Hospital Shortage? Segregated Medicine has Something to do with It
COVID-19, a novel coronavirus, has taken the world by storm, leading to the World Health Organization’s (WHO) pandemic declaration. The novel virus, never encountered before in human history, has laid bare our failings as a society. It has exposed significant systemic vulnerabilities and vulnerable populations—including the unhoused, the incarcerated, hourly-wage workers, and caregivers—to name just a few. We cannot close schools because food insecure children depend on them. Nursing homes and long-term care facilities have long existed on the margins of our healthcare system and there, COVID-19 thrives.
But the recent outbreak has revealed an unrecognized crisis that has been brewing for decades—the availability of hospitals. Concern for the number of available hospital beds, especially Intensive Care Unit (ICU) beds grows as governmental leaders, medical professionals, and hospital administrators prepare for “surge capacity.” Our healthcare system is simply unprepared for a pandemic of this size. In response to the virus, China quickly constructed hospitals in a matter of days. Such a project in the United States, unfortunately, is unimaginable.
Currently the US has more than 6,000 hospitals with less than one million beds. Many of these beds are being used in the normal operation of hospitals. Which begs the question, where are COVID-19 patients supposed to go to be treated? Why don’t we have enough hospital beds in preparation for such an emergency?
There is a reason why we in the United States, do not have enough emergency hospital capacity—and the history of segregated medicine has something to do with it. Though hospitals continue to close and consolidate around the country, this crisis is rooted in the history of racial segregation.
During the early twentieth century, the number of hospitals in the United States expanded to meet rising demand for hospital care. While African Americans managed health and wellbeing in the Jim Crow Era, the modern healthcare system grew into its current form. The federal government supported the development and modernization of hospitals beginning with the New Deal, which funded the construction of hospitals like St. Louis’s Homer G. Phillips. Following President Harry Truman’s failed attempt to secure universal healthcare, the 1946 Hill-Burton Hospital Construction and Modernization Act granted funds to construct hospitals around the nation. The legislation was the first to explicitly reference “separate but equal” institutions, a segregation loophole, which funded the construction of segregated hospitals in the United States. Cities, like St. Louis, found themselves supporting multiple segregated acute care hospital facilities for both White and Black citizens.
In the post-World War II years, however, African American activists began to attack Jim Crow institutions in growing numbers. Segregated hospitals specifically, and segregated medical education and professional organizations more generally, were targets for desegregation.
In the larger Civil Rights Movement medical professionals, who were often economically independent, led local NAACP branches and desegregation efforts. Organizations like the Medical Committee for Civil Rights, later renamed the Medical Committee for Human Rights, treated injuries incurred by activists and later fought for equity within the medical profession itself.
Amid the achievements of the Civil Rights Movement in the 1960s, American healthcare was desegregated. The 1963 Simkins V. Moses Cone court decision, later supported by Title VI of the Civil Rights Act of 1964, and enforced by federal funding through Medicare in 1965, American hospitals could no longer segregate patients on the basis of race. Doing so would prohibit their ability to receive federal funding. Though the American Medical Association (AMA) opposed Medicare, the National Medical Association—the African American medical organization formed as an alternative to the segregated AMA—supported the landmark legislation. Additionally, opportunities continued to expand in the education and training of African American physicians and nurses.
Concerns over inflation and rapidly rising health care costs accompanied hospital desegregation efforts. Segregated hospitals were no longer economically feasible. They were deemed “unnecessary duplication of services.” Cities, like St. Louis, could no longer maintain multiple public hospitals. Formerly segregated Black hospitals began to close—either by force or because their constrained patient base now had other options. Many closed because they were no longer economically viable. In the civil rights era, therefore, the number of American hospitals began to contract rather than expand. The Nixon and Reagan administrations sought to control rising health care costs in the 1970s and 80s, by controlling the construction of new hospitals and by promoting Health Maintenance Organizations. The number of available hospital beds has been decreasing as hospitals closed and consolidated around the country, especially in rural areas. Now, more than ever, where you live dictates your health experience and your ability to access care. Communities, like the Ville in St. Louis where the formerly segregated Homer G. Phillips Hospital operated, are now deemed “medically underserved.”
It should be clear that despite COVID-19, our healthcare system is in dire need of repair. Chasing capital has reduced hospital availability to the bare bones. Perhaps this pandemic makes clear the need for a more just, robust, and easily accessible healthcare system.
For more on segregated hospitals, the medical civil rights movement, and its impact on the evolution of American healthcare, look out for my forthcoming book project: Segregated Medicine: The Homer G. Phillips Hospital Story (1937-1979).
Ezelle Sanford III, PhD
Postdoctoral Fellow, Penn Program on Race, Science, and Society (PRSS)
Project Manager, Penn Medicine and the Afterlives of Slavery (PMAS) Project
University of Pennsylvania