Next month, the Civil Rights Act of 1964 will celebrate its 50th birthday. It was the product of more than 150 years of advocacy, violence, court fights and public demonstrations during which many people were imprisoned, injured and even killed as they endeavored to force the United States, to use the words of the great Princeton economist Uwe Reinhardt, "to live up to its own Constitution."

The act had an impact on virtually every aspect of American life, and nowhere did it change things more than in many U.S. hospitals.

A Common Misperception

There has long been a misperception about the act's role in the racial desegregation of American health care. The widespread belief is that passage of the Social Security Amendments of 1965 (Public Law 89-97, which created Medicare and Medicaid) was the determining factor. That was not the case; by the time it was passed, many hospitals that had practiced racial segregation already had abandoned it. Medicare was more of a clean-up operation with recalcitrant facilities. The Civil Rights Act, specifically Title VI, was the key to racial equality in the health care setting.

Uncomfortable as it is to remember less enlightened times, racial segregation was commonplace in U.S. hospitals well into the 20th century. It took several forms. One was simply that, particularly in the South, there were hospitals for white people and hospitals for African-Americans, the latter often founded by African-American physicians who could not obtain admitting privileges at white hospitals. Care at the black hospitals tended to be of lower quality, usually due to lack of resources. Some hospitals admitted both groups, but the African-American patients were segregated, often in subpar attic or basement wards.

In the case of Grady Memorial Hospital in Atlanta, a wall was constructed between the "black" and "white" sides of the hospital, leading many people to refer to the facility as "the Gradies."

Segregation in health care took other forms. In some hospitals, white and black patients could not share the same room. African-American physicians could not get privileges except in black hospitals. African-American nurses, no matter how senior, were not allowed to supervise white nurses. Transfusion of blood donated by a member of one racial group to a patient belonging to a different group often was prohibited, regardless of the clinical quality of the match. Even newborns often were segregated in different nurseries.

A Widespread Practice

How widespread was all this? According to Professor P. Preston Reynolds, M.D., Ph.D., of the University of Virginia School of Medicine, who has chronicled the history of hospital desegregation in a series of instructive articles, and on whose work I am drawing heavily for this story, it wasn't rare. She reports that in 1959, pioneering African-American physician Paul Cornely, M.D., conducted a survey of racial segregation in health care. He found that 83 percent of Northern hospitals were integrated in terms of patient admissions, but only 6 percent of Southern hospitals were. Of the other 94 percent of facilities in the South, 33 percent admitted no African-Americans, 50 percent admitted them to segregated wards, and segregation was present in some form in the others.

It wasn't much better for African-American physicians. Only 10 percent of Northern hospitals accepted African-American interns or residents; only 20 percent had them on staff. Only 6 percent of Southern hospitals accepted them as interns or residents, and only 25 percent granted them staff privileges.

However, by the late 1950s, 42 percent of medical schools in the South were admitting African-Americans, and 53 percent of Southern medical societies accepted them. Some change was in the wind. But for the most part, it was business as usual.

Segregation had clinical consequences. It is widely believed that the great blues singer Bessie Smith, critically injured in an auto accident, died as a result of being refused admission to a white hospital; the physician who treated her on the scene said that was not the case and that she died of non-survivable injuries. There is also a myth that Charles R. Drew, M.D., another pioneering African-American physician whose work greatly improved blood storage and blood bank efficiency, thus saving thousands of lives, bled to death because he was refused "white" blood. This is also untrue.

But Reynolds reports that prominent African-Americans did die as a result of hospital segregation. One was Juliette Derricotte, dean of women at Fisk University, who died following an auto accident because she was refused care at a hospital that did not accept African-Americans. Another was the father-in-law of Walter White, executive director of the National Association for the Advancement of Colored People, who, after being hit by a car, died after being transferred during a rainstorm from Grady's "white" side to its "black" side. There were undoubtedly many others.

Pressure for Change

Change finally came as the result of years of work by African-American physicians, the NAACP and the courts.

It should have come earlier than it did, because the Hill-Burton Act of 1946, which provided funds for construction and improvement of hospitals all over the United States, had a provision requiring equal treatment of all patients. However, it also had a "separate but equal" provision, allowing segregated hospitals to receive Hill-Burton funds as long as the quality of care was the same. It wasn't, and neither was the distribution of Hill-Burton funds, which grossly favored white hospitals.

Interpretation of the Hill-Burton requirements sometimes defied logic. The general counsel of the Department of Health, Education, and Welfare decided that Hill-Burton hospitals could not deny admission to any person to the part of the hospital that used federal funds (it must have been fun figuring that out), but patients could be denied access to other areas.

Also, even if a Hill-Burton hospital accepted African-American patients, often their black physicians could not continue to treat them once they were admitted, because they did not have privileges and could not get them.

In 1956 (two years after Brown vs. Board of Education ended separate-but-equal practices in education), the NAACP decided it was time to challenge the separate-but-equal provision of the Hill-Burton Act. The first lawsuit was Eaton vs. Board of Managers of the James Walker Memorial Hospital, filed by a trio of African-American physicians who had been denied privileges. They argued that because the hospital received federal funds, discriminating against them violated the 14th Amendment. They lost at the district and appeals level, and the Supreme Court declined to review the case. However, three justices dissented.

Buoyed by the possibility of future success at the Supreme Court, the NAACP pushed forward, and soon the ideal case emerged. George Simkins, D.D.S., a North Carolina African-American dentist, had been denied privileges at Moses H. Cone Memorial Hospital, which admitted black patients and received Hill-Burton funds. Working with the NAACP, and with support from the Department of Justice, Simkins recruited African-American patients and other practitioners to join a suit, and on Feb. 12, 1962, Simkins vs. Moses H. Cone Memorial Hospital was filed in district court. The plaintiffs asked that the separate-but-equal provision of the Hill-Burton Act be struck down, that discrimination in admitting and treatment privileges be ended, and that refusal to admit African-American patients be banned.

The district court found for the defendants, but the plaintiffs appealed and won at the Fourth Circuit Court of Appeals. The case was appealed to the Supreme Court. At that point, HEW Assistant Secretary James Quigley offered support to the NAACP effort and, as all the stakeholders awaited a decision from the Supreme Court, Quigley stopped Hill-Burton payments to eight hospitals being constructed under the separate-but-equal provision.

On March 2, 1964, the Supreme Court declined to review the case, and the appeals court verdict stood. Separate-but-equal under Hill-Burton was dead. Hospitals receiving funds from the program would have to desegregate.

HEW officials were quick to enforce the decision, although there was little they could do to desegregate hospitals that no longer received Hill-Burton funds or those that never had. That would have to be voluntary on the part of the hospitals.

The Last Nail in the Coffin

But four months later, President Lyndon B. Johnson signed the Civil Rights Act, which was pretty much the last nail in segregation's coffin. The key provision of Title VI read:
"No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance."

Passage of a law is one thing; enforcement is quite another. The Eisenhower administration had been somewhat lackadaisical in its enforcement of the Brown vs. Board of Education decision; the Johnson administration was ready for a full-court press to use Title VI to end, in the words of African-American physician W. Montague Cobb, "the greatest of all discriminatory evils, differential treatment toward African-Americans with respect to hospital facilities."

Less than a month after passage of the Civil Rights Act, Surgeon General Luther Terry, M.D. (back then, the surgeon general was much more than a figurehead), who was one of the federal health officials charged with seeking hospital compliance with the act, wrote an article in Hospitals in which he urged American Hospital Association members to comply. He pointed out that Title VI applied to hospitals receiving federal funds of any type.

He also noted that before the act was even passed, the AHA "had gone on record as favoring the adoption by hospitals of nondiscrimination policies in the admission and care of patients and the granting of staff privileges." He urged health care associations to "create a favorable climate of opinion" to ensure that all hospitals were in compliance with the act. The AHA subsequently took that request seriously.

Federal reviewers fanned out across the country, seeking to document compliance. They encountered a mixed bag, ranging from hospitals that had long since desegregated (or had always been integrated) to those that were trying to comply (hospital administrators would tell the feds that they wanted to end racist policies, but that their boards would not let them) to those that had no interest in complying and were determined to hold out.

On Sept. 1, 1965, HEW Assistant Secretary Quigley spoke at the AHA annual meeting in San Francisco and related some tales of recalcitrance. Some hospitals said there were no African-American newborns in the nurseries because all of their mothers wanted to nurse them, so they were kept in their mothers' rooms. A few administrators said that they did not segregate African-American patients, but rather "reserved" a section of the hospital for them. Other administrators claimed that African-Americans preferred to use entrances that had only recently been marked "Colored." One hospital executive said he could not convince his staff to write "Mr.," "Mrs." or "Miss" in front of an African-American patient's name on the chart. Someone else told reviewers that there were no African-Americans on the hospital board because black people were not public-spirited enough to volunteer. A few administrators said that African-American patients did not want to share rooms with white patients.

One hospital, in Quigley's words, "removed 'Colored' and 'White' signs from their rest rooms and installed locks on the doors — then issued keys only to the white staff."

But in what Quigley described as "the ultimate step in our education to date," a hospital placed African-American and white patients in the same rooms, closed the segregated dining room for African-Americans and integrated the nursery — then changed everything back to segregated circumstances once the review team had left town.

Quigley ended his remarks by asking AHA's members, "You have been unsparing in the past — will you join us now in this biggest job of all?"

And Then Came Medicare

Many hospitals did — but not all. And that posed a problem when Medicare and Medicaid were passed a year later; President Johnson signed the Social Security Amendments of 1965 on July 30. Medicare funds were federal funds; if a hospital received them, it had to be in compliance with Title VI of the Civil Rights Act.

Although federal representatives directed by Sherry Arnstein, HEW's new director of hospital civil rights compliance, had successfully desegregated 21 Southern hospitals, by April 1966 — shortly before Medicare and Medicaid were to take effect — only 49 percent of American hospitals were in full compliance with Title VI. In seven Southern states, only 15 percent were.

Federal authorities did everything they could to change the situation, because, very simply, reimbursement for care of Medicare and Medicaid patients would not be forthcoming if a hospital remained segregated. President Johnson had been worried ever since the passage of Medicare that there would not be enough physicians to treat newly enfranchised patients (the AMA had fiercely opposed the legislation); now there might not be enough hospitals willing to accept those patients.

Deputy Surgeon General Leo Gehrig, M.D. (who later served for 10 years as director of the AHA's Washington, D.C., office) approached Edwin Crosby, M.D., president of the AHA, and asked for help. Crosby said he would do anything he could. He arranged many meetings between federal compliance staff and hospital leaders. The AHA also produced a short film and a pamphlet for Southern state hospital associations to help them educate their members about what had to be done.

Federal authorities also made the point that segregation was expensive for hospitals, given the cost of duplicating so many services. And the idea of not being eligible for Medicare and Medicaid reimbursement was also a powerful incentive, once it was obvious that the feds meant business and would not pay noncompliant facilities.

The pressure started to pay off. Even conservative Southern politicians conceded that the fight was over. As Reynolds writes, by June 1965, "The word was out. [The Department of Health, Education, and Welfare] would not cave in."

By that same month, 85 percent of hospitals were in compliance with Title VI, and Crosby continued to facilitate meetings between federal representatives and officials of hospitals that were still holding out.

Blue Cross and Blue Shield plans, which at the time had an extremely close relationship with the AHA (ah,the good old days!), joined the effort and informed noncompliant hospitals that they would not pay them for patients older than 65 because they would be eligible for Medicare. And if the hospitals wanted Medicare reimbursement for those patients, they would have to comply with Title VI. Sometimes a Catch-22 makes sense.

On June 30 — the day before Medicare became effective — federal officials produced the latest numbers. In 14 states and three territories, 100 percent of hospitals were in compliance. In all but five Southern states, 80 percent of hospital beds would be available for Medicare patients. President Johnson told a television audience that night, "Medicare will succeed if hospitals accept their responsibility under the law not to discriminate against any patient because of race." And with the help of their national and state associations, they did just that.

There were many unsung heroes in this effort: the NAACP legal team, which included Thurgood Marshall (later the first African-American Supreme Court Justice), Jack Greenberg and Michael Meltsner (of the hundreds of Hill-Burton complaints sent to the Justice Department, Meltsner wrote most of them); Surgeon General Luther Terry, M.D. (who in 1964 also issued the landmark federal report on the dangers of smoking) and his deputy, Leo Gehrig, M.D.; a host of HEW officials, including James Quigley, Sherry Arnstein and Peter Libassi, who was appointed special assistant to HEW Secretary John Gardner for civil rights; HEW secretaries Anthony Celebrezze and John Gardner; the African-American physicians, dentists and patients who would no longer tolerate being treated as second-class health care citizens; and the American Hospital Association and Edwin Crosby, M.D., who risked his job to do the right thing.

And just for the record, in our current partisan and sometimes hateful times, a lot of these folks were white.

An Unfinished Crusade

So is racism in health care history? Not unless you just took a header off the turnip truck. A 2011 study by the Institute for Diversity in Health Management and the Health Research & Educational Trust found that "although minorities represent a reported 29 percent of patients nationally, they comprise only 14 percent of board members, an average of 14 percent of executive leadership positions, and 15 percent of first- and midlevel management positions." Whites continued to be overrepresented on boards, whereas African-Americans and Latinos were grossly underrepresented. Although 60 percent of chief diversity officers were members of minority groups (surprise), only 16 percent of chief medical officers, 14 percent of COOs, 10 percent of chief nursing officers, 9 percent of CEOs and 7 percent of CFOs were.

(The latest version of this survey will be released at the Institute's National Leadership and Education Conference in Chicago June 12–13.)

Racial and ethnic disparities in access to care, insurance and outcomes are still with us, and although progress has been made, some of them seem intractable.

And as recently as 2010, there was still racial friction on health care's front lines. That year, Brenda Chaney, a certified nursing assistant in a long-term care facility, sued her employers when they sought to honor a white patient's request to have only white caregivers. The courts found the nursing home in violation of Title VI.

There were casualties of Title VI as well, notably the historically African-American hospitals, of which there were once as many as 500, which in the years after passage of the Civil Rights Act were closed or merged with other facilities. They represented a significant part of health care history, and they are gone. Nathaniel Wesley Jr., however, has chronicled their story, so it has not been lost (see below).

But there has been progress as well. The AHA has had three African-American chairs (the late Carolyn Boone Lewis, Kevin Lofton and John Bluford) and the American Medical Association an African-American president, Lonnie Bristow, M.D. African-Americans have served as both surgeons general and as secretary of HEW (now HHS).

A Cultural Shift

More importantly, the culture has changed. Most people working in hospitals today wouldn't think of determining admission on the basis of color; insurance, maybe, but not color. Most physician privileges are awarded on the basis of qualification. Minorities supervise white employees all the time. In most settings, it just isn't an issue. And hospital efforts to increase minority representation in the C-suite and the boardroom, and to address racial and ethnic disparities, are ongoing.

I was witness to the beginning of this cultural shift. In 1969, I was the laboratory test slip delivery person in a hospital in Oakland, Calif. (It was one of several jobs I have had that no longer exist.) I was crazy about the work, because I love hospitals and I got to roam all over the facility, delivering little pieces of paper and pasting them into charts.

One day, there was an incident, and it was the talk of the hospital. An African-American surgical resident was in danger of being dismissed. It certainly wasn't his skill level; he was considered one of the best surgeons ever to set foot in the place. Nor was it his color.

No, it turned out that a lady friend had embroidered flowers on the lapels of his resident's coat, and he was out of compliance with uniform code. The hospital was threatening to take action against him, not because of his race, but because he had embroidered lapels.

Hey, it was the Bay Area in the '60s. The times they were a-changing.

(I left employment at the hospital before the dispute was settled; I hope the surgical resident won. I like embroidery.)

ACKNOWLEDGMENTS: With thanks to Sara Beazley, director of the American Hospital Association Resource Center, and P. Preston Reynolds, M.D., Ph.D., for invaluable research and writings.

REFERENCES AND READINGS

Friedman, Emily. "Tapestry." Hospitals & Health Networks OnLine. Feb. 9, 2006. Available at www.emilyfriedman.com.

Friedman, Emily. "Private black hospitals: a long tradition faces change." Hospitals. July 1, 1981, pp. 65–68.

Institute for Diversity in Health Management/Health Research & Educational Trust. Diversity & Disparities: A Benchmark Study of U.S. Hospitals. 2011. Available at http://www.hpoe/diversity-disparities.

Reynolds, P. Preston. "Hospitals and Civil Rights, 1945–1963: The Case of Simkins v. Moses H. Cone Memorial Hospital." Annals of Internal Medicine, vol. 126, no. 11, June 1, 1997, pp. 898–906.

Reynolds, P. Preston. "The federal government's use of Title VI and Medicare to racially integrate hospitals in the United States, 1963 through 1967." American Journal of Public Health, vol. 87, no. 11, Nov. 1997, pp. 1850–1858.

Quigley, James. Hospitals and the Civil Rights Act of 1964. Journal of the National Medical Association, vol. 57, no. 6, Nov. 1965. (Speech presented to the annual meeting of the American Hospital Association, Sept. 1, 1965.)

Terry, Luther. Hospitals and Title VI of the Civil Rights Act. Hospitals, vol. 39, part 1, Aug. 1, 1968.

Wesley Jr., Nathaniel. Black Hospitals in America: History, Contributions, and Demise. Tallahassee, Fla: NRW Publications, 2010.

Copyright © 2014 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express.