Hospitals in the United States, Black

Black hospitals have been of three broad types: segregated, black controlled, and demographically determined. Segregated black hospitals included facilities established by whites to serve blacks exclusively, and they operated predominantly in the South. Black-controlled facilities were founded by black physicians, fraternal organizations, and churches. Changes in population led to the development of demographically determined hospitals. As was the case with Harlem Hospital, they gradually evolved into black institutions because of a rise in black populations surrounding them. Historically black hospitals—the previously segregated and the black-controlled hospitals—are the focus of this article.

Until the advent of the civil rights movement, racial customs and mores severely restricted black access to most hospitals. Hospitals—both in the South and in the North—either denied African Americans admission or accommodated them, almost universally, in segregated wards, often placed in undesirable locations such as unheated attics and damp basements. The desire to provide at least some hospital care for black people prompted the establishment of the earliest segregated black hospitals. Georgia Infirmary, established in Savannah in 1832, was the first such facility. By the end of the nineteenth century, several others had been founded, including Raleigh, North Carolina's St. Agnes Hospital in 1896 and Atlanta's MacVicar Infirmary in 1900. The motives behind their creation varied. Some white founders expressed a genuine, if paternalistic, interest in supplying health care to black people and offering training opportunities to black health professionals. However, white self-interest was also at work. The germ theory of disease, widely accepted by the end of the nineteenth century, acknowledged that "germs have no color line." Thus the theory mandated attention to the medical problems of African Americans, especially those whose proximity to whites threatened to spread disease.

Following the precedent set by other ethnic groups, African Americans themselves founded hospitals to meet the particular needs of their communities. Provident Hospital, the first black-controlled hospital, opened its doors in 1891. The racially discriminatory policies of Chicago nursing schools provided the primary impetus for the establishment of the institution. In addition, the hospital proved beneficial to black physicians, who were likewise barred from Chicago hospitals. Several other black-controlled hospitals opened during the last decade of the nineteenth century. These included Tuskegee Institute and Nurse Training School at Tuskegee Institute, Alabama, in 1892; Provident Hospital at Baltimore, in 1894; and Frederick Douglass Memorial Hospital and Training School at Philadelphia, in 1895. The establishment of these institutions also represented, in part, the institutionalization of Booker T. Washington's political ideology. These hospitals would advance racial uplift by improving the health status of African Americans and by contributing to the development of a black professional class.

By 1919 approximately 118 segregated and black-controlled hospitals existed, 75 percent of them in the South. Most were small, ill-equipped facilities that lacked clinical training programs. Consequently, they were inadequately prepared to survive sweeping changes in scientific medicine, hospital technology, and hospital standardization that had begun to take place at the turn of the century.

The most crucial issue faced by the historically black hospitals between 1920 and 1945 was whether they could withstand the new developments in medicine. In the early 1920s a group of physicians associated primarily with the National Medical Association (NMA), a black medical society, and the National Hospital Association (NHA), a black hospital organization, launched a reform movement to ensure the survival of at least a few quality black hospitals. The leaders of these organizations feared that the growing importance of accreditation and standardization would lead to the elimination of black hospitals and with it the demise of the black medical profession. For most African-American physicians, black hospitals offered the only places in which they could train and practice.

The NMA and NHA engaged in various activities to improve the quality of black hospitals, including the provision of technical assistance and the publication of educational materials. They also worked to raise funds for black hospitals. But funds were not readily forthcoming. Indeed, the depression forced all hospitals to grapple with the problem of financing. However, three philanthropies, the Julius Rosenwald Fund, the General Education Board, and the Duke Endowment, responded to the plight of black hospitals and provided crucial financial support.

The activities of the black hospital reformers and the dollars of white philanthropists produced some improvements in black hospitals by World War II. One prominent black physician hailed these changes as the "Negro Hospital Renaissance." This, however, was an overly optimistic assessment. The renaissance was limited to only a few hospitals. In 1923 approximately 200 historically black hospitals operated. Only six provided internships, and not one had a residency program. By 1944 the number of hospitals had decreased to 124. The AMA now approved nine of the facilities for internships and seven for residencies; the American College of Surgeons fully approved twenty-three, an undistinguished record at best. Moreover, the quality of some approved hospitals was suspect. Representatives of the American Medical Association freely admitted that a number of these hospitals would not have been approved except for the need to supply at least some internship opportunities for black physicians. This attitude reflected the then accepted practice of educating and treating black people in separate, and not necessarily equal, facilities.

The growth of the civil rights movement also played a key role in limiting the scope of black hospital reform. In the years after World War II, the energies of black medical organizations, even those that had previously supported separate black hospitals, shifted toward the dismantlement of the "Negro medical ghetto" of which black hospitals were a major component. Their protests between 1945 and 1965 posed new challenges for the historically black hospitals and called into question their very existence.

The NMA and the NAACP led the campaign for medical civil rights. They maintained that a segregated health care system resulted in the delivery of inferior medical care to black Americans. The organizations charged that the poorly financed facilities of the black medical ghetto could not adequately meet the health and professional needs of black people and rejected the establishment of additional

ones to remedy the problem. Instead, the NMA and the NAACP called for the integration of existing hospitals and the building of interracial hospitals.

Legal action was a key weapon in the battle to desegregate hospitals. Armed with the precedent set by the Supreme Court ruling in Brown v. Board of Education of Topeka, Kansas, the medical civil rights activists began a judicial assault on hospital segregation. Simkins v. Moses H. Cone Memorial Hospital proved to be the pivotal case. The 1963 decision found the separate-but-equal clause of the 1946 Hill-Burton Act, which provided federal monies for hospital construction, unconstitutional. The Simkins decision represented a significant victory in the battle for hospital integration. It extended the principles of the Brown decision to hospitals, including those not publicly owned and operated. Its authority, however, was limited to those hospitals that received Hill-Burton funds. The 1964 federal court decision in Eaton v. Grubbs broadened the prohibitions against racial discrimination to include voluntary hospitals that did not receive such funds.

The 1964 Civil Rights Act supplemented these judicial mandates and prohibited racial discrimination in any programs that received federal assistance. The 1965 passage of the Medicare and Medicaid legislation made most hospitals potential recipients of federal funds. Thus, they would be obligated to comply with federal civil rights legislation.

The predominant social role of the historically black hospitals before 1965 had been to provide medical care and professional training for black people within a segregated society. The adoption of integration as a societal goal has had an adverse effect on the institutions. Civil rights legislation increased the access of African Americans to previously white institutions. Consequently, black hospitals faced an ironic dilemma. They now competed with hospitals that had once discriminated against black patients and staff. In the years since the end of legally sanctioned racial segregation, the number of historically black hospitals has sharply declined. In 1944, 124 black hospitals operated. By 1990 the number had decreased to eight, and for several of them the future looks grim.

Desegregation resulted in an exodus of physicians and patients from black hospitals. Where white physicians had once used these facilities to admit and treat their black patients, they abruptly cut their ties. Furthermore, since 1965, black physicians have gained access to the mainstream medical profession and black hospitals have become less crucial to their careers. This loss of physician support contributed to declines in both patient admissions and revenues at many black hospitals. As a result of changing physician referral practices and housing patterns, black hospitals have also lost many of their middle-class patients. They have become facilities that treat, for the most part, poor people who are uninsured or on Medicaid. This pattern of decreased physician support, reduced patient occupancy, and diminished patient revenues forced many black hospitals to close after 1965. It also makes the few surviving institutions highly vulnerable.

The historically black hospitals have had a significant impact on the lives of African Americans. Originally created to provide health care and education within a segregated society, they evolved to become symbols of black pride and achievement. They supplied medical care, provided training opportunities, and contributed to the development of a black professional class. The hospitals were once crucial for the survival of African Americans. They have now become peripheral to the lives of most Americans and are on the brink of extinction.

The push for cost containment and vertical integration in the 1990s saw many firms in the entire health care environment either consolidate or close. The survival of these institutions was even more in question as they faced the same challenges as their counterparts in more traditional institutions. Government reimbursement regulations, improved health care access for more affluent African Americans, and increasing competition from HMOs (health maintenance organizations) had more adverse affects on the black hospitals. Of the remaining facilities, in 1990, none had positive profit margins and half had deficits in excess of $1.75 million, while the median profit margin for all hospitals in the United States was a positive 2.73 percent, or about $300,000.

The individuals that black hospitals serviced were most in need of care and least likely to be able to pay. These facilities served as the safety net and the primary-care providers for a large population of persons of color, a business condition that created mounting financial instabilities. Many black hospitals, and equally many major general hospitals in urban areas, had to seek bankruptcy protection and were eventually subsumed into the indigent-care mechanisms of the communities they served or purchased by larger health care systems.

As of 2005, five of the eight facilities that remained in 1990 were still operating (this was the number that submitted a required report on their prior year's financial activity to the CMS). There has been significant expansion in some, and three of the five have maintained or acquired affiliation with a medical school. While only one of the five remaining black hospitals turned a profit in fiscal year 2004, the firms did manage to survive the very turbulent health care environment of the 1990s. These institutions are poised to remain viable and effective institutions in the health care continuum well into the twenty-first century.

See also Brown v. Board of Education of Topeka, Kansas ; Civil Rights Movement, U.S.; Freedmen's Hospital; National Association for the Advancement of Colored People (NAACP); Nursing

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vanessa northington gamble (1996)

norris white gunby, jr. (2005)