A Contextual and Historical Overview of Brown et A v. Borad of Education of Topeka et Al.

Segregated Communities. The reality of segregated communities across the United States of America caused development of many institutions devoted to meeting the needs of formerly enslaved citizens. Health care was no exception. Blacks were known for skills as midwives and herbalists during slavery, and their illness care knowledge was passed on to the next generation through a combination of apprenticeship-like preparation and oral guidance. Such approaches were necessary in an era during which teaching Black people to read was unlawful. Some educated individuals ignored the inhumane laws, and education became a valued resource hidden during slavery and a skill greatly needed within segregation.

The church-sponsored schools that followed the American Civil War provided the same range from poor to outstanding that can be seen in educational institutions today. Grade schools, high schools and normal schools were initiated, to quench the thirst for knowledge of a newly freed people. The surviving written reports of those times describe the hardships and sacrifices endured by children and adults seeking and education, often starting in a church until a separate location could be secured. Classical and practical education persisted side by side, with aspirations encouraged to reach beyond existing social constraints.

The 1890s had a proliferation of medical and nursing schools, many in name only. They had meager facilities and no staff except the physician or the nurse who advertised for the student nurses who worked for their education. The reform of schools for physicians came with the 1910 Flexner report that graded the schools and recommended closings, leaving three hospital schools to produce the bulk of physicians of African descent in America: Howard University, Freedman's Hospital and Meharry. Similar in impact, the Ethel Johns report that graded nursing schools and had the same effect for African American schools of nursing. Better equipped hospitals with related nursing schools survived, including Provident in Chicago, the Hampton Training School in Virginia, the John A. Andrew Hospital in Tuskegee, Flint Hospital, Hubbard Hospital, and Goodrich Hospital to name some of the survivors. However, in spite of these institutions devoted to care for African Americans, much of illness care was still provided in homes well into the twentieth century.

Among the widely acceptable professions of being a teacher, a nurse, a dentist or physician, or a clergyman, the greatest need among all Americans -- until well after World War I -- was for good teachers in the common public schools, to secure an educated citizen population beyond the landed wealthy few. This was true for all citizens, but particularly for Blacks seeking a professional education. Obtaining such formal education was limited for African Americans, even after schools of nursing were established at Spelman and elsewhere. Sometimes preparation had to be pursued in other countries. Those who obtained any professional medically-related education, in the United States or abroad, having completed the course of education or leaving before earning the final certification, were frequently role models of community leadership.

The stock market crash, the sweeping economic devastation of the 1930s, and union activism led to shorter work hours in hospitals, as facilities in the remaining health professions’ schools were being scrutinized. Much of the United States was rural, and few paved roads or personal vehicles provided ease of transportation. The New Deal brought social reforms and relief for Americans through the dignity of work, promoting hope, better nutrition, and some color-blind opportunities to preserve art, music, and oral histories for future researchers.

World War II provided a boost to professional illness care and educational benefits for students in needed professions such as nursing (the Bolton Bill for cadet nurses) and for veterans returning home. Soldiers, airmen and naval personnel who aspired to and felt equal or superior to whites after having experienced closer contact during combat were not contented to return and stay on Southern farms and endure daily discrimination. By 1945, of 5,859,169 total farms, 689,215 were classified as being operated by non-whites.

In the South, there were 2,881,135 farms, of which 402,597 were non-white tenant farmers (standing renters paying a fixed quantity of products). Another 73,142 were cash tenant non-white farmers in southern states. Regardless of race, most people could -- and often did -- live and die within fifty miles of where they were born. School lunch programs existed after 1943, but race of the students attending the schools was not indicated for the 30 percent participation rates, and November was the peak month for numbers of children participating.

Every two years, the survey of education provided statistics regarding selected characteristics of schools. During segregation, Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia – each jurisdiction had some data reported separately. In 1950, the public elementary and secondary school enrollment for those jurisdictions was reported by the Office of Education with the average number of days attended by White and Negro students: 157 and 147.9 respectively. Negro students averaged only 120.9 days in school in Mississippi during that year. That was influenced greatly by the agricultural life and work expectations for a livelihood.

Before 1954, a farm was three acres with an annual produce output valued at $150 or more. When the census changed the definition in 1959, the farm definition changed to a lower limit of 10 acres as the minimum; and produce value increased to $250 for small farms. That was done the same year that the census stopped classifying the sharecropper system: because of its decreasing importance in the South. Economics in the larger society dictated the migration of people from rural areas to urban centers where different job skills, exposure to more communicable diseases, and unanticipated hostilities were encountered in non-southern states. As noted by d’Toqueville, nowhere was active prejudice more evident than in those states that had never had slavery.

In 1960, the farm population was re-defined as all persons living in a rural territory on ten or more acres producing at least $50 worth of agricultural produce a year. Illiteracy rates, for Americans fourteen years of age or more, were 4 percent among farm areas for females in contrast to 2 percent for rural non-farm areas and urban areas. Among males, the differences were greater, with 6.5 percent on farms, 2.9 percent in rural non-farm areas, and only 1.9 percent in urban areas. The main characteristics that differentiated farm populations were its (a) higher age profile, (b) higher migration outflow of people, and (c) higher birth rates. Most descendents of former slaves lived in rural areas, many on farms, were part of the great migration to cities seeking better lives, and their fertility rates were high.

The movement from a rural life fostered other patterns of behavior change, including some related to health. Traditional sickness care at home was replaced more rapidly by hospital care. Professional schools were adopting standards for education, and medical discoveries began to make strides that were accelerated by both the volunteerism of the Red Cross and military medicine changes that were adopted during World War II. Disease patterns and longevity expectations demonstrated some areas of difference between Negroes (or Blacks and Others) and Whites. A few areas are notable because no discernible statistical difference existed.

Diseases and Causes of Death. The leading causes of illness during the mid-twentieth century continue to be known, but with immunization making the numbers significantly different worldwide. In the United States, during 1950, important reportable diseases included measles (321,054), whooping cough (120,257), acute poliomyelitis (33,209), diphtheria (5,931), Undulant fever or Brucellosis (3,163), malaria (2,227), scarlet fever and streptococcal throat (77,748) and smallpox (42). The diseases of the cardiovascular system, hypertension, diseases of the kidney and urinary tract, sexually transmitted diseases, tuberculosis and cancers were important. Parasites, including roundworm, hookworm, and pinworm, that thrive on exposure to dirt, little clean water, poorly constructed out-houses and manure of farm animals, were prevalent and contributed to poor nutritional states of their hosts.

There were other deaths that did not make the leading causes of death list, but affected the mental health of both the victims of inhumanity and the perpetrators. Often the entire white community would gather with an almost carnival atmosphere where a Black person or group was to be lynched. Photographs were taken, postcards sent to friends and relatives, and the images reinforced that no one was stopping the murders of Blacks by Whites. Within segregation, particularly in rural areas, this was a means of keeping an entire segment of the population in fear and helplessness. The reported statistics are suspected to be incomplete, because the men and women who died from lynching were not identified in the statistical notes as to how such deaths were counted, if at all.

Those historic realities alter the health potential of families and can directly effect changes in the well-being of school children. For example, a white male, ten years of age in 1900, was expected to live another 50.59 years; by 1961, 59.78 years, and by 1971, 60 years. White females exceeded them at 52.15, 66.05, and 67.1 in those respective years. All other males and females lagged seven to ten years less life expectancy after ten years of age during those specific years. By age fifteen years, the gap had widened for All Other Males and Females to twelve years in 1900, decreased to only five years' difference for males in 1961, and hovered around seven years' difference for females favoring Whites over All Others.

The same infectious and parasitic diseases that resulted in prolonged illness and debilitating conditions also caused a significant number of deaths among Whites and Negroes. Some of the disproportions, in relation to the percent in the population, are depressingly similar to patterns observed with deaths from preventable diseases in the early twenty-first century. In 1969, overall reported deaths from infectious and parasitic diseases were 1,921,990. There were 1,683,622 reported for Whites and 225,537 for Negroes. The remaining reports were divided among classifications of Indian, Chinese, Japanese, and Other. Some of those statistics are presented below.

Selected Deaths	1969, by Race and	Infectious and	Parasitic Diseases
Race	Total	White	Negro
Disease
Cause	1,921,990	1,683,622	225,537
Enteritis & Diarrhea	2,612	1,826	1,523
Tetanus	744	555	181
Poliomyelitis	13	10	3
Helmenthiasis	16	7	8
Measles	41	31	10
Syphilis	543	300	234

Death rates from 1945 to the present continue to document disparities between the races; however ethnicity was classified differently from one census to the next. Gender differences persist also. White males who were born in 1973 were expected to live 68.4 years. The same expected age attainment was evident for Black males, but not achieved until 1990 - seventeen years later. Females follow a very similar pattern. The 1990 life expectancy of Black females had been surpassed by White females during 1974 by .3 years, sixteen years difference with continuing disparities into the twenty-first century.

The news is far from being all bad. Progress in medications, maternal care, passing of legislation such as Roe V. Wade, reducing the social marketing of tobacco products, and other societal changes do impact the health and illness patterns of various population groups differentially. The raw numbers are more difficult to compare than rates within the population sub-groups. When rates are presented per 1000 population by race and sex, differences can be identified and progress in attaining better health is evident, from 1945 through 1984. The mortality rates presented below for selected years exclude fetal deaths.

Selected Year	Black &	Black &	White	White Male
	Other	Other	Female
	Female	Male
1945	10.5	13.5	8.6	12.5
1954	8.8	11.4	7.6	10.6
1964	8.3	11.1	8.0	10.8
1974	7.2	10.4	8.1	10.4
1984	7.1	9.6	8.2	9.5

Youth, 10 -19 Years of Age. School age children have different significant causes of mortality when compared to infants, pre-school children, and adults. The next section focuses on school-aged youth and some of their statistics, because their health has an impact on school attendance and learning. As with adults, more children are made sick or disabled by diseases than die from those same maladies. The patterns of illness, with some nutritional deficiency diseases such as rickets, the feared crippler of poliomyelitis, few antibiotics for infections and the availability of treatment for diabetes by insulin were far different in the early 1950s when Brown was being argued and decided.

Those historical realities were exacerbated by poor sanitary facilities in segregated schools for African American children. Several causes of death, presented in table form below, were selected for youth who died at 10 to 19 years of age in 1969, fifteen years after the Brown decision. Some of the causes of mortality, such as malignant hypertension, are diseases not expected to kill children in the twenty-first century.

Cause of		All Ages,	10-19	10-19	10-19	10-19
Death, by		Total	Years,	Years,	Years,	Years,
Years of Age,		Number	White	White	Negro	Negro
1969		Of Deaths	Male	Female	Male	Female
Accidents,
Poisoning,		159,373	12,204	3,860	2,738	764
Violence
Diseases of
Circulatory		1,029,363	533	370	152	158
System
Enteritis &
Other
Diarrheal	2,612		841	985	383	331
Diseases
Tuberculosis	5,567		16	10	5	5
Diphtheria	25		2	2	0	1
Malignant	1,496		2	1	2	1
Hypertension
Meningococcal	744		62	50	22	9
Infections
Chronic
Rheumatic	15,112		61	28	22	35
Heart Disease
Viral
Encephalitis	381		28	30	2	4
Other Viral
Diseases	889		18	27	4	1
Neoplasms	327,769		1,376	879	164	152
Leukemia	14,450		446	161	59	33
Diabetes	38,541		39	63	14	19
Cystic Fibrosis	580		77	86	2	1

Automobile accidents were presented together with violence -- which may have included lynching-- and poisoning by the National Center for Health Statistics. Several communicable diseases were important, as well as some that now are prevented largely by immunizations, medications, better access to prompt diagnosis, and full, adequate treatment.

Such recommended care is not universally accessible even in 2005. School health can be enhanced in the twenty-first century through policy and funding priorities: universal illness insurance coverage, adequate health care for poor families, school boards supplying the resources and personnel for school nurses, and providing clinics in the schools. Such measures affect health of school children by providing for triage quickly to prevent diseases from spreading and avoiding the disabling or mortality-causing sequels. Family life education, protecting youth through refusal skills and early accurate sex education was not an approach used in the 1950s against syphilis in Alabama, but is being used against HIV in Illinois in the twenty-first century. Recurring themes are of concern, visited anew as emerging diseases arise.

Summary and Conclusion. Some of the causes of illness and death during segregation are familiar only historically. One is the death by lynching and its mental stress. The conditions of education for health leadership were greatly constrained by the American legal separation that denied opportunities for people of color to reach their full potentials, live in preferred neighborhoods, or enter certain establishments. Some establishments could only be entered by specified back doors. Greater access has come at a price, and the positive role models for youth who used to be forced to live next door now can and do move to neighborhoods that are economically more affluent.

Work was limited to remain outside of identified spheres of influence. This had an effect on the mental well-being, particularly for those who resisted external boundaries of acceptable behavior as dictated by Jim Crow laws and general customs of the time, and an economic incentive to keep people of color always in invidious positions. The move from rural farm life required better education for urban employment, a convergence -- as Derrick Bell explains it - of needs of the greater society that made educational changes timely in history. Even by the people who could foresee the hardships and disruptions that demands for educational equality would require of those living in segregated communities, the greater good was evaluated as worth the individual sacrifices.

The caring teachers, warm memories recalled by those who learned well during segregation are part of the legacy inherited that one must consider. One cannot condone inhumane subjugation of individual freedoms that lead to the frustrated scientists, administrators, and potential leaders in so many other fields being forced to take teaching jobs, but there they did inspire kids in segregated schools to believe in themselves and prepare for a better tomorrow.

The health care landscape does not provide universal illness care or access to health promotion providers fifty years after the Brown decision. If one focuses on the improved opportunities for access to health for African Americans and many economically poor school children -- and if one includes the greater good for people who are disabled, women, and other protected categories -- and if one recognizes the contributions that the Brown decision made in fostering civil rights for others worldwide, the mental health and optimism of African Americans who made the sacrifices leading up to the Brown decision were justified. And yet, we have far more to do to reach the promise of that decision.

The world community can see that progress has been made. We live in a world inhabited by people who are two thirds neither White nor Christian; have neither clean drinking water nor adequate sanitary facilities nor enough to eat; and a high quality basic education remains an unlikely hope for the future: but let us never forget that the world majority population is reflected here in poverty. Those same deplorable conditions apply in the United States of America in 2005 for poor and rural people and, particularly, for African Americans, Native Americans and migrant workers -- disproportionately people of color.

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