Uché Blackstock is an emergency physician and founder and chief executive of Advancing Health Equity. This essay is adapted from her new book, “Legacy: A Black Physician Reckons With Racism in Medicine.”

When I was a little girl, my twin sister, Oni, and I used to visit our mother at work. Her name was Dr. Dale Gloria Blackstock and, in the 1980s and ’90s, she was an attending physician at Kings County Hospital Center in Brooklyn, not far from our home in Crown Heights.

Our mother worked long hours. So sometimes, we’d head to the hospital after school to see her and do our homework. Walking the hallways, our shoes squeaking on the linoleum floors, we’d make our way to the large cafeteria, where we’d pull textbooks from our backpacks and settle down to work alongside the physicians, nurses, technicians and aides taking a break. The staff behind the counter knew us well. They would smile warmly and ask, “Visiting your mother today?”

After our homework was done, we’d sneak into our mother’s clinic to ask for small change to spend on our favorite, red Jell-O. She’d hand it to us and, if we were quiet, let us stay and observe for a minute or two as she examined a patient. Our mother was warm but serious with those in her care. Occasionally, she would smile, but more often than not, she was extremely focused on what they were saying and what was going on in their lives.

Our mother always seemed to know as much about her patients’ children and families as she did about their medical problems. When you came for a visit with Dr. Blackstock, you weren’t only having your blood pressure or cholesterol checked — you were meeting with someone who would assess your whole being.

I believe our mother practiced what is now known as structurally competent and culturally responsive care, in which the entire complex nature of a patient’s background and the social context in which they live, work, love and pray is considered during evaluation. And people loved her for it. She wasn’t just taking care of patients. She was tending to her neighbors.

The daughter of a single mother, raised on public assistance, our mother grew up to become the first person in her family to graduate from college — and then from Harvard Medical School, in 1976.

“What am I doing here?” she remembered asking herself on her first day.

The majority of her classmates were White and from affluent backgrounds. In her class alone, one student was a relative of Jackie Onassis. Several students had parents who were Harvard professors and had written the textbooks they were using in class. Another student’s father had won the Nobel Prize in medicine.

My mother’s life couldn’t have been more different from theirs. She was a Black girl from Brooklyn. While she wanted to believe that she deserved to be at Harvard, she wasn’t always certain. Her own claim to fame was that her mother had received her licensed practical nursing degree after raising six children, attending school full time, working full time, taking care of the family and getting off welfare. Our mother was so proud of her mother’s achievements. But they weren’t a Nobel Prize in medicine.

When we were children, our mother insisted she hadn’t experienced overt racism while at Harvard. Notably, her class was one of the most diverse in the school’s history, thanks to diversity initiatives begun soon after the Rev. Martin Luther King Jr.’s assassination. A full 10 percent of her class was Black.

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Even so, there were incidents that led her to wonder whether racism was at work. During one of her rotations, a professor held open a door for a White male student, then let it slam in my mother’s face. Another time, when a male professor made a joke in bad taste about women, he apologized to a White student within earshot but not to my mother, who was standing right next to him. Once, she was told not to sleep in an empty patient room — as was customary after a night shift — because a White male resident needed the bed.

Then there was the White patient who didn’t want to be treated by a Black student-doctor and told my mother this in no uncertain terms. By the time she graduated, she was exhausted — and not just because of the rigor of her schooling.

Although I always want to celebrate my mother’s achievements, I would be doing her memory a disservice if I were to portray her story only as one of exceptionalism, of the plucky young Black woman from humble beginnings who through grit and determination rose to success. To truly pay tribute to her, I know I must situate her story within the broader context of the historical barriers that Black people in the United States have faced entering the medical field.

Those barriers have been legion.

For centuries in this country, White-only medical schools, with exclusionary policies and practices, made it virtually impossible for Black people to receive medical training. It was only after the Civil War, with thousands of injured veterans in desperate need of medical care, that a small handful of Black trainees began to be admitted to White medical schools in the North. And it wasn’t until Reconstruction that a number of Black medical schools sprang up in the South, enabling Black people to finally have access to medical training in greater numbers.

These schools were Howard University College of Medicine, established in D.C. in 1868; Meharry Medical College, established in Nashville in 1876; Leonard Medical School, established in Raleigh, N.C., in 1882; New Orleans University Medical College, founded in 1887; Knoxville College Medical Department, founded in 1895; Chattanooga National Medical College, founded in 1902; and the University of West Tennessee College of Physicians and Surgeons, founded in Memphis in 1904. By 1905, those Black medical schools had trained 1,465 doctors. Each of those doctors was poised to train a new generation of physicians, who would have gone on to train a generation of their own.

And then, that promising legacy was abruptly extinguished.

The reason was the publication of the Flexner Report — a landmark document in U.S. medical history that had a devastating effect on the number of Black physicians in this country.

Abraham Flexner, the White author of the report, was an education specialist who at the turn of the 20th century was employed by the Carnegie Foundation and the American Medical Association to travel to all 155 medical schools in the United States and Canada to assess the state of medical education. His report, published in 1910, led to broad standardization of medical schools, with the top school in the country at the time — Johns Hopkins — held up as the example for all others to follow.

The new standards did go some way toward elevating the quality of U.S. medical care. Flexner’s recommendations included more-stringent admissions criteria; well-equipped laboratories and facilities; and a higher level of instruction by physician scientists, resembling the model found in Western European medical schools. The problem was that smaller Black institutions simply did not have the resources or endowments to implement the more rigorous instruction the new standards required.

Flexner had strongly racist opinions on the role of Black people in medicine. He wrote that Black students should be trained in “hygiene rather than surgery” and were best employed as “sanitarians” who could help protect White people from common diseases such as tuberculosis.

“Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors,” Flexner wrote, begrudgingly admitting that Black people did need some role in health care, if mostly as it pertained to Whites. “The negro must be educated not only for his sake, but for ours. He is, as far as the human eye can see, a permanent factor in the nation.” He added that Black medical schools were “wasting small sums annually and sending out undisciplined men, whose lack of real training is covered up by the imposing M.D. degree.”

After the Flexner Report, five of the seven Black medical schools in the United States were forced to close, leaving only Howard and Meharry.

Almost a hundred years later, in June 2020, amid a global pandemic and the Black Lives Matter protests, I read an article about the Flexner Report that popped up in my Twitter feed. My heart dropped as my eyes scanned the information. I wasn’t prepared for its contents.

The article described a new study estimating that if the majority of Black medical schools had been allowed to remain open after the Flexner Report’s publication, and if they had continued training Black doctors to this day, they would have educated roughly 25,000 to 35,000 people. In essence, tens of thousands of future Black physicians had disappeared. I remember sobbing as I absorbed the magnitude of those numbers.

The loss of so many Black physicians to the field of medicine and to our communities has been undeniably profound. We know — as I witnessed in my mother’s clinic — that racial concordance in patient-physician interactions influences everything from how patients feel when they leave their appointment to how likely they are to take their medications. We know that because Black physicians are more likely to mentor and sponsor Black students, those students would have felt more comfortable, and would have been more likely to thrive, in academic medical environments, resulting in greater academic success and career opportunities — and generations of new doctors.

We know that had those Black medical schools remained open, the health of our communities might be in a different place, most likely better than it is today.

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Instead, more than a century after the Flexner Report, we are still recovering from its impact. In 1900, 1.3 percent of U.S. physicians were Black, when Black people made up 11.6 percent of the population. Today, the number of Black physicians remains stubbornly low, with only 5.7 percent of all U.S. physicians identifying as Black — although Black people make up 13.6 percent of the population.

My mother died of leukemia in 1997, at age 47, when Oni and I were only 19. I remember feeling the loss then not only for myself, but also for my mother’s patients. They had experienced the care of a physician who listened to them, understood their lives and experiences, and was invested in them as whole human beings. Today, I imagine the hundreds of thousands of similar patient-physician relationships that never had a chance to exist because of a report that was designed to improve health outcomes — but only for White patients.

Since the time of the Flexner Report, the racism undergirding our medical institutions has hardly dissipated. Exclusionary criteria in medical school admissions look different than they did in the past, but they still have the same detrimental effect on the representation of Black physicians.

Reliance on the MCAT, the standardized test required to enter medical school, has been shown to be discriminatory against Black students and other students of color, even as the test does a poor job of predicting people’s future success as doctors. Studies have shown also that election to the national medical school honor society, Alpha Omega Alpha (AOA), which often determines entry into selective medical specialties such as ophthalmology and dermatology, is embedded in racism, resulting in few Black student members. Admission to AOA relies heavily on traditional criteria, such as grades, test scores and publications, which are all influenced by inequitable factors leading up to and during medical school — including a lack of quality K-12 education in underserved communities; lack of social, parental and familial privilege and resources; lack of race-concordant teaching, mentoring and advising; and mistreatment based on race or ethnicity.

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Because academic medical centers receive federal funding for education and training, they have a social contract with the public to ensure that medical schools accept and support a student body that fully represents the communities being served. Some medical schools have recently adopted a holistic review process that places value on lived experience and personal attributes apart from traditional metrics such as MCAT scores and grades; however, this process has not been implemented consistently by schools.

But training more Black physicians is only one of the many solutions needed to address the glaring health inequities that exist in this country. The fact is, we need multiple fixes, and we need them now — because since the days, 30 years ago, when my mother was practicing medicine in Brooklyn, health outcomes have gotten only worse, not better, for Black Americans.

Today, we are in the midst of an undeniable maternal mortality crisis largely driven by the deaths of Black people, who are at least three times more likely to die than their White peers. Black babies also have the highest infant mortality rate. And Black men have the shortest life expectancy of any major demographic group. These horrifying trends were true even before the covid-19 pandemic devastated our communities.

What is perhaps most shocking about racial health inequities is that these outcomes often persist across socioeconomic strata and levels of formal education. Even with my two Harvard degrees, I have a pregnancy-related mortality rate two to four times that of a White woman who never finished high school.

As the saying goes: If you’re not furious about this, you’re not paying attention.

Since summer 2020, there has been increasing public demand to reform racist U.S. policies and address the structural inequities at their root. This includes the health-care system, which needs to give practitioners of all backgrounds a framework for understanding what Black patients and communities have experienced here for centuries — and what they are still enduring.

Because of glaring gaps in my own education, it took me years to fully understand the long history underpinning racism in medicine. And it took me until well into my career as a physician to recognize the sheer scale of the problem, to free myself from the institutional status quo.

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Now, the problems I see are crystal clear. So, too, are some of the solutions.

First, White physicians and health-care professionals must acknowledge that systemic racism exists, and that racism is not Black people’s struggle to fight alone. Your Black colleagues are exhausted. Your Black patients are dying. We need you to do your own due diligence to understand how racism operates and affects health outcomes.

Second, our health-care institutions must strive to provide structurally competent and culturally centered care to Black communities — care that takes into consideration the social, economic and political context in which people live. These institutions need to be intentional about earning the trust of Black communities, via reparative processes, so that people will be willing to seek care even before they really need it and have the opportunity to form meaningful, healthy relationships with health-care professionals. Institutions also need to implement clinical protocols to track inequities in practice and intervene when necessary — with buy-in from their leadership. Simply put, they must hold themselves accountable.

Part of that accountability is ensuring that the health-care workforce reflects the diversity of its patient population. Schools and academic medical centers have the most important job here and must commit to reforming their admissions policies and practices.

The responsibility of equity has been largely carried since the late 1800s by historically Black colleges and universities. Their mission since their creation, among other goals, has been to educate and train Black doctors. From 2009 to 2019, according to the Association of American Medical Colleges, two historically Black medical schools, Howard and Morehouse, graduated more Black students than any predominantly White medical school in the country. Recently, two HBCUs, Xavier University of Louisiana and Morgan State, announced they will open medical schools, as will seven other predominantly White institutions. While this is welcome news, these additional schools will create only a small uptick in the number of Black medical school graduates in the short term.

One of the major barriers to entry for Black medical school students is economic inequality, rooted in the legacy of slavery and Jim Crow, and in persistent racism. As a result of a lack of generational wealth, Black students don’t have the same financial resources as their White peers. The median White household has a net worth six times that of the median Black household. Black households and other households of color are overrepresented among the poor and working class, and underrepresented among the upper middle class and the wealthy.

To address this inequity, institutions ought to provide Black students full grants and scholarships for college and medical school. And they should specifically engage with students descended from enslaved Black Americans, especially Black men, whose matriculation rate into medical school has declined.

The recent Supreme Court decision to ban race-conscious admissions policies could have the same dire repercussions as the Flexner Report in terms of decreasing the number of Black medical school graduates. Academic medicine is often resistant to change, and many medical schools will most likely want to avoid legal challenges. Schools, such as the University of California at Davis, that have implemented race-neutral policies might have initial success diversifying their classes. But excluding race entirely could prove harmful, as it does not directly address how racism has disproportionately and pervasively affected the lives of potential Black applicants.

Solving these problems will require existing schools to invest in the pipeline of Black physicians and health-care professionals early, engaging with children and young people at every step along the path to medical school. In addition to financial assistance, this could mean medical schools making long-term investments in education, housing and employment in Black communities (areas not typically considered the domain of medical schools, but factors which can influence an applicant’s success); establishing mentoring programs in K-12 schools, in which students would be paired with health professionals; sponsoring opportunities where students can be exposed to a variety of clinical environments early in their education; and re-examining traditional admissions criteria, including grades and standardized test scores, in favor of more meaningful criteria such as community service and a commitment to practicing in underserved communities.

Schools must also commit to a meaningfully diverse, anti-racist learning environment in which Black students can show up as their full selves. They must listen to Black students when they articulate what they need to be successful: conditions under which they are graded equitably and fairly in their courses and rotations, where the curriculum is taught through a health- and racial-equity lens, and where students can learn free of discrimination by their peers and faculty.

As a young girl, and even into my 20s, I thought my mother had been successful because she worked incredibly hard, loved science and was determined. More recently, I’ve realized that she wasn’t exceptional — she was just one of the lucky ones who made it through. There have always been many “exceptional” Black people like my mother; they simply never had the same opportunities.

This is a lesson my mother came to understand for herself — something I learned only after her death, when, rummaging through her belongings, trying to find ways to stay connected to her, I found a book about the experiences of women in medical education, to which she’d contributed an essay.

In the book, physicians shared how being a woman had affected their personal and professional lives. My mother wrote in detail about growing up in poverty, her decision to pursue a career in medicine, and her time at Harvard and in her residency and fellowship training. Toward the end of her essay, she questioned whether sexism had been a significant factor in her trajectory.

“In looking back, I believe that many of my negative experiences were as a result of race, not sexism,” she wrote. “This is not to minimize the sluggishness of women’s progress in medicine, but in this society, race is such a major factor in our actions and policymaking that not to acknowledge it is unrealistic and naive.”

Returning to that essay as an adult — a woman in my 40s, a physician and a mother in my own right — I realized I no longer saw my mother’s story as one of success against the odds. Instead, I was far more aware of the demands placed on her as the first person in her family to attend college and then medical school, as a Black physician navigating predominantly White spaces, and as a Black woman juggling motherhood and her career.

I could sense her complicated feelings — her passion for medicine but also her ambivalence, as the journey had been far from easy. I realized the magnitude of what she had gone through: the lack of food on her childhood table, the absence of a stable home environment, the challenges of coming from a community where few people had walked the same path she was on. The nun who told her she should become a social worker when my mother told her she wanted to be a physician. Being told by a White patient that he did not want to be seen by a Black doctor.

“Black people in society learn to develop thick skin,” my mother wrote. “We learn to depend on inner strength to keep us on course. At the present time, for my perseverance, I look to my mother as my role model. I marvel at her just as I marvel at all the Black mothers who have achieved the unachievable.”

My mother will always be my role model and idol, but it hurts me to know she had to go through all that she did, to overcome all those barriers. Life should not have been so hard for her. It should not be so hard for anyone.

For me, my mother’s success, and the way she stewarded her daughters toward our own success as physicians, is a reminder of every Black doctor who is not here with us but should be. It’s a reminder of this tremendous loss — and of our nation’s duty to rectify centuries of injustice.

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