This article first appeared in the St. Louis Beacon: In 1875, amid steamboats churning the muddy waterway, a tugboat came up the river from New Orleans and docked in St. Louis with an unexpected problem on board. In addition to a load of sugar from Havana, the boat carried a sick passenger. He was taken to City Hospital where the worst fears of doctors there were confirmed: yellow fever.
At the time, nobody knew the cause of this dreaded disease, but a little detective work by one physician at the hospital, Dr. D.V. Dean, turned up the answer. Noticing a mosquito bite on the patient's body, the doctor speculated that the insect was the carrier.
It would take medical science several years to confirm Dean's theory. But the incident speaks to a commitment found in the city's charter to fight disease and provide medical support for the "care of children and sick, aged or insane poor persons and paupers."
While the city's heart was in the right place, this noble promise failed to apply to black residents then and to the present day. To begin at the turn of the 20th century, blacks might have benefited from the state-of-the-art care at the rebuilt City Hospital, which opened in 1904 at 1515 Lafayette St., just south of what is now our downtown. That same year, St. Louis hosted the World's Fair, introducing millions of visitors to hamburgers, hot dog buns and ice cream cones.
Nobody is certain how many of the city's 35,000 black residents were allowed to visit the fair, but it's a sure bet that few of them set foot inside the new City Hospital. True, they might have been lucky enough to get care there for a contagious disease, such as yellow fever. Or get help for a wound from the same kind of .32-caliber revolver that Frankie Baker used during that boarding house shooting made famous in the "Frankie and Johnnie" ballad.
For the most part, however, City Hospital was built to serve whites, and it treated the health needs for African-Americans as an afterthought. This limited access to care is one of the factors that help explain how St. Louis got in the situation it now faces, a city with stark health differences between blacks and white. Some of the causes didn't start in our time. Rather, they are deeply rooted in public policy and political disputes, social conditions and economic circumstances, personal health habits, and, yes, in race.
Separate and Unequal
Because blacks were shut out of care at City Hospital, many sought medical services at two small private hospitals where black doctors were granted staff privileges. They were St. Mary's Infirmary, 1536 Papin St., about seven blocks north of City Hospital and People's Hospital, 2221 Locust St., just west of downtown near Jefferson Avenue.
Rather than opening City Hospital to all, the city set up a dual medical system. Blacks were sent to City Hospital No. 2, which opened in 1919 at Lawton Place and Garrison Avenue, west of downtown in the Mill Creek Valley. This was at the site of the old Barnes Medical College, a hand-me-down, second-rate facility that African- American doctors nicknamed the firetrap. In the meantime, these doctors were denied staff privileges at City Hospital. Black patients lucky enough to get treatment in it were sent to the rear sections of the second and third floors.
Dr. Frank O. Richards, a retired black surgeon, shakes his head in wonder as he recalls that the black public hospital tried to cope with overcrowded conditions by tying together two beds at night to accommodate three patients.
But the most shocking of incidents was yet to come, says Richards. It involved Dr. Bernice A. Yancey, a black physician. He was electrocuted in the summer of 1930 when using a defective X-ray machine at City Hospital No. 2. The incident added fuel to a black political movement that culminated in pressuring the city to add money to a bond issue to build Homer G. Phillips Hospital, a first-rate facility for blacks. It was opened in 1937 at 2601 Whittier St., about two miles north and west from City Hospital No. 2 in a neighborhood known as the Ville. (Homer G. Phillips was an attorney who led the fight to include funding for the hospital in the bond issue. He was murdered in 1931 -- a crime that remains unsolved.)
Political squabbles also have affected health policy. Dr. Daniel R. Berg, a St. Louisan who has followed the history of health care for the poor in the city, says it was customary for the city to make higher per patient allocations to City Hospital than to Phillips. In 1944, Phillips got $4.84 a patient, while City Hospital was given $6.81 a patient -- or 30 percent more. By 1964, Phillips was operating with 75 percent of the per patient funding that went to City Hospital. The funding of the two hospitals was never equal until 1970, nine years before the city closed Phillips, Berg reports.
Another more dated example of political wrangling with implications for present-day health disparities involves the city's decision, regarded now with regret, to separate from St. Louis County in 1876.
"In other cities, boundaries were expanded to capture the population and the tax base, but we could not do that," said Richard Patton, director of Vision for Children at Risk, an advocacy group for children.
When the middle class began leaving St. Louis for the suburbs, the city was left with less money to cover essential services, including health care.
"People left the urban core in other cities, too," Patton said. "But in St. Louis you have to move a shorter distance before you're off the population rolls and the tax rolls than in any place else."
The upshot is that St. Louis lost population and became poorer at a much faster rate than many other cities where middle-class flight also occurred. The city's population peaked at 856,000 in 1950 and began a downward spiral. The number now stands at about 354,000, which means the city is no larger than it was 1880. On a positive note, it appears the decline has bottomed out.
Impoverished and Isolated
The movement also left more people in socially isolated, impoverished and segregated neighborhoods, many of them with fewer ingredients needed to promote healthy lifestyles. Examples include convenient access to doctors, clinics and safe parks and other places for exercise.
Robert Fruend, chief executive officer of the Saint Louis Regional Health Commission, says environment and lifestyle factors are two other issues that explain health status in St. Louis. Environmental factors, he says, have led to high rates of asthma in St. Louis. He adds that Missouri's high smoking rates explain why certain chronic diseases - such as lung diseases, cardiovascular diseases and some types of cancer -- are more common in some populations in Missouri. Also common are the preventable illnesses highlighted in this series: diabetes and obesity, lead poisoning, infant mortality and sexually transmitted diseases, or STDs.
"We smoke more in Missouri and in St. Louis and low-income folks smoke at a disproportionately higher rate than other folks," he says. (He adds that targeted advertising for cigarettes and alcohol is another factor that drives disparities.)
Maggie Callon, the research coordinator who produces the statistical data for Vision for Children's annual report, observes that lifestyles are also a big factor.
"There are families, maybe generations of families, who have never shopped in a produce section of a store," she says. While she thinks people do acquire knowledge through public service announcements, she is concerned that the message is lost because "most of their friends and people they know aren't doing these things." She attributes this to "the culture of poverty in very concentrated areas."
Ideals 'lost in Time'
Meanwhile, Patton says, the situation involving health disparities and child poverty in particular could be turned around.
"We need to start with political will," he says. "We always hear what terrible shape the Missouri budget is in. Well, we still invest billions of dollars in Missouri in certain types of things that could be invested in other ways to address certain problems. If you want to pull up the economy, you do what we need to do for kids and families. Study after study shows that it's the investment in human capital that pays returns."
More health resources clearly are needed in many north side neighborhoods where health disparities are the greatest. The three city zip codes identified by the Beacon as having the most dramatic health-care disparities are 63113, 63106 and 63107. They are home to about 43,000 city residents, representing about 12 percent of the city's population. Yet fewer than 1 percent of the city's primary care physicians practice in the zip codes.
St. Louis has a rich history of trying to solve medical mysteries, whether it's the City Hospital doctor working alone to figure out the cause of yellow fever 130 years ago, or a high tech research team seeking to uncover the mysteries of cancer in our time. But Dr. Berg suggests there is a lot of unfinished business.
He writes that "there is an entire underclass within the city that suffers from health outcomes more comparable to the Third World countries than to our neighbors in west St. Louis County. The ideals of the city founders have been lost in a sea of time."
This story was written with the assistance of the Dennis A. Hunt Fund for Health Journalism, which is administered by the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.
This article is the second in a series that examines health-care disparities that persist in the St. Louis area, despite the fact that the region is blessed with some of the finest medical facilities in the world. Where we live can determine how long we live