Deluxe Jim Crow: Civil Rights and American Health Policy, 1935–1954 (review)

Karen Kruse Thomas places the region of the American South, and its rural and African American populations, at the center of national health care policy from the New Deal through the mid-1950s. Drawing on meticulous, comprehensive research in published sources, archival materials, and oral interviews, Thomas looks at the debates over and implementation of state and federal health programs in the South, with particular attention given to North Carolina. The result is a book that illuminates the key influence of region and race on health policies in the first half of the twentieth century. It also sheds much-needed light on the neglected topic of medical care in relation to civil rights struggles in the critical pre–Brown v. Board of Education period.

As Thomas explains up front, African American newspapers and reformers used the term “deluxe Jim Crow” to refer to “first-class” but still racially segregated public facilities. Thomas shows how health programs created a deluxe Jim Crow system in regard to medical care. It was a system, the author argues, that narrowed regional, rural/urban, and racial disparities in health care and laid the groundwork for later struggles to desegregate medical schools and hospitals.

Regional health disparities were stark in the early twentieth century, leading Surgeon General Thomas Parran to identify the South as “the Nation’s No. 1 health problem” in 1938 (pp. 31–32). The South had shorter life expectancies and fewer physicians and hospital beds than other parts of the United States. Thomas provides a detailed analysis of how the U.S. Public Health Service and African American and white reformers pushed for federal funds to improve the health of the South, and how many of these advocates downplayed race in their arguments for regional uplift. Also during these years, the National Association for the Advancement of Colored People (NAACP) launched successful legal challenges to racial discrimination, convincing some southern officials to begin to work toward equalizing segregated facilities, such as medical schools and hospitals. During World War II, national leaders defined health—and the high number of rejections of military recruits from the South—as a national security issue, giving further impetus to health programs.

For Thomas, the Hill–Burton Act of 1946 (officially the Hospital Survey and Construction Act) serves as the culmination of deluxe Jim Crow health policy. This federal legislation to provide need-based fund allocation for large-scale hospital construction emerged out of a fragile coalition, involving those—such as the American Medical Association, Republicans, and conservative southern Democrats—who had long opposed federal involvement in medical care. The act has been widely criticized by scholars for allowing the use of federal funds for the construction of racially segregated hospitals. But it is doubtful, Thomas says, whether the legislation would have passed had it required desegregation. Moreover, Thomas emphasizes the fact that it was the first major federal legislation in the twentieth century to include a nondiscrimination clause. Thomas is careful to explain that deluxe Jim Crow policy never achieved racial parity in health care. Yet in contributing funds to the construction and expansion of biracial hospitals, Hill–Burton increased the access of both African American and white patients to modernized hospital care in the South and created a transitional stage on the way to desegregation.

Thomas provides a timeline, tables, figures, and appendices to help readers follow the developments, individuals, and organizations involved in this history. What also may have been useful to readers is a clearer sense of the standards by which the author measures the success of health policy. Improved access to public health services and well-equipped hospitals seems to be one primary measure of achievement. Thomas gives attention as well to decreasing mortality rates in some southern states, to the increase of hospitalization among African American and white patients, and to...