The Hill-Burton Act and civil rights: expanding hospital care for black southerners, 1939-1960.

THE HOSPITAL SURVEY AND CONSTRUCTION ACT--COMMONLY KNOWN as the Hill-Burton Act or simply Hill-Burton in recognition of its Senate sponsors, Lister Hill (D-Ala.) and Harold H. Burton (R-Ohio)--was debated in Congress and passed into law in 1946 at the height of the South's paradoxical status as the nation's neediest yet most politically powerful region. From 1947 to 1971 Hill-Burton underwrote the creation of a modern health care infrastructure with $3.7 billion in federal funding and $9.1 billion in matches from state and local governments. Space for nearly a half million beds was constructed in 10,748 projects, including nursing homes, mental health and other specialized facilities, and public health centers as well as hospitals. Edward H. Beardsley's seminal 1987 study of southern health care, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South, contains the most nuanced and detailed historical analysis to date of Hill-Burton's impact on the South, where half the facilities were built. While recognizing that most participating southern hospitals remained closed to black physicians, Beardsley asserts that with the help of Hill-Burton projects "Southerners of both races, but blacks particularly, began to enjoy an access to modern hospital care that they had never known before." (1)

Most scholars since Beardsley have focused on Hill-Button's separate-but-equal clause and the program's failure to completely end racial discrimination in southern hospitals. This body of work at times views Hill-Burton in a deterministic light, with some scholars essentially sharing the view of integrationist medical activists that eliminating segregation in health care was a "magic bullet" that would end racial health disparities. This article posits a "long civil rights movement" in health care by surveying and elaborating on the historiography of Hill-Burton in the South and considering multiple factors that contributed to the expansion of hospital care for blacks and whites, particularly in underserved rural areas. The essay focuses mainly on the fifteen-year period from 1939, when hospital construction was first debated in Congress as part of proposals to establish a national health plan, to 1954, when the Supreme Court in Brown v. Board of Education of Topeka declared segregation unconstitutional and inherently unequal in public elementary and secondary education. Finally, this article uses North Carolina as a case study to evaluate Hill-Burton's record in improving blacks' access to hospital care during the two decades before full compliance with integration was made a condition of federal aid in all health care programs as a result of the Supreme Court's 1963 Simkins v. Cone decision, the Civil Rights Act of 1964, and the Medicare and Medicaid legislation of 1965. (2)

Hill-Burton contributed to a series of major transitions in the life of the South and the nation. Scholars commonly cite the Fair Labor Standards Act of 1938 as the New Deal's end point, but Hill-Burton was the last and perhaps the most progressive expression of redistributive New Deal liberalism. Lawrence J. Clark, a health administrator and policy analyst, and his coauthors judged the act to be "one of the most ambitious efforts for the development of social capital to that time." Hill-Burton was the first federal program to incorporate a graduated, need-based allocation formula that favored the South, paving the way for federal sponsorship of health, education, and welfare as well as costly new infrastructure that made Sun Belt prosperity possible while allowing southern states to maintain low taxes. As an outgrowth of Florida Democratic senator Claude D. Pepper's Subcommittee on Wartime Health and Education, Hill-Burton was among the first and most successful examples of a new postwar brand of federal reform that garnered bipartisan support by blending centralized planning, economic development, and a rationale for domestic spending based on national defense. Hill-Burton also fostered the growth of institution-based, capital- and technology-intensive medicine in the South. About 20 percent of projects aided teaching hospitals, including the burgeoning new academic medical centers at the state universities of Alabama, North Carolina, Texas, and Florida. (3)

Perhaps the most important changes ushered in by Hill-Burton were the transformation of segregation in health care and the philosophical evolution of black medical activism from pursuing equalization to advocating full integration. During hearings on hospital construction legislation, black pragmatists proposed federal guarantees of racial parity in funding and facilities built in areas where segregation was required by law. Hill-Burton was the only federal program to include such a clause, which resulted in the proliferation of modern, well-equipped hospitals that admitted black and white patients but internally segregated them by ward or floor. These biracial hospitals substantially included blacks in the dramatic postwar expansion, modernization, and geographic redistribution of southern hospital facilities, which without the federal program would have remained racially separate and grossly inadequate for patients of all races. Hill-Burton was applied most successfully in North Carolina: it built hospital facilities in areas where the majority of the state's approximately one million African Americans were concentrated and significantly increased the amount of care available to black and indigent patients.

The South in 1940 contained 76.6 percent of African Americans and 54.1 percent of rural Americans, whose abysmal health status was starkly portrayed in a flurry of reports and articles highlighting that the region had the nation's worst rates of morbidity, mortality, and wartime draft rejections. Echoing the critical Report on Economic Conditions of the South, prepared by President Franklin D. Roosevelt's administration in 1938, Surgeon General Thomas Parran called the South "[t]he number one health problem of the Nation." In the last decades of the nineteenth century, southern blacks had accepted segregation as the price of inclusion within the new graded school system as well as other public institutions. Until World War II the South's hospitals had been as racially separate and unequal as its schools, except that in many rural communities no hospitals existed at all for either race. Black patients were primarily cared for in all-black hospitals, whose number nationwide had decreased from 202 in 1923 to 124 in 1944. Only 16 were rated grade A by the National Hospital Association. In sixteen southern states 9.7 million African Americans were served by 79 black hospitals, most of which were unaccredited, underequipped, and struggling to remain open. Most southern white-run hospitals did not accept blacks, but a few placed black patients of white physicians on inferior black wards, often in the basement, and usually with no separation by disease process, so that mothers of newborn infants lay next to contagious cases. In small towns, black as well as white physicians ran proprietary facilities, most with fewer than ten beds. Fraternal organizations also provided hospital facilities, such as the Taborian Hospital in Mound Bayou, Mississippi. Black patients received medical care from some white physicians (who had separate waiting rooms or saw black patients one day of the week) as well as 8,000 black nurses nationwide in 1945, including 1,101 employed in public health. Black midwives attended approximately 80 percent of births to black southern women during the 1930s. At various moments during the 1940s, only 475 black public health nurses, 644 black dentists, and 1,751 black physicians practiced in the South, the majority in cities. In North Carolina, for example, fewer than one in ten black doctors served rural areas, where 70 percent of black residents lived. Despite such limited access to hospitals and physicians, rates of death and disease among black and white southerners began to abate during the second third of the twentieth century due to improvements in sanitation, housing, nutrition, and standards of living, as well as income and levels of education (see Table 1). (4)

Some of these health gains can also be credited to federal health programs that were the striking exception to the New Deal's overall marginalization of southern blacks. According to historian Colin Gordon, "The South's principal victory in the formative years of the New Deal was the exclusion of agricultural and domestic labor from coverage under the National Recovery, Agricultural Adjustment, Social Security, National Labor Relations, and Fair Labor Standards acts--leaving fully 90 percent of the southern black workforce untouched by the new federal programs." In contrast, thousands of poor southern blacks and whites benefited from federal aid to health care under the Social Security Act and innovative programs such as the Farm Security Administration's rural health cooperatives and the Emergency Maternal and Infant Care initiative for soldiers' families, which cared for one in six babies born in the U.S. in 1944. Federally sponsored maternal and infant care clinics and midwife training programs were largely responsible for the 20 percent decline in infant mortality in several southern states between 1941 and 1942, with black infant and maternal mortality improving slightly more than white. Milton Roemer of the Yale University Department of Public Health observed in 1949 that "the personal health services offered by many Southern health department programs are provided overwhelmingly to Negro people." Federal aid transformed southern health policy to enable state and local governments to take substantial responsibility for black, rural, and indigent health. Black southerners became more knowledgeable users of health care, and they established patterns of seeking treatment that intensified the demand for integration once access to hospitals dramatically expanded after the war. (5)

The postwar expansion of the number of black hospital beds took place largely within biracial hospitals that represented a new public policy approach to civil rights and health care. Carl V. Reynolds, North Carolina's state health officer, declared in May 1946 (shortly before Hill-Burton was enacted in August) "that the influential are determined to make available adequate medical, surgical, obstetrical and hospital care,--certainly for the underprivileged citizens--regardless of race, creed or color." The "influential" included not only national health reform leaders but also southern state officials who, in response to mounting pressure from antidiscrimination lawsuits, began to accept the responsibility to equalize public services for blacks in the context of health, education, and welfare spending that grew slowly during the 1930s but skyrocketed after the war. In health, unlike in education, these efforts were substantially aided by federal and state funding. Public aid to hospital construction facilitated a more gradual transition in the architecture of health care segregation, from spatial isolation in completely separate buildings to partitioning of racial groups within shared structures via separate entrances, floors, wards, etc. (6)

Historian Douglas L. Smith notes that "Hospital improvements were among the top priorities in the southern cities" for federal works programs. Between 1933 and 1941, grants and loans from the federal Public Works Administration (PWA) built 668 new hospital projects at a cost of nearly $300 million and supported the construction, enlargement, or renovation of 2,100 hospitals, representing two-thirds of hospital construction nationwide. Under the Lanham Act, the PWA also built 444 hospital projects for military purposes during World War II at a total cost of $66 million, $55.5 million from federal funds. The PWA added nearly 8,000 new beds in all-black hospitals or wards in sixteen southern states, not including an undetermined number of beds in biracial hospitals that admitted black patients. Nearly 60 percent of black beds built were in mental wards or hospitals, 25 percent were in general hospitals, and 15 percent were in tuberculosis and other hospitals. The PWA built space for 685 beds, at a cost of over three million dollars, at the Homer G. Phillips Municipal Hospital in St. Louis and 1,170 beds at the North Carolina State Hospital for the Colored Insane. But the single largest PWA hospital project was the biracial Charity Hospital in New Orleans, built for $12 million. Smith describes the new twenty-story, 2,700-bed main hospital building as "a truly magnificent structure [with] ... separate but roughly equal wards for whites and blacks." The expansion made Charity Hospital "the second largest in the United States and the largest state health facility in the world for the treatment of acute and contagious diseases." At a time when most general hospitals were private and virtually all admitted either blacks or whites exclusively, Charity's pathbreaking biracial architecture placed blacks in wards on the east side and whites on the west, with private rooms for paying patients in the center of each floor. Variations on Charity's biracial floor plan were replicated in the southern postwar hospital construction boom. The PWA hospital construction program presaged Hill-Burton's principle of favoring the South and increased the number of facilities where black health professionals could treat their patients. (7)

A 1940 study of hospital service for blacks showed that the ratio of beds to black residents in the nineteen states (plus the District of Columbia) where hospitals reported official policies of segregating or denying admission to patients on the basis of race was actually higher than the same ratio for the general population in five states (Indiana, Kentucky, Missouri, Oklahoma, and West Virginia). In eleven states where the overall supply of hospital beds was low, the ratio was less than one bed per thousand fewer for blacks than for the general population, and in only three instances (the District of Columbia, Florida, and Louisiana) was the disparity between the black and general population ratios greater than one bed per thousand. Between 1940 and 1946 the number of general hospital beds for blacks in eight southern states reporting racial breakdowns rose by 3,437, or 51 percent (see Table 2 for figures from four of the southern states). (8)

North Carolina arguably gave the most serious thought to the health needs of black southerners. In response to public alarm over North Carolina's ranking forty-second in hospital beds per capita, forty-fifth in doctor-to-population ratio, and highest in rates of World War II draft rejections, Governor J. Melville Broughton in 1943 proposed a comprehensive health plan for "more doctors, more hospitals, and more insurance." Broughton had corresponded with Senator Pepper after hearing him speak at the March 1943 Southern Governors' Conference in Tallahassee, Florida. Like Pepper, Broughton pursued health reform that appealed politically to southern whites but held great potential for addressing black needs. Dr. Clarence Poe, a prominent segregationist and editor of the Progressive Farmer, chaired the governor's Commission on Hospital and Medical Care and also served on the American Hospital Association's Commission on Hospital Care, which was instrumental in generating support to pass Hill-Burton. Both commissions affirmed the goal of providing equal quality care for black patients "in hospitals that serve white patients rather than in separate hospitals." The commissions also advocated that hospitals admit qualified black physicians to their staffs on the same basis as other physicians and provide equal opportunities for professional education. (9)

Under Broughton and Poe's leadership, North Carolina pursued an attenuated form of segregation in health care that mitigated (but did not eliminate) some of the worst aspects of the old racially separate hospital system. Blacks gained access on a rationed basis to white-run hospitals with state-of-the-art facilities staffed by more, better-trained personnel than could be found in the aging private black hospitals that had been established since the late nineteenth century. North Carolina's state health plan also addressed the many residents who could not pay for care, including most black citizens, by declaring its ultimate purpose to be "that no person in North Carolina shall lack adequate hospital care or medical treatment by reason of poverty or low income." Surgeon General Parran commended the North Carolina General Assembly's financial commitment to hospitalization for indigent patients, "thus recognizing ... the need for making medical services available to all, regardless of race, creed, or economic status." (10)

The General Assembly in 1945 approved the state health plan formulated by the advisory commission and created a permanent Medical Care Commission to implement it. In a report to the commission, rural sociologist Selz Mayo identified the existing pattern of segregation as a major obstacle to improving the quality, accessibility, and efficiency of health care delivery. "The people of North Carolina are too poor to afford bilateral arrangements in health education, medical care facilities and in methods of paying for their services," he argued. "At the same time, the state is too poor not to provide for one complete system of medical care. Two systems will mean lower standards and poorer services for both the white and the Negro population." Mayo's vision of "one complete system of medical care" built on the Duke Endowment's success during the 1930s in promoting equal quality care for black patients in white-run hospitals. During World War II black and white patients had also been cared for by integrated staffs in southern military hospitals, including Fort Bragg, North Carolina, and Camp Livingston, Louisiana. The new model of biracial but internally segregated facilities was incorporated into the blueprints of North Carolina's postwar hospital construction boom. When the University of North Carolina (UNC) drew up plans in 1949 for a teaching hospital funded by Hill-Burton, the administration and the Board of Trustees envisioned "from the very first" a facility that would be "for both white and Negro patients, with separate wards, dining facilities, and so forth. This concept has been carried out in all the planning of the hospital." Mayo and the UNC Board of Trustees prided themselves on living up to the promise of separate but equal as they reinvented segregation for the postwar world. (11)

This reinvention of segregation in health care had emerged in the Senate hearings and floor debates on federal aid to hospital construction between 1939 and 1946, when leaders of both African Americans and white southerners presented compelling but distinct arguments for a need-based calculus that would channel public resources to their respective constituencies. In An American Dilemma, published in 1944, Swedish sociologist Gunnar Myrdal noted the difficulty of separating the effects of racial discrimination in health care from the effects of blacks' disproportionate concentration in the region and income bracket where access to medical facilities was most limited. Southern whites used this to political advantage by lobbying for federal health legislation on the basis of rural and regional uplift. By using aggregate regional morbidity and mortality data without racial breakdowns, they cloaked the more dire needs of urban blacks in the politically salable cause of aiding rural southerners, more than one-fifth of whom had already migrated to cities in the five years before Hill-Burton was enacted. To white southerners like Clarence Poe, medical need was "most appalling among farmers, and among sections of America, the need is most appalling in the South." But John Davis, national secretary of the National Negro Congress, asserted, "there can be no improvement of the conditions in the southern section of our country without a very careful and conscious effort to see that improvement is made equitably for the Negro and white populations." A fragile coalition of progressive southerners, non-southern liberals--particularly Senators James E. Murray (D-Mont.) and Robert F. Wagner (D-N.Y.)--and black activists pursued a pragmatic strategy that promised to meet black and rural needs by prioritizing medically underserved areas and guaranteeing a proportional share of services and funding to black patients based on racial population ratios. Since a direct assault on segregation would doom passage of any proposed legislation, the coalition pursued the equalization rather than the elimination of segregated facilities and wards. This was the most viable method for immediately extending health care to African Americans, half of whom lived in the rural South in 1940. (12)

A proposal for federal aid to hospital construction was first introduced in Congress by Senator Claude Pepper in March 1938 and passed into law in August 1946 as the Hospital Survey and Construction Act, commonly known as Hill-Burton. Pepper and Lister Hill, the South's two most progressive senators, were at the forefront of legislative efforts to meet the pressing, overlapping needs of the nation's most medically impoverished populations: southerners, rural dwellers, and blacks. During the 1943-1944 session, Pepper's Subcommittee on Wartime Health and Education investigated "the educational and physical fitness of the civilian population as related to national defense." The draft rejection rate for thirteen southern states was 49.6 percent, versus 35.6 percent for non-southern states. North Carolina ranked worst in World War II draft rejections, with 71 percent of black and 49 percent of white recruits deemed unfit for service. Unlike prewar attempts at federal health reform, the Pepper Committee Report appealed to conservatives, particularly organized medicine and the southern bloc in Congress, by definitively linking health with national defense, documenting the negative impact of health deficiencies on the armed forces and war production capacity, and emphasizing the need to prepare for postwar demobilization and the increased demand for health services. In the wake of the Pepper Report, Pepper and Hill made passage of federal aid to hospital construction a top priority and urged their southern colleagues to consider the needs and self-interest of their own region above their fears of federal interference in race relations. Historian Bruce J. Schulman argues that as a result of the Report on Economic Conditions of the South and the leadership of new southern liberals such as Hill and Pepper, "the principle of entitlement--the southern liberal view of the South as a national problem deserving of federal aid--would translate into preferential treatment for the region in the disbursement of funds for highways, airports, and public education." Schulman concludes, however, that federally sponsored southern regional development "did little to advance blacks economically." Hill-Burton was unique in its application of regional entitlement to benefit blacks as well as whites. (13)

Without Hill-Button's nondiscrimination language, which included a separate-but-equal clause, the targeting of federal hospital construction funds to the South would have been no more effective in reaching black southerners than previous New Deal programs had been. The standard interpretation of the origins of the separate-but-equal clause labels it a "loophole" that was antithetical to the nondiscrimination statement and claims that as the price of passage southern segregationists forced liberal integrationists to allow southern states to build racially exclusive facilities. Historian Rosemary A. Stevens asserts that "a major opportunity was lost for including racial desegregation as a condition of federal funding" in Hill-Burton. Yet had desegregation been made a condition of funding, Hill-Burton would probably not have passed at all, since similar attempts immediately after the war to make desegregation a condition for federal aid to medical education helped to defeat these otherwise popular measures. And even if integrationists had overcome very unfavorable political odds to pass Hill-Burton with a desegregation requirement, ensuring compliance would have been extremely difficult, given the subsequent white backlash against the Brown decision eight years later and the recalcitrance of southern hospitals when desegregation finally did become a condition of federal health funding nearly twenty years later. (14)

The dilemma faced by black health activists was summed up in a joint report by the Committee on Research in Medical Economics and the National Association for the Advancement of Colored People (NAACP): "How far is it wise to agree to the postponement of the ultimate goal of complete equality and integration of the Negro into the general public health program, in order to assure at least some improved provisions for Negro Health now?" During an era of hostility to civil rights legislation, whether anti-lynching and anti-poll tax measures or a permanent Fair Employment Practices Committee, hearings on the federal health bills of the 1940s gave representatives of every major national black organization an alternative forum to promote equality. Leading integrationists Walter White and Dr. Louis T. Wright of the NAACP were joined by members of the National Medical Association (NMA), National Hospital Association, National Negro Congress, Urban League, and other black groups in their calls for the equal inclusion of blacks in federally sponsored health programs. Yet David McBride observes that before Brown, "Black medical leaders did not place highest priority on integration of hospitals and health centers" but instead emphasized "national health insurance, essentially an economic reform measure." The pragmatic philosophy that dominated the black medical profession until at least the early 1950s prioritized expanding black health services over ending segregation, particularly if support was available for black hospitals. (15)

Although Lister Hill promoted the Hospital Survey and Construction Act as a states' rights measure with the intention of protecting segregation, he was by no means the first to propose the separate-but-equal clause commonly attributed to him. Ironically, the concept of equalization within segregated health care was first advanced by Dr. Louis Wright, the Harvard-trained medical doctor who chaired the board of directors of the NAACP. Wright was a vehement integrationist throughout his career, but even he temporarily advocated equalization during his testimony at the 1939 hearings on the Wagner National Health Bill. The principle of federal support for racial parity had originated in education with the NAACP's campaign during the 1930s to equalize black and white southern schools with federal funds (legislation to achieve this goal was proposed in the Harrison-Thomas-Fletcher Bill, which was introduced in the Senate in 1936, debated through the 1940s, but never enacted) and the organization's fight to force southern states to provide equal opportunity and funding for black higher education. In the 1938 Missouri ex rel. Gaines v. Canada case, the U.S. Supreme Court ruled that since the state of Missouri did not provide comparable educational opportunity at a public, in-state black law school, the University of Missouri must open its law school to the black plaintiff. In a decision that had clear implications for health care, the Court stated, "The admissibility of laws separating the races in the enjoyment of privileges afforded by the State rests wholly upon the equality of the privileges which the laws give to the separated groups within the State." (16)

In November 1938, Dr. George W. Bowles, president of the National Medical Association, and Dr. John A. Kenney, editor of the NMA's journal, had led a delegation of black physicians to meet with federal officials on the Technical Committee on Medical Care, a division of the Interdepartmental Committee to Coordinate Health and Welfare Activities of the Federal Government. In subsequent communication between Kenney and Senator Robert Wagner as well as in Bowles's testimony before the Senate during the Wagner Health Bill hearings, the NMA advocated a nondiscrimination amendment that would ensure that black physicians could treat their patients in government-supported facilities. It was the NAACP's Wright, however, who proposed specific language for an amendment to guarantee equalization of funding and services in federal health programs. Drawing on the Gaines decision and the proposed Harrison-Thomas-Fletcher Bill, Wright suggested amending the Wagner Health Bill to include the statement, "In States where separate health facilities are maintained for separate races, provide for a just and equitable apportionment of such funds to carry out the purposes of this title for hospitals and health centers for minority races...." Subsequent hospital construction bills, including the 1946 Hill-Burton Act, incorporated remarkably similar language. Until Congress amended it in 1964, section 622 (f) stipulated: "such hospital or addition to a hospital will be made available to all persons residing in the territorial area of the applicant, without discrimination on account of race, creed, or color, but an exception shall be made in cases where separate hospital facilities are provided for separate population groups, if the plan makes equitable provision on the basis of need for facilities and services of like quality for each such group." Wright also called for guarantees that federal health funds were "never to be in smaller proportion to the whole sum than the minority bears to the total population," a principle that the U.S. Public Health Service (USPHS) adopted in a formula that allocated planned Hill-Burton hospital beds to blacks and whites based on racial population ratios. (17)

Although Wright and the NAACP fought throughout the 1940s for the complete removal of racial distinctions in federally funded health programs, his initial definition of nondiscrimination as equalization rather than integration made Hill-Burton the first and only federal program to incorporate a guarantee of racial parity within segregated facilities. In An American Dilemma Myrdal criticized the "compromise formula: that Negroes and whites share in the benefits from the public economy in proportion to their numbers. This norm is in conflict with the Constitution, since it refers to the Negro group and does not guarantee individuals their right. It has its utility only as a practical yardstick in the fight against discrimination. Its very presence in the public debate, and sometimes in public regulations, is an indication of the existing discrimination." Yet it was primarily black civil rights leaders, particularly physicians in the National Medical Association, who promoted federal enforcement of racial parity in health care. The NMA's chief lobbying concern for most of the 1940s was not dismantling segregation but protecting the right of black physicians to admit their patients to new government-funded health facilities. Although Hill-Burton did not ban all forms of racial discrimination against patients and health professionals, as Wright and other integrationists had hoped, it represented the first national legislative victory for blacks since Reconstruction. (18)

Hill-Burton also revealed and widened ideological splits between northern and southern blacks as well as between the leadership and rank-and-file of black medical and civil rights organizations. Historian Vanessa N. Gamble has shown that northern black medical activists in cities such as Chicago and New York had already shifted from separatism to integrationism during the 1930s, but a new black hospital was established in Cleveland as late as 1957. The pattern of civil rights activism in health care paralleled that in education. As historian Charles C. Bolton writes, "From 1925 until 1950, black southerners, working primarily through the [NAACP], focused their efforts on trying to equalize educational spending rather than directly assaulting the Plessy doctrine of 'separate but equal'; after the NAACP shifted its tactics to challenge Jim Crow head on, many black southerners continued to embrace the equalization policy as the best method for improving black education." In the early 1940s the NAACP lobbied against stronger nondiscrimination clauses that explicitly banned segregation for fear that they would kill beneficial legislation, as in the case of a 1943 bill to federally subsidize teacher pay. Shortly after Hill-Burton's passage, integrationists warned proponents of equalization that a rising tide of federal aid to the South might not lift all boats and blacks would not receive fair treatment in programs administered by southern whites. White and Wright did not succeed in making zero tolerance for segregation a condition of black support for federal legislation until the late 1940s, when they joined black physician activists W. Montague Cobb and Paul B. Comely to mount a joint NMA-NAACP campaign against racial discrimination in medical societies, medical education, and hospitals. The national NAACP, after successfully integrating Veterans Administration hospitals, adopted a new policy in 1952 that forbade any chapter to support private or public funding for all-black hospitals or wards. In a 1952 editorial in the Journal of the National Medical Association (JNMA) titled "The Crushing Irony of De Luxe Jim Crow," Cobb wrote of the thousands of new hospital beds for blacks, "De luxe Jim Crow is just as objectionable as any other kind. It is merely a new line of defense against the slow, but irresistible advance of liberal change." Addressing the national NAACP convention in June 1953, Cobb attacked Hill-Burton for presenting "the threat of foisting on generations unborn the entrenched ghetto hospital system, through the construction of new segregated hospitals." From then on, the national leadership of the NMA and NAACP embraced integration as a "magic bullet" that promised to eliminate racial disparities in health care just as medical authorities of the era hailed penicillin as a wonder drug for fighting infectious disease. (19)

Among the NAACP and NMA's rank-and-file membership in the South, however, many African Americans still subscribed to a separatist self-help philosophy that focused on building and expanding black institutions. Dozens of southern black communities established new hospitals and wards for black patients with government aid from the Public Works Administration before the war and Hill-Burton afterward. Southern cities also refitted outdated white facilities and opened them to blacks after new facilities for whites were constructed, a practice that Cobb blasted as giving "old clothes to Sam." In Memphis the new E. H. Crump Hospital, a teaching facility funded by a municipal bond issue but tailored to the needs of black professionals and their private patients, opened in 1956 over NAACP opposition. As historian Keith Wailoo writes, new black hospitals "responded to the rising socioeconomic ideals of African Americans" in the postwar South's growing middle class. These facilities both "preserve[d] Jim Crow medicine [and] incorporate[d] large numbers of African American consumers and practitioners into the burgeoning health care system." (20)

The vast majority of black hospitals, however, did not receive aid from Hill-Burton. By raising the physical and technological standards for hospitals in the postwar era, Hill-Burton sped the demise of preexisting black hospitals, which typically ran on shoestring budgets and bore the burdens of outdated equipment and aging physical plants. By expanding and shifting the supply of black hospital beds from all-black to white-run, biracial facilities, did Hill-Burton result in better or worse care for black patients? Although the current literature on health care integration emphasizes the severe health consequences suffered by individuals who could not gain admittance to racially exclusive or overcrowded facilities, statistically, black hospital beds were in fact underutilized. The 1939 American Medical Association (AMA) Annual Census of Hospitals found that eighty-eight Negro general hospitals with 6,413 total beds had an average occupancy rate of 62.2 percent, versus 69.3 percent in non-black (i.e., white and multiracial) general hospitals. Black hospitals reported 16.4 admissions per bed versus 20.3 in non-black hospitals. The AMA Council on Medical Education and Hospitals found that "Negroes do not utilize existing Negro hospitals to the same extent that the general population utilizes existing hospitals." This also held true for black beds in biracial facilities. According to the Duke Endowment, occupancy rates in North Carolina's biracial general hospitals were 15.7 percentage points lower for black than white beds (54.6 percent and 70.3 percent, respectively) in 1944. The AMA found, however, that large black nonprofit and municipal charity hospitals had higher occupancy rates, ranging from 77.7 percent at Grady Hospital in Atlanta to 89.7 percent at Negro Hospital in Galveston, which reflected the urban concentration of black health professionals and middle-class black patients who could afford hospitalization and also possibly resulted from a higher level of tax-supported indigent care in larger cities where blacks exerted greater political influence. (21)

In 1945, 80 percent of North Carolina's 8,464 hospital beds were reserved for whites and 20 percent for blacks. The 1,683 beds for blacks were divided evenly between all-black and biracial facilities, although of seventy-four biracial hospitals, forty-one had 10 or fewer beds for blacks. Two black hospitals that received Hill-Burton funds, St. Agnes, a private general hospital in Raleigh, and the State Hospital for the Colored Insane at Goldsboro, not only illustrate the harsh pre-renovation conditions black patients faced but also demonstrate widely varying long-term outcomes for black institutions. The transformation of the State Hospital through PWA and Hill-Burton funding was nothing short of phenomenal. In 1937 an investigation by the Bureau of Negro Work in the Department of Public Welfare uncovered shocking conditions of neglect and use of mental patients as maintenance, child care, and field laborers even after they were eligible for discharge. By 1940 the PWA had built seven new patient dormitories with a total of 1,170 beds, making the black wards "far superior," according to one 1945 account, to those in the white state mental hospital at Raleigh. Hill-Burton further upgraded the hospital with 487 new beds and two service facilities at a cost of just under $1.5 million, one-third from federal funds and two-thirds from a special appropriation for improvements to state facilities. Twenty years after the 1937 investigation, Goldsboro's new superintendent received praise for his "very excellent and progressive plans for the treatment of the mentally ill at Goldsboro." The expansion of the Goldsboro hospital accounted for 88 percent of beds added and two-thirds of the total expenditures for black hospitals during the first seven years of Hill-Burton in North Carolina. Since mental hospital dormitories cost considerably less per bed to build than general hospital beds, the overall expenditure per bed for black facilities was substantially lower than for biracial or white facilities. (22)

Hill-Burton funding was much more modest and less transformative for Raleigh's St. Agnes Hospital, a private 100-bed facility that built an $86,000 service facility under the program. St. Agnes was among the black hospitals that received substantial public and philanthropic assistance in return for providing indigent care. In 1954 Wake County compensated St. Agnes for 58 percent of the cost of charity cases, which made up over half the hospital's patient load. But when St. Agnes was condemned in 1955, the inspection committee unanimously called its physical plant "a disgrace to the people of Raleigh and of Wake County.... in considerably worse condition than any place ever inspected by the present Grand Jury." The hospital re-opened for a few years after the devastating report, with yearly contributions of $72,000 from Wake County, $18,000 from the state of North Carolina, and $15,500 from the Duke Endowment to cover about half the days of charity care, but St. Agnes closed for good in 1961, the same year that a new, integrated, county-owned Hill-Burton facility opened. Black hospitals like St. Agnes had far fewer paying patients to offset the costs of charity care and increasingly fell behind in making the capital improvements and technological investments necessary for modernization, thereby further hindering their ability to retain paying patients. (23)

Despite their limitations black hospitals nonetheless provided a safe haven from the humiliation of segregation and enabled patients to retain a black physician. During the 1950s Doris Cochran, the wife of a black physician activist in Weldon, chose to drive eighty miles to deliver her three children at Lincoln Hospital in Durham, rated grade A by the National Hospital Association, rather than endure inferior treatment on the Jim Crow ward in Roanoke Rapids Hospital only five miles away. As more beds for blacks opened in modern, biracial institutions, black patients began to choose them over black hospitals. Henry James (pseudonym), a civil rights leader in eastern North Carolina, called the private black hospital in his hometown "nothing but a convalescent home" after his wife received treatment there during a high-risk pregnancy in 1950. The hospital's doctors "just were not that equipped, not that up on the job," and failed to recognize that James's wife was carrying twins. In 1945 the hospital's death rate of 10.5 percent compared very unfavorably with death rates of 2.5 and 2.0 percent at the town's two white hospitals, and the black hospital treated patients at a per-diem cost of $2.88, about 40 percent of spending at the two white hospitals. After James's wife collapsed from a kidney stone attack, he rushed her to Duke Hospital, a private 120-bed facility fifty miles away with a fifteen-bed Negro ward. Doctors there told James, "you're going to have to bring her to Duke [for the delivery] because if she goes to [the black hospital] she'll die. So will the children, more than likely." (24)

Southern health care stood at the brink of fundamental transformation in 1950, the year Mrs. James delivered her twins at Duke Hospital and car accidents in Alamance County in North Carolina's central piedmont claimed the lives of two black men, Dr. Charles Drew and Maltheus Avery. Historian Spencie Love has disproved the widespread legend that Drew, the internationally renowned pioneer in blood plasma banking and outspoken advocate of health care integration, died as a result of being refused treatment on racial grounds; Drew in fact died of his severe injuries after three white surgeons treated him in the emergency room of Alamance General Hospital in Burlington. But the Drew legend was based on the remarkably similar circumstances of another black man, Maltheus Avery, whose death eight months after Drew's sparked outrage among black North Carolinians. After sustaining critical injuries in a car accident, Avery was shuttled among three area hospitals. Alamance General, where Drew had received emergency treatment, also evaluated Avery but transferred him to Duke Hospital for specialized care for a serious head injury requiring surgery. Duke's neurosurgeon examined Avery and administered supportive measures, but the hospital's fifteen-bed black ward was full and Avery was refused admission. He was sent on to Lincoln, the only area hospital without racial admitting restrictions, where he died almost immediately. (25)

Love ends her investigation in 1950, without acknowledging the changes Hill-Burton brought to every hospital involved in the Drew-Avery story. Sadly, at the time of Avery's death a new, million-dollar, 100-bed, county-owned, biracial hospital was under construction in Burlington. The UNC School of Medicine, which expanded its two-year program to become an M.D.-granting school in 1951, also built a $5 million, 296-bed teaching hospital in Chapel Hill, between Burlington and Durham, where critically injured patients like Drew and Avery could receive quality care. By 1955 the one black and four biracial general hospitals in Alamance, Orange, and Durham Counties had added 186 more beds for blacks to the 113 available in 1950. Although all these hospitals except Lincoln continued to segregate black patients, increasing the supply of beds relieved demand and eased acceptance of non-paying and emergency patients. From 1940 to 1960 rates of hospitalization in North Carolina increased 213.8 percent for blacks versus 113.2 percent for whites. Blacks' outrage over white-run facilities refusing care to black patients appears to have peaked in 1952, when the Raleigh Carolinian, one of the black newspapers that publicized Avery's death in 1950, ran three front-page stories during a six-month period. The paper carried no such stories for the rest of the 1950s. (26)

Increasing hospital utilization among blacks helped to promote a shift from mass to minority exclusion from medical care that mirrored the postwar economic shift from majority to minority poverty. Hill-Burton helped to reduce the large number of non-hospital births without a physician, particularly among rural blacks, that contributed to high southern rates of maternal and infant mortality. The proportion of nonwhite births in southern hospitals increased from 24 percent in 1945 to 74 percent in 1960, whereas the white proportion increased from 68 to 97 percent. This did not result in an overall reduction in southern black infant mortality, however. According to economists William J. Collins and Melissa A. Thomasson, "the massive redistribution of blacks out of the rural South might have had adverse health consequences that tended to offset health improvements associated with proximity to hospital care and/or higher incomes." In many ways the death of Maltheus Avery, the foundation of the legend that Charles Drew died as a result of racist exclusion from medical care, is less representative of the direction of southern health care in the 1950s than are the experiences of Dr. Drew and Mrs. James, who were among the growing number of black patients receiving emergency and maternity care in biracial, "deluxe Jim Crow" hospitals. (27)

In spite of the aspects of segregation preserved in the Hill-Burton legislation, blacks gained improved access to hospital care; however, a detailed analysis of the act's implementation shows that blacks did not achieve a level of parity with whites. The program raised challenging political questions from its inception. How would federal officials enforce Hill-Button's provisions to achieve racial parity in funding and facilities, and how would southern officials and black activists in turn shape the practical application of federal health policy at the state and local levels? Rep. Helen Gahagan Douglas (D-Calif.), writing in the Journal of the National Medical Association in 1948, doubted that Hill-Burton would benefit blacks because poorer communities would be unable to raise the required matching two-thirds of construction costs or to guarantee funding for ongoing operation and maintenance. In contrast, Dr. Vane Hoge, chief of the Hospital Facilities Division of the U.S. Public Health Service, reassured JNMA readers that construction projects would be prioritized according to "percentage of need met by existing facilities," with special consideration for poor and rural areas and "availability to population groups less adequately served by reason of race, creed, or color. All of these factors will operate in favor of the groups with the greatest need of all--the Negroes in the rural South." Black and white liberal reformers were divided on whether federal aid to hospitals and medical schools would guarantee equality or entrench segregation. The fate of black patients and professionals under Hill-Burton depended on how the federal government chose to enforce the law's nondiscrimination provisions. (28)

In contrast to the National Medical Association, the American Medical Association was highly suspicious of any federal involvement in health care and also barred most black southern doctors from membership because its constituent county medical societies excluded blacks in most southern states. Members of the AMA were chagrined when Congress designated the Public Health Service, then a division of the Federal Security Agency (FSA), to administer Hill-Burton. Surgeon General Thomas Parran and Oscar Ewing, the head of the FSA from 1947 to 1953, faced criticism from the ranks of organized medicine and southern politics who feared that aid to hospital construction would provide an avenue for federal interference in health care, race relations, or both. Parran and Ewing were avowed supporters of national health insurance who, along with Senator Pepper, became targets of the AMA's campaign against so-called socialized medicine. Ewing went further than Parran to champion the rights of African Americans to equal access to health care. Southern Democrats opposed Ewing for his racial views and in 1950 blocked a proposed reorganization plan to elevate the FSA into a cabinet-level Department of Health, Education, and Security. In the Journal of the National Medical Association, Ewing declared that "we must cut [the racial disparity in life expectancy] down until there is no disparity at all, and we should not have to wait half a century before we have done so." The NMA praised the FSA as "the most liberal Government agency" and vaunted Ewing's record of expanding career opportunities for black professionals within federal agencies, particularly the Public Health Service. In contrast, the AMA-affiliated North Carolina Medical Journal complained about "the distinctly 'left' hand of the U.S.P.H.S. and other federal bureaus [who were] marching up and down the land--and even visiting foreign lands--stumping for compulsory federal sickness insurance and government control of medicine." In response to such sentiments, Parran stressed decentralization as one of Hill-Button's virtues, assuring readers of the Journal of the American Medical Association that final authority for the program's administration lay with the states and communities. According to Parran, the federal role was "largely that of guidance," but both doctors and Dixiecrats read "guidance" as control. (29)

In fact the Public Health Service's guidance was very specific and encouraged the bureaucratic standardization of medicine in every area from architectural blueprints to the day-to-day operation of hospitals to safeguards against racial and religious discrimination. State and federal officials wrangled at length over just how far southern states had to go to meet the Hill-Burton Act's requirement for "equitable provision, on the basis of need, for facilities and services of like quality for each [racial] group in the area." Correspondence between Samuel C. Ingraham, director of USPHS District 2 (including the southern states from Delaware to Florida), and John A. Ferrell, the first executive secretary of the North Carolina Medical Care Commission, reveals how state and federal officials who administered the Hill-Burton program negotiated the meaning of nondiscrimination. Ferrell had served as a county health director during the 1900s under Watson Smith Rankin, one of the most progressive state health officials in the country. During the 1910s as assistant secretary of the State Board of Health he led North Carolina's campaign against hookworm, which was so successful that it became a template for health modernization efforts around the world by the Rockefeller Foundation's International Health Board. During the 1930s Ferrell served as associate director of the Rockefeller Foundation and head of its cooperative program with state governments. In a 1933 speech to the American Public Health Association, Ferrell stated that "any program for the improvement of health and the lowering of death rates in the South must afford [the] negro health protection." But despite Ferrell's moderate racial views, the Medical Care Commission submitted a Hill-Burton plan that clearly favored whites over blacks. (30)

In April 1947 Ferrell requested clarification of Hill-Burton's nondiscrimination requirements. Ingraham responded that the Hospital Facilities Division had ruled that "in an area for which separate hospital facilities are programmed for the exclusive use of a racial group, if funds become available only for that particular group, and funds are not available for other groups, that project may be approved. It would be impossible because of lack of funds to approve a companion project to provide facilities for other racial groups." If whites could raise matching funds and blacks could not, Hill-Burton would fund all-white facilities. Ingraham commented that the decision "should resolve many programming difficulties for those sections of North Carolina for which the 'Non-discrimination Statement' cannot be made." Ferrell sent out several copies of Ingraham's letter, alerting other officials to the availability of funds for racially separate facilities. (31)

Ingraham had to eat his words before the year was out. The Public Health Service adopted a stricter definition of nondiscrimination to discourage states that wanted to build all-white hospitals with federal money. Ingraham explained to Ferrell that the Public Health Service had so far received only one state plan for separate facilities. Ultimately, fourteen of the sixteen southern states (not including Texas or Arkansas) submitted state plans to allow separate facilities, yet only twenty all-black and eighty-four all-white Hill-Burton hospital projects were constructed before 1964, representing 1 percent of all projects. Ingraham encouraged Ferrell to follow the "more expeditious" example of other states that used the official nondiscrimination statement in their comprehensive plans. The statement required individual project applicants to promise to make their facilities "available to all persons residing in the area to be served without discrimination on account of race, creed or color," but it still allowed patients to be segregated within hospitals. (32)

Despite Ingraham's advice, North Carolina's original state plan included a statement of its intent to provide care in racially separate facilities and an accompanying plan to provide an equal proportion of beds based on racial population ratios in each county. A section titled "Minimum Standards for the Maintenance and Operation of Hospitals" required hospital staff to submit quarterly reports with patient statistics by race, with number and rate of fatalities by departments. North Carolina's state Hill-Burton plan met all requirements and was approved by the surgeon general in July 1947, when the required ratio of black to white beds in state Hill-Burton plans was calculated using only proposed facilities. In November 1947 the general counsel of the FSA interpreted the nondiscrimination requirement to include existing as well as proposed facilities, which favored blacks, since far fewer existing facilities accommodated them. According to the FSA's Hospital Facilities Division, the state plan could not call for new white beds to be constructed in a county until enough black beds had been built to match the ratio of existing white beds. Ingraham apologized that the different interpretation would require North Carolina's state plan to be amended and assured Ferrell, "we are making every effort to obtain Central Office approval for your revised Plan." The Hospital Facilities Division in Washington accepted the amended plan on November 20, 1947, but the USPHS Central Office rejected it, citing forty-five of the state's one hundred counties where the number of beds planned was unacceptable. The Central Office directed North Carolina that the number of beds programmed for nonwhites should be increased in thirty-four counties and decreased in eleven counties. Apparently, the state commission had still not recovered from this blow by the end of April 1948, when Ingraham had to ask Ferrell to submit the revisions to meet the nondiscrimination requirement "as soon as possible" in order to grant final approval for the North Carolina state plan. (33)

The USPHS continued to intervene periodically to enforce the nondiscrimination provisions of Hill-Burton. The black weekly Raleigh Carolinian noted in 1951 that "Both Negroes and whites will be treated without discrimination at the proposed new tubercular hospital which the State of North Carolina is planning to build at Chapel Hill, but it is because the State had no choice but to bow to integration or lose federal support. Original plans for the hospital ... [to] be operated in connection with the 'liberal' University of North Carolina medical school provided that it would treat only white patients, but.... the State Tuberculosis Hospital Board signed a stipulation promising there would be no discrimination in the new hospital, and that the huge hospital being built at the UNC medical school with state funds will treat members of all races." "Integration" and "no discrimination" here applied only to admitting patients of both races to the same facility, not eliminating racial segregation within the hospitals. (34)

After Ewing retired as head of the FSA in 1953, the USPHS made little progress in its fight against hospital discrimination. If Ewing, given his strong record as a supporter of black equality, had remained the chief federal official overseeing Hill-Burton after the Brown decision, he likely would have pushed to end separate-but-equal provisions in federal health care programs. Instead, officials in the new Department of Health, Education and Welfare (HEW), under Secretary Oveta Culp Hobby and her immediate successor, Marion B. Folsom, continued to insist they had no power to change the original interpretation of the nondiscrimination clause until Congress chose to do so by amending the legislation. Attempts by Rep. Thomas M. Pelly (R-Wash.) and Rep. Adam Clayton Powell (D-N.Y.) to amend a 1957 appropriations bill to deny Hill-Burton grants to facilities practicing segregation were defeated in the House, 123 to 70. With the appointment of Arthur S. Flemming as secretary in 1958, HEW began active efforts to promote desegregation, but they were focused on schools. No high-level federal official until President Lyndon Johnson championed civil rights in federal health programs to the extent Ewing had. Until then, the USPHS never took a strong stand against segregation, but its representatives did force states to give greater attention to the health needs of minorities, such as when the USPHS rejected North Carolina's state plan because it did not include enough hospital beds for blacks. Although the USPHS changed its interpretation of Hill-Burton's nondiscrimination clause three times during the program's first year, it successfully convinced southern states to provide care to blacks in biracial rather than racially separate hospital facilities. (35)

Federal enforcement of Hill-Burton's principle of racial parity can be quantified by examining patterns of funding and construction in North Carolina as a case study. During the first five years of Hill-Burton, North Carolina's share of federal funds totaled over $17 million, which the North Carolina General Assembly supplemented with another $17 million for hospital construction and the expansion of the UNC School of Medicine. According to Beardsley, North Carolina's legislature was more generous toward hospital construction and its planning agency more farsighted than that of any other southern state. North Carolina ultimately ranked first in the number of projects built under Hill-Burton and fifth in total federal funds expended, resulting in a 115 percent increase in beds during the program's first two decades. Hill-Burton qualitatively and quantitatively improved access to health care for southern black and indigent patients by funding the construction of health centers and biracial hospitals, one-third of which were publicly owned. With Hill-Burton aid, North Carolina built eighty-six public health centers where, according to the North Carolina Advisory Committee to the U.S. Commission on Civil Rights, "the clinical and service elements of the State-wide program favor availability to the Negro." The vast majority (fifty-four) of the new general hospitals constructed under Hill-Burton in North Carolina were biracial but segregated by ward. On the other hand, Hill-Burton funded more racially separate projects in North Carolina than in any other state: two new general hospitals and twenty-five additions to existing hospitals exclusively for whites, and two new general hospitals and two additions exclusively for blacks. (36)

Analyzing project-level data from the North Carolina Medical Care Commission and hospital statistics from the Duke Endowment demonstrates the dramatic impact of Hill-Burton on North Carolina. By 1960 the vast majority of both black and white patients were being treated in biracial hospitals, whereas nearly half of white hospitals had either opened their doors to black patients or shut down since the end of World War II (see Table 3). In 1945 the number of black beds was divided about evenly between black and biracial institutions; by 1960 approximately one-third of black beds were in black hospitals and two-thirds were in biracial hospitals. Although the number of black beds in biracial hospitals more than doubled, by far the greatest numerical increase of any category was white beds in biracial hospitals (4,405). Hill-Burton did not equalize beds based on racial population ratios, as the state plan and federal guidelines proposed, but it was not capable of doing so alone. Blacks represented 27.5 percent of North Carolina's population in 1940, but their share of hospital beds decreased slightly from 19.6 percent in 1945 to 18.6 percent in 1960. (37) The decrease would have been much greater without Hill-Burton due to the growing availability of non-federal sources of hospital construction financing. In addition, the disproportionate growth in the share of white beds reflected the rise of biracial hospitals in which predominately white paying patients subsidized predominately black charity patients (Hill-Button's role in expanding care for indigent patients is discussed further below).

Tables 4a-4d depict the effect of the Hill-Burton Act on thirty-nine counties that had comparatively high concentrations of black residents and sixty-one counties that had lower concentrations. Statistics were tabulated for both the twenty-five counties with the highest percentage of blacks and the twenty-five counties that had the highest number of blacks. Some counties fell into both categories, resulting in a total of thirty-nine counties with a high concentration of blacks. In 1940 these thirty-nine counties included 693,822 African Americans (70.7 percent of North Carolina blacks) and a total population of 1,841,650 (51.6 percent of all North Carolinians).

The twenty-five counties with the highest percentage of blacks, sparsely populated and concentrated in the rural northeastern and south-central sections of the state, contained 19.3 percent of the state's total population but 35 percent of African Americans, who made up between 43 and 65 percent of these counties' populations. USPHS official Vane Hoge's prediction that Hill-Burton's emphasis on poor, underserved areas would benefit rural blacks was true for these counties, half of which had no hospital in 1947. Hill-Burton built thirteen new hospital buildings and sixteen new health centers, with at least one facility in all but three of the high-percentage black counties. Only two counties, Hoke and Jones, still had no general hospital or health center by 1954.

The twenty-five counties with the highest numbers of black residents were concentrated among the wealthier, more densely populated urban piedmont counties containing the cities of Charlotte, Durham, Raleigh, Winston-Salem, and Greensboro, as well as counties containing the cities of Wilmington in the east, Fayetteville in the south, and Asheville in the west. These counties, comprising just under a third of North Carolina's black and total populations, received disproportionate shares of federal and local matching funding, while the lion's share of state funding (61.9 percent) went to the sixty-one counties with predominately white, rural populations. Although hospital beds were already concentrated in urban areas, residents of these wealthier counties benefited from the greater availability of local matching funds and constructed 47.6 percent of hospital and nursing home beds built under Hill-Burton to 1954. The urban, high-number counties built fewer but larger, more elaborate, more expensive facilities (the five most expensive projects were for teaching hospitals in or near urban areas). The rural counties--both those with high percentages of blacks and those with low concentrations--built smaller, cheaper facilities with proportionally more government funding. The sixty-one counties with low concentrations of African Americans provided local matching funds for only 29.7 percent of hospital construction costs versus 51.2 percent in high number counties. Poor blacks in the rural, high-percentage counties were least able to raise matching funds but with government aid built proportionally more new hospitals and health centers at lower cost. This outcome upholds the North Carolina Medical Care Commission's claim to be "responsible for an equitable distribution of facilities to all the people in the 100 counties of the State" and to apply state appropriations for hospital construction "only in the economically disadvantaged counties to help them match the Federal share of the cost of construction." Participation in Hill-Burton was much higher in the thirty-nine high-concentration counties, where all but six of thirty-one biracial general hospitals received funding; in the sixty-one low-concentration counties, twenty of fifty-seven biracial general hospitals had not received Hill-Burton funds as of 1954. (38)

Sociologist Jill Quadagno observes, "Hospitals presented a powerful barrier to civil rights objectives" because their segregated practices were protected by the principle that the hospital was a private institution beyond the regulatory authority of the state. Although twice as many privately as publicly owned facilities were constructed during Hill-Burton's first seven years in North Carolina, by 1967 local governments had passed seventy-seven bond issues to provide matching funds. As a result, the number of hospitals owned by state and local governments increased 282 percent, while the number of private voluntary non-profit and proprietary facilities decreased by 30 and 24 percent, respectively. The number of county-owned hospitals increased by 511 percent and their bed capacity by 1,500 percent. Hill-Burton dramatically increased the number of publicly owned hospitals in which racial discrimination could be deemed state action and thus unconstitutional under the Fourteenth Amendment. But in the 1963 Simkins v. Cone decision, which declared Hill-Burton's separate-but-equal clause unconstitutional, the Supreme Court ultimately judged that even private hospitals that received Hill-Burton funds were involved in state action. (39)

Hill-Burton also dramatically expanded the capacity of teaching hospitals, which represented 20.7 percent of all projects aided and 29.7 percent of total federal funding expended during the program's history (see Table 5). Health services researcher James E. Rohrer notes that "advancement of medical education and training by aiding in the construction of teaching facilities was an important secondary effect of Hill-Burton.... Subsequent shifts in Hill-Burton funding increased the share of resources devoted to large, acute care hospitals, many of which also had medical school affiliations." Although usually located in urban centers, southern teaching hospitals also functioned as tertiary care centers for rural patients. The five most expensive Hill-Burton projects in North Carolina through 1954, ranging from $2.6 to $5.3 million, were for large teaching hospitals in or adjacent to urban, high number black counties; four were private, and the fifth was a new state-owned facility for the UNC School of Medicine. Urban teaching hospitals fulfilled large numbers of required black beds for the state Hill-Burton plan and drew upon concentrations of indigent patients as clinical material. One high-cost project, the new private, three-hundred-bed Moses Cone Hospital in Greensboro, did not admit blacks (the discriminatory admissions policies at Cone and another Hill-Burton hospital would later be overturned in Simkins v. Cone). The importance of teaching hospitals in providing care to black and indigent patients is illustrated by the three facilities in North and South Carolina affiliated with the Medical College of South Carolina, UNC, and Duke (the North Carolina Baptist Hospital, affiliated with the Bowman Gray School of Medicine in Winston-Salem, was an all-white private facility that did not receive Hill-Burton funds). North and South Carolina's three university hospitals that admitted blacks provided 271,588 days of charity care in 1964, roughly half of them for black patients (see Table 6). (40)

In the absence of national universal health financing, the inability of the majority of black patients to pay for their care was at least as important as race per se in determining hospital access for blacks. Postwar economic gains did increase both income and health insurance coverage among blacks nationally (by 1962 about 46 percent of non-whites and 74 percent of whites had hospital insurance, although the percentage of southern nonwhites was probably significantly lower), which reduced financial barriers to obtaining hospital care made more available by Hill-Burton. Postwar prosperity also provided a tax base to support indigent care within the growing number of municipal and teaching hospitals funded by Hill-Burton. From 1940 to 1960 the incidence of hospitalization per thousand in North Carolina increased from 29 to 91 for blacks versus 68 to 145 for whites, due to both the expanded supply of hospital beds under Hill-Burton and improved health care financing from private hospital insurance and indigent care supported by taxes and philanthropy. The North Carolina General Assembly first appropriated state funds for hospitalization of indigent patients in 1945, at the rate of one dollar per day per patient up to a total of $500,000 per biennium. In 1950 Congress initiated a program of federal grants to states for vendor payments to providers who cared for public welfare recipients. By 1959 federal and state funding provided $3 million annually for the hospitalization of welfare patients in North Carolina. (41)

In addition to public and philanthropic support for charity care, the advent of biracial Hill-Burton hospitals included blacks in the cost-shifting

system by which hospitals subsidized indigent care via revenues from paying patients. In the fiscal year ending September 30, 1962, North Carolina's 102 public and private biracial hospitals provided 574,085 patient-days of free care (17.7 percent of total days) versus 98,953 free patient-days (39.9 percent of total days) at ten black hospitals. Fourteen white-only hospitals, all but one of them private, dispensed free care for only 10.2 percent of the days of care provided. Southern historian David Beito asserts that in Mississippi, "It]he spread of free care in the 1950s [in Hill-Burton hospitals] cut deeply into the patient base [of black fraternal hospitals] among the poor." But Hill-Burton hospitals were better able to serve the urban than rural poor, large numbers of whom continued to suffer the debilitating effects of poverty, malnutrition, and utter lack of medical care. Historian Numan V. Bartley goes so far as to argue that "The massive health problems of the southern rural poor were ultimately ameliorated not by doctors but by the depopulation of the rural South." Quoting Lister Hill biographer Virginia V. Hamilton, he asserts that under Hill-Burton, "free care for the poor was almost completely ignored." Health activists grew increasingly vocal during the 1960s and 1970s in their demands that Hill-Burton fulfill its pledge to provide "a reasonable volume of hospital services to persons unable to pay." Even though virtually all its chief framers had expected Hill-Burton to operate in tandem with federally funded health financing, its primary purpose was hospital construction, not indigent care. One of the greatest ironies of "deluxe Jim Crow" was that, given the continued failure of Congress to pass either civil rights or health financing reform in the two decades before the advent of the Civil Rights Act, Medicare, and Medicaid, Hill-Burton hospitals ensured a minimum amount of care for blacks, much of it uncompensated (see Table 7). (42)

Hill-Burton spread hospital-based health care, already standard in the urban North by the 1920s, to the South, where half of all Hill-Burton hospitals were built during the program's first decade. The concept of equalization, or distributing federal grants on the basis of need according to a variable formula, had first been forwarded by southern senators as an amendment to Social Security in 1939, but Congress did not adopt a variable aid formula until 1946 in Hill-Burton and other postwar legislation. Senator Hill observed in 1949 that the Hill-Burton Act was "unique for its recognition--for the first time in any Federal legislation--of the principle that the low-income States should receive the greatest proportion of Federal aid and for its preference to rural areas and small communities." That year, Hill amended the program to double its annual appropriation from 75 to 150 million dollars and increased the federal share, originally 33 percent for all projects, to a range from 33 to 66 percent based on the state's percapita income. Southern senators began including a graduated, need-based formula to decide the amount of federal matching grants to states in virtually all the social welfare legislation they proposed, from school health programs to medical education to health insurance vouchers for the indigent. Oveta Culp Hobby, secretary of the Department of Health, Education, and Welfare under President Dwight Eisenhower, applied the Hill-Burton formula to all HEW grants. This strategy soon spread beyond health to programs such as highway and airport construction, and today, despite the marked improvement of the southern economy over the past sixty years, many southern states receive more in federal aid than they pay in federal taxes. (43)

Did Hill-Burton's allocation formula achieve its intended goal of redistributing federal tax revenues from wealthier to poorer states in order to build hospitals in poor, underserved, and rural areas, and did this redistributive liberalism benefit blacks as well as whites? The above statistical analysis suggests a qualified yes for North Carolina, the state where Hill-Burton arguably realized its fullest potential, but what about the rest of the South? Lawrence J. Clark and his coauthors found that "net redistribution of beds [by 1970] to the lowest ranking states [in 1950] would have been only about half as great had it not been for the systematic market-countering effects of Hill-Burton." Five of the top seven recipients of Hill-Burton funding per capita were southern states, which benefited from a formula that allocated federal funds to the five poorest states at a per-capita rate 3.56 times that allocated to the five richest. But Paul Starr, in his prize-winning work of medical sociology The Social Transformation of American Medicine, contends that within states, middle-income (and thus most often white) communities benefited disproportionately from Hill-Burton, since they were best able to meet the requirements for matching funds. Beardsley, however, argues that "A few Southern states, such as Arkansas and Oklahoma, did give priority attention to blacks, and all gave first attention to their poorest rural areas.... Nationwide, 53 percent of projects were in communities of less than 5,000." Of the fifteen top recipients from 1948 to 1970, nine were southern states (Mississippi, Alabama, North Carolina, Arkansas, Georgia, South Carolina, Kentucky, Tennessee, and Louisiana) with a combined African American population of seven million (52 percent of the nation's total) in 1940. (44)

Mississippi offers an excellent comparison of the results of equalization in hospitals versus schools. In education, Bolton argues, equalization failed to close the enormous gap between black and white schools because state funding was insufficient and unfairly administered at the local level and because white Mississippi officials refused to consider federal funding that might endanger the segregated school system that equalization was intended to protect. The racial gap in southern hospital facilities, though significant, was less pronounced than in education and therefore easier to close because in so many communities across the region, both blacks and whites were starting from ground zero. This was especially true in Mississippi, where the ratios of hospital beds to population in 1940 were the lowest in the country for blacks and second-lowest for whites (only Georgia's was lower, by 0.1 bed per thousand). The equalization of hospital facilities was more successful because it attracted high levels of federal as well as state and local funding, which garnered widespread support from southern whites who believed segregation was protected and from southern blacks who believed they would gain equal access to desperately needed hospital care. Mississippi, the first state to build a hospital with Hill-Burton support, appropriated $4 million (6.6 percent of its 1947-1948 state budget) in matching funds for the first two years of its building program. Between 1940 and 1950, Mississippi expanded the number of general hospital beds for blacks by 216 percent, increasing the ratio of hospital beds from about 0.5 to 1.7 per thousand black residents. Beito notes, "[H]ealth facilities in the [majority-black Delta] counties of Bolivar, Coahoma, Sunflower, and Washington obtained $4.6 million from the federal government [from 1948 through 1965],.... ]which] enabled the non-fraternal hospitals to upgrade their equipment and add more than 450 beds." Mississippi, the poorest, most rural state, with the largest percentage black population and the fewest hospital beds per capita, received the most Hill-Burton funding per capita. (45)

Equalization in education was motivated almost solely by whites' desire to protect segregation, not to truly improve black education; improving black health care access not only deflected attacks on segregation but also served a variety of other, broader purposes that sustained white commitment over several decades. Because "germs knew no color line" and the southern economy depended heavily on a healthy black labor force, white self-interest in black health was much greater than in black education. White medical schools needed patients for clinical training, so teaching hospitals were often constructed near large indigent black populations and served both as volume providers of charity care and as referral centers for the surrounding region. The greater expense and increasing technological requirements of health care drove cost-conscious white policy makers to eschew wasteful duplication and build more efficient facilities that were shared by both races. Ironically, public policy in hospital construction built small biracial hospitals in rural areas while in education, the school consolidation movement gathered rural students into large schools but never combined black and white pupils. In addition, the rationale of rural and regional uplift in health served to emphasize the universal benefits of federal aid to southern health and to defuse whites' concerns over racial conflict, whereas the campaign to equalize southern education was primarily led by the NAACP, which inherently threatened most southern whites. Equalization in education attempted to address both school facilities and teacher salaries but failed on both counts; equalization in health care was limited to hospital construction but did not extend to guaranteeing equal compensation or even staff privileges for black medical professionals, even though this had been precisely the goal of the earliest proposed nondiscrimination clauses in federal health legislation. Because the success of equalization in hospital care was in part conditioned on maintaining white control over its administration, equalization benefited black patients much more than black professionals, though black doctors and especially nurses did gain inclusion in white-run hospitals to a much greater extent than during the prewar era. (46)

Hill-Burton was the result of a fleeting compromise that combined the pragmatic promise of parity under segregation with redistributive New Deal liberalism to achieve a mutually desired goal of non-southern liberals, black activists, and southern Democrats: the expansion of hospital care for black and white southerners in medically underserved communities. But by the late 1940s such sentiments had grown outmoded due, on the one hand, to increasing calls by northern liberals, civil rights organizations, and the Truman administration for an end to segregation and, on the other hand, to American liberalism's rightward shift to replace redistributive social justice with economic growth and national security. By 1954, when the U.S. Supreme Court declared segregation in public elementary and secondary education unconstitutional in the landmark Brown v. Board decision, a sweeping expansion and modernization of southern hospitals was well underway. The most important practical result of Hill-Button's separate-but-equal clause was ironically to force states that insisted on the right to build separate facilities to plan for and implement a proportional share of hospital beds and services for blacks, almost entirely within biracial facilities. Thus North Carolina was the state that built the most racially separate facilities under Hill-Burton yet also abided most faithfully by its principle of parity for black patients. (47)

Still, Hill-Burton undeniably failed to meet a post-Brown standard of nondiscrimination. Black patients and health professionals continued to experience racism in a variety of forms, from separately labeled, inferior quality equipment and facilities to outright exclusion. Within southern Hill-Burton hospitals, Beardsley observes, black patients became accepted routinely with diminishing distinctions in services, but by 1956, of the two-thirds of white-run southern hospitals that admitted blacks, "over half had gotten no Hill-Burton funds and were thus under no compulsion to accord equal treatment to blacks they did admit." Even within Hill-Burton hospitals, the program's tolerance of fixed racial quotas for bed space meant that black patients could be turned away if black wards were full, even if white wards were not. The Senate Subcommittee on Health's 1973 evaluation of the Hill-Burton program concluded that "[t]he establishment of need based on bed-population ratios for large population aggregates failed to recognize the variations in utilization of facilities within a community or of particular services within an institution (e.g., a surplus of obstetrical beds)." The subcommittee also acknowledged that "[t]he spread of third-party payment coverage for hospital costs made it possible for most institutions to go directly to the capital market for construction financing, thereby obviating much of the impact of Hill-Burton state plans on the distribution of facilities." The bed allocation formulas based on racial population ratios in southern state Hill-Burton plans were more effective in the early years of the program, before the plans were made obsolete by rapid demographic changes (especially rural outmigration to southern and northern cities) and greater availability of non-federal construction financing through private lenders and, after 1963, the ability of hospitals themselves to issue tax-free bonds. (48)

In the pre-Brown era, when legislative action to end segregation was politically unthinkable, Hill-Burton both met the South's immediate health needs and provided a transitional infrastructure to promote the acceptance of black patients and health professionals into the mainstream health care system until integrationists achieved their goals in the mid-1960s. Despite its failure to remove all forms of racial discrimination from southern hospitals, by 1954 federal aid to hospital construction had already definitively shifted the balance of new beds away from private, racially separate hospitals. As the only enacted federal legislation to incorporate a racial parity clause and the first to use a graduated allocation formula based on per-capita income that favored the poor southern states and underserved rural communities where most African Americans lived, Hill-Burton materially benefited black southerners as a group more than any other Roosevelt-era program. It was the last and most progressive expression of New Deal liberalism and the first legislative victory of the twentieth-century civil rights movement.

(1) Paul Starr, The Social Transformation of American Medicine (New York, 1982), 350; U.S. Senate, Committee on Labor and Public Welfare, Subcommittee on Health, 93 Cong., I Sess., Hill-Barton Hospital Survey and Construction Act: History of the Program and Current Problems and Issues (Comm. Print; Washington, D.C., 1973), 11-13, hereinafter cited as History of the Program; Edward H. Beardsley, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South (Knoxville, 1987), 247. Support for research for this article was generously provided by a visiting scholar research grant from the Claude Pepper Library at Florida State University and by a Reynolds Research Fellowship at the University of Alabama at Birmingham Archives. The author wishes to acknowledge the assistance of Burt Altman and John Nemmers at the Pepper Library, Tim Pennycuff at the UAB Archives, and the staffs at the Florida State Archives, the North Carolina State Archives, and the North Carolina Collection and the Southern Historical Collection at the University of North Carolina at Chapel Hill. She also wishes to thank James Leloudis, Jacquelyn Hall, Clarence Mohr, and the anonymous Journal of Southern History reviewers for their valuable criticisms of previous drafts of this article.

(2) Scholars who have evaluated mid-century federal health programs, particularly Hill-Burton, primarily as racially discriminatory, include Paul B. Comely, "Segregation and Discrimination in Medical Care in the United States," American Journal of Public Health, 46 (September 1956), 1074-81; Herbert M. Morais, The History of the Afro-American in Medicine (Cornwallis Heights, Pa., 1976), 140-53; Colin Gordon, Dead on Arrival: The Politics of Health Care in Twentieth-Century America (Princeton, 2003), chap. 5; P. Preston Reynolds, "Professional and Hospital Discrimination and the U.S. Court of Appeals Fourth Circuit 1956-1967," American Journal of Public Health, 94 (May 2004), 710-20; Mitchell F. Rice and Woodrow Jones Jr., Public Policy and the Black Hospital: From Slavery to Segregation to Integration (Westport, Conn., 1994), chap. 4; David Barton Smith, Health Care Divided: Race and Healing a Nation (Ann Arbor, 1999), chaps. 2 and 3; Vanessa Northington Gamble, Making a Place for Ourselves: The Black Hospital Movement, 1920-1945 (New York, 1995), 185-90; Jill Quadagno and Steve McDonald, "Racial Segregation in Southern Hospitals: How Medicare 'Broke the Back of Segregated Health Services,'" in Elna C. Green, ed., The New Deal and Beyond: Social Welfare in the South since 1930 (Athens, Ga., 2003); and David McBride, From TB to AIDS: Epidemics Among Urban Blacks Since 1900 (Albany, N.Y., 1991), 140, 153; for a critique of historical determinism in race and medicine scholarship, see Barbara Rosenkrantz, "Non-Random Events," in Susan M. Reverby, ed., Tuskegee's Truths: Rethinking the Tuskegee Syphilis Study (Chapel Hill, 2000), 244-47; Allan M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880 (expanded ed.; New York, 1987), 4; Jacquelyn Dowd Hall, "The Long Civil Rights Movement and the Political Uses of the Past," Journal of American History, 91 (March 2005), 1233-63; P. Preston Reynolds, "Hospitals and Civil Rights, 1945-1963: The Case of Simkins v. Moses H. Cone Memorial Hospital," Annals of Internal Medicine, 126 (June 1, 1997), 898-906; and P. Preston Reynolds, "The Federal Government's Use of Title VI and Medicare to Racially Integrate Hospitals in the United States, 1963-67," American Journal of Public Health, 87 (November 1997), 1850-58.

(3) Lawrence J. Clark et al., "The Impact of Hill-Burton: An Analysis of Hospital Bed and Physician Distribution in the United States, 1950-1970," Medical Care, 18 (May 1980), 532; History of the Program, 13.

(4) University of Virginia Geospatial and Statistical Data Center, United States Historical Census Data Browser, 1940 census data, http://fisher.lib.virginia.edu/ collections/stats/histcensus/php/start.php?year=V1940. Unless otherwise specified, for statistics throughout the text South is defined, following the U.S. Census Bureau's standard, as including the eleven former Confederate states, West Virginia, Delaware, Oklahoma, Kentucky, and Maryland. In the years leading up to the passage of Hill-Burton, the Journal of Negro Education, the Journal of the National Medical Association, the American Journal of Public Health, Hospital Management, the Southern Conference for Human Welfare's Southern Patriot, the U.S. Public Health Service, southern state boards of health, and rural sociology departments of southern universities such as Louisiana State and North Carolina State were among the principal documenters of black and rural health. See Alva W. Taylor, "Health Deficit Limits Southern Manpower," Southern Patriot, 1 (August 1943), 3 (first quotation); and Howard N. Rabinowitz, "From Exclusion to Segregation: Southern Race Relations, 1865-1890," Journal of American History, 63 (September 1976), 325-50; for a comparison of school and hospital facilities for southern blacks versus whites, see Gunnar Myrdal, An American Dilemma: The Negro Problem and American Democracy (New York, 1944), 337-46: Commission on Hospital Care, Hospital Care in the United States (New York, 1947), 163-67; Thomas J. Ward Jr., Black Physicians in the Jim Crow South (Fayetteville, Ark., 2003), 153-70: Morals, History of the Afro-American in Medicine, 127, 140-41; Gamble, Making a Place for Ourselves, 183; and Rice and Jones, Public Policy and the Black Hospital, 21 (second quotation), 34; figures for black hospitals (general and specialized, registered by the American Medical Association in 1946) and black private and public health nurses (1945) are from Florence Murray, ed., The Negro Handbook, 1946-47 (New York, 1947), 78-88; figure for black midwives is from Beardsley, History of Neglect, 167; figures for black physicians (1948) and dentists (1940) are from Jessie Parkhurst Guzman, ed., 1952 Negro Year Book (New York, 1952), 164 (a higher figure of 2,018 black southern physicians as of 1942 was published in Paul B. Cornely, "Distribution of Negro Physicians in the United States in 1942," Journal of the American Medical Association, 124 [March 25, 1944], 827); Selz C. Mayo, "Progress Report No. RS-5, 'Negro Hospital and Medical Care Facilities in North Carolina'" (hereinafer cited as Mayo, "Negro Hospital and Medical Care Facilities"), April 1945, TMs p. 8, Box 1, Series 94.2, Executive Secretary's Office, Hospital and Medical Care Study Commission, North Carolina Medical Care Commission Record Group (State Records, North Carolina State Archives, Raleigh: collection hereinafter cited as MCC); Lynn Marie Pohl, "Long Waits, Small Spaces, and Compassionate Care: Memories of Race and Medicine in a Mid-Twentieth-Century Southern Community," Bulletin of the History of Medicine. 74 (Spring 2000), 107-37; and William J. Collins and Melissa A. Thomasson, "The Declining Contribution of Socioeconomic Disparities to the Racial Gap in Infant Mortality Rates, 1920-1970," Southern Economic Journal 70 (April 2004), 746-76.

(5) Harvard Sitkoff, "The Impact of the New Deal on Black Southerners," in James C. Cobb and Michael V. Namorato, eds., The New Deal and the South (Jackson, Miss., 1984), 119; Gordon, Dead on Arrival, 185 (first quotation); Beardsley, History of Neglect, 156-85; Michael R. Grey, New Deal Medicine: The Rural Health Programs of the Farm Security Administration (Baltimore, 1999), 41: Brenda J. Taylor, "The Farm Security Administration and Rural Families in the South: Home Economists, Nurses, and Farmers, 1933-1946," in Green, ed., New Deal and Beyond, 30-46; James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment (New York, 1993), 162-64; Elizabeth Temkin, "Driving Through: Postpartum Care During World War II," American Journal of Public Health, 89 (April 1999), 587-95; William H. Richardson, "Maternity-Child Care for Service Men's Families," Health Bulletin [published by the North Carolina State Board of Health], 60 (May 1945), 5-7; Karen Kruse Thomas, "'Law Unto Themselves': Black Women as Patients and Practitioners in North Carolina's Campaign to Reduce Maternal and Infant Mortality," Nursing History Review, 12 (2004), 47-66; "Southern Infant and Maternity Mortality Rates Drop Sharply," Southern Patriot, 2 (August 1944), 8; Milton Roemer, "Special Health Problems of Negroes in Rural Areas," Journal of Negro Education, 18 (Summer 1949), 321-22 (second quotation). See also Lee J. Alston and Joseph P. Ferrie, Southern Paternalism and the American Welfare State: Economics, Politics, and Institutions in the South, 1865-1965 (Cambridge, Eng., 1999); Robert C. Lieberman, Shifting the Color Line: Race and the American Welfare State (Cambridge, Mass., 1998); Jill Quadagno, The Transformation of Old Age Security: Class and Politics in the American Welfare State (Chicago, 1988); and Alan Dawley, Struggles for Justice: Social Responsibility and the Liberal State (Cambridge, Mass., 1991), 391-93. Myrdal concluded that there was "less discrimination against Negroes--and in some cases no discrimination at all--in respect to the so-called 'out-patient' services of public health institutions" and that "tremendous improvements [in public health] have been achieved in recent years, and ... Negroes have shared in the benefits." American Dilemma, 345-46.

(6) Carl V. Reynolds, "Annual Report [of the] North Carolina State Board of Health To Con joint Session State Medical Society," Health Bulletin, 61 (June 1946), 3 (quotations); Robert R. Wyeneth, "The Architecture of Racial Segregation: The Challenges of Preserving the Problematical Past," Public Historian, 27 (Fall 2005), 15-17, 28-33. For more information on the efforts of southern state governments to equalize social welfare spending for blacks, see Charles C. Bolton, "Mississippi's School Equalization Program, 1945-1954: A Last Gasp to Maintain a Segregated Education System," Journal of Southern History, 66 (November 2000), 781-814; and the files on the Southern Governors Conference and Southern Regional Education Board (SREB) in the papers of Florida governors Millard F. Caldwell, Fuller Warren, LeRoy Collins, and Farris Bryant in the State Archives of Florida in Tallahassee.

(7) "Federal Works Agency--P.W.A., Office of Advisor oil Negro Affairs," Journal of the National Medical Association, 32 (May 1940) 136: Douglas L. Smith, The New Deal in the Urban South (Baton Rouge, 1988), 114 (second and third quotations), 122 (first quotation); figure for total black beds in PWA hospitals is from Charles S. Johnson, "The Negro," American Journal of Sociology, 47 (May 1942), 857; Federal Works Agency, Second Annual Report (Washington, D.C., 1941), 189, 315,460; Federal Works Agency, Fourth Annual Report (Washington, D.C., 1943), 61; William Ivy Hair, The Kingfish and His Realm: The Life and Times of Huey P. Long (Baton Rouge, 1991), 230-31: John E. Salvaggio. New Orleans' Charity Hospital: A Story of Physicians, Politics, and Poverty (Baton Rouge. 1992).

(8) T. R. Ponton, "Hospital Service for Negroes," Hospital Management, 51 (March 1941), 14-15; T. Carr McFall, "Needs for Hospital Facilities and Physicians in Thirteen Southern States," Journal of the National Medical Association, 42 (July 1950), 236. (McFall's article, the source for the number of beds in 1946, refers to non-whites, rather than specifying blacks.) Both Louisiana and North Carolina demonstrate the efforts of southern state governments, even before the passage of Hill-Burton, to remedy the worst aspects of the prewar racially separate hospital system by devoting new resources and attention to black health care access within biracial institutions. Louisiana constructed five additional state charity hospitals around the state to supplement those already in operation at New Orleans and Shreveport. On the eve of Hill-Burton, out of 7,110 acceptable general hospital beds in Louisiana, 3,113 were in the seven charity hospitals, whose physical plants according to a 1948 report were "better than is generally found in the private institutions in the state." Despite this expansion, the charity hospitals still experienced overcrowding so that at tour of the seven institutions, "the physical facilities ... are not adequate to support the number of beds they are now required to provide." Half the charity hospital beds were allocated for blacks, who composed just under 30 percent of Louisiana's population. The state charity hospitals admitted 22,324 more black than white patients in 1946-1947, due to shorter average hospitalizations for blacks than whites. Charles Mitchell and Jesse H. Bankston, Hospital and Health Facilities in Louisiana (Baton Rouge, 1948), 29 31. A 1947 study of hospital admissions of children in six southern states conducted by the American Academy of Pediatrics ranked Louisiana first in rates of both black and white admissions. Louisiana's rate of 47.2 admissions per 1,000 black children was nearly equal to the white rate for the six states as a whole (47.8) but was still inferior to the rate of 70.2 for white Louisiana children. Goldstein, "Longevity and Health Status of Whites and Nonwhites," 94-95.

(9) "North Carolina's Draft Rejection Figures," North Carolina Medical Journal, 6 (January 1945), 39-40; "Current Good Health Crusade Is Deep Rooted," Alumni Review [published by the University of North Carolina], 35 (October 1946), 36-37; Clarence Poe, Final Report of the North Carolina Hospital and Medical Care Commission (Raleigh, 1945), 16 (first quotation; this document is cataloged as part of the larger North Carolina Hospital and Medical Care Commission, To the Good Health of All North Carolina [8 vols. in 1; Raleigh, 1944-1945]); J. Melville Broughton to Claude Pepper, May 10, 1943, Folder 3, Box 12, Series 203B, "Southern Governors Conference" (Claude Pepper Library, Florida State University, Tallahassee); Commission on Hospital Care, Hospital Care in the United States, 3, 163-67 (second quotation on p. 165); William M. Coppridge, "Suggestions from the Committee on Hospitals of the Governor's Commission," North Carolina Medical Journal, 5 (November 1944), 546-47; Edson E. Blackman, "Negro Hospital and Medical Needs in North Carolina," in Poe, Final Report, 5-11. Broughton, along with the black educator Dr. Albert W. Dent, president of Dillard University and former director of Flint-Goodridge Hospital in New Orleans, went on to serve on the Federal Hospital Council, which formulated regulations barring racial and religious discrimination in Hill-Burton.

(10) "Current Good Health Crusade Is Deep Rooted," 34 (first quotation); Thomas Parran, "Parran Evaluates N. C. Good Health Program," Alumni Review, 35 (April 1947), 219 (second quotation).

(11) Mayo, "Negro Hospital and Medical Care Facilities," 19-20 (first, second, and third quotations); Beardsley, History of Neglect, 121-22; Morais, History of the Afro-American in Medicine, 130: W. D. Carmichael to David S. Coltrane, November 3, 1949, Desegregation: Medical Care, 1949-1951 Folder, Subgroup I, General Administration: Controller and Vice President for Finance (University Archives, Wilson Library, University of North Carolina at Chapel Hill; hereinafter cited as UNC Archives) (fourth and fifth quotations).

(12) Myrdal, American Dilemma. 172: figure on southern rural outmigration is from Numan V. Bartley, "The Era of the New Deal as a Turning Point in Southern History," in Cobb and Namorato, eds., New Deal and the South, 139: U.S. Senate, Committee on Education and Labor, 79 Cong., 1 Sess., Hospital Construction Act: Hearings Before the Committee on Education and Labor ... on S. 191 ... February 26. 27, 28, March 12, 13. and 14, 1945 (Washington, D.C., 1945), 201 (first quotation): U.S. Senate, Committee on Education and Labor, 76 Cong., 1 Sess., To Establish a National Health Program: Hearings Before a Subcommittee of the Committee on Education and Labor ... on S. 1620 ... April 27 and Max, 4, 5, 11, and 12, 1939 (Washington, D.C., 1939), 897-98 (second quotation).

(13) Claude Pepper, diary entry for March 8, 1938, Folder 2, Box 1, Series 439, Claude Pepper Personal Papers--Personal Diaries, Pepper Library; Congressional Record, 75 Cong., 3 Sess., 3008 (March 8, 1938); Starr, Social Transformation of American Medicine, 348; John Egerton, Speak Now Against the Day: The Generation Before the Civil Rights Movement in the South (New York, 1994), 177-81; entries for Claude Denson Pepper and Joseph Lister Hill, http://bioguide.congress.gov (accessed June 22, 2004); Virginia Van der Veer Hamilton, Lister Hill: Statesman from the South (Chapel Hill, 1987): Claude Denson Pepper with Hays Gorey, Pepper: Eyewitness to a Century (New York, 1987); William E. Leuchtenburg, Franklin D. Roosevelt and the New Deal, 1932-1940 (New York, 1963), 266; "Pepper and Hill," New Republic, 110 (April 24, 19441, 551; "Pepper Committee Investigates Southern Shipbuilding Community," Southern Patriot, 2 (July 1944), 7: "How Sick is the South?" ibid., 3 (May 1945), 2; "North Carolina's Draft Rejection Figures," 39-40; "Current Good Health Crusade Is Deep Rooted," 36-37; U.S. Senate, Committee on Education and Labor, Subcommittee on Wartime Health and Education, 78 Cong., 2 Sess., Wartime Health and Education: Interim Report ... (Comm. Print; Washington, D.C., 1945), i (first quotation), l-2, 5-6, 22; Pepper, Senate speech, Cong. Record, 81 Cong., 1 Sess., 2134 (March 10, 1949): Bruce J. Schulman, From Cotton Belt to Sunbelt: Federal Policy, Economic Development, and the Transformation of the South, 1938-1980 (New York, 1991), 47-51, 61 (second quotation), 208 (third quotation).

(14) Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York, 1989), 219 (second quotation), 254; Beardsley, History of Neglect, 178-80; Ward, Black Physicians in the Jim Crow South, 176 (first quotation); Quadagno and McDonald, "Racial Segregation in Southern Hospitals," 119-21 ; David Barton Smith, Health Care Divided, 46-47; P. Preston Reynolds, "Professional and Hospital Discrimination," 710-11; Gordon, Dead on Arrival, 193-94: Starr, Social Transformation of American Medicine, 275-77; P. Preston Reynolds, "Federal Government's Use of Title VI and Medicare." On the role of anti-discrimination clauses in defeating federal aid to medical education, see the remarks of Sen. Elbert Thomas (D-Utah) and President M. Don Clawson of Meharry Medical College, Cong. Record, 80 Cong., 2 Sess.. 5659-68 (May 12, 1948). as well as "The Federal Aid and Regional Plan Chimerae," Journal of the National Medical Association, 43 (September 1951), 339.

(15) Michael M. Davis and Hugh H. Smythe, Providing Adequate Health Service to Negroes (New York, 1949), 8 (first quotation); To Establish a National Health Program, 237-43, 285-90, 891-98; U.S. Senate, Committee on Education and Labor, 76 Cong., 3 Sess., Construction of Hospitals: Hearings on S. 3230, March 18-19. 1940 (Washington. D.C., 1940), 78-91; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, 79 Cong., 2 Sess., Hospital Construction Act: Hearings on S. 191, March 7, 8, 11-13, 1946 (Washington, D.C., 1946), 184-88; McBride, From TB to AIDS, 142 (second and third quotations); Ward, Black Physicians in the Jim Crow South, 177-82; Beardsley, History of Neglect, 246 50, 312-13.

(16) Gamble, Making a Place for Ourselves, 186-87; Ann Short Chirhart, "Gender, Jim Crow, and Eugene Talmadge: The Politics of Social Policy in Georgia," in Green, ed., New Deal and Beyond, 86-88; Richard Kluger. Simple Justice: The History of Brown v. Board of Education and Black America's Struggle for Equality (new ed., New York, 2004), 201-3, 211-12 (quotation), 259, 268-69; Egerton, Speak Now Against the Day, 152 53. On Wright's outspoken advocacy of health care integration in other contexts, see P. Preston Reynolds, "Dr. Louis T. Wright and the NAACP: Pioneers in Hospital Racial Integration," American Journal of Public Health, 90 (June 2000), 883-92. At the October 1947 Southern Governors Conference, Tennessee governor Jim N. McCord cited the Gaines decision as the original catalyst for state support of black regional education, which, like Hill-Burton, originated in a defense of separate-but-equal policies but ultimately undermined segregation. McCord predicted that opening graduate education to blacks "would effectively destroy the operation of our professional schools" yet claimed that "in this investigation I not only had in mind the Gaines decision but also the moral obligation which every State has to provide opportunities for the medical and dental education of Negroes in the Southern area." By 1950 the SREB had moved beyond Governor McCord's original rationale of preserving segregation and had substantially included black institutions and educators in its planning and leadership. From 1949 to 1961 the SREB disbursed $2.5 million from southern state governments to aid approximately five hundred black medical students and an additional $1 million for black dental students to attend Meharry Medical College in Nashville, Tennessee, representing its largest single source of income. The SREB later facilitated meetings between southern educators and the federal Office of Civil Rights to encourage compliance with integration. "Governor McCord's Recommendation of Meharry as a Regional School," p. 5, Folder 1, Box 19, Governor Jim McCord Papers (Tennessee State Library and Archives, Nashville) (quotations); "Colleges: Fewer But Better?" U.S. News and World Report, June 20, 1952, p. 35; SREB minutes, June 23, 1950, Folder 1, Box 79, Governor Fuller Warren Papers, Record Group 102, Series $235, Florida State Archives; Winfred L. Godwin, "Report on SREB Regional Contract Program, 1959-60," Exhibit J in SREB minutes, June 12-14, 1960, "Corresp. Southern Regional Education Board, 1959-61," Box 55, Series P 14a, President Wayne J. Reitz Papers (University Archives, Department of Special and Area Studies Collections, George A. Smathers Libraries, University of Florida, Gainesville).

(17) "Recommendations of a Special Committee of the National Medical Association to the Technical Committee on Medical Care, in conference, U.S. Public Health Service Building, Washington, D.C., November 22, 1938," Journal of the National Medical Association, 31 (January 1939), 35-36: "Address by Dr. Bowles Before the Senate Committee," ibid., 31 (July 1939), 173 75; "The National Health Act of 1939," ibid., 31 (July 1939), 154-60; "Senator Wagner Says Non-Governmental Hospitals are Eligible for Support Under His Bill. Negroes Are Protected," ibid., 32 (July 1939), 175-77; To Establish a National Health Program, 237-43 (first and third quotations on p. 238); North Carolina Advisory Committee to the U.S. Commission on Civil Rights, "Equal Protection of the Laws Concerning Medical Care in North Carolina," November 9, 1961, p. 4, Series 94.8, Director's Office, Agencies and Organizations Correspondence, 1947-1974 (hereinafter cited as Agencies and Organizations), MCC (second quotations

(18) Myrdal, American Dilemma, 336-37; Ward, Black Physicians in the Jim Crow South, 170-82.

(19) Gamble, Making a Place for Ourselves, 142-50, 184-90; Preston Reynolds, "Dr. Louis T. Wright and the NAACP," 883-92; Bolton, "Mississippi's School Equalization Program," 782 (first quotation); Cong. Record, 78 Cong., 1 Sess., 8559-65 (October 20, 1943); Chirhart, "Gender, Jim Crow, and Eugene Talmadge," 86-88; Amos H. Carnegie, "The Hospital Situation in Miami, Florida," Journal of the National Medical Association, 42 (January 1950), 58-59; "N.C. Cities to Fight Jimcrow Hospitals," Raleigh Carolinian, June 13, 1953; "Negro Voters Defeat Hospital Bond Issue," Journal of the National Medical Association, 45 (November 1953), 438; "Hospital Discrimination Must End!" ibid., 45 (July 1953), 284-86; W. Montague Cobb, "The Crushing Irony of De Luxe Jim Crow," ibid., 44 (September 1952), 386-87 (second quotation on p. 386); Cobb, "The National Health Program of the N.A.A.C.P.," ibid., 45 (1953), 333-39 (third quotation on p. 334), quoted in David Barton Smith, Health Care Divided, 49; Ward, Black Physicians in the Jim Crow South, 170-82; Brandt, No Magic Ballet, 4, 161.

(20) "Memphis NAACP Branch Rescinds Endorsement of Negro Hospital," Journal of the National Medical Association, 44 (July 1952), 314-15: David Barton Smith, Health Care Divided, 40, 47-49; "Florida A. and M. College Hospital, Tallahassee, Fla.," Journal of the National Medical Association, 42 (May 1950), 186-87; "Professional News," ibid., 24 (May 1937), 71; "Federal Works Agency--P.W.A., Office of Advisor on Negro Affairs," 136; Beardsley, History of Neglect, 99, 245-51, 255-59: Ward, Black Physicians in the Jim Crow South, 176-78; Rice anti Jones, Public Policy and the Black Hospital, 109-10: W. Montague Cobb, "Medical Care and the Plight of the Negro," Crisis, 54 (July 1947), 201-11 (first quotation on p. 208); Keith Wailoo, Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health (Chapel Hill, 2001), 94-103 (third quotation on p. 103), 111-14 (second quotation on p. 111).

(21) AMA Council on Medical Education and Hospitals, "Hospitalization of Negro Patients," Journal of the American Medical Association, 115 (October 26, 1940), 1461 (quotation); Duke Endowment Hospital Section, "North Carolina General Hospitals Caring for Negro Patients in 1944," Box 1, Series 94.2, Executive Secretary's Office, Hospital and Medical Care Study Commission, MCC.

(22) Alan P. Smith, "The Institutional Care of Negroes with Mental Diseases in the United States," Journal of the National Medical Association, 24 (November 1937), 146 (Va., W.Va., Md., and Okla. also had separate state mental hospitals for blacks, and S.C. and Fla. had separate black divisions within their state mental hospitals. Smith spoke highly of care for mentally ill black veterans within the Veterans Administration hospital system, particularly in the facility at Tuskegee.); Maurice H. Greenhill, "The Present Status of Mental Health in North Carolina," North Carolina Medical Journal, 5 (January 1945), 10, 12 (first quotation); William R. Johnson, "Report of Visit to State Hospital, Goldsboro," Cherry Hospital, Goldsboro, N.C., Folder, Box 241, Bureau of Work Among Negroes Series, MCC; "Professional News," Journal of the National Medical Association, 29 (May 1937), 71; "Federal Works Agency--P.W.A., Office of Advisor on Negro Affairs," 136; N.C. Medical Care Commission, "One Hundred Ninety-Two Projects Aided By the Commission During the First Seven Years of Construction," November 24, 1954, 1953-1963 Folder, Box 17, Health Affairs: Records of the Office of the Vice Chancellor, Series 1.1, UNC Archives; "Hospital Construction Under Hill-Burton Program," Journal of the National Medical Association, 42 (September 1950), 328; John Larkins to J. Melville Broughton, May 11, 1956, Larkins to M. M. Vitols, January 8, 1957 (second quotation), Larkins, "Notes regarding State School for Mentally Defective Children," Cherry Hospital, Goldsboro, N.C., Folder, Box 241, Bureau of Work Among Negroes Series. MCC.

(23) Michael A. Dowell, "Hill-Burton: The Unfulfilled Promise," Journal of Health Politics, Policy and Law, 12 (Spring 1987), 154; Stevens, In Sickness and in Wealth, 269-70; "Saint Agnes Hospital Condemned," Raleigh Carolinian, May 14, 1955 (quotation); "Ford Grant Brings New Hope to St. Agnes Hospital," ibid., October 27, 1956; Rice and Jones, Public Policy and the Black Hospital, 61-62; Beardsley, History of Neglect, 256. As was the case in Raleigh, new biracial Hill-Burton hospitals prompted the closings of black hospitals in many communities. See Pohl, "Long Waits," 113; and Gamble, Making a Place for Ourselves. 192-94.

(24) Pohl, "Long Waits," 111-31 ; Duke Endowment Hospital Section, "North Carolina General Hospitals Caring for Negro Patients in 1944," MCC; Department of Rural Sociology, North Carolina Agricultural Experiment Station, Medical Care Services in North Carolina: A Statistical and Graphic Summary ... (Raleigh, 1945), 34-35; Poe, Final Report; Rice and Jones, Public Policy and the Black Hospital, 21, 34; David T. Beito, "Black Fraternal Hospitals in the Mississippi Delta, 1942-1967," Journal of Southern History, 65 (February 1999), 134-40; Gamble, Making a Place for Ourselves, 182-96; Salter Cochran and Doris Cochran, interview by author, Weldon, N.C., April 12, 1997, Interview R-14, Southern Oral History Program Collection #4007 (Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill); Henry James [pseudonym], interview by author, August 15, 1994, in author's possession (quotations): N.C. Medical Care Commission, "Hospital Survey, Wilson County," 1945, Box 1, Series 94.2, Executive Secretary's Office, Hospital and Medical Care Study Commission, MCC.

(25) Spencie Love, One Blood: The Death and Resurrection of Charles R. Drew (Chapel Hill, 1996), 1, 21-31,217-27.

(26) Anslee Willett, "Technology Brings Comfort to Patients," Burlington (N.C.) Times-News, November 11, 1999; N.C. Medical Care Commission, "One Hundred Ninety-Two Projects," UNC Archives; beds for blacks are calculated by multiplying total beds by percentages of Negro patients from Duke Endowment, 1961 Miscellaneous Hospital Statistics (n.p., 1961), A-1, A-5, Box HCCD 16, Hospital Division Subseries, Duke Endowment Archives (Duke University Rare Book, Manuscript and Special Collections Library, Durham, N.C.); N.C. Advisory Committee, "Equal Protection of the Laws," 17, 20, MCC; "Student Succumbs After Aid is Refused at Hospital," Raleigh Carolinian, December 9, 1950; "Seriously-Burned Woman Refused Admittance to Two NC Hospitals: White, Negro Hospitals Refuse Aid," ibid., February 16, 1952; "Lawyer Intervened: Hospitals Filled: Youth Is Jailed," ibid, March 8, 1952; "Prisoner Is Refused Medical Care; Dies," ibid., August 2, 1952.

(27) Starr, Social Transformation of American Medicine, 373; Richard Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929 (Baltimore, 1990), 173-74; Collins and Thomasson, "Declining Contribution of Socioeconomic Disparities," 769-70 (quotation on p. 769). Collins and Thomasson note that "even as the colossal Hill-Burton program pumped federal funds into the health care system ... the secular decline in infant mortality stagnated for nonwhites from 1950 to 1965 and for whites between 1955 and 1965" (p. 758). They conclude that the largest single factor contributing to the racial gap in infant mortality before 1970 was the gap in education levels of women between 20 and 40, followed by income, urban residence, and geographic distribution of physicians. Although the Great Migration of southern blacks from farms to southern and northern cities improved levels of income, education, and access to hospitals and physicians, these improvements were outweighed by the negative consequences of urbanization compounded by racial discrimination, resulting in increased costs of housing, food, and health care; increased rates of cigarette smoking; overcrowded and unhealthy living conditions in urban ghettos: increased exposure to communicable disease and environmental pollution: hazardous industrial employment; and separation from family support networks (pp. 752-61).

(28) Helen Gahagan Douglas, "What Price Medicine: Current Legislation Dealing with Health Before the Present Congress," Journal of the National Medical Association, 40 (January 1948), 17; Vane M. Hoge, "The National Hospital Construction Program," ibid., 40 (May 1948), 102, 104 (quotations); "Federal Aid and Regional Plan Chimerae," 339.

(29) Morais, History of the Afro-American in Medicine, 132; Oscar R. Ewing, "Facing the Facts on Negro Health," Journal of the National Medical Association, 44 (March 1952), 108-12 (first quotation on p. 108); "The Honorable Oscar Ross Ewing," ibid., 43 (November 1951), 402-4 (second quotation on p. 403); '"Let Not Thy Left Hand Know ...,'" North Carolina Medical Journal, 9 (May 1948), 271 (third quotation); Parran, "Abstract of 'Hospitals and the Health of the People,'" TMs, 600.1 Reference Material (USPHS) Folder, Box 4, Agencies and Organizations, MCC (fourth and fifth quotations; this abstract summarizes Thomas Parran, "Hospitals and the Health of the People," Journal of the American Medical Association, 133 [April 12, 1947], 1047-49). Parran identified the South and venereal disease as the two most important targets for federal public health efforts, and Beardsley notes that "eradication of syphilis, especially among Southern blacks, was almost an obsession" (Beardsley, History of Neglect, 171). Though Parran worked hard to extend public health initiatives to southern blacks, he believed that syphilis was biologically different in whites than blacks (Parran, "Shadow on the Land: Syphilis, the White Man's Burden," in Reverby, ed., Tuskegee's Truths, 66).

(30) U.S. Commission on Civil Rights, Report of the U.S. Commission on Civil Rights, 1963 (Washington, D.C., 1963), 131 (first quotation): Beardsley, History of Neglect, 149 (second quotation); William A. Link, "'The Harvest Is Ripe, but the Laborers Are Few': The Hookworm Crusade in North Carolina, 1909-1915," North Carolina Historical Review, 67 (January 1990), 3-4.

(31) Samuel C. Ingraham II to John A. Ferrell, April 22, 1947, Rules and Regulations (State Plan) Governing Approps. for Hosp. Constr. Folder (hereinafter cited as Rules and Regulations), Box 4, Agencies and Organizations. MCC.

(32) Ingraham to Ferrell, November 21, 1947, ibid. (first quotation): Rice and Jones, Public Policy and the Black Hospital, 75: Morals, History of the Afro-American in Medicine, 181: Gordon, Dead on Arrival, 194: U.S. Commission on Civil Rights, Report of the U.S. Commission on Civil Rights. 131 (second quotation).

(33) North Carolina State Hill-Burton Plan, "Minimum Standards for the Maintenance and Operation of Hospitals," Rules and Regulations, Agencies and Organizations, MCC; Parran to Ferrell, July 8, 1947, Ingraham to Ferrell, November 21 (first quotation) and 24, 1947, and April 27, 1948 (second quotation), ibid.

(34) "Jimcrow Hospital Nixed, TB Hospital to Be Utilized By All the People" Raleigh Carolinian, September 22, 1951, pp. 1, 8.

(35) Quadagno and McDonald, "Racial Segregation in Southern Hospitals," 120-22; Clarence Mitchell to Oveta Culp Hobby, December 22, 1953, Parke M. Banta to Mitchell, March 10, 1954, Gladys Harrison to Edward J. Rourke, November 16, 1956, Maurice B. Gatlin to Marion Folsom, February 5, 1957, Marion E. Gardner to General Counsel Files, April 5, 1957, Hospital Construction, Segregation and Discrimination File, Records of the Public Health Service, Record Group 90 (National Archives at College Park, College Park, Md.); "Nix Hospital Plan," Raleigh Carolinian, May 1, 1954; Robert Fredrick Burk, The Eisenhower Administration and Black Civil Rights (Knoxville, 1984), 196; Cong. Record, 85 Cong., 1 Sess., 5024-25 (April 3, 1957).

(36) Parran, "Parran Evaluates," 218-19: Beardsley. History of Neglect, 184; N.C. Medical Care Commission, The Expansion of Medical Facilities and Services in North Carolina Two Decades of Progress (Raleigh, 1967), 11; William F. Henderson, "Remarks Before the North Carolina Legislative Research Commission," January 5, 1968, TMs. Legislative Research Commission Folder, Box 3, Agencies and Organizations, MCC: N.C. Advisory Committee, "Equal Protection of the Laws," 18, 23, 26 (quotation), MCC: David Barton Smith, Health Care Divided, 194; figure for racially separate hospital projects in North Carolina is from U.S. Commission on Civil Rights, Report of the U.S. Commission on Civil Rights, 132, cited in Rice and Jones, Public Policy and the Black Hospital, 75, 80: Gamble, Making a Place for Ourselves, 187.

(37) For the percentage of blacks in North Carolina in 1940 see University of Virginia Geospatial and Statistical Data Center, United States Historical Census Data Browser, 1940 census data.

(38) Ferrell to Ralph Moody, October 3, 1950. USPHS Genera) Correspondence Folder, Agencies and Organizations, MCC (quotations). For national context see "Hospital Construction Under Hill-Burton Program," 328.

(39) Jill Quadagno, One Nation Uninsured: Why the U.S. Has No National Health Insurance (New York, 2005), 82 (quotation): Stevens, 117 Sickness and in Wealth, 5; N.C. Medical Care Commission, Expansion of Medical Facilities and Services in North Carolina, 11; Gamble, Making a Place for Ourselves, 188-90: Karen Kruse Thomas, "The Wound of My People: Segregation and the Modernization of Health Care in North Carolina, 1935-1975" (Ph.D. dissertation, University of North Carolina at Chapel Hill, 1999), 175-88; P. Preston Reynolds, "Hospitals and Civil Rights, 1945-1963."

(40) N.C. Medical Care Commission, "'One Hundred Ninety-Two Projects," UNC Archives: History of the Program, 13: James E. Rohrer, "The Political Development of the Hill-Burton Program: A Case Study in Distributive Policy," Journal of Health Politics. Policy and Law, 12 (Spring 1987), 142-43 (quotation): Jacquelyn Hochban et al., "The Hill-Burton Program and Changes in Health Services Delivery," Inquiry, 18 (Spring 1981), 61: Duke Endowment, 1964 Miscellaneous Hospital Statistics (n.p., 1964), A-1. Box HCCD 16, Hospital Division Subseries, Duke Endowment Archives: Walter Reece Berryhill to Henry Clark, April 11, 1953, Black Student Admissions Folder, Series 3. Student Affairs, Office of Minority Students, Subgroup 1, Health Affairs: Dean of the School of Medicine. UNC Archives: N.C. Advisory Committee, "Equal Protection of the Laws," 17-18, MCC. Another high-cost project, a 107-bed expansion to the all-white Watts Hospital in Durham, was paired with a 35-bed addition to the all-black Lincoln Hospital, with federal and local funding allocated based on racial population ratios. P. Preston Reynolds, "Watts Hospital, 1895-1976: Paternalism and Race in the Evolution of a Southern Institution in Durham, North Carolina" (Ph.D. dissertation, Duke University, 1986); P. Preston Reynolds, "Hospitals and Civil Rights, 1945-1963."

(41) Peter F. Drucker, "The Age of Social Transformation," Atlantic Monthly, November 1994, pp. 53 72; Carolanne H. Hoffman, "Health Insurance Coverage," Series 10, Number 11, National Center for Health Statistics (Washington, D.C., 1964), as cited in Collins and Thomasson, "Declining Contribution of Socioeconomic Disparities." 770; N.C. Advisory Committee, "Equal Protection of the Laws," 20, MCC: Stevens. In Sickness and in Wealth, 268-75; "Current Good Health Crusade Is Deep Rooted," 35: Roy Parker Jr.. "Welfare Officials See Progress For NC Hospitalization Program," Raleigh News and Observer, August 23, 1959.

(42) Duke Endowment, Annual Reports of the Hospital and Orphan Sections, For the Fiscal Year October 1, 1961-September 30, 1962, pp. 22-25; Beito, "Black Fraternal Hospitals in the Mississippi Delta," 136, 140 (quotation); Robert Coles, Farewell to the South (Boston, 1972), 170-77; Hamilton, Lister Hill, 139 (third quotation); Numan V. Bartley, The New South, 1945-1980 (Baton Rouge, 1995), 156 (second quotation and third quotation, quoting Hamilton). Two examples of criticism of Hill-Button's failure to fulfill its pledge that participant hospitals would provide substantial care to indigent patients are Lawrence A. Schneider, "Comments: Provision of Free Medical Services By Hill-Burton Hospitals," Harvard Civil Rights-Civil Liberties Law Review, 8 (1973), 351-83 (fourth quotation on p. 352); and Michael A. Dowel[, "Hill-Burton: The Unfulfilled Promise," Journal of Health Politics, Policy and Law, 12 (Spring 1987), 153-75.

(43) Starr, Social Transformation of American Medicine, 350: Schulman, From Cotton Belt to Sunbelt, 120-33, 280-81n9: Hill. "The Growth of Hospitals and Voluntary Health insurance," address to the American Hospital Association, September 26, 1949, Cong. Record, 81 Cong., 1 Sess., A6373 (October 17, 1949) (quotation): Pepper, speech, July 30, 1947, p. 4., Folder 2, Box 5, Subseries U.S Senate--Speeches, Series 203B, Pepper Library: Lewis E. Weeks and Howard J. Berman, Shapers of American Health Care Policy: An Oral History (Ann Arbor, 1985), 39; "The Republican Welfare States," Atlantic Monthly, March 2004, p. 48; "A Decade of Hill-Burton," American Journal of Public Health, 47 (November 1957), 1446-47 (states that half of the Hill-Burton hospitals in the program's first decade were built in the South but does not define South).

(44) Clark et al., "Impact of Hill-Burton," 538-42 (first quotation on p. 542), 548-50: Starr, Social Transformation of American Medicine, 350, 373: Beardsley, History of Neglect, 184, 342n88 (second quotation: Beardsley cites the Southern Regional Council's hospital study and "A Decade of Hill-Burton"); History of the Program, 11: University of Virginia Geospatial and Statistical Data Center, United States Historical Census Data Browser. 1940 census data.

(45) Bolton, "Mississippi's School Equalization Program," 783-84; Ponton, "Hospital Service for Negroes," 15: Michael M. Davis, How a National Health Program Would Serve the South (New York, 1949), 5; McFall, "Needs for Hospital Facilities and Physicians," 236; History of the Program, 11: Beito, "Black Fraternal Hospitals in the Mississippi Delta," 136-37 (quotation); University of Virginia Geospatial and Statistical Data Center, United States Historical Census Data Browser, 1940 census data; Clark et al., "Impact of Hill-Burton," 550.

(46) Gamble, Making a Place far Ourselves, 7 (quotation): Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York, 1999), 163-65; Bolton. "Mississippi's School Equalization Program," 783-84; Comely, "Segregation and Discrimination in Medical Care in the United States," 1079-80.

(47) Schulman, From Cotton Belt to Sunbelt, 135-39, 206-7; Rice and Jones, Public Policy and the Black Hospital, 75, 80; Morais, History, of the Afro-American in Medicine, 181: Gordon, Dead on Arrival, 194.

(48) Beardsley, History of Neglect, 256-58 (first quotation on p. 257); History of the Program, 17 (second and third quotations); Clark et al., "Impact of Hill-Burton," 546.

MS. THOMAS is associate director of the Reichelt Oral History Program and a research affiliate at the Claude Pepper Institute on Aging and Public Policy at Florida State University.

TABLE 1
AGE-ADJUSTED MORTALITY PER 1,000 PERSONS

                             South

                 Nonwhite              White

Year          Urban     Rural     Urban     Rural

1931-1933     27.81     17.22     16.33     11.22
1950          15.07     12.88      9.73      8.34

                             North

                 Nonwhite              White

Year          Urban     Rural     Urban     Rural

1931-1933     22.62     23.81     14.18     12.02
1950          14.19     12.08     10.09      8.72

SOURCE: Marcus S. Goldstein, "Longevity and Health Status of Whites
and Nonwhites in the United States," Journal of the National Medical
Association, 46 (March 1954), 90.

NOTE: Mortality rates adjusted "to the age distribution of the total
continental population of the United States in 1950." For this table,
the South includes Ala., Ark., D.C., Fla., Ga., Ky., La., Md., Miss.,
N.C., Okla., and S.C. The North includes Ill., Ind.. Mich., Mo.,
N.J., N.Y., Ohio, Pa., and W.Va. Urban and rural designations follow
the U.S. Census definitions of 1950, with urban areas having 10,000
or more inhabitants and rural ones fewer than 10,000.

TABLE 2
GENERAL HOSPITAL BEDS FOR BLACKS IN FOUR SOUTHERN STATES

State           1940     1946      1950

Virginia         958     1,630     1,745
N. Carolina    1,297     1,808     2,176
Georgia        1,184     1,862     1,493
Mississippi      545     1,710     1,720
Total          3,984     7,010     7,134

                   Change,        Change in Black
State             1940-1950       Pop., 1940-1950

Virginia         +787     +82%    +78,043     +12%
N. Carolina      +879     +68%    +66,055      +7%
Georgia          +309     +26%    -22,165      -2%
Mississippi    +1,175    +216%    -88,084      -8%
Total          +3,150     +79%    +33,879    +0.9%

SOURCES: Figures for 1940 from Ponton, "Hospital Service for
Negroes," 15; figures for 1946 and 1950 from McFall, "Needs
for Hospital Facilities and Physicians in Thirteen Southern
States," 236 (McFall's figures refer to nonwhites); University
of Virginia Geospatial and Statistical Data Center, United
States Historical Census Data Browser, 1940 and 1950 census
data.

TABLE 3
NORTH CAROLINA GENERAL HOSPITALS

                      Black

               Hospitals      Beds

1945              13          840
1960              11          919
No. change        -2          +79
% change         -15.4         +9.4

                          Biracial

                             Black      White
               Hospitals      Beds       Beds

1945              66          815        4,417
1960             116        1,758        8,822
No. change       +50         +943       +4,405
% change         +75.8       +108.5        +99.7

                      White

               Hospitals      Beds

1945              48         2,382
1960              27         2,905
No. change       -21          +523
% change         -43.8         +22.0

                           Totals

                 Black       White      Total
                 Beds         Beds       Beds

1945             1,655       6,799      8,454
1960             2,677      11,727     14,404
No. change       1,022      +4,928      5,950
% change           +59.1       +72.5      +69.8

SOURCES: Numbers of hospitals from N.C. Advisory Committee,
"Equal Protection of the Laws," 17, MCC; beds for each race
are from Duke Endowment Hospital Section. "North Carolina
General Hospitals Caring for Negro Patients in 1944," MCC;
and Duke Endowment, 1961 Miscellaneous Hospital Statistics,
A1-A13, Duke Endowment Archives.

TABLE 4a
HILL-BURTON PROJECTS IN NORTH CAROLINA, 1947-1954

                    Counties w/High             Counties w/High
                    Number of Blacks            Percentage of
                    (n = 25)                    Blacks (n = 25)

Project type        No.   Beds                  No.      Beds

Addition             15   1,025                   9        302
New bldg.            12   1,572                  13      1,064
Nursing home         13   1,045                   8        268
Service facility/
  staff housing       7   n/a                     4      n/a
Health center        15   n/a                    16      n/a
Total                62   3,642                  50      1,634
% of total                   47.6                           21.3

                    Total Counties              Counties w/Low
                    w/High Concentration        Concentration
                    of Blacks (n = 39)          of Blacks (n = 61)

Project type        No.   Beds                  No.      Beds

Addition             18   1,088                  19        821
New bldg.            19   1,894                  28      1,886
Nursing home         17   1,177                  21        794
Service facility/
  staff housing       8   n/a                     6      n/a
Health center        24   n/a                    33      n/a
Total                86   4,159                 107      3,501
% of total                   54.3                           45.7

                    Total N.C. Counties
                    (N = 100)

Project type        No.   Beds

Addition             37   1,909
New bldg.            47   3,780
Nursing home         38   1,971
Service facility/
  staff housing      14   n/a
Health center        57   n/a
Total               193   7,660
% of total

SOURCES: For Tables 4a-4d the number of Hill-Burton projects, beds
constructed, and cost are from N.C. Medical Care Commission, "One
Hundred Ninety-Two Projects," UNC Archives; hospital-level data for
race of patients admitted and number of beds for each racial group
are from Duke Endowment, 1961 Miscellaneous Hospital Statistics, A1-
A13, Duke Endowment Archives; location and type of hospital ownership
are from Duke Endowment, Annual Reports of the Hospital and Orphan
Sections, For the Fiscal Year October 1, 1961-September 30, 1962
(n.p., 1962), 22-25; rankings of North Carolina counties by number
and percentage of black population in 1940 are from the University
of Virginia Geospatial and Statistical Data Center, United States
Historical Census Data Browser.

TABLE 4b
HILL-BURTON FUNDING IN NORTH CAROLINA, 1947-1954

                        Counties w/High      Counties w/High
                       Number of Blacks       Percentage of
Funding Source             (n = 25)          Blacks (n = 25)

Federal                    $11,861,612           $4,894,967
State                        6,181,472            4,589,158
Local                       18,933,945            3,849,562
Total                      $36,977,029          $13,333,687

                      Total counties w/High    Counties w/Low
                        Concentration of      Concentration of
Funding Source           Blacks (n = 39)      Blacks (n = 61)

Federal                    $13,521,436          $15,182,744
State                        7,922,965           12,868,370
Local                       20,151,324           11,865,539
Total                      $41,595,725          $39,916,653

                       Total N.C. Counties
Funding Source              (N = 100)

Federal                    $28,704,180
State                       20,791,335
Local                       32,016,863
Total                      $81,512,378

TABLE 4c
HILL-BURTON HOSPITAL FACILITIES IN NORTH CAROLINA, 1947-1954

                        Black      Biracial      White *        Total

Projects ([dagger])            7          113           16          136
Beds                         552        6,136          972        7,660
Funding Source
  Federal               $852,860  $23,162,884   $3,358,457  $27,374,201
  State                  988,226   17,633,456    1,225,999   19,847,681
  Local                  473,062   22,108,456    8,331,050   30,912,568
Total                 $2,314,148  $62,904,796  $12,915,506  $78,134,450
$ per bed                  2,989        9,924       13,199        9,914

* "White" defined as less than 1 percent black patients

([dagger]) Includes multiple projects at some facilities

TABLE 4d
OWNERSHIP OF HILL-BURTON HOSPITAL FACILITIES IN NORTH CAROLINA,
1947-1954

                                   Country/
                       State *     Municipal     Private       Total

Projects ([dagger])           10           34           92          136
Beds                       1,024        1,769        4,867        7,660
Funding Source
  Federal             $2,779,700   $6,901,066  $17,693,434  $27,374,200
  State                5,267,686    4,964,981    9,615,014   19,847,681
  Local                        0    7,110,957   23,801,611   30,912,568
Total                 $8,047,386  $18,977,004  $51,110,059  $78,134,449

* Includes mental, tuberculosis, and cerebral palsy hospitals.

([dagger]) Includes multiple projects at some facilities.

TABLE 5
TYPES OF FACILITIES AIDED BY HILL-BURTON IN U.S., 1947-1971

                     Number of
Type                 Projects          Beds     Hill-Burton Funding

Teaching hospitals    2,223 (20.7%)             $1.1 billion (29.7%)
Public-owned          5,280 (49.1%)   189,543   $1.5 billion (41%)
                                      (40.3%)
All races admitted   10,644 (99%)
    (segregated and
    integrated)
All-white                84
All-black                20
Inpatient             9,670 (90%)     470,329     $3.3 billion
  General             5,787 (73%)     344,453     $2.6 billion
  Long-term           1,733 (16%)      97,358   $523.1 million
  Mental                               21,034    $78.5 million
  Tuberculosis                          7,484    $27.7 million
Outpatient            1,078 (10%)               $453.2 million
Health centers        1,281 (11.9%)   n/a        $99.7 million
Total projects       10,748           470,329     $3.7 billion

SOURCES: History of the Program, 11-13: Morais,
History of the Afro-American in Medicine, 181.

NOTE: Since categories overlap, the bottom row is not the
total of all categories listed. The figure for the number
of inpatient projects includes rehabilitation facilities,
public health centers, and state health laboratories.

TABLE 6
CHARITY AND BLACK PATIENTS CARED FOR BY
UNIVERSITY HOSPITALS IN N.C. AND S.C., 1964

                         Avg. for 4
                          Hospitals       Duke (Durham)

Avg. beds in use              498                653
Charity days of care       82,293            102,220
% charity patients             53.5               49.0
% black patients               26.2               27.5

                          N.C. Baptist       Medical College
                         (Winston-Salem)   of S.C. (Charleston)

Avg. beds in use                479                  453
Charity days of care         57,585               85,762
% charity patients               35.7                 64.0
% black patients                  0.4                 44.8

                          N.C. Memorial
                          (Chapel Hill)

Avg. beds in use               408
Charity days of care        83,606
% charity patients              65.4
% black patients                32.2

SOURCE: Duke Endowment. 1964 Miscellaneous Hospital
Statistics, A-1, Duke Endowment Archives.

TABLE 7
MEDIAN PERCENTAGE OF BLACK PATIENTS IN N.C. BIRACIAL GENERAL
HOSPITALS, 1961

                  Counties    Counties     Counties
                  w/High      w/High       w/Low
                  Number      Percentage   Concentration   Total N.C.
                  of Blacks   of Blacks    of Blacks       Counties
                  (n = 25)    (n = 25)     (n = 61)        (N = 100)

Hill-Burton       23.0        32.3         13.2            18.0
Non-Hill-Burton   16.1        16.2         11.5            13.3

SOURCES: Hill-Burton hospitals are listed in N.C. Medical Care
Commission, "One Hundred Ninety-Two Projects," UNC Archives;
percentages of black patients in sixty-three Hill-Burton and
twenty-five non-Hill-Burton North Carolina biracial hospitals
are from Duke Endowment, 1961 Miscellaneous Hospital Statistics,
A1-A5, Duke Endowment Archives.