Health Impact of Reparations for Black Americans (Position Paper)

Introduction

Reparations for the legacy of slavery and the resulting structural racist policies and practices in the United States are a significant tool for addressing the health inequities that currently impact Black American communities.

In the United States, racial inequities in health care outcomes persist because the legacy of more than 400 years of slavery and a multitude of structural racist policies and practices have impacted social determinants of health (SDOH). Black Americans have been deprived of the conditions necessary to achieve optimal health. Life expectancy—a key metric for measuring population health—has consistently been lower for Black Americans than for white Americans. Provisional data for 2022 showed that the estimated life expectancy for Black people was 72.8 years compared with 77.5 years for white people and 80.0 years for Hispanic people.¹ Further, a 2024 analysis of key data on health status, outcomes and behaviors among people from different racial and ethnic groups found that Black Americans fared worse in 75% of examined measures compared with white Americans.²

Unless persistent racial health inequities are addressed now, they will continue to adversely affect Black Americans for generations to come. According to Camara Jones, MD, MPH, PhD, a family physician and past president of the American Public Health Association whose work focuses on naming, measuring and addressing the impacts of racism on health and well-being, “Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need.”³  Reparations are a means to rectify historical injustices. Therefore, they are a significant tool for addressing the health inequities that Black communities in the United States continue to experience.

Historical background

Origins of slavery in the United States

Beginning around 1619, Africans were enslaved and brought by force to the British North American colonies to provide labor for international agricultural trade (e.g., sugar, rice, cotton, tobacco, coffee). They belonged to a wide variety of cultural and language groups. Slavery played a central role in the economy of the South, where enslaved people made up more than 32% of the population in 1860.^4-6 Enslaved people’s lives and labor fueled economic growth in the Americas, as well as in British industries such as shipbuilding, banking and insurance.⁷

Harsh life on plantations deprived enslaved people of basic human rights, with many enduring family separation, poor living conditions, brutal beatings, sexual assault and murder. Throughout this time, resistance to slavery took various forms, including escapes, rebellions and the abolitionist movement, which gained momentum in the 1830s.⁷ An 1857 U.S. Supreme Court decision (Dred Scott v. Sandford) stated that only white people could be citizens with constitutional protections and that Congress did not have the authority to prohibit slavery in any federal territory.⁸ This ruling impacted U.S. expansionist policies and intensified disputes over slavery, eventually leading to the secession of 11 Southern states and the Civil War, which was waged from 1861 to 1865.⁷ In 1865, slavery was abolished at the federal level with the adoption of the 13^th Amendment to the Constitution.

Post-slavery discrimination

Significant racial inequities in health outcomes and SDOH today stem from the cumulative effects of more than 400 years of slavery, persistent racism, and the systemic denial and active deprivation of human rights for Black Americans, which continued even after slavery was abolished.⁹ The following are some examples of post-slavery discrimination in the United States.

• Black Codes: Fear of giving freedom and equal status to formerly enslaved people after the Civil War led to the continued suppression of newly freed people’s rights. Former Confederate states subverted federal laws by adopting “Black Codes,” which were local laws that maintained white supremacy and restricted the rights of newly freed people to engage in interracial marriage, business or land ownership and unrestricted travel.^10,11 These laws kept newly freed people in predatory working environments (e.g., sharecropping) that resulted in extremely harsh work conditions and insurmountable debt. Southern states also passed vagrancy laws under which newly freed people could be unfairly imprisoned for petty infractions and forced to work on public infrastructure projects under grueling conditions similar to slavery.¹⁰

• Jim Crow laws: Jim Crow laws and related practices perpetuated racial segregation and discrimination in the South from 1874 until the passage of the Civil Rights Act of 1964, the Voting Rights Act of 1965 and the Fair Housing Act of 1968.^10,12 Predicated on the “separate but equal” myth, these laws institutionalized the race-based oppression that underlies many of the social, economic, educational, political and health inequities that still exist in the United States.

• Redlining: Redlining—the “systematic denial of … financial services to residents of certain areas, based on their race or ethnicity”¹³—is a notable example of persistent institutional racism resulting from the legacy of slavery in the United States. By deeming Black neighborhoods as “dangerous” or “hazardous,” banks and insurance companies blocked residents and entire communities from accessing mortgages, loans and insurance.¹³ These discriminatory practices denied Black residents and communities the ability to finance crucial infrastructure (e.g., schools, grocery stores, medical facilities, local Black-owned businesses) and accumulate generational wealth, and they stripped entire neighborhoods of political power. A leading U.S. health policy organization notes, “Today’s housing patterns continue to reflect these past discriminatory policies and leave Black people facing increased health risks. As a result of ongoing residential segregation and disinvestment into areas where Black people are more likely to live, they are more likely to live in areas that have more limited educational and employment opportunities, more limited access to healthy food options, less access to green space, and more limited transportation options, which in turn make it more difficult to access health coverage and care and pursue healthy activities. Moreover, many of these areas pose increased environmental and climate-related health risks, including increased exposure to extreme heat, lead, pollution, and toxic or hazardous materials.”¹⁴

Racism and mistreatment of Black Americans in medical research

It is critical for the American Academy of Family Physicians (AAFP) to acknowledge the role that American medicine has played in the blatant mistreatment of enslaved Africans and their descendants, as well as how it has benefited from this mistreatment. Exploitation and abuse of power are evident in medical research and experimentation on Black Americans, mirroring the inhumane treatment of Black people during and after the times of slavery.¹⁵ Throughout history, there are numerous documented examples of egregious cases in which physicians propagated, reinforced or accepted racist policies and practices that have negatively impacted the health of Black people and worsened SDOH in Black American communities.

The following examples are just a few of the many acts of medical exploitation deeply rooted in racial bias and stigmatization throughout U.S. history. There is a direct connection between this legacy of unethical treatment and discrimination in medical research and an enduring distrust in the health care system among Black Americans. These historical harms, along with countless others, have shaped the social, financial, political and educational realities currently faced by Black American communities, underscoring the need for restoration in the form of reparations.

[WARNING: The following text describes institutional violence perpetrated on Black Americans. Details of the transgressions are not included, but general descriptions are given for historical context and to increase awareness of the depth of abuse and mistreatment endured by this community in the United States.]

James Marion Sims and gynecological experiments

P’s policy on race-based medicine states, “Race is a social construct that is used to group people based on physical characteristics, behavioral patterns and geographic location. Racial categories are broad, poorly defined, vary by country and change over time. People who are assigned to the same racial category do not necessarily share the same genetic ancestry; therefore, there are no underlying genetic or biological factors that unite people within the same racial category.”¹⁶ By perpetuating the use of race as a proxy for biology or genetics, race-based medical research has implicitly and explicitly reinforced the mistreatment of Black Americans. One example of this involves James Marion Sims, a physician who became president of the AMA in 1876 and president of the American Gynecological Society in 1880.¹⁷ Sims performed experimental pelvic operations on enslaved Black women without anesthesia because he believed that Black people did not experience pain like white people did. He is also reported to have operated on enslaved Black children. Unfortunately, evidence from recent studies shows that false beliefs about racial differences in the experience of pain still exist among medical students and residents and have a detrimental impact on patient outcomes.¹⁸

U.S. Public Health Service syphilis experiments

A striking example of the harm caused by race-based medicine on an institutional level is the Untreated Syphilis Study at Tuskegee (originally called the Tuskegee Study of Untreated Syphilis in the Negro Male), which was conducted by the U.S. Public Health Service from 1932 to 1972.¹⁹ It involved 600 Black American men, most of whom were sharecroppers and some of whom had no access to health care services outside of participation in the study.²⁰ The men were falsely recruited with promises of free medical care and were not informed that the study’s goal was to observe the long-term effects of syphilis in Black men. Two-thirds of the participants actually had latent syphilis but were never told of their diagnosis so that researchers could observe the disease course.²⁰

Even after penicillin became a widely available treatment for syphilis in the 1940s, none of the Tuskegee study participants with the disease were ever treated. They experienced many related complications, including blindness, severe mental illness and death. Participants’ families, who had to care for their declining loved ones, were indirectly harmed by the study. In addition, some participants’ families were directly harmed by the study, with at least 40 spouses and 19 newborns contracting syphilis.²⁰

A U.S. Public Health Service investigator challenged the ethics of the study in the mid-1960s. However, officials decided to continue it in hopes of tracking the participants until they all died to allow for autopsies and further data analysis. The study was finally stopped in 1972 after an Associated Press article sparked public outcry. The egregious harm caused by the Untreated Syphilis Study at Tuskegee and its blatant immorality prompted the U.S. government to create new guidelines to protect people from harm inflicted upon them in research projects.

Henrietta Lacks and the HeLa cell line

The use and distribution of the HeLa cell line is an example of an abuse of power by the medical community on a global scale. In 1951, Henrietta Lacks, a young Black American mother, died at the age of 31 due to an aggressive case of cervical cancer.^21,22 Prior to her death, physicians harvested cervical cancer cells from Lacks without her knowledge or consent. She died unaware that her cells would become the first human cell line able to stay alive and continue replicating indefinitely (i.e., an immortal cell line). Due to their unique properties, Lacks’ cells—known as the HeLa cell line—have been cultured and used worldwide for wide-ranging scientific and medical research over the decades, leading to groundbreaking health advancements, research discoveries and substantial economic gains. However, as Lacks’ cells were being used to make significant contributions to society and generate profits, her family was not notified or offered restitution.²³ The 2010 publication of the book The Immortal Life of Henrietta Lacks by Rebecca Skloot brought public attention to Lacks’ story and the harms her children endured, including poor access to the medical care made possible by their mother’s cells.²¹ In 2023, Lacks’ family reached a private financial settlement with a science and technology company that profited from products developed using the HeLa cell line.²³

Impact of reparations on social determinants of health for Black Americans

The United Nations defines reparations as “measures to redress violations of human rights by providing a range of material and symbolic benefits to victims or their families as well as affected communities.”²⁴ Reparations for the legacy of slavery in the United States are an attempt to redress past and present injustices. Table 1 describes the five key components of reparations. While the AAFP’s recommendation highlights the health impacts of slavery on Black Americans, a multipronged approach to reparations that includes all five components would be most equitable.

Table 1. The five components of reparations0

Information from reference 25. 

Historically, reparations have taken a variety of forms, including post-war payments from one nation to another, official acknowledgment of past injustices and financial compensation of individuals. The following examples from different historical contexts illustrate diverse approaches to reparations.

• Luxembourg Agreements: The Luxembourg Agreements, signed in September 1952, resulted from negotiations between West Germany, Israel and the Conference on Jewish Material Claims Against Germany (a group representing 20-plus international Jewish organizations).²⁶ Germany acknowledged its responsibility for damages and expenses incurred during World War II by committing to provide approximately $714 million in goods and services to Israel and approximately $107 million in individual compensation.

• United States v. Sioux Nation of Indians: In 1980, the U.S. Supreme Court ruled that the federal government had to pay more than $100 million to the Sioux Nation as reparations for the forceful seizure of their ancestral tribal lands.²⁷ This legal ruling acknowledged past injustices and sought to rectify them through financial compensation.
  
  
• Civil Liberties Act of 1988: In 1988, the U.S. government authorized reparations of $20,000 per person to Japanese Americans who had endured seizure of their land, property and businesses and incarceration in prison camps during World War II; the initial compensation cap of $1.25 billion was later increased to more than $1.6 billion.^28,29 This financial compensation was intended to acknowledge the wrongful internment and financial losses and provide redress to those affected.
  
  
• Reparations for enslavement: Throughout history, numerous initiatives and legislative efforts to provide reparations to enslaved people and their descendants have been undertaken, often driven by tireless demands from Black American activists. The following are some notable examples:

o   “40 acres and a mule”: In January 1865, after meeting with 20 Black leaders in Savannah, Georgia, Gen. William T. Sherman signed Special Field Order No. 15, which promised to redistribute approximately 400,000 acres of land in the South to formerly enslaved people.^30,31 This form of restitution became known as “40 acres and a mule.” However, in an act that highlighted the contentious nature of the issue at the time, President Andrew Johnson overturned this order later in 1865, returning the land to plantation owners.

^o     Pension movement: Between 1890 and the U.S. entry into World War I in 1917, Black American organizations lobbied Congress for federal pensions for formerly enslaved people and their descendants.³² One notable example is an 1894 Senate bill proposing a one-time payment of up to $500 per person and a modest monthly pension.^30,32 However, this and similar bills ultimately failed.

^o     Black Manifesto: In 1969, James Forman, a former head of the Student Nonviolent Coordinating Committee, issued a "Black Manifesto" that demanded $500 million from American churches and synagogues for their historical role in perpetuating slavery.³³

Financial reparations for Black Americans would address the large wealth gap caused by intergenerational monetary and capital losses experienced by the descendants of enslaved Africans.³⁴ Another advantage of paid restitution is that it also “offers the internalized benefits of societal recognition for the brutality and loss of identity caused by African chattel slavery.”³⁵ Nevertheless, reparations payments alone will not fully address the impact of the legacy of slavery on structural determinants in the United States (i.e., social, economic and political mechanisms that generate class inequalities in society³⁶). This impact must be countered by concentrating financial resources and payments that boost community-level resources and improve access to grocery stores, financial institutions, well-funded public schools, health care facilities and Black-owned businesses for Black Americans.

Discussions regarding reparations for Black Americans continue to evolve. For example, the NAACP has outlined a multifaceted approach to reparations that includes “a national apology, rights to the cannabis industry, financial payment, social service benefits, and land grants to every descendant of an enslaved African American.”³⁰ This proposal reflects ongoing efforts to address historical injustices and foster equitable redress for Black American communities that have been historically marginalized.

The legacy of more than 400 years of slavery in the United States has resulted in significant damage in many Black American communities nationwide in the form of poor health outcomes and persistent inequities.⁹ These inequities are unacceptable, and change is long overdue. Reparations would help these communities navigate toward not only health equity but also political, social and environmental justice. Damage from the legacy of slavery is pervasive and entrenched. A knowledgeable, thorough and meticulous reparations strategy that includes analysis and forecasting of potential benefits and harms in the present and future is required. 

CONCLUSION:

The AAFP believes that reparations are appropriate and necessary when a direct connection between specific acts of violence or discrimination and the people who have been impacted by such acts can be identified. The legacy of slavery and the resulting structural racist policies and practices that have targeted Black Americans over generations (e.g., redlining, predatory race-based banking practices, discriminatory criminal justice system) are directly connected to numerous modern-day social and institutional inequities that affect health, wealth distribution, life expectancy, education and employment for Black Americans. Therefore, the AAFP supports reparations for Black American populations that continue to be impacted by the legacy of slavery.

Monetary reparations alone can never restore the loss of connections to one's lineage, land and indigenous knowledge. Therefore, the AAFP recommends a multipronged approach to reparations as the most holistic means of achieving restorative justice for the Black American descendants of enslaved people. The specific nature of reparations will vary among different Black American communities, depending on what restorative justice entails for each community. It is important to note that the familial and genealogical connections of enslaved people were intentionally disrupted and erased under the system of slavery, so it is extremely difficult to use direct ancestral links between enslaved people and their descendants as the basis for distributing reparations. However, the historical trauma from countless acts of medical mistreatment can be traced through generations of Black Americans, substantiating the eligibility of Black American people and communities for reparations.

Family physicians have powerful political voices. The AAFP strongly calls on its members to be steadfast and vocal advocates for the form of reparations that will best serve their communities. As the most powerful nation in the world, the United States must no longer tolerate inequities in health. The critical importance of political, social, environmental and cultural determinants of health must be addressed now. Family physicians know that health equity is the only acceptable option for our patients and communities. To reiterate Dr. Jones’ words, “Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustice, and providing resources according to need.”³

CALL TO ACTION:

To address health equity for Black American descendants of enslaved people, the AAFP recommends a multipronged approach to reparations that involves institutional, structural and financial changes.

The AAFP recommends that Family Physicians:

• Practice cultural humility and safety with the mindset that implicit bias is common
• Learn and understand the history of the historically and intentionally excluded communities they served
• Become informed about the impact of the legacy of slavery and structural racist policies and practices
• Acknowledge how health care institutions perpetuated and sustained racial harms
• Advocate for institutional and structural changes that create health equity for Black Americans using a public health framework