This historical analysis addresses several questions. Why did black dentists, physicians, and patients pursue the integration of hospitals as a means to improve health care for black persons? Why did leaders in the black community work through the court system in laying the foundation for the racial integration of hospitals? What were the consequences of judicial decisions about the use of federal funds on executive action and legislative initiatives? This analysis also describes the federal grant system and effect of racism in federal funding on hospital practices. The case of Simkins v Moses H. Cone Memorial Hospital became the landmark decision leading to the elimination of segregated hospital care through Title VI of the 1964 Civil Rights Act and the Medicare program.

Hospitals: The Target for the Elimination of Discrimination in Medicine

At the close of World War II, Dr. Paul Cornely, Professor of Preventive Medicine at Howard University, was acting as consultant to the National Urban League and surveyed the health and social services that were offered to black persons in five cities-three in the North and two in the South. Beyond the general absence of social services for black persons in every city that he studied, Cornely found a significantly lower ratio of beds per person for black persons than for white persons. Existence of hospital beds, however, was no guarantee that black persons would be granted access to those beds [8]. Two examples follow:

Near Dalton, Georgia, a woman was injured in a car crash. The closest hospital advertised "no Negroes," so an ambulance was summoned from 66 miles away to take her to the closest hospital that treated black persons. The woman, Juliette Derricott, died. She had been a national YWCA executive and Dean of Women at Hampton and Fisk College.

A 70-year-old man with white skin and blue-gray eyes was hit by an automobile. The motorist who hit the man rushed him to Grady Municipal Hospital. The physician worked to save the patient's life while the family was notified of the accident. The first family member to arrive was the patient's son-in-law. When the physician saw the son-in-law, who was a nationally prominent black man, he declared, "What! Have we put a nigger in the white ward?" Still unconscious, the patient was wheeled across the street through the rain to the black ward in the old building; in the black ward, the patient died. He was the father-in-law of Walter White, executive director of the National Association for the Advancement of Colored People (NAACP).

Walter White came to know Dr. Louis Wright, another opponent of discrimination, through the work of the NAACP.

The NAACP and Louis T. Wright: Integration in Federal Grant Programs

Louis Tompkins Wright experienced overt discrimination while he was a student at Harvard Medical School from 1912 to 1915. Wright learned that he was not allowed to rotate to the obstetrics ward at the Boston Lying-in Hospital because the patients were white. Arrangements had been made for Wright with a local black obstetrician. Wright refused this option and argued that his tuition payment and the curriculum promised obstetrics at the Boston Lying-in Hospital. Supported by his classmates, Wright succeeded where previous students had failed. The last painful incident came when Wright, graduating cum laude and fourth in his class, was denied the right to march in the order of scholastic achievement because he was black [9].

Wright later became the Chair of Surgery at Harlem Hospital and chairman of the national board of directors of the NAACP. He directed the policies of the NAACP from 1935 until his death in 1952 and steered the organization through its campaign against discrimination in professional and public education. During his tenure, Wright established the National Health Committee to spearhead the NAACP's fight against separate-but-equal policies in hospital care [10, 11].

The NAACP quickly identified the abuse of the distribution of state and federal tax dollars to public institutions. In parallel, the NAACP Legal Defense and Education Fund directed its litigation activities toward ending the system of discrimination in education, beginning with higher education in the 1930s with the case of Murray v University of Maryland, followed by Gaines v Canada in 1939, Sipuel v Board of Regents in 1948, McLaurin v Oklahoma State Regents in 1948, and Sweat v Painter in 1950. The NAACP Legal Defense and Education Fund ultimately succeeded with its litigation strategy in Brown v Board of Education of Topeka, Kansas in 1954 [12, 13]. The same strategy would be applied to achieve social change in health care.

Before World War II, 27 major grant statutes provided federal assistance for agriculture, public health, public assistance (welfare), education, unemployment, compensation, and employment services. After World War II, federal grants expanded substantially. State agencies were chosen as the channel through which federal dollars would flow to communities. Regulations, second in importance only to the statutes themselves, specified who could receive grants, under what conditions, for what purpose, subject to what criteria, and with what exceptions. Before Medicare, the largest federal grant program in health care after World War II was the Hospital Survey and Construction Act of 1946, commonly known as "Hill-Burton."

The Hill-Burton Act was designed to increase the number of hospital beds throughout the country, particularly in rural communities. Its sponsors were Senators Lister Hill of Alabama and Harold Burton of Ohio. The act authorized $75 million per year for 5 years beginning in 1947 (for grants to state agencies for hospital construction) plus $3 million per year (for state surveys of hospital facilities) [14]. As a federal-state partnership, state agencies were given an initial grant to survey hospital needs and to develop a plan to apportion construction funds on the basis of population distribution and existing hospital beds. Federal dollars without control was the guiding principle.

The Hill-Burton Act sought to provide equal facilities for all citizens, but it allowed hospitals that were receiving federal funds to continue existing patterns of discrimination on the basis of a separate-but-equal provision in the legislation [15]. Regulations for the Hill-Burton legislation reflected congressional discussions. They allowed states to develop statewide hospital plans that included segregated institutions if the state health-planning agency considered these facilities adequate for the population served. Hospital facilities that were built for separate populations were to be of similar quality for each population group and adequate to meet the needs of that group [15].

Facilities that were not constructed as separate but equal had to ensure access to all persons without discrimination. The Hill-Burton Act, as interpreted by the General Counsel of Health, Education, and Welfare, meant that no person could be denied admission because of race, creed, or color to that portion of the facility for which federal funds were used; however, the patient could be denied admission to other sections. It was also interpreted to mean that no patient could be denied any service that was essential to his or her health; however, patients could be segregated in the facility by race, creed, or color, and professionally qualified persons could be denied staff privileges [15-17].

In practice, Hill-Burton funds were used by communities throughout the South to build hospitals that excluded black patients from admission and to prevent black physicians from caring for their patients once they were admitted to mixed-race hospitals. When such possibilities became real in Tallahassee, Atlanta, and Memphis, the NAACP Board of Directors required that the local NAACP chapters refuse support for the construction or expansion of a segregated Hill-Burton hospital. If this requirement was ignored, the national NAACP would revoke the local chapter's charter [18]. Dr. Wright, as chairman of the NAACP Board of Directors, argued that the way to fight segregation in health care was to refuse to support its institutionalization, particularly when institutions were funded by tax dollars.

Over the years, two strategies emerged among the leaders of the black community to improve health care for black persons. One was a strategy of accommodation whereby black leaders would request through well-established patterns of civility, from the white business elite, monies for black institutions, such as hospitals. In Durham, North Carolina, this form of negotiation led to the construction of Lincoln Hospital, an all-black hospital, in 1901 and three subsequent expansions. In terms of investments, however, the differential between Watts Hospital, the all-white hospital in Durham, and Lincoln Hospital grew with each decade. By 1950, Watts Hospital's assets totaled more than $2 800 000, whereas Lincoln Hospital's assets reached only $740 000 [4, 5].

The other strategy was one of integration. In developing this strategy, Wright established the National Health Committee of the NAACP and worked with two faculty members from Howard University: Dr. Montague Cobb, Professor of Anatomy, and Dr. Paul Cornely. The three worked together to orchestrate a collaborative initiative among the NAACP; the National Medical Association; the National Urban League; and, when possible, the American Public Health Association. The NAACP Health Committee asked Cobb to direct its first two projects. Cobb's subsequent publications [19, 20] described a system of inferior medical schools and hospitals for black persons throughout the North and South that he thought were grossly inadequate to serve the medical needs of black persons. In this separate-but-equal medical system of hospital care and medical education, black persons would always be disadvantaged and would continue to fall further behind [19, 20].

By the early 1950s, Wright, Cobb, and Cornely determined that it was time for a direct attack on "what is perhaps the greatest of all discriminatory evils, differential treatment with respect to hospital facilities" [21]. The NAACP joined with Cobb and Cornely to sponsor an annual meeting from 1957 to 1963, the Imhotep Conference, in which physicians, leaders of professional organizations, and members of the press were invited to discuss the racial integration of hospitals. The first step was to eliminate the separate-but-equal clause of the Hill-Burton Act. Wright laid the foundation by arguing for use of the courts as the critical component.

Hospital Integration: The Judicial Approach

The first case on hospital discrimination to reach the courts was brought by three black physicians from Wilmington, North Carolina: Dr. Hubert A. Eaton, Dr. Daniel C. Roane, and Dr. Samuel J. Gray. Two hospitals were available in Wilmington. James Walker Memorial Hospital admitted primarily white patients but also maintained about 25 beds for black patients in a separate building that was located in back of the main building; this annex had substandard lighting, heating, and ventilation. Sadly, Dr. Eaton considered these facilities better than those available at the second hospital in Wilmington, Community Hospital, which could accommodate 100 black patients. The medical staff at James Walker Memorial Hospital was composed of white persons, whereas the staff at Community Hospital was biracial. Eaton assumed that discrimination against black physicians existed at James Walker Memorial Hospital because it was a private institution [22].

In 1954, Eaton accidentally discovered that James Walker Memorial Hospital paid no city or county taxes. Thinking that the hospital was a public institution because it paid no taxes, Eaton applied for staff privileges. His application was rejected [23, 24]. Eaton decided to seek legal counsel and hired Conrad O. Pearson, the lawyer for the North Carolina chapter of the NAACP Legal Defense and Education Fund who lived in Durham, and Robert Bond, a black lawyer from Wilmington. For the next year, Pearson and Bond gathered data; in 1956, they filed suit in North Carolina district court. The lawyers argued in Eaton v Board of Managers of the James Walker Memorial Hospital that because of the land contracts between the city and county and James Walker Memorial Hospital, contributions from the local governments to the hospital for maintenance and payment of services to the poor, and the conditions of the will of James Walker about the hospital, discrimination of the physicians was unconstitutional under the Fourteenth Amendment [25-30].

Judge Donald L. Gilliam held the first hearing on the case 23 months after the suit was filed. The lawyers for James Walker Memorial Hospital moved to dismiss the case on the grounds that denial of staff privileges by the hospital medical board was not state action in the purview of the Fourteenth Amendment, and thus the litigation contained no basis for federal jurisdiction. One month later, the judge dismissed the case, ruling that the "act of discrimination did not constitute state action" [22, 30]. On appeal, the United States Court of Appeals upheld the lower court's ruling. Before proceeding, Pearson asked the national office of the NAACP Legal Defense and Education Fund for advice and assistance.

Thurgood Marshall and Jack Greenberg, two of the most renowned and successful Fund lawyers, examined the case and quickly realized that a victory would set an extraordinary precedent. They agreed to take the case to the Supreme Court and filed a writ of certiorari, which is an order requiring a lower court to forward the records of a case to the higher court for review [31-36]. In May 1959, the Supreme Court declined to issue the writ. The cause seemed lost until Marshall and Greenberg noted that they received dissents from three Supreme Court justices: Chief Justice Earl Warren, William O. Douglas, and William Brennan [37-39]. This was very unusual; as a result, Marshall and Greenberg examined the potential for success if a rehearing was granted. Marshall and Greenberg discussed the case at length and ultimately decided not to petition the court for a rehearing [38]. They speculated that a fourth judge did not dissent because of the like-lihood that the Supreme Court would uphold the ruling of the lower courts.

Shortly after the Eaton case was closed, Greenberg received a phone call from Dr. George Simkins asking for advice about discrimination in a hospital that had used Hill-Burton funds to expand. Simkins, a dentist in Greensboro, North Carolina, wanted to treat one of his patients in the Moses H. Cone Memorial Hospital because this hospital offered better equipment and facilities (Interview with Simkins GC, 5 February 1989). Three hospitals were available to the citizens of Greensboro. The Wesley Long Community Hospital was a 78-bed hospital that had never admitted a black patient or accepted a black physician for staff privileges. L. Richardson Memorial Hospital was a 91-bed hospital that admitted only black patients; at this hospital, black physicians and dentists had admitting privileges and cared for their patients. The Moses H. Cone Memorial Hospital was a 300-bed hospital that admitted black patients for special procedures but refused staff privileges to black physicians [40].

What initially seems to be an insignificant event often turns out to be a seed of revolutionary change. So it was with Simkins, whose patient had an impacted molar and needed oral surgery. Simkins tried to admit his patient to L. Richardson Memorial Hospital, but no beds were available. Simkins' patient did not want to be treated by a white dentist; therefore, he refused to be admitted to Moses H. Cone Memorial Hospital. In frustration, George Simkins called Jack Greenberg (Interview with Simkins GC, 5 February 1989).

Simkins was a medical and political leader of his community. He was familiar with the resources of the NAACP Legal Defense and Education Fund and knew Thurgood Marshall and Jack Greenberg through his efforts to integrate the public golf courses and school system in Greensboro. Simkins served as president of the local NAACP chapter, an active and large chapter, and believed strongly in the integration approach to solving inequities in education and health care that was being pursued by the NAACP and the NAACP Legal Defense and Education Fund. Simkins, who had been successful in integrating other public institutions, called Greenberg and asked for advice on integrating Moses H. Cone Memorial Hospital or Wesley Long Community Hospital and opening these hospitals to black health professionals ([40, 41]; Interview with Simkins GC, 5 February 1989).

On Greenberg's recommendation, Simkins wrote to the administrators of both hospitals and requested an application for admitting privileges. He received an application for the Moses H. Cone Memorial Hospital, filled it out, and was subsequently turned down. He never received an application from the Wesley Long Community Hospital. Simkins also wrote to the Secretary of Health, Education, and Welfare, Arthur S. Fleming, complaining that both hospitals had used Hill-Burton money in the past and were to receive additional federal funds to expand although the hospitals discriminated against black physicians, dentists, and patients. Greenberg now had a case of discrimination in hospitals that had used Hill-Burton funds ([42-48]; Interview with Simkins GC. 5 February 1989).

Greenberg put Michael Meltsner, a young associate at the NAACP Legal Defense and Education Fund, in touch with Simkins to discuss obtaining other plaintiffs. Simkins enlisted the help of six black physicians, two other dentists, and two black patients. Meltsner was delighted with this outcome because the group would represent a unified black community to the courts (Interview with Meltsner M, 19 April 1989). The dentists and physicians all requested applications for staff privileges at both hospitals, and all were turned down [49]. One of the patients who was named as a plaintiff had a confirmed gastric ulcer and wanted a complete medical work-up done by his black physician using the best equipment available. Because he was black, the patient could not be admitted to Wesley Long Community Hospital; because his physician was black, the patient could not secure care from his physician if admitted to Moses H. Cone Memorial Hospital [34]. Discrimination clearly existed. For Meltsner, the issue was not proving equality of services but proving state action in the activities of these predominantly white hospitals (Interview with Meltsner M, 19 April 1989). The Hill-Burton program was the link.

The Hill-Burton statute required that, to be eligible to receive federal funds, all states had to establish a statewide medical-care commission to develop a plan and to serve as the conduit of federal monies to communities. In North Carolina, the state legislature established the North Carolina Medical Care Commission "to provide for the licensing, inspection, and regulation of hospitals; to authorize subdivisions of government to construct, equip, operate, and maintain hospital facilities; and to provide adequate medical care to the people of the State of North Carolina." The Commission was also authorized to provide funds to nonprofit hospitals for the costs of charity care and to build a 4-year medical school and teaching hospital at the University of North Carolina [4, 5].

Meltsner recognized, however, that the Hill-Burton Act was originally designed to provide money to construct hospitals and was intended to limit federal participation in hospital operations; to argue otherwise was a departure from the status quo. Meltsner needed to build the case for state action in hospital care on the basis of state and federal controls as they applied to hospitals receiving Hill-Burton federal grants. This involvement and control would then become the centerpiece for arguments of protection under the Fifth and Fourteenth Amendments. In preparation, Meltsner studied the plan for allocation of hospital beds under the Hill-Burton program that had been developed by the North Carolina Medical Care Commission and noted that the Commission had approved expansion and renovation plans for the Moses H. Cone Memorial and Wesley Long Community Hospitals in 1954, 1959, 1960, and 1961 ([40]; Interview with Meltsner M, 19 April 1989).

At the time of the trial, Moses H. Cone Memorial Hospital had received $1 270 000, or 15% of its construction costs (in 1954 and 1960), under Hill-Burton and Wesley Long Community Hospital had received $1 950 000, or 50% of its construction costs for two expansions (in 1959 and 1961) [38]. Meltsner built the case of state action on the fact that the Moses H. Cone Memorial Hospital and the Wesley Long Community Hospital were licensed by the state, had received Hill-Burton funds to expand their facilities, and had a tax-exempt status. Involvement in the Hill-Burton program was most important ([48, 49]; Interview with Greenberg J, 2 March 1989). As Meltsner argued in federal district court, participation in the Hill-Burton program subjected hospitals to elaborate patterns of state and federal government regulations. These included 1) the right of the federal government to recover part of its grant if the hospital at some future date no longer existed as a hospital; 2) the stipulation that hospitals receiving federal grants had to meet specified minimum standards for maintenance and operation; 3) the requirement that each state inventory all existing hospital facilities to determine the number of beds needed in each area and to prioritize projects; and 4) the stipulation that a state had to submit, for approval by the Surgeon General, a plan for hospital care that did not discriminate on the basis of race, creed, or color [48, 49]. If a separate-but-equal facility was built, the state agency had to submit a report enumerating the number of beds that were available for each racial group to the Surgeon General. If the government was involved in hospitals using Hill-Burton funds, citizens were entitled to protection under the Fourteenth Amendment. As Meltsner argued, the Hill-Burton legislation was unconstitutional because separate but equal (as described in the Hospital and Survey Construction Act of 1946) was unconstitutional under the Fourteenth Amendment.

Greenberg and Meltsner were obligated by law to notify the Justice Department when a case before the courts challenged the constitutionality of a federal statute. When Burke Marshall, Assistant Attorney General, requested permission to intervene on behalf of the plaintiffs, Greenberg and Meltsner knew they had secured an important vote of support (Interview with Meltsner M, 19 April 1989; Interview with Greenberg J, 2 March 1989).

Pearson filed the suit, Simkins v Moses H. Cone Memorial Hospital, on 12 February 1962. The plaintiffs asked the court to order the hospitals to cease denying black physicians and dentists the use of hospital facilities on grounds of race; to cease denying the admission of patients on the basis of race; to cease refusing patients the permission to be treated by their own physicians and dentists; and to declare the separate-but-equal provisions of the Hill-Burton Act and its implementing regulations unconstitutional under the due process clause of the Fifth Amendment and the equal protection clause of the Fourteenth Amendment [50].

Burke Marshall submitted a 48-page brief to the Justice Department. He recommended that the courts overthrow the separate-but-equal provision of the Hill-Burton Act because it violated the Fifth and Fourteenth Amendments. Marshall argued that hospital care was not a private affair and elucidated many areas in which federal and state controls under the Hill-Burton program affected hospital operations [51]. Two months earlier, the Federal Hospital Council, which was authorized to advise the Surgeon General on the Hill-Burton program, recommended that steps be taken at the federal level to ensure that patients would be admitted to federally aided hospitals without discrimination and that the Hill-Burton legislation be changed to reflect this policy. Council members argued that "there is no place for racial discrimination; it is unjust and detrimental to the physicians and patients involved, the professional staff of the hospital, and indeed, to the community at large when staff privileges are granted or denied on the basis of race" [54].

In December 1962, Judge Edwin M. Stanley ruled in favor of the defendants in the case of Simkins v Moses H. Cone Memorial Hospital. Stanley concluded that the courts did not have jurisdiction over civil rights activities as they related to hospitals, and the motion of the defendants to dismiss the case was therefore granted [49]. Greenberg and Meltsner, however, were not disheartened. If the case was overturned by the Court of Appeals, more hospitals would be affected. In fact, 89 separate-but-equal hospitals, all-black or all-white facilities, had been built in the South with Hill-Burton dollars ([54]; Interview with Meltsner M, 19 April 1989; Interview with Greenberg J, 2 March 1989). The Legal Defense and Education Fund learned, during litigation of school cases, the importance of obtaining a Supreme Court ruling. Greenberg filed the appeal, and on 1 April 1963, he argued the case before the Fourth Circuit Court of Appeals. On 1 November 1963, the Circuit Court ruled in favor of the plaintiffs, granting them the relief they sought [48, 54-56].

Chief Judge Simon E. Sobeloff wrote the majority decision and found that the state government was involved in hospitals through extensive federal-state participation in hospital planning and through the appropriation of "millions of dollars of public monies." Meltsner's argument proved successful. The defendants appealed, and the Supreme Court's ruling was the next important step.

James Quigley, Assistant Secretary of the Department of Health, Education, and Welfare (DHEW), lent his support. Awaiting the Supreme Court's ruling on the Simkins case, Quigley wrote to Lee White, Special Assistant to President Johnson responsible for civil rights, asking for his counsel on implementation of the Hill-Burton program. As Quigley noted, the DHEW had eight separate-but-equal facilities under construction using Hill-Burton money. After the Fourth Circuit Court ruled on the Simkins case, Quigley informed the regional offices that no further payments should be made on these projects until the Supreme Court had issued its decision [57].

On 2 March 1964, the Supreme Court denied the issuance of a writ of certiorari, upholding the Fourth Circuit Court of Appeals' ruling against the separate-but-equal provisions in the Hill-Burton program [58]. Hospitals that were receiving Hill-Burton funds were forced to integrate. Quigley could now stand on firm ground in his effort to eliminate racism in medicine.

Window of Transition: Hill-Burton and the 1964 Civil Rights Act

The DHEW had anxiously awaited direction on Hill-Burton applications. Immediately after the Supreme Court ruled on the Simkins case, DHEW Secretary Anthony Celebrezze called for new regulations consistent with "the intent of the law" [58]. This meant that new applications for federal funds would not be approved, except on a totally nondiscriminatory basis. In the case of existing Hill-Burton hospitals, the Secretary would require assurances of nondiscrimination if the hospital sought additional money for expansion or renovation. Celebrezze required that new applicants guarantee nondiscrimination in patient admission and the right of physicians to admit their patients and other staff privileges.

One of the criticisms of the Eisenhower administration's handling of the monumental decision in Brown v Board of Education of Topeka, Kansas was the reluctance to play a strong leadership role in executing the new interpretation of the law. The Simkins v Moses H. Cone Memorial Hospital was the Brown case for hospitals. Assertive action was important if hospital desegregation was to be achieved. Celebrezze and Quigley took the initiative. After receiving approval by the Federal Hospital Council the week after the Supreme Court ruling on the Simkins case, the Surgeon General published new regulations for the Hill-Burton program on 9 March 1964. The new regulations [59, 60] provided the following:

"Before a construction application is recommended by the State agency for approval, the State agency shall obtain assurances from the applicant that all portions and services of the entire facility for the construction of which ... aid under the Federal Act is sought, will be made available without discrimination on account of race, creed, or color; and that no professionally qualified person will be discriminated against on account of race, creed, or color with respect to the privilege of professional practice in the facility."

However, with respect to applications that had previously been approved and to all completed projects, desegregation could be accomplished only by voluntary change in operating policies or subsequent approval of applications for additional Hill-Burton assistance. The federal government could not force hospitals to integrate if they had already used Hill-Burton funds [59, 60].

In May 1964, Celebrezze testified before the House Committee on Interstate and Foreign Commerce in support of extending the Hill-Burton Act and announced his plan to convene leaders of medical and hospital organizations for the purpose of speeding up the integration of hospitals through voluntary compliance [61]. Quigley organized the DHEW Conference on Civil Rights and invited representatives from six national medical and nursing organizations, the Federal Hospital Council, and leadership of DHEW and the Public Health Service.

Addressing conference participants, Celebrezze admitted that DHEW had unfinished business that involved the elimination of discrimination in all aspects of health care. He drew the group's attention to the recently passed 1964 Civil Rights Act and specifically Title VI, which required that "no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance" [61].

As Charles Hite, a field officer for the Hill-Burton program who worked out of the Charlottesville, Virginia, office explained, Title VI of the Civil Rights Act brought many more hospitals under the requirements of civil rights legislation because it affected every health program that was funded by the federal government. Although the Hill-Burton program provided monies to build many hospitals that admitted black and white patients to the same institution, internal segregation continued in these hospitals, with separate rooms, wards, buildings, cafeterias, lavatories, linens, blood banks, and sometimes entrances. Moreover, the federal government could not force a hospital that had already received and spent its Hill-Burton money to change its policies, as stated by the Court of Appeals that ruled on the Simkins case ([62]; Interview with Hite C, 10 February 1989). Civil rights activists in the federal government needed more than rewritten Hill-Burton regulations to achieve any substantial change. Title VI was the leverage they needed because it threatened to withhold all old and new federal funds to institutions that upheld policies of discrimination [62].

Title VI was also the leverage needed by civil rights groups who wanted to lodge complaints against noncompliant hospitals and thereby apply pressure from another direction. Meltsner maintained contact with lawyers from the NAACP Legal Defense and Education Fund throughout the country. He also received information on hospitals, such as the Moses H. Cone Memorial Hospital, that continued to discriminate against black patients, physicians, and employees. On the basis of this information, Meltsner drafted formal complaints against the discriminatory hospitals, most of which were located in the South, and sent them to the DHEW. These complaints charged hospitals with failure to comply with Title VI. As Meltsner explained, this tactic was used to force the DHEW to develop an enforcement strategy for Title VI ([63, 64]; Interview with Meltsner M, 19 April 1989). Before 1965 ended, Quigley would receive 323 complaints against hospitals, most of which were written by Meltsner. As Quigley reflected ([65]; Interview with Quigley J, 3 March 1989), all these complaints represented the truth.

Conclusion

Top Conclusion Author & Article Info References

Discrimination in health care resulted in the exclusion of black physicians from hospital medical staffs and medical organizations, black patients from hospital care, and black students from medical schools. Three physicians-Louis T. Wright, W. Montague Cobb, and Paul Cornely-saw the integration of hospitals as the best way to improve the health of black persons because they knew that a separate hospital system would never match the quality of health care facilities that were available for white persons. They designed a strategy that combined political action through local NAACP chapters, legal action through the NAACP Legal Defense and Education Fund, education of black physicians, and research to document the health outcomes of black persons cared for in an unequal system. They initiated their campaign just as the federal government launched its largest hospital construction program.

The Hill-Burton program reflected the past and the future. It permitted construction of separate-but-equal hospitals but required that comparable facilities be provided for both races in the same community. This policy permitted states to maintain the social system of segregation and, at the same time, attempted to address the hospital needs of black persons. Although black patients and white patients were hospitalized in the same facility for the first time in some communities, social segregation persisted even in biracial hospitals as patients were put into separate wards or buildings.

Wright, as Chairman of the Board of Directors of the NAACP, created a health committee to direct the activities against discrimination in medicine and required that local NAACP chapters oppose the construction of separate-but-equal hospitals in their own communities. The NAACP Legal Defense and Education Fund pioneered efforts to eliminate discrimination in higher education and then in all public education. The strategy was later applied to hospitals, focusing on similar separate-but-equal language. The first court case involving racial discrimination in hospital care, Eaton v Board of Managers of the James Walker Memorial Hospital, did not specifically involve the Hill-Burton program. However, the idea of seeking evidence of discrimination in a hospital receiving federal funds emerged from the judges' dissent.

A turning point in the effort to integrate hospitals came when the Supreme Court ruled in favor of the plaintiffs in the case of Simkins v Moses H. Cone Memorial Hospital. Meltsner and Greenberg successfully argued that state action in the Hill-Burton program demanded that the separate-but-equal clause be eliminated and that federal funds be distributed without regard to race, creed, or national origin, as required under the Fifth and Fourteen Amendments. The Simkins verdict had a substantial effect not only on executive action in the White House, the DHEW, and the Public Health Service in the implementation of the Hill-Burton program but also on the 1964 Civil Rights Act, Title VI regulations, and the implementation of major federal health programs. Such programs included Medicare, which affected almost every public hospital in the United States. Step by step, persons who advocated the end of discrimination in health care moved closer to their goal, first by obtaining a victory in the courts, then by amassing support from professional organizations, Congress, and the public.