Thomas J. Ward, Jr.
One of the most devastating effects of discrimination during the Jim Crow era was the effect on the health care of African Americans. The combination of poverty and racism put black Americans, especially in the segregated South, in a precarious position regarding their health. Blacks were far more likely than whites to die of ailments such as tuberculosis (TB) and heart disease than whites in the Jim Crow South, because of both poor living conditions and the lack of available medical care. The malnutrition of poor blacks had a tremendous effect on their susceptibility to diseases like TB, and the lack of concern for black health from state governments kept those infected from receiving treatment. For example, while the black death rate for TB was three to four times that of whites in South Carolina in the early twentieth century, it took five years before the state TB sanitarium even admitted blacks, and it was not until the 1950s that blacks were admitted to the hospital on a par with whites.
In addition to exclusion from proper care, during the Jim Crow era, many African Americans, especially from poverty-stricken rural areas of the South, rarely sought professional medical care, even if it was available. Doctors were people one saw only when they were “really sick,” many believed, and hospitals were places where people went to die. Others refused to patronize physicians because of the cost involved. “I was really sick enough for a doctor, but I didn't call one,” recalled one black Southerner. “They say they won't come less you have money.” Poor people knew they could not afford proper medical care, and therefore did not seek it, resorting instead to patent medicines, folk healers, or unlicensed practitioners when they were ill. Because of both the lack of access and the unwillingness to seek professional medical care, “unknown causes” was a leading explanation for black deaths in many parts of the South well into the twentieth century, as so few African Americans in the South died in a physician's care.
The use of homemade remedies and “conjure doctors” to supplement health care needs was a legacy of slavery that was still common in many black communities, especially in rural areas, during the Jim Crow era. Many rural blacks went through a type of “lay referral system” in attaining health care, first taking home remedies or patent medicines, then seeking the aid of friends and relatives before moving on to traditional healers, and only turning to the services of a professional physician when a condition persisted.
Midwives were also central to the health care system of African Americans in the Jim Crow era. Well into the twentieth century, the majority of black children born in many Southern states were delivered by midwives. Accessibility, cost, and tradition were the main reasons for the persistence of midwifery in the South. There were very few hospitals open to black patients in the rural South, and even if there was a hospital bed available, few Southern blacks could—or would—pay for a hospital stay for something as “routine” as childbirth. Midwives typically charged less than half of what physicians did to attend to a birth, and were usually more willing to accept payment in kind. The midwife, not the physician, was also the traditional birth attendant in Southern black culture. Many black women expressed a dislike for male physicians delivering their babies, preferring instead to have women attend to births. While a mother was in confinement, midwives also often performed numerous household duties, such as cooking and cleaning, that a physician would not be expected to do. In addition to delivering infants, midwives were often also called in to administer all types of health care—usually, but not exclusively, to women. One woman interviewed by sociologist Charles S. Johnson in the 1930s stated:
When I gets sick, [my husband] don't take me to no doctor. He'll buy medicine and bring it to me . . . Last time I was sick I had stomach trouble and he kept getting me medicine and I got worse, so he got me a midwife and she said my womb had fallen. She fixed it up and I got all right.
While traditional healers continued to care for many Southern blacks during the Jim Crow era, the desire by most Americans to be treated by professionally trained physicians increased dramatically during the early twentieth century. African Americans in the Jim Crow South sought care from white and black physicians alike, although most white physicians treated only those blacks who could pay their fees, while subjugating them to segregated service. “All of the white doctors and white dentists have separate waiting rooms for colored people,” recalled T. M. Bibbs of Cleveland, Mississippi. “Most of the time they work out all of the white people and then they get to the colored.” Physician Ranzy Weston remembered that similar practices were used by white physicians in Georgia. A white doctor, he recalled, “would see all of his white patients first and then he would see his black patients afterwards. In the meantime some patients did sit up and die; black patients.” While not all white practitioners treated their black patients poorly, Weston believed “white doctors would not give the same type of service to the black patients as they did to the white patients.”
While no public medical school in the South admitted African Americans before the 1950s, in the late nineteenth century, a number of institutions were founded to train black doctors in the South. However, as a result of medical reforms, in the first three decades of the twentieth century, medical schools for African Americans in New Orleans, Louisiana, Raleigh, North Carolina, Chattanooga, Tennessee, Louisville, Kentucky, and Memphis, Tennessee, all closed their doors, leaving Howard University in Washington, DC, and Meharry Medical College in Nashville, Tennessee, as the only institutions south of the Mason-Dixon line where African Americans could receive a medical education. While some medical schools outside of the South, most notably Harvard University and the University of Michigan, did accept a limited number of African Americans, up until 1969, Howard and Meharry together annually produced more than 50 percent of the nation's black medical graduates.
Black physicians often tried to exploit the lack of dignity and respect that white doctors showed African Americans as a means to lure those patients into their own offices. South Carolina's black medical leaders publicly criticized the state's African American population as late as the 1950s for “seeking aid from sources where segregated waiting rooms are not much more than broom closets with a few chairs.” However, African Americans did have a host of legitimate reasons for choosing white physicians, despite the humiliations of segregated waiting rooms and Jim Crow care. Because of either discrimination or expense, black doctors often could not provide patients with the same services as their white counterparts, as white doctors usually had better-equipped offices with more modern facilities and medicines than did blacks. Some drug companies even refused to sell medicine to black physicians. Outside of Washington and Nashville, there were almost no black specialists in the South before the end of World War II, so African Americans who wanted and could afford specialized treatment had to go to white physicians.
Economic pressure also played a role in the decision of Southern blacks to choose white doctors. Many African Americans went to the doctor their employer told them to go, and, more often than not, white employers steered their employees to white physicians—especially if the employer was paying the bill. “Most of the people are in domestic service and their white bosses and mistresses influence them to use their doctors,” bemoaned a black New Orleans physician in the 1930s. The economic pressure of the Jim Crow South that was used to keep blacks out of the voting booths and “in their place” therefore also aided white professionals in competition for the black dollar. White physicians, recalled Mississippi's B. L. Bell in 1939, had an advantage in soliciting black patients because white doctors “can work through the people that the Negroes work for.”
Access to hospital care was another factor in African Americans' decision to patronize white doctors. Because black physicians were rarely allowed to treat their patients in Southern hospitals, African Americans often needed to have a white physician in order to receive hospital treatment, even though that treatment would most always be in a segregated, basement ward. “The rural Negro physician is simply unable to practice modern medicine,” wrote Milton Roemer in 1949, because “when his patient needs hospitalization he is nearly always compelled to release the case to a white practitioner.” Montague Cobb, the dean of black medical history and long-time editor of the Journal of the National Medical Association, concluded in 1947 that because of the lack of facilities and professional opportunities, “the Negro doctor [in the South] tends to retrogress.” Black patients understood this, and therefore, according to Cobb, “the majority of Negro patients will seek medical attention from white physicians, whom they believe better, no matter how badly they are treated or even exploited.”
As a result of discrimination, violence, lack of opportunities, and the migration of Southern blacks from the region, by 1930, 40 percent of the nation's 3,805 black physicians resided outside of the South, where 80 percent of the nation's almost 12 million African Americans still lived, and the vast majority of those who remained in the South were located in urban areas. In rural states, the situation was most acute. Mississippi saw its number of black physicians decline from 71 in 1930 to 55 in 1940, and the bulk of those physicians were located in the cities; 56 of the state's 82 counties had no black physicians at all. Even Southern cities saw a decline in their number of black physicians as the century progressed. For example, New Orleans, once a hub of the black medical community, saw the number of black physicians practicing in the city decline from 50 in the 1930s to only 16 by the mid-1950s.
Even if attended to by a white physician, African Americans were barred from many hospitals in the Jim Crow South, and most that admitted black patients usually did so only in segregated basement wards. In 1910, 30 percent of all hospitals in the South refused black patients entirely; in some states the exclusion rate was much higher. Some hospitals, moreover, regarded black patients, especially indigent ones, as training subjects for white interns and residents, contributing to black distrust of white-run health care facilities.
Excluded from most of the larger, better-equipped hospitals of the South, a number of African American physicians founded their own small, private hospitals and clinics to serve their communities and keep their patients from abandoning them for white doctors. These hospitals were often little more than clinics set up in physicians' offices or homes, sometimes having only five or 10 beds. Unlike public or nonprofit hospitals, these institutions were often designed to generate income for the proprietor. Most of these small hospitals did not meet the minimum standards set by the American Hospital Association in the early twentieth century in regards to size, equipment, resources, or even cleanliness. Yet, in this time and place, these small clinics met a valuable need for both doctors and patients, especially in the more rural areas of the South. In some areas, in fact, they were the only hospital facilities for persons of any race for dozens of miles in any direction.
By the 1930s, more than 200 small, independent black-run hospitals had opened in the United States. Serving an impoverished clientele with little or no outside financial help, physicians constantly struggled to keep their small hospitals open. Many private black hospitals of the Jim Crow South did not prove to be the moneymaking ventures that their proprietors had initially hoped, but instead consumed not only the bulk of the fees collected but often the physician's savings as well. Others, like the Burruss Sanitarium in Augusta, Georgia, prospered and grew during the early twentieth century. G. S. Burruss's private hospital eventually had 27 rooms, modern equipment, and a staff of a dozen black physicians, making Burruss a wealthy man. Despite the fact that, unlike the Burruss Sanitarium, many of the proprietary hospitals opened by black physicians were ill-equipped, poorly staffed facilities that survived only a few years, they represent an assault on the unjust exclusion of black physicians from white-run public and private hospitals, and serve as a striking example of the self-help mentality of many black physicians who made the tough choice to practice in the Jim Crow South.
In addition to small hospitals built and owned by physicians, African American organizations in some Southern communities built their own hospital facilities. Many of these hospitals were owned and run by fraternal organizations, churches, or independent boards. Two of the most successful black fraternal hospitals were located in the Mississippi Delta towns of Yazoo City and Mound Bayou. The first fraternal hospital opened for Mississippi's black population was the Afro-American Sons and Daughter's Hospital in Yazoo City. Fraternal hospitals provided both inexpensive medical care for the working classes, and private care—without the indignities of Jim Crow—for the black middle classes. Because of the success of society hospitals, a number of fraternal organizations built their own hospitals in the South during the first half of the twentieth century. In addition to those in Mississippi, there were black fraternal hospitals in Arkansas, South Carolina, and Florida. Arkansas alone had four such hospitals by the end of the 1920s, including the 100-bed facility of the Woodmen of the Union in Hot Springs. Other black-run hospitals were administered by black colleges and medical schools, some of which survived even after the medical school folded.
At Booker T. Washington's Tuskegee Institute, a hospital was established in 1892 to care for the school's faculty and students and to train black nurses. The hospital expanded after the appointment of John A. Kenney as director in 1902 and began serving the surrounding African American community as well. During the early twentieth century, the hospital was renamed the John A. Andrew Memorial Hospital, in honor of the Civil War governor of Massachusetts, and became a center for the postgraduate training of black physicians in the Deep South.
Like Tuskegee, a number of the South's black hospitals also served as training centers for black nurses. These facilities filled a need for both young women looking for a career in nursing, and for physicians who desperately needed black nurses to aid them, as the caste system of the South strictly prohibited white nurses from working with—and taking orders from—black doctors. In Charleston, South Carolina, Alonzo B. McClennan proposed the establishment of a nurse training school in 1896 to Charleston's black medical community, which at that time consisted of six physicians and one dentist. With a great deal of community support, McClennan opened the Cannon Street Hospital and Training School for Negroes in 1897. The hospital and nurse training facility survived until 1949, when it closed because the 26-bed facility did not meet the state's new minimum patient load requirements for a nursing program.
With the aid of philanthropic organizations such as the Julius Rosenwald Fund and the Duke Endowment, a number of all-black hospitals, or all-black wings to existing hospitals, were built in the South between the 1920s and 1960s. In Kansas City, Missouri, City Hospital #2 (City Hospital #1 was for whites) was opened exclusively for black patients in 1930, while across the state in St. Louis, Homer G. Phillips Hospital was opened for blacks in 1937. In Winston-Salem, North Carolina, the Kate Bitting Reynolds Memorial Hospital was opened in 1938 for the city's African Americans with both public and private funding. The construction of black hospitals, or the renovation of older hospitals for black patients, was seen by many whites and blacks as an answer to the hospitalization needs of the South's black community, the demands of black physicians for hospital access, and white insistence of racial separation. Many black leaders, however, deemed such facilities as “Deluxe Jim Crow,” which only served to make discrimination more palatable to the general public.
Hospital care, even at all-black hospitals, was often an expense black Southerners could not afford in the Jim Crow South, however. Many physicians, white and black, therefore gave of their time and expertise to bring health care and education to African American communities at little or no cost. Some of the public health work done for the African American community was sponsored by private industry, black medical hospitals and schools, or philanthropic organizations, where physicians donated their time and services; still other doctors spent significant sums out of their own pockets in order to fill the glaring public health need of Southern black communities. Public health projects conducted by black physicians serve as a shining example of the self-help movement within African American communities during the segregation era, and is evidence of the desire of many physicians to reach across class lines to aid their less fortunate neighbors.
Booker T. Washington was one of the first African American leaders to understand fully the need for improved public health if Southern blacks were going to be able to lift themselves up and gain equal opportunity in American society. In conjunction with Howard University, the National Medical Association (the African American counterpart to the American Medical Association), the National Insurance Association, and the National Business League, Washington started National Negro Health Week at Tuskegee Institute in 1915 to raise consciousness to proper health care. Negro Health Week was patterned on a program begun in 1913 by the Negro Organization Society of Virginia called “Clean-up Day,” which encouraged black communities to improve the sanitary conditions of their homes and schools. Clean-up Day was such a success that the following year, Hampton Institute president Robert Russa Moton sponsored a “Clean-up Week.” By the 1930s, counties throughout the United States celebrated Negro Health Week every April, with lectures and demonstrations pertaining to health and sanitation concerns at home and school, and rallies designed to persuade local white health authorities to give more attention to their black citizenry. On the national level, special commissions were appointed in conjunction with Negro Health Week to study a number of diseases as they related to blacks, including a tuberculosis commission, a hookworm commission, and a pellagra commission. Support for the program was bolstered in 1921 with the sponsorship of the U.S. Public Health Service. Twenty years after its inception, Negro Health Week programs were conducted in over 2,000 communities, reaching over a million black families.
Churches were another vital element in the health care delivery system in black communities of the Jim Crow South, as African American churches were much more than simply religious centers; they were often the center of black society as well. “The church has been the one place that black people had control of,” recalled Reverend William Holmes Borders of Georgia. “Black people never controlled the school. . . . The school belongs to the white folks. So they dictated its use, and you got turned down.” Black churches, however, were “always open.” Because the churches were always open to black physicians and nurses, whereas other public buildings—schools, hospitals, auditoriums, gymnasiums—were not, churches were a natural place to hold health clinics. They were not only large enough facilities to handle the need, but also symbols of black autonomy and self-reliance—owned and operated by the black community, free of white control. Black churches were also centers of communication, especially in the rural areas of the Deep South. In a time before television, among poor and sometimes illiterate populations without access to radios or newspapers, the minister was not only the mouthpiece of the Lord, but also the town crier. Ministers announced coming events, like health clinics, and encouraged their congregations to attend. Preachers often participated in health education as well, instructing their flock to get immunized, eat properly, and maintain a clean home. A church also had another great advantage as a community health center—everyone knew where it was located.
Church clinics were founded in many areas of the Jim Crow South. In 1907, physicians from Washington, DC's Medico-Chirurgical Society opened a free dispensary clinic at the 19th Street Baptist Church. Twelve physicians, along with two dentists and two pharmacists, donated their time to the clinic. The White Rock Baptist Church of Durham, North Carolina, opened a health clinic at its community center in conjunction with the city health department in 1939. The next year a similar program was begun in Jackson, Mississippi, when the Galloway Memorial Church opened a community center in a cottage on its property. A small room was added to the center, and a retired physician donated his office equipment for a health clinic, which was conducted every Wednesday morning for the local community. The state board of health provided a public health nurse, and local black doctors donated their services. Children received free examinations and vaccines at the church clinic, and one day a month was dedicated to prenatal care for expectant mothers.
In addition to free treatment, many African Americans during the Jim Crow era paid for their health care through a variety of methods known as contract medicine. Contract medicine represented any one of a number of agreements that physicians entered into to treat groups of people for a fixed price. Sometimes these were prepaid arrangements; at other times, flat rates were assessed to members of the group for certain medical treatments and procedures. Insurance companies, fraternal and benevolent societies, private clubs, factory and shop organizations, and even some plantations made health care provisions for their members and workers, and physicians competed for the often lucrative contracts to serve these clients. Black physicians in particular saw contract medicine as a means both to build a reputation and secure a steady income. While contract medicine was openly denounced by most American physicians and medical associations, physicians of all races participated in different forms of contract service in the nineteenth and twentieth centuries.
The most common form of contract medicine entered into by African Americans in the Jim Crow South was through fraternal and benevolent societies. Many of these societies were sponsored by local churches, while others were fraternal, neighborhood, or even drinking clubs. New Orleans, for example, had African American benevolent societies as far back as the eighteenth century, but in the immediate post-Reconstruction era, they became an integral part of life in black New Orleans. While these clubs provided benefits only for those who were able to pay their dues, it was estimated that as much as 80 percent of the city's population belonged to such groups in the late nineteenth century. Outside of churches, more black New Orleanians belonged to benevolent societies in the early twentieth century than to any other type of voluntary association.
Many of the medical services benevolent societies provided to black communities in the South were eventually replaced by industrial insurance agencies. These companies provided benefits similar to those of fraternal organizations, affording limited protection against sickness, accident, and death, usually for a weekly premium. As African Americans were typically unable to afford ordinary life insurance policies, and white companies were unwilling to insure them at the same rates as whites, the insurance industry created an opportunity for black entrepreneurs. One of the forerunners in the industrial insurance industry was the Sun Mutual and Benevolent Association, organized in the 1880s by J. T. Newman and Constantine Perez in Louisiana. It provided the services of a physician, supplied pharmaceuticals, and offered a burial contract to members. Joseph Hardin ran the Metropolitan Relief Association in New Orleans. Along with Hardin, the Metropolitan employed three other physicians who treated patients for a weekly assessment of 15 cents. The company also had contracts with six drug stores that provided its members with pharmaceuticals.
While prevalent in urban areas, contract medicine was by no means limited to the cities. Plantations were the most common areas that physicians formed contracts for service in the rural South. Carter Woodson found that “Occasionally a Negro physician may be engaged by a rich man to visit his tenants on his plantation from time to time.” Daisy Balsley recalled that her father, Robert Fullilove, “did a large plantation practice” in the area around Yazoo City during the early twentieth century. “Those who could bring their patients in from the farms did so,” she remembered, but he had to go out to the plantations to treat those who were unable to make it to town.
Throughout the Jim Crow era, black leaders fought for both an end to segregated medical facilities and to improve health care for African Americans. The National Association for the Advancement of Colored People (NAACP) and the National Medical Association led the charge for change, agitating governmental bodies and the American Medical Association to desegregate, and by bringing lawsuits to enforce desegregation. In 1963, the federal bench handed down the landmark case in the fight for hospital integration in Simkins v. Moses H. Cone Memorial Hospital. It took the enforcement of the Simkins case, along with the Civil Rights Act of 1964, to finally bring integration to the South's hospitals. Between 1964 and 1970, most Southern hospitals accepted the integration of both black patients and staff without the application of federal sanctions. Along with the Civil Rights Act of 1964, another major incentive for southern hospitals to integrate was the advent of Medicare in 1965. This federal program, part of President Lyndon B. Johnson's Great Society, provided financial support to hospitals for the medical care of elderly patients, costs that had previously often gone uncompensated. In order to qualify for Medicare funding, however, hospitals were required to abide by Title VI of the Civil Rights Act, which forbade the federal government from allocating funds to any institution which discriminated on the basis of race, creed, or national origin. Providing the carrot to the Civil Rights Act's stick, Medicare funding helped sway the last segregated hospitals into compliance with the law by the end of the decade. See alsoFolk Medicine; Tuskegee Syphilis Experiment.
Beardsley, Edward. A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South. Knoxville: University of Tennessee Press, 1987;
Morais, Herbert M. The History of the Negro in Medicine. New York: Publishers Co., 1967;
Smith, David Barton. Health Care Divided: Race and Healing a Nation. Ann Arbor: University of Michigan Press, 1999;
Ward. Thomas J., Jr. Black Physicians in the Jim Crow South. Fayetteville: University of Arkansas Press, 2003.