Until the late 19th century, almost all patients received their medical care at home. Therapy was comparatively simple, and surgery was rudimentary. The introduction of asepsis from 1867 to 1870 and the adoption of anesthesia between 1846 and 1880 advanced the development of abdominal surgery and helped move surgery from kitchen tables to hospitals. Experiences with mass casualties during the Civil War and the advent of professional nursing made hospitals safer and more effective. Physicians, with expanded skills and capabilities and the need to use their time more efficiently, increasingly insisted on the use of hospitals. The number of acute-care hospitals in the United States grew from fewer than 200 in 1873 to greater than 4000 in 1910 and 6000 in 1920. By 1937, more than 80% of the nation's physicians had hospital privileges [1]. Hospitals had become established and essential for proper care. Unfortunately, they also exposed stark examples of medical injustice.

In many areas of the country, African-American patients were barred from appropriate hospital care. They were either denied admission to hospitals or, if admitted, were often segregated in special areas and usually received poor care and services. African-American physicians were refused appointments to hospital staffs and could not treat their hospitalized patients [2, 3].

As an alternative, about 150 hospitals were established for African-American patients between the Civil War and the 1960s; some of these hospitals were established by African-Americans. Because these hospitals were poorly funded and poorly staffed, it is not surprising to learn that many of them could not provide adequate care.

What changed the situation is chronicled in the article by Reynolds in this issue [4]. Reynolds describes the struggle in the early 1960s for African-American physicians and patients to gain access to hospitals in Greensboro, North Carolina. In brief, federal help inadvertently came with the 1946 Hill-Burton Act. This act, with the goal of stimulating the growth of hospitals, included provisions that hospitals have separate-but-equal facilities for African-American patients. A case was made that the denial of privileges at a hospital receiving Hill-Burton funds was unconstitutional because the separate-but-equal premise itself was unconstitutional. This case was won after an appeal, and the decision was upheld by the U.S. Supreme Court. Thus, it was the courts that ultimately provided the basis for access by patients and physicians to federally supported hospitals. The inclusion of Title VI in the 1964 Civil Rights Act subsequently barred discrimination in the use of all federal funds. Equality in access to health care facilities became enforced by law.

These events coincided with civil rights legal actions, in which antidiscrimination regulations were tacked onto regulations surrounding federal funding of health care facilities and tax exemption status. At the same time, the new Medicare program enforced compliance by denying funds to hospitals that racially discriminated.

As an irony of the times, many African-American hospitals actually suffered while mainstream hospitals and their staffs became more accessible to African-American persons and care became more equitable. With fewer patients and physicians, more hospitals that were set aside for African-American persons closed, although these closings were not always matched by ready access to other hospitals.

History informs and should guide the present and the future. Looking back, the United States was generally willing to deny proper health care on the basis of race. Health care, embedded as it was in intense racism and discrimination, as were all other aspects of life, was not seen as a separable right. For the most part, this view was not challenged by the organized medical profession. Indeed, African-American physicians were denied membership in many medical societies, and their National Medical Association was the only organization to substantially contest the situation. Change came eventually as part of a wave of civil rights reform that also affected education, housing, and transportation. Justice in health care had to be mandated by federal regulations.

What has happened since then? Have beliefs and actions changed? The setting is certainly different. Our view of medical care that has developed during the past 30 years is generally broader, clearer, and more sophisticated. The medical profession and the public have learned a great deal about the delivery of care and what it means to lack proper care. Quality and outcome information are shared openly.

With the introduction of advanced technology, the complexity of care has increased. That complexity has been accompanied by recent indications of more subtle differences in access to medical procedures [5-15]. Thus, African-American patients are far less likely than white patients to undergo cardiac catheterization, coronary angiography, angioplasty, and bypass graft surgery. African-American patients also undergo fewer invasive, diagnostic, and therapeutic coronary procedures after myocardial infarction. Similar observations of differences have been made with decisions about discretionary surgery [16], surgical treatments for breast cancer [10, 13], orchiectomies for prostate cancer (which are done more often in African-American patients) [15], and amputation rates compared with rates of revascularization (more amputations are done in African-American patients with peripheral vascular disease) [11]. As institutional care has evolved, indications of bias based on race and source of payment have appeared in nursing homes; even in hospitals, the intensity of care and the provision of services have been found to vary with race and economic status [17-20].

Various analyses have not fully explained these findings. The reports come from several geographic areas, and the findings persist despite adjustments for age, sex, clinical condition, and socioeconomic factors. The findings are also not explained by differences in overuse or refusal of procedures. Many causative factors are certainly possible, but discrimination, subconscious or otherwise, remains a lurking possibility.

Moreover, we do not know the true extent of these disturbing circumstances. Our present information is limited to relatively few methods of treatment, although information indicates that the experiences of women and Hispanic persons are similar [8, 9]. Data strongly indicate that, independent of the source of payment for care, poor persons receive worse care than those who are affluent [15].

What are the broader implications of all this? The health care system in the United States is currently challenged by glaring gaps in access to care, including the existence of more than 43 million uninsured persons. Universal access to effective and appropriate care has widespread support, and insurance coverage is generally seen as the principal means to access. However, our earlier history and more recent information indicate that to achieve real access, we must address more issues than simply insurance coverage. For whatever reasons, our society and our health care system have produced worse access and outcomes in relation to race, economic group, and probably other factors, such as sex.

We must find out why these deeper and more persistent inequities exist and ensure effective corrective measures. At a minimum, this means a more intense and honest study of equality in medical care, its identification as a major aspect of quality assessment, and the use of mandated monitoring and compliance procedures.

For physicians, the quest for access, equality, and medical justice is in keeping with our professional pledges and responsibilities. Physicians should be the informed, committed, and insistent conscience of such standards.