David Barton Smith. The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America's Health Care System. Nashville: Vanderbilt University Press, 2016. 256 pp. $27.95 (cloth), ISBN 978-0-8265-2107-1.
Reviewed by Ezelle Sanford (Princeton University)
Published on H-Afro-Am (March, 2017)
Commissioned by Jewell Debnam
The product of a decades-long career exploring the politics of desegregation, discrimination, and disparities in US healthcare, David Barton Smith’s The Power to Heal: Civil rights, Medicare, and the Struggle to Transform America's Health Care System synthesizes and builds upon his previous work to explore the implementation of Medicare and its role in desegregating American hospitals. Unlike other histories of Medicare which situate the legislation within the contexts of President Lyndon Johnson’s Great Society and health and welfare policy more broadly, Smith argues that Medicare was the unacknowledged “gift of the civil rights movement” (p. 3). The civil rights historiography has explored desegregation efforts in education, housing, and labor, yet more work could be done to recover the place of medical and health activism. Smith’s work is situated at this understudied, yet important nexus. The Power to Heal recovers the untold story of how civil rights activists doubled as policy enforcers helping to desegregate American hospitals while simultaneously implementing landmark policy on the ground. Published on the heels of Medicare’s fiftieth anniversary, Smith provides a novel interpretation of this landmark policy.
The Power to Heal begins with an impressive, yet oft unrecognized claim: that America's healthcare system, as we know it today, came of age in the Jim Crow era. The era’s social norms were thus embedded into the very fabric of the system, generating three peculiar, according to Smith, values upon which the system operated and matured: volunteerism, duty to neglect, and exploitation of the vulnerable Many American hospitals were voluntary, nonprofit institutions that excluded African Americans. Volunteerism, therefore, became a hallmark value of (white) American healthcare. Similarly, the maturing system developed a duty to neglect, an inverse relationship between the availability of care and the need for it. Finally, African Americans were an exploited, vulnerable population that provided critical clinical material for medical education.
Black physicians, as Smith explores in his second chapter, comprised the “backbone” of the civil rights movement. As independent entrepreneurs, these professionals could actively fight for civil rights without fear of economic reprisal from whites. Smith divides six central figures into the “street fighters,” those involved in direct action activism, and the “Brahmins,” those who worked within political and professional systems to achieve change. Smith studies well-known figures such as T. R. M Howard and W. Montague Cobb along with lesser-known figures like Sonnie Hereford and Charles Watts. Though Smith rightly situates the role of black male physicians in civil rights activism, the activism of other health professionals including nurses, technicians, and administrators is not directly explored. Furthermore, a more explicit distinction between civil rights activism in the health and medical fields, and the participation of health professionals in broader civil rights struggles would have been useful here. Some of the figures explored here were crusaders in a much larger battle, while others focused directly on desegregation and attaining equal rights within their own professional spheres.
Chapters 3 and 4 are by far the best in the book. Smith charts how the implementation of Medicare became the mechanism that transformed hospitals from one of the most segregated institutions to one of the most integrated in the nation. The 1963 Simkins v. Moses Cone Memorial Hospital ruling, upheld by the United States Supreme Court, and the Civil Rights Act of 1964 mandated the desegregation of hospitals. These two moments paved the way for hospital desegregation but there was no mechanism for enforcement. The federal government’s influence over healthcare increased as entities like the National Institutes of Health began funding biomedical research in the postwar era. The precedent had been established. In order to force hospitals to desegregate, Medicare funding was tied to compliance with federal policies. Compared with the desegregation of schools with “all deliberate speed,” as Smith notes, the civil rights struggles in healthcare were often quick, quiet, and uneventful, generating little publicity. Though the history of Medicare is often told as a high political narrative, of presidents and department secretaries, Smith illuminates how messy a process it was to implement the legislation on the ground, where many decisions were made in real time. The Office of Equal Health Opportunity, a small office in the United States Public Health Service which had a “short and happy life,” is a key figure in these chapters, coordinating volunteers of bureaucrats and civil rights activists alike. Smith truly captures the often chaotic and haphazard operation of this little office. These volunteers, who visited hospitals to ensure Title VI compliance, were a “hidden army” of activists engulfed in a sometimes bitter battle to desegregate healthcare.
Though the desegregation of hospitals was largely uneventful, the fifth chapter does explore the movement’s casualties. Black hospitals suffered tremendously with the desegregation of American healthcare. Many succumbed to economic pressures by the late 1970s. Through the stories of three figures, James Cheney, Fred Hampton, and Dr. Jean Cowsert (the only woman highlighted in the book), the author chronicles the consequences of activism. Smith’s choices in “casualties” further demonstrate that it would have been useful here, as in chapter 3, to fully distinguish between a civil rights movement in medicine and the broader influence of medicine in the civil rights movement. The degree to which each highlighted figure was directly involved in the implementation of Medicare and the larger hospital desegregation program is highly variable. In his last chapter, Smith connects the history of Medicare and civil rights to more contemporary phenomena, namely the ever-growing segregation of individuals in nursing homes and the growing numbers of incarcerated people of color. Of course, Smith weaves preliminary evaluations of the Affordable Care Act into this chapter.
Although Smith successfully exposes the often messy and unsteady implementation of Medicare on the ground and its role in the desegregation of US hospitals, he leaves the reader to wonder more about the broader history of civil rights and its relationship to the history of medicine. Unfortunately, Smith rarely interacts with the very best of the voluminous civil rights corpus, particularly newer works which expand the periodization of the black liberation struggle, highlight the voices of women and grassroots activists, and expand and critique the North/South divide. The text occasionally stumbles with regard to these questions. Smith does not overtly define his periodization of the movement. Moreover, of the six figures he studies in depth, only one is a woman. Though the author identifies Chicago as his northern case study, much of his focus remains on hospitals in the American South. Clarifying his view on these questions would have made this text a more significant contribution to civil rights historiography, augmenting its contributions in other subfields.
More than anything, David Barton Smith has illuminated a fascinating, understudied, yet important episode in civil rights and political history that could be a generative area of inquiry for younger scholars. Lengthy quotations from oral history interviews conducted by the author make The Power to Heal a compelling narrative and give it necessary detail and depth. He has left a substantial archive of documents and interviews housed at Temple University. Given these strengths, The Power to Heal and the forthcoming accompanying documentary film would make a great addition to undergraduate courses on the history of US medicine and healthcare, civil rights, and policy more generally.
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Ezelle Sanford. Review of Smith, David Barton, The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America's Health Care System.
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