increasingly specialized body of knowledge, spiritual authority related to medicine's early ties with religious and priestly functions, and the taking of an oath. During the Renaissance the European medical profession became a highly prestigious, universityaffiliated "calling," which gained formal professional recognition by the sixteenth century. The first professional associations began in Italy in the Middle Ages, and memberships were built around the faculties of early medical schools. As this practice spread northward, the English physician Thomas Linacre obtained what may have been the first official charter for a medical association. At his request King Henry VIII of England granted a charter for the College of Physicians in 1518. Other European nations followed this precedent.

In comparison, American medicine gained professional status, authority, and prestige only in the nineteenth century. The low status of the medical professional was demonstrated by the late formation of stable, functional professional associations and the absence of medicallicensing laws until the late nineteenth century. Despite the emergence of a few well-trained black physicians before the Civil War, such as James McCune Smith, John Sweat Rock, and Martin Robison Delany, the professional exclusion of African Americans was a routine aspect of American medical subculture.

After the institutionalization of the Atlantic slave trade in the fifteenth and sixteenth centuries, the participation of blacks as health caregivers in Western-oriented slave-based cultures was restricted to the functions of traditional healers, root doctors, and granny midwives. They worked in an inferior, slave-based health subsystem that matured in the New World. African-American attainment of formal Western medical education in this era was virtually unknown. After the Civil War, the country's medical profession helped strengthen a dual and unequal health system. The inferior lower tier was reserved for blacks and the poor; the compelling health needs of the newly freed slaves, and their already poor and deteriorating health status, were virtually ignored by the profession. White medical associations and their infrastructure continued to exclude African Americans from training and participation in the medical profession. These policies generated an African-American health crisis after the Civil War. The alarming black death rates and the health outcomes that resulted led to emergency passage of legislation enacting the Freedmen's Bureau health programs and the opening of race-, gender-, and class-neutral medical schools. The first of the sixteen multiracial medical schools in America was at Howard University in Washington, D.C. (founded in 1868), and the second was Meharry Medical College of Nashville, Tennessee (founded in 1876). The subsequent development of a cadre of black health professionals, including physicians, dentists, nurses, pharmacists, and allied health professionals, had salutary effects on the health status of African Americans and increased their access to high-quality health and hospital care. The African-American health professionals produced by the black schools functioned as the sole professionally trained advocates for black health progress; started sorely needed black hospital, clinic, and health-professional-training movements; organized medical associations; and offered the African-American community access to the most up-to-date medical care.

Beginning in the 1870s black physicians began efforts to correct the AMA's exclusionary and discriminatory racial policies. Howard University's racially integrated medical school faculty struggled unsuccessfully to desegregate the AMA at local levels, through litigation and pressure from the U.S. Congress, in a campaign lasting several years. These actions pressured white organized medicine to declare racial segregation as its official national policy by 1872. In frustration, black physicians, dentists, and pharmacists established more than fifty local, state, and regional black medical associations organized around the NMA by the 1920s. The NMA is now a multicomponent national organization representing approximately fifteen thousand physicians. The earliest desegregated medical professional associations were the National Medical Society of the District of Columbia (1870), the Academy of Medicine (1872), and the State Colored Medical Association in Nashville, Tennessee (1880). African-American health-professions associations became permanent fixtures with the founding of the Medical Chirurgical Society of the District of Columbia in 1884, the Lone Star State Medical Association in Galveston, Texas, in 1886, and the NMA in Atlanta, on November 18, 1895.

The Civil War dramatically exposed the inadequacies of America's medical-education system. Therefore, a great deal of pressure was generated within the white medical profession and by the AMA for medical-education reform. This reform era, lasting from the late nineteenth century through the 1920s, focused on rigorous scientific standards and technology, bedside clinical training, higher entry requirements, and the limitation of physician supply.

The AMA and the corporate-based educational infrastructure closed six of the eight extant black healthprofessions schools between 1910 and 1923 and underfunded the remainder. This resulted from an educational reform movement led by Abraham Flexner, an educational consultant hired by the Carnegie Foundation and the AMA to coordinate an upgrading of the nation's medical schools, based on European models. Throughout the "Flexner era," the NMA fought vigorously, but unsuccessfully, to improve and maintain existing entry points for African Americans into the health professions. Flexner reform adversely impacted black health status and outcomes, cut African-American access to basic services, and decreased black representation in the health professions. Though Meharry and Howard were forced to serve as virtually the sole sources of black health-care personnel from 1910 to 1970 on shoestring financing, they were also excluded from the stewardship white medical schools were obtaining over America's government and city hospitals and clinics. Control of these institutions provided clinical training bases critical to the new accreditation processes and requirements. Yet the racially segregated health system supported the survival of the remaining black healthprofessions schools. The NMA was crucial in maintaining the accreditation and financing of these schools and allied hospitals and health facilities. Despite vigorous campaigns by the NMA, black representation in the medical profession in America has remained tenuous, ranging between 2 percent and 3 percent of physicians since the turn of the twentieth century.

From its beginnings the NMA was forced to function as a civil rights organization. It has worked in concert with the NAACP, the National Urban League, and many other black civil rights and service organizations to further the cause of African-American health concerns. This was a natural development, since African Americans are the only racial or ethnic group forced to view health care as a civil rights issue. On several levels the NMA's policies represent a positive response to the AMA's traditional policies of racial segregation, massively funded campaigns against progressive health-care legislation, health discrimination based on race and class, and insensitivity to the health status, needs, and concerns of the nation's African-American, poor, and other underserved patient populations. The NMA has been singular at both the community and national levels in supporting progressive health-care legislation—from before the Wagner Plan in the 1930s through Medicare and Medicaid in 1965 to a fair national health plan in the 1990s. The NMA continues its history-based struggle to end race and class discrimination in the health system, to form a socially responsible covenant between the medical profession and American society, and to obtain justice and equity in health care for African Americans.

See also Professional Organizations

Bibliography

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michael byrd (1996)