Structural Racism in American Psychiatry and APA: Part 6

In his Special Message to Congress on November 19, 1945, President Harry Truman restated his belief that every American citizen has “the right to adequate medical care and the opportunity to achieve and enjoy good health.” He advocated for more hospitals and more medical professional staff to serve in them. He said:

• The States, localities and the Federal Government should share in the financial responsibilities. The Federal Government should not construct or operate these hospitals. It should, however, lay down minimum national standards for construction and operation, and should make sure that Federal funds are allocated to those areas and projects where Federal aid is needed most.

He believed that prevention should be an important function of these hospitals, including the prevention of mental disorders.

In 1946 Congress passed the Hill-Burton Act to support the building and expansion of hospitals through federal grants and loans. The law posed problems for poor and minority communities. While facilities receiving the funds could not discriminate based on race, color, national origin, or creed, they could have separate but equal facilities in the same area. Hospitals were required to provide a “reasonable volume” of free care each year, but no regulation defined that volume. The state and municipality where the hospital was located each had to put up one-third of the costs for construction and have the resources to maintain and operate the hospitals. Thus, low-income areas did not get much of the funding, but middle-class areas did.

In 1962, a black dentist, George Simkins; a black surgeon, Alvin Blount; and others sued two North Carolina hospitals in Greensboro that had received a considerable amount of Hill-Burton funds, claiming the hospitals denied “the admission of physicians and dentists to hospital staff privileges, and the admission of patients to hospital facilities, on the basis of race.” They also sought a ruling that the Hill-Burton Act’s provision for separate-but-equal facilities and services was unconstitutional. The plaintiffs won the case on appeal in the U.S. Court of Appeals, Fourth Circuit. The Simkins v. Cone decision marked the first time that federal courts applied the Equal Protection clause of the 14th Amendment to prohibit racial discrimination by a private entity and set the stage for Congress to pass the 1964 Civil Rights Act the next year, which prohibited using federal funds for racial segregation.

The major force for the integration of hospitals, it turns out, was President Lyndon Johnson through Medicare. In a bold move, the Johnson administration made it clear that no segregated hospital would receive federal Medicare dollars. This precipitated a truly amazing turnaround. In January 1966, no less than two-thirds of Southern and border hospitals were out of compliance, and many Northern hospitals operated as de facto segregated facilities. By June 15, more than 80% of hospitals were complying, and by June 30, the number had risen to 94%. By January 1967, there were very few hospitals not in compliance.

In December 1963, APA approved a position statement on the desegregation of hospitals for the “mentally ill and retarded.” There is no record of what exactly this position statement said. The sequence of and some perspectives on the desegregation of the all-Black state hospitals follow.

State Hospital Desegregation

• West Virginia, 1954: A few state hospitals desegregated before the Civil Rights Act of 1964. The Lakin Hospital for the Colored Insane was one of four state facilities for Blacks with special needs in West Virginia, the others being the Lakin Industrial School for Colored Boys, West Virginia Industrial Home for Colored Girls, and the West Virginia School for the Colored Deaf and Blind. Larkin opened in 1926 and became integrated in 1954. It was unusual in its time in that all the staff were Black. The staff and patients lived together at the hospital because local housing was practically nonexistent for Blacks, and they operated a self-sufficient community. The quality of care was said to be good, and Lakin has been described as “a serious attempt to accomplish the ‘equal’ portion of the separate-but-equal doctrine.”

• Maryland, 1963: Maryland also initiated its state hospital desegregation plan prior to 1964. In 1963, Maryland’s health commissioner ordered the desegregation of all Maryland state hospitals. The all-Black facility was Crownsville State Hospital. The initial push for desegregation at Crownsville was started by the National Association for the Advancement of Colored People and Black community leaders in the 1940s. Up until 1948, all of the hospital staff were white. Knowing integration would someday occur, members of the Black community, worried what would happen to Black patients when white patients were admitted and there were no Black staff. The first Black employee was a psychologist and others followed—the first Black social worker was hired in 1950 and the first Black aide in 1952. The first Black superintendent was hired in 1962. An issue arose with on-campus housing, a benefit of the job. White staff did not want to live with the Black staff. The superintendent told the white staff they could live in integrated housing on campus or at their own expense off campus. The first white patient was admitted January 1, 1963. Also in the 1960s, the hospital started an outpatient clinic in Baltimore, because Johns Hopkins and other facilities—by practice but not by policy—would not treat Black patients.

• Oklahoma,1964: Taft State Hospital was an all-Black facility, with an all-Black staff, located in an all-Black town. In 1940 its 738 patients were cared for by three psychiatrists (including the superintendent), three nurses, and an unknown number of direct care staff, who apparently all lived in one room. In 1949, Oklahoma consolidated the state hospital with the Institute for Colored Blind, Deaf, and Orphans and the Training School for Negro Girls, creating one large facility for Blacks with all manner of clinical needs. Oklahoma desegregated its public facilities in 1964. Rather than admit white patients to its state hospital for Black patients, as most of the other states would do, Oklahoma transferred the Black patients to its two other (all white) state hospitals. Taft was closed in 1970 and converted into a correctional facility, thus confounding in the public’s mind people with mental illness and criminals. (Some state hospitals have converted some of their units into correctional facilities, leading some people to think that psychiatric patients are being held behind multi-layered, barbed wire, razor-topped fences.)

• North Carolina, 1965: Cherry Hospital, one of the state’s all-Black state hospitals, admitted its first white patients in 1965 following years of clear health care inequities between its white and Black state hospitals. In 1957-1958, the state spent $886 per patient per year at Cherry Hospital, while per capita expenditures at the all-white state hospitals were about twice as much. While cotton was not raised on the farms of Cherry Hospital, Black patients were routinely leased to local white farmers to pick their cotton. The hospital was paid a fee for the patients’ labor; the patients received nothing. An employee who had joined the hospital staff in the 1960s said in an interview in the 21st century that he thought integration had been easier at the hospital than it had been in the community outside the hospital. The integration of North Carolina’s state hospitals and the shift to a regionally based system of state hospital admissions occurred simultaneously, but it’s not clear if one drove the other.

• Virginia, 1965: In the 1950s, overcrowding was an increasing problem at Central State Hospital in Petersburg: One ward had 300 patients in a single large room, and patients in the forensic building were sleeping on the floor. The hospital constructed a maximum-security forensic unit and a geriatrics unit, and its patient population reached almost 5,000 in the 1950s. In the 1960s, in a run-up to the admission of whites, Central State Hospital upgraded its physical plant, started treating adolescents, and opened an alcohol abuse treatment program. The first admission of a white person to Central State Hospital, on August 27, 1965, was a matter of happenstance. A sheriff whose jurisdiction was near Petersburg was supposed to take a white patient to the forensic unit at Southwestern State Hospital. To avoid the trip of about 300 miles, he brought the patient to the Black forensic unit at Central State Hospital. A hospital employee at the time later recalled the confusion when the medical records department wanted to process this patient as a light-skinned Black patient. Other white people were admitted soon thereafter. The first Black superintendent/director was Olivia Garland. Hired in 1985, she stayed at Central State Hospital until transferred to Eastern State Hospital in Staunton, Va., to clean up scandalous conditions there. By the 1990s the Central State Hospital census included about 50% Black patients and 50% white patients. Other races totaled less than 1%.

• South Carolina, 1966: In South Carolina, William S. Hall, the state commissioner of mental health from 1963 to 1985, was concerned that too rapid desegregation of the state’s all-Black facility would be dangerous: “Long-term mental wards are more like Barracks or dormitories than hospital wards. Most of the patients are ambulatory; a great many are quite able bodied. Massive forced racial mixing very possibly would provoke bloodshed, especially if it were done overnight.” Political pressures caused Hall to revise his desegregation plan from five years to two years. Desegregation started with the opening of an integrated admissions building in February 1966.

• Alabama, 1969: Mt. Vernon Hospital for the Colored Insane (subsequently Searcy Hospital) in Alabama was the last of the segregated hospitals to integrate. While serving only Black patients since it opened in 1902, it was staffed predominantly by white staff. During the period 1964 through 1969, Alabama was engaged in a battle with the federal government regarding compliance with the Civil Rights Act of 1964, a struggle led by Alabama Gov. George Wallace. When sworn in as Alabama’s governor, he had proclaimed, “In the name of the greatest people that have ever trod this earth, I draw the line in the dust and toss the gauntlet before the feet of tyranny, and I say segregation now, segregation tomorrow, segregation forever.” There do not appear to be records of how the hospital achieved integration in 1969.

Conclusion

Some authorities would like to believe segregation in health care ended in the 1960s. Others point out that it hasn’t ended yet. In the May 18 Atlantic, staff writer Vann R. Newkirk wrote:

• The sweeping tide of Civil Rights papered over the fissures that were built into Jim Crow-era health care, but progress was slow and proved much more difficult to assess than progress in education or housing. Generations of strict geographical segregation left hospitals that served Black people deeply segregated, understaffed, and under-resourced. … [T]here is no real high-water mark for the state of health-care integration.

APA recognized that segregation in psychiatric hospitals, state schools for people with developmental disabilities, and related institutions did not end by 1970. In 1975, APA updated its Position Statement on Desegregation of Hospitals for the Mentally Ill and Retarded:

• The American Psychiatric Association is in favor of desegregation of all hospitals for the mentally ill and retarded. This statement is offered as contributory to the national will to eliminate legal and social impediments to the extension of all services to all citizens. The acceptance of this principle and its translation into practice would remove the need to duplicate facilities to accommodate segregation. It would release all available resources in support of a wider range of treatment services for the benefit of all mentally ill citizens.

In May 1969, a contingent of Black psychiatrists came to the Board of Trustees meeting demanding changes in how APA addressed—actually failed to address—the roles of Black psychiatrists and the treatment of Black patients. This position statement, which, oddly, partially justifies integration by indicating it will be a fiscally prudent change, was surely well intentioned. But in many respects, it was the easiest of the many actions Black psychiatrists of the era were pushing APA to take. It required no changes within APA itself. It did not address matters that could have led to changes for Black psychiatrists. ■