Introduction
For many Black and immigrant families in the American South, medical care has never been perceived as a safe or welcoming institution. The legacy of segregated hospitals, the absence of culturally competent care, and decades of structural exclusion have produced a deeply rooted mistrust of the healthcare system. This mistrust, grounded in lived experience and historical injustice, continues to shape when and how individuals seek care, whom they trust, and whether they receive adequate treatment. The lived experiences of marginalized individuals in North Carolina reveal how exclusion from healthcare systems cultivates mistrust that persists across generations and affects outcomes today.
From Segregation to Self-Reliance: Generational Mistrust in Black Communities
The historical exclusion of Black Americans from equitable medical care has fostered a culture of mistrust that continues to influence health behaviors and outcomes today. Jennie Franklin, born in 1941 in Henderson, North Carolina, experienced firsthand the systemic exclusion that defined medical care for African Americans during the Jim Crow era. She was born at Jubilee Hospital, the only healthcare facility in the region that accepted Black patients. “You had to depend on whether you could get to town or whether the doctor would make a house call,” she recalled.¹ Hospitals were frequently inaccessible, either geographically or due to racial policies. Consequently, most children in her community were delivered at home by midwives, who were certified and trained by physicians but operated largely outside formal institutions.¹ This reliance on community-based care was not born of cultural preference, but of necessity in the face of exclusion from white-dominated healthcare systems.
Franklin’s account illustrates how institutional neglect created a culture of self-reliance in Black communities. This legacy is not confined to the past. A 2022 meta-analysis by van Daalen et al. found that Black women who reported experiencing racial discrimination faced a 40 percent higher risk of preterm birth compared to those who did not.² This research confirms that mistrust of the healthcare system is not merely emotional or symbolic—it produces measurable, physiological harm. Chronic stress, delayed engagement with care, and avoidance of medical institutions perceived as hostile or indifferent all contribute to adverse outcomes.
Franklin’s mistrust was not an anomaly; it was a shared, adaptive response to a system that repeatedly failed to value Black lives. Her community’s reliance on midwives, home remedies, and local knowledge arose from necessity, and these practices have informed attitudes toward healthcare that persist across generations. Such mistrust is not only historically justified—it remains structurally reinforced.
Language, Culture, and the Immigrant Experience of Disconnection
While Franklin’s experience reflects the long shadow of segregation, Andrea Williams-Morales provides a modern view into how medical mistrust forms among immigrant families. Born in Guerrero, Mexico, Williams-Morales moved to North Carolina with her parents in the early 1990s. Her family, she recalled, “did not go to the doctor unless we were really, really sick.” Her mother could not remember ever taking her children to wellness visits.³ There was no routine care—only reactive treatment during emergencies.
This situation did not stem from ignorance or parental neglect. Her parents were hard-working factory employees, but they lacked health insurance and the language skills required to navigate the American healthcare system. “They were not aware,” she explained, referring to the structural inaccessibility of care and the absence of outreach from medical institutions.³ Even as Williams-Morales now works in healthcare, she observes that these barriers persist in Latinx communities. Approximately 60 percent of the patients at her community health clinic are uninsured, and many avoid seeking medical care altogether because they do not feel respected or understood.³
Williams-Morales’s account highlights how institutional exclusion is reproduced across generations. Mistrust in healthcare systems is not based on singular negative encounters but on a systemic lack of access, representation, and engagement. A 2018 study by Alsan et al. found that Black patients were significantly more likely to accept preventive services and share personal health information when treated by Black physicians.⁴ These findings underscore the importance of representation and cultural concordance in medical care. When patients recognize themselves in their providers—linguistically, culturally, or racially—they are more likely to trust them, seek care, and remain engaged with the healthcare system. For immigrant communities, trust must be rebuilt through cultural sensitivity, inclusive policy, and systemic accessibility.
Conclusion: Mistrust as Memory and Structural Consequence
Jennie Franklin and Andrea Williams-Morales represent different generations, racial identities, and cultural backgrounds. Yet their narratives converge on a shared truth: the American healthcare system has consistently failed to serve marginalized populations. Franklin’s early life was shaped by racially segregated hospitals and exclusionary policies. Williams-Morales’s family, decades later, experienced the persistent inaccessibility of care due to language barriers, lack of insurance, and institutional indifference.
Mistrust is not irrational. It is a learned, and in many cases necessary, response to historical and ongoing exclusion. However, mistrust carries significant consequences. It contributes to late diagnoses, underutilization of preventive services, and worsened health outcomes across generations. If healthcare institutions intend to regain the trust of historically underserved communities, they must begin by addressing the systems that created that mistrust in the first place.
This process requires more than superficial reforms. It demands structural transformation, including culturally competent care, equitable access, community investment, and provider diversity. Trust cannot be assumed; it must be actively earned through acknowledgment, accountability, and inclusivity. Until then, the message from many patients will remain the same: they do not trust the system because the system has given them little reason to.
Footnotes
- Jennie Franklin, interview by Adante Hart and Reverend Bill Kearney, November 14, 2018, Southern Oral History Program Collection (#4007), Wilson Library, University of North Carolina at Chapel Hill.
- Kim Robin van Daalen et al., “Racial Discrimination and Adverse Pregnancy Outcomes: A Systematic Review and Meta-Analysis,” BMJ Global Health 7, no. 8 (2022): e009227. https://doi.org/10.1136/bmjgh-2022-009227.
- Andrea Williams-Morales, interview by Madelaine Katz, July 23, 2019, Southern Oral History Program Collection (#4007), Wilson Library, University of North Carolina at Chapel Hill.
- Marcella Alsan et al., “Does Diversity Matter for Health? Experimental Evidence from Oakland,” National Bureau of Economic Research Working Paper No. 24787 (2018). https://doi.org/10.3386/w24787.