January27,2014

TranscriptforInterviewWithDavidSmith
Interviewer:InwhatwaydidtheJimCrowLegislationleadtothecreationofAfricanAmerican hospitals?` Smith:YoumeanhowthePlessyvs.FergusoncreatedtheJimCrowrestrictionsinallthe southernstates? Interviewer:Yes,thatswhatImean. Smith:Well,basicallywhatitdid,itdidtwothings,lotsofhospitalsinthesouthrefusedtoadmit blackpatientsandsopeoplehadtodelivertheirbabiesathome.Sometimespeopledied travelingtotheplacewheretheycouldgetcare,iftheygotintoanautomobileaccidentor somethinglikethat.Itwasarealdifficultproblemintermsofgettingaccesstohospitalcare whenyouneededit.Infact,evenblackdoctorsinthesouthhadtodelivertheirwifesbabiesin theirownhomes.TheywerentallowedtoadmitthemtolocalhospitalsinNorthCarolinaorin otherplacesinthesouth.Butifthereasonthattheblackhospitalswerecreatedwasbecause blackphysicianswerentgivenprivilegestoadmitpatientstothehospitals,sotheysortofaspart ofcommunitywiththephysiciansprovidingsomeleadership,blackhospitalswerecreatedall overthecountry.Duringthe20thcenturythereweremorethan500blackhospitalsthatwere createdandall,maybe5or6,ofthemhaveclosedasaresultofeffortstodesegregatehospital care.Hospitalsinthesouthweretoldtheywouldntreceivemedicareormedicaidmoneyifthey didntdesegregate.Allofthathappenedinaverybriefperiodintheearlypartof1966before medicarebecameaprogramforthepeopleover65inthiscountry.Itisinterestingthatsomany hospitalswerecreatedbutitwasntuniquetotheblackcommunity,therewerecatholic hospitals,therewereJewishhospitals,theirwereRussianJewishhospitals,and GermanJewishHospitals,becausetheRussianJewsandtheGermanJewsdidntlikeeach other,sotheirwerealotofhospitalsthatwerecreatedbecauseoftheexclusionofpeopleof differentethnicgroups,fromhavingprivilidges,totheabilitytoadmitpatientstoaparticular hospital.AlrightIshouldstopthereandletyouaskanyquestionsthatyouhaveorsomethingthat youdontunderstandthatIsaid,Illtryandclarify. Interviewer:Ournextquestionis,DoyoubelieveAfricanAmericanmedicalassociations contributedtothecreationofBlackhospitals?Ifso,towhatextent? Smith:Wellinmostcasestheblackmedicalassociationshadamajorroleinthecreationof thosehospitals.Theyalsoplayamajorroleinthecivilrightsmovement.thatdesegregatedthe hospitals,thatdesegregatedhealthcarealloverthecountry.Theadvantageblackdoctorshadin thesouthistheyhadveryloyalgroupofpatientsbecauseinmanycases,ifablackpatientwent toawhitedoctor,hehadtogotoasegregatedwaitingroomandhewouldonlyseehimwhenall thewhitepatientshadseenhim,sohewouldhavetowaitalongtime.Theywerebasically treatedverypoorly,sopeoplewerereallyveryexcitedwhenablackphysicianmovedintotheir communityandthenbasicallytoldthemwellwewillgiveyouourservices,sinceyou'regoingto

January27,2014

beinsulatedfromretaliationbythewhitecommunity,sinceyourbeingprovidedwithyourliving, fromtheblackcommunityyouhavetorepresentusandyouhavetobeapartoftheeffortsto desegregateschools,desegregatedlunchcountersandalltheotherstuff.Infact,ifitwasntfor theblackconstituentintheSouththeremightnothavebeenacivilrightsmovementatall.But schoolteachersandotherpeoplecouldalwaysberetaliatedagainstandlosetheirlivingand havetoleavethecommunity.InfactinsomeplacesinNorthCarolinafamilieshadtoleave becausetheywereinvolvedinthecivilrightsmovement,theyhadtoleavebecausetheyhadno wayofmakingaliving.AwholegroupofthemfromNCwererelocatedtoAustinbyotherchurch groupsthatweresupportingitandnowtheirgenerationarealldoctorsandlawyersandarevery successfulintheAustinarea.Theyhaveareallytoughtimewhentheycouldnolongermakea living.Thatspartofthatstory. Interviewer:CouldyouelaborateontheNAACPAndNMArolesinthehealthcarestruggle. Smith:Theywerereallyaunitedfront.Particularlyinthe1960swhenNAACPhadsomevery strongleadership.InfactpeoplethatwereleadingtheNMAforexample,JohnHolleman, Dr.Holleman,etc.werealsoleadersoftheNAACP.Justtopointoutifyouwouldliketogoand lookattherecords,localchaptersoftheNAACPintheSouthyouwilldiscoverthatmostofthe peopleontheleaderheads,thosewerethepeoplewhowereofficersofthelocalchaptersofthe NAACP.Theyweremostlydoctorsanddentistsbecausetheywereinsulatedfromretaliationby thewhitepowerstructure. Interviewer:DoyoubelievetheintegrationofAfricanAmericansandWhitesinhealthcareina place,suchasChicago,wouldbemoredifficulttoachievetheninacitylocatedintheSouthor viceversa?AndWhy? Smith:Thatsaveryinterestingandveryintelligentquestionthatyouareasking.Theadvantages thesouthhaswasthatallofthediscriminationagainstblackswasveryobviousandveryclear. Therewerewhiteandtherewerecoloredsigns,andtherewerewhitewingsandcoloredwings ofhospitalsandallthatotherstuff.InfacttheblackhospitalsintheSouthwererightnexttothe whitehospitals.Becausethewhitedoctorshadblackpatientsanddidntwanttohavetotravela longwaytotakecareoftheirblackpatients.Eventhoughtherewereseparatehospitals.Ina senseitwasveryeasytointegrateinthesouth.Inthenorthinchicago,healthcareinChicagois probablymoresegregatedthanmostplacesintheSouth.Becauseofwherepeoplelive,where thecommunitiesare,ethnicgroupsandstufflikethat.InplaceslikeChicagowhereyouhavea lotofresidentialsegregation,itismuchmoredifficult.Becauseyoucantjustsay,okwewill openthedoorsandeverybodycanjustcometowhateverhospitaltheywant,becausepeople liveindifferentcommunities,theyhavedoctorsinthosecommunitiesthatonlyhavemany privilegestothehospitalsinthatparticulararea.Itsalottougher,sothatssortofthekindsof strugglewearehavingnowintermsofhowtodealwiththatproblem.Oneofthethingsthatwas done,wasthathospitalswereintegrated,theywerebasicallytoldyoucant,youhavetoadmit anybodythatcomes,butphysicianscouldbasicallydowhatevertheywanted.Theywere exemptedfromthecivilrightsact.Theycouldn'tbethreatenedwithwithholdingofmedicare

January27,2014

funds,iftheychosetoadmittheirblackpatientsinoneplaceandtheirwhitepatientsinanother place.Theywerestrugglingwiththatkindofproblem.Therewasnoneweffectivewayof controllingwhetherdoctorschoosetoadmittheirpatientsonbasisofrace.Thatsapretty complicatedthingtoabsorb.Itswhytodayweseebigdisparitiesinpeoplegettingspecialized typesofsurgicaltreatmentsandstufflikethat.Becauseofthenatureofhowphysicianswould referpatientstohospitalsandtospecialistswhowouldlendthatcare.

Interviewer:Whatarethechoicesthatproducedthehealthcarecivilrightsstruggleintheearly andmidtwentiethcentury? Smith:Whatarethechoices?Well,thebigchoice,thebigbigbattleintheblackcommunityand particularlyintheblackmedicalcommunityiswhetherweshouldgoonourown,buildourown system,blackhospitals,orwhetherweshouldtrytoassimilate,intothemainstreamwhite hospitals.Thatwasthebigbattle.Itwasaveryheatedbattleandprobablythemajorityofblack physiciansthoughtthatitwouldbebetterjusttogoitontheirown.Setuptheirownhospitals,set uptheirowncarebecausetheydidntreallythinkwhitehospitalswouldbefairtotheminterms ofgettingthemadmittingprivilegesandtakinggoodcareoftheirpatients.Thepeoplethatledthe civilrightmovementwereactuallyaminorityofpeople,smallgroupofpeople,smallgroupof doctorsthatsaidnothatsnotright,thatdoesntmakeanysense,wearegoingtofightfor integration.InfactthelawsuitthathelpedtoopenuphospitalsinChicago,welltherewerea smallgroupofblackphysiciansthatbasicallysuedthehospital,notforcivilrightsviolations,but forwhatareknownasantitrustissues.Whereagroupofpeoplekeepotherpeoplefrommaking alivingbyrestrictingtheiraccesstotheresourcestheyneedinthiscasethehospitals,sothat suitgotsettledintheearly1960sandatthattimearesultofthatoutofcourtsettlementthedocs inCHicagothatwantedadmittingprivilegeswerehistoricallywhitehospitals.Buttheotherdocs attheProvidentHospitalstaffwouldnttalktothem,theywereveryangrywiththembecause theyweresortofmuddingthewaters.Whattheyreallywantedtodowastryandprotect Providenthospitalandmakesureitsurvived.Mostoftheblackhospitalsinthecountrywere forcedtoclose,thedoctorsandthepatientsendupchoosingthemainstreaminstitutions.For example,Providenthospitalgotabrandnewbuilding,50milliondollarstructurethatwas completedintheearly80s.Itsoonfacedfinancialdiscordandwastakenoverbythecounty. Manyhospitalsfacedthatproblemevenaftertheybuiltbrandnewbuildings,aftertheycouldget moneyforitaftermedicareandmedicaid.ALotofpeopledidntthinkthatthingshadreally changedinthe60sandtheyhadalotofbrandnewbuildingsthateventuallyhadtobeusedfor otherpurposes.Alotofpeoplefeelbadaboutthehospitalsthatclosed.InfactObamawas supposedtogivehisacceptancespeechinCharlotte,NorthCarolina,afterhegotrenominated forhissecondterm,inafootballstadiumthatwasstillovertheoldblackhospitalthathadblack nursestrainingandwhereblackphysicianshadpositions.Thathospitalwasclosedandthey hadtohaveaprotest,foraplaquetobeputuponthestadium,acknowledgingthattherehad beenanimportanthospitalintheblackcommunitythere. Interviewer:Werethereanyclearhistoricalindicatorsofdiscriminationagainst AfricanAmericansbywhitehospitals?Canyouprovideexamplesifso?

January27,2014

Smith:Inthesouthyoujustcouldn'tgetadmitted,thewhitehospital,ortheirwouldbeablack wingwhichwasusuallyinthebasement.Actually,insomeplacesinordertogetsurgery patientshadtobemovedtothecourtyardintherainorsnowintowheretheoperatingtheatre wasinthemainhospital,thenmovedbackafterwards.Thatwasrealclear.Inthenorthitwas muchmoresubtle.Thedocsonthemedicalstaffpickedthepatientsthatwereadmitted,there wereinstanceswhereapatientofaparticularracegotplacedinthehospital.Blackpatients regardlessiftheywereprivatepaygotputintotheblackwingofthehospital,althoughitwasnt legalthen.Theotherthingthatwasrealclearfromsurveysandstufflikethat,particularlyin chicago,washowmanyhospitalspeoplehadtotravelbyinordertogetadmittedtoahospitalif youwereblack.InChicagotherewereonlytwohospitalsthatwereadmittingblackpatients,that wasProvidentandCookCounty,evenifyouhadprivateinsurance,youcouldntgetadmittedto theotherhospitals.Youjustgotautomaticallysenttothosetwohospitals.Theyweretheonly oneswhereyourphysicianshadprivilegesthatallowedthemtoadmittheirpatients. Interviewer:Whathistoricalfactorhadthegreatestimpactinthestruggletocreateintegrated hospitals,suchasProvidenthospital? Smith:Thebiglessonwasthattheirwasalwayssomethingmoreimportantthanraceanditwas usuallymoney.ThebigfactorwasthatLyndonJohnsonandthesecretaryofhealthandhuman services,JohnGardner,sayswewillnotgiveanymedicaretoanyhospitalthatdoesntintegrate andwithintwomonthsalmostallthehospitalsintheSouthintegrated.Infactinonehospitalsthe inspectortriedtopersuadethehospitaltobedesegregatedandtheadministratorsaidsaidgoto hell,wewillneverdesegregatethishospital,thisisawhitehospitalandthenadaylater,the chairmanoftehboardofthehospitalsays,Wejustfiredtheadministrator,telluswhatwehave todotogetthemedicaremoney.Becauseallhospitalswouldhavetochoose,eithergoing bankruptbecausethemedicareaidedelderlyovertheageof65andthesepatientscouldonlygo todesegregatedhospitals.Theyallpoundedtheirchestsandtalkedabouthowcourageousthey were,butitallhadtodowiththeassistanceofthefederalgovernment,thatwouldnotgivethem anydowers,iftheydiscriminatedagainstthepatientsthattheywouldsee.Soaboutathousand hospitalsgotsegregatedintwomonths. Interviewer:Howhasthegovernmentinthepastbecomeinvolvedintheefforttoend discriminationinhealthcare? Smith:Thefederalgovernmenthadthebigstickintermsofdollarsandthecivilrightsactof 1964basicallysaidthatthefederalgovernmentcouldnotgiveanydowerstoanyorganization thatdiscriminatedonthebasisofrace.Andthatfirstefforttoenforcethatlawcamewiththe establishmentofthemedicareandmedicaidprogramsin1966.Nowthetrickishowdowe makesurewhathospitaldesegregatedinsomeway.Nowthatsalotmoresubtleandthe hospitalscandiscriminatejustbyrelocatingfromablackareatoawhitearea.Andtheycan searchforthisbutinmostcasesthosesuitshavenotbeensuccessful,sotheirarelotsofways todiscriminatesubtllyandwearenotasgoodathandlingthatkindofstuff,onlywiththemore

January27,2014

obviousstuffthatexistinthe1960s.Forexample,therearebigdifferencesincardiovascular treatmentbyrace,relatedpartlytowherethespecialistsareandhowtheyadmittheirpatients andthatkindofstuff.Theirmaybesomesubtleformsofdiscrimination,thatswhywestillhave disparitiesintermsoftreatment.Wehaventreallyfiguredouthowtoaddress.Inthenew healthcarereformlegislation,notjustdealingwithhospitals,butalsowiththedoctors,and insurancecompanies,tomakesurepeopleweretreatedfairly.Buttheproblemisthefundingfor theprogramhasbeenprettydoubtfulintheamountofmoneythatwillbeadvocatedforthat.Its justgoingtobesortofapaperinsurancewithnothingunderneathittoenforceit.Sothestruggle continues. Interviewer:ThisyeartheNationalHistoryFairdaythemeisRightsandResponsibilities.What medicalrightsweredeniedbyAfricanAmericansduringthelatenineteenthandearlytwentieth century. Smith:Theyhadnorights,Whathappenedwasthatbasicallybecausetheirwasanunwritten lawthatsaidthatwewillgivecarebasedonpeoplesabilitytopayandbasedonyourrace.What youseeisthattheamountofcarepeoplereceivewasdirectlyrelatedtotheirincomeandtheir race.Whathappenedafterthe1960sthelawwasreversed.Blacksaresomewhatmorelikelyto reachthehospitalcare,andsomewhatmorelikelytobeseenbythehospitalsthanwhites.And evenstrongerrelationshipwithincome.Poorpeopletendedtohavemorevisitsandmore hospitaladmissionthanrichpeople.Whichiswhatyouexpect,peoplearepoorbecausethey aresickandsickbecausetheyarepoor.Andthatallchangedinthe1960s,sothecrude numberschanged,roughnumbers.Butthemorespecializedkindofcare,thethingsthatweget concernedaboutwerereallysortofkindofamoresmallerpiecethatusedtoexistinthe1960s. Itsinterestingtoknow,upuntilthe1990swetlakaboutracialdifferencesintermofhealthcare, andracialdifferencesintermsofhealth,nowwetalkaboutdisparities.Thedifferencesisthat maybeitsthefaultoftheindividualandnotthefaultofthesystem.Nowwecallthemdisparities. Thisisunjustitisthefaultofthesystem,notthefaultoftheindividual.Thesystemhastobe healednottheindividual.Thatsabigchange. Interviewer:Whataretheconsequencesofsegregationinhealthcare?Currentlyand Historically Smith:Inthepastitwasactuallyforratic.Therewasbasically,inlargeareaofthecountry, peoplecouldnotgetaccesstocare,theonlyaccesstheycouldgetwastoteachinghospitals. Wheretheywereusedformedicalstudentsasapartofresearch.Thereasonthatwascarried outbecausethepeopleweren'tgoingtogetanycareanywayssoitdoesntmatter.Thatswhat existedbeforethe1950s,whatweseetodayintermsoftheconsequencesofsegregationare problemsthathavehappenedingettingcarefromspecialistliketoworkingeographicareas wheretherearentaffluentpeoplethatcantakeprivaterates,soweseealotofsubtle differencesthataffectallintermsofhealthcare. Interviewer:Doyoubelievethatdiscriminationstillexistswithinourhealthcareintodays

January27,2014

presentday? Smith:Therearetwokindsofdiscrimination,andthisgetsintothecivilrightsactintermsof regulation.Discriminationinvolves,disparatetreatmentIwonttreatyoubecauseyou'reblack orIwillgiveyoudifferenttypeoftreatmentsthenIwouldmywhitepatients.Thatsdisparate treatment.Otherkindofdiscriminationiswhatwecalldisparateimpact,itseemslikeeveryone isnotdirectlydiscriminating,butifyou'reblackyoudontgetasgoodcarebecauseyoudont haveaccesstothatcareinyourcommunity.Mostofwhatweseetodayisnotdisparate treatment,itsmostlydisparateimpact.Therearestillcaseswherephysicianswhoathospitals, haveadmittingclerkswhowillrefusepatientsbecausetheyareblack,theydontwanttoadmit thembecausetheyarepoorandthatkindofstuff.Mostofthekindofdiscriminationwehave now.Isdisparateimpactandthatismuchhardertodealwithbecauseitshardertobringalegal suitagainstitbecausetheprovidercanalsosaythatIjustmovedmypracticetoanallwhite areabecauseIcanmakemoremoneythere.Thatsdisparateimpactoristhepersonjust makingmoremoneythere,makingarationalbusinessdecision.Thatsoneoftheproblemswe havebecausewehaveadividedsystemintermsofhowhealthprovidersgetpaid,aslongas wehavethatwewillhaveproblemsofdisparateimpact. Interviewer:Arethereanyothertopicsthatyouwouldliketodiscusspertainingtodiscrimination withinhealthcare? Smith:IthinkinChicago,youhaveaseriousproblemintermsofaccesstonursinghomecare, youhavealotofhomesthathavegrowninthesuburbandtheyhavesunkinthecity,andalotof thehomeinthecityaresubstandard,anditsreallyhardforfamiliestobeensuredthattheyare gettingdecentnursinghomecarefortheirparentsortheirgrandparents.Andthatsyouknow prettyblatantbecauseweactuallyhavethenumbersofwhereblackandwhitepatientsgofor nursinghomecare.Andwealsohavenumbersforthequalityofcareforthosenursinghomes thatarecollectedbythefederalgovernment.Thatsaseriousproblemespeciallywithsomeof thehomesinthecitybecauseoflowcensusadmittingpsychiatricpatients,evenadmitting peopledirectlytothenursinghomeandthatcreatedalltypesofproblems.